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Care Plan In Pregnancy With Laceration

Care Plan In Pregnancy With Laceration

The latent phase of labor starts during the onset of true labor contractions until cervical dilatation. The latent phase is considerably longer and less predictable concerning the rate of cervical change than is observed in the active phase (Hutchison et al., 2021). A birthing parent who is multiparous progresses more quickly than a nullipara. Nursing care plans and diagnoses in this phase include:
Deficient Knowledge
Risk for Fluid Volume Deficit
Risk For Fetal Injury
Risk For Maternal Infection
Risk For Ineffective Coping
Risk For Anxiety
Deficient Knowledge
Early labor is when there are frequent moments for decision-making for laboring individuals, nurses, and healthcare providers. Clinicians felt that many factors impact a client’s decision-making about early labor, including parity, risks, anxiety or fear, support, expectations, knowledge about birth, and coping. Prenatal care or childbirth education is an important opportunity for clients to receive information about the latent phase of labor. Inclusion of information during prenatal care and childbirth education may increase the client’s confidence during early labor to delay admission until active labor (Breman & Neerland, 2022).
Nursing Diagnosis
Deficient Knowledge
May be related to
Common related factors for this nursing diagnosis:
Information misinterpretation
Lack of exposure/recall
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
Inaccurate follow-through of instruction
Statements of misconception
Desired Outcomes
Common goals and expected outcomes:
The client will verbalize understanding of psychological and physiological changes.
The client will participate in the decision-making process.
The client will demonstrate appropriate breathing and relaxation techniques.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess the client’s baseline knowledge and expectations during pregnancy.
This will guide in establishing learning needs and setting priorities. Client needs to understand what is happening to them during labor to make informed decisions about their care. Knowing and recognizing what is normal and not normal can help ensure the safe provision of care.
2. Determine the client’s preferences for nursing care early in labor.
Assess the client whether she might benefit from such caring measures as having her handheld or her back rubbed or if she wants this only from her support person. If the client is not proficient in English, make arrangements to locate an interpreter. If she is hearing challenged, the healthcare facility’s responsibility is to provide an interpreter to receive adequate explanations of her progress.
3. Assess for cultural factors that may influence the client’s labor experience.
Cultural factors can strongly influence a client’s experience and satisfaction with labor. Every client responds to cultural cues in some way. This makes their response to pain, choice of nourishment, preferred birthing position, proximity and involvement of a support person, and customs related to the immediate postpartum period highly individualized. Be prepared to adapt to the client’s specific needs. If the client has traditions that run counter to hospital protocols, address these differences and make arrangements to accommodate her desires, beliefs, or customs, such as advocating special foods to eat or saving the placenta for the client to take home.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Provide and discuss options for care during the labor process. Provide information about birthing alternatives, if available and appropriate.
Active participation of the client/couple is important in the decision-making process. Efforts to improve shared decision-making could potentially increase the use of nonpharmacological methods, perhaps in environments where that may not be the norm. One way to communicate the pregnant client’s preferences among the team is a birth plan or birth partnership (Breman & Neerland, 2022).
2. Provide information about procedures (especially fetal monitor and telemetry) and normal progression of labor.
Prenatal education can facilitate the labor and delivery process, assist the client in maintaining control during labor, help promote a positive attitude, and decrease reliance on medication. Educating the client about early labor and physiologic birth processes was often mentioned for improving outcomes (Breman & Neerland, 2022).
3. Review appropriate activity levels and safety precautions, whether the client remains in the hospital or returns home.ORDER WITH US AND GET FULL ASSIGNMENT HELP FOR THIS QUESTION AND ANY OTHER ASSIGNMENTS (PLAGIARISM FREE)Care Plan In Pregnancy With Laceration
Providing guidelines can help the client make appropriate informed choices and allows the client to engage in safe diversional activities to refocus attention. The client should move around freely throughout labor, not be confined to bed. 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.
4. Review roles of staff members.
Reviewing roles helps identify resources for specific needs or situations. There is an increasing importance of person-centered care due to the potentially shifting clinical landscape. To achieve person-centered care, the healthcare team, the client, and the family members should work together and share power over clinical decision-making and care. Nurses can advocate for clients and provide education on options because they provide the most hands-on care during labor birth (Pillitteri, A., & Silbert-Flagg, J., 2018).
5. Explain the procedures and the possible risks associated with labor and delivery. Obtain informed consent for procedures (e.g., forceps delivery, episiotomy).
When procedures involve the client’s body, the client must have the appropriate information to make informed choices. Because the first stage of labor begins with uterine contractions and takes hours to complete, most clients have had labor contractions for hours before arriving at the birthing center. When they arrive, one of their chief needs is reassurance that their judgment has been correct, everything is going well, and the exhaustion and increasing pain they feel is part of the usual labor.
6. Encourage the client to express her feelings about the labor.
Some clients may handle the stress of labor by becoming extremely passive and quiet. Still, others feel a need to show their emotions by shouting or crying. Help the client express her feelings her way or the best way for her.
7. Educate the client about breathing and relaxation techniques appropriate to each phase of labor; teach and review pushing positions for stage II.
