Which parameter does the nurse monitor in a patient who is administered butorphanol during labor

Labor is defined as a series of rhythmic, involuntary, progressive uterine contraction that causes effacement and dilation of the uterine cervix. It is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus (Milton & Isaacs, 2019). The process of labor and birth is divided into three stages.

The first stage of dilatation begins with the initiation of true labor contractions and ends when the cervix is fully dilated. The first stage may take about 12 hours to complete and is divided into three phases: latent, active, and transition. The latent or early phase begins with regular uterine contractions until cervical dilatation. Contractions during this phase are mild and short, lasting 20 to 40 seconds. Cervical effacement occurs, and the cervix dilates minimally.

The active phase occurs when cervical dilatation is at 6 to 7 cm and contractions last from 40 to 60 seconds with 3 to 5 minutes intervals. Bloody show or increased vaginal secretions and perhaps spontaneous rupture of membranes may occur at this time. 

The last phase, the transition phase, occurs when contractions peak at 2 to 3-minute intervals and dilatation of 8 to 10 cm. If it has not previously occurred, the show will occur as the last mucus plug from the cervix is released. By the end of this phase, full dilatation (10 cm) and complete cervical effacement have occurred.

The second stage of labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered. The fetus begins the descent, and as the fetal head touches the internal perineum to begin internal rotation, the client’s perineum begins to bulge and appear tense. As the fetal head pushes against the vaginal introitus, crowning begins, and the fetal scalp appears at the opening to the vagina.

Lastly, the third stage, or the placental stage, begins right after the baby’s birth and ends with the delivery of the placenta. Two separate phases are involved: placental separation and placental expulsion. Active bleeding on the maternal surface of the placenta begins with separation, which helps to separate the placenta further by pushing it away from its attachment site. Once separation has occurred, the placenta delivers either by natural bearing down the client’s effort or gentle pressure on the contracted uterine fundus.

There are instances where labor does not start on its own, so when the risks of waiting for labor to start are higher than the risks of having a procedure to get labor going, inducing labor may be necessary to keep the client and the newborn healthy. This may be the case when certain situations such as premature rupture of the membranes, post-term pregnancy, hypertension, preeclampsia, heart disease, gestational diabetes, or bleeding during pregnancy are present.

Nursing Care Plans

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 41 nursing care plans (NCP) and nursing diagnoses for the different stages of labor, including care plans for labor induction, labor augmentation, and dysfunctional labor:

The active phase occurs when cervical dilatation is at 4 to 7 cm and contractions last from 40 to 60 seconds with 3 to 5 minutes intervals.  Show and perhaps spontaneous rupture of membranes may occur at this time. This phase can be difficult for the client because contractions grow stronger and last longer than in the latent phase. Here are five (5) nursing care plans for the active phase of labor:

Acute Pain

During the active phase of labor, cervical dilatation occurs more rapidly. Because the first stage of labor begins with uterine contractions and takes hours to complete, most clients have been having labor contractions for hours before they even arrive at a birthing center or hospital. 

Nursing Diagnosis

May be related to

Common related factors for this nursing diagnosis:

• Pressure on adjacent structures
• Stimulation of both parasympathetic and sympathetic nerve endings
• Tissue dilation/muscle hypoxia

Possibly evidenced by

The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

• Distraction behaviors (restlessness)
• Muscle tension
• Verbalizations

Desired Outcomes

Common goals and expected outcomes:

• The client will identify/use techniques to control pain/discomfort.
• The client will report discomfort is minimized.
• The client will appear relaxed/resting between contractions
• The client will be free of untoward side effects if analgesia/anesthetic agents are administered.

Nursing Assessment and Rationales

The following are the nursing assessment for this labor nursing care plan.

1. Assess the client’s pain level by verbal, pain scale, and nonverbal indicators. Use a 1 to 10 scale and evaluate response to techniques used.
Support the client in her ability to manage pain until her epidural can be given.

2. Assess the degree of discomfort through verbal and nonverbal cues; note cultural practices on pain response.
Attitudes and reactions to pain are individual and based on past experiences, understanding of physiological changes, and cultural expectations. For instance, in Korean culture, women should remain silent during childbirth because they wouldn’t like to shame their families. Whereas European and American women show a wide range of reactions to labor pain. Some Chinese women do not scream or cry during labor because they believe that crying depletes the energy stored required for childbirth (Yadollahi et al., 2018).

3. Assess and record the nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent.
Cervical dilation during the active phase should be approximately 1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with a fetal descent. Descent is expected to occur at a rate of at least 1.0 cm/hr in the nullipara and 2.0 cm/hr in the multipara. The degree of dilation and contractile pattern affects the choice and timing of medication. A Friedman curve is often used to graph the progress of cervical dilation and fetal descent.

4. Time and record the frequency, intensity, and duration of uterine contractile pattern per protocol.
Monitor the labor progress and provide information for the client. Give the couple frequent progress reports during labor, so they do not become discouraged or fearful this way at a seeming lack of progress. Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion. As a rule, uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because this interferes with adequate uterine artery filling.

