36 Labor Stages, Induced and Augmented Labor Nursing Care Plans

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Labor is defined as a series of rhythmic, involuntary, progressive uterine contraction that causes effacement and dilation of the uterine cervix. It is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus (Milton & Isaacs, 2019). The process of labor and birth is divided into three stages.

The first stage of dilatation begins with the initiation of true labor contractions and ends when the cervix is fully dilated. The first stage may take about 12 hours to complete and is divided into three phases: latent, active, and transition. The latent or early phase begins with regular uterine contractions until cervical dilatation. Contractions during this phase are mild and short, lasting 20 to 40 seconds. Cervical effacement occurs, and the cervix dilates minimally.

The active phase occurs when cervical dilatation is at 6 to 7 cm and contractions last from 40 to 60 seconds with 3 to 5 minutes intervals. Bloody show or increased vaginal secretions and perhaps spontaneous rupture of membranes may occur at this time. 

The last phase, the transition phase, occurs when contractions peak at 2 to 3-minute intervals and dilatation of 8 to 10 cm. If it has not previously occurred, the show will occur as the last mucus plug from the cervix is released. By the end of this phase, full dilatation (10 cm) and complete cervical effacement have occurred.

The second stage of labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered. The fetus begins the descent, and as the fetal head touches the internal perineum to begin internal rotation, the client’s perineum begins to bulge and appear tense. As the fetal head pushes against the vaginal introitus, crowning begins, and the fetal scalp appears at the opening to the vagina.

Lastly, the third stage, or the placental stage, begins right after the baby’s birth and ends with the delivery of the placenta. Two separate phases are involved: placental separation and placental expulsion. Active bleeding on the maternal surface of the placenta begins with separation, which helps to separate the placenta further by pushing it away from its attachment site. Once separation has occurred, the placenta delivers either by natural bearing down the client’s effort or gentle pressure on the contracted uterine fundus.

There are instances where labor does not start on its 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 client and the newborn healthy. This may be the case when certain situations such as premature rupture of the membranes, post-term pregnancy, hypertension, preeclampsia, heart disease, gestational diabetes, or bleeding during pregnancy are present.

Nursing Care Plans

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

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:

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Labor Stage IC: Transition Phase

The transition phase occurs when contractions reach their peak with intervals of 2 to 3 minutes with a duration of 60 to 70 seconds and maximal cervical dilatation of 8 to 10 cm. By the end of this phase, full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred. Nursing care plans in this labor phase include:

  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

Normally, contractions of involuntary muscles, such as the heart, stomach, and intestine, do not cause pain. This concept makes uterine contractions unique because they do cause pain. During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. As labor progress and contractions become longer and more intense, the ischemia to cells increases, the anoxia increases, and the pain intensifies.

Nursing Diagnosis
  • Acute Pain
May be related to

Common related factors for this nursing diagnosis:

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

The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

  • Autonomic responses
  • Distractability (e.g., restlessness)
  • Facial mask of pain
  • Narrowed focus
  • Verbalizations of pain (crying, moaning during and between contractions)
  • Tense, guarded body posture or thrashing with contractions
Desired Outcomes

Common goals and expected outcomes:

  • The client will verbalize perceived or actual reduction of pain.
  • The client will rest between contractions.
  • The client will use appropriate techniques to enhance comfort and
    maintain control of the labor process.
Nursing Assessment and Rationales

The following are the nursing assessment for this labor nursing care plan.

1. Monitor frequency, duration, and intensity of uterine contractions.
Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion. Observe if there is a period of relaxation between contractions so the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. Uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because it interferes with adequate uterine artery filling.

2. Monitor cervical dilation. Note perineal bulging or vaginal show.
Discomfort levels increase as the cervix dilates, the fetus descends, and small blood vessels rupture. Labor may progress more rapidly than expected. Observe for signs that birth may be near: increase in the bloody show, perineal bulging, crowning. These are signs associated with imminent birth that should be evaluated by the experienced nurse, nurse-midwife, or healthcare provider.