Unprepared couples need to learn coping mechanisms on admission to help reduce stress and anxiety. Couples with prior preparation can benefit from review and reinforcement. Some clients may have practiced breathing exercises in a supine position while at home and may need additional coaching to do them in a sitting or dancing position. A dancing position is when the pregnant woman puts her hands on her partner’s shoulders and sways from left to right while the partner massages the woman’s sacral area. They can dance with someone they prefer, accompanied by light, calming music. The labor dance starts in the active labor phase of the first labor stage and continues until the end of the first stage to reduce the pain of contractions and provide emotional support (Akin & Saydam, 2020).
8. Provide frequent progress reports during labor.
At first, it is exciting for the client to feel labor contractions. They are little more than menstrual cramps and project a “this-is-really-happening” sensation. Soon, however, if the client is not concentrating on controlled breathing, the contractions become biting in intensity. Even though she is becoming more uncomfortable, nothing seems to be happening and can cause the couple to worry that something is going wrong. Give the client and her partner frequent progress reports during labor so they do not become discouraged or fearful at this seeming lack of progress.
9. Be prepared to repeat instructions as necessary during labor.
The client in labor may be enduring so much pain and stress that they do not hear or process instructions well. Gently repeat the instructions or information without reminding them they were previously given it. A reminder is not therapeutic because it can lower self-esteem and a sense of self-control.
Risk for Deficient Fluid Volume
Restricting fluids and food during labor is common practice across many birth settings, with some clients only being allowed sips of water or ice chips. The rationale to withhold food and fluid during labor is to decrease the risk of maternal morbidity and mortality from Mendelson’s syndrome if a general anesthetic is required. Gastric content regurgitation and aspiration into the lungs during general anesthesia is a risk first identified by Mendelson in the 1940s (Singata et al., 2013). However, when food and fluids are restricted, the client may experience dehydration symptoms, such as dryness of the mouth, nausea, and dizziness (Ozkan et al., 2017).
Nursing Diagnosis
Risk for Deficient Fluid Volume
May be related to
Common related factors for this nursing diagnosis:
Restriction of oral intake
Loss of fluid through abnormal routes–vomiting, diaphoresis
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 maintain a fluid intake of at least one glass of selected beverage every hour as tolerated.
The client will verbalize the absence of frequent thirst.
The client will demonstrate adequate hydration (e.g., moist mucous membranes, yellow/amber urine of appropriate amount, absence of thirst, afebrile, stable vital signs/FHR).
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess intake & output. Note urine-specific gravity.
Intake and output should be approximately equal, dependent on the degree of hydration. The urine concentration increases as urine output decreases and may warn of dehydration. Additionally, there can be insensible fluid losses, such as diaphoresis and increased rate and depth of respirations.
2. Determine cultural practices regarding intake.
Some cultures, like Mexican women, practice drinking milk to make the babies larger and drinking chamomile tea to have a healthy labor. Some practices known by women to help easier delivery include making the pregnant woman have oily bread, sweetened fruit juice, butter, or molasses (Ozkan et al., 2017).
3. Assess the client’s vital signs and fetal heart rate (FHR) as indicated.
Increases in temperature, BP, pulse, respirations, and FHR may indicate the presence of dehydration or hypovolemia. Although a drop in BP is generally a late sign of fluid deficit, widening pulse pressure may occur early. Epidural anesthesia may cause hypotension. Therefore, the nurse should ensure that the client is well hydrated before epidural administration.
4. Assess the client’s skin temperature and palpate peripheral pulses.
Cool, clammy skin or weak pulses indicate decreased peripheral circulation and the need for additional fluid replacement. Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming.
5. Monitor the client’s hemoglobin and hematocrit level.
Both the hemoglobin and hematocrit increase with a dehydrated client. A reduction of the central circulating blood volume due to hypovolemia accompanying dehydration may result in the concentration of hemoglobin and hematocrit values (Ashraf & Rea, 2017).
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Provide mouth care and hard candy, as appropriate.
Proper oral care and hard candy may reduce the discomfort of a dry mouth. Sucking on ice chips, popsicles, or lollipops can help fluid intake. Even with adequate fluid intake, the client’s mouth and lips can become uncomfortably dry because of mouth breathing. Applying lip balm to prevent or relieve this discomfort can also be helpful.
2. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted.
Clear liquids promote hydration and may provide some calories for energy production. Encourage the client to sip fluid during labor (as they would 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.
3. Educate the client about the benefits of consuming sports drinks during labor.
A total of 61.4% of hospitals in China supported pregnant women’s consumption of sports drinks during labor. Sports medicine scientists believe that childbirth is similar to athletes’ strenuous exercise, and sports drinks contain a lot of energy. Although sports drinks do not reduce delivery time and the incidence of vomiting, it has been shown that they could reduce the number of ketones produced by pregnant clients (Huang et al., 2020).
4. Encourage the client to empty the bladder at least once every hour.
The pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Encourage the client to void approximately every two hours during labor to avoid overfilling the bladder.
5. Administer IV fluids, as indicated.
The client may need IV fluids if oral intake is inadequate or restricted. In dehydration or hemorrhage, fluid resuscitation is necessary to counteract some negative effects of anesthesia/analgesia. According to Garite et al. (2000), the first phase of labor is significantly shorter in clients receiving fluids at 250ml/hr than those receiving fluids at 125 ml/hr (Lopez et al., 2019).
