Labor Stages Nursing Care Plans

Labor is defined as a series of rhythmic, involuntary, progressive uterine contraction that causes effacement and dilation of the uterine cervix. The process of labor and birth is divided into three stage.

The first stage of labor is the longest and involves three phases namely latent, active, and transition. The latent phase begins with the onset of regular uterine contractions until cervical dilatation. The active phase occurs when cervical dilatation is at 4 to 7 cm and contractions last from 40 to 60 seconds with 3 to 5 minutes interval and the last phase which is transition phase occurs when contractions reach their peak with intervals of 2 to 3 minutes and dilatation of 8 to 10 cm.

The second stage of labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered.

Lastly, the third stage or the placental stage begins right after the birth of the baby and ends with the delivery of the placenta.

There are instances where labor doesn’t start on it’s own so when the risks of waiting for labor to start are higher than the risks of having a procedure to get labor going, inducing labor may be necessary to keep the woman and baby healthy. This may be the case when certain situations such as premature rupture of the membranes, overdue pregnancy, hypertension, preeclampsia, heart disease, gestational diabetes, or bleeding during pregnancy are present.

Nursing Care Plans

The nursing care plan for a woman in labor includes providing information regarding labor and birth, providing comfort and pain relief measures, monitoring mother’s vital signs and fetal heart rate, facilitating postpartum care, and preventing complications after birth.

Here are 36 nursing care plans (NCP) for the different stages of labor including care plans for labor induction and labor augmentation:

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Labor Stage IA: Latent Phase


The latent phase of labor starts during the onset of true labor contractions until cervical dilatation. Included nursing care plans and diagnoses in this phase include:

  1. Deficient Knowledge
  2. Risk for Fluid Volume Deficit
  3. Risk For Fetal Injury
  4. Risk For Maternal Infection
  5. Risk For Ineffective Coping
  6. Risk For Anxiety
Deficient Knowledge 

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

  • Information misinterpretation
  • Lack of exposure/recall

Possibly evidenced by

  • Inaccurate follow-through of instruction
  • Questions
  • Statements of misconception

Desired Outcomes

  • Client will verbalize understanding of psychological and physiological changes.
  • Client will participate in decision-making process.
  • Client will demonstrate appropriate breathing and relaxation techniques.
Nursing Interventions Rationale
Assess client’s baseline knowledge and expectations during pregnancy. This will guide in establishing learning needs and set priorities.
Provide and discuss options for care during the labor process. Provide information about birthing alternatives, if available and appropriate. Active participation of the client/couple is important in the decision-making process.
Provide information about procedures (especially fetal monitor and telemetry) and normal progression of labor. Prenatal education can facilitate the labor and delivery process, assist the client in maintaining control during labor, help promote a positive attitude, and may decrease reliance on medication.
Review appropriate activity levels and safety precautions, whether client remains in hospital or returns home. Provides guidelines for client to make appropriate informed choices; allows client to engage in safe diversional activities to refocus attention.
Review roles of staff members. Identifies resources for specific needs /situations.
Obtain informed consent for procedures, e.g., forceps delivery, episiotomy. Explain the procedures and the possible risks associated with labor and delivery. When procedures involve client’s body, it is necessary for client to have appropriate information to make informed choices.
Educate the client about breathing and relaxation techniques appropriate to each phase of labor; teach and review pushing positions for stage II. Unprepared couples need to learn coping mechanisms on admission to help reduce stress and anxiety. Couples with prior preparation can benefit from review and reinforcement.
Risk for Fluid Volume Deficit

Risk for Fluid Volume Deficit: At risk for experiencing vascular, cellular, or intracellular dehydration.

May be related to

  • Decreased intake, increased losses (e.g., nausea & vomiting, mouth breathing, hormonal shifts)

Possibly evidenced by

  • [not applicable]

Desired Outcomes

  • Client will maintain fluid intake as able.
  • Client will demonstrate adequate hydration (e.g., moist mucous membranes, yellow/amber urine of appropriate amount, absence of thirst, afebrile, stable vital signs/FHR).
Nursing Interventions Rationale
Assess production of mucus, amount of tearing within eyes, and skin turgor. To provide information on the hydration status of the client.
Monitor intake & output. Note urine specific gravity. Encourage client to empty bladder at least once every 1 1/2–2 hr. Intake and output should be approximately equal, dependent on degree of hydration. Concentration of urine increases as urine output decreases and may warn of dehydration. Fetal descent may be impaired if bladder is distended.
Determine cultural practices regarding intake. Some cultures like Mexican women practice of drinking milk to make the babies larger, and drinking chamomile tea to have a healthy labor.
Monitor vital signs/FHR as indicated. Increases in temperature, BP, pulse, respirations, and FHR may indicate presence of dehydration.
Monitor Hematocrit level. Hematocrit increases as the plasma component decreases in the presence of severe dehydration.
Provide mouth care and hard candy, as appropriate. Reduces discomfort of a dry mouth.
Provide clear fluids (e.g., clear broth, tea
cranberry juice, jell-O, popsicles) and ice chips, as permitted.
Helps promote hydration and may provide some calories for energy production.
Administer bolus of parenteral fluids, as indicated. May be needed if oral intake is inadequate or restricted. In the event of dehydration or hemorrhage, fluid resuscitation is necessary; counteracts some negative effects of anesthesia/analgesia.
Risk For Fetal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to

