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 II: Expulsion

The second stage starts at full cervical dilatation until the infant’s birth. The woman may experience an uncontrollable urge to push and bear down 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

Pain is an unpleasant and distressing symptom that is personal and subjective. It is usually a symptom of injury or illness, yet pain during labor is an almost universal part of the normal process of birth. Although excessive pain is detrimental to the labor process, pain also can be beneficial. According to the gate control theory, pain is transmitted through small-diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the conduction of impulses through small-diameter fibers. 

Nursing Diagnosis
  • Acute Pain
May be related to

Common related factors for this nursing diagnosis:

  • Intensified contractile pattern
  • Mechanical pressure of presenting part
  • Muscle hypoxia
  • Nerve compression
  • Tissue dilation/stretching
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
  • Distraction behavior (e.g., restlessness)
  • Facial mask of pain
  • Narrowed focus
  • Verbalizations
Desired Outcomes

Common goals and expected outcomes:

  • The client will verbalize a reduction in pain.
  • The client will use appropriate techniques to maintain control.
  • The client will rest between contractions.
Nursing Assessment and Rationales

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

1. Monitor and record pain from uterine activity with each contraction.
This provides information/legal documentation about continued progress; helps identify abnormal contractile patterns, allowing prompt assessment and intervention. Assess the level of pain from uterine contractions and pelvic pressure by verbal and nonverbal indicators using a rating scale of 1 to 10. Pain is a subjective symptom, so only the client can determine the degree of pain or what is most helpful to relieve it.

2. Identify the degree of discomfort and its sources.
The amount of discomfort the client experiences during contractions differs according to her expectations of and preparation for labor; the length of labor; the position of her fetus; the presence of fear, anxiety, worry, body image, and self-efficacy; and the availability of meaningful people around her to offer support.

3. Observe for perineal and rectal bulging, the opening of vaginal introitus, and changes in the fetal station.
Anal eversion and perineal bulging occur as the fetal vertex descends, indicating the need to prepare for delivery. The fetal presenting part acts as a wedge to efface and dilate the cervix as each contraction pushes it downward. In an abnormal presentation or position, the fetus applies uneven pressure to the cervix, resulting in less effective effacement and dilation, thus prolonging the labor and delivery process.

4. Review information with client/couple about type stage-specific to the delivery setting (e.g., local, pudendal block, lumbar epidural reinforcement) or transcutaneous electrical nerve stimulation (TENS), acupressure, or acupuncture. Review advantages and disadvantages as appropriate.
Although the 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. For best results, be certain that the client is included in the selection of these methods and understands any fetal effects or maternal side effects that might occur.

5. Monitor maternal BP and pulse and FHR.
The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This blocking leads to decreased peripheral resistance in the client’s circulatory system. Fetal hypoxia or bradycardia is possible, owing to decreased circulation within the maternal portion of the placenta.

6. 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 the face, eyes, or mouth.
Other adverse reactions may occur after administering a spinal or peridural anesthetic, especially when morphine is used. Epidural block’s most common side effects are maternal hypotension and urinary retention. After initiation of the epidural block, the FHR and BP should be monitored and documented every 5 minutes for 15 minutes and then every 30 minutes for 1 hour. The nurse should palpate the suprapubic area for a full bladder every 2 hours or more because it may delay birth or cause hemorrhage after birth.

7. Monitor level of block per protocol.
Migration of decreased sensation from the belly button (dermatome T-10) to the tip of the breastbone (appx. T-6) increases the risk of profound hypotension. Numbness or loss of movement after a small test dose indicates that her dura mater was probably punctured. The drug was injected into the subarachnoid space rather than the epidural space. Numbness around the mouth, ringing in the ears or tinnitus, visual disturbances, or jitteriness are signs that suggest injection into a vein. This necessitates an evaluation of drug concentration /infusion rate by anesthesia personnel.

Nursing Interventions and Rationales

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

1. Provide information and support related to the progress of labor.
This keeps the couple informed of the proximity of delivery; reinforces that efforts are worthwhile and the “end is in sight.” Tell the client and her partner when labor progresses; for example, if she pushes and her infant’s head becomes visible, let her see or feel it. Labor does not last forever; knowing that her efforts have the desired results gives her courage to continue and helps her tolerate the pain.

2. Provide comfort measures for a conducive environment.
This promotes psychological and physical comfort, allowing the client to focus on labor, and may reduce the need for analgesia or anesthesia. Adjust the room temperature and light level for comfort. Change the client’s wet underpads to reduce irritants. These general measures reduce outside irritants that make it harder for the client to use childbirth preparation techniques and are a source of discomfort. A comfortable environment is conducive to relaxation.

3. Encourage client/couple to manage efforts to bear down with spontaneous, rather than sustained, pushing during contractions. Stress the importance of using abdominal muscles and relaxing the pelvic floor.
Anesthetics may interfere with the client’s ability to feel sensations associated with contractions, resulting in ineffective bearing down. Valsalva technique or directed pushing requires prolonged and repeated breath-holding and bearing down, which causes the glottis to close, increasing intrathoracic pressure. In spontaneous pushing, the woman pushes three to five times per contraction, following their instincts (open glottis). Spontaneous, rather than sustained, efforts to bear down avoid the 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 the effort to expel the fetus. Spontaneous pushing increases the levels of satisfaction of women with their birth experiences. It also improves fetal and maternal oxygenation (Hassan et al., 2021).

4. Encourage the client to relax all muscles and rest between contractions.
Complete relaxation between contractions promotes rest and helps limit muscle strain/fatigue. Relaxation keeps the abdominal wall from becoming tense, allowing the uterus to rise with contractions without pressing against the hard abdominal wall. It also serves as a distraction technique because, while concentrating on relaxing, the client cannot concentrate on the pain.

5. Assist the client in assuming the optimal position for bearing down; (e.g., squatting or lateral recumbent semi-Fowler’s position (elevated 30–60 degrees). Assess the effectiveness of efforts to bear down.
Proper positioning with the relaxation of perineal tissue optimizes bearing-down efforts, facilitates labor progress, reduces discomfort, and reduces the need for forceps application. Squatting during a contraction increases the diameter of the pelvis, facilitating fetal rotation and descent. The lateral Sims position encourages rest and helps prevent pressure on the sacrum. These regular changes of position make the laboring woman more comfortable and promote the normal labor processes.

6. Assist with reinforcement of medication via indwelling lumbar epidural catheter when caput is visible. Monitor vital signs and adverse responses.
This reduces the discomfort associated with episiotomy, forceps application, and fetal expulsion. The ultrasound-guided indwelling epidural catheter can be used to give epidural anesthesia to puerpera to reduce the pain during childbirth. Results of a research study showed that epidural anesthesia could significantly relieve the pain of parturients, accelerate the progress of labor, and shorten the delivery time of the parturient (Wang et al., 2020). Adverse reactions include maternal hypotension, muscle twitching/ convulsions, loss of consciousness, reduced FHR, and beat-to-beat variability.

