Labor is a series of contractions that help with dilation and effacement of the cervix to allow the fetus to move through the birth canal and out of the vagina. Labor usually begins around the EDD (expected date of delivery), but no one can predict exactly when it will start.
In this article:
- Stages of Labor
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Anxiety
- Risk for Decreased Cardiac Output
- Risk for Imbalanced Fluid Volume
- Risk for Infection
Stages of Labor
Labor can be broken down into three stages:
Stage 1: Early and active labor. This is the longest stage of labor. Contractions will progress until they are five minutes apart, which is when the patient should present to the hospital. The cervix will begin to dilate to 4-6 centimeters. In active labor, contractions become stronger and occur more frequently. Patients may feel the urge to push as the baby moves farther into the birth canal.
Stage 2: Delivery of the baby. Once the cervix is dilated to 10 centimeters, it is time to push. Contractions are more frequent, and the mother is instructed to push during them. This stage ends with the delivery of the baby.
Stage 3: Delivery of the placenta. Once the baby is delivered, the placenta will pass through the uterus and finally out of the vagina.
Depending on the circumstances, babies are delivered via vaginal delivery or Cesarean section. The most common and preferred method is vaginally because it carries the lowest risk for complications and results in a faster recovery.
A C-section is done by an obstetrician making surgical incisions in the abdomen and uterus. It can be planned in advance or may occur during labor if an emergency arises, such as fetal distress, placental abruption, umbilical cord prolapse, or excessive bleeding.
Nursing Process
Labor and delivery nurses take care of women and their babies before, during, and after the delivery. They serve as the connection between the patient and the doctor. The nurse is a source of support for the mother and provides education, comfort measures, and updates about the progress of their labor, and about any possible interventions that may be needed further on. During C-section delivery, the nurse may also scrub in to assist in the surgery.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to labor and delivery.
Review of Health History
1. Review the patient’s prenatal care.
The patient’s prenatal care should be reviewed, together with confirmation of the expected delivery date, as part of the initial assessment of labor.
2. Obtain a thorough history.
Ask the patient about the fetus’ movements, the frequency and timing of contractions, the status of the amniotic membranes, and the presence or absence of vaginal bleeding. The nurse should also review the mother’s medical, surgical, and obstetric history, along with recent lab values and imaging data.
3. Ensure the contractions are true.
True contractions must be distinguished from Braxton-Hicks contractions, which are irregular and not as severe as true labor contractions. Braxton-Hicks contractions commonly subside when the patient walks or changes activity.
Physical Assessment
1. Assess for signs of labor.
Signs of labor vary for every patient, but the most common ones are:
- Progressive, regular contractions
- Rupture of the amniotic sac or “water breaking”
- Bloody show or blood-tinged mucus
- Pain in the abdomen and lower back
2. Perform Leopold’s maneuver.
Leopold’s maneuvers determine the position of the fetus:
- The first maneuver involves gentle palpation to identify which fetal part is present in the fundus.
- The second maneuver involves separating the fetal spine from its limbs to determine the position of the fetal back.
- The third maneuver confirms fetal presentation and enables the measurement of fetal weight and amniotic fluid content.
- The fourth maneuver involves checking which fetal presenting part is engaged in the mother’s pelvis.
Abnormal presentations such as breech, brow, face, or shoulder presentation can cause complications and require manipulation.
3. Monitor vital signs.
High blood pressure could indicate preeclampsia and eclampsia, which can be dangerous for the mother and fetus during labor and delivery.
4. Perform a pelvic exam.
Check the cervix’s opening for dilation and effacement (thinning of the cervix). The visual confirmation of amniotic fluid in the cervix is done during a sterile speculum examination if membrane rupture is suspected.
5. Monitor the pattern of contractions.
Contractions become stronger and more frequent as labor progresses. They may be two to five minutes apart and last for 60-90 seconds during the second stage of labor. The mother is instructed to push during a contraction and rest between.
6. Determine the fetal station.
The fetal station determines where the lowest part of the baby is in relation to the mother’s pelvis and is given a number -5 to +5 cm. A station of -5 means the baby’s head is not yet within the birth canal, while a station of +5 means the baby has descended into the vaginal opening. A station of 0 means the baby’s head is “engaged” within the mother’s ischial spines and occurs about two weeks before labor.
7. Determine the patient’s level of pain.
Utilize the numeric pain scale to determine the patient’s pain. The patient’s pain level is assessed frequently to determine a need for interventions.
Diagnostic Procedures
1. Assist with pelvic evaluation.
A clinical examination (clinical pelvimetry) and radiographic methods (CT or MRI) can be used to evaluate the shape and dimensions of the maternal pelvis to predict if complications may occur with delivery. This may be completed during a prenatal visit or at the time of labor.
