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].

• Risk for Injury [Maternal]

• Alteration of muscle tone/contractile pattern
• Maternal fatigue
• Mechanical obstruction to fetal descent

• [Not applicable]

• 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.

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.

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.

• Risk for Injury [Fetal]

• Abnormalities of the maternal pelvis
• Cephalopelvic disproportion [CPD]
• Fetal malpresentation
• Tissue hypoxia/acidosis
• Prolonged labor

• [Not applicable]

• 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.

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].

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].

• Risk for Fluid Volume Deficit

• Hypermetabolic state
• Vomiting
• Profuse diaphoresis
• Restricted oral intake
• Mild diuresis associated with oxytocin administration
• Length and work of labor

• [Not applicable]

• 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.

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 90 seconds], or inadequate rest interval [