Labor and Delivery Nursing Diagnosis and Nursing Care Plan

Labor and Delivery Nursing Care Plans Diagnosis and Interventions

Labor and Delivery NCLEX Review and Nursing Care Plans

Even though a full-term baby grows in an expectant mother’s womb for nine months, the duration of labor and delivery varies from person to person.

Labor is a remarkable experience; in some circumstances, it can be over in a few hours, while it can go for days in others, pushing a mother’s emotional and physical resilience to the limit.

Furthermore, an expectant mother will have no clue how labor and delivery will go until it transpires. They can, however, prepare for their child’s birth by comprehending the usual labor and delivery pattern.

Stages of Labor

There are three stages of labor and delivery that a pregnant woman must be aware of.

  1. First Stage of Labor. The first stage of labor comprises the beginning of labor until the complete cervical dilatation. This stage is the longest and subdivided further into three phases.
    • Early or Latent Phase of Labor. The cervix gets thinner and dilates to 3-4 cm during this phase. It is unpredictable and can last for days, weeks, or even just a few hours. The typical period for first-time mothers can range from hours to days, whereas it is usually shorter for successive deliveries. Contractions can range from moderate to severe and occur at regular or irregular intervals during this phase. Backache, cramping, and a blood-tinged mucous discharge are all probable indications during this phase.
    • Active Phase of Labor.  When cervical dilation is 4 to 7 cm and contractions last 40 to 60 seconds with a 3 to 5-minute interval, this phase begins. The active phase of labor can range somewhere between 4 to 8 hours, with the cervix dilating at a rate of 1 centimeter per hour on average. The pregnant woman’s legs may cramp, she may feel nauseous, and the pressure in her back may increase. The discomfort of a woman in labor escalates as the labor progresses.
    • Transition Phase of Labor. This is the most intense phase of labor when contractions occur every 2 to 3 minutes and dilatation is 8 to 10 cm. A woman in labor may feel pressure in her lower back and rectum, as well as a desire to push. Pushing too soon, when the cervix is not fully dilated, can make the mother exhausted and cause the cervix to swell, thus delaying delivery. Since the transition phase normally lasts 15 to 60 minutes, the mother must pant or blow her way through the contractions.
  2. Second Stage of Labor: Delivery of the Baby. This stage begins with complete cervical dilatation and lasts until the baby is born. With each contraction, the mother may feel an uncontrolled need to push and bear down until crowning or the presentation of the fetal head on the vaginal opening. Delivering the baby into the world might take anywhere from a few minutes to several hours or more. For first-time mothers and women who have had an epidural, this stage may take longer. The rest of the baby’s body will be delivered shortly after the head is out.
  3. Third Stage of Labor: Delivery of the Placenta. The mother will most certainly feel relieved when the baby is born, but there are still a lot of things going on. It is during the third stage of labor when the mother delivers the placenta, which usually takes 30 minutes but can take up to an hour. Mild, less painful, closer-together contractions will continue to assist the mother in pushing the placenta into the birth canal. The uterus will continue contracting after the placenta is delivered, for it to return to its usual size.

Fetal Position

During prenatal appointments in the third trimester, the doctor checks the baby’s position regularly. Between weeks 32 and 36, most babies transition into a head-down position, some remain in their old position, while the rest turn in a foot- or bottom-first position.

The doctor or midwife will utilize Leopold’s maneuvers, which are a series of hands-on examinations to help assess the baby’s position. Knowing the position of the baby before labor begins may assist the expectant mother in preparing for labor and delivery.

A vaginal exam will allow a nurse, doctor, or midwife to gain a more precise idea of the baby’s position once labor begins.

It is critical that the fetus keeps the head down and moves in the appropriate direction. When the fetus is in a breech position, most doctors will use external cephalic version (ECV) to gently change the position of the fetus into a head-down position using ultrasound as a guide. ECVs are frequently successful and can minimize the possibility of a Cesarean section.

Induction of Labor

The use of medicines or other measures to bring on or induce labor is referred to as labor induction. To achieve a vaginal birth, labor is accelerated to promote uterine contractions.