3. Monitor maternal vital signs and FHR variability after drug administration. Note the 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, usage of the drug may be limited or restricted, or naloxone hydrochloride (Narcan) may be administered to reverse adverse drug effects. The client should be observed for hypotension if an epidural or subarachnoid block is administered. Hospital protocols may vary, but blood pressure is usually measured every 5 minutes after the block begins until her blood pressure is stable. At the same time, the nurse observes the fetal monitor for signs associated with fetal compromise because maternal hypotension can reduce placental blood flow.

4. Assess the 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. Cultural factors can strongly influence the client’s experience and satisfaction with labor. This makes her response to pain, choice of nourishment, preferred birthing position, proximity and involvement of a support person, and customs related to the immediate postpartal period highly individualized.

5. Assess the 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. Several variations of massage are often used during labor, most of which can be taught to the client and her partner.

6. Evaluate client for tingling of lips, face, hands, or feet. If present, have the client breathe into cupped hands or paper bags.
Discomfort caused by respiratory alkalosis can be relieved by increasing carbon dioxide levels through the rebreathing process. Hyperventilation is sometimes a problem when the woman is breathing rapidly. She may complain of dizziness, tingling, and numbness around her mouth and may have spasms in her fingers and feet.

7. Assess the client for bladder distention regularly if she received an epidural or subarachnoid block.
Urinary retention is a common side effect of an epidural block. A full bladder can delay birth and can cause hemorrhage after birth. The nurse should palpate the suprapubic area for a full bladder every 2 hours or more if a large quantity of IV solution were infused. You can also assess for a full bladder by percussion (an empty bladder sounds dull; a full one sounds resonant). The client may need catheterization if she is unable to void.

8. Assess for numbness of fingers when spinal anesthesia is used.
When spinal anesthesia is used, the nurse should assess for numbness of fingers, which can mean the drug has reached the L6-L8 level and could affect the diaphragm, which could cause respiratory problems.

Nursing Interventions and Rationales

Below are the nursing interventions for this labor nursing care plan.

1. Inform the client of the onset of contractions, as appropriate.
The client may “sleep” and encounter partial amnesia between contractions. This can be a problem for some clients, impairing her ability to recognize contractions as they begin and thus harming her sense of control. Give the couple frequent progress reports during labor so they do not become discouraged or fearful. For others, the brief rest may “energize” them for the next contraction. Most clients want to feel in control of what is happening to them during labor to face this big event in their lives.

2. Encourage the client to void.
Voiding may enhance labor progress and reduce the risk of trauma to the bladder. A full bladder or bowel can impede fetal descent, so encourage the client to void, if possible, at least every 2 to 4 hours during labor. The client may mistakenly interpret the discomfort of a full bladder as part of the sensations of labor. If the client cannot void and the bladder becomes distended, she may need to be catheterized.

3. Assist client and partner with changing to more rapid breathing; (i.e., pant-blow).
Breathing exercises redirects and focus attention and help reduce pain perception within the cerebral cortex. Modified-paced breathing allows the client to breathe more rapidly and shallowly. The rate should be no more than twice her usual rate. She may combine slow-paced with modified-paced breathing. In this variation, she begins with a cleansing breath and breathes slowly until the peak of contraction, when she begins rapid, shallow breathing. As the contraction abates, she resumes slow, deep breathing and ends with a cleansing breath.

4. Instruct the client and her partner about skin stimulation techniques.
Several variations of massage can be taught to the client and her partner. Effleurage is a technique that stimulates the large-diameter nerve fibers that inhibit painful stimuli traveling through the small-diameter fibers. The woman strokes her abdomen in a circular movement during contractions. Sacral pressure applies firm pressure against the lower back to help relieve some back labor pain. The client tells her partner where to apply the pressure and how much pressure is helpful. Thermal stimulation through heat or cool compress can be applied with a warm blanket or a glove filled with warm water. Most clients also appreciate a cool cloth on the face.

5. Assist the client with relaxation techniques.
Relaxation techniques require concentration, thus occupying the mind while reducing muscle tension. The nurse should adjust the client’s environment and help her with general comfort measures. For example, water in a tub or shower helps refresh the client and promotes relaxation. The laboring woman may be guided to release the tension specifically, one muscle group at a time.