6. Administer dexamethasone to reduce nausea and vomiting, as indicated.
According to study findings, dexamethasone has better antiemetic efficacy compared with promethazine. Studies suggested that the antiemetic effect of steroids may be partially due to their activity on the central nervous system or activation of glucocorticoid receptors in the medulla (Tazeh kand et al., 2015).
Risk For Injury (Fetal)
The pressure and circulatory changes that occur with contractions affect the client and cause detectable physiologic changes in the fetus. Uterine contractions exert pressure on the fetal head. Therefore, the same response that is involved with increased intracranial pressure occurs. Uterine contractions in labor result in a 60% reduction in uteroplacental perfusion, causing transient fetal and placental hypoxia, which can be detrimental to fetuses with abnormal placental development (Turner et al., 2020).
Nursing Diagnosis
Risk for Injury (Fetal)
May be related to
Common related factors for this nursing diagnosis:
Tissue hypoxia
Abnormal placental development
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 fetus will display FHR and beat-to-beat variability within normal limits, with no ominous periodic changes in response to uterine contractions.
The fetus will be delivered successfully without any congenital complications or physical injuries.
Nursing Assessment and Rationales
Here are the nursing assessment for this labor nursing care plan.
1. Note the progress of labor and characteristics of the uterine contractions.
Prolonged or dysfunctional labor with an extended latent phase can contribute to infection, maternal exhaustion, severe stress, and hemorrhage caused by uterine atony/rupture, putting the fetus at greater risk for hypoxia and injury. 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.
2. Monitor baseline FHR manually and electronically.
The normal range for fetal heart rate is between 120–160 bpm with average variability, accelerating in response to maternal activity, fetal movement, and uterine contractions. The FHR can be assessed by intermittent auscultation, a fetoscope or Doppler transducer, or continuous electronic fetal monitoring (EFM). During the latent phase, assessment of FHR for low-risk clients may be done every hour; for high-risk clients, every 30 minutes; and every time during the rupture of the membranes, before and after ambulation, before and after anesthesia administration, after vaginal examination, and if the contractions are abnormal or excessive.
3. Evaluate FHR pattern variability and periodic changes in response to uterine contractions.
The FHR is evaluated for baseline rate, baseline variability, episodic changes, and periodic changes. Periodic changes are transient and brief changes in the FHR associated with uterine contractions such as accelerations and decelerations. Marked variability occurs when more than 25 beats of fluctuation over the FHR baseline indicate cord prolapse or maternal hypotension. Absent variability is less than six beats per minute change from baseline for 10 minutes and is typically caused by uteroplacental insufficiency.
4. Monitor FHR during rupture of membranes, reassess per protocol, obtain a 30-min EFM strip for the record. Evaluate periodic changes in FHR.
Variable decelerations are abrupt decreases of 15 beats/minute below the baseline, lasting 15 seconds to 2 minutes. The nurse should assess the FHR for at least one full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and compressed.
5. Note the presence of bradycardia/tachycardia or sinusoidal pattern.
Fetal bradycardia occurs when the FHR is less than 110 beats/minute for 10 minutes. Causes can include fetal hypoxia, maternal hypoglycemia, maternal hypotension, or prolonged umbilical cord compression. Fetal tachycardia is a baseline greater than 160 beats/minute that lasts 2 to 10 minutes and longer. It can be caused by maternal fever or maternal dehydration. The sinusoidal pattern is often associated with fetal anemia or severe fetal hypoxia before fetal demise.
6. Assess maternal perineum for chlamydial discharges, vaginal warts, or herpetic lesions.
The fetus can acquire sexually transmitted infections (STIs) during pregnancy; therefore, cesarean birth may be indicated, especially for clients with active herpes simplex virus type II. Untreated chlamydia infection has been linked to problems during pregnancy, including preterm labor, premature rupture of membranes, and low birth weight. The newborn may also become infected during delivery as the infant passes through the birth canal. The risk of transmission to the neonate from an infected mother is high among women who acquire genital herpes near the time of delivery (CDC, 2021). HIV infection is associated with both preterm births and low-birth-weight infants.
7. Assess for visible cord prolapse at vaginal introitus.
Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not fitted firmly into the cervix. In rare instances, the cord may be felt as the presenting part on an initial vaginal examination during labor or visualized on ultrasound. 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 (Pillitteri, A., & Silbert-Flagg, J. 2018).
8. Assess the amniotic fluid’s color, odor, and amount.
Green-stained amniotic fluid may indicate that the fetus has passed meconium before birth, which is associated with the fetal compromise that can cause respiratory problems at birth. Cloudy or yellow amniotic fluid with an offensive odor may indicate an infection and should be reported immediately.
9. Rule out maternal problems or medications that could affect an increase in FHR.
Factors such as fever, anxiety, anemia, or beta-sympathomimetic drugs can increase maternal and fetal heart rates. Fetal metabolic acidosis is one of the causes of decreased variability. Still, other etiologies include central nervous system depressants such as maternal narcotic use, fetal sleep cycles, congenital anomalies, prematurity, fetal tachycardia, administration of betamethasone, and preexisting fetal neurologic abnormality (Holmgren, 2020).
