36 Labor Stages, Induced and Augmented Labor Nursing Care Plans


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:


Labor Induced: Augmented

Labor induction is necessary for certain maternal health problems such as fetal compromise, postmaturity, or uterine dysfunction. When oxytocin is administered to stimulate contractions, it is called labor induction. When oxytocin is administered to stimulate contractions that have already begun, it is known as augmentation of labor. Induced labor and augmented labor include the following nursing care plans:

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

Acute Pain

One of the most common interventions in obstetrics today is the induction of labor. In most developed countries, one woman in five has labor induced. Experience of induction of labor was less positive for women requiring cervical ripening, according to a study. Women deplored a greater gap between what was expected and what was experienced, more unacceptable duration of labor, vaginal discomfort, intense pain, and dissatisfaction with induction (Blanc-Petitjean et al., 2021).

Nursing Diagnosis
  • Acute Pain
May be related to

Common related factors for this nursing diagnosis:

  • Altered characteristics of chemically stimulated contractions
  • Psychological concerns
Possibly evidenced by

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

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

Common goals and expected outcomes:

  • The client will report pain is reduced/manageable.
  • The client will appear relaxed between contractions.
  • The client will participate in behaviors to diminish pain sensations and enhance comfort.
Nursing Assessment and Rationales

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

1. Assess the client’s vital signs, FHR, contraction strength, and frequency for baseline values.
Oxytocin stimulates uterine contractions. Take the client’s pulse and blood pressure every hour to ensure safe induction. Monitor uterine contractions and FHR conscientiously. Contractions should occur no more often than every 2 minutes, should not be stronger than 50 mm Hg pressure, and should last no longer than 70 seconds. FHR must be assessed and recorded every 15 minutes during active labor and every 5 minutes during the transition.

Nursing Interventions and Rationales

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

1. Discuss anticipated changes/differences in labor patterns and contractions.
This helps prepare the client because induction procedures and oxytocin can result in the rapid onset of strong, frequent contractions, which often interfere negatively with the client’s ability to use learned coping techniques, which a slower buildup in the contractile pattern would allow. The client may find her contractions difficult to manage. Therefore, the nurse should help her stay focused on breathing and relaxation techniques with each contraction.

2. Establish a rapport that enables the client/ partner to feel comfortable asking questions.
Answers to questions can alleviate fear and promote understanding. Qualitative studies have already shown that a negative experience of induction was associated with a lack of preparation and information about the benefits and risks of induction and its course, the intensity of pain, the duration of the induction, and a poorer medical outcome, in particular, emergency cesarean birth (Blanc-Petitjean et al., 2021).

3. Review/provide instruction in simple breathing techniques.
Encourages relaxation and gives the client a means of coping with and controlling the level of discomfort. The client may worry that induced labor will be more painful or “so different” from normal labor that breathing exercises will be worthless or that labor will progress so fast it will be harmful to the fetus. Assure the client that it is the same as unassisted contractions so she does not fight the contractions or become unnecessarily tense, which could prevent her from using her breathing techniques effectively.

4. Encourage and assist the client with changing position and readjusting EFM.
This prevents/limits muscle fatigue and enhances circulation. Encourage the client to lie on her side or on her hands and knees as much as possible. A hands and knees position may encourage fetal rotation. Side-lying enhances placental perfusion.

5. Encourage the client to use relaxation techniques. Provide instruction as necessary.
Relaxation can aid in reducing tension and fear, which magnify pain and hamper labor progress. Promoting relaxation is basic to all other methods of pain management—Orient the client to the procedure and what is happening in her body during the process. 

6. Encourage; keep the client informed of progress. Allow the partner to become part of the process.
Encouragement reassures the client/couple, provides positive reinforcement for efforts, and promotes focus on the future. A partnership style of a nurse-client-labor partner is usual in maternity settings. Looking for signs of muscle tension and teaching her partner to look for these signs help the client who is not aware of becoming tense. She can change position or guide her partner to massage the area where muscle tension is noted.

7. Provide comfort measures (e.g., effleurage, back rub, propping with pillows, applying cool washcloths, offering ice chips/lip balm).
These techniques promote relaxation, reduce tension and anxiety, and enhance the client’s coping and sense of control. Firm pressure against the lower back helps relieve some back labor pain. The client may stroke her abdomen in a circular movement during contractions; this technique is called effleurage.