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6. Offer encouragement, provide information about labor progress, and provide positive reinforcement for the client’s efforts.
Help the woman express her feelings in a way that works best for her. It is important to keep the client and her support person informed about their options and how they differ as labor progresses. For instance, knowing that birth is getting closer can make the next few contractions easier to withstand. Encouragement is a powerful tool for intrapartum nursing care because it helps the client summon inner strength and gives her the courage to continue. Her partner also needs encouragement, as labor coaching is a demanding job.

7. Provide a quiet and comfortable environment for the laboring client.
A non-distracting environment provides optimal opportunities for relaxation between contractions. The environment of the labor room can be controlled by having the client listen to familiar music brought from home, which can produce a calming effect.

8. Provide a break for the partner as appropriate.
The 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 the partner. The partner should be encouraged to take a break and periodically eat a snack or meal. They may faint during birth if they have not eaten. A chair or stool near the bed allows the partner to sit down as much as possible.

9. Educate the client and her partner about bathing or hydrotherapy during labor.
Standing under a warm shower or soaking in a tub of warm water, jet hydrotherapy tub, or whirlpool is another way to apply heat to help reduce labor pain. The temperature of the water used should be 37℃ to prevent hyperthermia. Do not leave the client unsupervised in a tub, as they could slip and have difficulty getting their head above water. A support person can join the client in a tub or shower if she wishes and can continue with a back massage or other measures she finds soothing.

10. Administer analgesic as ordered. Assist the anesthesiologist if the 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. Pharmacologic management of pain during labor and birth includes analgesia, which reduces or decreases awareness of pain, and anesthesia, which causes a partial or complete loss of pain sensation. Be certain that the client is included in selecting these methods and understand any fetal or maternal side effects that might occur. Maintain a supportive presence to help the client make the best decision for herself and her baby.

11. Insert an indwelling catheter if the client cannot void, as indicated.
If the client cannot void and the bladder becomes distended, she may need to be catheterized. Catheterizing a client in labor is uncomfortable for her and difficult for the nurse. The vulva is edematous from the pressure of the fetal presenting part, stretching the urethral canal downward and making the urethra difficult to locate. Use a small catheter (No. 12 to 14F) for best results and insert it between contractions. Use an extremely careful aseptic technique to avoid introducing any microorganisms that might result in a urinary tract infection.

Fatigue

Fatigue reduces pain tolerance and the client’s ability to use coping skills. By the time the date of birth approaches, the client is generally tired from the normal discomforts of pregnancy and has not slept well for the past month. For example, a side-lying position caused backache; her back ached again when she turned back to her side. Sleep hunger from this discomfort can make it difficult for a woman to perceive situations clearly or adjust rapidly to new situations. It can make the process of labor loom as an overwhelming, unendurable experience unless she has competent people with her to offer support, reassurance, and comfort.

Nursing Diagnosis
  • Fatigue
May be related to

Common related factors for this nursing diagnosis:

  • 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

The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

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

Common goals and expected outcomes:

  • The client will use techniques to conserve energy between contractions.
  • The client will report a sense of control.
  • The client will appear moderately relaxed.
Nursing Assessment and Rationales

Here are the nursing assessment for this labor nursing care plan.

1. Assess the degree of the client’s fatigue.
Fatigue may interfere with the client’s physical and psychological abilities to participate in the labor process and master and carry out self-care and infant care after delivery. The use of questionnaires such as the Maternal Perception of Childbirth Fatigue Questionnaire (MCFQ) helps assess fatigue during labor and delivery. The MCFQ considers the perspective of postpartum women and the viewpoint of healthcare professionals from different areas in the field. The MCFQ represents three factors: one related to physical fatigue, the other to psychological fatigue, and the third are related to emotional fatigue. Since childbirth is an event requiring high energy expenditure due to an association of uterine contractions with feelings of anxiety, fear, and concern, it is expected that these three types of fatigue would be present (Delgado et al., 2019).