9. Perform Leopold’s maneuvers to determine fetal engagement, position, and presentation.
Leopold’s maneuvers are a systematic method of observation and palpation to determine fetal presentation and position and are done as part of a physical examination. A transverse lie or breech presentation may necessitate cesarean birth. Other abnormalities, such as the face, chin, and posterior presentations, may also require special interventions to prevent prolongation of labor/fetal harm.
10. Assist as needed with obtaining fetal scalp blood samples when indicated.
Oxygen saturation in a fetus is normally 40% to 70%. A fetus can be assessed for this by a catheter inserted next to the cheek. If fetal blood is obtained by scalp puncture, the finding of acidosis suggests fetal well-being is becoming compromised. Fetal pH between 7.20 and 7.25 may reflect intermittent umbilical cord compression, necessitating constant monitoring or immediate surgical intervention.
11. Assist with ultrasonography, if indicated.
If the fetal presentation is unclear, ultrasound confirms a breech or face presentation. Such a study also gives information on pelvic diameters, fetal skull diameters, and evidence of possible placenta previa causing the breech presentation. Pelvimetry or ultrasound can also be used to compare the size of the fetus with the client’s pelvic capacity, especially when the fetus is macrosomic.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Calm the client and partner, then explain the prolapsed cord and its implications.
The nurse should remain calm to avoid increasing the client’s anxiety, provide prompt corrective actions, and assist with emergency procedures. The prolapsed cord is a sudden development; anxiety and fear are inevitable reactions in the client and her partner. Calm, quick actions on the part of the nurse help the client and her family to feel that they are incompetent hands. Educating them about the complication also helps the couple understand the significance of prolapse and promotes cooperation measures.
2. Place the client in a Trendelenburg or a knee-chest position, push presenting part off of the cord and hold off while calling for help.
When a prolapsed cord occurs, the first action is to displace the fetus upward to stop compression against the pelvis. These positions may relieve the pressure of the presenting part on the cord as it causes the fetal head to fall back. The nurse may also place a gloved hand in the vagina to manually elevate the fetal head off the cord.
3. Check the cord for pulsations; wrap the cord in sterile gauze soaked in saline solution.
If the cord has prolapsed to the extent it is exposed to room air, it will begin to dry and lead to constriction and atrophy of the umbilical vessels. Cover any exposed portion with a sterile saline compress to prevent drying.
4. Place the client in a lateral recumbent position.
Implement position changes to relieve the pressure on the fetal umbilical cord or pressure on the inferior vena cava by turning the client into a left-lateral position. The client’s hips may be elevated by placing two pillows underneath them. This is often combined with the Trendelenburg position.
5. Perform perineal care according to protocol; change underpad when wet.
Perineal care helps prevent the growth of bacteria and eliminates contaminants that might contribute to maternal chorioamnionitis or fetal sepsis. Prelabor rupture of membranes at term accounts for 2-10% incidence. It is associated with maternal and fetal complications if not timely managed. Early complications include cord prolapse, cord compression, and placental abruption. Delayed complications include chorioamnionitis and maternal and fetal sepsis (Nair et al., 2020).
6. Administer oxygen via a face mask.
Administer oxygen via face mask at 10L/minute for 30 minutes to increase maternal oxygen available for fetal uptake. FHR patterns are not diagnostic, as they have many possible causes, but instead are used to detect possible identifiable complications that may be causing interruptions in the fetal oxygen supply.
7. Discontinue oxytocin and administer tocolytics as indicated.
Excess uterine activity or tachysystole is more than five contractions or fewer in 10 minutes, averaged over 30 minutes (the normal is five contractions or fewer in 10 minutes). Discontinuing oxytocin or administering tocolytic agents that decrease uterine activity may be prescribed by the healthcare provider.
8. Administer IV fluids, as indicated.
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.
9. Assist in amnioinfusion to relieve pressure on the cord.
Amnioinfusion is the addition of sterile fluid into the uterus to supplement the amniotic fluid and reduce compression on the cord. A sterile double-lumen catheter is introduced through the cervix into the uterus and attached to IV tubing, and a solution of warmed normal saline is rapidly infused. Initially, approximately 500mL is infused, and then the rate is adjusted to infuse the least amount necessary to maintain an FHR monitor pattern without variable decelerations.
10. Prepare for surgical intervention, as indicated.
If corrective measures do not improve the fetal heart tracings, Category 3 measures are instituted, focusing on expediting the fetus’s delivery. CNS damage occurs if fetal hypoxia or acidosis continues for more than 30 min. Cesarean birth is the treatment of choice for prolapsed cord before full cervical dilatation to avoid fetal compromise.
11. If the client is at home or in a free-standing birth setting, prepare for transfer to a level 2 or 3 hospital setting as indicated.
Compromised fetal status or identification of maternal conditions such as STD requires a closer birth setting. Observation may indicate a need for therapeutic interventions such as cesarean birth.
Risk For Infection (Maternal)
Theoretically, the uterus is sterile during pregnancy and up until the membranes rupture. After rupture, pathogens can invade; the risk of infection grows even greater if tissue edema and trauma are present. Puerperal infection is always potentially serious. Although it usually begins as only a local infection, it can spread to the peritoneum (peritonitis) or the circulatory system (septicemia), conditions that can be fatal in a woman whose body is already stressed from childbirth.