5. Assess BP and pulse every 1–2 min after regional injection for the first 15 min, then every 10–15 min for the remainder of labor.
Maternal hypotension, the most common side effect of regional block anesthesia, may interfere with fetal oxygenation. An almost inevitable complete sympathetic block occurs, and decreased venous return to the heart- exacerbated by inferior vena cava compression- results in hypotension and decreased cardiac output (Chooi et al., 2017).

6. Monitor FHR variability electronically during anesthesia administration.
Agents such as bupivacaine (Marcaine) and fentanyl (Sublimaze) reportedly have little effect on FHR variability (but, in practice, may decrease variability); alterations should be investigated by the nurse thoroughly. These side effects can begin 2–10 min after administration of anesthetic and may last for 5–10 min, on occasion. Combining bupivacaine with fentanyl for spinal analgesia in labor is usual, but commonly used doses may be excessive. A reduced dose of 2 mg bupivacaine with a lower dose of 15 μg fentanyl reduces the risk of FHR changes associated with a higher dose (Kuberan et al., 2018).

7. Using an alcohol pad, a cotton swab, or a piece of ice or cold pack on both sides of the abdomen, assess and record the level of sensation every 30 min.
Increasing loss of sensation following epidural block indicates migration of anesthesia. The level above T-9 may alter respiratory function, while loss of sensation at the breastbone level (appx. 7–6) increases the risk of profound hypotension. Local anesthetics block the conduction of the sensory, motor, and sympathetic nerve fibers. Sensitivity to changes in temperature along sensory dermatomes can be used to assess the level of the epidural block (Sugden, 2006).

8. Obtain a fetal scalp sample if bradycardia persists for 30 minutes per electronic monitor.
Prolonged fetal bradycardia may indicate the need to determine pH to evaluate hypoxia. Obtaining the fetal oxygen saturation level by inserting a fetal oximeter into the uterus to rest next to the fetal cheek or obtaining a positive response to scalp stimulation usually supplies the information as to whether a fetus is becoming acidotic; however, this information can also be obtained by scalp blood or fetal blood sampling. However, this practice is gradually disappearing due to the difficulty of the procedure and reasonable noninvasive alternatives.

Nursing Interventions and Rationales

Here are the nursing interventions for this labor nursing care plan.

1. Engage client in conversation to assess sensorium; monitor breathing patterns and pulse.
Systemic toxic responses with altered sensorium occur if medication is absorbed into the vascular system. Altered sensorium may also be an early indicator of developing hypoxia. Facilities often use a scale to assess for sedation so that all caregivers use the same criteria for assessment and documentation. Interference with respiratory functioning occurs if analgesia is too high, paralyzing the diaphragm. Her respiratory status is observed every 15 minutes for 1 to 2 hours.

2. Elevate head approximately 30 degrees, alternate position by turning side to side, and use of hip roll.
Position changes promote comfort and help the fetus adapt to the size and shape of the client’s pelvis. Elevating the head prevents the block from migrating up and causing respiratory depression. Lateral positioning increases venous return and enhances placental circulation. Supine position can result in supine hypotensive syndrome, which reduces placental blood flow and fetal oxygenation.

3. Encourage the client to void every 1–2 hr. Palpate above symphysis pubis to determine distension, especially after nerve block.
This keeps the bladder free of distension, increasing discomfort, resulting in possible trauma, interfering with fetal descent, and prolonging labor. Epidural or pudendal analgesia may interfere with sensations of fullness. The nurse should palpate the suprapubic area for a full bladder every 2 hours if a large IV solution is given. A full bladder can delay birth and cause hemorrhage after birth.

4. Institute safety measures.
Regional block anesthesia produces vasomotor paralysis so that sudden movement may precipitate hypotension. When pharmacological pain relief is administered, safety protocols must be implemented, such as raising the side rails, maintaining close observation, and having naloxone readily available. Analgesics alter perception, and the client may fall trying to get out of bed. Safety measures can include encouraging the client to move slowly, keeping side rails up after drug administration, and supporting the legs during positioning changes.

5. Assist with comfort measures.
One of the most effective non-pharmacological methods to reduce pain is massage. The basis of this theory is the gate control theory proposed by Melzak and Wall. The gate control theory states that during labor, the impulse of pain labor travels from the uterus along the large nerve fibers toward the uterus to the gelatinous substance within the spinal column. The transmission cells project pain messages to the brain. The presence of stimulation (such as vibration, rubbing, or massage) results in stronger and faster opposite messages along small nerve fibers. This opposite message closes the gate on the substance of gelatinosa and blocks pain messages, so the brain does not record the pain message (Oktriani et al., 2018). Comfort measures can include providing back or leg rubs, sacral pressure, backrest, mouth care, repositioning, shower or hot tub use, perineal care, and linen changes.

6. Teach and assist in using appropriate breathing and relaxation techniques and abdominal lifting.
Breathing and relaxation techniques may block pain impulses within the cerebral cortex through conditioned responses and cutaneous stimulation. It facilitates the progression of normal labor. Abdominal lifting is a technique for reducing labor pain by giving a stroke to the top of the stomach without pressing inward. This sweep can increase comfort because it can increase the circulation towards the abdomen so that the blood vessels around the abdomen are dilated, and this process can reduce pain (Oktriani et al., 2018).