7. Assess bladder fullness. Catheterize between contractions if distension is noted and the client cannot void.
A full uterus and fetal head can obstruct a full bladder. Catheterization may promote comfort, facilitate fetal descent, and reduce the risk of bladder trauma caused by presenting part of the fetus.

8. Position client in dorsal lithotomy position and assist with the administration of pudendal anesthetic.
A pudendal block anesthetizes the lower two-thirds of the vagina and perineum during delivery and for episiotomy repair. Although a pudendal block is local, assess the FHR and maternal BP immediately after the injection to ensure maternal hypotension does not occur.

9. Assist as needed with the administration of local anesthetic just before episiotomy, if done.
Local anesthetics anesthetize perineum tissue for incision/repair purposes. Local infiltration is the injection of an anesthetic such as lidocaine into the superficial nerves of the perineum along the vulva. The effect lasts for approximately 1 hour, allowing for a less painful birth and suturing of an episiotomy.

Lumbar, Epidural, or Low Spinal Anesthesia

1.  Administer IV fluid bolus of 500–1000 ml lactated Ringer’s as indicated, before administration of the agent.
Administration of IV fluid increases maternal circulating fluid as a means of preventing adverse reactions of anesthetic such as maternal hypotension, fetal hypoxia, and fetal bradycardia. Ringer’s lactate is preferable to a glucose solution because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn.

2. Position client in sitting or lateral recumbent position for insertion of drug/placement of a catheter for continuous infusion. Have client flex head sharply on chest/arch back during intrathecal administration.
If the client curves her back outward, this increases the intravertebral spaces and allows easier access to the injection site. Proper alignment of vertebrae maximizes space for needle /catheter placement.

3. Turn the client side to side periodically during continuous infusions.
Following anesthetic administration, be certain the client lies on her side, or if on her back, she should place a firm towel under her left hip to avoid hypotension from poor blood return to the heart. The nurse should be in continuous attendance as long as epidural anesthesia is being used.

4. Assist with administration of opiates (e.g., fentanyl [Sublimaze], morphine) into epidural space via an indwelling catheter. Have ephedrine, 10 mg, or naloxone (Narcan), 0.4 mg, available as an antidote, depending on the agent used.
Intraspinal narcotic, acting on opiate receptors within the spinal column, blocks pain for as long as 11 hr. Timing the administration of narcotics during labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after birth. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. Because of the fetal effects, a narcotic antagonist such as naloxone should be available for administration to the infant at birth if needed.

5. Administer oxygen and increase plain IV fluid. If hypotension occurs, displace the uterus to the left and elevate the legs.
This enhances venous return and circulating blood volume, increasing placental perfusion and oxygenation. Raise the client’s legs and administer oxygen and additional IV fluid along with an anti-hypotensive agent such as ephedrine to elevate the BP. this is an emergency because if the client is severely hypotensive, blood is shunted away from the uterus and leads to poor perfusion of the placenta, eventually causing fetal distress.

6. Assist with administration of intrathecal subarachnoid anesthetic. Identify the beginning and end of contractions. Administer anesthetic between contractions when the fetal head is on the perineum.
Subarachnoid block 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. A much smaller quantity of the drug is needed to achieve anesthesia using the subarachnoid block than with the epidural block. Anesthesia occurs quickly and is more profound than the epidural block. The client loses all movement and sensation below the block. The effect lasts longer than the epidural block.

Transcutaneous Electrical Nerve Stimulation

1. Encourage and assist client/couple with operating control knobs on battery-operated device.
The ability to turn on mild electrical currents during a contraction promotes a feeling of control for the client. TENS works to relieve pain by applying counterirritation to nociceptors. As labor and descent progress, the electrodes are moved to stimulate the S2 through S4 level. High-intensity stimulation is generally needed to control the pain at this stage.

2. Apply two pairs of electrodes on either side of the thoracic and sacral vertebrae.
Electrical stimulation of pain receptors (by TENS units) within the skin may block pain sensations by causing the release of endorphins. It has no adverse effect on the client or fetus and may reduce the need for analgesia or anesthesia. Women with extreme back pain may benefit most from a TENS unit because this type of pain is difficult to relieve with controlled breathing exercises. This method may reduce the need for epidural anesthesia and postpone the use of pharmacologic agents.

Complementary Therapy

1. Assist with acupressure /acupuncture.
Acupuncture is based on the concept that illness results from an energy imbalance. To correct the imbalance, needles are inserted into the skin at designated susceptible body points (tsubos) located along meridians that course throughout the body to supply the body’s organs with energy. Activation of these points (which are not necessarily near the affected organ) results in a release of endorphins, making this system helpful, especially in the first stage of labor.

Acupressure is the application of pressure or massage at these same points. It seems to be most effective for low back pain. A common point used for women in labor is Co4 (Hoku or Hegu point), which is located between the first finger and thumb on the back of the hand. Women may report their contractions to feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point.

General Anesthesia

1. 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. Pregnant women are particularly prone to gastric reflux and aspiration because of increased stomach pressure from the weight of the full uterus beneath it. The gastroesophageal valve at the top of the stomach also may be displaced and possibly functioning improperly.

2. Assist with general anesthesia (inhalation or IV administration).
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. There is a danger of vomiting with a general anesthetic; this can be fatal if a woman’s airway becomes occluded by foreign matter. In addition, stomach contents have an acid pH that can cause chemical pneumonitis and secondary respiratory tract infection.

3. Administer IV ranitidine or an oral antacid before the general anesthesia.
Some anesthesiologists may prescribe IV ranitidine (Zantac) or an oral antacid such as sodium citrate before general anesthesia is administered to reduce the acid level in stomach contents should aspiration occur. Metoclopramide (Reglan) increases gastric emptying and may also be prescribed. 

Altered Cardiac Output

As early as the first trimester of pregnancy, a rapid increase in cardiac output (CO) continues throughout the second trimester. Multiple studies investigating CO during delivery using a modified pulse-pressure method after arterial and central venous catheterization and continuous-wave ultrasound have suggested that stroke volume (SV) and CO increase during labor and immediately postpartum owing to pain, maternal bearing-down efforts, and the increase in venous return by autotransfusion from the contracted uterus and the sudden release of inferior vena cava obstruction (Bijl et al., 2019).