Nursing Diagnosis
Risk for Infection
May be related to
Common related factors for this nursing diagnosis:
Fecal contamination
Invasive procedures
Repeat vaginal examinations
Rupture of amniotic membranes
Prolapse of the umbilical cord
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 demonstrate techniques to minimize the risk of infection.
The client will be free of signs of infection (e.g., afebrile; amniotic fluid clear, nearly colorless, and odorless).
The client will maintain a safe aseptic environment.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Monitor vital signs and white blood cell (WBC) count, as indicated.
The incidence of chorioamnionitis (intra-amniotic infection) increases within 4 hours after rupture of membranes, as evidenced by elevations of WBC count and abnormal vital signs. According to facility policy, the client’s temperature is taken every 2 to 4 hours after her membranes rupture. A maternal temperature of 38℃ (100℉) or higher suggests infection. A WBC count of more than 18,000 to 20,000/mm³ suggests infection, especially if the count is increasing over serial blood draws.
2. Perform initial vaginal examination; repeat only during contractile pattern or client’s behavior indicates significant labor progress.
Frequent vaginal examinations can lead to the incidence of ascending tract infections. To limit the risk of infection, the nurse should keep vaginal exams to a minimum. Cleaning of the birth canal during vaginal examinations and other instrumental procedures can be used, in limited-resource settings, to minimize the risk of both neonatal sepsis and maternal infections (Hassan et al., 2020).
3. Assess vaginal secretions using phenaphthazine (nitrazine paper). Perform microscopic examination for positive ferning.
Spontaneous rupture of membranes 1 hr or more before the onset of labor increases the risk of chorioamnionitis during the intrapartum period. Diagnosis is confirmed by testing the fluid with nitrazine paper, which turns blue in the presence of amniotic fluid. A sample of vaginal fluid is placed on a slide and sent to the laboratory will show a ferning pattern under the microscope, confirming that it is amniotic fluid.
4. Assess the character of amniotic fluid.
The amniotic fluid’s color, odor, amount, and character are recorded. The fluid should be clear, possibly with flecks of vernix and lanugo, and should not have a bad odor. Cloudy, yellow, or malodorous fluid suggests infection. Amniotic fluid cannot be differentiated from urine by appearance, so a sterile vaginal speculum examination is done to observe for vaginal pooling of fluid. If the fluid is tested with Nitrazine paper, the amniotic fluid causes an alkaline reaction (appears blue).
5. Monitor the fetal heart rate.
Fetal tachycardia (rate >160 beats/min) may be the first sign of infection. Poor fetal oxygenation may also occur, especially with abnormal labor.
6. Obtain specimens for cultures and Gram stain if symptoms of sepsis are present.
Immediate identification of infective organism type by Gram stain allows prompt treatment, whereas more specific identification by cultures can be obtained in hours or days. The timing of tests is of paramount importance because the rate of colonization could falsely appear to be lower if done at 35-37 weeks of gestation. Researchers believe screening during labor would be the most appropriate time to prevent neonatal morbidity and mortality (Musleh & Al Qahtani, 2017).
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Use an aseptic technique during a vaginal examination and other invasive procedures.
The aseptic technique helps prevent the growth of bacteria and limits contaminants from reaching the vagina. Cleaning of the birth canal with a disinfectant during vaginal examinations and other instrumental procedures can be used, in limited-resource settings, to minimize the risk of both neonatal sepsis and maternal infections (Hassan et al., 2020).
2. Demonstrate good hand washing techniques.
Proper hand hygiene reduces the risk of acquiring/spreading infective agents. Hand hygiene is one of the safety measures at units that can protect the client in labor from infection; because the client in delivery is vulnerable to infections such as hepatitis B, hepatitis C, and human immunodeficiency virus, those infections may be happening because of improper hand hygiene and aseptic technique (Hassan et al., 2020).
3. Encourage perineal care after elimination and as indicated.
Proper perineal hygiene reduces the possibility of introducing bacteria into the birth canal. Be certain to instruct a postpartum client in proper perineal care, including wiping from front to back so that she does not bring E. coli organisms forward from the rectum. When giving perineal care, wash your hands and wear gloves. Each postpartum client should have their perineal supplies and should not share them to prevent the transfer of pathogens from one woman to another.
4. Change underpads and linens when wet or as needed.
Observe for wet underpads and linens after the membranes rupture. Change them as often as needed to keep the client relatively dry and reduce the risk for infection or skin breakdown, as a moist, warm environment favors the growth of microorganisms.
5. Carry out perineal preparation, as appropriate.
Some providers believe it may facilitate the perineal repair at delivery and cleaning of the perineum in the postpartum period, thereby reducing the risk of infection. Perineal massage is a simple and easy-to-perform technique developed to relax and lengthen the pelvic floor musculature. In a systematic review, Beckman and Stock verified that performing massage is associated with decreased incidence of perineal tears requiring suture and the probability of an episiotomy (Sisconeto de Freitas et al., 2018).
6. Educate the client about the signs and symptoms of infection that should be reported to their healthcare provider.
Before the client is discharged, be certain to ask if she has a thermometer and provides her with specific instructions regarding what degree of temperature she should report and if she understands the level of bed rest expected of her. Help the client understand the signs and symptoms of infection (fever, chills, foul-smelling vaginal secretions) so her white blood cell count can be assessed as necessary.