7. Review proper breathing techniques with the client.
Even though the client conscientiously practiced breathing or focusing in a relaxed setting of an antepartum class, the discomfort and stress of labor may make it easy for her to forget what she learned. As necessary, reinforce previously learned breathing techniques with her. Urge her to begin using these early in labor, before contractions become strong, so she gains confidence that they can be effective at diminishing pain.

8. Encourage comfortable positioning.
An upright position, sitting, walking, or swaying with a partner may be most comfortable for the client in early labor and aids contractions and descent through gravity. If the client wants to walk and has no support, walk with her as she may need support during a contraction. Leaning forward against a birthing ball or pelvic rocking between contractions may relieve tense back muscles.

9. Educate the client about the effects of hydrotherapy during labor.
Studies have shown that hydrotherapy lowers the vasopressin level, enhances uterine perfusion, and less painful contractions. Furthermore, hydrotherapy ensures pregnant women shift positions during labor, improves their sense of control, reduces anxiety, shortens labor by accelerating cervical dilation, facilitates adaptation to labor, and improves labor satisfaction. Hydrotherapy has no adverse effects on the mother or fetus/newborn and is a low cost. In the Cochrane Database of Systematic Reviews, water immersion applied during the first stage of labor minimized the need for epidural/spinal analgesia. It reduced the duration of the first stage of labor (Tuncay et al., 2017).

10. Support the client’s decision about using or nonuse of medication in a nonjudgmental manner. Continue encouragement for efforts and use of relaxation techniques.
This helps reduce feelings of failure in the client and couple who may have anticipated an unmedicated birth and did not follow through with that plan. It also enhances a sense of control and may prevent or decrease the need for medication. 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 the newborn.

11. Administer analgesics such as butorphanol tartrate (Stadol) or meperidine hydrochloride (Demerol) by IV or deep intramuscular (IM) during contractions, if indicated.
IV route is preferred because it ensures more rapid and equal analgesic absorption. Medication administered by the IM route may require up to 45 min to reach adequate plasma levels, and maternal uptake may be variable, especially if the drug is injected into subcutaneous fat instead of muscle. Administering IV drugs during uterine contraction decreases the amount of medication that immediately reaches the fetus. Meperidine has a 5 to 10-minute peak action if given intravenously or a 50-minute peak of action if given intramuscularly.

12. Administer IV bolus of 500–1000 ml of lactated Ringer’s solution just before administration of lumbar epidural block.
The increased circulating fluid level helps prevent side effects of hypotension associated with the block. Therefore, it is infused rapidly before the block is begun. The large number of IV fluids combined with reduced sensation may result in urinary retention.

13. Assist with epidural or caudal block anesthesia using an indwelling catheter.
Pharmacological interventions provide relief once active labor is established; reinforcement through the catheter provides sustained comfort during delivery. Such analgesia does not interfere with uterine activity and Ferguson reflex. While it relaxes the cervix and facilitates the labor process, it may alter internal fetal rotation and diminish the client’s ability to bear down when needed. Several pharmacological methods may slow labor progress if used early in labor.

14. Administer emergency medications as indicated, e.g., naloxone (Narcan) or ephedrine (Ephedra). Succinylcholine chloride and assist with intubation, as appropriate.
Narcan is used to reverse opiate-induced respiratory depression, usually in the infant, caused by opioid drugs such as meperidine. It can be given by the IV route or through the endotracheal tube during resuscitation. Adrenaline may be required for hypotensive episodes not responsive to IV fluid bolus. Systemic toxic reaction to epidural anesthetic may alter sensorium or cause convulsions if medication is absorbed into the vascular system.

15. Assist with complementary therapies as indicated, e.g., acupressure/ acupuncture.
Some clients and healthcare providers may prefer a trial of alternative therapies to mediate pain before pursuing invasive techniques. Acupuncture relieves pain in labor decreases the need for analgesics, forceps and vacuum use, and duration of labor. Acupuncture stimulates increased uterine contractility by releasing oxytocin by central or parasympathetic uterine stimulation. Shortening the duration of the first stage of labor is especially important for primiparas because their labor duration is much longer than that of multiparas (Pesic et al., 2019).

Impaired Urinary Elimination

One of an epidural block’s most common side effects is urinary retention. After initiation of the epidural block, the FHR and BP should be monitored and documented. To counteract hypotension, a large quantity (500 to 1000 mL or more) of IV solution is infused rapidly before the block is begun. The large number of IV fluids combined with the reduced sensation may result in urinary retention.

Nursing Diagnosis

• Impaired Urinary Elimination

May be related to

Common related factors for this nursing diagnosis:

• Altered intake
• Effects of regional anesthesia
• Fluid shifts
• Hormonal changes
• Mechanical compression of the bladder

Possibly evidenced by

The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

• Changes in amount/frequency of voiding
• Slowed progression of labor
• Urine retention
• Urinary urgency

Desired Outcomes

Common goals and expected outcomes:

• The client will empty the bladder appropriately.
• The client will be free of bladder injury.

Nursing Assessment and Rationales

The following are the nursing assessment for this labor nursing care plan.