8. Review available and appropriate analgesics for the client and explain their time factors and restrictions.
This enhances the client’s control of the situation and provides the information necessary for making an informed choice. If the client is medicated before she is 5 cm dilated, labor progress may be slowed; if delivery is imminent (within 2–4 hr), medication may depress the newborn, although the use of naloxone (Narcan) at the time of delivery improves neonates’ respiratory function.

9. Administer analgesic medications once dilation and contractions are established.
This relieves pain; promotes relaxation and coping with contractions, allowing the client to remain focused on labor work. Timing the administration of narcotic analgesics is especially important as, if given too early, 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.


Knowledge Deficit

Nurses assist with several obstetric procedures during birth; they also care for the clients after the procedures. Educating the client and her partner about the procedures and interventions necessary for a positive birth experience may encourage her to put in all her efforts to keep herself and the newborn safe.

Nursing Diagnosis
  • Knowledge Deficit
May be related to

Common related factors for this nursing diagnosis:

  • Lack of exposure/unfamiliarity with information resources
  • Misinterpretation of information
Possibly evidenced by

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

  • Verbalization of questions/concerns
  • Exaggerated behaviors
Desired Outcomes

Common goals and expected outcomes:

  • The client will verbalize understanding of procedures/situations.
  • The client will participate in the decision-making process.
Nursing Assessment and Rationales

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

1. Determine the client’s ability to learn and any cultural considerations.
The client may not be physically, mentally, or emotionally capable at the time to receive new information. The nurse may also need an interpreter to understand and provide optimal care to the client and her family. Cultural preferences influence the presence of partners, parents, siblings, and children in the labor and delivery room.

Nursing Interventions and Rationales

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

1. Explain the expected procedures to the client/couple. Demonstrate and explain the use of equipment.
Anxiety is alleviated when the client or couple knows what is happening and what to expect. Cooperation and involvement are also enhanced. The client may worry that induced labor will be more painful or different from normal labor or that labor will progress so fast it will be harmful to the fetus. 

2. Explain oxytocin infusion.
Oxytocin may be used before amniotomy or implemented after a trial of amniotomy that fails to induce labor. Initiation or stimulation of contractions with oxytocin is the most common labor induction and augmentation method in clients with a favorable or ripe cervix. Oxytocin for induction or augmentation of labor is diluted in an IV solution. The oxytocin solution is a secondary (piggyback) infusion inserted into the primary IV solution line so that it can be stopped quickly while an open IV line is maintained.

3. Review amniotomy procedure (artificial rupture of membranes [AROM]); explain that it is no more uncomfortable than sterile vaginal examination.
Amnihook is guided into the vagina by the examiner’s fingers during the sterile vaginal examination. Membranes, which do not contain nerves, are hooked or nicked to rupture, stimulating labor. When used alone or in conjunction with oxytocin, amniotomy can be a successful means of inducing labor. However, amniotomy generally commits the client to deliver within 24 hr. Amniotomy stimulates prostaglandin secretion, which stimulates labor, but the loss of amniotic fluid may result in umbilical cord compression.

4. Review the need for induction or augmentation of labor. Discuss Bishop’s score.
Informed consent and cooperation depend on the client’s understanding of the situation and choices. Bishop score is a numerical score assigned to cervical characteristics (position, consistency, ripeness, effacement, dilation) and fetal station that predicts whether induction will be successful. Continuous monitoring of uterine activity and FHR during labor is essential.

5. Discuss the possibility of failed induction and operative intervention if fetal distress occurs
Induction may not be successful depending on the degree of cervical ripening and the client’s response to procedures. If membranes are ruptured and induction fails, cesarean birth is indicated. If severe fetal distress is apparent or uterine hyperstimulation places the client at risk for uterine rupture, induction may be discontinued and cesarean delivery performed. Providing this information to the client/couple in advance can prepare them psychologically and may diminish disappointment.

6. Instruct the client/partner in the basic interpretation of fetal monitor, differentiating changes in the movement pattern.
A basic understanding of the patterns in the fetal monitor encourages involvement, gives a sense of control, and lessens anxiety regarding normal variations of tracing. Fathers provide emotional, psychological, and practical help during labor, promoting a more positive childbirth experience for both parents. Previous studies show that most partners prefer to be involved in childbirth and that they want information suiting their needs during that process (Eggermont et al., 2017).