2. Obtain samples for routine lab tests.
Routine laboratory tests done for a patient in labor include:
- Complete blood cell (CBC) count
- Blood typing and screening
- Urinalysis
3. Monitor uterine contractions.
External tocometer monitoring should begin as soon as the mother enters the labor and delivery area to determine the onset and duration of uterine contractions.
4. Assess the fetal heart tones and rate.
Use a Doppler device, external belt, or internal electrode to assess fetal heart tones and heart rate.
5. Assist with bedside ultrasound.
Bedside ultrasonography may be performed to confirm the fetal presentation and position of the fetal presenting part. Ultrasonography can identify potential complications that may require C-section delivery.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for labor and delivery.
Manage Patient and Fetus During Labor
1. Explain the need for frequent cervical exams.
Cervical exams monitor labor progress through cervical dilation and effacement. Unless problems necessitate more frequent assessments, sterile cervical exams are typically performed every 2 to 3 hours. A higher risk of infection is linked to more frequent cervical checks, particularly when there has been a membrane rupture.
2. Encourage ambulation and changes in position.
Women should be free to move around and change positions as they like. It helps the fetus descend further into the pelvis and relieves pain.
3. Initiate an IV line.
An intravenous catheter is often established to provide medication or fluids to the patient.
4. Let the patient eat.
There should be no restriction on oral intake. Intravenous fluids should be provided to help restore losses if the patient goes without food or liquid for an extended period.
5. Manage the labor pain.
For qualified candidates, analgesia is provided through intravenous opioids, inhaled nitrous oxide, and epidural blocks. Nonpharmacological methods of pain relief include massage, breathing, and movement.
6. Institute comfort measures.
Comfort measures that calm and relax the mother during labor may reduce discomfort and pain. The nurse can recommend the following:
- Create a calming atmosphere with warm lighting, quiet surroundings, soothing music, and privacy.
- Advise the patient to try walking, slow dancing with a partner, pelvic rocking, comfortable pillow placement, sitting and swaying on a birth ball (a large physiotherapy ball), and rocking in a rocking chair to increase physical comfort.
- Encourage massage, acupressure, or counterpressure to the lower back.
- Apply heat through a heated blanket/pad or shower/bath.
- Apply a cold compress to the lower back and a cool towel to the face.
7. Prepare for amniotomy if needed.
Amniotomy is the artificial rupture of membranes (AROM) that helps induce and shorten labor. Amniotomy is not always necessary or helpful.
8. Administer oxytocin.
Oxytocin may be administered intravenously to stimulate contractions if labor is stalled.
9. Prevent complications.
Any stage of labor can experience complications that lead to maternal or fetal injuries or even death.
- Women may experience arrest of labor during the first stage, necessitating a Cesarean section.
- The second stage of labor includes a range of issues connected to the stress of labor and delivery on the mother or the fetus.
- The fetus may experience the following:
- Asphyxiation
- Brain damage
- Low blood pH (acidemia)
- Shoulder lodged in the birth canal (shoulder dystocia)
- Bone fractures
- Fetal injury
- Nerve palsies
- Pooling of blood (hematoma) in the scalp
- The mother can also have a variety of complications, including:
- Uterine rupture
- Vaginal laceration
- Cervical laceration
- Uterine hemorrhage
- Amniotic fluid embolism
- The fetus may experience the following:
- The third stage of labor is associated with the following complications:
- Hemorrhage
- Cord avulsion
- Retained placenta
- Incomplete placenta evacuation
Monitor in the Postpartum Period
1. Control the pain.
A C-section delivery may require pain relief in the form of NSAIDs or narcotic analgesics. Mothers may experience “after pains” following delivery, caused by contractions of the uterus as it relaxes and contracts back to its normal size. A vaginal delivery will result in soreness, and if an episiotomy was required or if lacerations occurred, discomfort is expected. The nurse can offer the following remedies:
- Sitting on a donut pillow
- A warm sitz bath
- Placing an ice pack or chilled sanitary pad on the perineum
- Acetaminophen or ibuprofen to reduce inflammation
2. Monitor vaginal discharge.
Lochia is the vaginal discharge that occurs after childbirth. It is made up of blood, mucus, and tissues and has three stages:
- Lochia rubra: dark red in color, lasting 4 days
- Lochia serosa: color changes to pink, lasting 10 days
- Lochia alba: lochia is white or yellow, lasting up to 2 weeks
During the first 24 hours after childbirth, blood flow may be heavy, but should not soak more than one maternity pad every few hours. If the mother is soaking a maternity pad every hour or passing large clots, this is abnormal and requires intervention.
