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.

ADVERTISEMENT

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

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

ADVERTISEMENT
  • 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 InterventionsRationale
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 InterventionsRationale
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

ADVERTISEMENT
  • 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 InterventionsRationale
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

ADVERTISEMENT
  • 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 InterventionsRationale
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 InterventionsRationale
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 nurseFacilitates 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

ADVERTISEMENT
  • 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 InterventionsRationale
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.

Labor Stage IB: Active Phase

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. Here are five (5) nursing care plans for the active phase of labor:

  1. Acute Pain
  2. Impaired Urinary Elimination
  3. Risk For Impaired Fetal Gas Exchange
  4. Risk For Maternal Injury
  5. Risk For Ineffective Individual/Couple Coping

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

  • Pressure on adjacent structures
  • Stimulation of both parasympathetic and sympathetic nerve endings
  • Tissue dilation/muscle hypoxia

Possibly evidenced by

ADVERTISEMENT
  • Distraction behaviors (restlessness)
  • Muscle tension
  • Verbalizations

Desired Outcomes

  • Client will identify/use techniques to control pain/discomfort.
  • Client will report discomfort is minimized.
  • Client will appear relaxed/resting between contractions
  • Client will be free of untoward side effects if analgesia/anesthetic agents are administered.
Nursing InterventionsRationale
Assess degree of discomfort through verbal and nonverbal cues; note cultural practices on pain response.Attitudes and reactions to pain are individual and based on past experiences, understanding of physiological changes, and cultural expectations.
Assess nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent.Cervical dilation should be approximately 1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with a fetal descent. Choice and timing of medication is affected by the degree of dilation and contractile pattern.
Time and record the frequency, intensity, and duration of uterine contractile pattern per protocol.Monitor the labor progress and provide information for the client.
Provide information about available analgesics, usual responses/side effects (client and fetal), and duration of analgesic effect in light of current situation.Allows client to make informed choice about means of pain control. Note: If conservative measures are not effective and increasing muscle tension impedes progress of labor, minimal use of medication may enhance relaxation, shorten labor, limit fatigue, and prevent complications.
Assess BP and pulse every 1–2 min after regional injection for first 15 min, then every 10–15 min for remainder of labor. Elevate head approximately 30 degrees, alternate position by turning side to side and use of hip roll.Maternal hypotension, the most common side effect of regional block anesthesia, may interfere with fetal oxygenation. Elevating head prevents block from migrating up and causing respiratory depression. Lateral positioning increases venous return and enhances placental circulation.
Monitor FHR variability.Agents such as bupivacaine (Marcaine) and fentanyl (Sublimaze) reportedly have little effect on FHR variability (but in practice may decrease variability); alterations should be investigated thoroughly.
Using alcohol pad or cotton swab on both sides of abdomen, assess and record level of sensation q 30 min.Increasing loss of sensation following when epidural block indicates migration of anesthesia. Level above T-9 may alter respiratory function while loss of sensation at level of breastbone (appx. 7–6) increases risk of profound hypotension
Monitor FHR electronically, and note decreased variability or bradycardia.Decreased FHR variability is a common side effect of many anesthetics and/or analgesics. These side effects can begin 2–10 min after administration of anesthetic,
and may last for 5–10 min, on occasion.
Assess for warmth, redness of large toe or ball of the foot, and equal distribution of spinal medication if used.Ensures proper placement of the catheter for continuous block and adequate levels of anesthetic agent.
Engage client in conversation to assess sensorium; monitor breathing patterns and pulse.Systemic toxic responses with altered sensorium occur if medication is absorbed into the vascular system. Altered sensorium may also be an early indicator of developing hypoxia. Interference with respiratory functioning occurs if analgesia is too high, paralyzing the diaphragm.
Encourage client to void every 1–2 hr. Palpate above symphysis pubis to determine distension, especially after nerve block.Keeps bladder free of distension, which can increase discomfort, result in possible trauma, interfere with fetal descent, and prolong labor. Epidural or pudendal analgesia may interfere with sensations of fullness.
Provide safety measures; e.g., encourage client to move slowly, keep siderails up after drug administration, and support legs with position changes.Regional block anesthesia produces vasomotor paralysis, so that sudden movement may precipitate hypotension. Analgesics alter perception, and client may fall trying to get out of bed.
Assist with comfort measures (e.g., back/leg rubs, sacral pressure, back rest, mouth care, repositioning, shower/hot tub use, perineal care, and linen changes).Promotes relaxation and hygiene; enhances feeling of well-being. Note: Lateral recumbent position reduces uterine pressure on the vena cava, but periodic repositioning prevents tissue ischemia and/or muscle stiffness, and promotes comfort.
Assist in use of appropriate breathing and/or relaxation techniques and in abdominal effleurage.May block pain impulses within the cerebral cortex through conditioned responses and cutaneous stimulation. Facilitates progression of normal labor
Support client’s decision about the use or nonuse of medication in a nonjudgmental manner. Continue encouragement for efforts and use of relaxation techniques.Helps reduce feelings of failure in the client and/or couple who may have anticipated an unmedicated birth and did not follow through with that plan. Enhances sense of control and may prevent or decrease need for medication.
Obtain fetal scalp sample if bradycardia persists for 30 min or more per electronic monitor.Prolonged fetal bradycardia may indicate need to determine pH for evaluation of hypoxia.
Administer analgesic such as butorphanol tartrate (Stadol) or meperidine hydrochloride (Demerol) by IV or deep intramuscular (IM) during contractions, if indicated.IV route is preferred because it ensures more rapid and equal absorption of analgesic. Medication administered by IM route may require up to 45 min to reach adequate plasma levels, and maternal uptake may be variable, especially if drug is injected into subcutaneous fat instead of muscle. Administering IV drug during uterine contraction decreases amount of medication that immediately reaches the fetus.
Administer oxygen, and increase plain fluid intake if systolic blood pressure drops below 100 mm Hg or falls more than 30% below baseline pressure.Increases circulating fluid volume, placental perfusion, and oxygen available for fetal uptake.
Administer IV bolus of 500–1000 ml of lactated Ringer’s solution just before administration of lumbar epidural block.Increased circulating fluid level helps prevent side effects of hypotension associated with block.
Assist with epidural or caudal block anesthesia using an indwelling catheter.Provides relief once active labor is established; reinforcement through catheter provides sustained
comfort during delivery. Such analgesia does not interfere with uterine activity and/or Ferguson reflex. While it relaxes the cervix and facilitates the labor process, it may alter internal fetal rotation and
diminish client’s ability to bear down when needed.
Administer emergency medications as indicated, e.g., naloxone (Narcan) or ephedrine (Ephedra). Succinylcholine chloride, and assist with intubation, as appropriate.Narcan is used to reverse opiate induced respiratory depression. Adrenalin may be required for hypotensive episodes not responsive to IV fluid bolus. Systemic toxic reaction to epidural anesthetic may alter sensorium or cause convulsions if medication is absorbed into the vascular system.
Assist with complimentary therapies as indicated, e.g., acupressure/ acupuncture.Some clients and healthcare providers may prefer a trial of alternative therapies to mediate pain before pursuing invasive techniques.

Impaired Urinary Elimination

Impaired Urinary Elimination: Disturbance in urinary elimination.

May be related to

  • Altered intake
  • Effects of regional anesthesia
  • Fluid shifts
  • Hormonal changes
  • Mechanical compression of bladder

Possibly evidenced by

  • Changes in amount/frequency of voiding
  • Slowed progression of labor
  • Urine retention
  • Urinary urgency

Desired Outcomes

  • Client will empty bladder appropriately.
  • Client will be free of bladder injury.
Nursing InterventionsRationale
Record and compare intake and output. Note amount, color, concentration, and specific gravity of urine.Output should approximate intake. Increased output may reflect excessive fluid retention prior to the onset of labor and/or effects of bedrest; i.e., increased glomerular filtration rate and decreased
adrenal stimulation. Specific gravity reflects kidney’s ability to concentrate urine and the client’s hydration status. Decreased output may occur with dehydration, hemorrhage, and pregnancy-induced hypertension (PIH).
Assess dryness of skin and mucous membranesEvaluate degree of hydration.
Palpate above the symphysis pubis.Detects presence of urine in bladder and degree of fullness. Incomplete emptying of the bladder may occur because of decreased sensation and tone.
Position client upright, run water from the faucet, pour warm water over the perineum, or have client
blow bubbles through a straw.
Facilitates voiding/enhances emptying of the bladder.
Encourage periodic attempts to void, at least every 1–2 hr.Pressure of the presenting part on the bladder often reduces sensation and interferes with complete emptying. Regional anesthesia (especially in conjunction with IV fluid infusion and use of Stadol) also may contribute to voiding difficulties/bladder distension.
Catheterize as indicated.An overdistended bladder can cause atony, impede fetal descent, or become traumatized by presenting
part of the fetus.

