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 45 nursing care plans (NCP) and nursing diagnoses for the different stages of labor, including care plans for labor induction, labor augmentation, and dysfunctional labor:
Table of Contents
- Labor Stage IA: Latent Phase
- Risk for Deficient Fluid Volume
- Risk For Injury (Fetal)
- Risk For Infection (Maternal)
- Risk For Ineffective Coping
- Anxiety
Labor Stage IA: Latent Phase
The latent phase of labor starts during the onset of true labor contractions until cervical dilatation. The latent phase is considerably longer and less predictable concerning the rate of cervical change than is observed in the active phase (Hutchison et al., 2021). A birthing parent who is multiparous progresses more quickly than a nullipara.
Deficient Knowledge
Early labor is when there are frequent moments for decision-making for laboring individuals, nurses, and healthcare providers. Clinicians felt that many factors impact a client’s decision-making about early labor, including parity, risks, anxiety or fear, support, expectations, knowledge about birth, and coping. Prenatal care or childbirth education is an important opportunity for clients to receive information about the latent phase of labor. Inclusion of information during prenatal care and childbirth education may increase the client’s confidence during early labor to delay admission until active labor (Breman & Neerland, 2022).
Nursing Diagnosis
May be related to
Common related factors for this nursing diagnosis:
- Information misinterpretation
- Lack of exposure/recall
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Inaccurate follow-through of instruction
- Questions
- Statements of misconception
Desired Outcomes
Common goals and expected outcomes:
- The client will verbalize understanding of psychological and physiological changes.
- The client will participate in the decision-making process.
- The client will demonstrate appropriate breathing and relaxation techniques.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess the client’s baseline knowledge and expectations during pregnancy.
This will guide in establishing learning needs and setting priorities. Client needs to understand what is happening to them during labor to make informed decisions about their care. Knowing and recognizing what is normal and not normal can help ensure the safe provision of care.
2. Determine the client’s preferences for nursing care early in labor.
Assess the client whether she might benefit from such caring measures as having her handheld or her back rubbed or if she wants this only from her support person. If the client is not proficient in English, make arrangements to locate an interpreter. If she is hearing challenged, the healthcare facility’s responsibility is to provide an interpreter to receive adequate explanations of her progress.
3. Assess for cultural factors that may influence the client’s labor experience.
Cultural factors can strongly influence a client’s experience and satisfaction with labor. Every client responds to cultural cues in some way. This makes their response to pain, choice of nourishment, preferred birthing position, proximity and involvement of a support person, and customs related to the immediate postpartum period highly individualized. Be prepared to adapt to the client’s specific needs. If the client has traditions that run counter to hospital protocols, address these differences and make arrangements to accommodate her desires, beliefs, or customs, such as advocating special foods to eat or saving the placenta for the client to take home.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Provide and discuss options for care during the labor process. Provide information about birthing alternatives, if available and appropriate.
Active participation of the client/couple is important in the decision-making process. Efforts to improve shared decision-making could potentially increase the use of nonpharmacological methods, perhaps in environments where that may not be the norm. One way to communicate the pregnant client’s preferences among the team is a birth plan or birth partnership (Breman & Neerland, 2022).
2. Provide information about procedures (especially fetal monitor and telemetry) and normal progression of labor.
Prenatal education can facilitate the labor and delivery process, assist the client in maintaining control during labor, help promote a positive attitude, and decrease reliance on medication. Educating the client about early labor and physiologic birth processes was often mentioned for improving outcomes (Breman & Neerland, 2022).
3. Review appropriate activity levels and safety precautions, whether the client remains in the hospital or returns home.
Providing guidelines can help the client make appropriate informed choices and allows the client to engage in safe diversional activities to refocus attention. The client should move around freely throughout labor, not be confined to bed. In early labor, the client should be out of bed, walking or sitting in a chair, kneeling, squatting, on all fours, or in whatever position she prefers because the active movement can shorten the beginning stage of labor.
4. Review roles of staff members.
Reviewing roles helps identify resources for specific needs or situations. There is an increasing importance of person-centered care due to the potentially shifting clinical landscape. To achieve person-centered care, the healthcare team, the client, and the family members should work together and share power over clinical decision-making and care. Nurses can advocate for clients and provide education on options because they provide the most hands-on care during labor birth (Pillitteri, A., & Silbert-Flagg, J., 2018).
5. Explain the procedures and the possible risks associated with labor and delivery. Obtain informed consent for procedures (e.g., forceps delivery, episiotomy).
When procedures involve the client’s body, the client must have the appropriate information to make informed choices. Because the first stage of labor begins with uterine contractions and takes hours to complete, most clients have had labor contractions for hours before arriving at the birthing center. When they arrive, one of their chief needs is reassurance that their judgment has been correct, everything is going well, and the exhaustion and increasing pain they feel is part of the usual labor.
6. Encourage the client to express her feelings about the labor.
Some clients may handle the stress of labor by becoming extremely passive and quiet. Still, others feel a need to show their emotions by shouting or crying. Help the client express her feelings her way or the best way for her.
7. Educate the client about breathing and relaxation techniques appropriate to each phase of labor; teach and review pushing positions for stage II.
Unprepared couples need to learn coping mechanisms on admission to help reduce stress and anxiety. Couples with prior preparation can benefit from review and reinforcement. Some clients may have practiced breathing exercises in a supine position while at home and may need additional coaching to do them in a sitting or dancing position. A dancing position is when the pregnant woman puts her hands on her partner’s shoulders and sways from left to right while the partner massages the woman’s sacral area. They can dance with someone they prefer, accompanied by light, calming music. The labor dance starts in the active labor phase of the first labor stage and continues until the end of the first stage to reduce the pain of contractions and provide emotional support (Akin & Saydam, 2020).
8. Provide frequent progress reports during labor.
At first, it is exciting for the client to feel labor contractions. They are little more than menstrual cramps and project a “this-is-really-happening” sensation. Soon, however, if the client is not concentrating on controlled breathing, the contractions become biting in intensity. Even though she is becoming more uncomfortable, nothing seems to be happening and can cause the couple to worry that something is going wrong. Give the client and her partner frequent progress reports during labor so they do not become discouraged or fearful at this seeming lack of progress.
9. Be prepared to repeat instructions as necessary during labor.
The client in labor may be enduring so much pain and stress that they do not hear or process instructions well. Gently repeat the instructions or information without reminding them they were previously given it. A reminder is not therapeutic because it can lower self-esteem and a sense of self-control.
Risk for Deficient Fluid Volume
Restricting fluids and food during labor is common practice across many birth settings, with some clients only being allowed sips of water or ice chips. The rationale to withhold food and fluid during labor is to decrease the risk of maternal morbidity and mortality from Mendelson’s syndrome if a general anesthetic is required. Gastric content regurgitation and aspiration into the lungs during general anesthesia is a risk first identified by Mendelson in the 1940s (Singata et al., 2013). However, when food and fluids are restricted, the client may experience dehydration symptoms, such as dryness of the mouth, nausea, and dizziness (Ozkan et al., 2017).
Nursing Diagnosis
- Risk for Deficient Fluid Volume
May be related to
Common related factors for this nursing diagnosis:
- Restriction of oral intake
- Loss of fluid through abnormal routes–vomiting, diaphoresis
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 maintain a fluid intake of at least one glass of selected beverage every hour as tolerated.
- The client will verbalize the absence of frequent thirst.
- The client will demonstrate adequate hydration (e.g., moist mucous membranes, yellow/amber urine of appropriate amount, absence of thirst, afebrile, stable vital signs/FHR).
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess intake & output. Note urine-specific gravity.
Intake and output should be approximately equal, dependent on the degree of hydration. The urine concentration increases as urine output decreases and may warn of dehydration. Additionally, there can be insensible fluid losses, such as diaphoresis and increased rate and depth of respirations.
2. Determine cultural practices regarding intake.
Some cultures, like Mexican women, practice drinking milk to make the babies larger and drinking chamomile tea to have a healthy labor. Some practices known by women to help easier delivery include making the pregnant woman have oily bread, sweetened fruit juice, butter, or molasses (Ozkan et al., 2017).
3. Assess the client’s vital signs and fetal heart rate (FHR) as indicated.
Increases in temperature, BP, pulse, respirations, and FHR may indicate the presence of dehydration or hypovolemia. Although a drop in BP is generally a late sign of fluid deficit, widening pulse pressure may occur early. Epidural anesthesia may cause hypotension. Therefore, the nurse should ensure that the client is well hydrated before epidural administration.
4. Assess the client’s skin temperature and palpate peripheral pulses.
Cool, clammy skin or weak pulses indicate decreased peripheral circulation and the need for additional fluid replacement. Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming.
5. Monitor the client’s hemoglobin and hematocrit level.
Both the hemoglobin and hematocrit increase with a dehydrated client. A reduction of the central circulating blood volume due to hypovolemia accompanying dehydration may result in the concentration of hemoglobin and hematocrit values (Ashraf & Rea, 2017).
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Provide mouth care and hard candy, as appropriate.
Proper oral care and hard candy may reduce the discomfort of a dry mouth. Sucking on ice chips, popsicles, or lollipops can help fluid intake. 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 also be helpful.
2. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted.
Clear liquids promote hydration and may provide some calories for energy production. Encourage the client to sip fluid during labor (as they would if they were exercising) to keep hydrated. If the client is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.
3. Educate the client about the benefits of consuming sports drinks during labor.
A total of 61.4% of hospitals in China supported pregnant women’s consumption of sports drinks during labor. Sports medicine scientists believe that childbirth is similar to athletes’ strenuous exercise, and sports drinks contain a lot of energy. Although sports drinks do not reduce delivery time and the incidence of vomiting, it has been shown that they could reduce the number of ketones produced by pregnant clients (Huang et al., 2020).
4. Encourage the client to empty the bladder at least once every hour.
The pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Encourage the client to void approximately every two hours during labor to avoid overfilling the bladder.
5. Administer IV fluids, as indicated.
The client may need IV fluids if oral intake is inadequate or restricted. In dehydration or hemorrhage, fluid resuscitation is necessary to counteract some negative effects of anesthesia/analgesia. According to Garite et al. (2000), the first phase of labor is significantly shorter in clients receiving fluids at 250ml/hr than those receiving fluids at 125 ml/hr (Lopez et al., 2019).
6. Administer dexamethasone to reduce nausea and vomiting, as indicated.
According to study findings, dexamethasone has better antiemetic efficacy compared with promethazine. Studies suggested that the antiemetic effect of steroids may be partially due to their activity on the central nervous system or activation of glucocorticoid receptors in the medulla (Tazeh kand et al., 2015).
Risk For Injury (Fetal)
The pressure and circulatory changes that occur with contractions affect the client and cause detectable physiologic changes in the fetus. Uterine contractions exert pressure on the fetal head. Therefore, the same response that is involved with increased intracranial pressure occurs. Uterine contractions in labor result in a 60% reduction in uteroplacental perfusion, causing transient fetal and placental hypoxia, which can be detrimental to fetuses with abnormal placental development (Turner et al., 2020).
Nursing Diagnosis
- Risk for Injury (Fetal)
May be related to
Common related factors for this nursing diagnosis:
- Hypercapnia
- Infection
- Tissue hypoxia
- Abnormal placental development
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 fetus will display FHR and beat-to-beat variability within normal limits, with no ominous periodic changes in response to uterine contractions.
- The fetus will be delivered successfully without any congenital complications or physical injuries.
Nursing Assessment and Rationales
Here are the nursing assessment for this labor nursing care plan.
1. Note the progress of labor and characteristics of the uterine contractions.
Prolonged or dysfunctional labor with an extended latent phase can contribute to infection, maternal exhaustion, severe stress, and hemorrhage caused by uterine atony/rupture, putting the fetus at greater risk for hypoxia and injury. As a rule, uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because this interferes with adequate uterine artery filling.
2. Monitor baseline FHR manually and electronically.
The normal range for fetal heart rate is between 120–160 bpm with average variability, accelerating in response to maternal activity, fetal movement, and uterine contractions. The FHR can be assessed by intermittent auscultation, a fetoscope or Doppler transducer, or continuous electronic fetal monitoring (EFM). During the latent phase, assessment of FHR for low-risk clients may be done every hour; for high-risk clients, every 30 minutes; and every time during the rupture of the membranes, before and after ambulation, before and after anesthesia administration, after vaginal examination, and if the contractions are abnormal or excessive.
3. Evaluate FHR pattern variability and periodic changes in response to uterine contractions.
The FHR is evaluated for baseline rate, baseline variability, episodic changes, and periodic changes. Periodic changes are transient and brief changes in the FHR associated with uterine contractions such as accelerations and decelerations. Marked variability occurs when more than 25 beats of fluctuation over the FHR baseline indicate cord prolapse or maternal hypotension. Absent variability is less than six beats per minute change from baseline for 10 minutes and is typically caused by uteroplacental insufficiency.
4. Monitor FHR during rupture of membranes, reassess per protocol, obtain a 30-min EFM strip for the record. Evaluate periodic changes in FHR.
Variable decelerations are abrupt decreases of 15 beats/minute below the baseline, lasting 15 seconds to 2 minutes. The nurse should assess the FHR for at least one full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and compressed.
5. Note the presence of bradycardia/tachycardia or sinusoidal pattern.
Fetal bradycardia occurs when the FHR is less than 110 beats/minute for 10 minutes. Causes can include fetal hypoxia, maternal hypoglycemia, maternal hypotension, or prolonged umbilical cord compression. Fetal tachycardia is a baseline greater than 160 beats/minute that lasts 2 to 10 minutes and longer. It can be caused by maternal fever or maternal dehydration. The sinusoidal pattern is often associated with fetal anemia or severe fetal hypoxia before fetal demise.
6. Assess maternal perineum for chlamydial discharges, vaginal warts, or herpetic lesions.
The fetus can acquire sexually transmitted infections (STIs) during pregnancy; therefore, cesarean birth may be indicated, especially for clients with active herpes simplex virus type II. Untreated chlamydia infection has been linked to problems during pregnancy, including preterm labor, premature rupture of membranes, and low birth weight. The newborn may also become infected during delivery as the infant passes through the birth canal. The risk of transmission to the neonate from an infected mother is high among women who acquire genital herpes near the time of delivery (CDC, 2021). HIV infection is associated with both preterm births and low-birth-weight infants.
7. Assess for visible cord prolapse at vaginal introitus.
Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not fitted firmly into the cervix. In rare instances, the cord may be felt as the presenting part on an initial vaginal examination during labor or visualized on ultrasound. A prolapsed cord is always an emergency because the pressure of the fetal head against the cord at the pelvic brim leads to cord compression and decreased oxygenation to the fetus (Pillitteri, A., & Silbert-Flagg, J. 2018).
8. Assess the amniotic fluid’s color, odor, and amount.
Green-stained amniotic fluid may indicate that the fetus has passed meconium before birth, which is associated with the 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.
9. Rule out maternal problems or medications that could affect an increase in FHR.
Factors such as fever, anxiety, anemia, or beta-sympathomimetic drugs can increase maternal and fetal heart rates. Fetal metabolic acidosis is one of the causes of decreased variability. Still, other etiologies include central nervous system depressants such as maternal narcotic use, fetal sleep cycles, congenital anomalies, prematurity, fetal tachycardia, administration of betamethasone, and preexisting fetal neurologic abnormality (Holmgren, 2020).
9. Perform Leopold’s maneuvers to determine fetal engagement, position, and presentation.
Leopold’s maneuvers are a systematic method of observation and palpation to determine fetal presentation and position and are done as part of a physical examination. A transverse lie or breech presentation may necessitate cesarean birth. Other abnormalities, such as the face, chin, and posterior presentations, may also require special interventions to prevent prolongation of labor/fetal harm.
10. Assist as needed with obtaining fetal scalp blood samples when indicated.
Oxygen saturation in a fetus is normally 40% to 70%. A fetus can be assessed for this by a catheter inserted next to the cheek. If fetal blood is obtained by scalp puncture, the finding of acidosis suggests fetal well-being is becoming compromised. Fetal pH between 7.20 and 7.25 may reflect intermittent umbilical cord compression, necessitating constant monitoring or immediate surgical intervention.
11. Assist with ultrasonography, if indicated.
If the fetal presentation is unclear, ultrasound confirms a breech or face presentation. Such a study also gives information on pelvic diameters, fetal skull diameters, and evidence of possible placenta previa causing the breech presentation. Pelvimetry or ultrasound can also be used to compare the size of the fetus with the client’s pelvic capacity, especially when the fetus is macrosomic.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Calm the client and partner, then explain the prolapsed cord and its implications.
The nurse should remain calm to avoid increasing the client’s anxiety, provide prompt corrective actions, and assist with emergency procedures. The prolapsed cord is a sudden development; anxiety and fear are inevitable reactions in the client and her partner. Calm, quick actions on the part of the nurse help the client and her family to feel that they are incompetent hands. Educating them about the complication also helps the couple understand the significance of prolapse and promotes cooperation measures.
2. Place the client in a Trendelenburg or a knee-chest position, push presenting part off of the cord and hold off while calling for help.
When a prolapsed cord occurs, the first action is to displace the fetus upward to stop compression against the pelvis. These positions may relieve the pressure of the presenting part on the cord as it causes the fetal head to fall back. The nurse may also place a gloved hand in the vagina to manually elevate the fetal head off the cord.
3. Check the cord for pulsations; wrap the cord in sterile gauze soaked in saline solution.
If the cord has prolapsed to the extent it is exposed to room air, it will begin to dry and lead to constriction and atrophy of the umbilical vessels. Cover any exposed portion with a sterile saline compress to prevent drying.
4. Place the client in a lateral recumbent position.
Implement position changes to relieve the pressure on the fetal umbilical cord or pressure on the inferior vena cava by turning the client into a left-lateral position. The client’s hips may be elevated by placing two pillows underneath them. This is often combined with the Trendelenburg position.
5. Perform perineal care according to protocol; change underpad when wet.
Perineal care helps prevent the growth of bacteria and eliminates contaminants that might contribute to maternal chorioamnionitis or fetal sepsis. Prelabor rupture of membranes at term accounts for 2-10% incidence. It is associated with maternal and fetal complications if not timely managed. Early complications include cord prolapse, cord compression, and placental abruption. Delayed complications include chorioamnionitis and maternal and fetal sepsis (Nair et al., 2020).
6. Administer oxygen via a face mask.
Administer oxygen via face mask at 10L/minute for 30 minutes to increase maternal oxygen available for fetal uptake. FHR patterns are not diagnostic, as they have many possible causes, but instead are used to detect possible identifiable complications that may be causing interruptions in the fetal oxygen supply.
7. Discontinue oxytocin and administer tocolytics as indicated.
Excess uterine activity or tachysystole is more than five contractions or fewer in 10 minutes, averaged over 30 minutes (the normal is five contractions or fewer in 10 minutes). Discontinuing oxytocin or administering tocolytic agents that decrease uterine activity may be prescribed by the healthcare provider.
8. Administer IV fluids, as indicated.
Administer Iv fluids such as a saline solution to improve cardiac output, circulatory volume, and uteroplacental perfusion. The nurse should observe for fluid volume overload and pulmonary edema.
9. Assist in amnioinfusion to relieve pressure on the cord.
Amnioinfusion is the addition of sterile fluid into the uterus to supplement the amniotic fluid and reduce compression on the cord. A sterile double-lumen catheter is introduced through the cervix into the uterus and attached to IV tubing, and a solution of warmed normal saline is rapidly infused. Initially, approximately 500mL is infused, and then the rate is adjusted to infuse the least amount necessary to maintain an FHR monitor pattern without variable decelerations.
10. Prepare for surgical intervention, as indicated.
If corrective measures do not improve the fetal heart tracings, Category 3 measures are instituted, focusing on expediting the fetus’s delivery. CNS damage occurs if fetal hypoxia or acidosis continues for more than 30 min. Cesarean birth is the treatment of choice for prolapsed cord before full cervical dilatation to avoid fetal compromise.
11. If the client is at home or in a free-standing birth setting, prepare for transfer to a level 2 or 3 hospital setting as indicated.
Compromised fetal status or identification of maternal conditions such as STD requires a closer birth setting. Observation may indicate a need for therapeutic interventions such as cesarean birth.
Risk For Infection (Maternal)
Theoretically, the uterus is sterile during pregnancy and up until the membranes rupture. After rupture, pathogens can invade; the risk of infection grows even greater if tissue edema and trauma are present. Puerperal infection is always potentially serious. Although it usually begins as only a local infection, it can spread to the peritoneum (peritonitis) or the circulatory system (septicemia), conditions that can be fatal in a woman whose body is already stressed from childbirth.
Nursing Diagnosis
May be related to
Common related factors for this nursing diagnosis:
- Fecal contamination
- Invasive procedures
- Repeat vaginal examinations
- Rupture of amniotic membranes
- Prolapse of the umbilical cord
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 demonstrate techniques to minimize the risk of infection.
- The client will be free of signs of infection (e.g., afebrile; amniotic fluid clear, nearly colorless, and odorless).
- The client will maintain a safe aseptic environment.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Monitor vital signs and white blood cell (WBC) count, as indicated.
The incidence of chorioamnionitis (intra-amniotic infection) increases within 4 hours after rupture of membranes, as evidenced by elevations of WBC count and abnormal vital signs. According to facility policy, the client’s temperature is taken every 2 to 4 hours after her membranes rupture. A maternal temperature of 38℃ (100℉) or higher suggests infection. A WBC count of more than 18,000 to 20,000/mm³ suggests infection, especially if the count is increasing over serial blood draws.
2. Perform initial vaginal examination; repeat only during contractile pattern or client’s behavior indicates significant labor progress.
Frequent vaginal examinations can lead to the incidence of ascending tract infections. To limit the risk of infection, the nurse should keep vaginal exams to a minimum. Cleaning of the birth canal during vaginal examinations and other instrumental procedures can be used, in limited-resource settings, to minimize the risk of both neonatal sepsis and maternal infections (Hassan et al., 2020).
3. Assess vaginal secretions using phenaphthazine (nitrazine paper). Perform microscopic examination for positive ferning.
Spontaneous rupture of membranes 1 hr or more before the onset of labor increases the risk of chorioamnionitis during the intrapartum period. Diagnosis is confirmed by testing the fluid with nitrazine paper, which turns blue in the presence of amniotic fluid. A sample of vaginal fluid is placed on a slide and sent to the laboratory will show a ferning pattern under the microscope, confirming that it is amniotic fluid.
4. Assess the character 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. Amniotic fluid cannot be differentiated from urine by appearance, so a sterile vaginal speculum examination is done to observe for vaginal pooling of fluid. If the fluid is tested with Nitrazine paper, the amniotic fluid causes an alkaline reaction (appears blue).
5. Monitor the fetal heart rate.
Fetal tachycardia (rate >160 beats/min) may be the first sign of infection. Poor fetal oxygenation may also occur, especially with abnormal labor.
6. Obtain specimens for cultures and Gram stain if symptoms of sepsis are present.
Immediate identification of infective organism type by Gram stain allows prompt treatment, whereas more specific identification by cultures can be obtained in hours or days. The timing of tests is of paramount importance because the rate of colonization could falsely appear to be lower if done at 35-37 weeks of gestation. Researchers believe screening during labor would be the most appropriate time to prevent neonatal morbidity and mortality (Musleh & Al Qahtani, 2017).
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Use an aseptic technique during a vaginal examination and other invasive procedures.
The aseptic technique helps prevent the growth of bacteria and limits contaminants from reaching the vagina. Cleaning of the birth canal with a disinfectant during vaginal examinations and other instrumental procedures can be used, in limited-resource settings, to minimize the risk of both neonatal sepsis and maternal infections (Hassan et al., 2020).
2. Demonstrate good hand washing techniques.
Proper hand hygiene reduces the risk of acquiring/spreading infective agents. Hand hygiene is one of the safety measures at units that can protect the client in labor from infection; because the client in delivery is vulnerable to infections such as hepatitis B, hepatitis C, and human immunodeficiency virus, those infections may be happening because of improper hand hygiene and aseptic technique (Hassan et al., 2020).
3. Encourage perineal care after elimination and as indicated.
Proper perineal hygiene reduces the possibility of introducing bacteria into the birth canal. Be certain to instruct a postpartum client in proper perineal care, including wiping from front to back so that she does not bring E. coli organisms forward from the rectum. When giving perineal care, wash your hands and wear gloves. Each postpartum client should have their perineal supplies and should not share them to prevent the transfer of pathogens from one woman to another.
4. Change underpads and linens when wet or as needed.
Observe for wet underpads and linens after the membranes rupture. Change them as often as needed to keep the client relatively dry and reduce the risk for infection or skin breakdown, as a moist, warm environment favors the growth of microorganisms.
5. Carry out perineal preparation, as appropriate.
Some providers believe it may facilitate the perineal repair at delivery and cleaning of the perineum in the postpartum period, thereby reducing the risk of infection. Perineal massage is a simple and easy-to-perform technique developed to relax and lengthen the pelvic floor musculature. In a systematic review, Beckman and Stock verified that performing massage is associated with decreased incidence of perineal tears requiring suture and the probability of an episiotomy (Sisconeto de Freitas et al., 2018).
6. Educate the client about the signs and symptoms of infection that should be reported to their healthcare provider.
Before the client is discharged, be certain to ask if she has a thermometer and provides her with specific instructions regarding what degree of temperature she should report and if she understands the level of bed rest expected of her. Help the client understand the signs and symptoms of infection (fever, chills, foul-smelling vaginal secretions) so her white blood cell count can be assessed as necessary.
7. Administer prophylactic antibiotic IV, if indicated.
Although antibiotic administration during the intrapartum period is controversial because of the antibiotic load for the fetus, it may help protect against the development of chorioamnionitis in the client at risk. Prophylactic administration of broad-spectrum antibiotics effective against group B streptococcus during this period may delay the onset of labor and sufficiently reduce the risk of infection in the newborn.
8. Administer oxytocin infusion, as ordered.
If labor does not happen within 24 hr after rupturing of membranes, an infection may occur. If the client is at 36 weeks gestation, the onset of labor reduces the risk of negative effects on the client/fetus. Oxytocin for induction or augmentation of labor is diluted in an IV solution. The oxytocin solution is a secondary infusion inserted into the primary IV solution line so that it can be stopped quickly while an open IV line is maintained. Infusion of oxytocin solution is regulated with an infusion pump. Administration begins at a very low rate and is adjusted upward or downward according to how the fetus responds to labor and the client’s contractions.
Risk For Ineffective Coping
Coping is a dynamic process in which emotions and stress affect and influence each other; coping changes the relationship between the individual and the environment. The nurse must understand the physiology of the normal labor process to recognize abnormalities. With the absence of emotional, psychological, and physical support, the client may become unable to cope with the labor, creating unfavorable consequences for herself and the fetus.