Nursing Diagnosis
  • Altered Cardiac Output
May be related to

Common related factors for this nursing diagnosis:

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  • Changes in systemic vascular resistance
  • Fluctuation in venous return
Possibly evidenced by

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

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

Common goals and expected outcomes:

  • The client will maintain vital signs appropriate for the stage of labor.
  • The client will display FHR and variability within the normal limit.
  • The client will use appropriate techniques to sustain/enhance vascular return.
Nursing Assessment and Rationales

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

1. Monitor FHR after every contraction or bearing-down effort.
This detects fetal bradycardia and hypoxia associated with a reduction in maternal circulation and reduced placental perfusion caused by anesthesia, Valsalva’s maneuver, or incorrect positioning. The maternal hemodynamic changes associated with the Valsalva maneuver may result in reduced placental perfusion and fetal oxygenation (Lee et al., 2019).

2. Monitor BP and pulse frequently (every 5–15 min). Note amount and concentration of urine output; test for albuminuria.
The use of Valsalva results in an increased intrathoracic pressure leading to a reduction in venous return and subsequent cardiac output. 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. Intrapartum toxemia due to stress, excess sodium, fluid retention, or oxytocin administration may be manifested by increased BP, decreased urine output, and increased concentration of urine (Lee et al., 2019).

3. Monitor BP and pulse immediately after administration of anesthesia, and repeat until the 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. After initiation of the epidural block, the FHR and BP should be monitored and documented every 5 minutes for 15 minutes and then every 30 minutes for 1 hour. 

Nursing Interventions and Rationales

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

1. Encourage the 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 the client to push only when she feels the urge to do so. Avoid directed pushing.
Directed pushing has been associated with a decrease in mean cerebral oxygen concentration. 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 the fall of maternal PO2 and the rise in PCO2 levels, which would harm the fetus (Lee et al., 2019).

2. 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. 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). When the laboring woman is in an upright position to give birth, there is less risk of compressing the mother’s aorta, which means a better oxygen supply to the fetus (Berta et al., 2019).

3. Position the client in the lateral position during induction of neuraxial anesthesia.
Stroke volume is increased in the lateral position compared with the sitting position during induction of neuraxial anesthesia. This may reflect an increased venous return in the lateral positions, suggesting that aortocaval compression may be a complication of positioning in the sitting position (Armstrong et al., 2011).

4. 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 the development of intrapartum toxemia. If abnormalities are noted in either FHR or maternal vital signs, the nurse stops the oxytocin and begins measures to reduce contractions and increase placental blood flow.

Risk For Impaired Gas Exchange (Fetal)

The second stage of labor is defined as the period from full dilatation of the cervix until the expulsion of the fetus. This stage includes frequent and regular pushing and women experience frequent vaginal rectal pressure and extreme pushing. A common technique during this stage is the Valsalva maneuver. Several physiologic findings oppose the use of the Valsalva maneuver of 10 seconds or more, as this type of directed pushing can negatively affect fetal acid-base balance, Apgar scores, and cerebral oxygenation. A relationship has been observed between the Valsalva maneuver and the reduction of oxygen supply to the fetus (Basar & Hurata, 2018).

Nursing Diagnosis
  • Risk For Impaired Gas Exchange
May be related to

Common related factors for this nursing diagnosis:

  • Maternal hyperventilation
  • Mechanical compression of head/cord
  • Prolonged labor
  • Reduced placental perfusion
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 variable or late decelerations with FHR within the normal limit.
  • The client will use positions promoting venous return/placental circulation.
Nursing Assessment and Rationales 

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

1. Assess the client’s breathing pattern. Note reports of tingling sensation of face or hands, dizziness, or carpopedal spasms.
This identifies ineffective (inappropriate) respiratory patterns. During labor, maternal hyperventilation associated with anxiety and pain may become pronounced. 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 (Tomimatsu et al., 2012).

2. Assess FHR, with a fetoscope or fetal monitor, during and after each contraction or pushing effort.
Due to vagal stimulation from head compression, early decelerations should return to baseline patterns between contractions. Early decelerations normally occur late in labor, when the head has descended fairly low; they are viewed as innocent. Suppose they occur early in labor before the head has fully descended. In that case, the head compression causing the waveform change could result from cephalopelvic disproportion and is cause to investigate.

3. Determine fetal station, presentation, and position. Place the client on her side if the fetus is in an occiput posterior position.
During stage II labor, the fetus is most vulnerable to bradycardia and hypoxia, associated with vagal stimulation during head compression. Malpresentations such as the face, mentum (chin), or brow may prolong labor and increase the risk of hypoxia and the likelihood of the need for cesarean birth. In contrast, the posterior position increases the duration of stage II labor. Placing the client in a lateral recumbent position facilitates fetal rotation from the occiput posterior (OP) position to occiput anterior (OA) position.

4. Note short- and long-term FHR variability.
Average beat-to-beat changes should range from 6 to 10 bpm, indicating integrity of fetal CNS. Variability is reflected on an FHR tracing as a slight irregularity or “jitter” to the wave.  If no variability is present, it indicates the natural pacemaker activity of the fetal heart may be affected. This may occur as a response to narcotics or barbiturates administered to a woman in labor, but the possibility of fetal hypoxia and acidosis must also be considered. 

5. Monitor client for fruity breath odor.
This suggests acidosis is associated with hyperventilation. As shifts in acid-base levels occur, fetal status can be compromised with resultant acidosis and hypoxia. Maternal hypocapnia limits placental O2 transfer to the fetus by increasing oxyhemoglobin affinity. Because of the high diffusibility of CO2 across the placenta, maternal hypocapnia is also closely associated with low fetal PCO2 values (Tomimatsu et al., 2012).

6. Monitor periodic changes in FHR for severe, moderate, or prolonged decelerations. Note the presence of variable or late decelerations.
Variable decelerations indicate hypoxia due to possible cord entrapment or a 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, kidney problems, placental aging, or following maternal anesthesia.

7. Assist as needed with intermittent fetal scalp sampling, if done.
This determines trends in fetal acid-base status and sampling, if done, the presence of fetal acidosis. If FHR variability appears to be depressed during labor, the welfare of a fetus can be assessed by scalp stimulation. This is done by applying pressure with the fingers to the fetal scalp through the dilated cervix. This causes a tactile response in the fetus that momentarily increases the FHR. If the fetus is in distress and becoming acidotic, FHR acceleration will not occur. The pH of fetal blood falls rapidly during stage II labor, and prolonged hypoxia may result in anaerobic metabolism with lactic acid buildup. 

8. Assist in obtaining umbilical cord gases.
There are no contraindications to obtaining cord gases. The ACOG Committee on Obstetric Practice recommends obtaining umbilical venous and arterial blood samples in abnormal FHR tracing. Isolated respiratory acidemia is diagnosed when the umbilical artery pH is less than 7.20, the PCO2 is elevated, and the base deficit is less than 12 mmol/L. This reflects an interrupted exchange of blood gasses, usually a transient phenomenon related to umbilical cord compression (Grobman et al., 2018).