3. Discuss preventing constipation.
Having a bowel movement for the first few times after childbirth may be painful, and the mother is at risk for hemorrhoids from straining if constipated. The nurse can recommend the following strategies:
- Begin a stool softener or laxative to prevent constipation
- Eat high-fiber foods and drink plenty of water
- Use an over-the-counter hemorrhoid cream to relieve discomfort
- Use pads containing witch hazel to soothe the perineum
- Soak the perineum and anal area in a sitz bath several times per day
4. Advise the patient to practice proper hygiene.
Demonstrate appropriate perineal care and effective handwashing methods. After childbirth, cleansing the perineum from front to back will help reduce the risk of introducing microorganisms into perineal lacerations. After delivery, keeping the area clean will help the wound heal more quickly.
5. Recognize changes in mood and emotions.
Childbirth is an emotional experience, and the mother may experience a range of emotions, such as mood swings, anxiety, insomnia, and crying spells. Some emotional changes may be related to fluctuations in hormones. Still, if symptoms persist or are accompanied by loss of appetite, lack of joy in life, or withdrawal from the newborn, this may signal postpartum depression that necessitates intervention.
6. Promote breastfeeding.
As soon as the patient is ready, begin nursing. Consult a lactation consultant or nurse to educate the mother on how to support the infant and position herself comfortably during breastfeeding. Educate on methods to reduce breast engorgement and prevent cracked nipples and breast discomfort.
7. Remind of postpartum checkups.
The first postpartum checkup should occur within several weeks after delivery and may include several visits to monitor the mother’s mood, discuss contraception plans, and ensure healing from childbirth.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for labor and delivery, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for labor and delivery.
Acute Pain
Labor and delivery is an extremely painful process, and the duration and intensity vary for each individual. The pain is caused by muscle contractions in the uterus and immense pressure on the cervix. It will present itself as intense cramps in multiple parts of the body, such as the abdomen, groin, and back.
Nursing Diagnosis: Acute Pain
Related to:
- Muscle contractions
- Tissue trauma
As evidenced by:
- Restlessness
- Moaning, crying, wincing
- Verbalization of pain
- Facial mask of pain
- Diaphoresis
- Tachycardia and tachypnea
Expected outcomes:
- Patient will verbalize a decrease in pain.
- Patient will show signs of being at ease and comfort, as evidenced by resting and breathing even and unlabored.
- Patient will demonstrate and utilize practices that will help reduce the pain, such as relaxation and breathing techniques and changes in body positioning.
Assessment:
1. Assess the patient’s level of pain using the numeric pain scale.
Pain is always subjective. Finding out how much pain the patient is experiencing is important to drive further interventions.
2. Screen pain along with assessing vital signs.
Pain is often considered the fifth vital sign. In addition to this, blood pressure, pulse, and respiratory rates can elevate when experiencing pain.
Interventions:
1. Establish a rapport with the patient and their significant other.
Entertaining any questions they may have will reduce barriers in communication, ultimately easing any fears and promoting trust and relaxation.
2. Instruct the patient on breathing techniques.
Breathing can help distract from pain. The nurse can instruct on breathing techniques such as belly breathing or pant-pant-blow breathing through contractions.
3. Discuss pain relief options.
The mother should be in charge of her labor plan. The nurse can discuss and explain options for pain relief and help the mother decide what is best for them.
4. Assist the patient in positioning.
Adjusting the body’s positioning will help limit fatigue and enhance circulation. Allow the mother to decide which positions relieve pain, such as side-lying, leaning, or on all fours.
5. Provide comfort measures.
Back rubs, pillows for better positioning, and ice cubes can provide short-term relief.
6. Administer analgesics if ordered.
An epidural can be placed to block pain below the waist. The nurse assists the anesthesiologist with positioning and preparing the site for epidural insertion in the lower back.
Anxiety
Anxiety is normal and can begin long before labor and delivery. Especially with first-time mothers, childbearing comes with the fear of not knowing how the delivery will turn out and worries regarding the baby’s health and the pain of childbirth. The possible use of epidurals and the need for a C-section also contribute to the fear.
Nursing Diagnosis: Anxiety
Related to:
- Perceived threat to baby
- Fear of unexpected outcomes
- Surgical intervention (C-section)
- Threat to health
- Fear of pain
As evidenced by:
- Increased tension
- Feelings of inadequacy
- Expression of concerns
- Alterations in vital signs
- Restlessness
Expected outcomes:
- Patient will verbalize ease of worries and stress.
- Patient will express feelings of concern and anxiety.