1. Record and compare intake and output. Note the amount, color, concentration, and specific gravity of urine.
The output should approximate intake. Increased output may reflect excessive fluid retention before the onset of labor and effects of bedrest (i.e., increased glomerular filtration rate and decreased adrenal stimulation). Specific gravity reflects the kidney’s ability to concentrate urine and the client’s hydration status. Decreased output may occur with dehydration, hemorrhage, and pregnancy-induced hypertension (PIH).

2. Observe for changes in mental status, behavior, or level of consciousness.
Accumulation of wastes and electrolyte imbalances can be toxic to the central nervous system and affect the client and the fetus.

3. Assess the client’s voiding preference.
The nurse should assess the client’s voiding preference and how this may impact their sense of control and feelings of empowerment in labor. In a study, Hedgcorth (2021) notes that some women experienced frustration at being unable to void. Women in the continuous catheterization group cited feelings of relief, ease, and convenience, with the main negative themes being discomfort, pain, and stress.

4. Palpate the bladder above the symphysis pubis.
The nurse should palpate the suprapubic area for a full bladder every 2 hours or as necessary if a large IV solution is given. This detects the presence of urine in the bladder and the degree of fullness. Incomplete emptying of the bladder may occur because of decreased sensation and tone.

Nursing Interventions and Rationales

Here are the nursing interventions for this labor nursing care plan.

1. Position the client upright, run water from the faucet, pour warm water over the perineum, or have the client blow bubbles through a straw.
These measures facilitate voiding/enhance emptying of the bladder. The sound of the running water phenomenon might be explained by the mechanism of parasympathetic acceleration and Pavlovian conditioning because of the central and peripheral neural responsive system of the bladder detrusor muscle and urethral sphincter. Feeling the urge to urinate with the sound of running water appears to be in line with a conditioned response in Pavlovian conditioning. The sound of running water mimics the sound of urination itself and the feelings of urine passing through the urethra during micturition (Kwon et al., 2015).

2. Encourage periodic attempts to void, at least every 1–2 hr.
The pressure of the presenting part on the bladder often reduces sensation and interferes with complete emptying. Regional anesthesia (especially in conjunction with IV fluid infusion and use of Stadol) also may contribute to voiding difficulties/bladder distension.

3. Allow the client to choose between using a bedpan and catheterization.
Women felt like active participants in their care when choosing between using the bedpan or immediate catheterization. A study suggested that 60% of women offered a bedpan after epidural anesthesia could void independently. This was increased by 91% when nurses provided interventions to help. Researchers also investigated women’s feelings of empowerment over their birth when choosing the type of bladder care provided. 70% appreciated being offered the bedpan rather than automatic catheterization (Hedgcorth, 2021).

4. Catheterize as indicated.
An overdistended bladder can cause atony, impede fetal descent, or become traumatized by presenting part of the fetus. Infrequent catheterizations can lead to bladder distention, resulting in hypoactive detrusor and voiding dysfunction. Bladder overdistention may lead to bladder nerve damage and inhibition of micturition reflexes. More frequent catheterizations prevent bladder overdistention and can thus decrease the risk of postpartum urinary retention (Rosenberg et al., 2019).

5. Educate the client about the effects of acupuncture on urinary retention as a side effect of epidural analgesia.
Electroacupuncture is a non-pharmacological method that stimulates EX-B2 and SP6 acupoints, reducing labor pain and shortening the active phase of labor. Electroacupuncture regulates and stimulates the excitability of the visceral nerve that innervates the bladder, which improves the coordination function of the related muscle. Thus the normal urination function can be restored (Xiao et al., 2018).

6. Educate the client regarding pelvic floor muscle training.
Pelvic floor muscle training during pregnancy decreases the risk of postpartum urinary incontinence. Pelvic floor muscle training usually involves more than one daily set of repeated voluntary contractions of the pelvic floor muscles performed on at least several days, starting at approximately 30-32 weeks until labor (Berghella & Di Mascio, 2020).

Impaired Gas Exchange (Fetal)

Fetal compromise can occur because blood flow to the placenta is reduced if contractions are excessive (tachysystole). Most placental exchange of oxygen, nutrients, and waste products occurs between contractions. This exchange is likely impaired if the contractions are too long, frequent, or intense.

Nursing Diagnosis

May be related to

Common related factors for this nursing diagnosis:

• Altered oxygen supply/blood flow

Possibly evidenced by

The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

• Restlessness
• Dyspnea
• Cyanosis
• Nasal flaring
• Use of accessory muscles
• Hypoxemia
• Hypoxia
• Abnormal arterial blood gases

Desired Outcomes

Common goals and expected outcomes:

• The fetus will display FHR and beat-to-beat variability within the normal limit.
• The fetus will be free of the adverse effects of hypoxia during labor.

Nursing Assessment and Rationales

Below are the nursing assessment for this labor nursing care plan.

1. Assess FHR changes during a contraction, noting decelerations and accelerations.
As a rule, an FHR of more than 160 beats/min (fetal tachycardia) or less than 110 beats/min (fetal bradycardia) is a sign of possible fetal distress. An equally important sign is a late or variable deceleration pattern revealed on a fetal monitor. The fetus is vulnerable to potential injury during labor, owing to situations that reduce oxygen levels, such as cord prolapse, prolonged head compression, or uteroplacental insufficiency.