Nursing Interventions and Rationales

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

1. Position client in lateral recumbent or upright position, or turn side to side as indicated.
These positions also increase placental perfusion, prevent the supine hypotensive syndrome, and take pressure from presenting part of the cord, enhancing fetal oxygenation and improving FHR patterns. Giving birth in an upright position can benefit the mother and baby for several physiologic reasons. When a laboring woman is in an upright position to give birth, there is less risk of compressing the mother’s aorta, which means there is a better oxygen supply to the fetus. Upright positioning also helps the uterus contract more strongly and efficiently. As a result, it helps the fetus get in a better position (Berta et al., 2019).

2. Avoid placing the client in a dorsal recumbent position.
This position contributes to fetal hypoxia and acidosis; reduces baseline variability and placental circulation. Assist the client in whatever position she feels will be most effective for pushing (e.g., squatting, sitting upright), leaning forward against her partner) is important to help align the fetal presenting part with the cervix, increase the pelvic diameters, and use the fetal weight to help descent so that a prolonged second stage does not occur.

3. Assist partner in helping with verbal coaching of respirations.
This allows the couple to work together to maintain/regain control of the situation and maintain a state of relaxation during contractions. When it is time for the client to push, the client takes a cleansing breath, takes another deep breath, and pushes down while exhaling to a count of 10.

4. Encourage the client to focus on an object/mental picture.
Imagery and distraction may stimulate the client’s brain, thus limiting her ability to perceive sensations as painful. The client fixes her eyes on a picture, an object, or simply a particular spot in the room. The client may also learn to create a tranquil mental environment by imagining that she is in a place of relaxation and peace. During labor, the client can imagine her cervix opening and allowing the infant to come out as a flower opens from a bud to full bloom.

5. Encourage the client/couple to inhale and exhale every 10–20 seconds during bearing-down efforts. Monitor response to pushing efforts.
This helps maintain adequate oxygen levels. Exhaling while pushing minimizes the physiological effects of Valsalva’s maneuver, which can decrease maternal heart rate and PO2 and increase PCO2, potentially resulting in placental and fetal hypoxia and acidosis. The neonatal outcomes associated with direct pushing may also be related to the physiological effects of the directed pushing technique. The maternal hemodynamic changes associated with the Valsalva maneuver may reduce placental perfusion and fetal oxygenation (Lee et al., 2019).

6. Have the client breathe into cupped hands or a small paper bag.
During labor, maternal hyperventilation associated with anxiety and pain may become pronounced. In addition, hyperventilation may be induced by instructions to breathe deeply during labor. Breathing into a paper bag increases carbon dioxide levels and corrects respiratory alkalosis caused by hyperventilation (Tomimatsu et al., 2012).

7. 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. Intrapartum fetal surveillance is performed to prevent fetal/neonatal hypoxia, leading to childbirth-related neonatal encephalopathy, cerebral palsy, and perinatal death (Razem et al., 2020).

If severe bradycardia, late decelerations, or prolonged variable decelerations appear:

8. Place the client in a lateral recumbent position; increase plain IV fluid.
Late decelerations are when the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively. Immediately change the client’s position from supine if she is lying down to lateral to relieve pressure on the vena cava and supply more blood to the uterus and fetus.

9. Administer oxygen to the client.
Increases circulating oxygen available for fetal uptake. During this stage of labor, enhanced metabolic processes increase oxygen consumption by twice the normal level. It was shown that maternal O2 supplementation increases fetal cerebral tissue oxygenation. In cases where the client requires a high oxygen concentration, a partial rebreathing mask may be used with high oxygen flow (5-15 L/min) to achieve 40-70% O2 by preventing CO2 rebreathing (Tomimatsu et al., 2012).

10. 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. Emergent cesarean births are done for sudden reasons in labor, such as placenta previa, premature separation of the placenta, fetal distress, or failure to progress.

Risk For Imbalanced Fluid Volume

Labor pains ordinarily persist for more than several hours for a vaginal delivery. While the oral intake of fluids may be reduced in parturient women because of labor pains, insensible water loss may be increased due to excessive sweating and hyperventilation. This may lead to dehydration in the mother (Watanabe et al., 2001).

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

Common related factors for this nursing diagnosis:

  • Active loss
  • Fluid shifts
  • Reduced 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 within normal limits.
  • The client’s urine will be free from ketones; specific gravity is between 1.003 and 1.030; skin turgor and serum electrolyte levels are within acceptable parameters.
Nursing Assessment and Rationales

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

1. Assess FHR and baseline; note periodic changes and variability (if an 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. Variability is reflected on an FHR tracing as a slight irregularity or “jitter” to the wave.  If no variability is present, it indicates the natural pacemaker activity of the fetal heart may be affected. This may occur as a response to narcotics or barbiturates administered to a woman in labor, but the possibility of fetal hypoxia and acidosis must also be considered.

2. Monitor temperature, as indicated.
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.

3. Measure intake/output and urine-specific gravity. Assess skin turgor and production of mucus. Note albuminuria.
In 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. 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.

4. 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.

5. 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.

6. Assess for vomiting and diarrhea.
Vomiting and diarrhea occasionally accompany labor; they can add to fluid and electrolyte losses if they occur. Ask the client if she had any vomiting or diarrhea to determine the possible extent because extended vomiting and diarrhea can lead to serious dehydration and electrolyte imbalance.

Nursing Interventions and Rationales

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

1. Place the client in an upright or lateral recumbent position.
These positions also increase placental perfusion, prevent the supine hypotensive syndrome, and take pressure from presenting part of the cord, enhancing fetal oxygenation and improving FHR patterns. Giving birth in an upright position can benefit the mother and baby for several physiologic reasons. When a laboring woman is in an upright position to give birth, there is less risk of compressing the mother’s aorta, which means there is a better oxygen supply to the fetus. Upright positioning also helps the uterus contract more strongly and efficiently. As a result, it helps the fetus get better (Berta et al., 2019).

2. Reduce excess clothing, cool body with wet cloths, and maintain a cool environment. Protect from chilling.
This cools the body through evaporation; may reduce diaphoretic losses. Muscle tremors associated with chilling increase body temperature and general discomfort. Change the client’s linens and underpads to promote a comfortable environment if they are soaked.

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3. Encourage the intake of oral fluids such as 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).

4. Review the client’s urinalysis results.
Test and review the client’s urine each time she voids during labor for glucose, protein, ketones, and specific gravity. Ketones in the urine suggest starvation ketosis. A concentrated specific gravity suggests a lack of fluid. Extreme dehydration may slow labor and lead to increased blood viscosity, possibly increasing the risk for thrombophlebitis during the postpartal period.

5. 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.