- Patient will utilize support systems effectively.
Assessment:
1. Assess psychological and emotional state.
Emotions related to anxiety and uncertainty can affect the labor and delivery process and interfere with the patient’s willingness to cooperate.
2. Assess the patient’s specific concerns.
Inquiring about the patient’s causes of anxiety can open up a dialogue that allows the nurse to potentially clarify and assuage feelings of fear or the unknown.
Interventions:
1. Acknowledge the patient’s feelings and verbalizations that may indicate guilt.
Knowing how the patient feels towards the process will help gauge how they understand why interventions can sometimes be required during labor and delivery and that these choices are available because they may be medically necessary and not because they are lacking personally.
2. Acknowledge and include their support system.
Keeping the significant other/s involved during the process, as well as praising them for any progress, will help establish rapport and trust, leading to a more relaxed environment during childbirth.
3. Maintain a calm demeanor, giving clear and concise explanations.
During emergency deliveries, anxiety may occur due to the process not meeting their expectations. The nurse should remain calm and assertive to maintain control of the situation.
4. Encourage relaxation techniques.
To keep the abdominal wall from becoming tense, the patient needs to be instructed in proper relaxation techniques such as deep-breathing exercises, effleurage (light, rhythmic, circular strokes on the abdomen), and gentle massages of the shoulders and limbs. This will allow the uterus to rise with contractions without pressing against the hard abdominal wall.
5. Provide a calm environment.
Labor can be a long process. When appropriate, keep lighting dim and noises and interruptions to a minimum to allow for rest.
Risk for Decreased Cardiac Output
During labor, when the uterus contracts, there is a notable increase in cardiac output as it increases stroke volume and heart rate. However, complications of labor and delivery like hemorrhage, hypertension, and fluid imbalances can increase the risk of patients developing decreased cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Complications from labor and delivery
- Bleeding
- Uterine atony
- Dehydration
- Fluid and electrolyte imbalance
- Decreased fluid volume
- Hypertension
- Hypotension
- Cardiac conditions
- Childbirth process
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free from any signs of decreased cardiac output, like arrhythmias, shortness of breath, and alterations in vital signs.
- The fetal heart rate will remain within normal limits.
Assessment:
1. Assess the patient’s vital signs regularly and in between contractions.
Blood pressure naturally increases during the intrapartum phase. Cardiac output will be negatively affected when venous return is reduced due to uterine pressure on the inferior vena cava, dehydration caused by decreased circulating blood volume, or bleeding.
2. Assess fetal heart rate during labor and delivery.
The fetal status will be affected if the patient develops decreased cardiac output, causing uteroplacental insufficiency and reduced oxygen delivery to the fetus.
Interventions:
1. Instruct the patient to lie in the left lateral side-lying position.
Lateral positioning on the left side increases stroke volume and venous return, ensuring adequate blood circulation throughout the body.
2. Monitor for any signs of bleeding.
Pregnant women are prone to bleeding during labor and delivery. Heavy vaginal bleeding and a significant decrease in blood pressure must be monitored during labor and delivery, as this can further complicate cardiac output.
3. Administer supplemental oxygenation as needed.
Oxygenation may be compromised in patients who are in labor. Providing supplemental oxygenation can help ensure adequate circulating oxygen and uteroplacental perfusion.
4. Monitor vital signs after anesthesia.
Spinal anesthesia is used in the event of C-section delivery and carries the risk of cardiovascular effects like hypotension with compensatory tachycardia and increased stroke volume.
5. Perform fetal heart monitoring.
The fetal heart rate is monitored during labor and delivery and should be between 110-160 beats per minute. Late decelerations are caused by decreased blood flow to the placenta from maternal dehydration, hypotension from epidural, anemia, and hypoxia.
Risk for Imbalanced Fluid Volume
Labor and delivery predispose pregnant women to a risk for imbalanced fluid volume due to blood loss, dehydration, and nausea and vomiting.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume
Related to:
- Altered fluid intake
- Bleeding
- Nausea and vomiting
- Dehydration
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will display urine output and lab values within normal limits.
- Patient will maintain pulse rate, temperature, blood pressure, respiratory rate, and oxygen saturation within normal parameters.
Assessment:
1. Assess the medical history and factors that predispose the patient to fluid imbalance.
A thorough medical history can help determine if the patient is at risk for hemorrhage during labor and delivery. Patients with high-risk pregnancies due to complications like placenta previa or preeclampsia have an increased risk of bleeding and dehydration during labor and delivery.
2. Monitor the patient’s laboratory values.
A CBC (complete blood count) may be assessed prior to delivery and monitored closely for changes in hemoglobin and hematocrit that signal blood loss.
