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 PlansThe nursing care plan for a client in labor includes providing information regarding labor and birth, providing comfort and pain relief measures, monitoring the client’s vital signs and fetal heart rate, facilitating postpartum care, and preventing complications after birth. Here are 36 nursing care plans (NCP) and nursing diagnoses for the different stages of labor, including care plans for labor induction and labor augmentation:
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. Nursing care plans and diagnoses in this phase include: Deficient KnowledgeEarly 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 DiagnosisCommon 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. Assess the client’s baseline knowledge and expectations during pregnancy. 2. Determine the client’s preferences for nursing care early in labor. 3. Assess for cultural factors that may influence the client’s labor experience. Nursing Interventions and RationalesHere 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. 2. Provide information about procedures (especially fetal monitor and telemetry) and normal progression of labor. 3. Review appropriate activity levels and safety precautions, whether the client remains in the hospital or returns home. 4. Review roles of staff members. 5. Explain the procedures and the possible risks associated with labor and delivery. Obtain informed consent for procedures (e.g., forceps delivery, episiotomy). 6. Encourage the client to express her feelings about the labor. 7. Educate the client about breathing and relaxation techniques appropriate to each phase of labor; teach and review pushing positions for stage II. 8. Provide frequent progress reports during labor. 9. Be prepared to repeat instructions as necessary during labor. Risk for Deficient Fluid VolumeRestricting 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
Common 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 intake & output. Note urine-specific gravity. 2. Determine cultural practices regarding intake. 3. Assess the client’s vital signs and fetal heart rate (FHR) as indicated. 4. Assess the client’s skin temperature and palpate peripheral pulses. 5. Monitor the client’s hemoglobin and hematocrit level. Nursing Interventions and RationalesHere are the nursing interventions for this labor nursing care plan. 1. Provide mouth care and hard candy, as appropriate. 2. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted. 3. Educate the client about the benefits of consuming sports drinks during labor. 4. Encourage the client to empty the bladder at least once every hour. 5. Administer IV fluids, as indicated. 6. Administer dexamethasone to reduce nausea and vomiting, as indicated. 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 DiagnosisCommon 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. Note the progress of labor and characteristics of the uterine contractions. 2. Monitor baseline FHR manually and electronically. 3. Evaluate FHR pattern variability and periodic changes in response to uterine contractions. 4. Monitor FHR during rupture of membranes, reassess per protocol, obtain a 30-min EFM strip for the record. Evaluate periodic changes in FHR. 5. Note the presence of bradycardia/tachycardia or sinusoidal pattern. 6. Assess maternal perineum for chlamydial discharges, vaginal warts, or herpetic lesions. 7. Assess for visible cord prolapse at vaginal introitus. 8. Assess the amniotic fluid’s color, odor, and amount. 9. Rule out maternal problems or medications that could affect an increase in FHR. 9. Perform Leopold’s maneuvers to determine fetal engagement, position, and presentation. 10. Assist as needed with obtaining fetal scalp blood samples when indicated. 11. Assist with ultrasonography, if indicated. Nursing Interventions and RationalesThe 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. 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. 3. Check the cord for pulsations; wrap the cord in sterile gauze soaked in saline solution. 4. Place the client in a lateral recumbent position. 5. Perform perineal care according to protocol; change underpad when wet. 6. Administer oxygen via a face mask. 7. Discontinue oxytocin and administer tocolytics as indicated. 8. Administer IV fluids, as indicated. 9. Assist in amnioinfusion to relieve pressure on the cord. 10. Prepare for surgical intervention, as indicated. 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. 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 DiagnosisCommon 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 vital signs and white blood cell (WBC) count, as indicated. 2. Perform initial vaginal examination; repeat only during contractile pattern or client’s behavior indicates significant labor progress. 3. Assess vaginal secretions using phenaphthazine (nitrazine paper). Perform microscopic examination for positive ferning. 4. Assess the character of amniotic fluid. 5. Monitor the fetal heart rate. 6. Obtain specimens for cultures and Gram stain if symptoms of sepsis are present. Nursing Interventions and RationalesHere are the nursing interventions for this labor nursing care plan. 1. Use an aseptic technique during a vaginal examination and other invasive procedures. 2. Demonstrate good hand washing techniques. 3. Encourage perineal care after elimination and as indicated. 4. Change underpads and linens when wet or as needed. 5. Carry out perineal preparation, as appropriate. 6. Educate the client about the signs and symptoms of infection that should be reported to their healthcare provider. 7. Administer prophylactic antibiotic IV, if indicated. 8. Administer oxytocin infusion, as ordered. Risk For Ineffective CopingCoping 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
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 uterine contraction/relaxation pattern, fetal status, vaginal bleeding, and cervical dilatation. 2. Assess the client’s level of labor pain. 3. Note the age of the client and the presence of a partner/support person(s). 4. Determine the client’s cultural background, coping abilities, and verbal and nonverbal responses to pain. Determine previous experiences and antepartum preparation. 5. Assess the client’s and family’s current functional status and note how labor affects the ability to cope. 6. Assess the presence of positive coping skills and inner strengths. Nursing Interventions and RationalesHere 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. 2. Stay and provide a companion (e.g., doula) for a client who is alone. 3. Reinforce breathing and relaxation techniques during contractions. 4. Instruct the client to maintain an upright position during labor and educate about other acceptable positions to increase the client’s comfort. 5. Provide support to the client’s body using pillows. 6. Provide a calm, peaceful environment for the laboring client. 7. Educate the client about additional nonpharmacologic pain relief techniques. 8. Advise the client not to push during this stage of labor. 9. Discuss systemic/regional analgesics or anesthetics when available in the birth setting. 10. Discuss administration of sedatives such as secobarbital (Seconal), pentobarbital (Nembutal), or hydroxyzine (Vistaril). AnxietyThe 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 DiagnosisMay 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 RationalesHere are the nursing assessment for this labor nursing care plan. 1. Assess the client’s level of labor pains. 2. Assess the level and causes of anxiety and the effects of cultural background. 3. Assess the client’s or couple’s preparedness for childbirth, their sources of information, and the role of their significant other/partner. 4. Monitor pattern of uterine contraction. 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.) 6. Monitor FHR patterns and rhythm. Nursing Interventions and RationalesThe following are the nursing interventions for this labor nursing care plan. 1. Encourage the client and her partner. 2. Promote privacy and respect for modesty; reduce unnecessary exposure. Use draping during a vaginal examination. 3. Encourage the client to verbalize feelings, concerns, and fears. 4. Provide primary nurse or continuous intrapartum professional support as indicated. 5. Determine diversional needs; encourage various activities (e.g., music, books, cards, walking, rocking, showering, massage, painting, aromatherapy). 6. Demonstrate breathing and relaxation methods. Provide comfort measures. 7. Provide heat application at the lower back or the perineum as tolerated. 8. Provide an opportunity for conversation to include the choice of infant names, expectations of labor, and perceptions/fears during pregnancy. 9. Educate the client about psychological and physiological changes in labor, as needed. 10. Prepare for, and assist with discharge from the hospital setting. 11. Refer the client for professional support. Recommended ResourcesRecommended 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.
See alsoOther recommended site resources for this nursing care plan: Other care plans related to the care of the pregnant mother and her baby: References and SourcesJournal readings, books, articles, and other resources you can use to further your reading about labor.
Reviewed and updated by M. Belleza, R.N. |