Nursing Diagnosis
- Risk For Ineffective Coping
May be related to
Common related factors for this nursing diagnosis:
- Inadequate support systems and coping methods
- Personal vulnerability
- Situational crisis
- Anxiety/fear
- Severe pain
- Lack of sleep/rest
Possibly evidenced by
- A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention.
Desired Outcomes
Common goals and expected outcomes:
- The client will identify individually appropriate behaviors to maintain
Control. - The client will identify ineffective coping behaviors and consequences.
- The client will verbalize awareness of their coping abilities.
- The client will use medication appropriately.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess uterine contraction/relaxation pattern, fetal status, vaginal bleeding, and cervical dilatation.
Rule out possible complications that could be causing or contributing to the discomfort/reduced coping ability. During the first stage of labor, dysfunction involves a prolonged latent phase, which occurs when contractions become ineffective. The latent phase lasts longer than 20 hours in a nullipara or 14 hours in a multipara.
2. Assess the client’s level of labor pain.
Assess the client’s pain level by verbal, pain scale, and nonverbal indicators. Use a 1 to 10 scale and evaluate the response to the techniques used. Associating labor pain with usual circumstances can go a long way toward helping the client collect her resources and decide on a workable pain relief strategy.
3. Note the age of the client and the presence of a partner/support person(s).
Negative coping may result in increased anxiety, in which case the client may request medication too early in the labor process. Younger and unattended clients may exhibit more vulnerability to stress or discomfort and have difficulty maintaining control. Be certain an adolescent has a support person in labor to relax and breathe effectively with contractions.
4. Determine the client’s cultural background, coping abilities, and verbal and nonverbal responses to pain. Determine previous experiences and antepartum preparation.
Each client responds uniquely to the stresses of labor and associated discomfort based on these factors. The appearance of appropriate or inappropriate coping may be a manifestation of one’s culture; e.g., Asian or Native American women may be stoic because of fear of shaming self or family, whereas Hispanic and Middle Eastern cultures typically encourage the verbal expression of suffering. For this reason, it is important to compare both verbal and nonverbal responses when assessing coping ability. Culture has a role in tolerating pain. Research found that cultural factors influence pain perception (Solehati & Rustina, 2015).
5. Assess the client’s and family’s current functional status and note how labor affects the ability to cope.
The client’s SO or family members have been dealing with a major life adjustment and experiencing uncertainties regarding childbirth. They are also the family members or partners who would face the postpartum process with the client and the newborn. Therefore, factors that place demands on their life routines, time, energy, finances, and relationships should be identified. The information may help in identifying the needs and plan of care.
6. Assess the presence of positive coping skills and inner strengths.
Positive coping skills such as relaxation techniques, willingness to express feelings, and support systems may help the client cope successfully with labor. When the client has coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the client’s sense of control.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Establish rapport and accept behavior without judgment. Make verbal contracts about expected behaviors of client and nurse.
Establishing rapport facilitates cooperation and allows the client to leave the experience with positive feelings and enhanced self-esteem. The nurse should provide continuous labor support in a hands-on, in-person manner rather than rely on monitors viewed from outside the labor room. The nurse may need to assist the client in maintaining or regaining control of breathing and relaxation or set limits if inappropriate (unsafe) behavior occurs.
2. Stay and provide a companion (e.g., doula) for a client who is alone.
At a time of increased dependence, unmet needs and fear of being abandoned may interfere with focusing on the task. Doula describes an individual who provides emotional, physical, and informational support to the pregnant woman but does not perform clinical tasks. These childbirth companions may be volunteers or may be paid for their services. Research suggests that using doulas during labor and delivery results in shorter labors, decreased forceps and epidural anesthesia, reduced oxytocin use, fewer cesarean births, better infant outcomes, and enhanced client/partner satisfaction (Chen & Lee, 2020).
3. Reinforce breathing and relaxation techniques during contractions.
These practices minimize anxiety and provide a distraction, blocking the perception of pain impulses within the cerebral cortex. The breathing relaxation techniques in the labor process increase abdominal wall relaxation, increase oxygen supply into the uterus, enlarge the abdominal cavity, and ultimately reduce pain caused by friction between the uterus and the abdominal wall during contraction. Breathing and relaxation can also enhance physical relaxation by reducing tension and increasing emotional relaxation by reducing anxiety (Murtiningsih, 2018).
4. Instruct the client to maintain an upright position during labor and educate about other acceptable positions to increase the client’s comfort.
Maintaining an upright position during labor can shorten the first stage. The recommended comfort positions for the laboring client include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. The “towel-pull” involves the client pulling on a towel secured to the foot of the bed during contractions, which uses the abdominal muscles and aids in expulsion efforts. The lateral Sims position encourages rest and helps prevent pressure on the sacrum. Squatting during a contraction increases the diameter of the pelvis, facilitating fetal rotation and descent.
5. Provide support to the client’s body using pillows.
Pillows can provide body support to prevent back strain and can also be used to facilitate anterior rotation of the fetus when the client lies on the side of the fetal spine. The “lunge,” in which the client places her foot on a chair and turns that leg outward, helps the femur press on the ischium to increase pelvic space and facilitates the fetus’s rotation in an occiput position.
6. Provide a calm, peaceful environment for the laboring client.
The environment of the labor room can be controlled by having the client listen to familiar music brought from home, which can produce a calming effect. Changing the linen and the client’s gown, darkening the room lights, and decreasing noise and stimulation can be helpful. These measures usually combine to allow labor to become effective and progress.
7. Educate the client about additional nonpharmacologic pain relief techniques.
In addition to controlling the environment, nonpharmacological pain relief techniques such as touch, effleurage, massage, back pressure, application of heat or cold, and various relaxation techniques are effective means of labor support. Aromatherapy methods can improve physical health and affects the emotion of the person. The access to aromatherapy through nasal inhalation is much faster than in other ways, and lavender is one of the essential oils safe to use by laboring clients to improve relaxation and reduce pain during labor (Murtiningsih, 2018).
8. Advise the client not to push during this stage of labor.
The nurse must often help the client avoid pushing before her cervix is fully dilated. She can be taught to blow out in short puffs when the urge to push is strong before the cervix is fully dilated. Pushing before dilatation can cause maternal exhaustion and fetal hypoxia, thus slowing the progress rather than speeding it.
9. Discuss systemic/regional analgesics or anesthetics when available in the birth setting.
This information helps the client make an informed choice about methods to relieve pain and maintain control. Where pain registers are important in appreciating why epidural anesthesia is effective. The anesthetic block needs to suppress the lower thoracic synapses and block sacral nerves for birth for early labor. Support whichever decision the client has made coming into labor and any change she decides on as labor progresses.
10. Discuss administration of sedatives such as secobarbital (Seconal), pentobarbital (Nembutal), or hydroxyzine (Vistaril).
A barbiturate or ataractic may be administered during early labor to promote sleep. The client enters the active phase more relaxed and rested and better able to cope. If the client receives medication for pain, such as a narcotic, she may need to remain in bed for about 15 minutes to avoid a fall if she should become dizzy from the medication.
Anxiety
The processes of labor and childbirth involve a multitude of psychological and physical demands that result in maternal stress. Given that maternal stress levels were shown to peak during labor, this period may represent an important opportunity to reduce stress and associated adverse outcomes by targeting factors contributing to the stress response. These include the fear of labor pain or episiotomy, anxiety and fear regarding her inability to give birth, dying during childbirth, and lack of healthcare support (Tan et al., 2021).
Nursing Diagnosis
- Anxiety
May be related to
Common related factors for this nursing diagnosis:
- Interpersonal transmission
- Situational crisis
- Unmet needs
- Threat to, or change, in health status
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Feelings of discomfort, apprehension, or helplessness
- Decreased attention span
- Restlessness
- Poor impulse control
- Hyperactivity
Desired Outcomes
Common goals and expected outcomes:
- The client will verbalize feelings of anxiety are at a manageable level.
- The client will use breathing and relaxation techniques accordingly.
- The client will appear relaxed appropriate to the labor situation.
- The client will maintain vital signs within the normal range.
Nursing Assessment and Rationales
Here are the nursing assessment for this labor nursing care plan.
1. Assess the client’s level of labor pains.
During labor, use a standard method of pain assessment, such as asking the client to rate her pain level on a scale of 1 to 10 or show her paper with a line marked 1 to 10 if she’s more visually oriented so that she can rate her pain. Based on her response, evaluate whether pain relief is adequate and effective.
2. Assess the level and causes of anxiety and the effects of cultural background.
Anxiety magnifies pain perception, interferes with coping techniques, and stimulates the release of aldosterone, which may increase sodium and water resorption. Some clients believe their expected role during labor is to be stoic and nonverbal, even in the face of intense pain. Others believe that expressing their discomfort by screaming or verbalizing it is expected. Assess each client individually to determine what level of comfort she feels is right for her during labor and how she feels most able to express discomfort.
3. Assess the client’s or couple’s preparedness for childbirth, their sources of information, and the role of their significant other/partner.
In studies by Daglar and Nur (2014), Laursen, Hedegaard, and Johansen (2008), childbirth fear and anxiety levels were high for pregnant women with low education levels. Besides, the anxiety and fear levels of the pregnant women who received antenatal training from the books, the internet, and the courses were determined to be high as in the studies of Dönmez, Yeniel, and Kavlak (2014). In eliminating anxiety and birth fear, psychological factors such as social and spousal support are important (Sani, 2015). Likewise, high anxiety and birth fear were found in women with poor spouse support (Erkaya et al., 2017).
4. Monitor pattern of uterine contraction.
A hypertonic or hypotonic contractile pattern may develop if stress persists and causes prolonged catecholamine release. Tachysystole is more than five uterine contractions within 10 minutes, observed over 30 minutes. Tachysystole must be reported promptly.
5. Monitor vital signs, especially BP and pulse rate, as indicated. (If BP is elevated on admission, repeat the procedure in 30 min to obtain true reading once the client is relaxed.)
Stress activates the hypothalamic-pituitary-adrenocortical system, increasing the retention and resorption of sodium and water and increasing potassium‘s excretion. Uterine contractions release 400 ml of blood into the vascular system, causing an increase in cardiac output. BP may increase by 10 mmHg, and pulse rate may slow. Increased physical activity of labor increases oxygen consumption, increasing the respiratory rate.
6. Monitor FHR patterns and rhythm.
Alterations in FHR and rhythm may occur in response to contraction patterns. The normal range of FHR is 110-160 beats/minute. Monitor FHR frequently and time the frequency and duration of contractions.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Encourage the client and her partner.
Encouragement is a powerful tool for intrapartum nursing care because it helps the client summon inner strength and gives her the courage to continue. After each vaginal examination, she is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to cope with labor. Her partner also needs encouragement, as labor coaching is a demanding job.
2. Promote privacy and respect for modesty; reduce unnecessary exposure. Use draping during a vaginal examination.
Modesty is a concern in most cultures. A support person may or may not desire to be present while a client is examined or care provided. In the typical hospital environment, laboring clients are disturbed at every turn- with machines, intrusions, strangers, and a pervasive lack of privacy. The best labor support will protect the client’s privacy and ensure that she is not disturbed to tap into her inner wisdom and dig deep to find the strength she needs to give birth (Lothian, 2004). Be aware of the client’s need or preference for female caregivers/support persons. Cultural practices may prohibit men (even the child’s father) during labor and delivery.
3. Encourage the client to verbalize feelings, concerns, and fears.
Stress, fear, and anxiety profoundly affect the labor process, often prolonging the first phase because of the utilization of glucose reserves, causing excess epinephrine release from adrenal stimulation, which inhibits myometrial activity; and increasing norepinephrine levels, which tends to increase uterine activity. Such an imbalance of epinephrine and norepinephrine can create a dysfunctional labor pattern.
4. Provide primary nurse or continuous intrapartum professional support as indicated.
Continuity of care and assessment may decrease stress. Research studies suggest that these clients require less pain medication, resulting in shorter labor. A doula is a woman who is experienced in childbirth and postpartum support. These support persons provide physical, emotional, and informational support prenatally, during labor and birth, and even at home in the postnatal period.
5. Determine diversional needs; encourage various activities (e.g., music, books, cards, walking, rocking, showering, massage, painting, aromatherapy).
Diversional activities move enough attention away from labor, making time pass quickly. If condition permits, walking promotes cervical dilatation, shortens labor, and lowers the incidence of fetal heart rate (FHR) abnormalities. Concentrating intently on an object is another method of distraction or keeping sensory input from reaching the brain’s cortex.
6. Demonstrate breathing and relaxation methods. Provide comfort measures.
Relaxation keeps the abdominal wall tense, allowing the uterus to rise with contractions without pressing against the hard abdominal wall. Breathing patterns are taught in most preparation for childbirth classes and are well documented to decrease pain and anxiety in labor. Stay with the client until she appreciates how useful slow-paced breathing can be and feels comfortable using this technique independently.
7. Provide heat application at the lower back or the perineum as tolerated.
A client with back pain may find applying heat to the lower back with a heating pad, instant hot pack, or warm moist compress extremely comforting. Heat applied to the perineum provides dual benefits of soothing and softening the perineum and decreasing the risk of perineal tears. Always test the temperature of the head pad before applying it to the perineum.
8. Provide an opportunity for conversation to include the choice of infant names, expectations of labor, and perceptions/fears during pregnancy.
This presents an opportunity for the client to verbalize excitement about herself, the pregnancy, and her baby. A conversation serves as a diversion to help pass the time during the longest phase of labor.
9. Educate the client about psychological and physiological changes in labor, as needed.
Education may reduce stress and anxiety and promote labor progress. Be certain to explain the characteristics of contractions (e.g., labor contractions are rhythmic and come and go repeatedly) and reinstruct as necessary. Do not assume the client is aware simply because she is experiencing the contractions. Her pain may be so intense and the intensity so unexpected that she is unaware of any relief between contractions.
10. Prepare for, and assist with discharge from the hospital setting.
During the very early latent phase with no apparent progress of labor, the comfort and familiarity of the home environment may decrease anxiety and allow an opportunity for a variety of acceptable diversional activities, thereby hastening the labor process.
11. Refer the client for professional support.
Pregnancy-specific anxiety (PSA) is linked to a higher risk of preterm birth and low birth weight. Both childbirth fear and PSA are associated with a higher likelihood of cesarean birth. The interventions that were effective for clients with elevated childbirth fear were individual intensive therapy and individual telephone counseling with midwives with some training in psychotherapy (Stoll et al., 2017).
Labor Stage IB: Active Phase
The active phase occurs when cervical dilatation is at 4 to 7 cm and contractions last from 40 to 60 seconds with 3 to 5 minutes intervals. Show and perhaps spontaneous rupture of membranes may occur at this time. This phase can be difficult for the client because contractions grow stronger and last longer than in the latent phase. Here are five (5) nursing care plans for the active phase of labor:
Acute Pain
During the active phase of labor, cervical dilatation occurs more rapidly. Because the first stage of labor begins with uterine contractions and takes hours to complete, most clients have been having labor contractions for hours before they even arrive at a birthing center or hospital.
Nursing Diagnosis
May be related to
Common related factors for this nursing diagnosis:
- Pressure on adjacent structures
- Stimulation of both parasympathetic and sympathetic nerve endings
- Tissue dilation/muscle hypoxia
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)
- Muscle tension
- Verbalizations
Desired Outcomes
Common goals and expected outcomes:
- The client will identify/use techniques to control pain/discomfort.
- The client will report discomfort is minimized.
- The client will appear relaxed/resting between contractions
- The client will be free of untoward side effects if analgesia/anesthetic agents are administered.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess the client’s pain level by verbal, pain scale, and nonverbal indicators. Use a 1 to 10 scale and evaluate response to techniques used.
Support the client in her ability to manage pain until her epidural can be given.
2. Assess the degree of discomfort through verbal and nonverbal cues; note cultural practices on pain response.
Attitudes and reactions to pain are individual and based on past experiences, understanding of physiological changes, and cultural expectations. For instance, in Korean culture, women should remain silent during childbirth because they wouldn’t like to shame their families. Whereas European and American women show a wide range of reactions to labor pain. Some Chinese women do not scream or cry during labor because they believe that crying depletes the energy stored required for childbirth (Yadollahi et al., 2018).
3. Assess and record the nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent.
Cervical dilation during the active phase should be approximately 1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with a fetal descent. Descent is expected to occur at a rate of at least 1.0 cm/hr in the nullipara and 2.0 cm/hr in the multipara. The degree of dilation and contractile pattern affects the choice and timing of medication. A Friedman curve is often used to graph the progress of cervical dilation and fetal descent.
4. Time and record the frequency, intensity, and duration of uterine contractile pattern per protocol.
Monitor the labor progress and provide information for the client. Give the couple frequent progress reports during labor, so they do not become discouraged or fearful this way at a seeming lack of progress. Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion. As a rule, uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because this interferes with adequate uterine artery filling.
5. Assess BP and pulse every 1–2 min after regional injection for the first 15 min, then every 10–15 min for the remainder of labor.
Maternal hypotension, the most common side effect of regional block anesthesia, may interfere with fetal oxygenation. An almost inevitable complete sympathetic block occurs, and decreased venous return to the heart- exacerbated by inferior vena cava compression- results in hypotension and decreased cardiac output (Chooi et al., 2017).
6. Monitor FHR variability electronically during anesthesia administration.
Agents such as bupivacaine (Marcaine) and fentanyl (Sublimaze) reportedly have little effect on FHR variability (but, in practice, may decrease variability); alterations should be investigated by the nurse thoroughly. These side effects can begin 2–10 min after administration of anesthetic and may last for 5–10 min, on occasion. Combining bupivacaine with fentanyl for spinal analgesia in labor is usual, but commonly used doses may be excessive. A reduced dose of 2 mg bupivacaine with a lower dose of 15 μg fentanyl reduces the risk of FHR changes associated with a higher dose (Kuberan et al., 2018).
7. Using an alcohol pad, a cotton swab, or a piece of ice or cold pack on both sides of the abdomen, assess and record the level of sensation every 30 min.
Increasing loss of sensation following epidural block indicates migration of anesthesia. The level above T-9 may alter respiratory function, while loss of sensation at the breastbone level (appx. 7–6) increases the risk of profound hypotension. Local anesthetics block the conduction of the sensory, motor, and sympathetic nerve fibers. Sensitivity to changes in temperature along sensory dermatomes can be used to assess the level of the epidural block (Sugden, 2006).
8. Obtain a fetal scalp sample if bradycardia persists for 30 minutes per electronic monitor.
Prolonged fetal bradycardia may indicate the need to determine pH to evaluate hypoxia. Obtaining the fetal oxygen saturation level by inserting a fetal oximeter into the uterus to rest next to the fetal cheek or obtaining a positive response to scalp stimulation usually supplies the information as to whether a fetus is becoming acidotic; however, this information can also be obtained by scalp blood or fetal blood sampling. However, this practice is gradually disappearing due to the difficulty of the procedure and reasonable noninvasive alternatives.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Engage client in conversation to assess sensorium; monitor breathing patterns and pulse.
Systemic toxic responses with altered sensorium occur if medication is absorbed into the vascular system. Altered sensorium may also be an early indicator of developing hypoxia. Facilities often use a scale to assess for sedation so that all caregivers use the same criteria for assessment and documentation. Interference with respiratory functioning occurs if analgesia is too high, paralyzing the diaphragm. Her respiratory status is observed every 15 minutes for 1 to 2 hours.
2. Elevate head approximately 30 degrees, alternate position by turning side to side, and use of hip roll.
Position changes promote comfort and help the fetus adapt to the size and shape of the client’s pelvis. Elevating the head prevents the block from migrating up and causing respiratory depression. Lateral positioning increases venous return and enhances placental circulation. Supine position can result in supine hypotensive syndrome, which reduces placental blood flow and fetal oxygenation.
3. Encourage the client to void every 1–2 hr. Palpate above symphysis pubis to determine distension, especially after nerve block.
This keeps the bladder free of distension, increasing discomfort, resulting in possible trauma, interfering with fetal descent, and prolonging labor. Epidural or pudendal analgesia may interfere with sensations of fullness. The nurse should palpate the suprapubic area for a full bladder every 2 hours if a large IV solution is given. A full bladder can delay birth and cause hemorrhage after birth.
4. Institute safety measures.
Regional block anesthesia produces vasomotor paralysis so that sudden movement may precipitate hypotension. When pharmacological pain relief is administered, safety protocols must be implemented, such as raising the side rails, maintaining close observation, and having naloxone readily available. Analgesics alter perception, and the client may fall trying to get out of bed. Safety measures can include encouraging the client to move slowly, keeping side rails up after drug administration, and supporting the legs during positioning changes.
5. Assist with comfort measures.
One of the most effective non-pharmacological methods to reduce pain is massage. The basis of this theory is the gate control theory proposed by Melzak and Wall. The gate control theory states that during labor, the impulse of pain labor travels from the uterus along the large nerve fibers toward the uterus to the gelatinous substance within the spinal column. The transmission cells project pain messages to the brain. The presence of stimulation (such as vibration, rubbing, or massage) results in stronger and faster opposite messages along small nerve fibers. This opposite message closes the gate on the substance of gelatinosa and blocks pain messages, so the brain does not record the pain message (Oktriani et al., 2018). Comfort measures can include providing back or leg rubs, sacral pressure, backrest, mouth care, repositioning, shower or hot tub use, perineal care, and linen changes.
6. Teach and assist in using appropriate breathing and relaxation techniques and abdominal lifting.
Breathing and relaxation techniques may block pain impulses within the cerebral cortex through conditioned responses and cutaneous stimulation. It facilitates the progression of normal labor. Abdominal lifting is a technique for reducing labor pain by giving a stroke to the top of the stomach without pressing inward. This sweep can increase comfort because it can increase the circulation towards the abdomen so that the blood vessels around the abdomen are dilated, and this process can reduce pain (Oktriani et al., 2018).
7. Review proper breathing techniques with the client.
Even though the client conscientiously practiced breathing or focusing in a relaxed setting of an antepartum class, the discomfort and stress of labor may make it easy for her to forget what she learned. As necessary, reinforce previously learned breathing techniques with her. Urge her to begin using these early in labor, before contractions become strong, so she gains confidence that they can be effective at diminishing pain.
8. Encourage comfortable positioning.
An upright position, sitting, walking, or swaying with a partner may be most comfortable for the client in early labor and aids contractions and descent through gravity. If the client wants to walk and has no support, walk with her as she may need support during a contraction. Leaning forward against a birthing ball or pelvic rocking between contractions may relieve tense back muscles.
9. Educate the client about the effects of hydrotherapy during labor.
Studies have shown that hydrotherapy lowers the vasopressin level, enhances uterine perfusion, and less painful contractions. Furthermore, hydrotherapy ensures pregnant women shift positions during labor, improves their sense of control, reduces anxiety, shortens labor by accelerating cervical dilation, facilitates adaptation to labor, and improves labor satisfaction. Hydrotherapy has no adverse effects on the mother or fetus/newborn and is a low cost. In the Cochrane Database of Systematic Reviews, water immersion applied during the first stage of labor minimized the need for epidural/spinal analgesia. It reduced the duration of the first stage of labor (Tuncay et al., 2017).
10. Support the client’s decision about using or nonuse of medication in a nonjudgmental manner. Continue encouragement for efforts and use of relaxation techniques.
This helps reduce feelings of failure in the client and couple who may have anticipated an unmedicated birth and did not follow through with that plan. It also enhances a sense of control and may prevent or decrease the need for medication. Many clients come into labor wishing to avoid drugs entirely. Once in labor, they may change their minds but hesitate to say so, especially if their partners also believe a birth without the use of drugs is ideal. Maintain a supportive presence to help the client make the best decision for herself and the newborn.
11. Administer analgesics such as butorphanol tartrate (Stadol) or meperidine hydrochloride (Demerol) by IV or deep intramuscular (IM) during contractions, if indicated.
IV route is preferred because it ensures more rapid and equal analgesic absorption. Medication administered by the IM route may require up to 45 min to reach adequate plasma levels, and maternal uptake may be variable, especially if the drug is injected into subcutaneous fat instead of muscle. Administering IV drugs during uterine contraction decreases the amount of medication that immediately reaches the fetus. Meperidine has a 5 to 10-minute peak action if given intravenously or a 50-minute peak of action if given intramuscularly.
12. Administer IV bolus of 500–1000 ml of lactated Ringer’s solution just before administration of lumbar epidural block.
The increased circulating fluid level helps prevent side effects of hypotension associated with the block. Therefore, it is infused rapidly before the block is begun. The large number of IV fluids combined with reduced sensation may result in urinary retention.
13. Assist with epidural or caudal block anesthesia using an indwelling catheter.
Pharmacological interventions provide relief once active labor is established; reinforcement through the catheter provides sustained comfort during delivery. Such analgesia does not interfere with uterine activity and Ferguson reflex. While it relaxes the cervix and facilitates the labor process, it may alter internal fetal rotation and diminish the client’s ability to bear down when needed. Several pharmacological methods may slow labor progress if used early in labor.
14. Administer emergency medications as indicated, e.g., naloxone (Narcan) or ephedrine (Ephedra). Succinylcholine chloride and assist with intubation, as appropriate.
Narcan is used to reverse opiate-induced respiratory depression, usually in the infant, caused by opioid drugs such as meperidine. It can be given by the IV route or through the endotracheal tube during resuscitation. Adrenaline may be required for hypotensive episodes not responsive to IV fluid bolus. Systemic toxic reaction to epidural anesthetic may alter sensorium or cause convulsions if medication is absorbed into the vascular system.
15. Assist with complementary therapies as indicated, e.g., acupressure/ acupuncture.
Some clients and healthcare providers may prefer a trial of alternative therapies to mediate pain before pursuing invasive techniques. Acupuncture relieves pain in labor decreases the need for analgesics, forceps and vacuum use, and duration of labor. Acupuncture stimulates increased uterine contractility by releasing oxytocin by central or parasympathetic uterine stimulation. Shortening the duration of the first stage of labor is especially important for primiparas because their labor duration is much longer than that of multiparas (Pesic et al., 2019).
Impaired Urinary Elimination
One of an epidural block’s most common side effects is urinary retention. After initiation of the epidural block, the FHR and BP should be monitored and documented. To counteract hypotension, a large quantity (500 to 1000 mL or more) of IV solution is infused rapidly before the block is begun. The large number of IV fluids combined with the reduced sensation may result in urinary retention.
Nursing Diagnosis
May be related to
Common related factors for this nursing diagnosis:
- Altered intake
- Effects of regional anesthesia
- Fluid shifts
- Hormonal changes
- Mechanical compression of the bladder
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 amount/frequency of voiding
- Slowed progression of labor
- Urine retention
- Urinary urgency
Desired Outcomes
Common goals and expected outcomes:
- The client will empty the bladder appropriately.
- The client will be free of bladder injury.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Record and compare intake and output. Note the amount, color, concentration, and specific gravity of urine.
