The nursing student demonstrates an understanding of dystocia with which statement?

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.

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:

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 Maternal Injury
• Risk For Fetal Injury
• Risk For Fluid Volume Deficit
• Ineffective Individual Coping
• Acute Pain

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

• 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

• 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.

Recommended nursing diagnosis and nursing care plan books and resources.

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Journal readings, books, articles, and other resources you can use to further your reading about labor.

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