2. Assess the client’s degree of contractions.
Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion. This problem may be correctable but needs augmentation or other interventions to accomplish this.

3. Assess when the client had her last meal.
Upon admission, assess the likelihood of glucose depletion by asking when the client ate her last meal. Because labor is work, the client’s glucose stores can deplete over hours of labor. If she ate her breakfast at 8:00 am and then began labor by 2:00 pm, it has only been 6 hours since her last full meal. 

Nursing Interventions and Rationales

The following are the nursing interventions for this labor nursing care plan.

1. Monitor the energy level of the partner. Assume supportive responsibilities as needed.
This allows the partner to have a brief break and refresh their self-enhancing ability to maintain focus and support the client. Partners vary considerably in the degree of involvement with which they are comfortable. The partner should be permitted to provide the type of support comfortable for the couple. The partner should be encouraged to take a break and periodically eat a snack or meal. Many partners are reluctant to leave the woman’s bedside, but they may faint during birth if they have not eaten. A chair or stool near the bed allows the partner to sit down as much as possible.

2. Position the client in a comfortable position.
A comfortable position facilitates muscle relaxation. The recommended comfort positions for laboring women include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. The “towel-pull” involves the woman pulling on a towel secured to the foot of the bed during contractions, which uses the abdominal muscles and aids in expulsion efforts. The lateral Sims position encourages rest and helps prevent pressure on the sacrum. Squatting during contractions increases the diameter of the pelvis, facilitating fetal rotation and descent.

3. Keep the client informed of the progress of the labor.
Offer explanations of all procedures and the client’s progress of labor. Allow the woman and her support person as many choices as possible to give them a sense of control. Many women are discouraged when their cervix is about 5 cm dilated because it has taken many hours to reach that point. They think they are only halfway through labor; however, a 5-cm dilation signifies that about two-thirds of the labor is completed as progress increases. Laboring women often need support and reassurance to overcome their discouragement at this point.

4. Plan care to limit interruptions and promote rest.
This maximizes opportunities for rest. The best labor support will protect a woman’s privacy and ensure that she is not disturbed to tap into her inner wisdom and dig deep to find the strength she needs to give birth. Strangers should be kept away, filtered information, and questions, interruptions, and intrusions should be kept to a minimum. Continuously supported, protected, and cared for, but not disturbed, the laboring woman can let go of fear even in a busy maternity hospital. Ideally, the client is surrounded by family and professionals who listen, watch, and quietly and patiently encourage her, making sure that she is not disturbed and has the privacy she needs to do the work of labor (Lothian, 2004).

5. Provide a dimly lit, comfortable environment
Reducing stressors helps promote rest. An individual client may find complementary therapy such as aromatherapy, acupressure, or music helpful for relaxation. Favorite music or relaxation recordings divert the woman’s attention from pain. The sounds of rainfall, wind or the ocean contribute to relaxation and block disturbing sounds; the client can also listen to her favorite music types on various electronic devices.

6. Provide comfort measures to the laboring client.
Comfort measures promote relaxation, enhance the sense of control, and may strengthen coping. Remember that long-term pain is depressing and exhausting. Encourage the client’s partner to use nonpharmacologic comfort measures such as breathing with the woman, offering a back rub, changing the sheets, using cool washcloths, or whatever seems comforting. 

7. Encourage efforts the client makes.
Realizing that labor is progressing toward a goal may help the client maintain maximal effort. After each vaginal examination, the client is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to cope with labor. Her partner also needs encouragement, as labor coaching is a demanding job.

8. Provide calorie-rich fluids, e.g., fruit juices, broth.
Calories are necessary to maintain energy levels to help with labor work. The client may be encouraged to drink a high-carbohydrate fluid such as a sports drink or eat a light meal if she is in early labor. Sucking on a lollipop or hard candy is an enjoyable way to supply additional glucose for energy.