The output should approximate intake. Increased output may reflect excessive fluid retention before the onset of labor and effects of bedrest (i.e., increased glomerular filtration rate and decreased adrenal stimulation). Specific gravity reflects the kidney’s ability to concentrate urine and the client’s hydration status. Decreased output may occur with dehydration, hemorrhage, and pregnancy-induced hypertension (PIH).
2. Observe for changes in mental status, behavior, or level of consciousness.
Accumulation of wastes and electrolyte imbalances can be toxic to the central nervous system and affect the client and the fetus.
3. Assess the client’s voiding preference.
The nurse should assess the client’s voiding preference and how this may impact their sense of control and feelings of empowerment in labor. In a study, Hedgcorth (2021) notes that some women experienced frustration at being unable to void. Women in the continuous catheterization group cited feelings of relief, ease, and convenience, with the main negative themes being discomfort, pain, and stress.
4. Palpate the bladder above the symphysis pubis.
The nurse should palpate the suprapubic area for a full bladder every 2 hours or as necessary if a large IV solution is given. This detects the presence of urine in the bladder and the degree of fullness. Incomplete emptying of the bladder may occur because of decreased sensation and tone.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Position the client upright, run water from the faucet, pour warm water over the perineum, or have the client blow bubbles through a straw.
These measures facilitate voiding/enhance emptying of the bladder. The sound of the running water phenomenon might be explained by the mechanism of parasympathetic acceleration and Pavlovian conditioning because of the central and peripheral neural responsive system of the bladder detrusor muscle and urethral sphincter. Feeling the urge to urinate with the sound of running water appears to be in line with a conditioned response in Pavlovian conditioning. The sound of running water mimics the sound of urination itself and the feelings of urine passing through the urethra during micturition (Kwon et al., 2015).
2. Encourage periodic attempts to void, at least every 1–2 hr.
The pressure of the presenting part on the bladder often reduces sensation and interferes with complete emptying. Regional anesthesia (especially in conjunction with IV fluid infusion and use of Stadol) also may contribute to voiding difficulties/bladder distension.
3. Allow the client to choose between using a bedpan and catheterization.
Women felt like active participants in their care when choosing between using the bedpan or immediate catheterization. A study suggested that 60% of women offered a bedpan after epidural anesthesia could void independently. This was increased by 91% when nurses provided interventions to help. Researchers also investigated women’s feelings of empowerment over their birth when choosing the type of bladder care provided. 70% appreciated being offered the bedpan rather than automatic catheterization (Hedgcorth, 2021).
4. Catheterize as indicated.
An overdistended bladder can cause atony, impede fetal descent, or become traumatized by presenting part of the fetus. Infrequent catheterizations can lead to bladder distention, resulting in hypoactive detrusor and voiding dysfunction. Bladder overdistention may lead to bladder nerve damage and inhibition of micturition reflexes. More frequent catheterizations prevent bladder overdistention and can thus decrease the risk of postpartum urinary retention (Rosenberg et al., 2019).
5. Educate the client about the effects of acupuncture on urinary retention as a side effect of epidural analgesia.
Electroacupuncture is a non-pharmacological method that stimulates EX-B2 and SP6 acupoints, reducing labor pain and shortening the active phase of labor. Electroacupuncture regulates and stimulates the excitability of the visceral nerve that innervates the bladder, which improves the coordination function of the related muscle. Thus the normal urination function can be restored (Xiao et al., 2018).
6. Educate the client regarding pelvic floor muscle training.
Pelvic floor muscle training during pregnancy decreases the risk of postpartum urinary incontinence. Pelvic floor muscle training usually involves more than one daily set of repeated voluntary contractions of the pelvic floor muscles performed on at least several days, starting at approximately 30-32 weeks until labor (Berghella & Di Mascio, 2020).
Impaired Gas Exchange (Fetal)
Fetal compromise can occur because blood flow to the placenta is reduced if contractions are excessive (tachysystole). Most placental exchange of oxygen, nutrients, and waste products occurs between contractions. This exchange is likely impaired if the contractions are too long, frequent, or intense.
Nursing Diagnosis
- Impaired Gas Exchange
May be related to
Common related factors for this nursing diagnosis:
- Altered oxygen supply/blood flow
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Restlessness
- Dyspnea
- Cyanosis
- Nasal flaring
- Use of accessory muscles
- Hypoxemia
- Hypoxia
- Abnormal arterial blood gases
Desired Outcomes
Common goals and expected outcomes:
- The fetus will display FHR and beat-to-beat variability within the normal limit.
- The fetus will be free of the adverse effects of hypoxia during labor.
Nursing Assessment and Rationales
Below are the nursing assessment for this labor nursing care plan.
1. Assess FHR changes during a contraction, noting decelerations and accelerations.
As a rule, an FHR of more than 160 beats/min (fetal tachycardia) or less than 110 beats/min (fetal bradycardia) is a sign of possible fetal distress. An equally important sign is a late or variable deceleration pattern revealed on a fetal monitor. The fetus is vulnerable to potential injury during labor, owing to situations that reduce oxygen levels, such as cord prolapse, prolonged head compression, or uteroplacental insufficiency.
2. Assess for maternal factors or conditions that compromise uteroplacental circulation (e.g., diabetes, PIH, kidney or cardiac disorders). Note prenatal testing of placental functioning by nonstress test (NST) or contraction stress test (CST).
High-risk situations that negatively affect circulation are likely manifested in late decelerations and fetal hypoxia. In preeclampsia, vascular dysfunction leads to increased vascular resistance and reduced blood flow in the uteroplacental circulation (Hu & Zhang, 2021).
3. Note and record color, amount, and odor of amniotic fluid and time of membrane rupture.
In a vertex presentation, prolonged hypoxia results in meconium-stained amniotic fluid owing to vagal stimulation, which relaxes the fetal anal sphincter. Hydramnios may be associated with fetal anomalies and poorly controlled maternal diabetes.
4. Monitor uterine activity manually or electronically.
The development of hypertonicity can compromise uteroplacental circulation and fetal oxygenation. Observe if there is a period of relaxation between contractions so the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because this interferes with adequate uterine artery filling.
5. Monitor fetal descent in the birth canal through vaginal examination. In cases of breech presentation, assess FHR more frequently.
Prolonged head compression stimulates vagal responses and may result in fetal bradycardia if the rate of descent is not at least 1 cm/hr for primiparas or 1.5 cm/hr for multiparas. Fundal pressure in the breech presentation may cause vagal stimulation and head compression.
6. Check FHR immediately if membranes rupture, and then again 5 min later. Observe maternal perineum for visible cord prolapse.
The risk for prolapsed cord increases if the membranes rupture before the fetal presenting part is completely engaged in the pelvis—monitoring and documenting the fetal heart rate after the membranes rupture is an essential nursing responsibility.
7. Prepare for and assist with fetal scalp sampling, repeating as indicated;
Prolonged, decreased variability may indicate acidosis. On occasion, determining fetal pH value may help identify fetal respiratory acidosis and metabolic reserves. Obtaining the fetal oxygen saturation level by inserting a fetal oximeter into the uterus to rest next to the fetal cheek or obtaining a positive response to scalp stimulation usually supplies the information as to whether a fetus is becoming acidotic; however, this information can also be obtained by scalp blood or fetal blood sampling.
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 as a transient phenomenon related to umbilical cord compression.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Talk to the client/couple as care is being given, and provide information about a situation as appropriate.
This provides psychological support and assurance to reduce anxiety related to increased monitoring. Inform the client and her partner when labor progresses. Labor does not last forever; knowing that her efforts have desired results gives her courage to continue and helps her tolerate the pain.
2. Encourage the client.
After each vaginal examination, the client is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to summon inner strength and give her courage to continue.
3. Instruct the client to avoid pushing before her cervix is fully dilated.
The nurse must often help the client avoid pushing before her cervix is fully dilated. Pushing before full dilation can cause maternal exhaustion and fetal hypoxia, thus slowing progress rather than speeding it. The client can be taught to blow out in short puffs when the urge to push is strong before the cervix is fully dilated.
4. Place the client in a lateral recumbent position.
This position increases placental perfusion, correcting the problem if it is caused by uteroplacental insufficiency. Regular position changes make the laboring client more comfortable and promote the normal labor processes.
5. Place the client in a knee-chest or side-lying position as indicated.
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 Trendelenberg can accomplish this displacement. Placing the mother in a side-lying position with her hips elevated on pillows reduces cord pressure.
6. Increase plain IV infusion rate.
IV fluids increase circulating fluid volume and placental perfusion. Administer IV fluids such as a saline solution to improve cardiac output, circulatory volume, and uteroplacental perfusion. The nurse should observe for fluid volume overload and pulmonary edema.
7. Discontinue oxytocin if it is being administered.
Strong contractions caused by oxytocin may inhibit uterine relaxation and lower fetal oxygen levels. If abnormalities are noted in either fetal heart rate or maternal vital signs, the nurse stops the oxytocin and begins measures to reduce contractions and increase placental blood flow.
8. Administer oxygen as indicated.
Maternal oxygen administration increases available oxygen for placental transfer. Althabe et al. demonstrated that maternal O2 administration during active labor showed an increased fetal muscular pO2 and improvements in the “abnormal” features of FHTs (Watkins et al., 2020).
9. Assist in amnioinfusion, as indicated.
Amnioinfusion involves instilling a saline infusion by catheter into the uterine cavity to restore amniotic fluid volume to relieve umbilical cord compression that can interrupt fetal oxygenation.
10. Prepare for delivery by the most expeditious means or by surgical intervention, if not accompanied by decreased variability.
Repetitive late decelerations over a 30-min period mean or by surgical intervention may warrant a cesarean birth to prevent fetal injury and death from hypoxia. After appropriate conservative measures have been implemented, it is reasonable to make a good-faith estimate of the time needed to accomplish delivery in a sudden deterioration of the FHR.
11. If late or persistent variable decelerations occur, transfer to level II or III hospital settings as indicated.
The decision to perform routine or heightened surveillance is based on clinical judgment. If the FHR progresses to category III, delivery is expedited as quickly as possible despite corrective measures. Tracings that remain in category II warrant additional evaluation.
Risk For Injury (Maternal)
Pregnancy has effects on many systems of the birthing parent. During labor, there are yet other effects that may require the nurse to deliver specific care to their client. Knowing and recognizing what is normal and what is not can help ensure the safe provision of care.
Nursing Diagnosis
- Risk for Injury (Maternal)
May be related to
Common related factors for this nursing diagnosis:
- Delayed gastric motility
- Effects of medication
- Physiological urges
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 verbalize understanding of individual risks and reasons for specific interventions.
- The client will follow directions to protect self/the fetus from injury.
- The client will be free of preventable injury/complications.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Monitor the client’s temperature and any signs of infection.
Increased temperature and pulse are indicators of a developing infection. The temperature may increase up to (1℉) during labor. Clients who receive labor epidural analgesia are more likely to develop a fever. Maternal fever is associated with an increased risk of neonatal mortality and morbidity, including encephalopathy, hyaline membrane disease, and meconium aspiration (Sultan & Segal, 2020). Monitor the clients’ temperature every 4 hours during labor and every 2 hours after the rupture of the membranes because the possibility for infection markedly increases after that time.
2. Monitor for hemorrhage and signs of pathology with hypertensive episodes.
The client’s cardiac output increases 40–50% from its pre-labor levels. The BP may rise with pain response and, due to work of the system during contractions, by an average systolic rise of 15 mmHg per contraction. The client’s pulse may be rapid on admission because she is nervous and anxious. A constant pulse rate of more than 100 beats/min could be tachycardia from dehydration or hemorrhage and so needs investigation.
3. Assess the client’s respiratory rate.
During labor, the client’s respiratory rate increases due to increased cardiovascular parameters. Do not count respirations during contractions because the client tends to breathe rapidly from pain. Monitor the client for any signs of hyperventilation and provide a brown paper bag for the client to rebreathe into if this occurs.
4. Monitor urine for ketones.
Urinary ketones indicate metabolic acidosis resulting from a deficiency in glucose metabolism, which may reduce uterine activity and cause myometrial fatigue that prolongs labor. However, ketonuria accompanied by hyperglycemia requires prompt evaluation for diabetic ketoacidosis. Ketoacidosis can be rapidly fatal to the fetus.
5. Monitor uterine activity manually or electronically, noting the frequency, duration, and intensity. of contractions
The uterus is susceptible to possible rupture if a hypertonic contractile pattern develops spontaneously or if tachysystole develops due to labor induction with oxytocin administration. Placental separation and hemorrhage can also occur if contraction persists. If the uterine contractions become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). This problem may be correctable but needs augmentation or other interventions.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Instruct the client to pant or blow out if she feels the premature urge to bear down.
Panting during the active phase or the transition phase prevents bearing down too early and reduces the risk of lacerations or edema of the cervix/birth canal. A technique that has been established during labor is to encourage the client to push as soon as the cervix reaches the 10 cm dilatation, regardless of the station of the fetal presenting part, and this technique is called “the immediate pushing technique.” However, evidence supports that the strong urge to push might be present after or even before the observation of the full cervical dilatation (Antsaklis et al., 2020).
2. Place the client in a lateral recumbent or semi-upright position.
This position increases placental perfusion and reduces supine hypotensive syndrome. In early labor, the client should be out of bed, walking or sitting in a chair, kneeling, squatting, on all fours, or in whatever position she prefers because the active movement can shorten the beginning stage of labor.
3. Promote bed rest and use of side rails (as labor intensifies). Avoid leaving the client unattended.
This promotes safety should dizziness or precipitous delivery occurs following administration of medication. The nurse keeps the bed’s rails up if the client receives pain-relief drugs. Narcotics may cause drowsiness or dizziness. Regional anesthesia reduces sensation and movement to varying degrees, and therefore the client may have less control over her body. Side rails on the bed may be necessary for safety.
4. Offer the client clear liquids or ice chips as appropriate.
Insensible water loss increases during labor due to diaphoresis and increased rate and depth of respirations. Encourage the client to sip fluid during labor the same as if they were exercising to keep hydrated. If the client is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.
5. Encourage the client to consume food as tolerated during labor.
Delayed gastric motility inhibits digestion during labor, placing the client at risk for aspiration. However, the client can benefit from the intake of calories in PO fluids to help generate energy for work of labor. Pain due to uterine contractions and administration of opiates may both affect gastric emptying. Although gastric emptying remains to a certain degree during labor, the gastric volume was larger within the first hour after delivery in clients who were allowed solid food during labor compared to those who fasted for solids (Bouvet et al., 2022).
6. Instruct the client to void every 2 hours during labor.
The pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces the bladder tone or the ability of the bladder to sense filling. Ask the client to void approximately every 2 hours during labor to avoid overfilling because overfilling can decrease postpartal bladder tone.
7. Monitor for appropriate mobility and be mindful of fall risks.
During pregnancy, relaxin is secreted from the ovaries, causing the cartilage between joints to be more flexible. This allows the joints of the pelvis to open as much as 2 cm in labor to allow for fetal passage.
8. Use therapeutic communication techniques in conversing with the client and their family members.
Warnings of psychological danger during labor are as important to consider in assessing maternal well-being as are physical signs. As the client approaches the second stage of labor, the woman who is becoming increasingly apprehensive despite clear explanations of unfolding events may not be “hearing” because she has a concern that has not been met. Using an approach such as “You seem more and more concerned. Could you tell me what is worrying you?” may be helpful. Increasing apprehension also needs to be investigated for physical reasons because it can indicate oxygen deprivation or internal hemorrhage.
9. Discontinue or decrease the flow rate of oxytocin when used if the contraction lasts longer than 90 sec or if the uterus fails to relax completely between contractions.
This helps prevent hypertonic contractile patterns with resultant decreased placental blood flow and risk of uterine rupture. 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.
10. Administer IV antibiotics, if indicated.
Administration of antibiotics during labor is controversial but, on occasion, may protect against infection in cases of prolonged rupture of membranes. A downward trend in the incidence of postpartum fever among women who received antibiotics for nonsustained, isolated maternal fever has been observed compared with those who did not receive antibiotics. However, there is an increase in NICU admissions and 5-minute Apgar scores of <7 among neonates of clients who received antibiotics, suggesting a potential increase in neonatal risk associated with maternal antibiotic administration (Bank et al., 2022).
11. Assist in sweeping of membranes, as indicated.
Sweeping of membranes performed weekly, usually starting at approximately 37-38 weeks of gestation, reduces the duration of pregnancy and reduces the frequency of pregnancy continuing beyond 41 weeks of gestation. Sweeping of membranes usually involves inserting > 1 finger between the cervix and the membranes and sweeping 360 degrees at least 2-4 times (Berghella & Di Mascio, 2020).
Risk For Ineffective Individual/Couple Coping
Coping is a dynamic process in which emotions and stress affect and influence each other; coping changes the relationship between the individual and the environment. The nurse may help the client cope with labor by comforting, positioning, teaching, and encouraging her. Adjustment is the outcome of coping at a specific point in time.
Nursing Diagnosis
- Risk For Ineffective Individual Coping
May be related to
Common related factors for this nursing diagnosis:
- Inadequate support systems
- Personal vulnerability
- Situational crises
Possibly evidenced by
- A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention.
Desired Outcomes
Common goals and expected outcomes:
- The client will identify effective coping behaviors.
- The client will engage in activities to maintain/enhance control.
- The client verbalizes confidence in her ability to maintain active participation.
Nursing Assessment and Rationales
Here are the nursing assessment for this labor nursing care plan.
1. Assess the effectiveness of labor partners. Provide role modeling as indicated.
The client is influenced by those around her and may respond positively when others remain calm and in control. Assess how the client’s partner views their role in the labor and allow them occasional breaks while staying with the client. A support person increases satisfaction with labor; they may help with imagery and controlled breathing.
2. Ascertain the client’s understanding and expectations of the labor process.
The client’s/couple’s coping skills are most challenged during the active and transition phases as contractions become increasingly intense. Lack of knowledge, misconceptions, or unrealistic expectations may increase the client’s anxiety and result in difficult labor. Be sure to offer careful explanations of what is happening or what will happen during labor because this can help alleviate anxiety and thereby reduce some discomfort.
3. Note withdrawn behavior.
Adolescents, in particular, may become withdrawn and not express needs to be nurtured. This may also be true for some cultures (such as Native American or Chinese), where women are encouraged to be stoic/suffer in silence. Chinese women did not scream during labor and believed that crying out depleted the energy stores required for childbirth. They applied soft voices and maintained a silent demeanor when giving birth (Yadollahi et al., 2018).
4. Inspect the client’s suprapubic area and palpate for bladder distention.
A full bladder contributes to discomfort and may impede fetal descent, possibly prolonging labor. Encourage voiding every 2 hours during labor.
5. Assess the client’s pain level and if she desires any pharmacologic pain relief.
Determine the client’s pain level by verbal, pain scale, and nonverbal indicators. Use a 1 to 10 scale and evaluate response to techniques used. Provide information on epidural anesthesia as needed and support the client in her ability to manage pain until her epidural can be given.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Encourage verbalization of feelings.
Knowing the client’s feelings helps the nurse gain insight into individual needs and assists the client/couple deal with concerns. There are cultural language differences for expressing pain distress both verbally and non-verbally. Response to pain is also different in each individual and depends on several factors such as personality traits, culture, gender, religious beliefs, and age (Yadollahi et al., 2018).
2. Provide positive reinforcement for efforts. Use touch and soothing words of encouragement.
This encourages the repetition of appropriate behaviors and enhances an individual’s confidence in their ability to cope with or handle labor while also meeting their dependency needs. Encouragement is a powerful tool for intrapartum nursing care because it helps the woman summon inner strength and gives her the courage to continue. Her partner also needs encouragement, as labor coaching is a demanding job.
3. Reinforce the use of positive coping mechanisms and relaxation techniques.
This assists the client in maintaining or gaining control. It enhances feelings of competence and fosters self-esteem. The stressors that accompany labor can be threatening to a woman’s self-esteem, especially if she has not coped positively with past experiences and accomplished the tasks of pregnancy. Because pain is not a new phenomenon for a woman of childbearing age, it can be helpful to ask her to recall methods she usually uses to combat pain or anxiety, such as meditation or applying a cool cloth. Associating labor pain with usual circumstances can go a long way toward helping her collect her resources and decide on a workable pain relief strategy.
4. Limit verbalization or instruction during contractions to a single “coach.”
This allows the client to focus attention and may enhance the ability to follow directions. Multiple coaches may result in decreased concentration, confusion, and loss of control. Teaching the laboring woman and her partner is an ongoing task of the intrapartum nurse. Even women who attended prepared childbirth classes often find that the measures they learned are inadequate or need adaptation.
5. Provide a comfortable environment for the laboring client.
The environment of the labor room can be controlled by having the woman listen to familiar music brought from home, which can produce a calming effect. The client’s sheets and clothing may wrinkle rapidly and stick to her skin if she perspires. The waterproof pad under her buttocks will become soiled with vaginal secretions and will begin to feel hot and sticky. Change the waterproof pads frequently and offer the client a clean gown to help her feel clean and refreshed.
6. Assist the client in assuming positions of comfort.
Maintaining an upright position during labor can shorten the first stage. The recommended comfort positions for the laboring woman include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. The “towel-pull” involves the client pulling on a towel secured to the foot of the bed during contractions, which uses the abdominal muscles and aid in expulsion efforts. The lateral Sims position encourages rest and helps prevent pressure on the sacrum.
7. Promote nonpharmacological pain relief techniques.
Measures such as touch, effleurage, massage, back pressure, application of heat or cold, and various relaxation techniques are effective means of labor support. Electroacupuncture (EA) could help reduce labor pain because its analgesic effect has a lot to do with the release of endorphins and related neuroactive substances and the block of pain signals upward to the brain after EA stimulation (Xiao et al., 2018). Counter pressure techniques performed in the sacrum area with persistent pressure during contraction can affect the large diameter afferent fibers affecting the sweep and the pressure that also will affect the gelatinous substance in the spinal cord, thus inhibiting the pain impulses to the brain called gate control theory (Oktriani et al., 2018).
8. Provide the usual comfort measures.
Assist the client’s support person 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, moisten the lips with a wet cloth, or moisturizing jelly or balm can be helpful. A cool cloth to wipe perspiration from the forehead, neck, and chest can keep the client from feeling overheated.
9. Instruct the client to avoid pushing before her cervix is fully dilated.
The nurse must often help the client to avoid pushing before her cervix is fully dilated. She can be taught to blow out in short puffs when the urge to push is strong before the cervix is fully dilated. Pushing before full dilatation can cause maternal exhaustion and fetal hypoxia, thus slowing the progress rather than speeding it.
Labor Stage IC: Transition Phase
The transition phase occurs when contractions reach their peak with intervals of 2 to 3 minutes with a duration of 60 to 70 seconds and maximal cervical dilatation of 8 to 10 cm. By the end of this phase, full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred. Nursing care plans in this labor phase include:
Acute Pain
Normally, contractions of involuntary muscles, such as the heart, stomach, and intestine, do not cause pain. This concept makes uterine contractions unique because they do cause pain. During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. As labor progress and contractions become longer and more intense, the ischemia to cells increases, the anoxia increases, and the pain intensifies.
Nursing Diagnosis
- Acute Pain
May be related to
Common related factors for this nursing diagnosis:
- Emotional and muscular tension
- Mechanical pressure of presenting part
- Stimulation of parasympathetic and sympathetic nerves
- Tissue dilation/stretching and hypoxia
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Autonomic responses
- Distractability (e.g., restlessness)
- Facial mask of pain
- Narrowed focus
- Verbalizations of pain (crying, moaning during and between contractions)
- Tense, guarded body posture or thrashing with contractions
Desired Outcomes
Common goals and expected outcomes:
- The client will verbalize perceived or actual reduction of pain.
- The client will rest between contractions.
- The client will use appropriate techniques to enhance comfort and
maintain control of the labor process.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Monitor frequency, duration, and intensity of uterine contractions.
Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion. Observe if there is a period of relaxation between contractions so the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. Uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because it interferes with adequate uterine artery filling.
2. Monitor cervical dilation. Note perineal bulging or vaginal show.
Discomfort levels increase as the cervix dilates, the fetus descends, and small blood vessels rupture. Labor may progress more rapidly than expected. Observe for signs that birth may be near: increase in the bloody show, perineal bulging, crowning. These are signs associated with imminent birth that should be evaluated by the experienced nurse, nurse-midwife, or healthcare provider.
3. Monitor maternal vital signs and FHR variability after drug administration. Note the drug’s effectiveness and the physiological response.
Narcotics can have a depressant effect on the fetus, particularly when administered 2–3 hr before delivery. Therefore, usage of the drug may be limited or restricted, or naloxone hydrochloride (Narcan) may be administered to reverse adverse drug effects. The client should be observed for hypotension if an epidural or subarachnoid block is administered. Hospital protocols may vary, but blood pressure is usually measured every 5 minutes after the block begins until her blood pressure is stable. At the same time, the nurse observes the fetal monitor for signs associated with fetal compromise because maternal hypotension can reduce placental blood flow.
4. Assess the degree of discomfort through verbal and nonverbal cues. Assess personal and cultural implications of pain.
Attitudes toward pain and reactions to pain are individual and based on past experiences, cultural background, and self-concept. Cultural factors can strongly influence the client’s experience and satisfaction with labor. This makes her response to pain, choice of nourishment, preferred birthing position, proximity and involvement of a support person, and customs related to the immediate postpartal period highly individualized.
5. Assess the client’s need for physical touch during contractions.
Touch may serve as a distraction, provide supportive reassurance and encouragement, and may aid in maintaining control/reducing pain. Several variations of massage are often used during labor, most of which can be taught to the client and her partner.
6. Evaluate client for tingling of lips, face, hands, or feet. If present, have the client breathe into cupped hands or paper bags.
Discomfort caused by respiratory alkalosis can be relieved by increasing carbon dioxide levels through the rebreathing process. Hyperventilation is sometimes a problem when the woman is breathing rapidly. She may complain of dizziness, tingling, and numbness around her mouth and may have spasms in her fingers and feet.
7. Assess the client for bladder distention regularly if she received an epidural or subarachnoid block.
Urinary retention is a common side effect of an epidural block. A full bladder can delay birth and can cause hemorrhage after birth. The nurse should palpate the suprapubic area for a full bladder every 2 hours or more if a large quantity of IV solution were infused. You can also assess for a full bladder by percussion (an empty bladder sounds dull; a full one sounds resonant). The client may need catheterization if she is unable to void.
8. Assess for numbness of fingers when spinal anesthesia is used.
When spinal anesthesia is used, the nurse should assess for numbness of fingers, which can mean the drug has reached the L6-L8 level and could affect the diaphragm, which could cause respiratory problems.
Nursing Interventions and Rationales
Below are the nursing interventions for this labor nursing care plan.