It may be considered if the mother’s or fetus’ health is at risk, particularly if the pregnancy has reached week 42, if the mother’s water breaks and labor do not start soon after, or if the mother or baby has complications.

The method used will be decided by several factors because labor can be artificially induced in a variety of ways. The preparedness of the cervix for labor, whether the woman is a first-time mother, the mother’s pregnancy stage, whether her membranes have ruptured, and the specific reasons for induction of labor must all be taken into consideration when selecting a method.

  • Stripping the membranes. Cervical ripening must be accomplished during early labor since there will be no dilatation or coordination of uterine contractions without it. Stripping the membranes, or manually detaching the membranes from the lower uterine section using a gloved finger in the cervix, is one method to ripen the cervix.
  • Hygroscopic suppositories. Another method is to use hygroscopic suppositories or seaweed suppositories that gradually and gently induce dilatation. They expand when they come into touch with the secretions of the cervix.
  • Prostaglandin. The administration of a prostaglandin gel to the internal surface of the cervix is a more prevalent means of expediting cervical ripening. Subsequent prostaglandin doses can be administered every six hours, although two or three doses are usually sufficient for ripening. Women with asthma, renal or cardiovascular disorders, or glaucoma should use prostaglandin with caution. It is also not recommended for women who have previously had a cesarean birth.
  • Oxytocin. In a full-term pregnancy, oxytocin is administered to stimulate contractions in the uterus. It must be administered intravenously so that it can be terminated promptly if excessive stimulation arises. Because the effects of oxytocin are fast, occurring at about 3 minutes, the rate should not be adjusted without further instructions from the attending physician.

When a woman has had a previous C-section or the baby is in breech presentation, the nurse or healthcare professional must constantly remember that induction of labor is generally not suggested. The labor process is the key to a successful birth; thus, the woman must have a pleasant labor experience to deliver her beautiful child.

Pain Relief During Labor

Medical technology offers several alternatives for dealing with pain and discomforts that may emerge during labor and delivery. A pregnant mother has the right to ask for and selects between a natural or pharmacological means of managing her pain, as they are the only ones who can determine their need for pain relief.

  1. Natural Pain Relief. Pregnant women considering nonmedical pain relief for labor and delivery have a range of options. They may use structured breathing, Lamaze method, hydrotherapy, TENS or transcutaneous electrical nerve stimulation, psychotherapy or hypnosis, acupuncture, or massage therapy to minimize pain perception without using any medicine.
  2. Pharmacological Pain Relief. Some of the medications available for pain relief during labor and delivery include narcotics, nitrous oxide, and epidural.
    • Narcotics. Women in labor are usually given narcotics by intramuscular injection or an intravenous line. Considering they cause considerable maternal, fetal, and neonatal relaxation, they are only utilized for pain treatment during the early stages.
    • Analgesics. Inhaled analgesic drugs like nitrous oxide, on the other hand, are sometimes administered, especially in the early stages of labor, because they can deliver sufficient pain relief for certain women when administered intermittently.
    • Epidural block. The epidural blockade is the most popular technique of pain management during labor and delivery. It is used to deliver anesthetic during labor and delivery, as well as during a cesarean birth, by blocking pain signals being sent through nerves before merging with the spinal cord.