Studies on women’s induction experience have often provided a negative picture, highlighting the disparity between women’s expectations and experiences and a lack of satisfaction with their labor. Evidence from a study demonstrates how induction separates women from their everyday surroundings, upturns their expected trajectory of labor and birth, and places them in an unfamiliar and sometimes frightening environment, where control is relinquished, creating chaos and anxiety for the laboring client (Jay et al., 2017).

Nursing Diagnosis
  • Anxiety
May be related to

Common related factors for this nursing diagnosis:

  • A perceived threat to client/fetus
  • Situational “crisis”
  • Unanticipated deviation from expectations
Possibly evidenced by

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

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

Common goals and expected outcomes:

  • The client will report anxiety diminished and/or managed.
  • The client will use support systems effectively.
  • The client will appear relaxed.
  • The client will accomplish successful labor.
Nursing Assessment and Rationales

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

1. Assess psychological and emotional status.
Any interruption of the normal progression of labor can contribute to feelings of anxiety and failure. These feelings can interfere with client cooperation and hamper the induction process. From 5% to 20% of women describe their delivery experience as negative. These negative experiences may have short- or long-term effects: impairment of the mother-child bond from the very start, postpartum depression, decisions to not become pregnant again, fear of delivery, and requests for a repeat cesarean for a subsequent pregnancy (Blanc-Petitjean et al., 2021).

Nursing Interventions and Rationales

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

1. Use positive terminology; avoid using terms that indicate an abnormality of procedures or processes.
This helps the client/couple accept the situation without self-recrimination. Qualitative studies have already shown that a negative experience of induction was associated with a lack of preparation and information about the benefits and risks of induction and its course, the intensity of pain, the duration of the induction, and a poorer medical outcome, in particular, emergency cesarean birth (Blanc-Petitjean et al., 2021).

2. Encourage verbalization of feelings.
The client may be frightened or may not clearly understand the need for inducing labor. A sense of failure at being unable to “labor naturally” may occur. Asking a question such as “Is labor what you thought it would be?” to both the client and her support person often helps them express their concerns.

3. Encourage the use/continuation of breathing techniques and relaxation exercises.
This helps to reduce anxiety and enables the client to participate actively. Assure the client that contractions during labor induction are the same as unassisted contractions so that she does not fight the contractions or become unnecessarily tense, which could prevent her from using her breathing techniques effectively.

4. Listen to the client’s comments that may indicate a loss of self-esteem.
The client may believe that any intervention to aid the labor process negatively reflects her abilities. Spontaneous labor, once established, normally leads to birth within a matter of hours, provided skilled help is at hand. Induction may fail or be indefinitely postponed or interrupted for reasons which are entirely beyond the client’s control. In such circumstances, the client may find herself powerless to progress without the agency and permission of others.

5. Provide opportunities for client input into the decision-making process.
This enhances the client’s sense of control even though much of what is happening may be beyond her control. For the client to feel capable and in control of situations experienced and not show powerlessness, educational actions are relevant factors since they provide trust and harmony in the relationship between professional and pregnant women, reducing subordination and favoring the client’s autonomy (Apolonio et al., 2021).


6. Allow the support partner to accompany the client during labor induction.
It is recognized that long periods of discomfort and isolation from their usual support networks can cause women to become physically and emotionally drained when labor is fully established, which may result in dysfunctional labor because of the effects of stress hormones on the production and release of oxytocin. Therefore, it is possible that the stresses caused by induction could have contributed to subsequent delays in labor (Jay et al., 2017).

Risk For Impaired Fetal Gas Exchange

Several intrapartum conditions can endanger the life or well-being of the fetus. These conditions necessitate prompt nursing and medical action to reduce the likelihood of damage. In prolapsed umbilical cord, the umbilical cord prolapses if it slips downward in the pelvis after the membranes rupture. In this position, it can be compressed between the fetal head and the client’s pelvis, interrupting blood supply to and from the placenta.