3. Assess the patient’s vital signs.
Alterations in vital signs are indicators of fluid and electrolyte imbalance. A bounding pulse and elevated blood pressure can indicate fluid volume excess, while a decreased blood pressure, weak thready pulse, and tachycardia can indicate fluid volume deficit.
Interventions:
1. Monitor the patient’s blood pressure and pulse during oxytocin infusion.
Oxytocin infusion is typically indicated to stimulate contractions when labor is not progressing. Water intoxication can occur during oxytocin infusion as this medication reduces urine excretion and promotes fluid retention.
2. Encourage fluid intake.
Eating and drinking are no longer prohibited during labor. The patient can eat and drink freely unless directed otherwise.
3. Administer IV fluids as indicated.
IV fluids may be necessary if the patient is experiencing nausea or vomiting or is unable or uninterested in consuming fluids.
4. Monitor intake and output.
Patients undergoing C-section delivery will have a urinary catheter inserted and kept in place for at least 8 hours after delivery. Closely monitor intake and output for imbalances.
Risk for Infection
The risk of infection increases due to the ability of some pathogens to invade after the rupture of amniotic membranes. Puerperal sepsis is an infection in the genital tract that can occur after giving birth and spread throughout the body.
Nursing Diagnosis: Risk for Infection
Related to:
- Repetitive vaginal examinations
- Rupture of amniotic membranes
- Fecal contamination
- Umbilical cord prolapse
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will verbalize signs and symptoms of infection to notify the nurse and/or provider of.
- Patient will demonstrate keeping their environment clean, safe, and aseptic.
- Patient will show no signs of infection.
Assessment:
1. Assess vaginal secretions and amniotic fluid.
If the secretions are tested using Nitrazine paper, an alkaline reaction (blue) will confirm the presence of amniotic fluid. The color, odor, amount, and character should be recorded. Discoloration and foul odor will indicate possible infection as normal fluids should appear clear, with some specks of vernix (protective layer on baby’s skin) and lanugo (hair covering the baby’s body).
2. Monitor and record fetal heart rate.
A rate greater than 160 beats per minute (fetal tachycardia) may indicate infection. Poor oxygenation may also occur, especially during abnormal labor.
3. Monitor vital signs and white blood cell count.
An elevation of WBC count and abnormal vital signs can indicate infection (maternal temperatures of 38℃/100°F or higher and a WBC count of more than 18,000-20,000/mm³). There is an increased risk for intra-amniotic infection (chorioamnionitis) within 4 hours of membrane rupture.
Interventions:
1. Limit vaginal examinations.
Repeated vaginal examinations increase the risk of introducing pathogens into the vagina and birth canal.
3. Utilize aseptic technique during invasive procedures.
The use of aseptic technique will help in preventing and limiting the growth of bacteria, such as during IV or urinary catheter insertions.
4. Demonstrate proper perineal care and good handwashing techniques.
Proper handwashing reduces the risk of infection. Proper perineal hygiene, such as wiping from front to back after giving birth, will help lessen the possibility of introducing pathogens into perineal lacerations. Keeping the site clean after birth will also aid in faster wound recovery.
5. Administer antibiotics as prescribed.
The administration of antibiotics during labor is controversial as the medication may affect the baby. Still, when needed, it may protect against infection, such as in case of prolonged rupture of membranes.
6. Administer oxytocin as prescribed.
Oxytocin is a natural hormone used to induce labor by causing the uterus to contract. The longer it takes for the baby to come out, the more susceptible the mother and the baby are to infections.
References
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- Johns Hopkins Medicine. Labor. https://www.hopkinsmedicine.org/health/wellness-and-prevention/labor. Accessed Nov. 26, 2022
- Healthwise Staff. (2022, February 23). Breathing techniques for childbirth. MyHealth.Alberta.ca. Retrieved May 2023, from https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=tn7421
- Hutchison, J., Mahdy, H., Hutchison, J. (2022). Stages of Labor. StatPearls Publishing LLC.
- Hutchison, J., Mahdy, H., & Hutchison, J. (2023, January 23). Stages of labor – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK544290/
- Mayo Clinic. Labor induction. https://www.mayoclinic.org/tests-procedures/labor-induction/about/pac-20385141. Accessed Nov. 26, 2022
- Mayo Clinic. (2022, January 13). Stages of labor and birth: Baby, it’s time! Retrieved May 2023, from https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/stages-of-labor/art-20046545
- Milton, S. H. (2021, April 3). Normal labor and delivery: Practice essentials, definition, stages of labor and epidemiology. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/260036-overview#a7
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