1. Inform the client of the onset of contractions, as appropriate.
The client may “sleep” and encounter partial amnesia between contractions. This can be a problem for some clients, impairing her ability to recognize contractions as they begin and thus harming her sense of control. Give the couple frequent progress reports during labor so they do not become discouraged or fearful. For others, the brief rest may “energize” them for the next contraction. Most clients want to feel in control of what is happening to them during labor to face this big event in their lives.
2. Encourage the client to void.
Voiding may enhance labor progress and reduce the risk of trauma to the bladder. A full bladder or bowel can impede fetal descent, so encourage the client to void, if possible, at least every 2 to 4 hours during labor. The client may mistakenly interpret the discomfort of a full bladder as part of the sensations of labor. If the client cannot void and the bladder becomes distended, she may need to be catheterized.
3. Assist client and partner with changing to more rapid breathing; (i.e., pant-blow).
Breathing exercises redirects and focus attention and help reduce pain perception within the cerebral cortex. Modified-paced breathing allows the client to breathe more rapidly and shallowly. The rate should be no more than twice her usual rate. She may combine slow-paced with modified-paced breathing. In this variation, she begins with a cleansing breath and breathes slowly until the peak of contraction, when she begins rapid, shallow breathing. As the contraction abates, she resumes slow, deep breathing and ends with a cleansing breath.
4. Instruct the client and her partner about skin stimulation techniques.
Several variations of massage can be taught to the client and her partner. Effleurage is a technique that stimulates the large-diameter nerve fibers that inhibit painful stimuli traveling through the small-diameter fibers. The woman strokes her abdomen in a circular movement during contractions. Sacral pressure applies firm pressure against the lower back to help relieve some back labor pain. The client tells her partner where to apply the pressure and how much pressure is helpful. Thermal stimulation through heat or cool compress can be applied with a warm blanket or a glove filled with warm water. Most clients also appreciate a cool cloth on the face.
5. Assist the client with relaxation techniques.
Relaxation techniques require concentration, thus occupying the mind while reducing muscle tension. The nurse should adjust the client’s environment and help her with general comfort measures. For example, water in a tub or shower helps refresh the client and promotes relaxation. The laboring woman may be guided to release the tension specifically, one muscle group at a time.
6. Offer encouragement, provide information about labor progress, and provide positive reinforcement for the client’s efforts.
Help the woman express her feelings in a way that works best for her. It is important to keep the client and her support person informed about their options and how they differ as labor progresses. For instance, knowing that birth is getting closer can make the next few contractions easier to withstand. Encouragement is a powerful tool for intrapartum nursing care because it helps the client summon inner strength and gives her the courage to continue. Her partner also needs encouragement, as labor coaching is a demanding job.
7. Provide a quiet and comfortable environment for the laboring client.
A non-distracting environment provides optimal opportunities for relaxation between contractions. The environment of the labor room can be controlled by having the client listen to familiar music brought from home, which can produce a calming effect.
8. Provide a break for the partner as appropriate.
The support person may be reluctant to leave but does need a break for renewal of energy and relaxation, which can enhance the ability to help the partner. The partner should be encouraged to take a break and periodically eat a snack or meal. They may faint during birth if they have not eaten. A chair or stool near the bed allows the partner to sit down as much as possible.
9. Educate the client and her partner about bathing or hydrotherapy during labor.
Standing under a warm shower or soaking in a tub of warm water, jet hydrotherapy tub, or whirlpool is another way to apply heat to help reduce labor pain. The temperature of the water used should be 37℃ to prevent hyperthermia. Do not leave the client unsupervised in a tub, as they could slip and have difficulty getting their head above water. A support person can join the client in a tub or shower if she wishes and can continue with a back massage or other measures she finds soothing.
10. Administer analgesic as ordered. Assist the anesthesiologist if the epidural or caudal anesthetic is to be used.
Judicious use of a pharmacologic agent assists the client in coping with contractions and may facilitate labor. Pharmacologic management of pain during labor and birth includes analgesia, which reduces or decreases awareness of pain, and anesthesia, which causes a partial or complete loss of pain sensation. Be certain that the client is included in selecting these methods and understand any fetal or maternal side effects that might occur. Maintain a supportive presence to help the client make the best decision for herself and her baby.
11. Insert an indwelling catheter if the client cannot void, as indicated.
If the client cannot void and the bladder becomes distended, she may need to be catheterized. Catheterizing a client in labor is uncomfortable for her and difficult for the nurse. The vulva is edematous from the pressure of the fetal presenting part, stretching the urethral canal downward and making the urethra difficult to locate. Use a small catheter (No. 12 to 14F) for best results and insert it between contractions. Use an extremely careful aseptic technique to avoid introducing any microorganisms that might result in a urinary tract infection.
Fatigue
Fatigue reduces pain tolerance and the client’s ability to use coping skills. By the time the date of birth approaches, the client is generally tired from the normal discomforts of pregnancy and has not slept well for the past month. For example, a side-lying position caused backache; her back ached again when she turned back to her side. Sleep hunger from this discomfort can make it difficult for a woman to perceive situations clearly or adjust rapidly to new situations. It can make the process of labor loom as an overwhelming, unendurable experience unless she has competent people with her to offer support, reassurance, and comfort.
Nursing Diagnosis
- Fatigue
May be related to
Common related factors for this nursing diagnosis:
- Changes in energy production
- Decreased caloric intake (restricted/nothing by mouth [NPO] status)
- Discomfort/pain
- Increased energy requirements
- Overwhelming psychological-emotional demands
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Altered coping ability
- Emotional lability or irritability
- Impaired ability to concentrate
- Lethargy
- Verbalizations
Desired Outcomes
Common goals and expected outcomes:
- The client will use techniques to conserve energy between contractions.
- The client will report a sense of control.
- The client will appear moderately relaxed.
Nursing Assessment and Rationales
Here are the nursing assessment for this labor nursing care plan.
1. Assess the degree of the client’s fatigue.
Fatigue may interfere with the client’s physical and psychological abilities to participate in the labor process and master and carry out self-care and infant care after delivery. The use of questionnaires such as the Maternal Perception of Childbirth Fatigue Questionnaire (MCFQ) helps assess fatigue during labor and delivery. The MCFQ considers the perspective of postpartum women and the viewpoint of healthcare professionals from different areas in the field. The MCFQ represents three factors: one related to physical fatigue, the other to psychological fatigue, and the third are related to emotional fatigue. Since childbirth is an event requiring high energy expenditure due to an association of uterine contractions with feelings of anxiety, fear, and concern, it is expected that these three types of fatigue would be present (Delgado et al., 2019).
2. Assess the client’s degree of contractions.
Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion. This problem may be correctable but needs augmentation or other interventions to accomplish this.
3. Assess when the client had her last meal.
Upon admission, assess the likelihood of glucose depletion by asking when the client ate her last meal. Because labor is work, the client’s glucose stores can deplete over hours of labor. If she ate her breakfast at 8:00 am and then began labor by 2:00 pm, it has only been 6 hours since her last full meal.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Monitor the energy level of the partner. Assume supportive responsibilities as needed.
This allows the partner to have a brief break and refresh their self-enhancing ability to maintain focus and support the client. Partners vary considerably in the degree of involvement with which they are comfortable. The partner should be permitted to provide the type of support comfortable for the couple. The partner should be encouraged to take a break and periodically eat a snack or meal. Many partners are reluctant to leave the woman’s bedside, but they may faint during birth if they have not eaten. A chair or stool near the bed allows the partner to sit down as much as possible.
2. Position the client in a comfortable position.
A comfortable position facilitates muscle relaxation. The recommended comfort positions for laboring women include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. The “towel-pull” involves the woman pulling on a towel secured to the foot of the bed during contractions, which uses the abdominal muscles and aids in expulsion efforts. The lateral Sims position encourages rest and helps prevent pressure on the sacrum. Squatting during contractions increases the diameter of the pelvis, facilitating fetal rotation and descent.
3. Keep the client informed of the progress of the labor.
Offer explanations of all procedures and the client’s progress of labor. Allow the woman and her support person as many choices as possible to give them a sense of control. Many women are discouraged when their cervix is about 5 cm dilated because it has taken many hours to reach that point. They think they are only halfway through labor; however, a 5-cm dilation signifies that about two-thirds of the labor is completed as progress increases. Laboring women often need support and reassurance to overcome their discouragement at this point.
4. Plan care to limit interruptions and promote rest.
This maximizes opportunities for rest. The best labor support will protect a woman’s privacy and ensure that she is not disturbed to tap into her inner wisdom and dig deep to find the strength she needs to give birth. Strangers should be kept away, filtered information, and questions, interruptions, and intrusions should be kept to a minimum. Continuously supported, protected, and cared for, but not disturbed, the laboring woman can let go of fear even in a busy maternity hospital. Ideally, the client is surrounded by family and professionals who listen, watch, and quietly and patiently encourage her, making sure that she is not disturbed and has the privacy she needs to do the work of labor (Lothian, 2004).
5. Provide a dimly lit, comfortable environment
Reducing stressors helps promote rest. An individual client may find complementary therapy such as aromatherapy, acupressure, or music helpful for relaxation. Favorite music or relaxation recordings divert the woman’s attention from pain. The sounds of rainfall, wind or the ocean contribute to relaxation and block disturbing sounds; the client can also listen to her favorite music types on various electronic devices.
6. Provide comfort measures to the laboring client.
Comfort measures promote relaxation, enhance the sense of control, and may strengthen coping. Remember that long-term pain is depressing and exhausting. Encourage the client’s partner to use nonpharmacologic comfort measures such as breathing with the woman, offering a back rub, changing the sheets, using cool washcloths, or whatever seems comforting.
7. Encourage efforts the client makes.
Realizing that labor is progressing toward a goal may help the client maintain maximal effort. After each vaginal examination, the client is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to cope with labor. Her partner also needs encouragement, as labor coaching is a demanding job.
8. Provide calorie-rich fluids, e.g., fruit juices, broth.
Calories are necessary to maintain energy levels to help with labor work. The client may be encouraged to drink a high-carbohydrate fluid such as a sports drink or eat a light meal if she is in early labor. Sucking on a lollipop or hard candy is an enjoyable way to supply additional glucose for energy.
9. Administer an analgesic as ordered.
Pharmacological methods may help the client cope with contractions and facilitate relaxation between contractions. Use with caution because analgesics may cause fetal depression. Methods that use drugs to reduce pain during birth can help the client be a more active participant in birth. They help her relax and work with contractions. Drugs do not usually relieve all pain and pressure sensations. One important factor to consider is that two persons are medicated- the mother and the fetus. The drug may directly affect the fetus or indirectly affect the fetus because of its effects on the mother (Leifer G., 2018).
10. Assist in the possible induction and augmentation of labor.
When labor contractions are ineffective, several interventions, such as induction and augmentation of labor with oxytocin or amniotomy (artificial rupture of the membranes), may be initiated to strengthen them. Induction of labor means labor is started artificially. Augmentation of labor refers to assisting labor that has started spontaneously but is ineffective.
Risk For Decreased Cardiac Output
The range of hemodynamic changes during labor is caused by complex interactions of mechanical, neurophysiological, and endocrine factors. During stage 1, contractions induce considerable hemodynamic changes already during early active labor, and this suggests that the extent of these changes slightly increases between early and late stage 1. Prominent decreases in cardiac output (CO) and stroke volume (SV) are probably due to reduced venous return caused by increased thoracic pressure during the expulsive effort. Additionally, decreases in CO and SV were found during stage 1 contractions in the absence of bearing down (Kuhn et al., 2017).
Nursing Diagnosis
- Risk for Decreased Cardiac Output
May be related to
Common related factors for this nursing diagnosis:
- Changes in systemic vascular resistance
- Decreased venous return
- Hypovolemia
Possibly evidenced by
- A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention.
Desired Outcomes
Common goals and expected outcomes:
- The client will display FHR within normal limits.
- The client will maintain vital signs appropriate for the stage of labor, free of pathological edema and excessive albuminuria.
Nursing Assessment and Rationales
Below are the nursing assessment for this labor nursing care plan.
1. Note the presence and extent of edema and monitor FHR during and between contractions.
A decrease in blood volume and cardiac output triggers fluid retention (Shotan et al., 2005). Excess fluid retention places the client at risk for circulatory changes, with possible uteroplacental insufficiency manifested as late decelerations. Late decelerations suggest that the placenta is not delivering enough oxygen to the fetus.
2. Assess BP and pulse between contractions, as indicated. Note abnormal readings.
During contractions, blood pressure usually increases 5–10 mm Hg, except during the transition phase, when the blood pressure remains elevated. Increased resistance to cardiac output can occur if intrapartum hypertension develops, further elevating blood pressure. Finally, cardiac output/blood pressure may be negatively affected by uterine pressure on the inferior vena cava, reducing venous return, or by a decrease in circulating blood volume caused by dehydration or occasionally hemorrhage (Cohen et al., 2015).
3. Accurately record parenteral/oral intake and output. Measure specific gravity if kidney function is decreased.
Bedrest promotes cardiac, and urine output increases with a corresponding decrease in urine-specific gravity. An elevation of specific gravity and reduction in urine output suggests dehydration or possibly developing hypertension. A second side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. In its most severe form, water intoxication can lead to seizures, coma, and death because of the large shift in the interstitial tissue fluid. Keep an accurate intake and output record and test and record urine specific gravity throughout oxytocin administration to detect fluid retention.
4. Note any hypertensive responses to oxytocin administration.
Oxytocin increases the cardiac circulating volume (sodium and water absorption) and cardiac output and may increase BP and pulse. A side effect of oxytocin is that it causes peripheral vessel dilation, and peripheral dilation can lead to extreme hypotension. To ensure safe induction, take the client’s pulse and blood pressure every hour and strictly monitor uterine contractions and FHR.
5. Monitor BP and pulse per protocol or continually if hypotension is severe after administration of analgesia.
Analgesics relax smooth muscles within the blood vessels, reducing resistance to cardiac output and lowering BP and pulse. The client is observed for hypotension if an epidural or subarachnoid block is administered. Hospital protocols vary, but blood pressure is usually measured every 5 minutes after the block begins until her blood pressure is stable.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Place the client in a left lateral side-lying position.
Stroke volume is increased in the lateral position. This may reflect increased venous return suggesting aortocaval compression may be a complication of positioning in the sitting position. Maternal hemodynamics may influence FHR patterns in connection with different maternal body positions. Uteroplacental perfusion is dependent on maternal pressure and cardiac output, and it is important to determine which position will compromise uteroplacental perfusion least (Armstrong et al., 2011).
2. Monitor the client during spinal anesthesia administration.
Spinal anesthesia is commonly used for cesarean birth and can lead to major secondary cardiovascular effects. The most frequent cardiovascular response to spinal anesthesia for elective cesarean section is a marked decrease in systemic vascular resistance and compensatory increases in heart rate and stroke volume (Sanghavi & Rutherford, 2014).
3. Promote safe exercises such as walking or treadmill exercises.
Because resting cardiac output is increased in pregnancy, the maximal cardiac output induced by exercise is achieved at a lower level of work. During rest or weight-bearing exercise (e.g., walking or treadmill exercise), maternal oxygen uptake significantly increases compared with the non-pregnant state (Sanghavi & Rutherford, 2014).
4. Administer prophylactic intravenous phenylephrine before delivery.
In a review of randomized, controlled trials of spinal anesthesia and cesarean section, the administration of prophylactic intravenous phenylephrine before a delivery reduced the risk of hypotension by 64% compared with placebo. After delivery, it reduced the risks of hypotension, nausea, and vomiting by a similar amount. In recent years, phenylephrine, rather than ephedrine, has become the vasopressor of choice in obstetrics (Sanghavi & Rutherford, 2014).
Risk for Imbalanced Fluid Volume
As estrogen production increases, so does renin substrate production; thus, angiotensin levels increase throughout pregnancy. There is an increase in exchangeable sodium in the second and third trimesters. Furthermore, relaxin stimulates increased vasopressin secretion and drinking, resulting in increased water retention (Sanghavi & Rutherford, 2014). Natural childbirth is a process that requires huge amounts of energy; pregnancy can also lead to a higher basal metabolic rate, so oral intake measures in this process have been the focus of research. To prevent pregnant women from anesthesia accidents during labor, the measures of limiting eating and drinking during the labor process were adopted. This may result in a fluid volume deficit.
Nursing Diagnosis
- Risk for Imbalanced Fluid Volume
May be related to
Common related factors for this nursing diagnosis:
- Excess fluid loss/hemorrhage
- Excess fluid retention
- Rapid parenteral fluid administration
- Reduced oral intake
Possibly evidenced by
- A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention.
Desired Outcomes
Common goals and expected outcomes:
- The client will be free of thirst.
- The client will maintain vital signs and urine output/concentration within the normal limit.
- The client will drink at least one glass of selected beverage every hour.
- The client will state that she does not feel thirsty.
- The client will void at least 30 ml/hr every 2 to 4 hours.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess the amount of vaginal bloody show; observe excess blood loss.
Bloody show increases as the presenting part move down in the birth canal; excess bleeding may indicate placental separation. The amount of blood loss and blood clots will help determine the necessary interventions. The characteristics and quantity of blood passed can suggest excessive bleeding. For example, bright red blood is arterial and can indicate lacerations of the genital tract; meanwhile, dark red blood is likely of venous origin and may indicate superficial lacerations or varices of the birth canal.
2. Assess the amount and location of edema.
Intrapartum hypertension can develop, causing fluid shifts from the intravascular spaces and increasing Hct levels. Sodium retention is influenced by many factors, including elevated levels of pregnancy hormones. Although the fetus uses much of the sodium, the remainder is in the maternal circulation and can cause a maternal accumulation of water or edema. This fluid retention may cause a problem if the client in labor is given IV fluids containing oxytocin, which has an antidiuretic effect and can result in water intoxication.
3. Assess the client’s hematocrit and hemoglobin level.
Although plasma and red blood cells increase during pregnancy, they do not increase by the same amount. The fluid part of the blood increases more than the erythrocyte component. This leads to dilutional anemia or pseudoanemia. As a result, the normal prepregnant hematocrit level of 36% to 48% may fall to 33% to 46%. The hematocrit count is reevaluated to determine the client’s status and needs.
4. Record intake and output. Note the concentration of urine. Measure urine specific gravity, as indicated.
Bedrest results in decreased adrenal cortex activity, increased glomerular filtration rate, and increased urine output. When fluid volume is decreased, aldosterone acts to reabsorb water and sodium from the kidney tubules, reducing urine output. The urine concentration increases as urine output decreases and may warn of dehydration. This can be caused by insensible fluid losses such as diaphoresis and increased rate and depth of respirations.
5. Take temperature every 4 hours, as indicated (every 2 hours after membranes rupture). Assess skin and mouth for dryness.
Dehydration can result in elevated body temperature, dry skin, and reduced saliva production. Cool, clammy skin or weak pulses indicate decreased peripheral circulation and the need for additional fluid replacement. Diaphoresis may occur with accompanying evaporation to cool and limit excessive warming.
6. Monitor BP and pulse every 15 min and more frequently during oxytocin infusion.
Increased BP and pulse may indicate fluid retention; decreased BP and increased pulse may be late signs of fluid volume loss or dehydration. Water intoxication sometimes occurs because oxytocin inhibits the excretion of urine and promotes fluid retention. Epidural anesthesia may cause hypotension. Therefore, the nurse should ensure that the client is well hydrated before epidural administration.
7. Measure the amount and character of emesis.
During the transition phase, the client may experience intense discomfort that is so strong that it might be accompanied by nausea and vomiting. Opioids used during labor may cause nausea and vomiting. Nausea and vomiting contribute to fluid losses. With reduced gastric motility, food may remain in the stomach for up to 12 hr after ingestion and pose a risk for aspiration.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Position the client on the side, as appropriate.
This increases the venous return by taking pressure of the gravid uterus off the inferior vena cava and descending aorta. Stroke volume is increased in the lateral position. This may reflect increased venous return suggesting aortocaval compression may be a complication of positioning in the sitting position (Armstrong et al., 2011).
2. Encourage intake of sports drinks.
Some clients need isotonic sports to drink to prevent secondary uterine inertia (a cessation of labor contractions) and combat generalized dehydration and exhaustion. A total of 61.4% of hospitals in China support pregnant women’s consumption of sports drinks during labor. Sports medical scientists believe that childbirth is similar to the process of athletes’ strenuous exercise, and sports drinks contain a lot of energy (Huang et al., 2020).
3. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted.
Clear liquids promote hydration and may provide some calories for energy production. Encourage the client to sip fluid during labor if they exercise to keep hydrated. If the client is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.
4. Provide appropriate oral care.
Even with adequate fluid intake, the client’s mouth and lips can become uncomfortably dry because of mouth breathing. Applying lip balm to prevent or relieve this discomfort can be helpful. Proper oral care and hard candy may reduce the discomfort of a dry mouth.
5. Administer and monitor IV fluid infusion, as indicated.
Maintains hydration by replacing fluid losses. Rate may be adjusted to meet individual needs, but too rapid administration can lead to fluid overload, especially in a compromised client. According to Garite et al. (2000), the first phase of labor is significantly shorter in clients receiving fluids at 250ml/hr than those receiving fluids at 125 ml/hr (Lopez et al., 2019).
6. Administer dexamethasone to reduce nausea and vomiting, as prescribed.
According to study findings, dexamethasone has better antiemetic efficacy compared with promethazine. Studies suggested that the antiemetic effect of steroids may be partially due to their activity on the central nervous system or activation of glucocorticoid receptors in the medulla (Tazeh kand et al., 2015).
Risk for Ineffective Coping
Labor is such an intense process that it creates high emotional stress for the client and her support person. The ability to tolerate stress or cope adequately depends on the person’s perception of the event, the available support, and experience in using coping mechanisms.
Nursing Diagnosis
- Risk For Ineffective Coping
May be related to
Common related factors for this nursing diagnosis:
- Inadequate/exhausted support system
- Personal vulnerability
- Sense of “work overload”
- A perceived threat to health
Possibly evidenced by
- A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention.
Desired Outcomes
Common goals and expected outcomes:
- The client will identify effective coping behaviors.
- The client will engage in activities to maintain/enhance control.
- The client and her support person will express confidence in their ability to cope with this event.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess the client’s level of labor pain.
Pain perception differs from one person to the next and is influenced by the individual’s physical, psychological, and cultural conditions. It has been suggested that antenatal fears complicate and prolong labor, increase the intensity of labor pain, and lead to negative birth experiences (Junge et al., 2018).
2. Assess the degree of uterine contractions and the progress of labor.
The cervix is evaluated for effacement and dilatation. The descent of the fetus is determined by the ischial spines (station). The combined powers of uterine contractions and voluntary maternal pushing in stage 2 of labor propel the fetus downward through the pelvis. Maternal exhaustion or epidural analgesia may reduce or eliminate the natural urge to push. This may inhibit the progress of labor and reduce blood flow to the placenta and fetus.
3. Assess the client’s response to labor.
The nurse assesses the client’s response to labor, including her use of breathing and relaxation techniques, and supports adaptive responses. Nonverbal behaviors that suggest difficulty coping with labor include a tense body posture and thrashing in bed.
4. Determine cultural factors that may influence the client’s coping abilities.
Culture affects women’s beliefs and behaviors about labor pain. In Korean culture, women should remain silent during childbirth because they wouldn’t like to make their families ashamed. Whereas American and European women show a wide range of reactions to labor pain. Research indicated that childbirth pain has been accepted as part of a woman’s life in some societies and is considered a fundamental element of spiritual development (Yadollahi et al., 2018).
5. Assess the presence of positive coping skills.
Because pain is not a new phenomenon for a woman of childbearing age, it can be helpful to ask her to recall methods she usually uses to combat pain or anxiety, such as meditation or applying a cool cloth. Associating labor pain with usual circumstances can go a long way toward helping her collect her resources and decide on a workable pain relief strategy.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Inform client/partner of initiation of each contraction.
This allows the client to rest/relax and maintain control of breathing patterns as the contraction begins. When palpation is used to evaluate contractions, the entire hand is placed lightly on the uterine fundus. The nurse should keep the fingers still when palpating contractions. Contractions may come so fast that the client cannot recover from one before another begins.
2. Acknowledge the reality of both client’s and partner’s irritable feelings.
The increase in intensity and frequency of contractions and the sudden urge to push may add to a sense of loss of control. The client’s hostility may be manifested as anger at the nurse or support person. In addition, the general fatigue of both client and partner further impairs their ability to cope. Fatigue reduces pain tolerance and the client’s ability to use coping skills. Many clients are tired when labor begins because sleep during late pregnancy is difficult.
3. Reinforce information that labor is progressing; encourage the client to cope with one contraction at a time.
This provides reassurance that baby will soon be born. A natural response in the transition phase is for the client to feel that she has had enough and wants to “quit and go home.” After each vaginal examination, the client is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to cope with labor. Laboring women often need support and reassurance to overcome their discouragement at this point.
4. Ensure that the client initiates breathing patterns under the direction of the partner. Breathe with the client if necessary.
A more complex breathing pattern initiated at the beginning of a contraction is necessary as a distraction and helps reduce pain perception within the cerebral cortex. The client may have difficulty understanding directions because of inward focus. Even women who attended prepared childbirth classes often find that the measures they learned are inadequate or need adaptation. Refresh controlled breathing and imagery with the support of the partner.
5. Encourage client and partner to verbalize doubts about the ability to continue and fear of being left alone (even if this fear is unfounded).
Many women are discouraged when their cervix is about 5 cm dilated because it has taken many hours to reach that point. They think they are only halfway through labor; however, a 5-cm dilation signifies that about two-thirds of the labor is completed as progress increases. When these thoughts are expressed, they can be acknowledged, and the client/partner can realize that they are coping to the best of their ability in the situation and can move forward with support.
6. Provide support to the partner.
The client’s partner may feel helpless and require more support as the partner becomes less able to relieve the client’s pain. The partner should be permitted to provide the type of support comfortable for the couple. The nurse does not take the partner’s place but remains available. The partner should also be encouraged to take a break and periodically eat a snack or meal.
7. Assist the client in using natural methods to stimulate contractions.
Nipple stimulation causes the woman’s posterior pituitary gland to secrete natural oxytocin, strengthening contractions. Water may help the woman relax, which improves labor. All nonpharmacological methods stimulate labor to enhance her sense of control.
8. Help the client relax and use breathing techniques she learned in prepared childbirth classes.
Relaxation promotes normal labor. Praise and support the client when she uses breathing techniques. Praise encourages her to continue efforts at managing contractions.
9. Reposition the client frequently.
The recommended comfort positions for the laboring woman include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. Body support can be provided by pillows to prevent back strain. This position can also facilitate anterior rotation of the fetus when the client lies on the side of the fetal spine.
10. Assist with oxytocin augmentation if ordered.
The primary risks of oxytocin augmentation or labor induction relate to overstimulating the uterus. Observe contractions for excessive frequency, duration, or inadequate rest interval. Excessive contractions can reduce fetal oxygen supply. These are signs of potential uterine overstimulation. Observe FHR for rates outside the normal 110-160 beats/min range.