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

Common related factors for this nursing diagnosis:

  • Altered blood flow to the placenta or through the umbilical cord (prolapse)
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 display FHR within normal limits, free of late decelerations.
  • The client will engage in behaviors that enhance fetal safety.
Nursing Assessment and Rationales

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

1. Note the presentation and station of the fetus through Leopold’s maneuvers and sterile vaginal examination.
Leopold’s maneuver determines whether the fetus is in vertex presentation and rules out CPD. A posteriorly presenting head does not fit the cervix as snugly as one in an anterior position. Because this increases the risk of umbilical cord prolapse, the position of the fetus is confirmed by vaginal examination or ultrasound. If the presenting part is too high (22cm), amniotomy may need to be postponed due to the prolapsed cord risk.

2. Note fetal maturity based on the client’s history, EDB, and uterine measurements.
Gestational age of fetus should be 36 weeks or more for induction or augmentation of labor unless maternal condition warrants intervention before this time. At one time, induction could be completed if a fetus was proven to have adequate lung surfactant by amniocentesis at term but less than 39 weeks. However, the American College of Obstetricians and Gynecologists (ACOG) has issued a statement indicating that fetal lung maturity should not be used and inductions avoided until 39 weeks unless medically indicated.

3. Assess reaction of FHR to contractions via continuous EFM, noting bradycardia and late/variable decelerations; or sustained tachycardia.
Proper assessment is needed to avoid hypoxia. The normal range for FHR is 120–160 bpm. The danger of hyperstimulation is that a fetus needs 60 to 90 seconds between contractions to receive adequate oxygenation from placenta blood vessels. Hyperstimulation (tachysystole) is usually defined as five or more contractions in 10 minutes or contractions lasting more than 2 minutes in duration or occurring within 60 seconds of each other, situations that have the potential to interfere with placenta filling and fetal oxygenation.

4. Monitor FHR, as indicated, in conjunction with amniotomy.
Determining FHR before and the following procedure provides information to ensure fetal wellbeing. Acceleration for a short period after amniotomy is normal; however, signs of distress may indicate fetal hypoxia from compression of the cord or late decelerations. It is important only to perform an amniotomy if the fetal head is well applied to the cervix. Always measure the FHr immediately after the rupture of membranes to determine this did not happen.

5. Note time of rupture of membranes and character and consistency of the fluid.
To reduce the risk of ascending infection, a mature fetus should be delivered within 24 hr of rupture of membranes. The prolapsed cord risk increases if the membranes rupture before the fetal presenting part is completely engaged in the pelvis.

6. Review results of ultrasonography and amniocentesis, pelvimetry, and L/S ratio.
These procedures determine fetal age and presentation; help identify CPD and potential needs of fetus/neonate during and following delivery. It can be used to predict gestational age by measuring the biparietal diameter of the head or crown-to-rump measurement.

Nursing Interventions and Rationales

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

1. Place the client in positions that favor placental perfusion.
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 can accomplish this displacement. Placing the mother in a side-lying position with her hips elevated on pillows reduces cord pressure. Wedge relieves the pressure of the fetus on the vena cava and enhances placental circulation.

2. Apply electronic fetal monitor (EFM) 15–20 min before induction procedure.
Internal electronic monitoring is the most precise method for assessing FHR and uterine contractions. It is most often used to assess whether the contractions are strong enough to cause a cervical change in the case of a prolonged labor course. Contraction strength is evaluated by the height of the peak of the contraction on the tracing. Equally important to evaluate is the return of the uterine tone to baseline strength between contractions. This ensures there is placental filling between contractions.

3. Fill the client’s urinary bladder with saline before an elective cesarean delivery for umbilical cord prolapse.
Maternal urinary bladder filling is another “pushing” method to elevate the fetal presenting part. Caspi et al. used the same method and volume (500-750 mL), which successfully prevented perinatal mortality in their 88 cord prolapse cases. It is effective in elevating the fetal head, especially when a delay in delivery is expected or transportation of the client for a longer distance is needed. However, because the direction of elevation by the distended bladder is below the fetal presenting part level, it is less effective when the fetal head is at a higher station (Wong et al., 2021).

4. Have client void before administration of oxytocin and before application of fetal electrode.
A full bladder can interfere with fetal position and placement of monitor. The bladder can also be injured by the pressure of the fetal head pressing against it, and the pressure of the full bladder may not allow the fetal head to descend. 