Risk For Impaired Fetal Gas Exchange

Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

ADVERTISEMENT

May be related to

  • Altered oxygen supply/blood flow

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Fetus will display FHR and beat-to-beat variability within normal limit.
  • Fetus will be free of adverse effects of hypoxia during labor.
Nursing InterventionsRationale
Assess FHR changes during a contraction, noting decelerations and accelerations.Detects severity of hypoxia and possible cause. The fetus is vulnerable to potential injury during labor, owing to situations that reduce oxygen levels, such as cord prolapse, prolonged head compression, or uteroplacental insufficiency.
Assess for presence of maternal factors or conditions that compromise uteroplacental circulation (e.g., diabetes, PIH, kidney or cardiac disorders). Note prenatal testing of placental functioning by nonstress test (NST) or contraction stress test (CST).High-risk situations that negatively affect circulation are likely to be manifested in late decelerations and fetal hypoxia.
Note and record color, amount, and odor of amniotic fluid and time of membrane rupture.In a vertex presentation, prolonged hypoxia results in meconium-stained amniotic fluid owing to vagal stimulation, which relaxes the fetal anal sphincter. Hydramnios may be associated with fetal anomalies
and poorly controlled maternal diabetes.
Monitor uterine activity manually or electronically.Development of hypertonicity can compromise uteroplacental circulation and fetal oxygenation.
Monitor fetal descent in birth canal through vaginal examination. In cases of breech presentation, assess FHR more frequently.Prolonged head compression stimulates vagal responses and may result in fetal bradycardia if the rate of descent is not at least 1 cm/hr for primiparas or 1.5 cm/hr for multiparas. Fundal pressure in breech presentation may cause vagal stimulation and head compression.
Monitor FHR every 15–30 min if WNL. Monitor FHR electronically if it is less than 120 bpm or greater than 160 bpm. Periodically compare client’s apical heart rate with FHR.Fetal tachycardia or bradycardia is indicative of possible compromise, which may necessitate intervention. Note: External monitoring device may inadvertently record maternal rather than fetal heart activity.
Check FHR immediately if membranes rupture, and then again 5 min later. Observe maternal perineum for visible cord prolapse.Detects fetal distress due to visible or occult cord prolapse.
Talk to client/couple as care is being given, and provide information about a situation, as appropriate.Provides psychological support and assurance to reduce anxiety related to increased monitoring.
Instruct client to remain on bedrest if presenting part does not fill the pelvis (station 14).Reduces risk of cord prolapse.
Place client in lateral recumbent position.Increases placental perfusion, which may correct the problem if caused by uteroplacental insufficiency.
Turn client from side to side as indicated.Helps take pressure from the presenting part off the umbilical cord, if the cord is being compressed.
Increase plain IV infusion rate.Increases circulating fluid volume and placental perfusion.
Discontinue oxytocin if it is being administered.Strong contractions caused by oxytocin may inhibit or reduce uterine relaxation and lower fetal oxygen levels.
Administer oxygen as indicated.Increases available oxygen for placental transfer.
Prepare for and assist with fetal scalp sampling, repeating as indicated;Prolonged, decreased variability may indicate acidosis. On occasion, determining fetal pH value may be helpful in identifying fetal respiratory acidosis and metabolic reserves.
Prepare for delivery by the most expeditious means or by surgical intervention, if no accompanied by decreased variability.Repetitive late decelerations over a 30-min period means or by surgical intervention, may warrant a cesarean birth to prevent fetal injury and/or death from hypoxia.
If late or persistent variable decelerations occur: Transfer to level 2 or 3 hospital setting as indicated:May require specialized monitoring /interventions.

Risk For Maternal 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

  • Delayed gastric motility
  • Effects of medication
  • Physiological urges

Possibly evidenced by

ADVERTISEMENT
  • [Not applicable]

Desired Outcomes

  • Client will verbalize understanding of individual risks and reasons for specific interventions.
  • Client will follow directions to protect self/fetus from injury.
  • Client will be free of preventable injury/complications.
Nursing InterventionsRationale
Monitor temperature and pulse.Increase temperature and pulse are indicators of developing infection.
Monitor urine for ketones.Urinary ketones indicate metabolic acidosis resulting from a deficiency in glucose metabolism, which may reduce uterine activity and cause myometrial fatigue that prolongs labor.
Monitor uterine activity manually and/or electronically, noting frequency, duration, and intensity of contraction.The uterus is susceptible to possible rupture if a hypertonic contractile pattern develops spontaneously or in response to oxytocin administration. Placental separation and hemorrhage can also occur if contraction persists.
Have client pant or blow out if she feels the premature urge to bear down.Panting during the active phase or the transition phase prevents bearing down too early and can thereby reduce the risk of lacerations or edema of the cervix/birth canal.
Place client in lateral recumbent or semi-upright position.Increases placental perfusion and reduces supine hypotensive syndrome.
Institute bedrest and use of side rails (as labor intensifies) or following administration of medication. Avoid leaving client unattended.Promotes safety should dizziness or precipitous delivery occurs following administration of medication.
Offer client clear liquids or ice chips, as appropriate; avoid solid foods.Delayed gastric motility inhibits digestion during labor, placing the client at risk for aspiration. However, client can benefit from intake of calories in PO fluids to help generate energy for work of labor.
Discontinue or decrease flow rate of oxytocin when used if contraction lasts longer than 90 sec, or if the uterus fails to relax completely between contractions.Helps to prevent hypertonic contractile pattern with resultant decreased placental blood flow and risk of uterine rupture.
Administer IV antibiotics, if indicated.Administration of antibiotics during labor is controversial, but on occasion may protect against infection in cases of prolonged rupture of membranes.

Risk For Ineffective Individual/Couple Coping

Risk For Ineffective Individual 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
  • Personal vulnerability
  • Situational crises

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will identify effective coping behaviors.
  • Client/ will engage in activities to maintain/enhance control.
Nursing InterventionsRationale
Assess the effectiveness of labor partner. Provide role modeling as indicated.The client is influenced by those around her and may respond positively when others remain calm and in control.
Ascertain client’s understanding and expectations of the labor process.The client’s/couple’s coping skills are most challenged during the active and transition phases as contractions become increasingly intense. Lack of knowledge, misconceptions, or unrealistic expectations
Note withdrawn behavior.Adolescents, in particular, may become withdrawn and not express needs to be nurtured. This may also be true for some cultures (such as Native American or Vietnamese) where the woman is encouraged to be stoic/suffer in silence.
Encourage verbalization of feelings.Helps nurse gain insight into individual needs, and assists client/couple to deal with concerns.
Provide positive reinforcement for efforts. Use touch and soothing words of encouragement.Encourages repetition of appropriate behaviors. Enhances individual’s confidence in own ability to cope with or handle labor, while also meeting her needs for dependency.
Reinforce use of positive coping mechanisms and relaxation techniques.Assists client in maintaining or gaining control. Enhances feelings of competence, and fosters self-esteem. The stressors that accompany labor can be threatening to a woman’s self-esteem, especially if she has not coped positively with past experiences and/or successfully accomplished the tasks of pregnancy.
Limit verbalization or instruction during contractions to a single “coach.”Allows the client to focus attention and may enhance the ability to follow directions. Multiple coaches may actually result in decreased concentration, confusion, and loss of control.

Labor Stage IC: Transition Phase

The transition phase occurs when contractions reach their peak with intervals of 2 to 3 minutes and dilatation of 8 to 10 cm. Included care plans in this labor phase include:

ADVERTISEMENT
  1. Acute Pain
  2. Fatigue
  3. Risk For Decreased Cardiac Output
  4. Risk for Fluid Volume Deficit/Excess
  5. Risk for Ineffective Coping

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

  • Emotional and muscular tension
  • Mechanical pressure of presenting part
  • Stimulation of parasympathetic and sympathetic nerves
  • Tissue dilation/stretching and hypoxia

Possibly evidenced by

  • Autonomic responses
  • Distraction behavior (e.g., restlessness)
  • Facial mask of pain
  • Narrowed focus
  • Verbalizations

Desired Outcomes

  • Client will verbalize perceived or actual reduction of pain.
  • Client will rest between contractions.
  • Client will use appropriate techniques to enhance comfort and
    maintain control of labor process.
Nursing InterventionsRationale
Monitor frequency, duration, and intensity of uterine contractions.Detects progress and screens for an abnormal uterine response.
Monitor cervical dilation. Note perineal bulging or vaginal show.Discomfort levels increase as the cervix dilates, fetus descends, and small blood vessels rupture.
Monitor maternal vital signs and FHR variability after drug administration. Note drug’s effectiveness and the physiological response.Narcotics can have a depressant effect on the fetus, particularly when administered 2–3 hr before delivery. Therefore, use may be limited or restricted, or naloxone hydrochloride (Narcan) may be
administered to reverse adverse drug effects.
Assess degree of discomfort through verbal and nonverbal cues. Assess personal and cultural implications of pain.Attitudes toward pain and reactions to pain are individual and based on past experiences, cultural background, and self-concept.
Assess client’s need for physical touch during contractions.Touch may serve as a distraction, provide supportive reassurance, and encouragement, and may aid in maintaining control/reducing pain.
Inform client of onset of contractions, as appropriate.Client may “sleep” and/or encounter partial amnesia between contractions. This can be a problem for some clients, impairing her ability to recognize contractions as they begin and thus have a negative impact on her sense of control. For others, the brief rest may “energize” them for the next contraction.
Evaluate client for tingling of lips, face, hands, or feet. If present, have client breathe into cupped hands or paper bag.Discomfort caused by respiratory alkalosis can be relieved by increasing carbon dioxide levels through the rebreathing process.
Encourage client to void.May enhance labor progress and reduce the risk of trauma to the bladder.
Assist client and partner with changing to more rapid breathing;
(i.e., pant-blow).
Redirects and focuses attention; helps reduce the perception of pain within the cerebral cortex.
Assist client with comfort measures, including sacral/back rubs, positioning, mouth care, perineal care, change of pads/linens, hot cold compresses, sponge baths to face and neck, or bath/whirlpool.Such measures promote hygiene, relaxation, and physical comfort. Note: Individual needs or preference can change quickly during transition; i.e., client may request sacral rub, then the next moment demand everyone move away from her.
Offer encouragement, provide information about labor progress and provide positive reinforcement for client’s/couple’s efforts.Provides emotional support, which can reduce fear, lower anxiety levels, and help minimize pain.
Provide for a quiet environment that is adequately ventilated, dimly lit, and free of unnecessary personnel. Carry out nursing procedures between contractions whenever possible.Nondistracting environment provides optimal opportunity for rest and relaxation between contractions.
Provide break for the partner as appropriate.Support person may be reluctant to leave, but does need a break for renewal of energy and relaxation, which can enhance the ability to help partner.
Administer analgesic as ordered. Assist anesthesiologist if epidural or caudal anesthetic is to be used.Judicious use of a pharmacologic agent assists the client in coping with contractions and may facilitate labor.

Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

May be related to

ADVERTISEMENT
  • Changes in energy production
  • Decreased caloric intake (restricted/nothing by mouth [NPO] status)
  • Discomfort/pain
  • Increased energy requirements
  • Overwhelming psychological emotional demands

Possibly evidenced by

  • Altered coping ability
  • Emotional lability or irritability
  • Impaired ability to concentrate
  • Lethargy
  • Verbalizations

Desired Outcomes

  • Client will use techniques to conserve energy between contractions.
  • Client will report sense of control.
  • Client will appear moderately relaxed.
Nursing InterventionsRationale
Assess degree of fatigue.Fatigue may interfere with the client’s physical and psychological abilities to maximally participate in
labor process and to master and carry out self-care and infant care after delivery.
Monitor energy level of partner. Assume supportive responsibilities as needed.Allows partner to have a brief break and refresh self enhancing ability to maintain focus and support client.
Encourage client to close eyes, extend legs, and relax between contractions.A comfortable position facilitates muscle relaxation.
Keep client informed of the progress of labor.Provides reinforcement for desired behaviors.
Plan care to limit interruptionsMaximizes opportunities for rest.
Provide dimly lit, nondistracting environment.Reducing stressors helps promote rest.
Provide comfort measures.Promotes relaxation, enhances the sense of control, and may strengthen coping.
Provide encouragement for efforts client makes.Realizing that labor is progressing toward goal may help client maintain maximal effort.
Provide calorie-rich fluids, e.g., fruit juices, broths.Calories are necessary to maintain energy level to help with work of labor.
Monitor urine for ketones.Urinary ketones indicate metabolic acidosis resulting from a deficiency in glucose metabolism, which may
reduce uterine activity and cause myometrial fatigue, which can prolong labor.
Administer an analgesic as ordered.May help the client cope with contractions and facilitate relaxation between contractions. Use with
caution, because analgesics may cause fetal depression.

Risk For Decreased Cardiac Output

Risk for Decreased Cardiac Output: At risk for inadequate blood pumped by the heart to meet metabolic demands of the body.

May be related to

  • Changes in systemic vascular resistance
  • Decreased venous return
  • Hypovolemia

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

ADVERTISEMENT
  • Client will display FHR within normal limits.
  • Client will maintain vital signs appropriate for stage of labor, free of pathological edema and excessive albuminuria.
Nursing InterventionsRationale
Note presence and extent of edema. Monitor FHR during and between contractions.Excess fluid retention places the client at risk for circulatory changes, with possible uteroplacental insufficiency manifested as late decelerations.
Assess BP and pulse between contractions, as indicated. Note abnormal readings.During contractions, blood pressure usually increases 5–10 mm Hg, except during transition phase, when the blood pressure remains elevated. Increased resistance to cardiac output can occur if
intrapartal hypertension develops, further elevating blood pressure. Finally, cardiac output/blood pressure may be negatively affected by uterine pressure on the inferior vena cava, reducing venous return, or by a decrease in circulating blood volume caused by dehydration or occasionally hemorrhage
Accurately record parenteral/oral intake, and output. Measure specific gravity if kidney function is decreased.Bedrest promotes increases in cardiac and urine output with a corresponding decrease in urine specific gravity. An elevation of specific gravity and/or reduction in urine output suggests dehydration or possibly developing hypertension.
Test urine for albumin. Report levels above 12.Indicates glomerular spasms, which reduce the reabsorption of albumin. Levels greater than 12 indicate kidney involvement; levels 11 or lower may be due to muscle catabolism occurring with activity
(contraction) or to increased metabolism in the intrapartal period.
Note any hypertensive responses to oxytocin administration.Oxytocin increases cardiac circulating volume (sodium and water absorption) and cardiac output, and may also increase BP and pulse.
Monitor BP and pulse per protocol or continually if hypotension is severe after administration of analgesia.Analgesics relax smooth muscles within the blood vessels, reducing resistance to cardiac output and lowering BP and pulse.

Risk for Fluid Volume Deficit/Excess

Risk for Fluid Volume Deficit/Excess: At risk for decreased intravascular, interstitial, and intracellular fluid; At risk for increased isotonic fluid retention.

May be related to

  • Excess fluid loss/hemorrhage
  • Excess fluid retention
  • Rapid parenteral fluid administration
  • Reduced intake

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will be free of thirst.
  • Client will maintain vital signs and urine output/concentration within normal limit.
Nursing InterventionsRationale
Assess amount of vaginal bloody show; observe for excess blood loss.Bloody show increases as the presenting part moves down in the birth canal; excess bleeding may indicate placental separation.
Assess amount and location of edema, Hct level, changes in behavior, and reflex irritabilityIntrapartal hypertension can develop, causing fluid shifts from the intravascular spaces and increasing Hct levels. Cerebral edema/ vasospasms/hypoxia can cause increased reflex irritability and/
or behavior changes
Record intake and output. Note concentration of urine. Measure urine specific gravity, as indicated.Bedrest results in decreased adrenal cortex activity, increased glomerular filtration rate, and increased urine output. When fluid volume is decreased, aldosterone acts to reabsorb water and sodium from the kidney tubules, reducing urine output.
Take temperature every 4 hr, as indicated (every 2 hr after membranes rupture). Assess skin and mouth for dryness.Dehydration can result in elevated body temperature, dry skin, and reduced production of saliva.
Monitor BP and pulse every 15 min and more frequently during oxytocin infusion.Increased BP and pulse may indicate fluid retention; decreased BP and increased pulse may be late signs of fluid volume loss or dehydration.
Measure amount and character of emesis.Nausea and vomiting contribute to fluid losses. With reduced gastric motility, food may remain in the stomach for up to 12 hr after ingestion and pose a risk for aspiration.
Assess client’s anxiety level.Anxiety may alter BP and pulse, affecting assessment findings.
Position client on side, as appropriate.Increases venous return by taking pressure of the gravid uterus off the inferior vena cava and descending aorta.
Administer and monitor IV fluid infusion, as indicated.Maintains hydration by replacing fluid losses. Rate may be adjusted to meet individual needs, but too rapid administration can lead to fluid overload, especially in a compromised client.

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

ADVERTISEMENT
  • Inadequate/exhausted support system
  • Personal vulnerability
  • Sense of “work overload”

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will identify effective coping behaviors.
  • Client will engage in activities to maintain/enhance control.
Nursing InterventionsRationale
Inform client/partner of initiation of each contraction.Allows client to rest/relax and still maintain control of breathing pattern as contraction begins.
Acknowledge reality of both client’s and partner’s irritable feelings.The increase in intensity and frequency of contractions and the premature urge to push may add to sense of loss of control. The client’s hostility may be manifested as anger at the nurse or support person. In addition, general fatigue of both client and partner further impair their ability to cope.
Reinforce information that labor is progressing; encourage client to cope with one contraction at a time.Provides reassurance that baby will soon be born. A natural response in the transition phase is for the client to feel that she has had enough and wants to “quit and go home.”
Ensure that client, under direction of partner, initiates breathing patterns. Breathe with client if necessary.A more complex breathing pattern initiated at the beginning of a contraction is necessary as a distraction and helps reduce pain perception within the cerebral cortex. Client may have difficulty understanding directions because of inward focus.
Encourage client and partner to verbalize doubts about ability to continue and fear of being left alone (even if this fear is unfounded).When these thoughts are expressed, they can be acknowledged and the client/partner can realize that they are coping to the best of their ability in the situation and can move forward with support.
Provide support to partner.May feel helpless and require more support as the partner becomes less able to relieve client’s pain.

Labor Stage II: Expulsion

The second stage starts at full cervical dilatation until the birth of the infant. The woman may experience an uncontrollable urge to push and bear down with every contraction. Crowning or the appearance of the fetal head on the vaginal opening occurs. Nursing care plans for the second stage of labor: expulsion includes the following:

  1. Acute Pain
  2. Altered Cardiac Output
  3. Risk For Impaired Fetal Gas Exchange
  4. Risk For Fluid Volume Deficit
  5. Risk For Fetal Injury
  6. Risk For Maternal Infection
  7. Risk For Impaired Skin Integrity
  8. Risk For Ineffective Individual Coping
  9. Risk For Fatigue

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

  • Intensified contractile pattern
  • Mechanical pressure of presenting part
  • Muscle hypoxia
  • Nerve compression
  • Tissue dilation/stretching

Possibly evidenced by

ADVERTISEMENT
  • Autonomic responses
  • Distraction behavior (e.g., restlessness)
  • Facial mask of pain
  • Narrowed focus
  • Verbalizations