9. Administer an analgesic as ordered.
Pharmacological methods may help the client cope with contractions and facilitate relaxation between contractions. Use with caution because analgesics may cause fetal depression. Methods that use drugs to reduce pain during birth can help the client be a more active participant in birth. They help her relax and work with contractions. Drugs do not usually relieve all pain and pressure sensations. One important factor to consider is that two persons are medicated- the mother and the fetus. The drug may directly affect the fetus or indirectly affect the fetus because of its effects on the mother (Leifer G., 2018).

10. Assist in the possible induction and augmentation of labor.
When labor contractions are ineffective, several interventions, such as induction and augmentation of labor with oxytocin or amniotomy (artificial rupture of the membranes), may be initiated to strengthen them. Induction of labor means labor is started artificially. Augmentation of labor refers to assisting labor that has started spontaneously but is ineffective.

Risk For Decreased Cardiac Output

The range of hemodynamic changes during labor is caused by complex interactions of mechanical, neurophysiological, and endocrine factors. During stage 1, contractions induce considerable hemodynamic changes already during early active labor, and this suggests that the extent of these changes slightly increases between early and late stage 1. Prominent decreases in cardiac output (CO) and stroke volume (SV) are probably due to reduced venous return caused by increased thoracic pressure during the expulsive effort. Additionally, decreases in CO and SV were found during stage 1 contractions in the absence of bearing down (Kuhn et al., 2017).

Nursing Diagnosis
  • Risk for Decreased Cardiac Output
May be related to

Common related factors for this nursing diagnosis:

  • Changes in systemic vascular resistance
  • Decreased venous return
  • Hypovolemia
Possibly evidenced by
  • A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

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  • The client will display FHR within normal limits.
  • The client will maintain vital signs appropriate for the stage of labor, free of pathological edema and excessive albuminuria.
Nursing Assessment and Rationales

Below are the nursing assessment for this labor nursing care plan.

1. Note the presence and extent of edema and monitor FHR during and between contractions.
A decrease in blood volume and cardiac output triggers fluid retention (Shotan et al., 2005). Excess fluid retention places the client at risk for circulatory changes, with possible uteroplacental insufficiency manifested as late decelerations. Late decelerations suggest that the placenta is not delivering enough oxygen to the fetus.

2. Assess BP and pulse between contractions, as indicated. Note abnormal readings.
During contractions, blood pressure usually increases 5–10 mm Hg, except during the transition phase, when the blood pressure remains elevated. Increased resistance to cardiac output can occur if intrapartum 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 (Cohen et al., 2015).

3. Accurately record parenteral/oral intake and output. Measure specific gravity if kidney function is decreased.
Bedrest promotes cardiac, and urine output increases with a corresponding decrease in urine-specific gravity. An elevation of specific gravity and reduction in urine output suggests dehydration or possibly developing hypertension. A second side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. In its most severe form, water intoxication can lead to seizures, coma, and death because of the large shift in the interstitial tissue fluid. Keep an accurate intake and output record and test and record urine specific gravity throughout oxytocin administration to detect fluid retention.

4. Note any hypertensive responses to oxytocin administration.
Oxytocin increases the cardiac circulating volume (sodium and water absorption) and cardiac output and may increase BP and pulse. A side effect of oxytocin is that it causes peripheral vessel dilation, and peripheral dilation can lead to extreme hypotension. To ensure safe induction, take the client’s pulse and blood pressure every hour and strictly monitor uterine contractions and FHR.

5. 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. The client is observed for hypotension if an epidural or subarachnoid block is administered. Hospital protocols vary, but blood pressure is usually measured every 5 minutes after the block begins until her blood pressure is stable.

Nursing Interventions and Rationales

Here are the nursing interventions for this labor nursing care plan.

1. Place the client in a left lateral side-lying position.
Stroke volume is increased in the lateral position. This may reflect increased venous return suggesting aortocaval compression may be a complication of positioning in the sitting position.  Maternal hemodynamics may influence FHR patterns in connection with different maternal body positions. Uteroplacental perfusion is dependent on maternal pressure and cardiac output, and it is important to determine which position will compromise uteroplacental perfusion least (Armstrong et al., 2011).