5. Assist as needed in the application of internal fetal electrodes.
The internal fetal electrode should be used for more accurate observation, especially if signs of fetal distress or meconium are present. This can be done by wireless telemetry but is usually managed by a pressure-sensing catheter passed through the vagina after the membranes have ruptured, and the cervix has dilated to at least 3 cm. It is then passed into the uterine cavity and alongside the fetus. The end of the catheter extending from the vagina is attached to a pressure recorder.

6. Assist in emergency delivery as appropriate.
At present, the mainstay for umbilical cord prolapse with a viable fetus is emergency delivery. Delaying the delivery for extremely premature cases with rupture of membranes has been reported with a good outcome but it is exceptional (Wong et al., 2021).

Risk For Injury (Maternal)

Induction of labor may impose a risk of adverse consequences such as hyperstimulation, fetal asphyxia, PPH, uterine rupture, and in very rare cases, fetal and maternal death. Induction has also been shown to be related to additional interventions such as epidural analgesia, continuous fetal monitoring, confinement to bed, instrumental birth, and emergency CS, all of which puts the client at risk for injury (Rydahl et al., 2019).

Nursing Diagnosis
  • Risk for Injury (Maternal)
May be related to

Common related factors for this nursing diagnosis:

  • Adverse effects/response to therapeutic interventions
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 develop/maintain a good labor pattern; i.e., contractions 2–3 min apart, lasting 40–50 sec, with uterine relaxation to normal tone between contractions.
  • The client will accomplish delivery without complications.
Nursing Assessment and Rationales

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

1. Review prenatal records for the history of previous pregnancies and outcomes, prenatal laboratory studies, pelvic measurements, allergies, weight gain, vital signs, last menstrual period, and EDB.
This provides information needed in formulating a plan of care and alerts the nurse to the possibility of existing or developing problem(s). Because either augmentation or initiation of labor carries a risk of uterine rupture or premature separation of the placenta, it must be used cautiously in clients with multiple gestation, polyhydramnios, grand parity, who are older than 40 years or have previous uterine scars.

2. Obtain history regarding insertion of laminaria tent or prostaglandin vaginal suppository preparations  (e.g., p-gel).
Insertion of laminaria tent or prostaglandin preparations the evening before the induction softens the cervix and facilitates labor induction. The use of prostaglandins to ripen the cervix is contraindicated in clients with a history of uterine myomectomy surgery or previous cesarean birth because of the risk of uterine rupture.

3. Monitor intake and output. Measure urine-specific gravity as indicated. Palpate bladder.
Decreased output with increased specific gravity reflects fluid deficit. Urine retention may impede labor and fetal descent. In addition, oxytocin infusions of 20 ml/min or above may result in decreased urinary output because of the antidiuretic effect of the medication. Inadvertent administration of too great an amount of IV or oral fluid can increase the risk of fluid overload.

4. Note reports of abdominal cramping, dizziness, headache, and nausea/vomiting; the presence of lethargy, confusion, hypotension, tachycardia, and cardiac dysrhythmia (irregularities).
Water intoxication may develop depending on fluid administration/ oxytocin infusion rate above 20 ml/min. Water intoxication occurs because oxytocin inhibits the excretion of urine and promotes fluid retention. Water intoxication is not likely to occur if large doses of oxytocin and fluids are given intravenously during labor. Still, it is more likely to occur if large doses of oxytocin and fluids are given intravenously after birth.

5. Monitor temperature every 2 hr. Note color and odor of vaginal drainage.
This reduces the risk of infection and provides early detection of developing an infection. The presence of meconium staining indicates fetal distress. Green-stained fluid may indicate the fetus has passed meconium before birth, a situation associated with a fetal compromise that can cause respiratory problems at birth. Cloudy or yellow amniotic fluid with an offensive odor may indicate an infection and should be reported immediately.

6. Check BP and pulse per protocol after induction begins and before increasing oxytocin.
With the initiation of oxytocin infusion, BP may be decreased. As time passes, BP may increase up to 30% above baseline. Oxytocin is given slowly in increasing amounts based on maternal and fetal responses. Approximately 40 min of infusion is necessary to reach therapeutic blood levels of oxytocin. It is rapidly metabolized and excreted by the kidneys, so constant infusion should be maintained to achieve regular, consistent contractions of good quality to dilate the cervix effectively.