6. Administer fluids parenterally.
Solutions such as lactated Ringer’s administered intravenously help correct or prevent electrolyte imbalances. When inserting the IV catheter, try to use an insertion site in the client’s non-dominant hand and, if necessary, only a small “reminder” hand board. Use long tubing or attach extensions so that the client can move about freely, and her mobility is not limited or restricted by the short length of IV tubing.

Risk For Fetal Injury

Childbirth is a normal, natural event in the lives of most women and their families. Complications are unlikely when the many factors that affect the birth process function in harmony. However, some women experience complications during childbirth that threaten the infant’s well-being. Additionally, labor abnormalities may necessitate forceps or cesarean delivery, and they are more likely to result in injury to the mother or fetus.

Nursing Diagnosis
  • Risk for Injury
May be related to

Common related factors for this nursing diagnosis:

  • Malpresentations/positions
  • Precipitous delivery, or cephalopelvic disproportion (CPD)
Possibly evidenced by
  • Signs and symptoms do not evidence a risk diagnosis. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

  • The fetus will be free of preventable trauma or other complications.
  • The fetus will be delivered safely through spontaneous vaginal delivery.
Nursing Assessment and Rationales

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

1. Assess the amount of amniotic fluid expelled when membranes rupture and then during contractions.
Hydramnios is associated with fetal disorders such as anencephaly, gastrointestinal tract disorders, kidney dysfunction, and maternal diabetes. Oligohydramnios is associated with post maturity and intrauterine growth retardation secondary to placental insufficiency. The fetus can also become entangled in the umbilical cord during the version if the amount of amniotic fluid is minimal.

2. Note the color of amniotic fluid.
The amniotic fluid’s color, odor, amount, and character are recorded. The fluid should be clear, possibly with flecks of vernix and lanugo, and should not have a bad odor. Cloudy, yellow, or malodorous fluid suggests infection. Meconium-stained amniotic fluid, greenish in color, may indicate fetal distress caused by hypoxia in a vertex presentation or compression of the fetal intestinal tract in breech presentation.

3. Assess fetal position, station, and presentation.
Malpresentations such as the 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. The 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.

4. Determine fetal size before delivery.
A large fetus is generally considered to weigh more than 4000 g (8.8 lbs) at birth. The large fetus may not fit through the client’s pelvis. Sometimes a single part of the fetus is too large. Shoulder dystocia may occur, usually when the fetus is large. The fetal head is born, but the shoulders become impacted above the mother’s symphysis pubis. Shoulder dystocia is an emergency because the fetus needs to breathe. The head is out, but the chest cannot expand. The large infant is more likely to have a fracture of one or both clavicles. The infant’s clavicles are felt for crepitus or deformity of the bones, and the arms should be observed for equal movement.

5. 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 the dimensions of the birth canal. Descent is expected to occur at a rate of at least 1.0 cm/hr in a nulliparous client and 2.0 cm/hr in a multiparous client. Fetal oxygenation can be compromised by intense contractions because normally, the placenta is resupplied with oxygenated blood between contractions. Birth injury from a rapid passage through the birth canal may become evident in the infant after birth. These injuries can include intracranial hemorrhage or nerve damage.

6. Monitor FHR after the rupture of membranes.
The prolapsed cord risk increases if the membranes rupture before the fetal presenting part is completely engaged in the pelvis. Documenting the FHR after the membranes rupture is an essential nursing responsibility.

7. Assess the client’s pelvic measurements early during the pregnancy.
Every primigravida should have pelvic measurements taken and recorded before week 24 of pregnancy. Based on these measurements and the assumption the fetus will be of average size, a birth decision can be made. The measurement can be made by sonogram during pregnancy but can easily be made manually at a prenatal visit or at the beginning of labor.

Nursing Interventions and Rationales

1. Maintain a record of events and nursing care.
Accurate documentation provides information about neonate/client status and postpartal needs. Nursing documentation is an important aspect of safe and ethical nursing care. Failure to properly document nursing care significantly affects the diagnosis and treatment of serious clinical conditions (Tajabadi et al., 2020).

2. Remain with the client and monitor pushing efforts as the head emerges. Instruct the client to pant during the process.
This ensures that trained personnel are present and reduces the possibility of trauma to the fetal vertex; it allows gradual accommodation of skull bones to the birth canal and overriding of sutures. Continuous support by a professional (usually a doula, but also by midwives or nurses) during labor decreases operative vaginal and cesarean birth, is associated with a lower incidence of low neonatal Apgar scores. This support may include emotional support and information about labor progress. It may also include advice about coping mechanisms and comfort measures and speaking up when needed on behalf of the client (Berghella & Di Mascio, 2020).

3. Position the client in a knee-chest or Trendelenburg position in the event of a prolapsed cord.
The main risk of a prolapsed cord is to the fetus. When a prolapsed cord occurs, the first action is to displace the fetus upward to stop compression against the pelvis. Maternal positions such as the knee-chest or Trendelenburg position can accomplish this displacement. Placing the mother in a side-lying position with her hips elevated on pillows reduces cord pressure.

4. Encourage the client to assume positions that favor fetal rotation and descent.
Good positions for back labor include sitting, kneeling, or standing while leaning forward; rocking the pelvis back and forth while on hands and knees to encourage rotation; side-lying; squatting; lunging by placing one foot in a chair with the foot and knee pointed to that side, and lunging sideways repeatedly during a contraction for 5 seconds at a time.

5. Cover the exposed cord with a sterile saline compress to prevent drying.
If the cord has prolapsed to the extent it is exposed to room air; drying will begin, leading to constriction and atrophy of the umbilical vessels. Do not attempt to push any exposed cord back into the vagina because this could add to the compression by causing knotting or kinking. Instead, cover any exposed portion with a sterile saline compress to prevent drying.

6. Assist the client to flex her thighs sharply on her abdomen if there is shoulder dystocia.
Asking or assisting the client to flex her thighs sharply on her abdomen (McRoberts maneuver) widens the pelvic outlet and may allow the anterior shoulder to be born. Applying suprapubic pressure may also help the shoulder escape from beneath the symphysis pubis and be born. These are the first two maneuvers that help resolve shoulder dystocia.

7. Obtain an emergency delivery kit if delivery is not usually done in the labor room.
This assures the availability of needed equipment and supplies if labor progresses too rapidly for 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. Rapid labor poses a risk to the fetus because subdural hemorrhage may result from the rapid release of pressure on the head. Grand multiparas and clients with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled environment.

8. Transfer to the delivery room, as appropriate, when the vertex is visible at introitus in nullipara or when multipara is 8 cm dilated.
Suppose delivery is to occur in an area separate from the labor setting. In that case, transfer at this time ensures that the infant is born and emergency medications and equipment are available if needed. There is no exact time when the client should be prepared for delivery. In general, the client’s first child is prepared for delivery when about 3 to 4 cm of the fetal head is visible at the vaginal opening (crowning). If the client must be transferred to a delivery room rather than giving birth in an LDR room, she should be moved early enough to avoid a last-minute rush.