2. Monitor the client during spinal anesthesia administration.
Spinal anesthesia is commonly used for cesarean birth and can lead to major secondary cardiovascular effects. The most frequent cardiovascular response to spinal anesthesia for elective cesarean section is a marked decrease in systemic vascular resistance and compensatory increases in heart rate and stroke volume (Sanghavi & Rutherford, 2014).

3. Promote safe exercises such as walking or treadmill exercises.
Because resting cardiac output is increased in pregnancy, the maximal cardiac output induced by exercise is achieved at a lower level of work. During rest or weight-bearing exercise (e.g., walking or treadmill exercise), maternal oxygen uptake significantly increases compared with the non-pregnant state (Sanghavi & Rutherford, 2014).

4. Administer prophylactic intravenous phenylephrine before delivery.
In a review of randomized, controlled trials of spinal anesthesia and cesarean section, the administration of prophylactic intravenous phenylephrine before a delivery reduced the risk of hypotension by 64% compared with placebo. After delivery, it reduced the risks of hypotension, nausea, and vomiting by a similar amount. In recent years, phenylephrine, rather than ephedrine, has become the vasopressor of choice in obstetrics (Sanghavi & Rutherford, 2014).

Risk for Imbalanced Fluid Volume

As estrogen production increases, so does renin substrate production; thus, angiotensin levels increase throughout pregnancy. There is an increase in exchangeable sodium in the second and third trimesters. Furthermore, relaxin stimulates increased vasopressin secretion and drinking, resulting in increased water retention (Sanghavi & Rutherford, 2014). Natural childbirth is a process that requires huge amounts of energy; pregnancy can also lead to a higher basal metabolic rate, so oral intake measures in this process have been the focus of research. To prevent pregnant women from anesthesia accidents during labor, the measures of limiting eating and drinking during the labor process were adopted. This may result in a fluid volume deficit.

Nursing Diagnosis
  • Risk for Imbalanced Fluid Volume
May be related to

Common related factors for this nursing diagnosis:

  • Excess fluid loss/hemorrhage
  • Excess fluid retention
  • Rapid parenteral fluid administration
  • Reduced oral  intake
Possibly evidenced by
  • A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

  • The client will be free of thirst.
  • The client will maintain vital signs and urine output/concentration within the normal limit.
  • The client will drink at least one glass of selected beverage every hour.
  • The client will state that she does not feel thirsty.
  • The client will void at least 30 ml/hr every 2 to 4 hours.
Nursing Assessment and Rationales

The following are the nursing assessment for this labor nursing care plan.

1. Assess the amount of vaginal bloody show; observe excess blood loss.
Bloody show increases as the presenting part move down in the birth canal; excess bleeding may indicate placental separation. The amount of blood loss and blood clots will help determine the necessary interventions. The characteristics and quantity of blood passed can suggest excessive bleeding. For example, bright red blood is arterial and can indicate lacerations of the genital tract; meanwhile, dark red blood is likely of venous origin and may indicate superficial lacerations or varices of the birth canal.

2. Assess the amount and location of edema.
Intrapartum hypertension can develop, causing fluid shifts from the intravascular spaces and increasing Hct levels. Sodium retention is influenced by many factors, including elevated levels of pregnancy hormones. Although the fetus uses much of the sodium, the remainder is in the maternal circulation and can cause a maternal accumulation of water or edema. This fluid retention may cause a problem if the client in labor is given IV fluids containing oxytocin, which has an antidiuretic effect and can result in water intoxication.

3. Assess the client’s hematocrit and hemoglobin level.
Although plasma and red blood cells increase during pregnancy, they do not increase by the same amount. The fluid part of the blood increases more than the erythrocyte component. This leads to dilutional anemia or pseudoanemia. As a result, the normal prepregnant hematocrit level of 36% to 48% may fall to 33% to 46%. The hematocrit count is reevaluated to determine the client’s status and needs.

4. Record intake and output. Note the 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. The urine concentration increases as urine output decreases and may warn of dehydration. This can be caused by insensible fluid losses such as diaphoresis and increased rate and depth of respirations.