7. Perform sterile vaginal examination to determine readiness or ripeness of cervix and fetal station. Repeat as indicated by the client’s reaction and contraction pattern.
A soft, partially effaced (more than 50%) and dilated (at least 3 cm) “ripe” cervix is a good indication that induction will be successful. A firm, thick “unripe” cervix with little or no dilation may require two or three trials before successful induction. The time of amniotomy (AROM) depends on the fetal station. Repeat examinations determine labor progress, but to avoid infection, they should be limited as much as possible after membranes are ruptured.

8. Evaluate monitor tracing closely.
Careful monitoring is essential to determine client/fetal response to procedure, identify adverse reactions, and produce an effective labor pattern. Rates outside the normal range of 110 to 160 beats/minute for a term fetus suggest a prolapsed umbilical cord. Continuous electronic monitoring is the usual method to assess and record fetal and maternal responses to oxytocin. Many health care providers prefer internal methods of monitoring when oxytocin is used because these techniques are more accurate, especially with contraction intensity.

9. Palpate fundus to evaluate frequency and duration of contractions. Observe for overstimulation of the uterus (tetanic contraction). If used, note intensity and resting tone between contractions per palpation or via IUPC.
External uterine monitoring indicates the frequency, not intensity, of contractions. Rapid labor/delivery may occur, increasing the risk of cervical and soft tissue trauma. Overstimulation causes fetal hypoxia, uterine rupture, and premature separation of the placenta. If contraction lasts more than 90 sec, occurs more than 2–3 min apart, or if the uterus is not completely relaxed between contractions, oxytocin should be discontinued.

10. Review prenatal laboratory work. Perform nitrazine paper or fern test, if indicated.
This evaluates the maternal and fetal status and determines whether membranes have ruptured. The nitrazine paper trunks blue in the presence of amniotic fluid. A sample of vaginal fluid placed on a slide and sent to the laboratory will show a ferning pattern under the microscope, confirming amniotic fluid.

11. Obtain/monitor electrolytes, as indicated.
Water retention may occur during oxytocin infusion resulting in hypochloremia or hyponatremia. Water intoxication sometimes occurs because oxytocin inhibits the excretion of urine and promotes fluid retention.

Nursing Interventions and Rationales

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

1. Position the client comfortably.
Encourage the client to lie on her side or her hands and knees as much as possible. Hands and knee position may encourage fetal rotation. Side-lying enhances placental perfusion.


2. Encourage the client to use relaxation and breathing techniques during the induction/augmentation.
The client who has oxytocin stimulation of labor may find her contractions difficult to manage. Help her to stay focused on breathing and relaxation techniques for each contraction.

3. Assist with the application of prostaglandin preparations.
The most common method used to promote cervical ripening is the insertion of a prostaglandin such as dinoprostone into the cervix’s posterior fornix of the vagina. Oxytocin induction can be started 12 hours after the prostaglandin dose; beginning sooner might lead to hyperstimulation of the uterus.

4. Assist with amniotomy. Place the client in a low semi Fowler’s position with knees bent for vaginal examination.
AROM may stimulate labor without drug infusion, or it may be done in conjunction with oxytocin administration. Amniotomy is contraindicated if presenting part is high. A disadvantage of amniotomy is that it puts the fetus momentarily at risk for cord prolapse if a cord loop escapes into the vagina with the fluid.

5. Start primary IV line with a large-gauge indwelling catheter.
A large-gauge catheter is preferred in case of the need for surgical intervention, blood transfusion, or emergency fluid/drug administration. Piggyback the oxytocin solution to a maintenance IV solution such as Ringer’s lactate and add the piggyback to the main infusion at the port closest to the client. Then, if oxytocin needs to be discontinued quickly during the induction, the little solution remains in the tubing to still infuse, and the main IV line can still be maintained.

6. Assist as necessary with insertion of IUPC, if used.
Internal monitoring accurately quantitates the intensity and frequency of contractions and helps identify overstimulation and possible uterine rupture caused by over administration of oxytocin. It is the most precise method for assessing FHR and uterine contractions. It is most often used to assess whether contractions are strong enough to cause a cervical change in the case of a prolonged labor course.