2. Assess for maternal factors or conditions that compromise uteroplacental circulation (e.g., diabetes, PIH, kidney or cardiac disorders). Note prenatal testing of placental functioning by nonstress test (NST) or contraction stress test (CST).
High-risk situations that negatively affect circulation are likely manifested in late decelerations and fetal hypoxia. In preeclampsia, vascular dysfunction leads to increased vascular resistance and reduced blood flow in the uteroplacental circulation (Hu & Zhang, 2021).

3. Note and record color, amount, and odor of amniotic fluid and time of membrane rupture.
In a vertex presentation, prolonged hypoxia results in meconium-stained amniotic fluid owing to vagal stimulation, which relaxes the fetal anal sphincter. Hydramnios may be associated with fetal anomalies and poorly controlled maternal diabetes.

4. Monitor uterine activity manually or electronically.
The development of hypertonicity can compromise uteroplacental circulation and fetal oxygenation. Observe if there is a period of relaxation between contractions so the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 seconds are becoming long enough to compromise fetal well-being because this interferes with adequate uterine artery filling.

5. Monitor fetal descent in the birth canal through vaginal examination. In cases of breech presentation, assess FHR more frequently.
Prolonged head compression stimulates vagal responses and may result in fetal bradycardia if the rate of descent is not at least 1 cm/hr for primiparas or 1.5 cm/hr for multiparas. Fundal pressure in the breech presentation may cause vagal stimulation and head compression.

6. Check FHR immediately if membranes rupture, and then again 5 min later. Observe maternal perineum for visible cord prolapse.
The risk for prolapsed cord increases if the membranes rupture before the fetal presenting part is completely engaged in the pelvis—monitoring and documenting the fetal heart rate after the membranes rupture is an essential nursing responsibility.

7. Prepare for and assist with fetal scalp sampling, repeating as indicated;
Prolonged, decreased variability may indicate acidosis. On occasion, determining fetal pH value may help identify fetal respiratory acidosis and metabolic reserves. Obtaining the fetal oxygen saturation level by inserting a fetal oximeter into the uterus to rest next to the fetal cheek or obtaining a positive response to scalp stimulation usually supplies the information as to whether a fetus is becoming acidotic; however, this information can also be obtained by scalp blood or fetal blood sampling.

8. Assist in obtaining umbilical cord gases.
There are no contraindications to obtaining cord gases. The ACOG Committee on Obstetric Practice recommends obtaining umbilical venous and arterial blood samples in abnormal FHR tracing. Isolated respiratory acidemia is diagnosed when the umbilical artery pH is less than 7.20, the PCO2 is elevated, and the base deficit is less than 12 mmol/L. This reflects an interrupted exchange of blood gasses, usually as a transient phenomenon related to umbilical cord compression.

Nursing Interventions and Rationales

The following are the nursing interventions for this labor nursing care plan.

1. Talk to the client/couple as care is being given, and provide information about a situation as appropriate.
This provides psychological support and assurance to reduce anxiety related to increased monitoring. Inform the client and her partner when labor progresses. Labor does not last forever; knowing that her efforts have desired results gives her courage to continue and helps her tolerate the pain.

2. Encourage the client.
After each vaginal examination, the client is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to summon inner strength and give her courage to continue.

3. Instruct the client to avoid pushing before her cervix is fully dilated.
The nurse must often help the client avoid pushing before her cervix is fully dilated. Pushing before full dilation can cause maternal exhaustion and fetal hypoxia, thus slowing progress rather than speeding it. The client can be taught to blow out in short puffs when the urge to push is strong before the cervix is fully dilated.

4. Place the client in a lateral recumbent position.
This position increases placental perfusion, correcting the problem if it is caused by uteroplacental insufficiency. Regular position changes make the laboring client more comfortable and promote the normal labor processes.

5. Place the client in a knee-chest or side-lying position as indicated.
When a prolapsed cord occurs, the first action is to displace the fetus upward to stop compression against the pelvis. Maternal positions such as the knee-chest or Trendelenberg can accomplish this displacement. Placing the mother in a side-lying position with her hips elevated on pillows reduces cord pressure.

6. Increase plain IV infusion rate.
IV fluids increase circulating fluid volume and placental perfusion. Administer IV fluids such as a saline solution to improve cardiac output, circulatory volume, and uteroplacental perfusion. The nurse should observe for fluid volume overload and pulmonary edema.

7. Discontinue oxytocin if it is being administered.
Strong contractions caused by oxytocin may inhibit uterine relaxation and lower fetal oxygen levels. If abnormalities are noted in either fetal heart rate or maternal vital signs, the nurse stops the oxytocin and begins measures to reduce contractions and increase placental blood flow.

8. Administer oxygen as indicated.
Maternal oxygen administration increases available oxygen for placental transfer. Althabe et al. demonstrated that maternal O2 administration during active labor showed an increased fetal muscular pO2 and improvements in the “abnormal” features of FHTs (Watkins et al., 2020).

9. Assist in amnioinfusion, as indicated.
Amnioinfusion involves instilling a saline infusion by catheter into the uterine cavity to restore amniotic fluid volume to relieve umbilical cord compression that can interrupt fetal oxygenation.