Interventions Related to Delivery

  • Cesarean section or C-section. In complicated deliveries, a C-section which is considered a major operation is often the safest and quickest delivery method. Before the procedure, the mother will be given anesthesia to numb the region from the abdomen to below the waist, and the baby will be delivered through an abdominal wall and uterus incision rather than a vaginal delivery. Most women won’t know if they’ll have a C-section until labor starts, however it may be planned ahead of time if there are challenges with the mother or the baby. It may also be necessary if the prior C-section was a traditional, vertical incision, there is a fetal disorder or congenital abnormalities, the baby’s approximate weight is more than 4,500 g due to a diabetic mother, placenta previa, high viral load of an HIV-infected mother, or the baby is breech or transverse.
  • Vaginal birth after C-section (VBAC). It was formerly considered that a mother who had a C-section would always need one to birth her subsequent children. Repeat C-sections are no longer always necessary, and for many women, vaginal birth after C-section (VBAC) can be a safe alternative. Women who have had a C-section with a horizontal low-transverse uterine incision will have a fair probability of delivering a baby vaginally, however, women who have had a traditional vertical incision should not be permitted to try a VBAC due to the danger of uterine rupture during vaginal delivery. It is crucial to discuss past pregnancies and medical history with the doctor so that they can determine whether VBAC is a viable choice for the mother.
  • Assisted Delivery. A woman may require some additional assistance in delivering her baby nearing the completion of the pushing phase. A vacuum extractor or forceps may be used to aid in the delivery of the baby at this point.
  • Episiotomy. It is a downward incision made at the base of the vagina and perineal muscle to widen the entrance for the baby to emerge, particularly if the mother has been pushing for a long time and can’t get the baby beyond the very bottom of the opening of the vagina. Episiotomies were traditionally thought to be necessary for every woman giving birth vaginally, but they are now only done if the baby is struggling and needs assistance moving out immediately. Episiotomy is also performed if the baby’s head comes out but the shouldersdon’t, a condition known as dystocia.

Complications of Labor

When it finally happens to deliver the baby, even a pleasant pregnancy can have complications. Complications during labor and delivery are uncommon, but they do occur and are becoming more prevalent. The majority of complications can be recognized and controlled to ensure a safe delivery, but some complications during labor can be critical, even life-threatening for a pregnant woman and her infant. The following are some of the most common labor complications.

  1. Uterine Rupture. Uterine rupture is an uncommon yet dangerous complication that can occur during labor and delivery. It occurs when the uterus can no longer withstand the tension. Unexpected presentation, extended labor, multiple pregnancies, faulty oxytocin administration, and serious consequences of forceps or traction are all factors that might result in uterine rupture. The fetus’s viability and the woman’s outlook are dependent on the extent of the rupture, but fetal mortality can be prevented if a cesarean birth is performed immediately. The rupture of the uterus can be incomplete or complete.
    • Incomplete uterine rupture. Itis characterized by localized tenderness, enduring pain in the lower uterine wall, and inadequate fetal heart sounds and contractions.
    • Complete uterine rupture. Bleeding, shock, vanishing fetal heart sounds, distinctive marks of the extrauterine fetus, and retracted uterus are all symptoms of complete uterine rupture.
  2. Uterine Inversion. When the uterus turns inside out due to the delivery of the fetus or the placenta, this complication arises. Application of traction to the umbilical cord to remove the placenta, applied pressure to the uterine fundus when the uterus is not contracting, or if the placenta is connected to the fundus and the fundus pulls it down during birth are all factors that contribute to the inversion of the uterus. An abrupt rush of blood from the vagina, a non-palpable fundus, low blood pressure, dizziness, pale skin, and exsanguination if bleeding persists, are all signs of uterine inversion.
  3. Amniotic Fluid Embolism. When amniotic fluid is pushed into an open maternal uterine blood sinus, or following membrane rupture or partial premature separation of the placenta, this complication happens. Anaphylactoid or humoral response is the main reason for the embolism, with abruption placenta, hydramnios, and inappropriate oxytocin administration as risk factors. Amniotic fluid embolism cannot be prevented because it is unpredictable, although it can cause intense chest discomfort, difficulty breathing, cyanosis, and a deficiency of blood flow in the mother. As an emergency measure, administering oxygen and performing CPR must be done right away.
  4. Umbilical Cord Prolapse. When the umbilical cord prolapses into the vaginal canal before the baby enters the birth canal, it is known as umbilical cord prolapse. cord may be felt during a vaginal examination when determining the presenting fetal portion. A small fetus, placenta previa, Cephalopelvic Disproportion (CPD), early rupture of membranes, hydramnios, and multiple pregnancies are all conditions that might cause prolapse of the umbilical cord.
  5. Multiple Gestation. When a mother is pregnant with numerous babies, extra help is required in the delivery room. Also, since this condition frequently causes fetal anoxia in the second fetus, cesarean birth is preferred over normal delivery. Abnormal fetal presentation, an overextended uterus, premature placental separation, and uterine malfunction due to prolonged labor are all common complications of multiple gestations.