9. 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 the vertex may increase the risk of fetal injury, yet the OA position is the preferred position for delivery. OP positions are the most common type of malposition, comprising between 1% and 5%. They are often accompanied by deflexion, resulting in a larger presenting diameter. The presence of asynclitism and molding can make it difficult to correctly determine position, leading to an inaccurate diagnosis of occiput anterior (Cigna et al., 2016).

10. Assist with external cephalic version, if indicated.
The external cephalic version is the turning of the fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. Although not always successful, using an external cephalic version can decrease the number of cesarean births necessary from breech presentations.

11. Assist with vaginal delivery when the fetus is in the posterior position.
The posterior position increases the possibility of fetal trauma caused by neck injuries. Instead of flexing the head as labor proceeds, a fetus in a posterior position may extend the head, resulting in a face presentation; this usually occurs in a client with a contracted pelvis or placenta previa.

12. Assist with other methods of birth, such as forceps and vacuum extraction births.
Forceps or vacuum extraction may be used to end the second stage of labor if it is in the best interest of the mother or fetus. Women with cardiac or pulmonary disorders often have forceps or vacuum extraction births because prolonged pushing can worsen these conditions. However, the infant may have bruising, facial or scalp lacerations or abrasions, cephalhematoma, or intracranial hemorrhage. The vacuum extractor causes a harmless area of circular edema on the infant’s scalp (chignon) where it was applied.

13. Prepare for surgical intervention, if indicated.
This may be necessary in cases of CPD, persistent OP position, deep, transverse arrest of the head with prolonged stage II labor or fetal distress, or with breech or shoulder presentation. A fetus with anencephaly may not dilate maternal tissues effectively and may require surgical intervention.

Risk For Maternal Infection

Bacterial infections around the time of childbirth (peripartum infections) account for about one-tenth of maternal deaths globally. In addition to the high risk of mortality and acute morbidity, women who experience peripartum infections are also vulnerable to serious long-term disabilities such as chronic pelvic pain, fallopian tube blockage, and secondary infertility (the inability to become pregnant or carry a pregnancy to term after the birth of one or more children) (World Health Organization, 2015). 

Nursing Diagnosis
  • Risk for Infection
May be related to

Common related factors for this nursing diagnosis:

  • Exposure to pathogens
  • Prolonged labor, or rupture of membranes
  • Repeated invasive procedures
  • Traumatized tissues
Possibly evidenced by
  • Signs and symptoms do not evidence a risk diagnosis. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

  • The client will be free of infection.
  • The client will display vital signs within the normal range.
  • The client will be free of preventable complications.
Nursing Assessment and Rationales

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

1. Monitor temperature, pulse, and WBC count, as indicated.
Increased temperature or pulse greater than 100 bpm may indicate infection. Normal protective leukocytosis with a WBC count as high as 25,000/mm3 must be differentiated from an elevated WBC count caused by infection. According to facility policy, the client’s temperature is taken every 2 to 4 hours after her membranes rupture. A maternal temperature of 38.°C (100.4°F) or higher suggests infection. An increase in the FHR, especially if more than 160 beats/min, may precede the client’s temperature increase.

2. Note the date and time of rupture of membranes; observe the characteristics of the amniotic fluid.
Within 4 hr after rupturing of membranes, the client and fetus are at increased risk for ascending tract infections and possible sepsis. The amniotic fluid’s color, odor, amount, and character are recorded. The fluid should be clear, possibly with flecks of vernix and lanugo, and should not have a bad odor. Cloudy, yellow, or malodorous fluid suggests infection.

Nursing Interventions and Rationales

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

1. Perform perineal care per protocol, using medical asepsis.
Women with ruptured membranes who received vaginal preparation with povidone-iodine solution had a lower risk of post-cesarean endometritis. Vaginal preparation with povidone-iodine solution immediately before cesarean birth can reduce postoperative endometritis, particularly in women with ruptured membranes or those who are already in labor (World Health Organization, 2015).

2. Remove fecal contaminants expelled during pushing; change linens /underpads during pushing; change linens/underpads as needed.
This helps promote cleanliness; prevents the development of ascending uterine infection and possible sepsis. When amniotomy is anticipated, several disposable underpads are placed under the client’s hips to absorb the fluid that continues to leak from the woman’s vagina during labor. Disposable underpads are changed often enough to keep her reasonably dry and to reduce the moist, warm environment that favors the growth of microorganisms.

3. Perform strict hand hygiene before and after procedures.
The hand hygiene of healthcare workers (HCWs) is the cornerstone of these practices. Alcohol-based hand rubs (ABHRs) could provide a more practical and efficient system for hand hygiene, particularly when changing gloves. ABHRs that are effective against many of the pathogens associated with maternal and neonatal infections have improved hand hygiene in high-income settings when accessed through mobile dispensers or at the point of care (Buxton et al., 2019).

4. Perform vaginal examination only when necessary, using an aseptic technique.
Repeated vaginal examination increases the risk of endometrial infections. The recommended time intervals are consistent with the timing of vaginal examination on the partograph and further reinforce the importance of using the partograph as an essential tool to implement this practice. Priority must be given to restricting the frequency and the total number of vaginal examinations. This is particularly crucial in situations where there are other risk factors for infection (e.g., prolonged rupture of amniotic membranes and long duration of labor) (World Health Organization, 2015).

5. Use surgical asepsis in preparing equipment. Clean perineum with sterile water and soap or surgical disinfectant just before delivery.
Surgical asepsis reduces the risk of contamination. Women in labor who received vaginal preparation with povidone-iodine solution preoperatively had a lower risk of endometritis (World Health Organization, 2015).

6. Administer antibiotics, as indicated.
Used only occasionally, prophylactic antibiotics are controversial and must be used with caution because they may stimulate the overgrowth of resistant organisms. Antibiotic administration is recommended for clients with preterm prelabor rupture of membranes. According to WHO recommendations on interventions to improve preterm birth outcomes, Erythromycin is recommended as the antibiotic of choice for prophylaxis in clients with preterm prelabor rupture of membranes (World Health Organization, 2015).

7. Provide aseptic conditions for delivery.
This helps prevent postpartal infection and endometritis. Sepsis is a key contributor to maternal and neonatal mortality, accounting for 15% of all neonatal deaths and 1 in every 10 maternal deaths. Maternal sepsis is defined as life-threatening organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum (Buxton et al., 2019).

Risk For Impaired Skin Integrity

Trauma to the genital tract commonly accompanies vaginal birth. Perineal trauma is classified as first degree (involving the fourchette, perineal skin, and vaginal mucous membrane), second degree (involving the fascia and muscle of the perineal body), third-degree (involving the anal sphincter), and fourth-degree (involving the rectal mucosa) (Beckmann & Stock, 2013). Pushing before full cervical dilatation may cause cervical edema or lacerations, especially with a client’s first child, because the cervix is not as stretchable after one or more births. Contractions during precipitate labor can be so forceful they lead to lacerations of the perineum.