10. Prepare for delivery by the most expeditious means or by surgical intervention, if not accompanied by decreased variability.
Repetitive late decelerations over a 30-min period mean or by surgical intervention may warrant a cesarean birth to prevent fetal injury and death from hypoxia. After appropriate conservative measures have been implemented, it is reasonable to make a good-faith estimate of the time needed to accomplish delivery in a sudden deterioration of the FHR.

11. If late or persistent variable decelerations occur, transfer to level II or III hospital settings as indicated.
The decision to perform routine or heightened surveillance is based on clinical judgment. If the FHR progresses to category III, delivery is expedited as quickly as possible despite corrective measures. Tracings that remain in category II warrant additional evaluation.

Risk For Injury (Maternal)

Pregnancy has effects on many systems of the birthing parent. During labor, there are yet other effects that may require the nurse to deliver specific care to their client. Knowing and recognizing what is normal and what is not can help ensure the safe provision of care.

Nursing Diagnosis

• Risk for Injury (Maternal)

May be related to

Common related factors for this nursing diagnosis:

• Delayed gastric motility
• Effects of medication
• Physiological urges

Possibly evidenced by

• A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention. 

Desired Outcomes

Common goals and expected outcomes:

• The client will verbalize understanding of individual risks and reasons for specific interventions.
• The client will follow directions to protect self/the fetus from injury.
• The client will be free of preventable injury/complications.

Nursing Assessment and Rationales

The following are the nursing assessment for this labor nursing care plan.

1. Monitor the client’s temperature and any signs of infection.
Increased temperature and pulse are indicators of a developing infection. The temperature may increase up to (1℉) during labor. Clients who receive labor epidural analgesia are more likely to develop a fever. Maternal fever is associated with an increased risk of neonatal mortality and morbidity, including encephalopathy, hyaline membrane disease, and meconium aspiration (Sultan & Segal, 2020). Monitor the clients’ temperature every 4 hours during labor and every 2 hours after the rupture of the membranes because the possibility for infection markedly increases after that time.

2. Monitor for hemorrhage and signs of pathology with hypertensive episodes.
The client’s cardiac output increases 40–50% from its pre-labor levels. The BP may rise with pain response and, due to work of the system during contractions, by an average systolic rise of 15 mmHg per contraction. The client’s pulse may be rapid on admission because she is nervous and anxious. A constant pulse rate of more than 100 beats/min could be tachycardia from dehydration or hemorrhage and so needs investigation.

3. Assess the client’s respiratory rate.
During labor, the client’s respiratory rate increases due to increased cardiovascular parameters. Do not count respirations during contractions because the client tends to breathe rapidly from pain. Monitor the client for any signs of hyperventilation and provide a brown paper bag for the client to rebreathe into if this occurs.

4. Monitor urine for ketones.
Urinary ketones indicate metabolic acidosis resulting from a deficiency in glucose metabolism, which may reduce uterine activity and cause myometrial fatigue that prolongs labor. However, ketonuria accompanied by hyperglycemia requires prompt evaluation for diabetic ketoacidosis. Ketoacidosis can be rapidly fatal to the fetus.

5. Monitor uterine activity manually or electronically, noting the frequency, duration, and intensity. of contractions
The uterus is susceptible to possible rupture if a hypertonic contractile pattern develops spontaneously or if tachysystole develops due to labor induction with oxytocin administration. Placental separation and hemorrhage can also occur if contraction persists. If the uterine contractions become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). This problem may be correctable but needs augmentation or other interventions.

Nursing Interventions and Rationales

Here are the nursing interventions for this labor nursing care plan.

1. Instruct the client to pant or blow out if she feels the premature urge to bear down.
Panting during the active phase or the transition phase prevents bearing down too early and reduces the risk of lacerations or edema of the cervix/birth canal. A technique that has been established during labor is to encourage the client to push as soon as the cervix reaches the 10 cm dilatation, regardless of the station of the fetal presenting part, and this technique is called “the immediate pushing technique.” However, evidence supports that the strong urge to push might be present after or even before the observation of the full cervical dilatation (Antsaklis et al., 2020).

2. Place the client in a lateral recumbent or semi-upright position.
This position increases placental perfusion and reduces supine hypotensive syndrome. In early labor, the client should be out of bed, walking or sitting in a chair, kneeling, squatting, on all fours, or in whatever position she prefers because the active movement can shorten the beginning stage of labor.

3. Promote bed rest and use of side rails (as labor intensifies). Avoid leaving the client unattended.
This promotes safety should dizziness or precipitous delivery occurs following administration of medication. The nurse keeps the bed’s rails up if the client receives pain-relief drugs. Narcotics may cause drowsiness or dizziness. Regional anesthesia reduces sensation and movement to varying degrees, and therefore the client may have less control over her body. Side rails on the bed may be necessary for safety.

4. Offer the client clear liquids or ice chips as appropriate.
Insensible water loss increases during labor due to diaphoresis and increased rate and depth of respirations. Encourage the client to sip fluid during labor the same as if they were exercising to keep hydrated. If the client is nauseated by labor, encourage sips of fluid, ice chips, or hard candy to supply some extra fluid.