  • Hypercapnia
  • Infection
  • Tissue hypoxia

Possibly evidenced by

  • [not applicable]

Desired Outcomes

  • Fetus will display FHR and beat-to-beat variability within normal limits, with no ominous periodic changes in response to uterine contractions.
Nursing Interventions Rationale
Note progress of labor. Prolonged or dysfunctional labor with an extended latent phase can contribute to problems of infection, maternal exhaustion, severe stress, and hemorrhage caused by uterine atony/rupture, putting the fetus at greater risk for hypoxia and injury.
Monitor baseline FHR manually and/or electronically. Evaluate frequently per protocol. Note FHR variability and periodic changes in response to uterine contractions. Normal range for fetal heart rate is between 120–160 bpm with average variability, accelerating in response to maternal activity, fetal movement, and uterine contractions.
Monitor FHR during rupture of membranes, reassess per protocol, obtain 30-min EFM strip for record. Evaluate periodic changes in FHR. Changes in amniotic fluid pressure with rupture, and/or variable decelerations of FHR after rupture, may indicate umbilical cord compression, which decreases oxygen transfer to the fetus.
Monitor FHR and periodic changes if a problem is detected with fetoscopy or external monitor. Note presence of bradycardia/tachycardia or sinusoidal pattern. Any decrease in baseline FHR variability—severe and untreatable variable decelerations, recurrent late decelerations, or persistent bradycardia—reflects fetal decompensation, hypoxia, or acidosis resulting from anaerobic metabolism. Sinusoidal pattern is often associated with fetal anemia or severe fetal hypoxia just prior to fetal demise.
Assess maternal perineum for chlamydial discharges, vaginal warts, or herpetic lesions. STDs can be acquired by the fetus during pregnancy; therefore, cesarean birth may be to indicated, especially for clients with active herpes simplex virus type II.
Assess for visible cord prolapse at vaginal introitus. If present:
  • Calm client/partner, explain the prolapse and its implications.
Helps couple understand the significance of prolapse and promotes cooperation measures.
  • Elevate client’s hips (elevated Sims’ position), or client to assume the knee-chest position, push presenting part off of cord and hold off while summoning help.
Relieves pressure of presenting part on the cord. This help is an emergency situation requiring surgical intervention.
  • Check cord for pulsations; wrap the cord in sterile gauze soaked in saline solution.
Helps keep cord moist and minimize the risk of uterine infection.
Place the client in lateral recumbent position. Increases placental perfusion; prevents supine hypotensive syndrome.
Perform perineal care according to protocol; change underpad when wet. Helps prevent the growth of bacteria; eliminates contaminants that might contribute to maternal chorioamnionitis or fetal sepsis.
Perform Leopold’s maneuvers to determine fetal engagement, position, and presentation. A transverse lie or breech presentation may necessitate cesarean birth. Other abnormalities, such as the face, chin, and posterior presentations, may also require special interventions to prevent prolongation of labor/fetal harm.
Rule out maternal problems or medications that could effect an increase in FHR; Factors such as fever, anxiety, anemia, or use of beta-sympathomimetic drugs can increase maternal and fetal heart rate.
Assist as needed with obtaining fetal scalp blood sample when indicated. Direct measurement of fetal pH is occasionally indicated to determine fetal metabolic reserve and to differentiate fetal respiratory acidosis from metabolic or mixed acidosis. Fetal pH between 7.20 and 7.25 may reflect intermittent umbilical cord compression, necessitating constant monitoring and/or possibly immediate surgical intervention.
Administer oxygen via face mask; Increases maternal oxygen available for fetal uptake.
Turn off oxytocin if infusing, and increase plain IV solution; Promotes greater periods of uterine relaxation and increases uteroplacental blood flow; increases circulating blood volume available for oxygen transfer within the maternal circulation of the placenta.
Prepare for transfer to a level 2 or 3 hospital setting as indicated, if the client is at home, or in a free-standing birth setting. Compromised fetal status or identification of maternal conditions such as STD requires closer birth setting. Observation and may indicate need for therapeutic
interventions such as cesarean birth.
Prepare for surgical intervention, as indicated. CNS damage occurs if fetal hypoxia or acidosis continues for more than 30 min. To avoid fetal compromise, cesarean birth is treatment of choice for prolapsed cord prior to full cervical dilatation.
Risk For Maternal Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