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:
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:
- 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.
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 precipitous 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 precipitous 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.
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,
Labor Stage III: Placental Expulsion
The third stage of labor, also known as placental expulsion, begins with the infant’s birth until the delivery of the placenta. The signs of placental expulsion are lengthening of the umbilical cord, a sudden gush of vaginal blood, changes in the shape of the uterus and its firm contraction, and the appearance of the placenta at the vaginal opening. Nursing care plans for placental expulsion or the third labor stage include the following:
Acute Pain
Intermittent uterine contractions may cause afterpains similar to menstrual cramps. Afterpains occur more often in multiparas or clients whose uterus was overly distended. The perineum is often edematous, tender, and bruised. An episiotomy may have been performed, or a perineal laceration may have occurred, which is frequently the cause of pain following placental delivery. Pain control is essential to reduce the client’s distress and facilitate movement to prevent several complications.
Nursing Diagnosis
- Acute Pain
May be related to
Common related factors for this nursing diagnosis:
- Physiological response following delivery
- Tissue trauma
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 muscle tone
- Restlessness
- Verbalizations
Desired Outcomes
Common goals and expected outcomes:
- The client will verbalize management/reduction of pain.
- The client will state that pain relief is adequate with pharmacological and nonpharmacological measures.
Nursing Assessment and Rationales
Here are the nursing assessment cues for this labor nursing care plan.
1. Assess the client’s level of pain.
The severity, frequency, character, and location of discomfort should be assessed. Use a scale of 0 to 10 to evaluate the pain level before and after interventions. This provides a more objective way for the nurse to evaluate the client’s subjective experience of pain. Also, it evaluates the adequacy of pain relief. The scale helps the nurse choose the most appropriate relief methods and provides a method to evaluate the amount of relief the client receives from the pain interventions.
2. Assess the extent of lacerations to the perineal and cervical tissues.
Small lacerations or tears of the birth canal are common and may be considered a normal consequence of childbearing. Perineal lacerations are more apt to occur when the client is placed in a lithotomy position for birth because this position increases tension on the perineum.
3. Assess for signs of perineal hematomas.
A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum. The overlying skin, as a rule, is intact with no noticeable trauma. Hematomas are most likely to occur after rapid, spontaneous births and in clients with perineal varicosities. If the client reports severe pain in the perineal area or a feeling of pressure between her legs, inspect the perineal area to see if a hematoma could be causing this.
Nursing Interventions and Rationales
Below are the nursing interventions for this labor nursing care plan.
1. Apply ice bags to the perineum after delivery.
An ice pack or a chemical cold pack is applied for the first 12 to 24 hours to reduce edema and bruising and numb the perineal area. Cover the ice with a towel to prevent injury to the skin. A disposable rubber glove filled with ice chips and taped shut at the wrist can also be used. The cold pack is left off for 10 minutes when the ice melts before applying another for maximum effect. Sitting in a cool sitz bath, adding ice cubes, and remaining in the water for 20 minutes often provides immediate pain relief.
2. Apply a warm pack to the perineum or provide a sitz bath after 24 hours.
After 24 hours, heat in a warm chemical pack, a bidet, or a sitz bath increases circulation and promotes healing. The sitz bath may circulate either cool or warm water over the perineum to cleanse the area and increase comfort.
3. Provide a heated blanket.
Post-delivery tremors/chills may be caused by a sudden release of pressure on pelvic nerves or related to a fetus-to-mother transfusion occurring with placental separation. Warmth promotes muscle relaxation and enhances tissue perfusion, reducing fatigue and enhancing a sense of well-being.
4. Provide an air ring or “donut” during sitting.
To reduce pain when sitting, the client can be taught to squeeze her buttocks together as she lowers herself to a sitting position and then relax her buttocks. When sitting, an air ring or “donut” takes the pressure off the perineal area. The client should inflate the ring about halfway because she may wobble on a fully inflated ring. A small egg crate is an alternative to the air ring.
5. Assist with breathing techniques during surgical repair, as appropriate.
Breathing techniques help direct attention away from the discomfort, promote relaxation. They are largely distraction techniques because the client concentrating on slow-paced breathing cannot concentrate on the pain.
6. Promote lavender in any form to relieve perineal pain.
The use of lavender for episiotomy in several studies showed a significant reduction in inflammation and pain compared with placebo and other available methods, with no reported side effects. Using lavender in any form (aromatherapy or topical application) and any duration (every day of use from 1 to 10 days) leads to reduced pain and improved healing in episiotomy wounds (Abedian et al., 2020).
7. Administer medications to relieve or reduce pain.
Topical and systemic medications may be used to relieve perineal pain. Topical perineal medications such as hydrocortisone or benzocaine reduce inflammation or numb the perineum. Mild analgesics may be prescribed for the afterpains. However, aspirin is not used postpartum because it interferes with blood clotting.
Knowledge Deficit
The third stage of labor is the time from the baby’s birth until the placenta is delivered. For most clients, this is a time of great excitement because the infant has been born, but this can also be a time of feeling anticlimactic because the infant has finally arrived after being anticipated for so long. The nurse must adapt care to the client’s circumstances, such as those of the single or adolescent parent and families from other cultures.
Nursing Diagnosis
- Knowledge Deficit
May be related to
Common related factors for this nursing diagnosis:
- Lack of information or recall
- Misinterpretation of information
- Cognitive limitation
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Lack of cooperation
- Verbalizations of questions/concerns
- Inappropriate or exaggerated behaviors
Desired Outcomes
Common goals and expected outcomes:
- The client will verbalize an understanding of physiological responses.
- The client will actively engage in efforts to push to promote placental expulsion.
Nursing Assessment and Rationale
The following are the nursing assessment for this labor nursing care plan.
1. Ascertain the client’s ability to learn and any cultural concerns.
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
Here are the nursing interventions for this labor nursing care plan.
1. Explain why such behavioral responses are chills and leg tremors.
Understanding helps the client accept such changes without anxiety or undue concern. Chills may be due to the low temperature of a birthing room. Still, they may also result from the sudden release of pressure on pelvic nerves or excess epinephrine production during labor. The nurse may reassure the client that this is a transitory sensation, is very common, and passes quickly.
2. Discuss/review normal processes of stage III labor.
This provides an opportunity to answer questions/clarify misconceptions, enhancing cooperation with the regimen. Inform the client that the placenta will deliver spontaneously following most births. However, delivery up to 30 minutes is normal.
3. Advise the client to ask for assistance when planning to move or get out of bed.
When placed in the postpartum unit following delivery, all postpartum clients should be informed of the availability of assistance- and the advisability of asking for it the first time they get out of bed to prevent accidental falls. The first time the client gets out of bed, she is at increased risk for a fall because of the physiological events during delivery that can cause unstable blood pressure and syncope.
4. Discuss routine for recovery period during the first 4 hr following delivery. Orient the client to new staff and unit if a transfer occurs at the end of this stage.
This provides continuity of care and reassurance and enhances cooperation. Following the third stage of labor, there is a fall in the blood levels of placental hormones, human placental lactogen, human chorionic gonadotropin, estrogen, and progesterone that help return the body to the pre-pregnant state. The most dramatic changes after birth occur in the client’s reproductive system.
5. Inform the client if pharmacological interventions are needed during this stage.
If the client’s uterus has not contracted firmly on its own, the primary care provider will massage the fundus to urge it to contract. Oxytocin may be prescribed to be administered intramuscularly or per 1,000 ml fluid intravenously to also help contraction. Inform the client of these interventions to prevent apprehension on why medications are being given during this period.
Risk For Deficient Fluid Volume
An integral component of the birth process, the third stage of labor, is defined as the period from the delivery of the fetus to the delivery of the placenta and membranes. It is a normal physiologic period laden with possibilities of compromise, the most common being postpartum hemorrhage (PPH). The four most probable causes of bleeding in stage 3 begin with the letter T: Tone (uterine atony), Trauma (torn vessel, cervical or vaginal laceration), Tissue (placental or amniotic fragments, uterine rupture), and Thrombin (maternal bleeding disorders).
Nursing Diagnosis
- Risk For Deficient Fluid Volume
May be related to
Common related factors for this nursing diagnosis:
- Diaphoresis
- Increased insensible water loss
- Lack/restriction of oral intake
- Lacerations of the birth canal
- Retained placental fragments
- Uterine atony
- Vomiting
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 display BP and heart rate within the normal limits, palpable pulses.
- The client will demonstrate adequate contraction of the uterus with blood loss within the normal limits.
Nursing Assessment and Rationales
Here are the nursing assessment techniques for this labor nursing care plan.
1. Assess vital signs before and after administering oxytocin.
Because oxytocin causes hypertension by vasoconstriction, be certain to obtain a baseline blood pressure measurement before administration. Obtain vital signs every 15 minutes for the first hour and then according to agency policy or the client’s condition. Pulse and respiration may be fairly rapid immediately after birth, and blood pressure may be slightly elevated due to exertion and excitement of the moment or recent oxytocin administration.
2. Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature).
Hemorrhage associated with a fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability, and loss of consciousness. If the loss of blood is extremely copious, the client will quickly begin to exhibit symptoms of hypovolemic shock such as falling blood pressure; a rapid, weak, or thready pulse; increased and shallow respirations; pale, clammy skin; and increasing anxiety.
3. Inspect maternal and fetal surfaces of the placenta. Note size, cord insertion, intactness, vascular changes associated with aging, and calcification (possibly contributing to abruption).
If the placenta separates at its center and edges, it tends to fold on itself like an umbrella and presents at the vaginal opening with the fetal surface evident. Approximately 80% of placentas separate and present this way. Appearing shiny and glistening from the fetal membranes, this is called a Schultze presentation. If the placenta separates first at its edges, it may look raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces evident; this is called a Duncan presentation. Record which way the placenta is presented.
4. Obtain and record information related to inspection of uterus and placenta for retained placental fragments.
The uterus needs to be inspected after delivery to ensure it is intact and part of it was not retained. Retained placental tissue can contribute to postpartal infection and immediate or delayed hemorrhage. If detected, the fragments should be removed manually or with appropriate instruments.
5. Obtain and record information related to inspection of the birth canal for lacerations.
A laceration is an uncontrolled tear of the tissues resulting in a jagged wound. Lacerations of the perineum, vagina, cervix, or area around the urethra (periurethral lacerations) can cause postpartum bleeding. The vascular beds are engorged during pregnancy, and bleeding can be profuse. Blood lost in lacerations is usually a brighter red than lochia and flows in a continuous trickle.
6. Palpate uterus; note “ballooning.”
Palpate the client’s fundus for size, consistency, and position. A rapid contraction of the uterus accomplishes the sealing of the placenta site immediately after the delivery of the placenta. Because uterine contraction begins immediately after placental delivery, the fundus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth.
7. Assess and record the characteristics, amount, and site of the bleeding, including the stage of labor.
The amount of blood loss and blood clots will help determine the necessary interventions. The characteristics and quantity of blood passed can suggest excessive bleeding. For example, bright red blood is arterial and can indicate lacerations of the genital tract; meanwhile, dark red blood is likely of venous origin and may indicate superficial lacerations or varices of the birth canal. Spurts of blood with clots can indicate partial placental separation, and failure of the blood to clot or remain clotted may indicate coagulopathy, such as disseminated intravascular coagulation.
8. Assess the lochia for color, quantity, and clots.
Observing the lochia provides for an estimate of the actual blood loss. Lochia rubra should be dark red. During the first few hours, the amount of lochia should be no more than one saturated perineal pad per hour. Small clots may appear in the drainage, but large clots are not normal.
9. Assess for the presence of a vulvar and vaginal hematoma.
A hematoma is a collection of blood within the tissues. It may result from birth trauma and appear as a bulging or purplish mass. The client may also develop signs of concealed blood loss if the hematoma is large. Larger ones may require incision and drainage of the clots. Signs of concealed blood loss accompanied by maternal complaints of severe pain, perineal or vaginal pressure, or inability to void should be reported. Small hematomas usually resolve without treatment or with cold application.
10. Count and weigh perineal pads.
It is difficult to estimate the amount of blood a postpartal client loses because it is difficult to estimate the amount of blood it takes to saturate a perineal pad (between 25 and 50 ml). By counting the number of perineal pads saturated in given lengths of time, such as half-hour intervals, a rough estimate of blood loss can be formed. Five pads saturated in half an hour is different from five pads saturated in 8 hours. Weighing the perineal pads before use and then subtracting the difference is an accurate technique to measure vaginal discharge: 1 g of weight is comparable to 1 ml of blood volume.
11. Record time and mechanism of placental separation, i.e., Duncan’s mechanism (placenta separates from the inside to outer margins) versus Schulze’s mechanism (placenta separates from outer margins inward).
Separation should occur within 5 min after birth. Duncan’s separation mechanism carries an increased risk of retained fragments, necessitating close inspection of the placenta. Failure to separate may require manual removal. The more time it takes for the placenta to separate, and the more time the myometrium remains relaxed, the greater the blood loss.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Massage the uterus gently after placental expulsion.
Myometrium contracts in response to gentle tactile stimulation, reducing lochial flow and expressing blood clots. Even if the uterus responds well to massage, the problem may not be completely resolved with uterine atony. As soon as you remove your hand from the fundus, the uterus may relax, and the lethal seepage will begin again. To prevent this, remain with the client after massaging her fundus and assess to be certain her uterus is not relaxing again.
2. Place infant at client’s breast if she plans to breastfeed.
Suckling stimulates the release of oxytocin from the posterior pituitary, promoting myometrial contraction and reducing blood loss. Regarding the effect of early and late breastfeeding on the fundal level and uterine consistency, a study revealed that the majority of women in the early breastfeeding group had firm uterus below the level of the umbilicus compared to mothers in the late breastfeeding group. The oxytocin encourages the uterus to contract. This uterine contraction improves the genital tract involution so that the uterus of the lactating woman goes back to pre-pregnant condition faster (Al Sabati & Mousa, 2019).
3. Elevate fundus by dipping fingers down behind and moving the uterine body up away from symphysis pubis.
The practitioner may request this to facilitate internal examination. The nurse may also elevate the client’s lower extremities to improve circulation to essential organs.
4. Apply an ice pack on the hematomas if indicated.
The cold application can limit small hematoma because applications reduce blood flow to the area. Cold also numbs the area and makes the client more comfortable. Apply an ice pack covered with a towel to prevent thermal injury to the skin to prevent further bleeding. Larger ones may require incision and drainage of the clots.
5. Educate the client and significant others on identifying the signs and symptoms that need to be reported urgently.
Signs and symptoms of a possible cause of bleeding should be reported. A continuous trickling of blood can result in much or more blood loss than the dramatic bleeding associated with uterine atony. The nurse should also teach the client what to expect about changes in the lochia. Instruct the client to report the following signs of late postpartum hemorrhage: persistent bright red bleeding and return of red bleeding after it has changed to pinkish to whitish.
6. Apply controlled cord traction (CCT) on the umbilical cord as appropriate.
Force may contribute to breakage of the cord and retention of placental fragments, increasing blood loss. However, in settings where skilled birth attendants are available, CCT is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labor as important. This recommendation is based on a large RCT in which oxytocin 10 IU was used to prevent postpartum hemorrhage (PPH) in all participants. Based on this evidence, CCT was regarded as safe when applied by skilled birth attendants. It provides small beneficial effects on blood loss (average reduction in blood loss of 11 ml) and the duration of the third stage of labor (average reduction of 6 minutes). The care provider should discuss the decision to implement CCT in the context of a prophylactic uterotonic drug with the woman (World Health Organization, 2018).
7. Insert an indwelling Foley catheter (IFC) as ordered.
Catheterization will accurately measure the renal status and perfusion concerning fluid volume. Additionally, bladder distention is an easily corrected cause of uterine atony. The nurse should catheterize the client if she cannot urinate on the toilet or in a bedpan. Most healthcare providers include an order for catheterization to prevent delaying this corrective measure. After the uterus is firm from massage, the bladder should be emptied to keep the uterus firm.
8. Administer fluids through the parenteral route.
If fluid loss is excessive, parenteral replacement helps restore circulating volume and oxygenation of vital organs. Initial fluid replacement with a balanced crystalloid solution is recommended (102 mL of crystalloid for every 1 mL of blood loss). One randomized controlled trial in severe PPH found a very low incidence of fibrinogen depletion and coagulopathy when clients with an estimated blood loss of 1,400-2,000 mL were resuscitated with crystalloids (Muñoz et al., 2019).
9. Administer oxytocin (Pitocin) through the IM route or dilute IV drip in an electrolyte solution. IM methylergonovine maleate (Methergine) or prostaglandins may be given simultaneously.
Oxytocin promotes vasoconstrictive effect within the uterus to control postpartal bleeding after placental expulsion. IV bolus may result in maternal hypertension. Water intoxication may occur if an electrolyte-free solution is used. Oral misoprostol was regarded as an effective drug for the prevention of PPH. However, the relative benefits of oxytocin compared to misoprostol have been considered in preventing blood loss and the increased adverse effects of misoprostol compared to oxytocin.
10. Administer fresh whole blood or other blood products as indicated.
Fresh frozen plasma should be considered in massive ongoing PPH when there is a clinical suspicion of coagulopathy and laboratory tests are not normal. RBC transfusion should only be considered when the hemoglobin concentration is less than 7 g/dL. Platelets should be transfused when the count is <75×10⁹/L, aiming to maintain a level >50×10⁹/L during ongoing PPH (Muñoz et al., 2019).
11. Assist with repairing the cervix, vagina, and episiotomy extension.
Lacerations contribute to blood loss; can cause hemorrhage. Perineal lacerations are sutured and treated the same as an episiotomy repair. Both sutured lacerations and episiotomy incisions tend to heal in the same length of time. Vaginal repairs can be tricky, as vaginal tissue is friable. Oozing often occurs after a vaginal repair, so the vagina may be packed to maintain pressure on the suture line.
12. Assist as needed with manual removal of the placenta under general anesthesia and sterile conditions.
Hemorrhage stops once placental fragments are removed and the uterus contracts, closing venous sinuses. Removing the retained placental fragment is necessary to stop the bleeding and can usually be accomplished by a dilatation and curettage (D&C). If it cannot be removed, methotrexate may be prescribed to destroy the retained fragment.
Risk For Injury (Maternal)
Traumatic causes during delivery would include injury to the soft tissue and lacerations of the cervix or vaginal walls, especially if instrumental operative delivery using forceps or vacuum was performed. Uterine rupture and uterine inversion, although rare, are traumatic obstetric emergencies and lead to significant blood loss. At the time of delivery, the maternal surface of the placenta should be carefully inspected to ensure that no fragments are missing. The fetal surface is then examined, with particular attention to the margins, to look for severed blood vessels that may have led to a succenturiate placental lobe (Burke, 2010).
Nursing Diagnosis
- Risk for Injury (Maternal)
May be related to
Common related factors for this nursing diagnosis:
- Abnormal blood profile
- Difficulty with placental separation
- Positioning during delivery/transfers
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 observe safety measures.
- The client will be free of injury.
Nursing Assessment and Rationales
Below are the nursing assessment for this labor nursing care plan.
1. Assess the client’s respiratory rhythm and blood pressure.
With placental separation, the danger exists that an amniotic fluid embolus may enter maternal circulation, causing pulmonary emboli, or that fluid changes may result in emboli mobilization. Amniotic Fluid embolism is characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities triggered by the thromboplastin contained in the amniotic fluid. A pulse oximeter may be used to monitor the client’s oxygen saturation.
2. Assess client’s behavior, noting central nervous system (CNS) changes.
Increased intracranial pressure (ICP) during pushing and a rapid increase in cardiac output place the client with a preexisting cerebral aneurysm at risk for rupture. Idiopathic intracranial hypertension, although rare, increases the risk of increased ICP during labor due to pushing and pain. This can be controlled by an instrumental delivery and adequate analgesia during labor and delivery (Dominguez et al., 2017).
3. Palpate fundus to note “ballooning” of the uterus, and massage gently.
This helps identify relaxation of the uterus and subsequent bleeding into the uterus and facilitates placental separation. Palpate the client’s fundus for size, consistency, and position. The sealing of the placenta site is accomplished by a rapid contraction of the uterus immediately after the delivery of the placenta. Because uterine contraction begins immediately after placental delivery, the fundus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth.
4. Assess the client’s risk for falls.
After childbirth, resistance to blood flow in the vessels of the pelvis drops. As a result, the client’s blood pressure falls when she sits or stands, and she may feel dizzy or lightheaded. The first time the client gets out of bed, she is at increased risk for a fall because of the physiological events during delivery that can cause unstable blood pressure and syncope. Guidance and assistance are needed during early ambulation to prevent injury.
5. Assess the client’s bladder for distention.
To prevent permanent damage to the bladder from overdistention, assess the client’s abdomen frequently in the immediate postpartal period. On palpation, a full bladder is felt like a hard or formed area just above the symphysis pubis. On percussion (placing one finger flat on the client’s abdomen over the bladder and tapping it with the middle finger of the other hand), a full bladder sound resonant, in contrast to the dull, thudding sound of non-fluid-filled tissue.
6. Obtain a sample of cord blood; send to the laboratory for blood typing of newborn and banking as desired—record information regarding the sample being sent.
If the infant is Rh-positive and the client is Rh-negative, the client will require immunization with Rh immune globulin (Rh Ig) in the postpartal period. Cord blood contains hematopoietic stem cells that have a distinct advantage over bone marrow or peripheral stem cells for use in the treatment of multiple diseases such as immune, genetic, or neurological disorders.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Remove the client’s legs simultaneously from the leg supports if used.
Ambulation and limiting the time the client remains in obstetric stirrups encourages circulation in the lower extremities, promotes venous return, and decreases the possibility of clot formation, thus helping to prevent thrombophlebitis. If stirrups on examining tables or birthing rooms are used, be certain that they are well padded to prevent any sharp pressure against the calves of the legs and that the client remains in a lithotomy position for as short a time as possible.
2. Gently massage fundus after placental expulsion.
This enhances uterine contraction while avoiding overstimulation/trauma to the fundus. A poorly contracted (soft or boggy) uterus should be massaged until firm to prevent bleeding. It is essential not to push down on an uncontracted uterus to avoid inverting it.
3. Clean the vulva and perineum with sterile water and antiseptic solution; apply a sterile perineal pad.
This removes possible contaminants that might result in an ascending tract infection during the postpartal period. Teach the client to do perineal care after each voiding or bowel movement to cleanse the area without trauma. Perineal pads should be applied and removed in the same front-to-back direction to prevent fecal contamination of the perineum and vagina.
4. Assist the client when changing positions or sitting on the bed.
Advise the client always to sit up slowly and dangle her feet on the side of her bed before attempting to walk. If she notices obvious dizziness on sitting upright, support her during ambulation to avoid the possibility of a fall. Caution her not to attempt to walk carrying her newborn until her cardiovascular status adjusts to her blood loss.
5. Encourage the client to empty her bladder frequently.
If the client can ambulate, she should urinate in the bathroom. The first two or three voidings after birth or after catheter removal are measured. Provide her as much privacy as possible, but remain near her in case she may need assistance. Turning on running water or having the client squirt warm water over her perineal area to relax and stimulate the urethral sphincter may help her void.
6. Assist in transfer from delivery bed to recovery cart, as appropriate.
Although many clients remain in the labor/ delivery bed for the recovery period, if a transfer is required, the client may be unable to move lower limbs due to continued effects from anesthesia/leg “heaviness” or cramping. Additionally, a major complication in clients who have lost an appreciable amount of blood with birth is orthostatic hypotension or dizziness that occurs on standing because of the lack of adequate blood volume to nourish brain cells.
7. Use ventilatory assistance if needed.
Respiratory failure may occur following amniotic or pulmonary emboli. Treatment includes providing respiratory support with intubation and mechanical ventilation as necessary. The client may be transferred to the intensive care unit for closer monitoring and nursing care.
8. Administer Rho (D) immune globulin or rubella immunization, if indicated.
The Rh-negative mother should receive a dose of Rho (D) immune globulin (RhoGAM) within 72 hours after giving birth to an Rh-positive newborn. This prevents sensitization to Rh-positive erythrocytes that may have entered her bloodstream when the newborn was born. A mother who did not receive a rubella titer early in pregnancy should receive one in the immediate postpartum period to prevent infection with the rubella virus, which could cause congenital disabilities. Consent is needed for these vaccines.
If uterine inversion occurs:
9. Administer prophylactic antibiotics.
Uterine inversion refers to the uterus turning inside out with either the fetus’s birth or delivery of the placenta. Because the uterine endometrium is exposed, the client will need antibiotic therapy to prevent infection.
10. Administer volume replacement, insert indwelling urinary catheter; obtain blood type and cross-match; monitor vital signs. And maintain careful intake/output records.
Rapid maternal hemorrhage and shock follow inversion, and immediate lifesaving interventions may be necessary. Kidney function is a useful indicator of fluid volume levels/tissue perfusion. An IV fluid line should be inserted if one is not already present. Use a large-gauge needle because blood will need to be replaced. If a line is already in place, open it to achieve the optimal fluid flow to restore fluid volume.
11. Administer oxytocin IV, replace uterus under anesthesia, and give ergonovine maleate (Ergotrate) IM after replacement. Assist with the packing of the uterus, as indicated.
The client will immediately be given general anesthesia or nitroglycerin or a tocolytic IV drug to relax the uterus. After manual replacement, oxytocin administration helps the uterus contract and remain in its natural place.
Risk For Altered Family Process
Most parents handle newborn babies tentatively until they have “claimed” them or have become firmly acquainted. If an infant is ill at birth, it may take days or weeks before the parents can handle their baby comfortably and confidently because of the number of tubes involved in the care and their fear of doing something that could hurt the infant. The demands of parenthood may affect the communication between the partners, and there is little doubt that children distract from the relationship at times. Fatigue may trigger irritability, too. Both parents are concerned with increased economic responsibilities. Loss of freedom and a decrease in socialization may give the couple a sense of loneliness.
Nursing Diagnosis
- Risk for Altered Family Processes
May be related to
Common related factors for this nursing diagnosis:
- Developmental transition (gain of a family member)
- Situational crisis (change in roles/responsibilities)
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 family will demonstrate behaviors indicative of readiness to actively participate in the acquaintance process when both mother and infant are physically stable.
- The parents will visit frequently and hold the infant.
- The parents will speak of their child in positive terms.
Nursing Assessment and Rationales
Below is the nursing assessment for this labor nursing care plan.
1. Determine the relationship of family members to one another.
This can help provide a positive experience to prepare the family for new developmental tasks. The influence of a new child’s birth on siblings depends on their age and developmental level. The grandparent’s involvement with a new child is often dictated by how near they live to the younger family. A little conflict is likely if parents and grandparents agree on the grandparent’s role.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Provide client and father with the opportunity to hold the baby immediately after birth if the infant’s condition is stable.