7. Administer prophylactic antibiotic IV, if indicated.
Although antibiotic administration during the intrapartum period is controversial because of the antibiotic load for the fetus, it may help protect against the development of chorioamnionitis in the client at risk. Prophylactic administration of broad-spectrum antibiotics effective against group B streptococcus during this period may delay the onset of labor and sufficiently reduce the risk of infection in the newborn.
8. Administer oxytocin infusion, as ordered.
If labor does not happen within 24 hr after rupturing of membranes, an infection may occur. If the client is at 36 weeks gestation, the onset of labor reduces the risk of negative effects on the client/fetus. Oxytocin for induction or augmentation of labor is diluted in an IV solution. The oxytocin solution is a secondary infusion inserted into the primary IV solution line so that it can be stopped quickly while an open IV line is maintained. Infusion of oxytocin solution is regulated with an infusion pump. Administration begins at a very low rate and is adjusted upward or downward according to how the fetus responds to labor and the client’s contractions.
Risk For Ineffective 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 must understand the physiology of the normal labor process to recognize abnormalities. With the absence of emotional, psychological, and physical support, the client may become unable to cope with the labor, creating unfavorable consequences for herself and the fetus.
Nursing Diagnosis
Risk For Ineffective Coping
May be related to
Common related factors for this nursing diagnosis:
Inadequate support systems and coping methods
Personal vulnerability
Situational crisis
Severe pain
Lack of sleep/rest
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 individually appropriate behaviors to maintain
The client will identify ineffective coping behaviors and consequences.
The client will verbalize awareness of their coping abilities.
The client will use medication appropriately.
Nursing Assessment and Rationales
The following are the nursing assessment for this labor nursing care plan.
1. Assess uterine contraction/relaxation pattern, fetal status, vaginal bleeding, and cervical dilatation.
Rule out possible complications that could be causing or contributing to the discomfort/reduced coping ability. During the first stage of labor, dysfunction involves a prolonged latent phase, which occurs when contractions become ineffective. The latent phase lasts longer than 20 hours in a nullipara or 14 hours in a multipara.
2. Assess the client’s level of labor pain.
Assess the client’s pain level by verbal, pain scale, and nonverbal indicators. Use a 1 to 10 scale and evaluate the response to the techniques used. Associating labor pain with usual circumstances can go a long way toward helping the client collect her resources and decide on a workable pain relief strategy.
3. Note the age of the client and the presence of a partner/support person(s).
Negative coping may result in increased anxiety, in which case the client may request medication too early in the labor process. Younger and unattended clients may exhibit more vulnerability to stress or discomfort and have difficulty maintaining control. Be certain an adolescent has a support person in labor to relax and breathe effectively with contractions.
4. Determine the client’s cultural background, coping abilities, and verbal and nonverbal responses to pain. Determine previous experiences and antepartum preparation.
Each client responds uniquely to the stresses of labor and associated discomfort based on these factors. The appearance of appropriate or inappropriate coping may be a manifestation of one’s culture; e.g., Asian or Native American women may be stoic because of fear of shaming self or family, whereas Hispanic and Middle Eastern cultures typically encourage the verbal expression of suffering. For this reason, it is important to compare both verbal and nonverbal responses when assessing coping ability. Culture has a role in tolerating pain. Research found that cultural factors influence pain perception (Solehati & Rustina, 2015).
5. Assess the client’s and family’s current functional status and note how labor affects the ability to cope.
The client’s SO or family members have been dealing with a major life adjustment and experiencing uncertainties regarding childbirth. They are also the family members or partners who would face the postpartum process with the client and the newborn. Therefore, factors that place demands on their life routines, time, energy, finances, and relationships should be identified. The information may help in identifying the needs and plan of care.
6. Assess the presence of positive coping skills and inner strengths.
Positive coping skills such as relaxation techniques, willingness to express feelings, and support systems may help the client cope successfully with labor. When the client has coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the client’s sense of control.
Nursing Interventions and Rationales
Here are the nursing interventions for this labor nursing care plan.
1. Establish rapport and accept behavior without judgment. Make verbal contracts about expected behaviors of client and nurse.
Establishing rapport facilitates cooperation and allows the client to leave the experience with positive feelings and enhanced self-esteem. The nurse should provide continuous labor support in a hands-on, in-person manner rather than rely on monitors viewed from outside the labor room. The nurse may need to assist the client in maintaining or regaining control of breathing and relaxation or set limits if inappropriate (unsafe) behavior occurs.
2. Stay and provide a companion (e.g., doula) for a client who is alone.
At a time of increased dependence, unmet needs and fear of being abandoned may interfere with focusing on the task. Doula describes an individual who provides emotional, physical, and informational support to the pregnant woman but does not perform clinical tasks. These childbirth companions may be volunteers or may be paid for their services. Research suggests that using doulas during labor and delivery results in shorter labors, decreased forceps and epidural anesthesia, reduced oxytocin use, fewer cesarean births, better infant outcomes, and enhanced client/partner satisfaction (Chen & Lee, 2020).
3. Reinforce breathing and relaxation techniques during contractions.
These practices minimize anxiety and provide a distraction, blocking the perception of pain impulses within the cerebral cortex. The breathing relaxation techniques in the labor process increase abdominal wall relaxation, increase oxygen supply into the uterus, enlarge the abdominal cavity, and ultimately reduce pain caused by friction between the uterus and the abdominal wall during contraction. Breathing and relaxation can also enhance physical relaxation by reducing tension and increasing emotional relaxation by reducing anxiety (Murtiningsih, 2018).
