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. Show
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. 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: Labor Stage II: ExpulsionThe 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 PainPain 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced byThe common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesBelow are the nursing assessment for this labor nursing care plan. 1. Monitor and record pain from uterine activity with each contraction. 2. Identify the degree of discomfort and its sources. 3. Observe for perineal and rectal bulging, the opening of vaginal introitus, and changes in the fetal station. 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 anddisadvantages as appropriate. 5. Monitor maternal BP
and pulse and FHR. 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. 7. Monitor level of block per protocol. Nursing Interventions and RationalesThe following are the nursing interventions for this labor nursing care plan. 1. Provide information and support related to the progress of labor. 2. Provide comfort measures for a conducive environment. 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. 4. Encourage the client to relax all muscles and rest between contractions. 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. 6. Assist with reinforcement of medication via indwelling lumbar epidural
catheter when caput is visible. Monitor vital signs and adverse responses. 7. Assess bladder fullness. Catheterize between contractions if distension is noted and the client cannot void. 8. Position client in dorsal lithotomy position and assist with the administration of pudendal anesthetic. 9. Assist as needed
with the administration of local anesthetic just before episiotomy, if done. 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. 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. 3. Turn the client side
to side periodically during continuous infusions. 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. 5. Administer oxygen and increase plain IV fluid. If hypotension occurs, displace the uterus to the left and elevate the
legs. 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. Transcutaneous Electrical Nerve Stimulation 1. Encourage and assist client/couple with operating control knobs on battery-operated device. 2. Apply two pairs of electrodes on either side of the thoracic and sacral vertebrae. Complementary Therapy 1. Assist with
acupressure /acupuncture. 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. 2. Assist with general anesthesia (inhalation or IV administration). 3. Administer IV ranitidine or an oral antacid before the general anesthesia. Altered Cardiac OutputAs 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced byThe common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesThe following are the nursing assessment for this labor nursing care plan. 1. Monitor FHR after every contraction or bearing-down effort. 2. Monitor BP and pulse frequently (every 5–15 min). Note amount and concentration of urine output; test for albuminuria. 3. Monitor BP and pulse immediately after administration of anesthesia, and repeat until the client is stable. Nursing Interventions and RationalesHere 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. 2. Encourage client/couple to select laboring position that optimizes circulation, such as the lateral recumbent
position, Fowler’s position, or squatting. 3. Position the client in the lateral position during induction of neuraxial anesthesia. 4. Regulate IV infusion as indicated; monitor oxytocin administration, and decrease rate if necessary. 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesThe 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. 2. Assess FHR, with a fetoscope or fetal monitor, during and after each
contraction or pushing effort. 3. Determine fetal station, presentation, and position. Place the client on her side if the fetus is in an occiput posterior position. 4. Note short- and long-term FHR variability. 5. Monitor client for fruity
breath odor. 6. Monitor periodic changes in
FHR for severe, moderate, or prolonged decelerations. Note the presence of variable or late decelerations. 7. Assist as needed with intermittent fetal scalp sampling, if done. 8. Assist in obtaining umbilical cord gases. Nursing Interventions and RationalesHere 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. 2. Avoid placing the client in a dorsal recumbent position. 3. Assist partner in helping with verbal coaching of respirations. 4. Encourage the client to focus on an object/mental picture. 5. Encourage the client/couple to inhale and exhale every 10–20 seconds during bearing-down efforts. Monitor response to pushing efforts. 6. Have the client breathe into cupped hands or a small paper bag. 7. Monitor FHR electronically with internal
lead. If severe bradycardia, late decelerations, or prolonged variable decelerations appear: 8. Place the client in a lateral recumbent position; increase plain IV fluid. 9. Administer oxygen to the client. 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. Risk For Imbalanced Fluid VolumeLabor 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesHere 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). 2. Monitor temperature, as indicated. 3. Measure intake/output and urine-specific
gravity. Assess skin turgor and production of mucus. Note albuminuria. 4. Monitor BP and pulse every 15 min and more frequently during oxytocin infusion. 5. Assess the client’s hematocrit and hemoglobin level. 6. Assess for vomiting and diarrhea. Nursing Interventions and RationalesThe following are the nursing interventions for this labor nursing care plan. 1. Place the client in an upright or lateral recumbent position. 2. Reduce excess clothing, cool body with wet cloths, and maintain a cool environment. Protect from chilling. 3. Encourage the intake of oral fluids such as sports drinks. 4. Review the client’s urinalysis results. 5. Provide appropriate oral care. 6. Administer fluids parenterally. Risk For Fetal InjuryChildbirth 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesThe 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. 2. Note the color of amniotic fluid. 3. Assess fetal position, station, and presentation. 4. Determine fetal size before delivery. 5. Monitor labor progress and rate of fetal descent. 6. Monitor FHR after the rupture of
membranes. 7. Assess the client’s pelvic measurements early during the pregnancy. Nursing Interventions and Rationales1. Maintain a record of events and nursing care. 2. Remain with the client and monitor pushing efforts as the head emerges. Instruct the client to pant during the process. 3. Position the client in a knee-chest or Trendelenburg position in the event of a prolapsed cord. 4. Encourage the client to assume positions that favor fetal rotation and descent. 5. Cover the exposed cord 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. 7.