5. Encourage the client to consume food as tolerated during labor.
Delayed gastric motility inhibits digestion during labor, placing the client at risk for aspiration. However, the client can benefit from the intake of calories in PO fluids to help generate energy for work of labor. Pain due to uterine contractions and administration of opiates may both affect gastric emptying. Although gastric emptying remains to a certain degree during labor, the gastric volume was larger within the first hour after delivery in clients who were allowed solid food during labor compared to those who fasted for solids (Bouvet et al., 2022).

6. Instruct the client to void every 2 hours during labor.
The pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces the bladder tone or the ability of the bladder to sense filling. Ask the client to void approximately every 2 hours during labor to avoid overfilling because overfilling can decrease postpartal bladder tone.

7. Monitor for appropriate mobility and be mindful of fall risks.
During pregnancy, relaxin is secreted from the ovaries, causing the cartilage between joints to be more flexible. This allows the joints of the pelvis to open as much as 2 cm in labor to allow for fetal passage.

8. Use therapeutic communication techniques in conversing with the client and their family members.
Warnings of psychological danger during labor are as important to consider in assessing maternal well-being as are physical signs. As the client approaches the second stage of labor, the woman who is becoming increasingly apprehensive despite clear explanations of unfolding events may not be “hearing” because she has a concern that has not been met. Using an approach such as “You seem more and more concerned. Could you tell me what is worrying you?” may be helpful. Increasing apprehension also needs to be investigated for physical reasons because it can indicate oxygen deprivation or internal hemorrhage.

9. Discontinue or decrease the flow rate of oxytocin when used if the contraction lasts longer than 90 sec or if the uterus fails to relax completely between contractions.
This helps prevent hypertonic contractile patterns with resultant decreased placental blood flow and risk of uterine rupture. If abnormalities are noted in either FHR or maternal vital signs, the nurse stops the oxytocin and begins measures to reduce contractions and increase placental blood flow. 

10. Administer IV antibiotics, if indicated.
Administration of antibiotics during labor is controversial but, on occasion, may protect against infection in cases of prolonged rupture of membranes. A downward trend in the incidence of postpartum fever among women who received antibiotics for nonsustained, isolated maternal fever has been observed compared with those who did not receive antibiotics. However, there is an increase in NICU admissions and 5-minute Apgar scores of <7 among neonates of clients who received antibiotics, suggesting a potential increase in neonatal risk associated with maternal antibiotic administration (Bank et al., 2022).

11. Assist in sweeping of membranes, as indicated.
Sweeping of membranes performed weekly, usually starting at approximately 37-38 weeks of gestation, reduces the duration of pregnancy and reduces the frequency of pregnancy continuing beyond 41 weeks of gestation. Sweeping of membranes usually involves inserting > 1 finger between the cervix and the membranes and sweeping 360 degrees at least 2-4 times (Berghella & Di Mascio, 2020).

Risk For Ineffective Individual/Couple Coping

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 nurse may help the client cope with labor by comforting, positioning, teaching, and encouraging her. Adjustment is the outcome of coping at a specific point in time.

Nursing Diagnosis

• Risk For Ineffective Individual Coping

May be related to

Common related factors for this nursing diagnosis:

• Inadequate support systems
• Personal vulnerability
• Situational crises

Possibly evidenced by

• A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention. 

Desired Outcomes

Common goals and expected outcomes:

• The client will identify effective coping behaviors.
• The client will engage in activities to maintain/enhance control.
• The client verbalizes confidence in her ability to maintain active participation.

Nursing Assessment and Rationales

Here are the nursing assessment for this labor nursing care plan.

1. Assess the effectiveness of labor partners. Provide role modeling as indicated.
The client is influenced by those around her and may respond positively when others remain calm and in control. Assess how the client’s partner views their role in the labor and allow them occasional breaks while staying with the client. A support person increases satisfaction with labor; they may help with imagery and controlled breathing.

2. Ascertain the client’s understanding and expectations of the labor process.
The client’s/couple’s coping skills are most challenged during the active and transition phases as contractions become increasingly intense. Lack of knowledge, misconceptions, or unrealistic expectations may increase the client’s anxiety and result in difficult labor. Be sure to offer careful explanations of what is happening or what will happen during labor because this can help alleviate anxiety and thereby reduce some discomfort.

3. Note withdrawn behavior.
Adolescents, in particular, may become withdrawn and not express needs to be nurtured. This may also be true for some cultures (such as Native American or Chinese), where women are encouraged to be stoic/suffer in silence. Chinese women did not scream during labor and believed that crying out depleted the energy stores required for childbirth. They applied soft voices and maintained a silent demeanor when giving birth (Yadollahi et al., 2018).

4. Inspect the client’s suprapubic area and palpate for bladder distention.
A full bladder contributes to discomfort and may impede fetal descent, possibly prolonging labor. Encourage voiding every 2 hours during labor.

5. Assess the client’s pain level and if she desires any pharmacologic pain relief.
Determine the client’s pain level by verbal, pain scale, and nonverbal indicators. Use a 1 to 10 scale and evaluate response to techniques used. Provide information on epidural anesthesia as needed and support the client in her ability to manage pain until her epidural can be given.

Nursing Interventions and Rationales

The following are the nursing interventions for this labor nursing care plan.