5. Take temperature every 4 hours, as indicated (every 2 hours after membranes rupture). Assess skin and mouth for dryness.
Dehydration can result in elevated body temperature, dry skin, and reduced saliva production. Cool, clammy skin or weak pulses indicate decreased peripheral circulation and the need for additional fluid replacement. Diaphoresis may occur with accompanying evaporation to cool and limit excessive warming.

6. 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. Water intoxication sometimes occurs because oxytocin inhibits the excretion of urine and promotes fluid retention. Epidural anesthesia may cause hypotension. Therefore, the nurse should ensure that the client is well hydrated before epidural administration.

7. Measure the amount and character of emesis.
During the transition phase, the client may experience intense discomfort that is so strong that it might be accompanied by nausea and vomiting. Opioids used during labor may cause nausea and vomiting. 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.

Nursing Interventions and Rationales

Here are the nursing interventions for this labor nursing care plan.

1. Position the client on the side, as appropriate.
This increases the venous return by taking pressure of the gravid uterus off the inferior vena cava and descending aorta. Stroke volume is increased in the lateral position. This may reflect increased venous return suggesting aortocaval compression may be a complication of positioning in the sitting position (Armstrong et al., 2011).

2. Encourage intake of sports drinks.
Some clients need isotonic sports to drink to prevent secondary uterine inertia (a cessation of labor contractions) and combat generalized dehydration and exhaustion. A total of 61.4% of hospitals in China support pregnant women’s consumption of sports drinks during labor. Sports medical scientists believe that childbirth is similar to the process of athletes’ strenuous exercise, and sports drinks contain a lot of energy (Huang et al., 2020).

3. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted.
Clear liquids promote hydration and may provide some calories for energy production. Encourage the client to sip fluid during labor if they exercise to keep hydrated. If the client is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.

4. Provide appropriate oral care.
Even with adequate fluid intake, the client’s mouth and lips can become uncomfortably dry because of mouth breathing. Applying lip balm to prevent or relieve this discomfort can be helpful. Proper oral care and hard candy may reduce the discomfort of a dry mouth.

5. 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. According to Garite et al. (2000), the first phase of labor is significantly shorter in clients receiving fluids at 250ml/hr than those receiving fluids at 125 ml/hr (Lopez et al., 2019).

6. Administer dexamethasone to reduce nausea and vomiting, as prescribed.
According to study findings, dexamethasone has better antiemetic efficacy compared with promethazine. Studies suggested that the antiemetic effect of steroids may be partially due to their activity on the central nervous system or activation of glucocorticoid receptors in the medulla (Tazeh kand et al., 2015).

Risk for Ineffective Coping

Labor is such an intense process that it creates high emotional stress for the client and her support person. The ability to tolerate stress or cope adequately depends on the person’s perception of the event, the available support, and experience in using coping mechanisms.

Nursing Diagnosis
  • Risk For Ineffective Coping
May be related to

Common related factors for this nursing diagnosis:

  • Inadequate/exhausted support system
  • Personal vulnerability
  • Sense of “work overload”
  • A perceived threat to health
Possibly evidenced by
  • A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

  • The client will identify effective coping behaviors.
  • The client will engage in activities to maintain/enhance control.
  • The client and her support person will express confidence in their ability to cope with this event.
Nursing Assessment and Rationales

The following are the nursing assessment for this labor nursing care plan.

1. Assess the client’s level of labor pain.
Pain perception differs from one person to the next and is influenced by the individual’s physical, psychological, and cultural conditions. It has been suggested that antenatal fears complicate and prolong labor, increase the intensity of labor pain, and lead to negative birth experiences (Junge et al., 2018).

2. Assess the degree of uterine contractions and the progress of labor.
The cervix is evaluated for effacement and dilatation. The descent of the fetus is determined by the ischial spines (station). The combined powers of uterine contractions and voluntary maternal pushing in stage 2 of labor propel the fetus downward through the pelvis. Maternal exhaustion or epidural analgesia may reduce or eliminate the natural urge to push. This may inhibit the progress of labor and reduce blood flow to the placenta and fetus.