Labor and Delivery Nursing Diagnosis

Nursing Care Plan for Labor and Delivery 1

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to first pregnancy secondary to labor and delivery (latent phase) as evidenced by repetitive questions, verbalization of labor misconceptions, and incorrect instructions follow-through.

Desired Outcome: The patient will exhibit effective breathing and relaxation techniques as well as express comprehension of psychological and physiological changes.

Nursing Interventions for Labor and DeliveryRationale
Evaluate the patient’s basic understanding and expectations about pregnancy, labor, and delivery.To make an informed decision about their care, the patient must understand what is occurring to them throughout labor. Understanding what is acceptable and what is not can help them verify that care is delivered safely.
Determine the acceptable levels of activity and safety protocols at the current stage of labor.By providing instructions, the patient can participate in appropriate diversional activities to refocus their attention. During early labor, the client should be able to move freely rather than being limited to bed. Walking or sitting on a chair, squatting, kneeling, or in any position, the patient desires can effectively reduce the initial phase of labor.
Disclose the procedures and potential risks involved with labor and delivery, especially when obtaining informed consent to applicable procedures.The patient must have sufficient knowledge to make well-informed decisions concerning labor and delivery processes. One of the most pressing concerns for patients is reassurance that their decision was sound, that everything is progressing smoothly, and that the fatigue and escalating discomfort they are having are natural.
Encourage the patient to convey her thoughts and feelings concerning the labor and impending delivery.Assist the patient in effectively communicating her feelings.
Teach the client proper breathing and relaxation strategies for each stage of labor.Some patients may have tried breathing techniques in a supine position at home but require additional instruction.
Be ready to repeat instructions to the patient as needed during labor.The patient in labor may be in too much anxiety and discomfort to hear or comprehend instructions properly. Repeat the directions or information gently without reminding them that they have already been given them.

Nursing Care Plan for Labor and Delivery 2

Acute Pain

Nursing Diagnosis: Acute Pain related to increasing uterine contractions secondary to labor and delivery (active phase) as evidenced by restlessness, verbalized pain of 9 out of 10, inability to focus, and increasing pressure on the back.

Desired Outcome: The patient will recognize and utilize methods to control pain and discomfort brought about by the active phase of labor.

Nursing Interventions for Labor and DeliveryRationale
Engage the client in discussion to test sensory perceptions, and observe breathing patterns and pulse every 15 minutes for 1 to 2 hours.If the drug is absorbed into the bloodstream, systemic toxic reactions with impaired sensorium occur. An impaired sensorium may be a precursor to hypoxia, while excessive analgesia paralyzes the diaphragm and interferes with respiratory function.
Elevate the patient’s head 30 degrees, then vary positions by shifting side to side and hip rolling.Respiratory depression is prevented when the head of the patient is elevated. Position modifications let the fetus adjust to the size and form of the client’s pelvis and enhance comfort, particularly in a lateral position that increases venous return and improves placental circulation. On the other hand, a flat on-bed position causes hypotension, which decreases placental blood flow and fetal oxygenation
Encourage the patient to void every 1–2 hours and assess for bladder distension by palpating the suprapubic area.This prevents distension of the bladder, which causes discomfort, potential trauma, difficulty with fetal descent, and labor extension. A full bladder might induce delivery complications such as postpartum bleeding and birth delay.
Offer the patient appropriate comfort measures during labor.Massage is one of the most helpful non-pharmacological pain relief techniques. The presence of stimulation, such as vibrations, stroking, or massage, causes the opposite of pain impulses to be stronger and faster via tiny nerve fibers.
Instruct and support with proper breathing, relaxation, and abdominal lifting techniques.Breathing and relaxation strategies may help normal labor progress while blocking pain impulses. Abdominal lifting, on the other hand, is a labor pain relief technique that involves stroking the top of the stomach without pressing inside.
Provide analgesics through IV during contractions, if appropriate or advised by the physician.When medications are given through IV during uterine contractions, the amount of medication that instantly gets to the fetus is reduced.

Nursing Care Plan for Labor and Delivery 3

Fatigue

Nursing Diagnosis: Fatigue secondary to labor and delivery (transition phase) as evidenced by irritability, inability to focus and concentrate, verbalizations of exhaustion, and swelling of the cervix.