Obtain an emergency delivery kit if delivery is not usually done in the labor room. 8. Transfer to the delivery room, as appropriate, when the vertex is visible at introitus in nullipara or when multipara is 8 cm dilated. 9. Assist with vertex rotation from OP to OA (Scanzoni maneuver). 10. Assist with external cephalic version, if indicated. 11. Assist with vaginal delivery when the fetus is in the posterior position. 12.
Assist with other methods of birth, such as forceps and vacuum extraction births. 13. Prepare for surgical intervention, if indicated. Risk For Maternal InfectionBacterial 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesThe following are the nursing assessment for this labor nursing care plan. 1. Monitor temperature, pulse, and WBC count, as indicated. 2. Note the date and time of rupture of membranes; observe the characteristics of the amniotic fluid. Nursing Interventions and RationalesHere are the nursing interventions for this labor nursing care plan. 1. Perform perineal care per protocol, using medical asepsis. 2. Remove fecal contaminants expelled during pushing; change linens /underpads during
pushing; change linens/underpads as needed. 3. Perform strict hand hygiene before and after procedures. 4. Perform vaginal examination only when necessary, using an aseptic technique. 5. Use surgical asepsis in preparing equipment. Clean perineum with sterile water and soap or surgical disinfectant just before delivery. 6. Administer antibiotics, as indicated. 7. Provide aseptic conditions for delivery. Risk For Impaired Skin IntegrityTrauma 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesHere are the nursing assessment cues for this labor nursing care plan. 1. Assess for bladder fullness; catheterize before delivery, as appropriate. Nursing Interventions and RationalesThe 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. 2. Assist client/couple with proper positioning, breathing, and relaxing efforts. Ensure that client relaxes the perineal floor while using abdominal muscles in pushing. 3. Place the client in left lateral Sims’ position for
delivery, if desired/comfortable. 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. 5. Apply warm perineal compresses during contractions. 6. Educate the client on how to perform digital perineal massage antenatally. 7. Maintain accurate delivery records of the location of episiotomy and lacerations. Record type and timing of forceps if used. 8. Assist as needed with a perineal massage. 9. Assist with midline, or mediolateral episiotomy, if necessary Risk For Ineffective Individual CopingLabor 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesBelow are the nursing assessment for this labor nursing care plan. 1. Determine the client’s perception of behavioral response to labor. Note cultural influences. 2. Monitor response to contraction. Provide gentle but firm instructions for
efforts to bear down when the urge to push arises. 3. Assess the client’s pain level from uterine contractions and pelvic pressure. Nursing Interventions and RationalesHere are the nursing interventions for this labor nursing care plan. 1. Discuss normal emotional and physical changes and variations in emotional responses. 2. Discuss
options for pain control/reduction. 3. Provide comfort measures for the client. 4. Point out tense or furrowed brow, clenched fists, and so forth, and suggest that the partner touch tight areas. 5. Encourage the client to rest between contractions with eyes closed. 6. Provide positive reinforcement and encouragement. 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. 8. Support and teach the client about effective pushing techniques. 9. Facilitate partner’s participation in meeting client’s needs regarding comfort, pushing, and emotional support. 10. Support client/couple in deciding to use analgesia or anesthesia. Risk For FatigueFatigue 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
May be related toCommon related factors for this nursing diagnosis:
Possibly evidenced by
Desired OutcomesCommon goals and expected outcomes:
Nursing Assessment and RationalesThe 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. 2. Monitor fetal descent, presentation, and position. Nursing Interventions and RationalesHere are the nursing interventions for this labor nursing care plan. 1. Keep client/couple informed of progress. 2. Encourage rest/relaxation between contractions. Provide an environment conducive to
rest. 3. Instruct the client when to push if she is under regional
anesthesia. 4. Provide comfort measures to the client. 5. Encourage the use of relaxation techniques. Review them with client/partner, as necessary. 6. Supply fluids with glucose orally as appropriate or parenterally, if ordered. Test urine for ketones, as indicated. 7. Assist with anesthesia or use of forceps if the client’s efforts do not rotate fetal vertex and promote fetal descent. 8.
Prepare for cesarean birth if vaginal delivery is not possible. 9. Assist with augmentation and induction of labor, as indicated. Recommended nursing diagnosis and nursing care plan books and resources. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy. Journal readings, books, articles, and other resources you can use to further your reading about labor. What are the nursing interventions during labor and delivery?The most important nursing interventions are providing emotional support and encourage verbalization of feelings to reduce anxiety. Facilitate and encourage women for frequent position changes while women in bed. Show respect to the woman and allow her family member if she wants.
What are nursing interventions during the first stage of labor?These interventions can include bed rest/recumbent position, electronic fetal monitoring (EFM), limited oral intake during labor, frequent vaginal exams, inductions/augmentations, amniotomy, regional anesthesia, catheterization, ineffective pushing, episiotomy, instrumental vaginal birth, and cesarean surgery.
What are the recommended nursing care practices in the care of the pregnant mother during labor and delivery Why?Nurses need to be respectful, available, encouraging, supportive, and pro- fessional in dealing with all women. The nursing manage- ment for labor and birth should include comfort measures, emotional support, information and instruction, advocacy, and support for the partner (Simkin, 2002).
Which position would a laboring patient with a history of congenital heart disease assume during labor?The best position for the laboring woman with cardiac compromise is the left lateral recumbent position. In this position, pulse pressure increases only six percent, compared to an increase of 26 percent in the pulse pressure when the supine position is used.
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