Early physical contact helps foster attachment. Fathers are also more likely to participate in infant caretaking activities and feel stronger emotional ties if they are actively involved with the infant soon after birth. New fathers typically display interest in their new child, called engrossment. Adjustment to fatherhood is facilitated by involvement in the newborn’s care. Fathers should be included when the nurse shares instructions about newborn care and handling.
2. Provide unlimited visiting privileges for family and siblings, as appropriate.
This facilitates the attachment and bonding process. The nurse observes parenting behaviors, such as the amount of affection and interest shown to the newborn. Adults tend to talk with newborns in high-pitched voices. The extent to which the parents encourage the involvement of siblings and grandparents with the newborn should be noted. This information provides a basis for nursing interventions that encourage bonding and foster positive family relationships.
3. Facilitate interaction between the client/couple and the newborn as soon as possible after delivery.
This fosters the beginning of lifelong emotional ties between family members. Both mother and infant have a critically sensitive period during which interactional capabilities are enhanced. Newborns without complications should be kept in skin-to-skin contact with their mothers during the first hour after birth to prevent hypothermia and promote breastfeeding.
4. Delay installation of eye prophylaxis ointments (containing erythromycin or tetracycline) until client/couple and infant have interacted and dim room lights.
This allows the infant to open eyes fully to establish eye contact with the parent and actively participate in the interaction, free from the blurred vision caused by medication. In the past, eye prophylaxis was given immediately after birth, never to forget it. Now it is more customary to delay the ointment administration until after the first reactivity period so the newborn can see the parents during this important attachment period.
5. Provide anticipatory guidance concerning changes to expect and family adaptation options.
Meeting needs concerning housing, equipment, and community resources available for assisting will help the family adapt to changes. Studying the family as the client, rather than an individual as the client, can offer insight into community-based care and can help the nurse integrate the knowledge of the family structure, culture, and composition into a plan of care that will meet some goals of Healthy People 2030 (U.S. Department of Health and Human Services, 2018).
6. Provide written information for parents and suggested books for siblings concerning the new child.
Including the needs of each family member will promote family coping and adaptation. New parents should be given written instructions because they are often overwhelmed by the volume of information provided in such a short time. They should be reassured that the birth facility staff is available 24 hours a day to help them care for their newborn and refresh their memories if they forget what they have been instructed.
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:
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).
Anxiety
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, piggybacking 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.
Dysfunctional Labor (Dystocia)
Dystocia refers to difficult labor which is usually due to uterine dysfunction, fetal malpresentation/abnormality, or pelvic abnormality. Dystocia may arise from any of the four main components of the labor process: the power, or the force that propels the fetus (uterine contractions); the passenger (the fetus); the passageway (the birth canal); or the psyche (the woman’s and family’s perception of the event). In addition, the length of labor may be unusually short or long.
Risk factors for dysfunctional labor include the following:
- Advanced maternal age
- Obesity
- Overdistention of uterus
- Cephalopelvic disproportion (CPD)
- Overstimulation of the uterus
- Maternal fatigue
- Dehydration
- Fear or anxiety
- Lack of analgesic assistance
Dysfunction can occur at any point in labor, but it is generally classified as primary (occurring at the onset of labor) or secondary (occurring later in labor). Although the fetus is passive during birth, complications may arise if an infant is immature or preterm or if the maternal pelvis is so undersized that its diameters are smaller than the fetal skull. Aside from a concern with the power of labor and the passenger, the third reason dystocia can occur.
Nursing care plans for dysfunctional labor or dystocia include:
Risk for Injury (Maternal)
The American College of Obstetricians and Gynecologists (ACOG) practice bulletins published in 2002 and 2017 noted that maternal complications with shoulder dystocia include a postpartum hemorrhage rate of 11% and a third- and fourth-degree perineal laceration in 4% of cases. Health care professionals caring for women in labor need to be aware of the increased rate of maternal complications associated with dystocia and be prepared to manage these (Mendez-Figueroa et al., 2021).
Nursing Diagnosis
- Risk for Injury (Maternal)
Risk factors
- Alteration of muscle tone/contractile pattern
- Maternal fatigue
- Mechanical obstruction to fetal descent
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- The client will accomplish cervix dilation at least 1.2 cm/hr for primipara, 1.5 cm/hr for multipara in the active phase, with fetal descent at least 1 cm/hr for primipara, and 2 cm/hr for multipara.
- The client will display vital signs within normal limits.
Nursing Assessment and Rationales
1. Review the history of labor, onset, and duration.
This helps identify possible causes, needed diagnostic studies, and appropriate interventions. Uterine dysfunction may be caused by an atonic or hypertonic state. Uterine atony is classified as primary when it occurs before the onset of labor (latent phase) or secondary when it occurs after well-established labor (active phase). Prolonged labor appears to result from several factors but is most likely to occur if the contractions are hypotonic, hypertonic, or uncoordinated.
2. Assess for signs of amnionitis. Note elevated temperature or WBC; odor and color of vaginal discharge.
The development of amnionitis is directly related to the length of labor, so the delivery should occur within 24 hr after the rupture of membranes. Observe, report, and document maternal temperature above 38°C (100.4°F), fetal tachycardia, and tenderness over the uterine area. These are signs that an infection has developed.
3. Assess uterine contractile pattern manually (palpation) or electronically via external or internal monitor with an internal uterine pressure catheter (IUPC).
Dysfunctional contractions lengthen labor, increasing the risk of maternal/fetal complications. A hypotonic pattern is reflected by frequent, mild contractions measuring less than 30 mm Hg via IUPC or “soft as chin” per palpation. A hypertonic pattern is reflected by increased frequency, an elevated resting tone per palpation or greater than 15 mm Hg via IUPC, and possibly decreased intensity of contractions. Note: The intensity of contractions cannot be measured by an external monitor.
4. Evaluate the current level of fatigue and anxiety, as well as activity and rest before the onset of labor.
Excess maternal exhaustion contributes to secondary dysfunction or may result from prolonged labor/false labor. An exhausted client may be unable to gather her resources to push appropriately. The client may also not push effectively during the second stage of labor because she fears tearing her perineal tissues.
5. Note effacement, fetal station, and fetal presentation.
These indicators of labor progress may identify a contributing cause of prolonged labor. For example, breech presentation is not as effective a wedge for cervical dilation as is vertex presentation. Abnormalities in fetal presentation and position prevent the smallest diameter of the fetal head from passing through the smallest diameter of the pelvis for effective labor progress. A prolonged latent phase may occur if the cervix is not “ripe” at the beginning of labor.
6. Assess and record the client’s pelvic measurements.
Every primigravida should have pelvic measurements taken and recorded before week 24 of pregnancy so, based on these measurements and the assumption the fetus will be of average size, a birth decision can be made. Inlet contraction is the narrowing of the anteroposterior diameter of the pelvis to less than 11 cm or of the transverse diameter to 12 cm or less.
7. Evaluate the degree of hydration. Note the amount and type of intake.
Prolonged labor can result in a fluid-electrolyte imbalance and depletion of glucose reserves, resulting in exhaustion and prolonged labor with an increased risk of uterine infection, postpartal hemorrhage, or precipitous delivery in the presence of hypertonic labor. Low serum electrolytes or body fluid can occur in labor for the same reason as a decreased glucose level- there has been a long interval between eating and the end of labor.
8. Graph cervical dilation and fetal descent against time (i.e., Friedman curve).
This may be used on occasion to record progress/ prolongation of labor. The Friedman curve represents the basis for presenting labor progression graphically. It aimed to identify the abnormal progress of labor. It monitors cervical dilatation and includes observations of necessary intrapartum details (Lavender & Bernitz, 2020).
9. Palpate the abdomen of a thin client for the presence of a pathological retraction ring between uterine segments.
Two distinct swellings will be visible on the client’s abdomen: the retracted uterus and the extrauterine fetus. These rings are not palpable through the vagina or the abdomen in the obese client. In obstructed labor, a depressed pathological ring (Bandl’s ring) may develop at the juncture of lower and upper uterine segments, indicating an impending uterine rupture.
10. Investigate reports of severe abdominal pain. Note signs of fetal distress, cessation of contractions, and presence of vaginal bleeding.
This may indicate developing uterine tears/acute rupture necessitating emergency surgery. Note: Hemorrhage is usually occult since it is intraperitoneal with hematomas of the broad ligament. If a uterus should rupture, the client experiences a sudden, severe pain during a strong labor contraction, which she may report as a “tearing” sensation. Hemorrhage from the torn uterine arteries floods into the abdominal cavity and possibly into the vagina.
Nursing Interventions and Rationales
1. Encourage the client to void every two hours. Assess for bladder fullness over the symphysis pubis.
A full bladder may inhibit uterine activity and interfere with fetal descent. Urge the client in labor to void every two hours to keep the bladder empty, so this does not add to the slow progress caused by hypotensive or hypertensive contractions.
2. Place the client in a lateral recumbent position and encourage bed rest or sitting position/ambulation, as tolerated.
Relaxation and increased uterine perfusion may correct a hypertonic pattern. Ambulation may assist gravitational forces in stimulating normal labor patterns and cervical dilation. Contractions are usually stronger and more effective when the client assumes an upright position or lies on her side. Walking or nipple stimulation may intensify contractions.
3. Assist the client in positioning if shoulder dystocia is suspected.
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 of a series of maneuvers that help resolve shoulder dystocia.
4. Have an emergency delivery kit available.
This may be needed in the event of precipitous labor and delivery, which are associated with uterine hypertonicity. If decelerations in the FHR, an abnormally long first stage of labor, or lack of progress with pushing occurs, cesarean birth may be necessary. Be certain that the client and her partner understand that, although contractions are strong, they are ineffective and are not achieving cervical dilatation.
5. Remain with the client if possible, or arrange for the presence of a doula as appropriate.
A doula is a second support person in labor. The doula does not replace the client’s partner and does much more than time contractions. The use of a doula is an individual choice. Although research on the subject is not extensive, there are suggestions that rates of oxytocin augmentation, epidural anesthesia, and cesarean birth can all be reduced by doula support. With specific education, many nurses participate as either doula or special support nurses to clients in labor.
6. Provide a quiet environment as indicated.
Decreasing external stimuli may be important to allow sleep after medication administration to a client in a hypertonic state. It is also helpful in decreasing the level of anxiety, which can contribute to both primary and secondary uterine dysfunction. Providing dim lights and providing a warm temperature could be given more consideration in most institutions.
7. Prepare the client for amniotomy, and assist with the procedure, when the cervix is 3–4 cm dilated.
Rupture of membranes relieves uterine overdistension (a cause of both primary and secondary dysfunction) and allows presenting part to engage and labor to progress in the absence of cephalopelvic disproportion (CPD). Note: Active management of labor (AML) protocols may support amniotomy once the presenting part is engaged to accelerate labor/help prevent dystocia. The nurse assists the health care provider with the procedure and cares for the client and fetus afterward. Amniotomy stimulates prostaglandin secretion, which stimulates labor.
8. Avoid administration of narcotics or epidural block anesthetics until the cervix is 4 cm dilated.
A hypertonic contractile pattern may occur in response to oxytocin stimulation; sedation/analgesia given too early (or more than the client’s needs) can inhibit or arrest labor. Epidural or subarachnoid blocks may depress or eliminate the natural urge to push. The use of narcotic analgesics is also avoided if birth is expected within an hour.
9. Administer narcotic or sedative, such as morphine, pentobarbital (Nembutal), or secobarbital (Seconal), for sleep as indicated.
Morphine helps promote heavy sedation and eliminate hypertonic contractile patterns. Hypertonic contractions may occur more because more than one uterine pacemaker is stimulating contractions. They tend to be more painful than usual because the myometrium becomes tender from constant lack of relaxation and the anoxia of uterine cells that results. A period of rest conserves energy and reduces the utilization of glucose to relieve fatigue.
10. Use nipple stimulation to produce endogenous oxytocin.
This helps the client to use natural methods to stimulate contractions, such as nipple stimulation. Nipple stimulation causes the client’s posterior pituitary gland to secrete natural oxytocin, strengthening contractions.
11. Initiate infusion of exogenous oxytocin (Pitocin) or prostaglandins.
Oxytocin may be necessary to increase or institute myometrial activity for a hypotonic uterine pattern. It is usually contraindicated in hypertonic labor patterns because it can accentuate the hypertonicity but may be tried with amniotomy if the latent phase is prolonged and if CPD and malpositions are ruled out. Oxytocin is an effective uterine stimulant, but there is a thin line between adequate stimulation and hyperstimulation, so careful observation during the entire infusion time is an important nursing responsibility.
12. Prepare for forceps delivery, as necessary.
Excessive maternal fatigue, resulting in ineffective bearing-down efforts in stage II labor, necessitates the use of forceps. Today, the technique is rarely used (in only about 4% to 8% of births) because it can lead to rectal sphincter tears in the client, leading to dyspareunia, anal incontinence, or increased urinary stress incontinence.
13. Assist with preparation for cesarean delivery, as indicated, e.g., malposition, CPD, or Bandl’s ring.
Immediate cesarean birth is indicated for Bandl’s ring or fetal distress due to CPD. Note: Once labor is diagnosed, if delivery has not occurred within 12 hours, and amniotomy and oxytocin have been used appropriately, then a cesarean delivery is recommended by some protocols. Assist in preparing the client for a possible laparotomy as an emergency measure to control bleeding and the birth of the fetus. The fetus’s viability depends on the extent of the rupture and the time elapsed between rupture and abdominal extraction.
Risk For Injury (Fetal)
Although the fetus is passive during birth, complications may arise if an infant is immature or preterm or if the maternal pelvis is so undersized that its diameters are smaller than the fetal skull, such as occurs in early adolescence or women with altered bone growth from a disease such as rickets. It can also occur if the umbilical cord prolapses, if more than one fetus is present, or if a fetus is malpositioned or too large for the birth canal.
Nursing Diagnosis
- Risk for Injury (Fetal)
Risk Factors
- Abnormalities of the maternal pelvis
- Cephalopelvic disproportion (CPD)
- Fetal malpresentation
- Tissue hypoxia/acidosis
- Prolonged labor
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- The client will participate in interventions to improve labor patterns and/or reduce identified risk factors.
- The client will display FHR within normal limits, with good variability and no late decelerations noted.
- The fetus will be free of injury and complications.
Nursing Assessment and Rationales
1. Assess FHR manually or electronically. Note variability, periodic changes, and baseline rate.
This detects abnormal responses, such as exaggerated variability, bradycardia, and tachycardia, which may be caused by stress, hypoxia, acidosis, or sepsis. If in a free-standing birth center, check the fetal heart tone between contractions using a Doptone. Count for 10 min, break for 5 min, and count again for 10 min. Continue this pattern throughout the contraction to midway between it and the following contraction. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes, whether this occurs spontaneously or by amniotomy.
2. Note the frequency of uterine contractions. Notify the healthcare provider if the frequency is two minutes or less.
Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor.
3. Note uterine pressures during resting and contractile phases via intrauterine pressure catheter, if available.
Resting pressure greater than 30 mm Hg or contractile pressure greater than 50 mm Hg reduces or compromises oxygenation within intervillous spaces. Contractions should occur no more often than every two minutes, should not be stronger than 50 mm Hg pressure, and should last no longer than 70 seconds. The resting pressure between contractions should not exceed 15 mm Hg by monitoring.
4. Identify maternal factors such as dehydration, acidosis, anxiety, or vena caval syndrome.
Sometimes, simple procedures (such as turning the client to a lateral recumbent position) can increase circulating blood and oxygen to the uterus and placenta and may prevent or correct fetal hypoxia. The client with increased uterine muscle tone is uncomfortable and frustrated. Anxiety about the lack of progress and fatigue impair their ability to tolerate pain.
5. Monitor fetal descent in the birth canal concerning ischial spines.
A descent that is less than 1 cm/hr for a primipara, or less than 2 cm/hr for a multipara, may indicate CPD or malposition. The arrest of descent results when no descent occurs for two hours in a nullipara or one hour in a multipara. Failure of descent occurs when the expected descent of the fetus does not begin, or engagement or movement beyond 0 station does not occur. Cesarean birth usually is necessary.
6. Assess for malpositioning using Leopold’s maneuvers and findings on internal examination (location of fontanelles and cranial sutures). Review results of ultrasonography.
Determining the fetal lie, position, and presentation may identify the factor(s) contributing to dysfunctional labor. Leopold maneuvers and a vaginal examination usually reveal the presentation. If the presentation is unclear, ultrasound confirms the presentation. A head that feels more prominent than normal, with no engagement apparent on Leopold’s maneuvers, suggests a face presentation. It is also suggested that the head and the back are both felt on the same side of the uterus with Leopold maneuvers.
7. Assess for the deep transverse arrest of the fetal head.
Failure of the vertex to rotate fully from an OP to an occiput OA position may result in a transverse position, arrested labor, and the need for cesarean delivery. A mature fetus cannot be born vaginally from this presentation. Because there is no firm presenting part, the cord or an arm may prolapse, or the shoulder may obstruct the cervix.
8. Note odor and change in color of amniotic fluid with prolonged rupture of membranes or when the membranes rupture.
Ascending infection and sepsis accompanying fetal tachycardia may occur with prolonged rupture of membranes. Excess amniotic fluid causing uterine overdistention is associated with fetal anomalies. Meconium-stained amniotic fluid in a vertex presentation results from hypoxia, which causes vagal stimulation and relaxation of the anal sphincter. Noting characteristics of amniotic fluid alerts staff to potential needs of newborns, e.g., airway/ventilatory support.
9. Assist with the assessment of pelvic size or clinical pelvimetry.
Digital evaluation or clinical pelvimetry is an essential part of the overall physical examination. In general, the size of the pelvis can be determined to be large or ample, small, or borderline. Examining the essential landmarks and measurements should allow one to decide on normality or abnormality. The inability to determine size or morphology should elevate one’s index of suspicion and thus demand a more careful intrapartum assessment or possible consultation (O’Leary, 2009).
Nursing Interventions and Rationales
1. Instruct the client to void regularly every two hours.
During long labor, be certain that the client voids approximately every two hours to keep her bladder empty because a full bladder could further impede the descent of the fetus.
2. Arrange transfer to an acute care setting if malposition is detected in the client in a free-standing birth center without adequate surgical/high-risk neonatal capabilities.
The risk of fetal or neonatal injury or demise increases with vaginal delivery if the presentation is other than vertex. Caution a multiparous client by week 28 of pregnancy that because past labor was so brief, her labor this time also may be brief so that she has time to plan for adequate transportation to the hospital or alternative birthing center. Both grand multiparas and clients with histories of precipitous labor should have a 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 surrounding.
3. Prepare the client for the most expedient method of delivery if the fetus is in the brow, face, or chin presentation.
Such presentations increase the risk of CPD, owing to a larger diameter of the fetal skull entering the pelvis (11 cm in brow or face presentation, 13 cm in chin presentation, versus 9.5 cm for vertex presentation), often necessitating assisted delivery via forceps or vacuum, or cesarean delivery because of failure to progress and ineffective labor pattern. If the chin is posterior, cesarean birth is usually the method of choice; otherwise, it would be necessary to wait for a long posterior-to-anterior rotation to occur. Such rotation could result in uterine dysfunction or a transverse arrest.
4. Observe for visible cord prolapse or occult cord prolapse as indicated by variable decelerations on the monitor strip.
Cord prolapse is more likely to occur in the breech presentation because the presenting part is not firmly engaged, nor is it blocking the os, as in vertex presentation. Because the umbilicus precedes the head, a cord loop passes down alongside the head. The pressure of the head against the pelvic brim automatically causes compression on this loop of the cord.
5. Have the client assume the hands-and-knees position or lateral Sims’ position on the side opposite that to which fetal occiput is directed.
These positions encourage anterior rotation by allowing the fetal spine to fall toward the client’s anterior abdominal wall (70% of fetuses in the OP position rotate spontaneously). The client may lie on her side (on her left side if the fetus is in right occipitoposterior position (ROP) or on her right side if the fetus is in the left occipitoposterior position). Theoretically, shifting the weight from right to left or “lunging” or swinging her body right to left while elevating her left foot on a chair widens the pelvic path and makes fetal rotations easier. Study findings, however, observed no efficacy of the hands and knees position, but it was associated with increased maternal comfort (Guittier et al., 2016).
6. Assist in the birthing of the head in a fetus with breech presentation.
To aid in the birth of the head, the infant’s trunk is usually straddled over the primary care provider’s right forearm. Two fingers of the right hand are then placed in the infant’s mouth. The left hand is slid into the client’s vagina, palm down, along the infant’s back, and pressure is applied to the occiput to flex the head fully. The gentle traction applied to the shoulders (upward and outward) delivers the head.
7. Assist in relieving cord pressure in umbilical cord prolapse.
A prolapsed cord is always an emergency because the pressure of the fetal head against the cord at the pelvic brim leads to cord compression and decreased oxygenation to the fetus. Management aims to relieve pressure on the cord, thereby relieving the compression and the resulting fetal anoxia. This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord or by placing the client in a knee-chest or Trendelenburg position to cause the fetal head to fall back from the cord.
8. Cover the exposed cord with sterile saline compress.
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.
9. Administer antibiotics to the client, as indicated.
This prevents or treats ascending infection and will protect the fetus as well. Vaginal or cervical infections may cause prematurely ruptured membranes. Treatment of premature rupture of membranes is based on weighing the risks of early delivery of the fetus against the risks of infection in the mother and sepsis in the newborn.
10. Prepare for and assist in amnioinfusion.
Amnioinfusion is the addition of sterile fluid into the uterus to supplement the amniotic fluid and reduce compression on the cord. For this, a sterile double-lumen catheter is introduced through the cervix into the uterus. Attach the client to an FHR monitor and urge her to lie in a lateral recumbent position to prevent supine hypotension syndrome. This procedure can also be performed daily for clients diagnosed with oligohydramnios.
11. Assist and prepare for external cephalic version (ECV), as indicated.
The external cephalic version is the turning of the fetus from a breech to a cephalic position before birth. The evidence for the effectiveness of ECV in reducing breech vaginal and cesarean births is strong. ECV is considered the first-line option in most Western countries. Although ECV is a safe procedure with few complications, it should be performed in a setting where fetal monitoring and surgical delivery are available (Savchenko et al., 2020).
12. Prepare for delivery or a vacuum extraction in the posterior position.
Delivering the fetus in a posterior position results in a higher incidence of maternal lacerations. A vacuum extractor may be used to rotate and expedite the delivery of the fetus. A fetus, if positioned far enough down the birth canal, may be born by vacuum extraction. With the fetal head at the perineum, a soft, disk-shaped cup is pressed against the fetal scalp and over the posterior fontanelle. When the vacuum pressure is applied, the air beneath the cup is suctioned out, and the cup then adheres so tightly to the fetal scalp that traction on the vacuum cord leading to the cup extracts the fetus.
13. Prepare for cesarean delivery of breech presentation if fetus fails to descend, labor progress ceases, or CPD is identified.
Vaginal delivery of an infant in breech position is associated with injury to the fetal spinal column, brachial plexus, clavicle, and brain structures, increasing neonatal mortality and morbidity. The risk of hypoxia caused by prolonged vagal stimulation with head compression, and trauma such as intracranial hemorrhage, can be alleviated or prevented if CPD is identified and surgical intervention follows immediately.
Risk For Fluid Volume Deficit
Adequate maternal hydration during labor is fundamental to ensure efficient contractions. Some investigators propose that extrapolating the data of the physiological effects of uterine smooth muscle exertion might give an idea as to why some women could be inadequately hydrated if they experience prolonged labor. Inadequate hydration during labor can stimulate alterations in the acid-base balance of the myometrium provoking a reduction in contractility and prolonging labor, as well as increasing the probability of cesarean delivery (Lopez et al., 2019).
Nursing Diagnosis
- Risk for Fluid Volume Deficit
Risk factors
- Hypermetabolic state
- Vomiting
- Profuse diaphoresis
- Restricted oral intake
- Mild diuresis associated with oxytocin administration
- Length and work of labor
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- The client will maintain fluid balance, as evidenced by moist mucous membranes and palpable pulses.
- The client’s urine will be adequate, free of ketones, and the specific gravity is maintained between 1.003 and 1.030.
- The client will be free of complications.
- The client’s serum electrolyte results will be within acceptable parameters.
Nursing Assessment and Rationales
1. Monitor vital signs. Note reports of dizziness with a change of position.
Increased pulse rate and temperature and orthostatic BP changes may indicate a decrease in circulating volume. Maternal intrapartum fever, defined as a temperature of 38℃ (100.4℉) or above, commonly complicates labor. Its appearance is frequently considered a sign of chorioamnionitis, which necessitates the administration of antibiotics. Intrapartum fever is not only associated with increased use of antibiotics, but also with increased risk of cesarean births, respiratory distress syndrome, seizures during the first week of life, tachycardia, low Apgar score, and even the need for admittance to the NICU (Lopez et al., 2019).
2. Assess for vomiting and diarrhea.
Vomiting and diarrhea occasionally accompany labor; if these occur, they can add to fluid and electrolyte loss. Maternal hyponatremia (sodium level <135 mEq/l) can provoke nausea, vomiting, headaches, and even seizures. The fetus receives water from the mother’s circulation via the placenta, which, in such cases, can produce mild transplacental hyponatremia. This can provoke seizures in the newborn (Lopez et al., 2019).
3. Assess lips and oral mucous membranes and degree of salivation, as well as skin turgor.
Dry oral mucous membranes or lips and decreased salivation indicate dehydration. Dehydration is also evidenced by a dry tongue and decreased turgor (elasticity) of the skin.
4. Note abnormal FHR response.
This may reflect the effects of maternal dehydration and decreased perfusion. Fetal tachycardia is a baseline of FHR greater than 160 beats/minute that lasts 2 to 10 minutes or longer. It can be caused by maternal fever or maternal dehydration. When fetal tachycardia occurs along with loss of baseline variability or late decelerations, immediate intervention is required.
5. Keep accurate intake/output, test urine for ketones, and assess breath for fruity odor.
Decreased urine output and increased urine specific gravity reflect dehydration. Inadequate glucose intake results in a breakdown of fats and the presence of ketones. Test the urine each time the client 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.
Nursing Interventions and Rationales
1. Encourage oral fluids as appropriate.
Clear liquids such as fruit juices and broths provide not only fluids but also calories for energy production. Note: Oral fluids are not recommended if surgical intervention is contemplated. The client is also encouraged to drink bottled mineral water or isotonic drinks at a rate of 100 ml/hr until delivery (Lopez et al., 2019).
2. Review laboratory data, e.g., Hb/Hct, serum electrolytes, and serum glucose.
Increased hematocrit suggests dehydration. Low levels of serum electrolytes or body fluid can occur in labor for the same reason as a decreased glucose level- there has been a long interval between eating and the end of labor. Dilutional hyponatremia is a condition in which the serum concentration of sodium is reduced due to excessive water retention. Excessive oral water intake during labor and circulatory overload through the use of sodium-free solutions, together with the use of oxytocin, predisposes the development of dilutional hyponatremia (Lopez et al., 2019).