Desired Outcome: The patient will identify and practice methods to preserve energy between uterine contractions.

Nursing Interventions for Labor and DeliveryRationale
Determine the patient’s level of exhaustion.Fatigue can affect a patient’s physical and mental capacities to engage in labor and to learn and execute self-care and newborn care following delivery.
Place the patient in her most comfortable position during the most intense phase of labor.Sitting on a rocking chair or birthing ball, “towel-pull” posture, squatting, and the lateral Sims position are all recommended pleasant positions for muscle relaxation during labor. These positions induce rest, promote fetal descent, and reduce pressure on the sacrum.
Plan patient care to minimize disruptions and promote rest.This maximizes relaxation opportunities, protects a woman’s privacy, and ensures she is not disturbed while drawing the power she needs to give birth. Strangers should be avoided, information should be filtered, and queries, interruptions, and invasions should be minimized.
Provide the patient with a dimly lit, pleasant atmosphere.Minimizing stressors and promoting relaxation such as by allowing the patient to listen to her preferred music aids in resting.

Nursing Care Plan for Labor and Delivery 4

Altered Cardiac Output

Nursing Diagnosis: Altered Cardiac Output related to uterine contractions secondary to labor and delivery (expulsion stage) as evidenced by irregular pulse rate, diminished urinary output, low fetal heart rate, and changes in blood pressure.

Desired Outcome: The patient will sustain appropriate vital signs and keep the fetal heart rate within normal range.

Nursing Interventions for Labor and DeliveryRationale
Closely monitor the fetal heart rate after each contraction or patient attempts bearing down.This reveals slow fetal heart rate and inadequate oxygenation induced by anesthesia, Valsalva’s maneuver, or inappropriate posture, as well as a decline in maternal circulation and perfusion of the placenta.
Monitor the patient’s blood pressure and pulse every 5 to 15 minutes, as well as immediately after anesthesia administration, until the client is stable. Take note of the amount and quality of urine produced.Valsalva causes a rise in intrathoracic pressure, which decreases venous return and consequently cardiac output. Because vascular dilation delays venous return and lowers cardiac output, hypotension is the most common adverse effect after lumbar epidural or low spinal block.
Instruct the client to breathe in and out while bearing down, holding air for no more than 5 seconds at a time. Advise the patient to push only when she feels compelled to do so, rather than forcing it.Holding the breath while pushing on a closed glottis disrupts venous return and diminishes cardiac output, blood pressure, and pulse rate, whereas directed pushing has been linked to a decline in mean cerebral oxygen levels.
Encourage the patient to take a lateral recumbent, Fowler’s, or squatting position.Upright and lateral recumbent positions enhance venous return and avoid hypotension.

Nursing Care Plan for Labor and Delivery 5

Risk for Maternal Injury

Nursing Diagnosis: Risk for Maternal Injury related to placental separation difficulty secondary to labor and delivery (placental expulsion stage).

Desired Outcome: The patient will practice appropriate safety precautions and remain injury-free.

Nursing Stat Facts
Nursing Stat Facts
Nursing Interventions for Labor and DeliveryRationale
Check the size, firmness, and placement of the patient’s fundus and gently massage it.This aids in the detecting of uterine relaxation and associated uterine hemorrhage, as well as placental separation.
Assess the client’s risk of falling and assist with early ambulation to ensure safety.Blood flow resistance in the pelvic veins decreases, after delivery causing the patient’s blood pressure to drop when she sits or stands, and feels dizzy.
Remove the client’s legs at the same time from the leg support.Ambulation and minimizing the period the patient is in obstetric stirrups help to prevent thrombophlebitis through enhancing blood flow in the lower extremities, promoting venous return, and reducing the likelihood of clot formation.
Apply a sterile perineal pad to the vulva and perineum after cleansing them with sterile water and antiseptic solution.This eliminates any pathogens that could cause an ascending tract infection during the postpartum.
Instruct the patient to frequently empty her bladder.Overdistention in the immediate postpartum period might cause irreversible bladder injury.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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