4. Instruct the client to maintain an upright position during labor and educate about other acceptable positions to increase the client’s comfort.
Maintaining an upright position during labor can shorten the first stage. The recommended comfort positions for the laboring client 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 aids in expulsion efforts. The lateral Sims position encourages rest and helps prevent pressure on the sacrum. Squatting during a contraction increases the diameter of the pelvis, facilitating fetal rotation and descent.
5. Provide support to the client’s body using pillows.
Pillows can provide body support to prevent back strain and can also be used to facilitate anterior rotation of the fetus when the client lies on the side of the fetal spine. The “lunge,” in which the client places her foot on a chair and turns that leg outward, helps the femur press on the ischium to increase pelvic space and facilitates the fetus’s rotation in an occiput position.
6. Provide a calm, peaceful environment for the laboring client.
The environment of the labor room can be controlled by having the client listen to familiar music brought from home, which can produce a calming effect. Changing the linen and the client’s gown, darkening the room lights, and decreasing noise and stimulation can be helpful. These measures usually combine to allow labor to become effective and progress.
7. Educate the client about additional nonpharmacologic pain relief techniques.
In addition to controlling the environment, nonpharmacological pain relief techniques such as touch, effleurage, massage, back pressure, application of heat or cold, and various relaxation techniques are effective means of labor support. Aromatherapy methods can improve physical health and affects the emotion of the person. The access to aromatherapy through nasal inhalation is much faster than in other ways, and lavender is one of the essential oils safe to use by laboring clients to improve relaxation and reduce pain during labor (Murtiningsih, 2018).
8. Advise the client not to push during this stage of labor.
The nurse must often help the client 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 dilatation can cause maternal exhaustion and fetal hypoxia, thus slowing the progress rather than speeding it.
9. Discuss systemic/regional analgesics or anesthetics when available in the birth setting.
This information helps the client make an informed choice about methods to relieve pain and maintain control. Where pain registers are important in appreciating why epidural anesthesia is effective. The anesthetic block needs to suppress the lower thoracic synapses and block sacral nerves for birth for early labor. Support whichever decision the client has made coming into labor and any change she decides on as labor progresses.
10. Discuss administration of sedatives such as secobarbital (Seconal), pentobarbital (Nembutal), or hydroxyzine (Vistaril).
A barbiturate or ataractic may be administered during early labor to promote sleep. The client enters the active phase more relaxed and rested and better able to cope. If the client receives medication for pain, such as a narcotic, she may need to remain in bed for about 15 minutes to avoid a fall if she should become dizzy from the medication.
The processes of labor and childbirth involve a multitude of psychological and physical demands that result in maternal stress. Given that maternal stress levels were shown to peak during labor, this period may represent an important opportunity to reduce stress and associated adverse outcomes by targeting factors contributing to the stress response. These include the fear of labor pain or episiotomy, anxiety and fear regarding her inability to give birth, dying during childbirth, and lack of healthcare support (Tan et al., 2021).
Nursing Diagnosis
May be related to
Common related factors for this nursing diagnosis:
Interpersonal transmission
Situational crisis
Unmet needs
Threat to, or change, in health status
Possibly evidenced by
The common assessment cues could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
Feelings of discomfort, apprehension, or helplessness
Decreased attention span
Poor impulse control
Desired Outcomes
Common goals and expected outcomes:
The client will verbalize feelings of anxiety are at a manageable level.
The client will use breathing and relaxation techniques accordingly.
The client will appear relaxed appropriate to the labor situation.
The client will maintain vital signs within the normal range.
Nursing Assessment and Rationales
Here are the nursing assessment for this labor nursing care plan.
1. Assess the client’s level of labor pains.
During labor, use a standard method of pain assessment, such as asking the client to rate her pain level on a scale of 1 to 10 or show her paper with a line marked 1 to 10 if she’s more visually oriented so that she can rate her pain. Based on her response, evaluate whether pain relief is adequate and effective.
2. Assess the level and causes of anxiety and the effects of cultural background.
Anxiety magnifies pain perception, interferes with coping techniques, and stimulates the release of aldosterone, which may increase sodium and water resorption. Some clients believe their expected role during labor is to be stoic and nonverbal, even in the face of intense pain. Others believe that expressing their discomfort by screaming or verbalizing it is expected. Assess each client individually to determine what level of comfort she feels is right for her during labor and how she feels most able to express discomfort.
3. Assess the client’s or couple’s preparedness for childbirth, their sources of information, and the role of their significant other/partner.
In studies by Daglar and Nur (2014), Laursen, Hedegaard, and Johansen (2008), childbirth fear and anxiety levels were high for pregnant women with low education levels. Besides, the anxiety and fear levels of the pregnant women who received antenatal training from the books, the internet, and the courses were determined to be high as in the studies of Dönmez, Yeniel, and Kavlak (2014). In eliminating anxiety and birth fear, psychological factors such as social and spousal support are important (Sani, 2015). Likewise, high anxiety and birth fear were found in women with poor spouse support (Erkaya et al., 2017).