Nursing Diagnosis
  • Risk for Impaired Skin Integrity
May be related to

Common related factors for this nursing diagnosis:

  • Adolescence
  • Forceps application
  • Hypertonic contractile pattern
  • Large fetus
  • Precipitous labor
Possibly evidenced by
  • Signs and symptoms do not evidence a risk diagnosis. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

  • The client will relax perineal musculature during bearing-down efforts.
  • The client will be free of preventable lacerations.
Nursing Assessment and Rationales

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

1. Assess for bladder fullness; catheterize before delivery, as appropriate.
Inspect the client’s suprapubic area and palpate for bladder distention. A full bladder contributes to discomfort and may impede fetal descent, prolonging labor and causing perineal tears.

Nursing Interventions and Rationales

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

1. Help the client in assuming a position of choice/transfer to the delivery table between contractions. Monitor safety, and support legs, especially if an epidural (or caudal) catheter is in place.
This reduces the risk of injury, especially if the client cannot assist with the transfer. Urge the client to sit, stand, kneel on hands and knees, lie in a lateral recumbent position, squat, or use whatever position she prefers. Keep in mind that maintaining these positions often requires assistance from one or two support people to keep an unbalanced woman from falling.

2. Assist client/couple with proper positioning, breathing, and relaxing efforts. Ensure that client relaxes the perineal floor while using abdominal muscles in pushing.
This helps promote gradual stretching of perineal and vaginal tissue. Suppose 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, urethra, and clitoris are possible. The breathing technique of blowing is one of the methods that can reduce the pressure on the perineum. In this breathing technique, the increased pressure resulting from uterine contractions and the abdominal pressure during pushing is removed by exhalation and blowing. The muscles are slowly expanded only due to the phishing induced by the baby’s head (Ahmadi et al., 2017).

3. Place the client in left lateral Sims’ position for delivery, if desired/comfortable.
This reduces perineal tension, promotes gradual stretching, and reduces the need for an episiotomy. A population-based study conducted in Sweden on obstetric anal sphincter injury (OASI) and birth position found an increased risk of OASI with lithotomy position in nulliparous and parous clients and a decreased risk of OASI with a lateral birth position in nulliparous clients (World Health Organization, 2018).

4. Offer use of the birthing bed in an upright position. Encourage squatting, Fowler’s position, or standing while pushing if these positions are not contraindicated.
Upright positions reduce the duration of labor, enhance forces of gravity, reduce the need for episiotomy, and maximize uterine contractility. A practical approach to positioning in the second stage for clients desiring an upright birth position might be to adapt to a semi-recumbent or all-fours position just before expulsion of the fetus to facilitate perineal techniques to reduce perineal tears and blood loss (World Health Organization, 2018).

5. Apply warm perineal compresses during contractions.
Warm perineal compresses can be provided as pads soaked in warm sterile water (heated to between 45° and 59°C) and applied during contractions once the baby’s head distended the perineum. The pad can be re-soaked between contractions to maintain warmth. High-certainty evidence indicates that warm compresses reduce the incidence of third- or fourth-degree perineal tears (World Health Organization, 2018).

6. Educate the client on how to perform digital perineal massage antenatally.
Clients who practice digital perineal massage from approximately 35 weeks gestation are less likely to have perineal trauma, which requires suturing associated with vaginal birth. For every 15 clients who practiced digital perineal massage antenatally, one fewer will receive perineal suturing following the birth (Beckmann & Stock, 2013).

7. Maintain accurate delivery records of the location of episiotomy and lacerations. Record type and timing of forceps if used.
This ensures proper documentation of events occurring during the 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.

8. Assist as needed with a perineal massage.
Evidence suggests that perineal massage may increase the chance of keeping the perineum intact and reduce the risk of serious perineal tears. According to studies, perineal massage in the second stage of labor was performed with a lubricant. It generally involved the midwife inserting two fingers into the vagina and applying mild, downward pressure to the vagina towards the rectum while moving the fingers with steady strokes from side to side. Some studies performed massage only during contractions in the second stage, and others during and between pushes (World Health Organization, 2018).

9. Assist with midline, or mediolateral episiotomy, if necessary
Routine or liberal use of episiotomy is not recommended for clients undergoing spontaneous vaginal birth. Effective local anesthesia and the client’s informed consent are essential if an episiotomy is performed. The preferred technique is a mediolateral incision, as midline incisions are associated with a higher risk of complex OASI. A continuous suturing technique is preferred to interrupt suturing (World Health Organization, 2018).

Risk For Ineffective Individual Coping

Labor is such an intense process it creates a high level of emotional stress for both the client and her support person. The ability to tolerate stress or cope adequately depends on a 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 support system
  • Personal vulnerability
  • Situational crisis
  • Unrealistic perceptions/expectations
Possibly evidenced by
  • Signs and symptoms do not evidence a risk diagnosis. Interventions are directed at prevention. 
Desired Outcomes

Common goals and expected outcomes:

  • The client will verbalize feelings congruent with behavior.
  • The client will demonstrate effective coping skills by using self-directed techniques for bearing-down efforts.
  • The client will use breathing and relaxation techniques learned from childbirth class.
  • The client will verbalize an understanding of what is happening and how she can still participate in the birth process.
Nursing Assessment and Rationales

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

1. Determine the client’s perception of behavioral response to labor. Note cultural influences.
This helps the nurse gain insight into the 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. In China, the husband has no role during pregnancy and is not be present during labor. In India, the father plays a major role in supporting his wife and arranges a party to celebrate expecting a baby, similar to the western baby shower (Yadollahi et al., 2018).

2. 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 the descent of the fetus. The combined powers of uterine contractions and voluntary maternal pushing in stage 2 of labor propel the fetus downward through the pelvis. However, maternal exhaustion or epidural analgesia may reduce and eliminate the natural urge to push. Negative coping can result in prolonged labor and increases the likelihood that anesthesia and forceps or vacuum may be needed for the delivery.

3. Assess the client’s pain level from uterine contractions and pelvic pressure.
Assess the client’s pain level by using both verbal and nonverbal indicators such as the 1-10 pan rating scale. Pain is a subjective symptom, so only the client can determine her degree of pain or what is most helpful to relieve it. Nonverbal behaviors that suggest difficulty coping with labor include a tense body posture and thrashing in bed.

Nursing Interventions and Rationales

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

1. Discuss normal emotional and physical changes and variations in emotional responses.
Understanding helps the client cope with the 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. Some clients may react by growing argumentative and angry or crying and screaming. Even clients who have taken childbirth education classes and who believe they are well prepared for any length or type of contractions are surprised at the intensity of the pushing sensation they feel at this stage.