7. Dilute and administer oxytocin (Pitocin) in an electrolyte solution with a two-bottle IV system, piggy-backing oxytocin close to the IV site, according to unit policy and procedures.
The synthetic hormone oxytocin stimulates the uterine smooth muscle, increasing the excitability of the muscle cells, which increases the strength of contractions. For administration, oxytocin is commonly mixed in the proportion of 10 IU in 1,000 ml of Ringer’s lactate. An alternative dilution method is to add 15 IU of oxytocin to 250 ml of an IV solution; this yields a concentration of 60 mL per 1 mL.

8. Observe safety precautions related to infusion and proper labeling of oxytocin solution.
Errors or fluctuations in the rate of administration may cause under medication or over medication, resulting in inadequate contractions or uterine rupture. Drug delivery is verified by closely monitoring the pump and the decreasing fluid level. A healthcare provider’s prescription for oxytocin administration for induction usually designates the number of milliunits to be administered per minute. Be certain you know the dilution prescribed and recognize the concentration in each milliliter. Don’t increase the rate by more than two milliunits at a time.

9. Discontinue oxytocin, as indicated, and increase infusion of plain IV solution. Notify physician.
Hyperstimulation of the uterus (intrauterine pressure greater than 75 mm Hg) can lead to abruptio placentae, uterine tetany, and possible rupture. The surest method to relieve tachysystole is to discontinue the oxytocin infusion immediately. F in doubt, err on the side of stopping the infusion when the action isn’t needed (it can easily be restarted) rather than delaying stopping it so that fetal or maternal harm results.

10. Administer 1–2 g MgSO4 slowly, as necessary, or terbutaline (Brethaire) subcutaneously (SQ).
The health care provider may prescribe terbutaline to relax the uterus. Although the circulatory half-life of oxytocin is 3–9 min, uterine activity from the effects of oxytocin administration may last 20–30 min after the infusion is stopped. MgSO4 or terbutaline may be indicated to relieve oxytocin-induced uterine tetany.


Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Other recommended site resources for this nursing care plan:

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

References and Sources

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  • Ahmadi, Z., Torkzahrani, S., Roosta, F., Shakeri, N., & Mhmoodi, Z. (2017, January). Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial. Iranian Journal of Nursing and Midwifery Research, 22(1), 62-66. 10.4103/1735-9066.202071
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  • Lee, N., Gao, Y., Lotz, L., & Kildea, S. (2019, August). Maternal and neonatal outcomes from a comparison of spontaneous and directed pushing in the second stage. Women and Birth, 32(4), e433-e440. https://doi.org/10.1016/j.wombi.2018.10.005
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  • Lopez, A. B. H., Miguel, C. M., Morillo, A. F.-C., Lapeyrere, C. L., Medina, T. P., Mariña, A. S., Ruiz, I. F., Gonzalez, E. R., & Muñoz, M. S. (2019, April 13). Efficacy of“optimal hydration” during labor: HYDRATA study protocol for a randomized clinical trial. Research in Nursing and Health. 10.1002/nur.21998
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  • Oktriani, T., Ermawati, & Bachtiar, H. (2018). The Difference Of Pain Labour Level With Counter Pressure And Abdominal Lifting On Primigravida In Active Phase Of First Stage Labor. Journal of Midwifery, 3(2).
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  • Rosenberg, M., Many, A., & Shinar, S. (2019, June 20). Risk factors for overt postpartum urinary retention—the effect of the number of catheterizations during labor. International Urogynecology Journal, 31, 529-533. https://doi.org/10.1007/s00192-019-04010-y 
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  • Watkins, V. Y., Martin, S., Macones, G. A., Tuuli, M. G., Cahill, A. G., & Raghuraman, N. (2020, September). The duration of intrapartum supplemental oxygen administration and umbilical cord oxygen content. American Journal of Obstetrics and Gynecology, 222(3), 440.el-440.e7. https://doi.org/10.1016/j.ajog.2020.05.056
  • Wong, L., Kwan, A. H. W., Lau, S. L., Sin, W. T. A., & Leung, T. Y. (2021, October). Umbilical cord prolapse: revisiting its definition and management. American Journal of Obstetrics and Gynecology, 225(4), 357-366. https://doi.org/10.1016/j.ajog.2021.06.077
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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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