3. Administer fluids intravenously.
It is suggested that optimal hydration for clients in labor should include a mixed volume of solutions (crystalloid and mineral water) at the rate of 300 ml/hr. The administration of crystalloid solutions in continuous perfusion is initiated at a rate of 200 ml/hr, alternating normal saline and Ringer’s lactate solution. The perfusion rate is increased (at 300 ml/hr) if the client has diuresis lower than 35ml/hr or has a temperature higher than 37.8℃ (100.04℉) (Lopez et al., 2019).
4. Assist the client in managing her IV lines appropriately.
When inserting the IV catheter, try to use an insertion site in the client’s nondominant hand and, if necessary, only a small “reminder” 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. Assure the client that being out of bed and walking, turning freely, squatting, sitting, or using whatever position she prefers during labor will not disrupt the IV line of the infusion.
5. Ensure that the fluid volume infused into the client is accurate.
Researchers in other studies have evaluated the relationship between the number of solutions administered to mothers and newborn weight loss. Excessive newborn weight loss occurs when the volume of maternal fluids during the first stage of labor exceeds 200 ml/hr compared to 100 ml/hr. Weight loss in the newborn is considered to be excessive when greater than 10% between the first 70-98 hours of life (Lopez et al., 2019).
Ineffective Individual Coping
Labor and birth are unique events, requiring the client to employ all the psychological and physical coping methods she has available. The most common factors that can increase stress and cause dystocia include lack of analgesic control of excessive pain, absence of a support person or coach to assist with nonpharmacological pain relief measures, immobility and restriction to bed, and a lack of the ability to carry out cultural traditions.
Nursing Diagnosis
- Ineffective Individual Coping
May be related to
- Inadequate/exhausted support systems
- Personal vulnerability
- Situational crisis
- Unrealistic expectations/perceptions
- Inadequate coping methods
Possibly evidenced by
- Verbalizations and behavior indicative of an inability to cope
- Inability to meet role expectations, basic needs, or problem-solve
- Lack of appetite
- Sleep disturbances
- Withdrawn demeanor
- Depression
Desired Outcomes
- The client will verbalize understanding of the current situation.
- The client will identify and use effective coping techniques.
- The client will verbalize awareness of their coping abilities and strengths.
- The client will identify potentially stressful situations and steps to avoid or modify them.
Nursing Assessment and Rationales
1. Determine the progress of labor.
Labor progress and prevention of dystocia depend on harmonious interactions among various psycho-emotional, interpersonal, physical, and physiologic factors (Hanson et al., 2017). Prolonged labor with resultant fatigue can reduce the client’s ability to cope or manage contractions. Increasing pain when the cervix is not dilating or effacing can indicate developing dysfunction. Extreme pain may indicate developing anoxia of the uterine cells.
2. Assess degree of pain in relation to dilation/effacement.
In many hospitals, laboring clients are asked periodically to assess their pain, using a visual analog scale of 0 to 10. It also includes images of faces indicating expressions ranging from smiling to somber to agony. The client indicates her pain level and is offered pain medications if it reaches a particular level (Hanson et al., 2017).
3. Determine the anxiety level of the client and partner. Note evidence of frustration.
Excess anxiety increases the adrenal activity or the release of catecholamines, causing endocrine imbalance. High levels of catecholamines during labor suppress the usual endorphin effects that would otherwise alter the client’s state of consciousness and help her enter an instinctual mental state. Excess epinephrine inhibits myometrial activity. Stress also depletes glycogen stores, reducing glucose available for adenosine triphosphate (ATP) synthesis, which is needed for uterine contraction (Hanson et al., 2017).
4. Assess the effectiveness of past or present coping strategies by observing behaviors.
Coping is a dynamic process in which emotions and stress affect and influence each other; coping changes the relationship between the individual and the environment. The client may have had past coping strategies that could help her go through the labor dysfunction. Two tools can be used to assess the client’s ability to cope with labor pain. The Pain Coping Scale is a visual analog scale, which ranges from 10 to 0. The mid-range denotes the ability to cope, without or with help. The second tool, the Coping Algorithm for assessing a client’s coping during labor, assesses the broader context of the experience of pain and coping (Hanson et al., 2017).
Nursing Interventions and Rationales
1. Acknowledge the reality of the client’s reports of pain/discomfort.
Discomfort and pain may be misunderstood because of a lack of progression that is not recognized as a dysfunctional problem. Usually, anyone can tolerate a little discomfort from a backache, feeling thirsty, having dry lips, or having a leg cramp. However, few people can tolerate having all these discomforts simultaneously or feeling even one of them while experiencing a labor contraction. Feeling listened to and supported can help the client relax, reducing discomfort and enhancing the ability to cope with the situation.
2. Maintain a calm manner and environment.
A calm manner calms the parents and reduces anxieties and tension that can elevate pain perception. Provide a comfortable environment: clean sheets, a cool washcloth to the forehead, closed room door. A comfortable environment aids in relaxation, promoting effective coping.
3. Discuss the possibility of discharge of client to home until active labor is established.
Too early admission fosters a sense of a longer or prolonged labor for the client. The client may be able to relax better in familiar surroundings. This also provides an opportunity to divert or refocus attention and to attend to tasks that may be contributing to the level of anxiety or frustration. Based on research examining the progression of labor, ACOG recommended delaying admission until the onset of active labor (6 cm). The admission decision can influence subsequent clinical processes because admission in early labor compared with active labor is associated with a greater risk of medical interventions and cesarean birth (Breman et al., 2019).
4. Encourage the efforts of the client or the couple to date.
This may be useful in correcting the misconception that the client is overreacting to labor or is somehow to blame for the alteration of the anticipated birth plan. Encouragement is a powerful tool for intrapartum nursing care because it helps the client to summon inner strength and gives her courage to continue Liberal praise is given if she successfully uses techniques to cope with labor.
5. Provide comfort measures and reposition the client.
Assist the client’s support person 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 moisturizing jelly or balm can be helpful. A cool cloth to wipe perspiration from the forehead, neck, and chest can keep the client from feeling overheated. Change the client’s sheets, offer her a clean gown, and ask if she’d like to bathe or take a shower. These measures can help her feel clean and refreshed, with a ready-to-go-again feeling.
6. Encourage ambulation as appropriate.
If there is no contraindication, encourage the client to walk or sit upright in a bed or chair. Upright positions enhance fetal descent. Walking strengthens labor contractions. Walking may not be advisable if the membranes are ruptured and the fetus is high because it could lead to umbilical cord prolapse.
7. Provide factual information about what is happening.
This reduces the “unknowns” to assist with the reduction of anxiety and provides data necessary to make informed decisions. Explain how each method is expected to help her labor advance. Inform her any time she is making progress, either with improved contractions or with increasing cervical dilation. 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. Assist the client’s support person with their comfort measures as well.
Think of comfort measures for the client’s support person. Is the chair by the side of the bed comfortable? Does he or she need to stretch or take a beverage or bathroom break? Could you serve as the coach while the support person makes some phone calls? Breaks such as these allow a partner to come back rested and ready to give support again.
9. Help the client identify coping strategies.
Because pain is not a new phenomenon for a client of childbearing age, it can be helpful to ask her to recall methods she usually uses to combat pain or anxiety, such as meditation or applying a cool cloth. Associating labor pain with usual circumstances can go a long way toward helping her collect her resources and decide on a workable pain relief strategy.
10. Assist with oxytocin augmentation if ordered.
The primary risks of oxytocin augmentation or induction of labor relate to overstimulating the uterus. Observe contractions for excessive frequency (more frequent than every two minutes), duration (>90 seconds), or inadequate rest interval (<60 seconds). Excessive contractions can reduce fetal oxygen supply. Observe fetal heart rate for rates outside the normal range of 110-160 mm Hg. These are signs of potential uterine overstimulation.
Acute Pain
Maternal well-being in labor is associated with numerous factors, among which the survival of a healthy mother and baby are unquestionably the most important. Besides safety, labor pain, and the fear of that pain and associated damage, are probably the next greatest concerns of both women and their caregivers. The distinction between pain and suffering is crucial to the understanding of the client’s emotional well-being in labor (Hanson et al., 2017).
Nursing Diagnosis
- Acute Pain
May be related to
- Decreased coping ability
- Intense labor contractions
- The slow progress of labor
- The arrest of fetal descent
Possibly evidenced by
- Verbalizations of pain and discomfort
- Facial grimacing, distraction behaviors
- Narrowed focus, withdrawal
- Anxiety
- Restlessness, irritability
- Tachycardia, tachypnea, changes in BP
Desired Outcomes
- The client will verbalize a reduced or tolerable level of pain.
- The client will display a relaxed facial and body appearance between contractions.
- The client will be able to utilize techniques to handle contractions.
- The client will demonstrate the ability to listen and respond to questions and instructions.
Nursing Assessment and Rationales
1. Assess the nature of pain, such as location, intensity, and whether it is intermittent or constant.
Assessment enables the nurse to identify if the pain is normal for the client’s labor status and to choose the best interventions for pain relief. Assess pain by using a visual analog scale of 0 (“no pain”) to 10 (“worst pain imaginable”); it also includes images of faces indicating expressions ranging from smiling to somber to agony (Hanson et al., 2017).
2. Assess the client’s ability to cope with pain.
More important than pain assessment is the assessment of the client’s distress- an inability to cope with the pain. The Pain Coping Scale is a visual analog scale, which ranges from 10 (“no need to cope- very easy”) to 0 (“totally unable to cope”). The nurse may ask her after a contraction, “Could you tell me what was going through your mind during that contraction?” Her answer will indicate whether she is coping or is in distress, neutral, or some of each. The Coping Algorithm involves asking the laboring woman periodically, “how are you coping with your labor?” and observations for clues that she is not coping (e.g., crying, inability to focus, panic, thrashing in bed, clawing, biting) (Hanson et al., 2017).
3. Assess for nonverbal cues of pain.
Crying, moaning during and/or between contractions, thrashing with contractions or tense, guarded body posture, and “mask of pain” facial expression are common verbal and nonverbal signs of pain. Evaluating verbal and nonverbal communication helps the nurse evaluate the need for pain relief in clients who may not directly communicate their need for it or do not speak the prevailing language.
Nursing Interventions and Rationales
1. Provide general comfort measures.
Adjust the room temperature and light level according to the client’s preference. Reduce irritants such as wet underpads. Provide ice chips, Popsicles, or juices to relieve the client’s dry mouth. Avoid bumping or moving the bed. These general measures reduce outside irritants that could make it harder for the client to use childbirth preparation techniques and are themselves a source of discomfort. A comfortable environment is conducive to relaxation.
2. Encourage and assist the client in assuming comfortable positions.
Position changes promote comfort and help the fetus adapt to the size and shape of the client’s pelvis. An upright position, sitting, walking, or swaying with a partner may be most comfortable for the client in early labor and aids in contractions and descent through gravity. Leaning forward against a birthing ball or pelvic rocking between contractions may relieve tense back muscles.
3. Enforce bed rest as appropriate, but avoid the supine position.
If the client must remain in bed because of a situation such as her membranes have ruptured and the fetal head is not engaged, urge her to keep active within the limits of bed rest and not to lie on her back to avoid supine hypotension syndrome. Move bedclothes or monitor leads, if any are attached, as needed to allow her to be able to turn and remain active.
4. Promote the use of techniques learned in childbirth preparation.
Depending on the type of childbirth preparation the client and her support person have had, the method may include breathing exercises, distraction by focusing on an external object, acupressure, therapeutic touch, music therapy, guided imagery, self-hypnosis, or a combination of these methods.
5. Review learned breathing exercises with the client.
Even though the client conscientiously practiced breathing or focusing in a relaxed, fun setting of an antepartal class, the discomfort and stress of labor may make it easy for her to forget what she learned. As necessary, review previously learned breathing exercises with her. Urge her to begin using these early in labor, before contractions become so strong, so she gains confidence that they can effectively diminish pain. If the client has had no prior training in breathing exercises, sit with her and teach her a simple breathing pattern, so she can begin to utilize this to relieve some of her pain.
6. Assist the client experiencing signs of hyperventilation.
If the client has signs of hyperventilations (dizziness, numbness or tingling sensations, spasms of hands and feet), have her breathe into her cupped hands, a small bag, or a washcloth placed over her mouth and nose. Hyperventilation often occurs when the client uses rapid breathing patterns because she exhales too much carbon dioxide. These measures help her to conserve carbon dioxide and rebreathe it to correct for excess loss.
7. Explain to the client and her partner how the labor progresses.
Knowing that her efforts are having the desired results gives her courage and helps her to tolerate pain. Be certain to explain the characteristics of contractions and reinstruct them as necessary. Do not assume the client is aware of this simply because she is experiencing the contractions. Sometimes, knowing can help the client tolerate the pain even as it increases in intensity.
8. Teach the client and her support person about the benefits of massage.
Massage is another pain relief method that can be taught to a client and her support person during labor. This may be especially useful if the client is experiencing back pain because rubbing or massaging the sacral area often alleviates that. A firm massage on her shoulders can provide a relaxing distraction from the sensation of internal pressure and pain.
9. Observe for a full bladder every one to two hours or more.
If the client receives large amounts of oral or intravenous fluids, a full bladder may be a source of discomfort and can prolong labor by inhibiting fetal descent. It may cause pain that lingers after epidural analgesia is begun.
10. Allow the client to decide if she needs pharmacological relief or not.
Helping the client decide if and when medication for pain relief should be used requires an in-depth understanding of the available drugs, their effects on the mother and the fetus, and their mechanism and duration of action. Many clients come into labor wishing to avoid drugs entirely. Once in labor, they may change their minds but hesitate to say so, especially if their partners also believe a birth without the use of drugs is ideal. Maintain a supportive presence to help the client make the best decision for herself and her baby.
11. Assist in administering pharmacological relief for the client.
All obstetric anesthesia must be supervised by a registered nurse who is prepared to manage unexpected responses in the mother or the newborn. The client should be questioned closely about allergies to foods, drugs, and latex to identify pain relief measures that may not be advisable. She should be questioned about her preferences for pain relief.
Precipitous Labor
Precipitous labor is a form of labor in which all three stages of labor are completed within less than three hours (Awe et al., 2021). Such rapid labor is likely to occur with grand multiparity, or it may occur after induction of labor by oxytocin. Contractions can be so forceful they lead to premature separation of the placenta or lacerations of the perineum, placing the client at risk for bleeding. It also poses a risk to the fetus because subdural hemorrhage may result from the rapid release of pressure on the head. Precipitous labor can be predicted from a labor graph if, during the active phase of dilatation, the rate is greater than 5 cm/hr (1 cm every 12 minutes) in a nullipara or 10 cm/hr (1 cm every 6 minutes) in a multipara.
Nursing care plans for precipitous labor
The nursing care for clients with precipitous labor revolves around promoting maternal and fetal well-being, preventing complications, and providing a safe delivery. Here are four nursing care plans and nursing diagnosis for precipitous labor:
Risk for Deficient Fluid Volume
Trauma-related bleeding can be due to lacerations. If the client’s tissues do not yield easily to powerful contractions, she may have a uterine rupture, cervical lacerations, or hematomas. Cervical and vaginal tears may develop as a result of the natural processes of delivery or the forceful contractions during precipitous labor. They may not be noted until excessive postpartum vaginal bleeding prompts lower genital tract examination, including examination for vaginal and vulvar hematomas (Voros & Pappa, 2020).
Nursing Diagnosis
- Risk for Deficient Fluid Volume
Risk factors
- Loss of fluids through normal routes
- Forceful contractions
- Premature separation of the placenta
Possibly evidenced by
- Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes
- The client will identify individual risk factors and appropriate interventions.
- The client will demonstrate behaviors or lifestyle changes to prevent the development of fluid volume deficits.
Nursing Assessment and Rationales
1. Note the client’s level of consciousness and mentation.
Blood flow to the nonessential organs gradually stops to make more blood available for vital organs, specifically the heart and brain. As blood loss continues, flow to the brain decreases, resulting in mental changes, such as anxiety, confusion, restlessness, and lethargy.
2. Measure and record the intake and output balance.
Accurate documentation helps identify fluid losses and replacement needs and influences the choice of interventions. With slow bleeding, the client develops these symptoms over a period of hours; the end result of continued seepage, however, can be as life-threatening as a sudden profuse loss of blood. As blood flow to the kidneys decreases, they respond by conserving fluid. Urine output decreases and eventually stops.
3. Monitor vital signs.
Assess vital signs every 15 minutes until stable. Blood loss from a laceration or hematoma can be significant, even though it is less obvious. The body initially responds to a reduction in blood volume with increased heart and respiratory rate. Tachycardia is usually the first sign of inadequate blood volume. The first blood pressure change is a narrow pulse pressure. The blood pressure continues falling and eventually cannot be detected.
4. Assess for the presence of lacerations or hematomas. Inspect characteristics of blood.
When the amount and character of the lochia are normal and the uterus is firm, but signs of hypovolemia are still evident, the cause may be a large hematoma. Excessive bright red bleeding despite a firm fundus may indicate cervical or vaginal laceration.
5. Monitor skin temperature and palpate peripheral pulses.
Cool or clammy skin and/or weak pulses indicate decreased peripheral circulation and the need for additional fluid replacement.
6. Observe the client for early symptoms of shock.
The client should be observed for early signs of shock, such as tachycardia, pallor, cold and clammy hands, and decreased urine output. Reduced blood pressure may be a late sign of hypovolemic shock.
Nursing Interventions and Rationales
1. Encourage the client to resume oral intake gradually.
Increased intake of oral fluids within the provider’s advice helps replenish fluid losses. If the client underwent cesarean birth due to precipitous labor, provide clear liquids in small amounts to reduce the risk of gastric irritation and vomiting to minimize fluid loss.
2. Weigh the client’s perineal pads to measure blood loss.
It is difficult to estimate the amount of blood a postpartal client is losing because it is difficult to estimate the amount of blood it takes to saturate a perineal pad. Be certain that when you are counting perineal pads, you differentiate between saturated and used. Weighing perineal pads before and after use and then subtracting the difference is an accurate technique to measure vaginal discharge; 1 g of weight is comparable to 1 ml of blood volume.
3. Apply an ice pack to the perineal area for hematomas.
Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually, a hematoma is absorbed over the next three or four days.
4. Be calm and advise the client to remain calm, too, and assure her of the baby’s condition.
The client is not always aware of what is happening at this point, but she quickly senses something is seriously wrong. Try to maintain an air of calm and assure her of the baby’s condition and inform her about the need to stay in the birthing room a little longer than expected while the healthcare provider places sutures or packs.
5. Administer blood and blood products as indicated.
Hypovolemic shock is treated with packed red blood cells and other appropriate blood products. Transfusion should keep up with blood loss, with early activation of a protocol for large volume transfusion in clients with heavy bleeding (Awe et al., 2021).
6. Administer IV fluids as prescribed.
Provide intravenous fluids to maintain the circulating volume and to replace fluids. Intravenous infusions of crystalloids and colloids should be obligatory apart from previously mentioned drugs (Feduniw et al., 2020).
7. Administer medications and anesthetics as indicated.
Tranexamic acid, a clot-stabilizing medication, may be used to reduce bleeding and blood transfusions in low-risk women. Tranexamic acid was effective in reducing the rate of hemorrhage, especially if administered within three hours after labor (Feduniw et al., 2020). If the cervical laceration appears to be extensive or difficult to repair, it may be necessary for the client to be given a regional anesthetic to relax the uterine muscle and prevent pain. Administer a mild analgesic as prescribed for pain relief if hematomas are present.
8. Insert an indwelling Foley catheter, as indicated.
Place an indwelling Foley catheter to assess urine output, which reflects kidney function. An indwelling catheter may also be placed following the repair because the packing causes such pressure on the urethra that it can interfere with voiding.
9. Assist in the surgical repair of lacerations.
Perineal lacerations are sutured and treated the same as an episiotomy repair. Unfortunately, vaginal tissue is friable, making vaginal lacerations difficult to suture. A balloon tapenade similar to the type used with uterine bleeding may be effective if suturing does not achieve hemostasis. The repair of a cervical laceration usually requires sutures and can be difficult because if the bleeding is intense, this obstructs visualization of the area.
10. Prepare the client for the incision of a hematoma.
If the hematoma is large when discovered or continues to increase in size, the client may have to be returned to the birthing room to have the site incised and the bleeding vessel ligated under local anesthesia.
Anxiety
Women who experience precipitous labor may have panic responses about the possibility of not getting to the hospital in time or not having their healthcare provider present. Although they are relieved after birth, they may require continued support and reassurance concerning the deviation from their expected experience.
Nursing Diagnosis
- Anxiety
May be related to
- Situational crisis
- Threat to self and/or fetus
- Interpersonal tranmission
Possibly evidenced by
- Increased tension
- Fearful
- Restless, jittery
- Sympathetic stimulation
Desired Outcomes
- The client will use breathing and relaxation techniques effectively
- The client will cooperate with necessary preparations for a rapid delivery
- The client will follow directions and/or actively participate in the delivery process
Nursing Assessment and Rationales
1. Assess the client’s level of anxiety.
Anxiety levels of pregnant women increase during labor and make it difficult to relax. Additionally, anxiety can cause tension in pelvic floor muscles, which play a key role in labor, and this muscle tension increases pain. Excessive pain may lead to increased fear, making the client more sensitive to pain. This is when the concept of fear-tension-pain arises. The State Anxiety Inventory (SAI) can be used to measure the anxiety levels of the client during precipitous labor (Cicek & Basar, 2017).
2. Monitor physiological responses and vital signs.
Physical responses such as dizziness, headache, nausea, irritability, or restlessness may indicate the degree of fear the client is experiencing. Tachypnea and palpitations may be evident during the measurement of vital signs. The client may feel out of control of the situation or reach a state of panic. However, these symptoms may also be related to a state of hypovolemic shock, therefore, the client should be observed carefully.
Nursing Interventions and Rationales
1. Maintain a calm, deliberate manner. Offer clear and concise instructions. Provide explanations.
An emergency or extremely rapid delivery occurring out of the hospital or in a hospital setting without the presence of a clinician can be extremely anxiety-provoking for the client or couple, who had anticipated an orderly progression through labor and delivery. When the actual birth event is not in keeping with their expectations, reactions may include hostility, fear, and disappointment. The composure of the nurse and her reassurance help prevent or alleviate anxiety.
2. Acknowledge that this is a fearful situation and that others have expressed similar fears.
When the client is expressing her own fear, the validation that these feelings are normal can help the client feel less isolated and understood. This may help relieve the panic that occurs with a precipitous birth and help the client cope through forceful contractions.
3. Provide a quiet environment and privacy within the parameters of the situation—position the client for optimal comfort.
This reduces distractions and discomfort, allowing the client to focus and helps reduce “contagious” anxiety of onlookers in or out of hospital delivery, and supports modesty. Removing the client from outside stressors may also promote relaxation and enhance her coping skills. Assist the client to lie on her left side until it is established that the FHR is stable.
4. Encourage partner or SO to remain with the client, and provide support and assistance as needed.
Allowing full participation by an SO enhances self-esteem, furthers cohesion of the family unit, reduces anxiety, and provides assistance for the professional. Be certain to admit the client’s support person to the birthing area along with the client and encourage them to remain throughout the birth as appropriate because having someone familiar with her during labor helps counteract the sensation that everything is new and unexpected.
5. Remain with the client. Provide ongoing information regarding labor progression and anticipated delivery.
Effective support can make a difference in helping the client feel in control. There is no substitute for personal touch and contact as a way to provide support during labor (unless the client does not want to be touched). Patting an arm while telling the client about her progress in labor or wiping her forehead with a cool cloth are required methods of conveying support and producing several benefits. Additionally, frequent updates about the client’s progress help to alleviate anxiety.
6. Respect and promote the support person.
Acquaint the support person with the physical layout of the birthing room. Offer praise not only to the client but also to the support person as well because watching a birth is often as totally a new experience for this person as for the client. Relieve the support person as necessary so they can take a break or get something to eat or visit with older children.
7. Encourage appropriate coping or relaxation techniques.
Relaxation keeps the abdominal wall from becoming tense, allowing the uterus to rise with contractions without pressing against the hard abdominal wall. Asking the client to bring her favorite music or aromatherapy with her can help with relaxation. The favorable, but not conclusive, effects of inhalation aromatherapy on stress management in healthy adults have been proven. A systematic review indicated the positive anxiolytic effects of aromatherapy in people with anxiety symptoms (Tabatabaeichehr & Mortazavi, 2020).
8. Support the client’s pain management needs.
Many women plan on using nonpharmacologic measures such as hydrotherapy, position changes, or acupuncture during labor. Other women want pharmacologic help in labor. Support whichever decision the client has made coming into labor and any change she decides on as labor progresses. Part of being in control is knowing your options and feeling free to elect the one most appropriate at that time.
9. Arrange for services of medical or nursing staff as soon as possible. Inform the client that help has been requested.
The arrival of assistance helps the client or couple feel less anxious and more secure. Support needs to come from healthcare personnel as well as the client’s individual support person.
10. Conduct delivery in a calm manner; provide an ongoing explanation.
This helps the client remain calm and cooperate with instructions. If the fetus is visibly emerging (crowning), there is no time to transfer and the client should be delivered there and then. If the client is fully dilated and effaced, delivery should probably occur immediately unless the labor and delivery unit is close by. Any scenario requires clinical judgment and consideration, which also requires the healthcare personnel to remain calm and in control (Borhart & Voss, 2019).
11. Place newborn on maternal abdomen once newborn respirations are established. Allow the partner to hold the infant.
It helps promote bonding and establishes a positive feeling about the experience. Dry the infant well with a warmed towel, wrap him or her in a sterile blanket, and cover the head with a wrapped towel or cap.
12. Administer sedation as appropriate.
Sedation may help slow labor progress and allow the client to regain control. Narcotics may be given during labor because of their potent effect, but they may cause maternal respiratory depression as well as fetal CNS depression and should be used cautiously. Narcotics may be given early to slow the labor progress.
Risk for Infection
Precipitous labor may cause accidental out-of-hospital deliveries, which constitute <1% of all live births in most developed countries. These emergency births differ from planned home births and in-hospital births because they usually happen accidentally at home or en route to the hospital. The unpredictable characteristics of out-of-hospital deliveries mean that neonates are born in inappropriate locations without medical professionals on standby. Being born in contaminated places and suboptimal cord practices may increase the risk of infection (Chang et al., 2022). Additionally, the force of a sudden birth may leave the client with perineal and cervical lacerations that are also breeding grounds for infection if not managed properly.
Nursing Diagnosis
- Risk for Infection
Risk factors
- Inadequate primary defense (e.g. skin)
- Inadequate secondary defense (e.g. decreased hemoglobin)
- Premature rupture of membranes
Possibly evidenced by
- Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes
- The client will be afebrile and free from leukopenia.