Desired Outcomes

  • Client will verbalize reduction of pain.
  • Client will use appropriate techniques to maintain control.
  • Client will rest between contractions.
Nursing InterventionsRationale
Monitor and record uterine activity with each contraction.Provides information/legal documentation about continued progress; helps identify abnormal contractile pattern, allowing prompt assessment and intervention.
Identify degree of discomfort and its sources.Clarifies needs; allows for appropriate intervention.
Observe for perineal and rectal bulging, opening of vaginal introitus, and changes in fetal station.Anal eversion and perineal bulging occur as the fetal vertex descends, indicating need to prepare for delivery.
Review information with client/couple about type Review information with client/couple about type stage specific to the delivery setting (e.g., local, pudendal block, lumbar epidural reinforcement) or use of transcutaneous electrical nerve stimulation (TENS), acupressure or acupuncture. Review advantages and/or disadvantages, as appropriate.Although client is under the stress of labor and discomfort levels may interfere with normal decision-making skills, she still needs to be in control and make her own informed decisions regarding anesthesia.
Monitor maternal BP and pulse, and FHR. Observe unusual adverse reactions to medication, such as antigen-antibody reactions, respiratory paralysis, or spinal blockage. Note adverse reactions such as nausea/vomiting, urine retention, delayed respiratory depression, and pruritus of face, eyes, or mouth.Maternal hypotension caused by decreased peripheral resistance as vascular tree dilates is the main adverse reaction to subarachnoid or peridural block. Fetal hypoxia or bradycardia is possible, owing to decreased circulation within the maternal portion of the placenta. Other adverse reactions may occur after administration of spinal or peridural anesthetic especially when morphine is used.
Provide information and support related to progress of labor.Keeps couple informed of proximity of delivery; reinforces that efforts are worthwhile and the “end is in
sight.”
Provide comfort measures, such as mouth care; perineal care/massage; clean, dry linen and underpads; cool environment (68°F–72°F [20°C–22.1°C]), cool, moist cloths to face and neck; or hot compresses to     perineum, abdomen, or back, as desired.Promotes psychological and physical comfort, allowing client to focus on labor, and may reduce the need for analgesia or anesthesia.
Encourage client/couple to manage efforts to bear down with spontaneous, rather than sustained, pushing during contractions. Stress importance of using abdominal muscles and relaxing pelvic floor.Anesthetics may interfere with client’s ability to feel sensations associated with contractions, resulting in ineffective bearing down. Spontaneous, rather than sustained, efforts to bear down avoid negative effects of Valsalva’s maneuver associated with reduced maternal and fetal oxygen
levels. Relaxation of the pelvic floor reduces resistance to pushing efforts, maximizing effort to expel the fetus.
Encourage client to relax all muscles and rest between contractions.Complete relaxation between contractions promotes rest and helps limit muscle strain/fatigue.
Assist client in assuming optimal position for bearing down; (e.g., squatting or lateral recumbent semi-Fowler’s position (elevated 30–60 degrees). Assess effectiveness of efforts to bear down.Proper positioning with relaxation of perineal tissue optimizes bearing-down efforts, facilitates labor progress, reduces discomfort, and reduces need for forceps application.
Assist with reinforcement of medication via indwelling lumbar epidural catheter when caput is visible. Monitor vital signs and adverse responses.Reduces discomfort associated with episiotomy, forceps application, and fetal expulsion. Adverse reactions include maternal hypotension, muscle twitching/ convulsions, loss of consciousness, reduced FHR, and beat-to-beat variability.
Assess bladder fullness. Catheterize between contractions if distension is noted and client is unable to void.Promotes comfort, facilitates fetal descent, and reduces risk of bladder trauma caused by presenting part of fetus.
Position client in dorsal lithotomy position and assist as necessary with administration of pudendal anesthetic.Anesthetizes lower two-thirds of vagina and perineum during delivery and for episiotomy repair. May interfere with efforts to bear down but has no effect on maternal BP, FHR, or FHR variability.
Assist as needed with administration of local anesthetic just before episiotomy, if done.Anesthetizes perineum tissue for incision/repair purposes.
Lumbar, Epidural, or Low Spinal Anesthesia
Administer IV fluid bolus of 500–1000 ml lactated Ringer’s as indicated, before administration of agent.Increases maternal circulating fluid as a means of preventing adverse reactions of anesthetic such as maternal hypotension, fetal hypoxia, and fetal bradycardia.
Monitor level of block per protocol.Migration of decreased sensation from belly button (dermatome T-10) to tip of breastbone (appx. T-6) increases risk of profound hypotension. Necessitates evaluation of drug concentration /infusion rate by anesthesia personnel.
Assist with administration of opiates (e.g., fentanyl [Sublimaze], morphine) into epidural space via indwelling catheter. Have ephedrine, 10 mg, or naloxone (Narcan), 0.4 mg, available as an antidote, depending on agent used.Intraspinal narcotic, acting on opiate receptors within the spinal column, blocks pain for as long as 11 hr. Literature reveals mixed results regarding use of morphine via indwelling catheter in stage II labor (may be more effective in the active phase of stage I labor). Note: Because of the potential for life-threatening complications, initial and subsequent bolus dosing should be done by anesthesia service or
providers specifically trained and certified.
Position client in sitting or lateral recumbent position for insertion of drug/placement of catheter for continuous infusion. Have client flex head sharply on chest/arch back during intrathecal administration.Proper alignment of vertebrae maximizes space for needle /catheter placement.
Turn client side to side periodically during continuous infusions.Promotes even distribution of drug to prevent “one-sided” or unilateral block.
Administer diphenhydramine (Benadryl), promethazine hydrochloride (Phenergan), or metoclopramide hydrochloride (Reglan) when indicated.May relieve pruritus, a side effect of morphine administration.
Administer oxygen and increase plain IV fluid. If hypotension occurs, displace uterus to the left and elevate legs.Enhances venous return and circulating blood volume, increasing placental perfusion and oxygenation.
Assist with administration of intrathecal subarachnoid anesthetic. Identify beginning and ending of contractions. Administer anesthetic between contractions when fetal head is on the perineum.Anesthetizes nerves at lumbar spaces L3–L4 and L4–L5. Administration of medication during a contraction may cause the level of the anesthetic to rise too high, anesthetizing the diaphragm.
Transcutaneous Electrical Nerve Stimulation
Encourage and assist client/couple with operation of control knobs on battery-operated device.Ability to turn on mild electrical currents during a contraction promotes a feeling of control for the
client.
Apply two pairs of electrodes on either side of thoracic and sacral vertebrae.Electrical stimulation of pain receptors (by TENS units) within the skin may block pain sensations by causing release of endorphins. Has no adverse effect on client or fetus and may reduce need for analgesia or anesthesia.
Complementary Therapy
Assist with acupressure /acupuncture, moxibustion.May be used to stimulate/regulate contractions to restore balance to labor and reduce perception of pain.
General Anesthesia
Assist with monitoring BP, pulse, respirations, FHR, and variability. Watch for vomiting reaction.General anesthesia has a depressant effect on the client and fetus, and poses a risk of maternal aspiration.
Assist with general anesthesia (inhalation or IV administration), as indicated.Because of maternal and fetal side effects, general anesthesia should only be used in obstetric emergencies, such as hemorrhage, internal version with a second twin, or delivery of the aftercoming
head in a breech presentation.

Altered Cardiac Output

May be related to

  • Changes in systemic vascular resistance
  • Fluctuation in venous return

Possibly evidenced by

  • Changes in pulse rate
  • Decreased urine output
  • Fetal bradycardia
  • Variations in blood pressure

Desired Outcomes

  • Client will maintain vital signs appropriate for stage of labor.
  • Client will display FHR and variability within normal limit.
  • Client will use appropriate techniques to sustain/enhance vascular return.
Nursing InterventionsRationale
Monitor FHR after every contraction or bearing-down effort.Detects fetal bradycardia and hypoxia associated with reduction in maternal circulation and reduced placental perfusion caused by anesthesia, Valsalva’s maneuver, or incorrect positioning.
Monitor BP and pulse frequently (every 5–15 min). Note amount and concentration of urine output; test for albuminuria.Increases in cardiac output of 30%–50% occur in the expulsion stage, peaking at the acme of uterine contractions and slowly returning to a pre-contractile state as the contraction diminishes or ceases. Intrapartal toxemia due to stress, excess sodium and fluid retention, or oxytocin administration may be manifested by increased BP, decreased urine output, and increased concentration of urine.
Monitor BP and pulse immediately after administration of anesthesia, and repeat until client is stable.Hypotension is the most common adverse reaction to lumbar epidural or subarachnoid (low spinal) block as vascular dilation slows venous return and reduces cardiac output.
Encourage client to inhale/exhale during bearing-down efforts, using an open glottis technique and holding breath no longer than 5 sec at a time. Instruct client to push only when she feels the urge to do so. Avoid forced pushing.Repeated, prolonged Valsalva’s maneuvers (occurring when the client holds her breath while pushing against a closed glottis) eventually interrupt venous return and reduce cardiac output, BP, and pulse pressure. Avoiding Valsalva’s maneuver minimizes fall of maternal PO2 and rise in PCO2 levels, which would have a negative impact on fetus.
Encourage client/couple to select laboring position that optimizes circulation, such as the lateral recumbent position, Fowler’s position, or squatting.Upright and lateral recumbent positions prevent occlusion of the inferior vena cava and obstruction of the aorta, sustaining venous return and preventing hypotension.
Regulate IV infusion as indicated; monitor oxytocin administration, and decrease rate if necessary.IV line (or saline lock access) should be available in case the need to correct hypotension or administer emergency drugs arises. Excess fluid retention (a possible adverse reaction of oxytocin) may
contribute to development of intrapartal toxemia.

Risk For Impaired Fetal Gas Exchange

Risk For Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

May be related to

ADVERTISEMENT
  • Maternal hyperventilation
  • Mechanical compression of head/cord
  • Prolonged labor
  • Reduced placental perfusion