4. Monitor pattern of uterine contraction.
A hypertonic or hypotonic contractile pattern may develop if stress persists and causes prolonged catecholamine release. Tachysystole is more than five uterine contractions within 10 minutes, observed over 30 minutes. Tachysystole must be reported promptly.
5. Monitor vital signs, especially BP and pulse rate, as indicated. (If BP is elevated on admission, repeat the procedure in 30 min to obtain true reading once the client is relaxed.)
Stress activates the hypothalamic-pituitary-adrenocortical system, increasing the retention and resorption of sodium and water and increasing potassium’s excretion. Uterine contractions release 400 ml of blood into the vascular system, causing an increase in cardiac output. BP may increase by 10 mmHg, and pulse rate may slow. Increased physical activity of labor increases oxygen consumption, increasing the respiratory rate.
6. Monitor FHR patterns and rhythm.
Alterations in FHR and rhythm may occur in response to contraction patterns. The normal range of FHR is 110-160 beats/minute. Monitor FHR frequently and time the frequency and duration of contractions.
Nursing Interventions and Rationales
The following are the nursing interventions for this labor nursing care plan.
1. Encourage the client and her partner.
Encouragement is a powerful tool for intrapartum nursing care because it helps the client summon inner strength and gives her the courage to continue. After each vaginal examination, she is told of cervical change or fetal descent progress. Liberal praise is given if she successfully uses techniques to cope with labor. Her partner also needs encouragement, as labor coaching is a demanding job.
2. Promote privacy and respect for modesty; reduce unnecessary exposure. Use draping during a vaginal examination.
Modesty is a concern in most cultures. A support person may or may not desire to be present while a client is examined or care provided. In the typical hospital environment, laboring clients are disturbed at every turn- with machines, intrusions, strangers, and a pervasive lack of privacy. The best labor support will protect the client’s privacy and ensure that she is not disturbed to tap into her inner wisdom and dig deep to find the strength she needs to give birth (Lothian, 2004). Be aware of the client’s need or preference for female caregivers/support persons. Cultural practices may prohibit men (even the child’s father) during labor and delivery.
3. Encourage the client to verbalize feelings, concerns, and fears.
Stress, fear, and anxiety profoundly affect the labor process, often prolonging the first phase because of the utilization of glucose reserves, causing excess epinephrine release from adrenal stimulation, which inhibits myometrial activity; and increasing norepinephrine levels, which tends to increase uterine activity. Such an imbalance of epinephrine and norepinephrine can create a dysfunctional labor pattern.
4. Provide primary nurse or continuous intrapartum professional support as indicated.
Continuity of care and assessment may decrease stress. Research studies suggest that these clients require less pain medication, resulting in shorter labor. A doula is a woman who is experienced in childbirth and postpartum support. These support persons provide physical, emotional, and informational support prenatally, during labor and birth, and even at home in the postnatal period.
5. Determine diversional needs; encourage various activities (e.g., music, books, cards, walking, rocking, showering, massage, painting, aromatherapy).
Diversional activities move enough attention away from labor, making time pass quickly. If condition permits, walking promotes cervical dilatation, shortens labor, and lowers the incidence of fetal heart rate (FHR) abnormalities. Concentrating intently on an object is another method of distraction or keeping sensory input from reaching the brain’s cortex.
6. Demonstrate breathing and relaxation methods. Provide comfort measures.
Relaxation keeps the abdominal wall tense, allowing the uterus to rise with contractions without pressing against the hard abdominal wall. Breathing patterns are taught in most preparation for childbirth classes and are well documented to decrease pain and anxiety in labor. Stay with the client until she appreciates how useful slow-paced breathing can be and feels comfortable using this technique independently.
7. Provide heat application at the lower back or the perineum as tolerated.
A client with back pain may find applying heat to the lower back with a heating pad, instant hot pack, or warm moist compress extremely comforting. Heat applied to the perineum provides dual benefits of soothing and softening the perineum and decreasing the risk of perineal tears. Always test the temperature of the head pad before applying it to the perineum.
8. Provide an opportunity for conversation to include the choice of infant names, expectations of labor, and perceptions/fears during pregnancy.
This presents an opportunity for the client to verbalize excitement about herself, the pregnancy, and her baby. A conversation serves as a diversion to help pass the time during the longest phase of labor.
9. Educate the client about psychological and physiological changes in labor, as needed.
Education may reduce stress and anxiety and promote labor progress. Be certain to explain the characteristics of contractions (e.g., labor contractions are rhythmic and come and go repeatedly) and reinstruct as necessary. Do not assume the client is aware simply because she is experiencing the contractions. Her pain may be so intense and the intensity so unexpected that she is unaware of any relief between contractions.
10. Prepare for, and assist with discharge from the hospital setting.
During the very early latent phase with no apparent progress of labor, the comfort and familiarity of the home environment may decrease anxiety and allow an opportunity for a variety of acceptable diversional activities, thereby hastening the labor process.
11. Refer the client for professional support.
Pregnancy-specific anxiety (PSA) is linked to a higher risk of preterm birth and low birth weight. Both childbirth fear and PSA are associated with a higher likelihood of cesarean birth. The interventions that were effective for clients with elevated childbirth fear were individual intensive therapy and individual telephone counseling with midwives with some training in psychotherapy (Stoll et al., 2017).
Care plan in pregnancy with laceration

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