May be related to

  • Fecal contamination
  • Invasive procedures
  • Repeat vaginal examinations
  • Rupture of amniotic membranes

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will demonstrate techniques to minimize risk of infection.
  • Client will be free of signs of infection (e.g., afebrile; amniotic fluid clear, nearly colorless and odorless).
Nursing Interventions Rationale
Monitor vital signs, and white blood cell (WBC) count, as indicated. The incidence of chorioamnionitis (intra-amniotic infection) increases within 4 hours after rupture of membranes, as evidenced by elevations of WBC count and abnormal vital signs.
Perform initial vaginal examination; repeat only during contractile pattern or client’s behavior indicates significant progress of labor. Frequent vaginal examinations can lead to the incidence of ascending tract infections.
Use aseptic technique during a vaginal examination. Helps prevent the growth of bacteria; limits contaminants from reaching the vagina.
Demonstrate good hand washing techniques. Reduces risk of acquiring/spreading infective agents.
Assess vaginal secretions using phenaphthazine (nitrazine paper). Perform microscopic examination for positive ferning. Spontaneous rupture of membranes 1 hr or more before the onset of labor increases the risk of chorioamnionitis during the intrapartal period. Color changes of nitrazine paper from yellow to dark blue indicate presence of alkaline amniotic fluid; ferning indicates rupture of membranes. Note: Excess bloody show, which is more alkaline than vaginal secretions, may cause similar changes on nitrazine paper.
Monitor and describe the character of amniotic fluid. The amniotic fluid during an infection becomes thicker and yellow-tinged and has a foul-smelling odor.
Provide oral and parenteral fluids, as indicated. Maintains hydration and a general sense of well-being.
Encourage perineal care after elimination and prn as indicated; change underpad/ linen when wet. Reduces risk of ascending tract infection.
Carry out perineal preparation, as appropriate. Some providers believe it may facilitate perineal repair at delivery and cleaning of the perineum in the postpartal period, thereby reducing the risk of infection.
Obtain blood cultures if symptoms of sepsis are present. Detects and identifies causative organism(s).
Administer cleansing enema, if indicated. Although not often done, bowel evacuation may promote progression of labor and reduce risk of infection caused by contamination of the sterile field during delivery.
Administer prophylactic antibiotic IV, if indicated. Although antibiotic administration during the intrapartal period is controversial because of antibiotic load for the fetus, it may help protect against development of
chorioamnionitis in the client at risk.
Administer oxytocin infusion, as ordered. If labor does not happen within 24 hr after rupture of membranes, an infection may occur. If client is at 36 weeks’ gestation, onset of labor reduces risk of negative effects on client/fetus.
Risk For Ineffective Coping

Risk For Ineffective Coping: At risk for inability to form a valid appraisal of the stressors, inadequate choices of practiced responses and/or inability to use available resources.

May be related to

  • Inadequate support systems and/or coping methods
  • Personal vulnerability
  • Situational crisis