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will be free of variable or late decelerations with FHR within normal limit.
  • Client will use positions promoting venous return/placental circulation.
Nursing InterventionsRationale
Assess client’s breathing pattern. Note reports of tingling sensation of face or hands, dizziness, or carpopedal spasms.Identifies ineffective (inappropriate) respiratory pattern. Initially, hyperventilation results in respiratory alkalosis and an increase in serum pH; toward the end of labor, the pH falls and acidosis develops owing to lactic acid buildup from myometrial activity
Assess FHR, with fetoscope or fetal monitor, during and after each contraction or pushing effort.Early decelerations due to vagal stimulation from head compression should return to baseline patterns between contractions.
Determine fetal station, presentation, and position. If fetus is in occiput posterior position, place client on her side.During stage II labor, the fetus is most vulnerable to bradycardia and hypoxia, which are associated with vagal stimulation during head compression. Malpresentations such as face, mentum (chin), orbrow may prolong labor and increase risk of hypoxia and  the likelihood of the need for a cesarean birth, whereas posterior position increases duration of stage II labor. Placing client in lateral recumbent position
facilitates fetal rotation from occiput posterior (OP) position to occiput anterior (OA) position.
Note short- and long-term FHR variabilityAverage beat-to-beat changes should range from 6 to 10 bpm, indicating integrity of fetal CNS.
Monitor client for fruity breath odor.Suggests acidosis associated with hyperventilation. As shifts in acid-base levels occur, fetal status can be
compromised with resultant acidosis and hypoxia.
Monitor periodic changes in FHR for severe, moderate, or prolonged decelerations. Note presence of variable or late decelerations.Variable decelerations indicate hypoxia due to possible cord entrapment or to nuchal or short cord. Late decelerations indicate uteroplacental insufficiency, which should not be allowed to persist for more than 30 min. Late decelerations are more likely to occur in clients with pregnancy-induced hypertension, diabetes, and kidney problems; placental aging; or following maternal anesthesia.
Position client in lateral recumbent or upright position, or turn side to side as indicated.Increases placental perfusion, prevents supine hypotensive syndrome, and takes pressure from presenting part off cord, enhancing fetal oxygenation and improving FHR patterns.
Avoid placing client in dorsal recumbent position.Contributes to fetal hypoxia and acidosis; reduces baseline variability and placental circulation.
Assist partner in helping with verbal coaching of respirations. Remind client to focus on an object/mental picture.Provides opportunity for couple to work together to maintain/regain control of situation and maintain state of relaxation during contractions.
Encourage client/couple to inhale and exhale every 10–20 sec during bearing-down efforts. Monitor response to pushing efforts.Helps maintain adequate oxygen levels. Exhaling while pushing minimizes physiological effects of Valsalva’s maneuver, which can decrease maternal heart rate and PO2, and increases PCO2, potentially resulting in placental and fetal hypoxia and acidosis.
Have client breathe into cupped hands or small paper bag, as indicated.Increases carbon dioxide levels and corrects respiratory alkalosis caused by hyperventilation.
Monitor FHR electronically with internal lead.Electronic monitoring allows continued, accurate assessment. Direct scalp electrodes accurately detect abnormal fetal responses and reduction in beat-to-beat variability
If severe bradycardia, late decelerations, or prolonged variable decelerations appear:
Place client in lateral recumbent position; increase plain IV fluid;Increases maternal circulating blood volume and placental perfusion.
Administer oxygen to client;Increases circulating oxygen available for fetal uptake. During this stage of labor, enhanced metabolic processes increase oxygen consumption by twice the normal level.
Assist as needed with intermittent fetal scalp sampling, if done;Determines trends in fetal acid-base status, and sampling, if done; presence of fetal acidosis. The pH of fetal blood falls rapidly during stage II labor, and prolonged hypoxia may result in anaerobic metabolism with buildup of lactic acid.
Prepare for surgical intervention if spontaneous vaginal or low forceps delivery is not immediately possible after approximately 30 min, and fetal pH is 7.20 or less.The fastest means of delivery must be implemented when the fetus has severe or irreversible hypoxia or acidosis.

Risk For Fluid Volume Deficit

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

May be related to

  • Active loss
  • Fluid shifts
  • Reduced intake

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

ADVERTISEMENT
  • Client will be free of thirst.
  • Client will maintain vital signs within normal limit, adequate urine output, moist mucous membranes.
Nursing InterventionsRationale
Assess FHR and baseline; note periodic changes and variability (if internal scalp electrode is used).Initially, FHR may become tachycardic with maternal dehydration and fluid losses. Prolonged maternal acidosis may result in fetal acidosis and hypoxia.
Monitor temperature, as indicated.Elevated temperature and pulse may indicate dehydration or, on occasion, infection.
Measure intake/output and urine-specific gravity. Assess skin turgor and production of mucus. Note albuminuria.In presence of dehydration, urine output decreases, specific gravity increases, and skin turgor and mucus production decrease. Proteinuria may be caused by dehydration or exhaustion, or may indicate preeclampsia.
Place client in upright or lateral recumbent position.Optimizes placental perfusion.
Reduce excess clothing, cool body with wet cloths, and maintain cool environment. Protect from chilling.Cools the body through evaporation; may reduce diaphoretic losses. Muscle tremors associated with chilling increase body temperature and general discomfort.
Administer fluids orally (sips of juices/broth or ice chips), as allowed, or parenterally.Replaces fluid losses. Solutions such as lactated Ringer’s administered intravenously help correct or
prevent electrolyte imbalances.

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

  • Malpresentations/positions
  • Precipitous delivery, or cephalopelvic disproportion (CPD)

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Fetus will be free of preventable trauma or other complications.
Nursing InterventionsRationale
Assess amount of amniotic fluid expelled at the time membranes rupture and then during contractions.Hydramnios is associated with fetal disorders such as anencephaly, disorders of the gastrointestinal tract, kidney dysfunction, and maternal diabetes. Oligohydramnios is associated with post maturity and intrauterine growth retardation secondary to placental insufficiency.
Note color of amniotic fluid.Meconium-stained amniotic fluid, greenish in color, may indicate fetal distress caused by hypoxia in a vertex presentation or to compression of fetal intestinal tract in breech presentation.
Assess fetal position, station, and presentation.Malpresentations such as face, mentum (chin), or brow may prolong labor and increase the likelihood that cesarean delivery will be necessary, because lack of neck flexion increases the diameter of the fetal head as it passes through the pelvic outlet. Breech presentation usually necessitates surgical intervention, owing to the high risk of spinal cord injuries resulting from hyperextension of the fetal head during vaginal delivery.
Monitor labor progress and rate of fetal descent.Precipitous labor increases the risk of fetal head trauma because skull bones do not have adequate time to adjust to dimensions of the birth canal.
Maintain record of events.Accurate documentation provides information about neonate/client status and postpartal needs.
Remain with client and monitor pushing efforts as head emerges. Instruct client to pant during process.Ensures that trained personnel are present and reduces possibility of trauma to fetal vertex; allows
gradual accommodation of skull bones to birth canal and overriding of sutures.
Obtain emergency delivery kit if delivery not usually done in labor room.Assures the availability of needed equipment and supplies in the event that labor progresses too rapidly for a planned delivery. When precipitous delivery is imminent, transfer to the delivery room is postponed until the neonate is delivered and the cord is clamped and cut.
Transfer to delivery room, as appropriate, when vertex is visible at introitus in nullipara, or when multipara is 8 cm dilated.If delivery is to occur in area separate from the labor setting, transfer at this time ensures that infant is born where emergency medications and equipment are available, if needed.
Assist with vertex rotation from OP to OA (Scanzoni maneuver).Manual or vacuum rotation from OP to OA is possible (if no CPD exists). Double application of forceps to vertex may increase risk of fetal injury, yet OA position is preferred position for delivery.
Assist with vaginal delivery when fetus is in posterior position.Posterior position increases possibility of fetal trauma caused by neck injuries.
Prepare for surgical intervention, if indicated.May be necessary in cases of CPD, persistent OP position, or deep transverse arrest of the head with prolonged stage II labor or fetal distress, or with breech or shoulder presentation. Fetus with anencephaly may not dilate maternal tissues effectively and may therefore require surgical intervention.

Risk For Maternal Infection

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

May be related to

ADVERTISEMENT
  • Exposure to pathogens
  • Prolonged labor, or rupture of membranes
  • Repeated invasive procedures
  • Traumatized tissues

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will be free of infection.
Nursing InterventionsRationale
Monitor temperature, pulse, and WBC count, as indicated.Increased temperature or pulse greater than 100 bpm may indicate infection. Normal protective leukocytosis with WBC count as high as 25,000/mm3 must be differentiated from elevated WBC count caused by infection.
Perform perineal care per protocol, using medical asepsis. Remove fecal contaminants expelled during pushing; change linens /underpad during pushing; change linens/underpad as needed.Helps promote cleanliness; prevents development of an ascending uterine infection and possible sepsis.
Perform vaginal examination only when absolutely necessary, using aseptic technique.Repeated vaginal examination increases the risk of endometrial infections.
Note date and time of rupture of membranes.Within 4 hr after rupture of membranes, the client and fetus are at increased risk for ascending tract infections and possible sepsis.
Use surgical asepsis in preparing equipment. Clean perineum with sterile water and soap or surgical disinfectant just prior to delivery.Reduces risk of contamination.
Assist partner with dressing in scrub apparel (if indicated), washing hands, and so forth, as required by setting. Reduce number of persons present at delivery, depending on client’s/care provider’s wishes.Reduces risk of infection resulting from cross-contamination.
Administer antibiotics, as indicated.Used only occasionally; prophylactic antibiotics are controversial and must be used with caution because they may stimulate overgrowth of resistant organisms.
Provide aseptic conditions for delivery.Helps prevent postpartal infection and endometritis.

Risk For Impaired Skin Integrity

Risk for Impaired Skin Integrity: At risk for altered epidermis and/or dermis.

May be related to

  • Adolescence
  • Forceps application
  • Hypertonic contractile pattern
  • Large fetus
  • Precipitous labor

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

ADVERTISEMENT
  • Client will relax perineal musculature during bearing-down efforts.
  • Client will be free of preventable lacerations.
Nursing InterventionsRationale
Help client as needed in assuming position of choice/transfer to delivery table between contractions. Monitor safety, and support legs, especially if epidural (or caudal) catheter is in place.Reduces risk of injury, especially if client is unable to assist with transfer.
Assist client/couple with proper positioning, breathing, and efforts to relax. Ensure that client relaxes the perineal floor while using abdominal muscles in pushing.Helps promote gradual stretching of perineal and vaginal tissue. If maternal tissue within the birth canal or perineum resists gradual stretching as the presenting part of the fetus descends, trauma or lacerations of the cervix, vagina, perineum, uretha, and clitoris are possible.
Place client in left lateral Sims’ position for delivery, if desired/comfortable.Reduces perineal tension, promotes gradual stretching, and reduces need for episiotomy.
Offer use of birthing bed in upright position. Encourage squatting, Fowler’s position, or standing while pushing, if these positions are not contraindicated.Upright positions reduce duration of labor, enhance forces of gravity, reduce need for episiotomy, and maximize uterine contractility.
Lift legs simultaneously, if leg supports/stirrups are used, and place feet and legs properly in low position, supporting feet.Reduces muscle strain; prevents pressure on calf and popliteal space that could contribute to development of postpartal thrombophlebitis.
Assist as needed with hand maneuvers; apply pressure to fetal chin through maternal perineum while exerting pressure on the occiput with the other hand (modified Ritgen maneuver).Allows slow delivery once the fetal head has distended the perineum 5 cm; reduces trauma to maternal tissues.
Assess for bladder fullness; catheterize prior to delivery, as appropriate.Reduces bladder trauma from presenting part.
Assist with midline, or mediolateral episiotomy, if necessaryAlthough controversial, episiotomy may prevent tearing of perineum in cases of a large infant, rapid labor, and insufficient perineal relaxation. It may shorten stage I of labor, especially when forceps are used. Note: Research suggests use of midline episiotomy is associated with a fourfold increase of major perineal trauma, including extensive tearing, whereas mediolateral episiotomy reduces likelihood
of severe perineal lacerations, the surgical repair is more difficult, and problems with healing may occur.
Maintain accurate delivery records of location of episiotomy and/or lacerations. Record type and timing of forceps if used.Ensures proper documentation of events occurring during delivery process; identifies specific problems affecting postpartal recovery; e.g., maternal tissue trauma is increased with forceps application, which
may result in possible lacerations or extension of episiotomy, increased level of postpartal discomfort.