3. Assess the client’s response to labor.
The nurse assesses the client’s response to labor, including her use of breathing and relaxation techniques, and supports adaptive responses. Nonverbal behaviors that suggest difficulty coping with labor include a tense body posture and thrashing in bed. 

4. Determine cultural factors that may influence the client’s coping abilities.
Culture affects women’s beliefs and behaviors about labor pain. In Korean culture, women should remain silent during childbirth because they wouldn’t like to make their families ashamed. Whereas American and European women show a wide range of reactions to labor pain. Research indicated that childbirth pain has been accepted as part of a woman’s life in some societies and is considered a fundamental element of spiritual development (Yadollahi et al., 2018).

5. Assess the presence of positive coping skills.
Because pain is not a new phenomenon for a woman of childbearing age, it can be helpful to ask her to recall methods she usually uses to combat pain or anxiety, such as meditation or applying a cool cloth. Associating labor pain with usual circumstances can go a long way toward helping her collect her resources and decide on a workable pain relief strategy.

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Nursing Interventions and Rationales

Here are the nursing interventions for this labor nursing care plan.

1. Inform client/partner of initiation of each contraction.
This allows the client to rest/relax and maintain control of breathing patterns as the contraction begins. When palpation is used to evaluate contractions, the entire hand is placed lightly on the uterine fundus. The nurse should keep the fingers still when palpating contractions. Contractions may come so fast that the client cannot recover from one before another begins.

2. Acknowledge the reality of both client’s and partner’s irritable feelings.
The increase in intensity and frequency of contractions and the sudden urge to push may add to a sense of loss of control. The client’s hostility may be manifested as anger at the nurse or support person. In addition, the general fatigue of both client and partner further impairs their ability to cope. Fatigue reduces pain tolerance and the client’s ability to use coping skills. Many clients are tired when labor begins because sleep during late pregnancy is difficult.

3. Reinforce information that labor is progressing; encourage the client to cope with one contraction at a time.
This 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.” After each vaginal examination, the client is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to cope with labor. Laboring women often need support and reassurance to overcome their discouragement at this point.

4. Ensure that the client initiates breathing patterns under the direction of the partner. Breathe with the 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. The client may have difficulty understanding directions because of inward focus. Even women who attended prepared childbirth classes often find that the measures they learned are inadequate or need adaptation. Refresh controlled breathing and imagery with the support of the partner.

5. Encourage client and partner to verbalize doubts about the ability to continue and fear of being left alone (even if this fear is unfounded).
Many women are discouraged when their cervix is about 5 cm dilated because it has taken many hours to reach that point. They think they are only halfway through labor; however, a 5-cm dilation signifies that about two-thirds of the labor is completed as progress increases. 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. 

6. Provide support to the partner.
The client’s partner may feel helpless and require more support as the partner becomes less able to relieve the client’s pain. The partner should be permitted to provide the type of support comfortable for the couple. The nurse does not take the partner’s place but remains available. The partner should also be encouraged to take a break and periodically eat a snack or meal.

7. Assist the client in using natural methods to stimulate contractions.
Nipple stimulation causes the woman’s posterior pituitary gland to secrete natural oxytocin, strengthening contractions. Water may help the woman relax, which improves labor. All nonpharmacological methods stimulate labor to enhance her sense of control.

8. Help the client relax and use breathing techniques she learned in prepared childbirth classes.
Relaxation promotes normal labor. Praise and support the client when she uses breathing techniques. Praise encourages her to continue efforts at managing contractions.

9. Reposition the client frequently.
The recommended comfort positions for the laboring woman include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. Body support can be provided by pillows to prevent back strain. This position can also facilitate anterior rotation of the fetus when the client lies on the side of the fetal spine.

10. Assist with oxytocin augmentation if ordered.
The primary risks of oxytocin augmentation or labor induction relate to overstimulating the uterus. Observe contractions for excessive frequency, duration, or inadequate rest interval. Excessive contractions can reduce fetal oxygen supply. These are signs of potential uterine overstimulation. Observe FHR for rates outside the normal 110-160 beats/min range.

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Recommended Resources

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See also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her infant:

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With contributions by Marianne Belleza RN

Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
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