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will identify individually appropriate behaviors to maintain
    control.
  • Client will verbalize awareness of own coping abilities.
  • Client will use medication appropriately
Nursing Interventions Rationale
Assess uterine contraction/relaxation pattern, fetal status, vaginal bleeding, and cervical dilatation. Rule out possible complications that could be causing or contributing to the discomfort/reduced coping ability.
Note age of client and presence of partner/support person(s). Negative coping may result in increased anxiety, in which case the client may request medication too early in the labor process. Younger clients and those unattended may exhibit more vulnerability to stress or discomfort and have difficulty maintaining control.
Determine client’s cultural background, coping abilities, and verbal and nonverbal responses to pain. Determine previous experiences and antepartal preparation. Each client responds in a unique manner to the stresses of labor and associated discomfort based on these factors. The appearance of appropriate or inappropriate coping may actually be a manifestation
of one’s culture; e.g., Asian or Native American women may be stoic because of fear of shaming self or family, whereas Hispanic and Middle Eastern cultures typically encourage verbal expression of suffering. For this reason, it is important to compare both verbal and nonverbal responses when assessing coping ability.
Establish rapport and accept behavior without judgment. Make verbal contract about expected behaviors of client and nurse Facilitates cooperation; provides an opportunity for the client to leave the experience with positive feelings and enhanced self-esteem. Nurse may need to assist the client in maintaining or regaining control of breathing and relaxation, or set limits if inappropriate (unsafe) behavior occurs
Stay with/provide companion (e.g., doula [woman’s servant]) for a client who is alone. At a time of increased dependence, unmet needs and fear of being abandoned may interfere with the ability to focus on the task at hand. Note: Doula describes an individual who provides emotional, physical, and informational support to the pregnant woman but does not perform clinical tasks. These childbirth companions may be volunteers or may be paid for their services. Research suggests that using
doulas during labor and delivery results in shorter labors, decreased use of forceps and epidural anesthesia, reduced oxytocin use, fewer cesarean births, better infant outcomes, and enhanced client/partner satisfaction.
Reinforcing breathing and relaxation techniques during contractions. Minimizes anxiety and provides a distraction, which may block the perception of pain impulses within the cerebral cortex.
Discuss types of systemic/regional analgesics or anesthetics when available in the birth setting. Helps client make an informed choice about methods to relieve pain and maintain control.
Discuss administration of sedatives such as secobarbital (Seconal), pentobarbital (Nembutal), or hydroxyzine (Vistaril). Occasionally, a barbiturate or ataractic may be administered during early labor to promote sleep, so that the client enters the active phase more relaxed and rested and better able to cope. Note: Because barbiturates can have a prolonged depressant effect on the newborn, Vistaril may be the drug of choice.
Risk For Anxiety

Risk For Anxiety: At risk for experiencing a vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

  • Interpersonal transmission
  • Situational crisis
  • Unmet needs

Possibly evidenced by

  • [not applicable]

Desired Outcomes

  • Client will report anxiety is at a manageable level.
  • Client will use breathing and relaxation techniques proficiently.
  • Client will appear relaxed appropriate to the labor situation.
  • Client will remain normotensive.
Nursing Interventions Rationale
Assess level and causes of anxiety, preparedness for childbirth, cultural background, and role of significant other/partner. Provides baseline information. Anxiety magnifies pain perception, interferes with the use of coping techniques, and stimulates the release of aldosterone, which may increase sodium and water resorption.
Monitor pattern of uterine contraction. A hypertonic or hypotonic contractile pattern may develop if stress persists and causes prolonged catecholamine release.
Monitor BP and pulse as indicated. (If BP is elevated on admission, repeat the procedure in 30 min to obtain true reading once the client is relaxed.) Stress activates the hypothalamic-pituitary-adrenocortical system, which increases retention and resorption of sodium and water and increases excretion of potassium. Sodium and water resorption may contribute to the development of intrapartal toxemia/hypertension. Loss of potassium may contribute to the reduction of myometrial activity.
Orient client to environment, staff, and procedures. Provide information about psychological and physiological changes in labor, as needed. Education may reduce stress and anxiety and promote labor progress.
Promote privacy and respect for modesty; reduce unnecessary exposure. Use draping during a vaginal examination. Modesty is a concern in most cultures. Support person may or may not desire to be present while a client is examined or care provided.
Encourage client to verbalize feelings, concerns, and fears. Stress, fear, and anxiety have a profound effect on the labor process, often prolonging the first phase because of utilization of glucose reserves; causing excess epinephrine release from adrenal stimulation, which inhibits myometrial activity; and increasing norepinephrine levels, which tends to increase uterine activity. Such an imbalance of epinephrine and norepinephrine can create a dysfunctional labor pattern.
Provide primary nurse or continuous intrapartum professional support as indicated. Continuity of care and assessment may decrease stress. Research studies suggest that these clients require less pain medication, which may result in shorter labor.
Be aware of client’s need or preference for female caregivers/support persons. Cultural practices may prohibit the presence of men (even father of the child) during labor and/or delivery.
Determine diversional needs; encourage a variety of activities (e.g., music, books, cards, walking, rocking, showering, massage, painting, aromatherapy). Helps divert attention away from labor, making time pass more quickly. If condition permits, walking usually promotes cervical dilatation, shortens labor, and lowers the incidence of fetal heart rate (FHR) abnormalities.
Demonstrate breathing and relaxation methods. Provide comfort measures. Reduces stressors that might contribute to anxiety; provides coping strategies.
Provide an opportunity for conversation to include choice of infant names, expectations of labor and perceptions/fears during pregnancy. Presents an opportunity for the client to verbalize excitement about herself, the pregnancy, and her baby. Serves as a diversion to help pass time during what is commonly the longest phase of labor.
Prepare for, and/or assist with, discharge from hospital setting, as indicated. During very early latent phase with no apparent progress of labor, the comfort and familiarity of the home environment may decrease anxiety and allow opportunity for a variety of acceptable diversional activities, thereby hastening the labor process.
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