Risk For Ineffective Individual 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 system
  • Personal vulnerability
  • Situational crisis
  • Unrealistic perceptions/expectations

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will verbalize feelings congruent with behavior.
  • Client will demonstrate effective coping skills by the use of self directed techniques for bearing-down efforts.
Nursing InterventionsRationale
Determine client’s/couple’s perception of behavioral response to labor. Encourage verbalization of feelings. Note cultural influences.Helps nurse gain insight into couple’s feelings and identify needs. Depending on ethnic background and childbirth preparation, involvement in the birth process can be ego-enhancing for the father or support person who desires active participation. Conversely, negative feelings or disappointment about performance arise if active involvement is not allowed or supported.
Monitor response to contraction. Provide gentle but firm instructions for efforts to bear down when the urge to push arises.Active involvement provides positive means of coping and assists in descent of the fetus. Negative coping can result in prolonged labor and increases the likelihood that anesthesia and/or forceps or
vacuum may be needed for the delivery
Discuss normal emotional and physical changes as well as variation in emotional responses.Understanding helps client cope with situation and cooperate with pushing efforts. Emotional responses in this stage of labor vary from excitement at being able to participate more actively/control the forces of labor through pushing efforts, to embarrassment, irritability, or fear resulting from loss of control. This may be manifested by a lack of cooperation or ineffective pushing during contractions.
Discuss options for pain control/reduction.Client may require anesthesia or analgesia to promote relaxation and facilitate coping.
Provide comfort measures (e.g., applying cool cloths to face, neck, and extremities; eliminating excess clothing; positioning properly; providing perineal care; and providing a quiet, nonstimulating
environment).
Reduction of discomforts and distractions allows couple to focus on labor efforts.
Point out tense or furrowed brow, clenched fists, and so forth, and suggest that partner touch tense areas.Helps client focus on tension reduction, and allows couple to work together to regain control of situation.
Encourage client to rest between contractions with eyes closed.Conserves strength needed for pushing, thereby facilitating the coping process.
Provide positive reinforcement; inform couple of labor progress, appearance of fetal vertex, and that their efforts are helpful. Provide mirror for visualization of emerging infant or have client reach down
and touch baby’s head as she pushes.
Helps couple to feel positive about their participation and rewarded for their cooperation. Encourages continuation of efforts.
Facilitate partner’s participation in meeting client’s needs regarding comfort, pushing, and emotional support.Active participation fosters positive sense of self and may actually strengthen and enhance couple’s future relationship and their relationship to the child.
Support client/couple in their decision to use analgesia or anesthesia.The client’s perception of her performance may be influenced by her own goals for coping with pain. If she has planned an unmedicated birth, she may feel a sense of failure if she resorts to anesthesia as fatigue and pain become intense. The client may be concerned about the support person’s sense of failure as a coach if she resorts to medication. The nurse can
reduce these feelings of “failure” by accepting the decision in a nonjudgmental manner.

Risk For Fatigue

Risk For Fatigue: At risk for an overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

May be related to

ADVERTISEMENT
  • Decreased metabolic energy production
  • Increased energy requirements
  • Presence of pain
  • Overwhelming psychological/emotional demands

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will effectively participate in bearing-down activities
  • Client will relax/rest between efforts.
Nursing InterventionsRationale
Assess fatigue level, and note activities /rest immediately before onset of labor.The amount of fatigue is cumulative, so that the client who has experienced a longer-than-average stage I labor, and/or one who was not rested at the onset of labor, may experience greater feelings of
exhaustion.
Monitor fetal descent, presentation, and position.Malposition and malpresentation may prolong labor and cause/increase fatigue.
Keep client/couple informed of progress.Helps provide needed psychological energy.
Spontaneous efforts to bear down tend to lengthen stage II labor, but do not negatively affect the fetus.
Encourage rest/relaxation between contractions. Provide environment conducive to rest.Conserves energy needed for pushing efforts and delivery. Stage II can be extremely exhausting because of the muscular effort involved in bearing down, the intensity of the emotional response to the experience, inadequate rest, and/or length oflabor.
Encourage use of relaxation techniques. Review them with client/partner, as necessary.Tense muscles increase feelings of exhaustion and resistance to fetal descent and may prolong labor.
Supply fluids with glucose orally as appropriate or parenterally, if ordered. Test urine for ketones, as indicated.Replenishes reserves that may have been depleted in labor and possibly resulted in hypoglycemia or ketonuria.
Assist with anesthesia or use of forceps if client’s efforts do not rotate fetal vertex and promote fetal descent.Low forceps delivery may be necessary in the event of extreme maternal feelings and/or when maternal efforts to deliver are unsuccessful. Mid forceps delivery with rotation (Scanzoni maneuver) helps rotate fetus from OP to OA position.
Prepare for cesarean birth if vaginal delivery is not possible.Maternal fatigue and lack of progress may result from CPD or fetal malposition.

Labor Stage III: Placental Expulsion

The third stage of labor, also known as placental expulsion, begins with the birth of the infant until the delivery of the placenta. The signs of placental expulsion are lengthening of the umbilical cord, sudden gush of vaginal blood, changes in the shape of the uterus and its firm contraction, and the appearance of the placenta at the vaginal opening. Nursing care plans for placental expulsion or the third labor stage include the following:

  1. Acute Pain
  2. Knowledge Deficit
  3. Risk For Fluid Volume Deficit
  4. Risk For Maternal Injury
  5. Risk For Altered Family Process

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

  • Physiological response following delivery
  • Tissue trauma

Possibly evidenced by

ADVERTISEMENT
  • Changes in muscle tone
  • Restlessness
  • Verbalizations

Desired Outcomes

  • Client will verbalize management/reduction of pain.
Nursing InterventionsRationale
Change wet clothing and bedding.Promotes warmth, comfort, and cleanliness.
Apply ice bags to perineum after delivery.Constricts blood vessels, reduces edema, and provides local comfort and anesthesia.
Provide a heated blanket.Post delivery tremors/chills may be caused by sudden release of pressure on pelvic nerves or may possibly be related to a fetus-to-mother transfusion occurring with placental separation. Warmth promotes muscle relaxation and enhances tissue perfusion, reducing fatigue and enhancing sense of well-being.
Assist with use of breathing techniques during surgical repair, as appropriate.Breathing helps direct attention away from the discomfort, promotes relaxation.

Knowledge Deficit

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

May be related to

  • Lack of information and/or misinterpretation of information

Possibly evidenced by

  • Lack of cooperation
  • Verbalizations of questions/concerns

Desired Outcomes

  • Client will verbalize understanding of physiological responses.
  • Client will actively engage in efforts to push to promote placental expulsion.
Nursing InterventionsRationale
Explain reason for such behavioral responses as chills and leg tremors.Understanding helps client accept such changes without anxiety or undue concern.
Discuss/review normal processes of stage III labor.Provides opportunity to answer questions/clarify misconceptions, enhancing cooperation with regimen.
Discuss routine for recovery period during the first 4 hr following delivery. Orient client to new staff and unit if transfer occurs at the end of this stage.Provides continuity of care and reassurance; enhances cooperation.

Risk For Fluid Volume Deficit

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

ADVERTISEMENT

May be related to

  • Diaphoresis
  • Increased insensible water loss
  • Lack/restriction of oral intake
  • Lacerations of the birth canal
  • Retained placental fragments
  • Uterine atony
  • Vomiting

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will display BP and heart rate WNL, palpable pulses.
  • Client will demonstrate adequate contraction of the uterus with blood loss within normal limit.
Nursing InterventionsRationale
Assess vital signs before and after administering oxytocin.Hypertension is a frequent side effect of oxytocin.
Instruct the client to push with contractions; help direct her attention toward bearing down.Client attention is naturally on the newborn; in addition, fatigue may affect individual efforts, and she may need help in directing her efforts toward assisting with placental separation. Bearing down
helps promote separation and expulsion, reduces blood loss, and enhances uterine contraction.
Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature).Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability, and loss of consciousness.
Inspect maternal and fetal surfaces of placenta. Note size, cord insertion, intactness, vascular changes associated with aging, and calcification (which possibly contributes to abruption).Helps detect abnormalities that may have an impact on maternal or newborn status.
Obtain and record information related to inspection of uterus and placenta for retained placental fragments.Retained placental tissue can contribute to post partal infection and to immediate or delayed hemorrhage. If detected, the fragments should be removed manually or with appropriate instruments.
Palpate uterus; note “ballooning.”Suggests uterine relaxation with bleeding into uterine cavity.
Record time and mechanism of placental separation; i.e., Duncan’s mechanism (placenta separates from the inside to outer margins) versus Schulze’s mechanism (placenta separates from outer margins inward).Separation should occur within 5 min after birth. The Duncan’s mechanism of separation carries increased risk of retained fragments, necessitating close inspection of the placenta. Failure to separate may require manual removal. The more time it takes for the placenta to separate, and the more time in which the myometrium remains relaxed, the greater the blood loss.
Massage uterus gently after placental explusion.Myometrium contracts in response to gentle tactile stimulation, thereby reducing lochial flow and expressing blood clots.
Place infant at client’s breast if she plans to breastfeed.Suckling stimulates release of oxytocin from the posterior pituitary, promoting myometrial contraction  and reducing blood loss.
Elevate fundus by dipping fingers down behind and moving uterine body up away from symphysis pubis.May be requested by practitioner to facilitate internal examination.
Avoid excessive traction on umbilical cord.Force may contribute to breakage of the cord and retention of placental fragments, increasing blood loss.
Administer fluids through parenteral route.If fluid loss is excessive, parenteral replacement helps restore circulating volume and oxygenation of vital organs.
Administer oxytocin (Pitocin) through IM route, or dilute IV drip in electrolyte solution, as indicated. IM methylergonovine maleate (Methergine) or prostaglandins may be given at the same time.Promotes vasoconstrictive effect within the uterus to control postpartal bleeding after placental explusion. IV bolus may result in maternal hypertension. Water intoxication may occur if electrolyte-free solution is used.
Obtain and record information related to inspection of birth canal for lacerations. Assist with repair of cervix, vagina, and episiotomy extension.Lacerations contribute to blood loss; can cause hemorrhage.
Assist as needed with manual removal of placenta under general anesthesia and sterile conditions.Manual intervention may be necessary to facilitate expulsion of placenta and stop hemorrhage.