1. Encourage verbalization of feelings.
Knowing the client’s feelings helps the nurse gain insight into individual needs and assists the client/couple deal with concerns. There are cultural language differences for expressing pain distress both verbally and non-verbally. Response to pain is also different in each individual and depends on several factors such as personality traits, culture, gender, religious beliefs, and age (Yadollahi et al., 2018).

2. Provide positive reinforcement for efforts. Use touch and soothing words of encouragement.
This encourages the repetition of appropriate behaviors and enhances an individual’s confidence in their ability to cope with or handle labor while also meeting their dependency needs. Encouragement is a powerful tool for intrapartum nursing care because it helps the woman summon inner strength and gives her the courage to continue. Her partner also needs encouragement, as labor coaching is a demanding job.

3. Reinforce the use of positive coping mechanisms and relaxation techniques.
This assists the client in maintaining or gaining control. It enhances feelings of competence and fosters self-esteem. The stressors that accompany labor can be threatening to a woman’s self-esteem, especially if she has not coped positively with past experiences and accomplished the tasks of pregnancy. Because pain is not a new phenomenon for a woman 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.

4. Limit verbalization or instruction during contractions to a single “coach.”
This allows the client to focus attention and may enhance the ability to follow directions. Multiple coaches may result in decreased concentration, confusion, and loss of control. Teaching the laboring woman and her partner is an ongoing task of the intrapartum nurse. Even women who attended prepared childbirth classes often find that the measures they learned are inadequate or need adaptation.

5. Provide a comfortable environment for the laboring client.
The environment of the labor room can be controlled by having the woman listen to familiar music brought from home, which can produce a calming effect. The client’s sheets and clothing may wrinkle rapidly and stick to her skin if she perspires. The waterproof pad under her buttocks will become soiled with vaginal secretions and will begin to feel hot and sticky. Change the waterproof pads frequently and offer the client a clean gown to help her feel clean and refreshed.

6. Assist the client in assuming positions of comfort.
Maintaining an upright position during labor can shorten the first stage. The recommended comfort positions for the laboring woman include sitting upright on a rocking chair or birthing ball, which uses the natural force of gravity to promote fetal descent. The “towel-pull” involves the client pulling on a towel secured to the foot of the bed during contractions, which uses the abdominal muscles and aid in expulsion efforts. The lateral Sims position encourages rest and helps prevent pressure on the sacrum.

7. Promote nonpharmacological pain relief techniques.
Measures such as touch, effleurage, massage, back pressure, application of heat or cold, and various relaxation techniques are effective means of labor support. Electroacupuncture (EA) could help reduce labor pain because its analgesic effect has a lot to do with the release of endorphins and related neuroactive substances and the block of pain signals upward to the brain after EA stimulation (Xiao et al., 2018). Counter pressure techniques performed in the sacrum area with persistent pressure during contraction can affect the large diameter afferent fibers affecting the sweep and the pressure that also will affect the gelatinous substance in the spinal cord, thus inhibiting the pain impulses to the brain called gate control theory (Oktriani et al., 2018).

8. Provide the usual comfort measures.
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, moisten the lips with a wet cloth, or 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.

9. Instruct the client to avoid pushing before her cervix is fully dilated.
The nurse must often help the client to avoid pushing before her cervix is fully dilated. She can be taught to blow out in short puffs when the urge to push is strong before the cervix is fully dilated. Pushing before full dilatation can cause maternal exhaustion and fetal hypoxia, thus slowing the progress rather than speeding it.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her baby:

References and Sources

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

• Abedian, S., Abedi, P., Jahanfar, S., Iravani, M., & Zahedian, M. (2020, September). The effect of Lavender on pain and healing of episiotomy: A systematic review. Complementary Therapies in Medicine, 53.
• Ahmadi, Z., Torkzahrani, S., Roosta, F., Shakeri, N., & Mhmoodi, Z. (2017, January). Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial. Iranian Journal of Nursing and Midwifery Research, 22(1), 62-66.
• Akin, B., & Saydam, B. K. (2020, September). The Effect Of Labor Dance On Perceived Labor Pain, Birth Satisfaction, And Neonatal Outcomes. Explore, 16(5), 310-317.
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• Alhafez, L., & Berghella, V. (2020). Evidence-based Labor Management: First stage of labor (Part 3). American Journal of Obstetrics & Gynecology.
• Antsaklis, P., Papamichail, M., Theodora, M., Syndos, M., Daskalakis, G., & Loutradis, D. (2020, January). Natural Methods to Assist Delivery during the Second Stage of Labour: Part II: Timing and Type of Pushing. Obstetrics and Gynecology International Journal, 19(1), 11-26.
• Apolonio, F. R., Pontes, C. M., Albuquerque Perrelli, J. G., de Sousa, S. d. M. A., Gomes Mendes, R. C. M., Mangueira, S. d. O., & Linhares, F. M. P. (2021). Content validity of the nursing diagnosis powerlessness in women during natural childbirth. Revista Da Escola De Enfermagem.
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• Bank, T. C., Nuss, E., Subedi, K., Hoffman, M. K., & Sciscione, A. (2022, February). Outcomes associated with antibiotic administration for isolated maternal fever in labor. American Journal of Obstetrics and Gynecology, 226(2), 255.e1-255.e7.
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Reviewed and updated by M. Belleza, R.N.