2. Discuss options for pain control/reduction.
The client may require anesthesia or analgesia to promote relaxation and facilitate coping. Some healthcare providers are reluctant to suggest to a client that pharmacologic pain relief is available as this might influence her to accept an analgesic rather than continue to use nonpharmacologic methods. However, part of being in control is knowing your options and feeling free to select the one most appropriate at that time. Because pain is subjective, only the client knows how much pain she can endure and whether she needs some additional help to make childbirth the experience she planned.

3. Provide comfort measures for the client.
The reduction of discomforts and distractions allows the couple to focus on labor efforts. Assist the client’s partner in providing the usual comfort measures that are helpful for anyone with pain, such as reassurance, massage, or a change in position. For dry lips, ice chips to suck on, moistening the lips with a wet cloth, or using a lip balm can be helpful. A cool cloth to wipe sweat from the forehead, neck, and chest can keep the client from feeling overheated.

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4. Point out tense or furrowed brow, clenched fists, and so forth, and suggest that the partner touch tight areas.
This helps the client focus on tension reduction and allows the couple to work together to regain control of the situation. Although the effectiveness of therapeutic touch is not well documented, both touch and massage probably work to relieve pain by increasing the release of endorphins. Both may also work because they serve as forms of distraction. May clients find massage helpful in the first and second stages of labor. 

5. Encourage the client to rest between contractions with eyes closed.
Make sure the client pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable.

6. Provide positive reinforcement and encouragement.
Encouragement is a powerful tool for intrapartum nursing care because it helps the client summon inner strength and gives her the courage to continue. Liberal praise should be given if she successfully uses techniques to cope with labor. Her partner also needs encouragement, as labor coaching is a demanding job.

7. Inform a couple of labor progress, the appearance of fetal vertex, and their efforts are helpful. Provide mirror for visualization of the emerging infant or have client reach down and touch baby’s head as she pushes.
This helps the couple to feel positive about their participation and rewarded for their cooperation. It also encourages a continuation of efforts. Explain to the client how each method is expected to help her labor advance. If the client understands the reason for any interventions, she will more likely cooperate with them and feel more in control. Knowing that her efforts are having the desired effect encourages her to continue with her learned coping methods.

8. Support and teach the client about effective pushing techniques.
When the cervix is fully dilated, stage 2 of labor begins, and the nurse teaches or supports effective pushing techniques. If the client is pushing effectively and the fetus tolerates labor well, the nurse should not interfere with her efforts. The client takes a deep breath and exhales at the beginning of a contraction. She then takes another deep breath and pushes her abdominal muscles while exhaling.

9. Facilitate partner’s participation in meeting client’s needs regarding comfort, pushing, and emotional support.
Active participation fosters a positive sense of self and may strengthen and enhance the couple’s future relationship and relationship with the child. If the partner acts as a labor coach, ask whether they have attended a prepared childbirth class and exactly how the support person wants to help the client manage the pain of contractions.

10. Support client/couple in deciding 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 nonjudgmentally. Support whichever decision the client has made coming into labor and any change she decides on as labor progresses.

Risk For Fatigue

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. The active fetus, frequent urination, and shortness of breath when lying down interrupt sleep. Pelvic abnormalities can also result in longer labor and greater maternal fatigue.

Nursing Diagnosis
  • Risk For Fatigue
May be related to

Common related factors for this nursing diagnosis:

  • Decreased metabolic energy production
  • Increased energy requirements
  • Presence of pain
  • Overwhelming psychological/emotional demands
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 effectively participate in bearing-down activities
  • The client will relax/rest between efforts.
Nursing Assessment and Rationales

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

1. Assess fatigue level, and note activities/rest immediately before the 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. Fatigue may interfere with the client’s physical and psychological abilities to maximally participate in the labor process and to 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 in assessing fatigue during labor and delivery (Delgado et al., 2019).

2. Monitor fetal descent, presentation, and position.
Malposition and malpresentation may prolong labor and cause/increase fatigue. The fetus in an abnormal position or presentation applies uneven pressure to the cervix, resulting in less effective effacement and dilation, thus prolonging the labor and delivery process.

Nursing Interventions and Rationales

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

1. Keep client/couple informed of progress.
This helps provide needed psychological energy. Spontaneous efforts to bear down tend to lengthen stage II labor but do not negatively affect the fetus. The client may not push effectively during the second stage of labor because she does not understand which techniques to use or fears tearing her perineal tissues. The client may benefit from explanations that sensations of tearing and splitting often accompany fetal descent but that her body is designed to accommodate the fetus.

2. Encourage rest/relaxation between contractions. Provide an environment conducive to rest.
Resting between contractions conserves the energy needed for pushing efforts and delivery. An exhausted client may be unable to gather her resources to push appropriately. 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 of labor.

3. Instruct the client when to push if she is under regional anesthesia.
If the client cannot feel her contractions because of a regional block, the nurse tells her when to push as each contraction reaches its peak. The exhausted client may benefit from pushing only when she feels a strong urge.

4. Provide comfort measures to the 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 else seems comforting. 

5. Encourage the 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. Help the client relax and use the breathing techniques she learned in the prepared childbirth class. Praise and support her when she uses them. Relaxation promotes normal labor, and praise encourages the client to continue efforts at managing contractions.

6. Supply fluids with glucose orally as appropriate or parenterally, if ordered. Test urine for ketones, as indicated.
This replenishes reserves that may have been depleted in labor and possibly resulted in hypoglycemia or ketonuria. Those containing dextrose are associated with a 75-minute shorter first stage of labor than IV fluids without dextrose in labor where oral intake is restricted (Alhafez & Berghella, 2020).

7. Assist with anesthesia or use of forceps if the 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 when maternal efforts to deliver are unsuccessful. Mid forceps delivery with rotation (Scanzoni maneuver) helps rotate the fetus from OP to OA position. Obstetrical forceps are steel instruments constructed of two blades that slide together at their shaft to form a handle. One blade is slipped into the client’s vagina next to the fetal head, and the other is slipped into place on the other side of the head. The pressure registers on the steel blades rather than the fetal head so they can reduce pressure, thus avoiding a complication such as subdural hemorrhage.

8. Prepare for cesarean birth if vaginal delivery is not possible.
Maternal fatigue and lack of progress may result from CPD or fetal malposition. In the United States, most fetuses in the breech presentation are born by cesarean birth. A common cause of abnormal labor is a fetus in a persistent occiput position. Labor is likely to be longer when rotation does not occur.

9. Assist with augmentation and induction of labor, as indicated.
When labor contractions are ineffective, interventions such as induction and augmentation of labor with oxytocin or amniotomy 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 not effective,

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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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