Risk For Maternal 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

  • Abnormal blood profile
  • Difficulty with placental separation
  • Positioning during delivery/transfers

Possibly evidenced by

ADVERTISEMENT
  • [Not applicable]

Desired Outcomes

  • Client will observe safety measures.
  • Client will be free of injury.
Nursing InterventionsRationale
Assess respiratory rhythm and excursion.With placental separation, danger exists that an amniotic fluid embolus may enter maternal circulation, causing pulmonary emboli, or that fluid changes may result in emboli mobilization.
Assess client’s behavior, noting central nervous system (CNS) changes.Increased intracranial pressure during pushing and a rapid increase in cardiac output place the client with preexisting cerebral aneurysm at risk for rupture.
Palpate fundus to note “ballooning” of uterus, and massage gently.Helps identify relaxation of uterus and subsequent bleeding into the uterus and facilitates placental separation.
Remove client’s legs simultaneously from leg supports, if used.Helps avoid muscle strain.
Gently massage fundus after placental expulsion.Enhances uterine contraction while avoiding overstimulation/trauma to fundus.
Clean vulva and perineum with sterile water and antiseptic solution; apply sterile perineal pad.Removes possible contaminants that might result in an ascending tract infection during post partal period.
Assist in transfer from delivery bed to recovery cart, as appropriate.Although many clients remain in labor/ delivery bed for recovery period, if transfer is required, client may be unable to move lower limbs due to continued effects from anesthesia/leg “heaviness” or cramping.
Obtain sample of cord blood; send to laboratory for blood typing of newborn and banking as desired. Record information regarding the sample being sent.If infant is Rh-positive and client is Rh-negative, the client will require immunization with Rh immune globulin (Rh Ig) in the postpartal period.
Use ventilatory assistance if needed.Respiratory failure may occur following amniotic or pulmonary emboli.
If uterine inversion occurs:
  • Administer prophylactic antibiotics.
Limits potential for endometrial infection.
  • Administer volume replacement, insert indwelling urinary catheter; obtain blood type and cross-match; monitor vital signs, and maintain careful intake/output records.
Rapid maternal hemorrhage and shock follows inversion, and immediate lifesaving interventions may be necessary. Kidney function is a useful indicator of fluid volume levels/tissue perfusion.
  • Administer oxytocin IV, replace uterus under anesthesia, and give ergonovine maleate (Ergotrate) IM after replacement. Assist with packing of uterus, as indicated.
Promotes contractility of uterine myometrium.

Risk For Altered Family Process

Risk for Altered Family Processes: At risk for a change in family relationships and/or functioning.

May be related to

  • Developmental transition (gain of a family member)
  • Situational crisis (change in roles/responsibilities)

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Family will demonstrate behaviors indicative of readiness to actively participate in the acquaintance process when both mother and infant are physically stable.
Nursing InterventionsRationale
Provide client and father with the opportunity to hold baby immediately after birth if infant’s condition is stable.Early physical contact helps foster attachment. Fathers are also more likely to participate in infant caretaking activities and feel stronger emotional ties if they are actively involved with the infant soon after birth.
Facilitate interaction between the client/couple and the newborn as soon as possible after delivery.Fosters the beginning of lifelong emotional ties between family members. Both mother and infant have a critically sensitive period during which interactional capabilities are enhanced.
Delay installation of eye prophylaxis ointments (containing erythromycin or tetracycline) until client/couple and infant have interacted, and dim room lights.Allows infant to open eyes fully to establish eye contact with parent and actively participate in the interaction, free from the blurred vision caused by medication.

Labor Induced: Augmented

Induction of labor is necessary on certain maternal health problems such as fetal compromise, postmaturity, or uterine dysfunction. Administration of oxytocin can initiate contractions in a uterus in pregnancy term. If labor contractions begin spontaneously but become weak, irregular, and ineffective, augmentation of labor is required. Induced labor and augmented labor includes the following nursing care plans:

ADVERTISEMENT
  1. Acute Pain
  2. Knowledge Deficit
  3. Anxiety
  4. Risk For Impaired Fetal Gas Exchange
  5. Risk For Maternal Injury

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

  • Altered characteristics of chemically stimulated contractions
  • Psychological concerns

Possibly evidenced by

  • Distraction behaviors (restlessness, moaning, crying)
  • Facial mask of pain
  • Increased muscle tone
  • Verbalizations

Desired Outcomes

  • Client will report pain is reduced/manageable.
  • Client will appear relaxed between contractions .
  • Client will participate in behaviors to diminish pain sensations and enhance comfort.
Nursing InterventionsRationale
Discuss anticipated changes /difference in labor pattern and contractions.Helps prepare client because induction procedures and use of oxytocin can result in rapid onset of strong, frequent contractions, which often interfere negatively with the client’s ability to use learned coping techniques, which a slower buildup in the contractile pattern would allow.
Establish a rapport that enables client/ partner to feel comfortable asking questions.Answers to questions can alleviate fear and promote understanding.
Review/provide instruction in simple breathing techniques.Encourages relaxation and gives client a means of coping with, and controlling the level of, discomfort.
Review analgesics that are available and appropriate for client, and explain their time factors and restrictions.Enhances client’s control of situation and provides information necessary for making an informed choice. If client is medicated before she is 5 cm dilated, labor progress may be slowed; if delivery is imminent (within 2–4 hr), medication may depress the newborn, although use of naloxone (Narcan) at time of delivery improves neonates’ respiratory function.
Encourage and assist client with change of position, and readjust EFM.Prevents/limits muscle fatigue; enhances circulation.
Encourage client to use relaxation techniques. Provide instruction as necessary.Relaxation can aid in reducing tension and fear, which magnify pain and hamper labor progress.
Give encouragement; keep client informed of progress.Reassures client/couple. Provides positive reinforcement for efforts and promotes focus on the future.
Provide comfort measures (e.g., effleurage, back rub, propping with pillows, applying cool washcloths, offering ice chips/lip balm).Promotes relaxation, reduces tension and anxiety and enhances client’s coping and sense of control.
Administer analgesic medications once dilation and contractions are established.Relieves pain; promotes relaxation and coping with contractions, allowing client to remain focused on work of labor.

Knowledge Deficit

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

May be related to

ADVERTISEMENT
  • Lack of exposure/unfamiliarity with information resources
  • Misinterpretation of information

Possibly evidenced by

  • Verbalization of questions/concerns
  • Exaggerated behaviors

Desired Outcomes

  • Client will verbalize understanding of procedures/situation.
  • Client will participate in decision-making process.
Nursing InterventionsRationale
Explain the expected procedures to client/couple: Use of prostaglandin gel; continuous monitoring of contractions and FHR; BP checked frequently; administration of oxytocin may result in increased
discomfort because contractions will become more intense and onset of labor will be more rapid; analgesics may need to be administered after 5 cm dilation, or when good labor pattern is established.
Anxiety is allayed when client/ couple know what is happening and what to expect. Cooperation and involvement are also enhanced.
Explain oxytocin infusion.Oxytocin may be used prior to amniotomy or may be implemented after a trial of amniotomy that fails to induce labor.
Review amniotomy procedure (artificial rupture of membranes [AROM]); explain that it is no more uncomfortable than sterile vaginal examination.Amnihook is guided into the vagina by the examiner’s fingers during the sterile vaginal examination. Membranes, which do not contain nerves, are hooked or nicked to rupture, stimulating labor. When used alone or in conjunction with oxytocin, amniotomy can be a successful means of inducing labor. However, amniotomy generally
commits the client to delivering within 24 hr.
Review the need for induction or augmentation of labor. Discuss Bishop score.Informed consent and cooperation depend on the client’s understanding of the situation and choices. Bishop score is a numerical score assigned to cervical characteristics (position, consistency, ripeness, effacement, dilation) and fetal station that predicts whether induction will be successful.
Discuss possibility of failed induction and/or operative intervention if fetal distress occursDepending on the degree of cervical ripening and the client’s response to procedures, induction may not be successful. If membranes are ruptured, and induction fails, a cesarean birth is indicated. If severe fetal distress is apparent, or if uterine hyperstimulation places client at risk for uterine rupture, induction may be discontinued and cesarean delivery performed. Providing this information to the
client/couple in advance can prepare them psychologically and may diminish disappointment.
Instruct client/partner in basic interpretation of fetal monitor, differentiating changes in pattern that occur on movement.Encourages involvement, gives a sense of control, and lessens anxiety regarding normal variations of tracing.
Demonstrate and explain use of equipment (i.e., external or internal fetal monitor and IV infusion pump). Point out safety features and alarms.Knowledge can alleviate anxiety, enhance coping with false alarms, and give a sense of control over the situation.

Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

  • Perceived threat to client/fetus
  • Situational “crisis”
  • Unanticipated deviation from expectations

Possibly evidenced by

  • Apprehension
  • Decreased self-awareness
  • Feelings of inadequacy
  • Identification of specific concerns
  • Increased tension
  • Sympathetic stimulation

Desired Outcomes

ADVERTISEMENT
  • Client will report anxiety diminished and/or managed.
  • Client will use support systems effectively.
  • Client will appear relaxed.
  • Client will accomplish successful labor.
Nursing InterventionsRationale
Assess psychological and emotional status.Any interruption of the normal progression of labor can contribute to feelings of anxiety and failure. These feelings can interfere with client cooperation and hamper the induction process.
Use positive terminology; avoid use of terms that indicate abnormality of procedures or processes.Helps client/couple accept the situation without self-recrimination.
Encourage verbalization of feelings.Client may be frightened or may not clearly understand the need for inducing labor. A sense of failure at being unable to “labor naturally” may occur.
Encourage use/continuation of breathing techniques and relaxation exercises.Helps to reduce anxiety and enables client to participate actively.
Listen to client’s comments that may indicate loss of self-esteem.Client may believe that any intervention to aid the labor process is a negative reflection on her own abilities.
Provide opportunities for client input into decision-making process.Enhances client’s sense of control even though much of what is happening may be beyond her control.

Risk For Impaired Fetal Gas Exchange

Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

May be related to

  • Altered blood flow to placenta or through umbilical cord (prolapse)

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Fetus will display FHR within normal limits, free of late decelerations.
  • Client will engage in behaviors that enhance fetal safety.
Nursing InterventionsRationale
Perform Leopold’s maneuvers and sterile vaginal examination. Note presentation and station of fetus.Determines whether fetus is in vertex presentation and rules out CPD. If presenting part is too high (22cm), amniotomy may need to be postponed owing to risk of prolapsed cord.
Note fetal maturity based on client’s history, EDB, and uterine measurements.Gestational age of fetus should be 36 wk or more for induction or augmentation of labor to be performed, unless maternal condition warrants intervention before this time.
Position client on back with head of bed elevated and a pillow or wedge placed under one hip, preferably the right, so that client tilts to side.Aids in obtaining an adequate external fetal monitor strip to evaluate contraction pattern and FHTs. Wedge relieves pressure of fetus on vena cava and enhances placental circulation.
Apply electronic fetal monitor (EFM) 15–20 min before induction procedure.Determines fetal well-being and provides baseline assessment of FHR and uterine activity.
Monitor FHR, as indicated, in conjunction with amniotomy.Determining FHR prior to and following procedure provides information to ensure fetal wellbeing. Acceleration for a short period after amniotomy is normal; however, signs of distress may indicate fetal hypoxia from compression of cord or late decelerations.
Note time of rupture of membranes and character and consistency of fluid.To reduce risk of ascending infection, a mature fetus should be delivered within 24 hr of rupture of membranes.
Have client void before administration of oxytocin and before application of fetal electrode.A full bladder can interfere with fetal position and placement of monitor.
Assess reaction of FHR to contractions, via continuous EFM, noting bradycardia and late/variable decelerations; or sustained tachycardia.Proper assessment is needed to avoid hypoxia. Normal range for FHR is 120–160 bpm. To ensure fetal well-being, oxytocin may need to be discontinued and different measures taken, depending on interpretation of EFM tracing.
Review results of ultrasonography and amniocentesis, pelvimetry, and L/S ratio.Determines fetal age and presentation; helps identify CPD and potential needs of fetus/neonate during and following delivery
Apply fundal pressure, as indicated.Procedure is controversial but may be tried for firm positioning of presenting part on cervix to prevent cord prolapse during amniotomy.
Assist as needed in application of internal fetal electrode.Internal fetal electrode should be used for more accurate observation, especially if signs of fetal distress or meconium are present.

Risk For Maternal 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

ADVERTISEMENT
  • Adverse effects/response to therapeutic interventions

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Client will develop/maintain a good labor pattern; i.e., contractions 2–3 min apart, lasting 40–50 sec, with uterine relaxation to normal tone between contractions.
  • Client will accomplish delivery without complications.
Nursing InterventionsRationale
Review prenatal record for history of previous pregnancies and outcomes, prenatal laboratory studies, pelvic measurements, allergies, weight gain, vital signs, last menstrual period, and EDB.Provides information needed in formulating plan of care. Alerts nurse to the possibility of existing or developing problem(s).
Obtain history regarding insertion of laminaria tent or prostaglandin vaginal suppository preparations  (e.g., p-gel).Insertion of laminaria tent or prostaglandin preparations the evening before the induction softens the cervix and facilitates labor induction.
Monitor intake and output. Measure urine specific gravity as indicated. Palpate bladder.Decreased output with increased specific gravity reflects fluid deficit. Urine retention may impede labor and fetal descent. In addition, oxytocin infusions of 20 ml/min or above may result in decreased urinary output because of antiduretic
effect of medication.
Note reports of abdominal cramping, dizziness, headache, and nausea/vomiting; presence of lethargy, confusion, hypotension, tachycardia, and cardiac dysrhythmia (irregularities).Water intoxication may develop dependent on rate and type of fluid administration/ oxytocin infusion above 20 ml/min.
Provide perineal care, as indicated. Monitor temperature every 2 hr. Note color and odor of vaginal drainage.Reduces risk of infection and/or provides early detection of developing infection. Presence of meconium staining indicates fetal distress.
Check BP and pulse per protocol after induction begins and before increasing oxytocin.Assesses maternal well-being and detects the development of hypotension/ hypertension. With initiation of oxytocin infusion, BP may be decreased. As time passes, BP may increase up to 30% above
baseline. Oxytocin is given slowly in increasing amounts based on maternal and fetal response. Approximately 40 min of infusion is necessary to reach therapeutic blood levels of oxytocin. It is rapidly metabolized and excreted by the kidneys, so constant infusion should be maintained in order to achieve regular, consistent contractions of good quality to dilate the cervix effectively.
Perform sterile vaginal examination to determine readiness or ripeness of cervix and fetal station. Repeat as indicated by client’s reaction and contraction pattern.A soft, partially effaced (more than 50%) and/or dilated (at least 3 cm) “ripe” cervix is a good indication that induction will be successful. A firm, thick “unripe” cervix with little or no dilation may require two or three trials before induction is successful. Time of amniotomy (AROM) depends on fetal station. Repeat examinations determine labor progress, but to avoid infection, they should be limited as much as possible after membranes are ruptured.
Evaluate monitor tracing closely. Note rate and Evaluate monitor tracing closely. Note rate andCareful monitoring is essential to determine client/fetal response to procedure, to identify adverse reactions, and to produce an effective labor pattern.
Document vital signs, medications, oxytocin onset and dosage increases, change of position, oxygen administration, and times of sterile vaginal examinations on monitor tracing.Monitor tracing is a legal document, showing progress of induction, fetal/maternal response, and actions taken by healthcare staff.
Palpate fundus to evaluate frequency and duration of contractions. Observe for overstimulation of uterus (tetanic contraction). Note intensity and resting tone between contractions per palpation or via IUPC, if used.External uterine monitoring indicates the frequency, not intensity, of contractions. Rapid labor/delivery may occur, increasing risk of cervical and soft tissue trauma. Overstimulation causes fetal hypoxia, uterine rupture, and premature separation of placenta. If contraction lasts more than 90 sec, occurs more than 2–3 min apart, or if uterus is not completely relaxed between contractions, oxytocin should be discontinued.
Document vital signs, medications, oxytocin onset and dosage increases, change of position, oxygen administration, and times of sterile vaginal examinations on monitor tracing.Monitor tracing is a legal document, showing progress of induction, fetal/ maternal response, and actions taken by healthcare staff.
Review prenatal laboratory work. Perform nitrazine paper or fern test, if indicated.Evaluates maternal and fetal status, and determines whether membranes have ruptured.
Assist with application of prostaglandin preparations.Facilitates cervical ripening; may stimulate labor and/or enhance effectiveness of oxytocin infusion.
Assist with amniotomy. Place client in low semi Fowler’s position with knees bent as for vaginal  examination.AROM may stimulate labor without need of drug infusion (successful in approximately 80% of clients at term), or it may be done in conjunction with oxytocin administration. Amniotomy is
contraindicated if presenting part is high.
Start primary IV line with large-gauge indwelling catheter.Large-gauge catheter is preferred in case of the need for surgical intervention, blood transfusion, or emergency fluid/drug administration.
Assist as necessary with insertion of IUPC, if used. IInternal monitoring accurately quantitates intensity and frequency of contractions and helps identify overstimulation and possible uterine rupture caused by over administration of oxytocin.
Dilute and administer oxytocin (Pitocin) in electrolyte solution with a two-bottle IV system, piggy-backing oxytocin close to IV site, according to unit policy and procedures.The synthetic hormone oxytocin stimulates the uterine smooth muscle, increasing the excitability of the muscle cells, which increases the strength of contractions. Oxytocin can be discontinued if
necessary, and the primary site can be quickly cleared and available for other infusions when solution is infused close to IV site. In addition, water intoxication can result from excessive or rapid fluid
administration, especially when D5W is used instead of electrolyte solutions (e.g., lactated Ringer’s).
Observe safety precautions related to the use of infusion and to proper labeling of oxytocin solution.Errors or fluctuations in rate of administration may cause under medication or over medication, resulting in inadequate contractions or uterine rupture. Drug delivery is verified by closely monitoring the pump and the decreasing level of fluid.
Obtain/monitor electrolytes, as indicated.Water retention may occur during oxytocin infusion resulting in hypochloremia or hyponatremia.
Discontinue oxytocin, as indicated, and increase infusion of plain IV solution. Notify physician.Hyperstimulation of the uterus (intrauterine pressure greater than 75 mm Hg) can lead to abruptio placentae, uterine tetany, and possible rupture.
Administer 1–2 g MgSO4 slowly, as necessary, or terbutaline (Brethaire) subcutaneously (SQ).Although the circulatory half-life of oxytocin is 3–9 min, uterine activity from effects of oxytocin administration may last 20–30 min after infusion is stopped. MgSO4 or terbutaline may be indicated to relieve oxytocin-induced uterine tetany.

See Also

You may also like the following posts and care plans:

Maternal and Newborn Care Plans


Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:

ADVERTISEMENT
Last Updated On:
ADVERTISEMENT

LEAVE A REPLY

Please enter your comment!
Please enter your name here