- The client will verbalize understanding of individual risk factors.
- The client will identify interventions to prevent or reduce infection.
- The client will achieve timely wound healing.
Nursing Assessment and Rationales
1. Observe for localized signs of infection at the wound.
Inspect incision and dressings and note characteristics of drainage from wound and presence of erythema. This provides for early detection of developing infectious processes and timely intervention.
2. Monitor the client’s vital signs.
Precipitous labor predisposes the client to hemorrhage. The blood pressure, pulse rate, and respirations are checked to identify a rising pulse rate or falling blood pressure, and an oral temperature is taken and reported if it is 38℃ (100.4℉) or higher or if the client has a higher risk for infection. Take the client’s temperature every two to four hours or more if it is elevated.
3. Assess the infant for signs and symptoms of infection.
Some signs of sepsis include a low temperature, lethargy or irritability, poor feeding, and respiratory distress. Maternal infection and complications during labor can predispose the neonate to sepsis.
Nursing Interventions and Rationales
1. Stress proper hand hygiene by all caregivers between therapies and clients.
Hand hygiene practices reduce the risk of endogenous organism transmission from the client and exogenous organism transmission from other clients, the health care team, and the environment (Bashaw & Keister, 2018).
2. Recommend routine or preoperative scrubs or showers when indicated
Current evidence supports surgical hand scrubs (preferably brushless) and double-gloving. Brushless hand scrubbing techniques reduce the instance of microscopic cuts on the dermis and the excessive defoliation of skin cells while cleansing the skin surface of pathogens (Bashaw & Keister, 2018).
3. Maintain sterile technique for all invasive procedures.
To help prevent infection, any articles such as gloves or instruments that are introduced into the birth canal or cutting the umbilical cord should be sterile. In addition, adherence to standard infection precautions is essential.
4. Assist the client in maintaining good perineal hygiene.
Good hygiene reduces the possibility of introducing bacteria into the birth canal. Instruct the client to wipe from front to back to avoid bringing bacteria from the rectal area to the perineal area.
5. Insert an indwelling (Foley) catheter as indicated.
Vaginal lacerations are difficult to suture because of the friable vaginal tissue. Some oozing often occurs after a vaginal repair, so the vagina may be packed to maintain pressure on the suture line. An indwelling catheter may be placed following the repair because the packing causes such pressure on the urethra that it can interfere with voiding and predispose the client to urinary tract infection. However, an aseptic technique should be ensured during insertion to avoid introducing the cervical canal to infection.
6. Review laboratory studies for systemic infections.
Increased WBC count may indicate an ongoing infection. The presence of local or systemic infection may contraindicate or adversely affect any planned surgical procedure and/or anesthesia.
7. Obtain specimens for cultures and Gram stain.
Immediate identification of the infective organism type by Gram stain allows prompt treatment, whereas more specific identification by cultures can be obtained in hours or days.
8. Administer antibiotics and note the client’s response.
In the United States and Canada, the current approach to treating early-onset neonatal sepsis includes the administration of combined IV aminoglycoside and expanded-spectrum penicillin antibiotic therapy. The specific antibiotics to be used are chosen on the basis of maternal history and prevalent trends of organism colonization and antibiotic susceptibility in individual hospitals (Gollehon & Aslam, 2019).
9. Emphasize the necessity of taking antibiotics as directed.
Premature discontinuation of treatment when the client begins to feel well may result in the return of infection and the potentiation of drug-resistant strains. Antibiotic resistance is increasing in the general population worldwide, and infections are rising in neonatal units due to multi-drug and extensively multidrug-resistant bacteriuria, posing a significant treatment dilemma (Gollehon & Aslam, 2019).
10. Discuss the importance of not taking antibiotics or using leftover drugs unless specifically instructed by the healthcare provider.
Inappropriate use can lead to the development of drug-resistant strains or secondary infections. Antibiotics are normally continued until the septic process and surgical interventions have controlled the source of infection. Ordinarily, clients are treated for approximately two weeks, although the duration may vary according to the infection’s source, site, and severity (Bokhari & Stuart, 2019).
Risk for Injury
Precipitous labor is defined as the expulsion of the fetus within three hours of the start of contractions. Few studies have found that precipitous labor is harmful to both the mother and the newborn. Precipitous labor, which is most commonly associated with placental abruption and induction of labor, is a significant risk factor for maternal complications. Maternal morbidities reported included extensive birth canal laceration, uterine rupture, placental retention, the need for revision of the uterine cavity, postpartum hemorrhage, and blood transfusions (Ghasemi et al., 2021). Uterine rupture, which is a ripping of the uterine wall, commonly occurs in the lower segment of the uterus and would not only have short-term complications but ends in long-term complications, maternal mortality, and perinatal mortality (Getahun et al., 2018).
Nursing Diagnosis
- Risk for Injury
Risk factors
- Maternal age
- Multiparity
- Placental abruption
- Forceful contractions
- Spontaneous vaginal delivery
Possibly evidenced by
- Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes
- The client will be free of complications associated with precipitous labor.
- The client will identify individual risk factors.
- The client will be able to enhance safety and use resources appropriately.
Nursing Assessment and Rationales
1. Assess the client’s progress in labor.
Precipitous labor is an extremely rapid process of labor and delivery. It is generally caused by low resistance to the birth canal, strong, frequent contractions, unawareness of uterine contractions, and possibly a combination of these (Najam et al., 2021). Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset.
2. Monitor the client’s vital signs.
The initial assessment is for hemodynamic stability for clients with suspected uterine rupture. Blood pressure and heart rate should be obtained to assess for hypotension and tachycardia. Common symptoms of hypotension include lightheadedness, dizziness, nausea, vomiting, and anxiety (Togioka & Tonismae, 2020).
3. Monitor for hematuria and oliguria.
Oliguria and hematuria after traumatic childbirth increase the likelihood of bladder rupture. The lower urinary tract’s anatomic proximity to the reproductive tract predisposes it to an iatrogenic injury (Ghasemi et al., 2021).
4. Assess for signs and symptoms of uterine rupture.
The client may have no symptoms, or she may have sudden onset of severe signs and symptoms such as shock, abdominal pain, pain in the chest between the scapulae during inspiration, cessation of contractions, abnormal or absent fetal heart tones, and palpation of the fetus outside of the uterus.
5. Monitor the fetal heart rate closely.
When uterine rupture occurs, fetal death will follow unless immediate cesarean birth can be accomplished. With complete uterine rupture, fetal heart sounds may start to fade initially and then are absent. If the rupture is incomplete, fetal heart sounds may reveal fetal distress.
Nursing Interventions and Rationales
1. Avoid applying pressure when during the delivery.
As soon as the head of the fetus is prominent at the vaginal opening, one technique to help the fetus achieve extension and allow the smallest head diameter to present is for the care provider to place a sterile towel over the rectum and press forward on the fetal chin while the other hand presses down on the occiput, called Ritgen maneuver. However, pressure should never be applied to the fundus of the uterus to affect birth because uterine rupture could occur. This practice has not been shown to shorten the second stage of labor, and it increases the risk of uterine rupture (Togioka & Tonismae, 2020).
2. Alleviate the client’s and her partner’s anxiety.
Measures to alleviate anxiety in the client and her partner are necessary as emergency measures are being initiated. Stay calm while preparing the client for an emergency cesarean birth and teach her breathing techniques that would help calm her down. Allow the partner to sit and breathe with the client while preparations are being made.
3. Administer intravenous fluids as indicated.
Administer emergency fluid replacement therapy as prescribed. A large-bore intravenous line should be in place. If large-bore intravenous access cannot be obtained, central venous access with a large bore sheath introducer should be considered. Initial resuscitation is often provided by infusing Lactated Ringer’s electrolyte solution (Togioka & Tonismae, 2020).
4. Administer blood and blood products as prescribed.
Brisk and large volume blood loss should prompt early blood transfusion. A second large-bore intravenous line should also be in place, and blood should be ordered (Togioka & Tonismae, 2020). The client’s prognosis depends on the extent of the rupture and the blood loss.
5. Prepare the client for a possible laparotomy or cesarean birth.
Prepare the client for a possible laparotomy as an emergency measure to control bleeding and birth the fetus. The viability of the fetus depends on the extent of the rupture and the time elapsed between rupture and abdominal extraction. The initial treatment step can also be an emergent cesarean birth- with or without an exploratory laparotomy. A delay n delivery, resuscitation, or surgery increases the maternal and fetal risk (Togioka & Tonismae, 2020). Hysterectomy or the removal of the uterus is likely to be required for an extensive tear. Smaller tears may be surgically repaired.
6. Provide emotional support for the client and her partner.
Most women are advised not to conceive again after a rupture of the uterus unless the rupture occurred in the inactive lower segment. At the time of the rupture, the primary care provider, with consent, may perform a cesarean hysterectomy or tubal ligation, both of which will result in loss of childbearing ability. The client may have difficulty giving her consent for a hysterectomy because it is unknown whether her present baby will live. Allow them time to express their emotions without feeling threatened.
7. Refer the client to clergy or counselors.
If the fetus dies and the client will no longer be able to have children, they may become almost immediately angry that the rupture occurred. They may want to plan a funeral because, oftentimes, the baby is full term. Utilize the clergy or counselors as needed to help the couple begin the coping process. They are not only grieving for the loss of a child but also the cost of unexpected surgery and perhaps the loss of fertility.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her baby:
- Abortion (Termination of Pregnancy) | 8 Care Plans
- Cervical Insufficiency (Premature Dilation of the Cervix) | 4 Care Plans
- Cesarean Birth | 11 Care Plans
- Cleft Palate and Cleft Lip | 7 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans
- Hyperbilirubinemia (Jaundice) | 4 Care Plans
- Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor | 45 Care Plans
- Neonatal Sepsis | 8 Care Plans
- Perinatal Loss (Miscarriage, Stillbirth) | 6 Care Plans
- Placental Abruption | 4 Care Plans
- Placenta Previa | 4 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 5 Care Plans
- Prenatal Hemorrhage (Bleeding in Pregnancy) | 9 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans
- Prenatal Infection | 5 Care Plans
- Preterm Labor | 7 Care Plans
- Puerperal & Postpartum Infections | 5 Care Plans
- Substance Abuse in Pregnancy | 9 Care Plans
References and Sources
Journal readings, books, articles, and other resources you can use to further your reading about labor.
- Abedian, S., Abedi, P., Jahanfar, S., Iravani, M., & Zahedian, M. (2020, September). The effect of Lavender on pain and healing of episiotomy: A systematic review. Complementary Therapies in Medicine, 53.
- 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.
- Akin, B., & Saydam, B. K. (2020, September). The Effect Of Labor Dance On Perceived Labor Pain, Birth Satisfaction, And Neonatal Outcomes. Explore, 16(5), 310-317.
- Al Sabati, S. Y., & Mousa, O. (2019, June). Effect of Early Initiation of Breastfeeding on the Uterine Consistency and the Amount of Vaginal Blood Loss during Early Postpartum Period. Nursing & Primary Care, 3(3).
- Alhafez, L., & Berghella, V. (2020). Evidence-based Labor Management: First stage of labor (Part 3). American Journal of Obstetrics & Gynecology.
- Antsaklis, P., Papamichail, M., Theodora, M., Syndos, M., Daskalakis, G., & Loutradis, D. (2020, January). Natural Methods to Assist Delivery during the Second Stage of Labour: Part II: Timing and Type of Pushing. Obstetrics and Gynecology International Journal, 19(1), 11-26.
- Apolonio, F. R., Pontes, C. M., Albuquerque Perrelli, J. G., de Sousa, S. d. M. A., Gomes Mendes, R. C. M., Mangueira, S. d. O., & Linhares, F. M. P. (2021). Content validity of the nursing diagnosis powerlessness in women during natural childbirth. Revista Da Escola De Enfermagem.
- Armstrong, S., Fernando, R., Columb, M., & Jones, T. (2011, August). Cardiac Index in Term Pregnant Women in the Sitting, Lateral, and Supine Positions: An Observational, Crossover Study. International Anesthesia Research Society, 113(2).
- Awe, J., Odesanya, O., Durotoye, A., Bashir, N., & Morebise, O. (2021). Understanding the Factors Surrounding Precipitous Labor: A Study into Associated Causes, Risk Factors, and Complications. Asian Research Journal of Gynaecology and Obstetrics, 6(4), 30-37.
- Bank, T. C., Nuss, E., Subedi, K., Hoffman, M. K., & Sciscione, A. (2022, February). Outcomes associated with antibiotic administration for isolated maternal fever in labor. American Journal of Obstetrics and Gynecology, 226(2), 255.e1-255.e7.
- Bashaw, M. A., & Keister, K. J. (2018, December 28). Perioperative Strategies for Surgical Site Infection Prevention. AORN Journal, 109(1), 68-78.
- Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2013;30(4): CD005123.
- Berghella, V., & Di Mascio, D. (2020, February 1). Evidence-based labor management: before labor (Part 1). American Journal of Obstetrics and Gynecology, 2(1).
- Berta, M., Lindgren, H., Christensson, K., Mekonnen, S., & Adefris, M. (2019, December 4). Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis. BMC Pregnancy and Childbirth, 19(466).
- Blanc-Petitjean, P., Dupont, C., Carbonne, B., Salome, M., Goffinet, F., & Le Ray, C. (2021, September 14). Methods of induction of labor and women’s experience: a population-based cohort study with mediation analyses. BMC Pregnancy and Childbirth, 21(621).
- Bokhari, A. M., & Stuart, M. (2019, February 5). Bacterial Sepsis: Practice Essentials, Background, Etiology. Medscape Reference. Retrieved September 6, 2022, from
- Borhart, J., & Voss, K. (2019, May 01). Precipitous Labor and Emergency Department Delivery. Emergency Medicine Clinics, 37(2), 265-276.
- Bouvet, L., Schulz, T., Piana, F., Desgranges, F.-P., & Chassard, D. (2022, February 25). Pregnancy and Labor Epidural Effects on Gastric Emptying: A Prospective Comparative Study. Anesthesiology, 136(4), 542-550.
- Breman, R. B., & Neerland, C. (2022). Nursing Support During Latent Phase Labor: A Scoping Review | CE Article | NursingCenter. Lippincott Nursing Center. Retrieved February 11, 2022.
- Buxton, H., Flynn, E., Oluyinka, O., Cumming, O., Mills, J. E., Shiras, T., Sara, S., & Dreibelbis, R. (2019, April 11). Hygiene During Childbirth: An Observational Study to Understand Infection Risk in Healthcare Facilities in Kogi and Ebonyi States, Nigeria. International Journal of Environmental Research and Public Health, 16(7), 1301.
- Chang, C.-J., Chi, H., Jim, W.-T., Chiu, N.-C., & Chang, L. (2022, February 10). Risk of infection in neonates born in accidental out-of-hospital deliveries. PLOS One, 17(2).
- Chen, C.-C., & Lee, J.-F. (2020, April 1). Effectiveness of the doula program in Northern Taiwan. Tzu Chi Medical Journal, 32(4), 373-379.
- Chooi, C., Cox, J. J., Lumb, R. S., Middleton, P., Chemali, M., Emmett, R. S., Simmons, S. W., & Cyna, A. M. (2017). Techniques for preventing hypotension during spinal anesthesia for cesarean section. Cochrane Database of Systematic Reviews.
- Cicek, S., & Basar, F. (2017, November). The effects of breathing techniques training on the duration of labor and anxiety levels of pregnant women. Complementary Therapies in Clinical Practice, 29, 213-219.
- Cohen, J., Vaiman, D., Sibai, B. M., & Haddad, B. (2015). Blood pressure changes during the first stage of labor and for the prediction of early postpartum preeclampsia: a prospective study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 187, 103-107.
- Delgado, A., da Nobrega, P., de Oliveira, F., de Goes, P. S. A., & Lemos, A. (2019, January 19). Development and analysis of measurement properties of the ‘‘maternal perception of childbirth fatigue questionnaire’’ (MCFQ). Brazilian Journal of Physical Therapy, 23(2), 125-131.
- Dominguez, M. G., Cortabitarte, J. R., & Garcia, J. L. (2017). Clinical Management of Delivery in Pregnant Woman with Idiopathic Intracranial Hypertension. ARC Journal of Gynecology and Obstetrics, 2(1), 4-6.
- Eggermont, K., Beeckman, D., Van Hecke, A., & Delbaere, I. (2017, August). Needs of fathers during labour and childbirth: A cross-sectional study. Women and Birth, 30(4).
- Erkaya, R., Karabulutlu, Ö., & Calik, K. Y. (2017, February 21). Defining Childbirth Fear And Anxiety Levels In Pregnant Women. Procedia- Social and Behavioral Sciences, 237, 1045-1052.
- Feduniw, S., Warzecha, D., Szymusik, I., & Wielgos, M. (2020). Epidemiology, prevention and management of early postpartum hemorrhage — a systematic review. Ginekologia Polska, 91(1), 38-44.
- Getahun, W. T., Solomon, A. A., Kassie, F. Y., Kasaye, H. K., & Denekew, H. T. (2018, December 04). Uterine rupture among mothers admitted for obstetrics care and associated factors in referral hospitals of Amhara regional state, institution-based cross-sectional study, Northern Ethiopia, 2013-2017. PLOS One, 13(12).
- Ghasemi, N., Mehrnoush, V., Darsareh, F., & Jahromi, M. S. (2021). Combined cervical laceration and bladder rupture: a case report of an unusual complication of precipitated labor. International Journal of Clinical Images and Medical Reviews, 1(1).
- Gollehon, N. S., & Aslam, M. (2019, June 13). Neonatal Sepsis: Background, Pathophysiology, Etiology. Medscape Reference. Retrieved September 6, 2022, from
- Grobman, W. A., Berghella, V., Driscoll, D. A., Jauniaux, E. R. M., & Galan, H. L. (2018). Gabbe’s Obstetrics Essentials: Normal and Problem Pregnancies (W. A. Grobman, V. Berghella, D. A. Driscoll, M. B. Landon, E. R. M. Jauniaux, & H. L. Galan, Eds.). Elsevier.
- Guittier, M., Othenin-Girard, V., de Gasquet, B., Irion, O., & Boulvain, M. (2016, January 24). Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial. BJOG: an International Journal of Obstetrics & Gynecology, 123(13), 2199-2207.
- Hanson, L., Simkin, P., & Ancheta, R. (2017). The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia. Wiley.
- Hassan, H. E., Gamel, W. M. A., & Genedy, A. S. E. (2021, March 15). Spontaneous Versus Directed Pushing Technique: Maternal and Neonatal Outcomes: A Comparative Study in Northern Upper Egypt. International Journal of Studies in Nursing, 6(1).
- Hedgcorth, M. (2021, August). Bladder Management Post Epidural Anesthesia: Impact on the Second Stage of Labor [Dissertation]. UMSL Graduate Works.
- Hu, X., & Zhang, L. (2021, August 11). Uteroplacental Circulation in Normal Pregnancy and Preeclampsia: Functional Adaptation and Maladaptation. International Journal of Molecular Sciences, 22(16).
- Huang, C.-Y., Luo, B.-R., & Hu, J. (2020, June 5). Investigation on the status of oral intake management measures during labor in China. Medicine (Baltimore), 99(23).
- Jay, A., Thomas, H., & Brooks, F. (2017, September 14). In labor or limbo? The experiences of women undergoing induction of labor in hospital: Findings of a qualitative study. Birth, 45(1), 64-70.
- Junge, C., von Soest, T., Weidner, K., Seidler, A., Eberhard-Gran, M., & Garthus-Niegel, S. (2018, April 6). Labor pain in women with and without severe fear of childbirth: A population-based, longitudinal study. Birth, 45(4), 469-477.
- Kuberan, A., Jain, K., Bagga, R., & Makkar, J.K. (2018, March 26). The effect of spinal hyperbaric bupivacaine–fentanyl or hyperbaric bupivacaine on uterine tone and fetal heart rate in laboring women: a randomized controlled study. Anaesthesia, 73(7), 832-838.
- Kwon, W.-A., Kim, S. H., Kim, S., Joung, J. Y., Chung, J., Lee, K. H., & Seo, H. K. (2015, May 15). Changes in Urination According to the Sound of Running Water Using a Mobile Phone Application. PLoS One, 10(5).
- Lavender, T., & Bernitz, S. (2020, August). Use of the partograph – Current thinking. Best Practice & Research Clinical Obstetrics & Gynaecology, 67, 33-43.
- 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.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- 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, December 02). Efficacy of “optimal hydration” during labor: HYDRATA study protocol for a randomized clinical trial. Research in Nursing & Health, 43(1), 8-16.
- Lothian, J. A. (2004, Summer). Do Not Disturb: The Importance of Privacy in Labor. The Journal of Perinatal Education, 13(3), 4-6.
- Mendez-Figueroa, H., Hoffman, M. K., Grantz, K. L., Blackwell, S. C., Reddy, U. M., & Chauhan, S. P. (2021, July). Shoulder dystocia and composite adverse outcomes for the maternal-neonatal dyad. American Journal of Obstetrics & Gynecology, 3(4).
- Moorhouse, M. F., Doenges, M. E., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Muñoz, M., Stensballe, J., Ducloy-Bouthors, A.-S., Bonnet, M.-P., De Robertis, E., Fornet, I., Goffinet, F., Hofer, S., Holzgreve, W., Manrique, S., Nizard, J., Christory, F., Samama, C.-M., & Hardy, J.-F. (2019, March). Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion, 17(2), 112-136.
- Murtiningsih, S. T. A. (2018). Difference Effect of The Combination of Lavender Aromatherapy and Effleurage with Breathing Relaxation on Pain Intensity During Labor among Primiparas. Journal of Maternity Care and Reproductive Health, 1(1).
- Musleh, J., & Al Qahtani, N. (2017, December 14). Group B Streptococcus Colonization among Saudi Women During Labor. Saudi Journal of Medicine and Medical Sciences, 6(1), 18-22.
- Nair, P., Chaudhary, A., & Jaiswal, A. (2020, October). Study of Maternal and Fetal Outcome Following Term Prelabour Rupture of Membrane in a Peri-Urban Tertiary Care Centre. Indian Journal of Forensic Medicine & Toxicology, 14(4), 6402-6407.
- Najam, S., Solangi, H. S., Naqvi, S. U. B., Hassan, S. I., Farzana, S., Malik, S., Sheikh, S., & Saeed, S. (2021, February). Precipitate Labour Frequency, Risk Factors and Complication in Patients Delivering at Dr Sulaiman Alhabib Hospital Sweidi. International Journal of Health Sciences and Research, 11(2).
- O’Leary, J. A. (Ed.). (2009). Shoulder Dystocia and Birth Injury: Prevention and Treatment. Humana Press.
- 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).
- Ozkan, S. A., Kadioglu, M., & Rathfisch, G. (2017, April). Restricting Oral Fluid and Food Intake during Labour: A Qualitative Analysis of Women’s Views. International Journal of Caring Sciences, 10(1).
- Pesic, M., Klican-Jaic, K., Djakovic, I., Muratovic, A., Kosec, A., & Turkovic, T. M. (2019). Impact of prepartal acupuncture on labor and delivery. Acta Medica Croatica, 73(Suppl. 1), 5-9.
- Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- R. B., Iobst, S., Paul, J., & Low, L. K. (2019, September/October). Clinicians’ Perspectives on Admission of Pregnant Women A Triad. The American Journal Of Maternal/Child Nursing, 44(5), 260-268.
- 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.
- Sanghavi, M., & Rutherford, J. D. (2014, September 16). Cardiovascular Physiology of Pregnancy. Circulation, 130(12).
- Savchenko, J., Lindqvist, P. G., & Wendel, S. B. (2020, December). External cephalic version for breech presentation: The guideline landscape and a quest for an optimal approach. European Journal of Obstetrics & Gynecology and Reproductive Biology, 255, 197-202.
- Shotan, A., Dacca, S., Shochat, M., Kazatsker, M., Blondheim, D. S., & Meisel, S. (2005). Fluid overload contributing to heart failure. Nephrology Dialysis Transplantation, 20(Suppl 7).
- Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Sisconeto de Freitas, S., Cabral, A. L., Costa Pinto, R. d. M., Resende, A. P. M., & Baldon, V. S. P. (2018, October 20). Effects of perineal preparation techniques on tissue extensibility and muscle strength: a pilot study. International Urogynecology Journal, 30, 951-957.
- Solehati, T., & Rustina, Y. (2015, June 22). Benson Relaxation Technique in Reducing Pain Intensity in Women After Cesarean Section. Anesthesia and Pain Medicine, 5(3).
- Sugden, A. (2006, March 14). How to assess epidural blockade. Perioperative Nursing, 102(11), 26.
- Sultan, P., & Segal, S. (2020, February). Epidural-Related Maternal Fever: Still a Hot Topic, But What Are the Burning Issues? Anesthesia & Analgesia, 130(2), 318-320.
- Tabatabaeichehr, M., & Mortazavi, H. (2020). The Effectiveness of Aromatherapy in the Management of Labor Pain and Anxiety: A Systematic Review. Ethiopian Journal of Health Sciences, 30(3).
- Tazeh kand, N. F., Moeini, A., Rastad, H., Eslami, B., Manouchehrian, N., & Sanatkar, M. (2015). The Effect of Dexamethasone on Nausea and Vomiting during Labor and Labor Pain in Parturients Undergoing Normal Vaginal Delivery. Archives of Anesthesiology and Critical Care, 1(4), 126-129.
- Togioka, B. M., & Tonismae, T. (2020, July 10). Uterine Rupture – Abstract. Europe PMC. Retrieved September 8, 2022.
- Tomimatsu, T., Kakigano, A., Mimura, K., Kanayama, T., Koyama, S., Fujita, S., Taniguchi, Y., Kanagawa, T., & Kimura, T. (2012, May 3). Maternal Hyperventilation During Labor Revisited: Its Effects on Fetal Oxygenation. Reproductive Sciences, 19(11).
- Tuncay, S., Kaplan, S., & Tekin, O. M. (2017, December 12). An Assessment of the Effects of Hydrotherapy During the Active Phase of Labor on the Labor Process and Parenting Behavior. Clinical Nursing Research.
- Voros, C., & Pappa, K. (2020). Post Partum Hemorrhage – Mini Review. HJOG, 19(3), 109-114.
- Wang, Y., Ying, H., Zhang, W., He, R., & Lin, J. (2020, October). Application of ultrasound-guided epidural catheter indwelling in painless labour. Technology & Innovation in Healthcare System, 70(10).
- 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.
- 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.
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- Yadollahi, P., Khalajinia, Z., & Khormaei, F. (2018). Cultural differences in Perception of labor pain without considering to painless Technique. Journal of Advanced Pharmacy Education & Research, 8(S2), 9-14.
Reviewed and updated by M. Belleza, R.N.
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