Labor and Delivery Nursing Diagnosis & Care Plan

Labor is a series of contractions that help the cervix dilate to allow the fetus to move through the birth canal and out of the vagina. Labor usually begins around the EDD (expected date of delivery), but no one can predict exactly when it will start. Early signs of labor vary for every patient, but the most common ones are:

  • Progressive contractions
  • Rupture of the amniotic sac or “water breaking”
  • Bloody show or blood-tinged mucus

Labor includes the following natural processes:

  1. Dilation. Regular contractions will begin to dilate the cervix until it is fully open at 10 cm. This usually begins spontaneously but can also be medically induced for several reasons, such as a postterm pregnancy (42 weeks or beyond), when labor does not begin even after the water breaks, or when the mother and/or the fetus are experiencing distress.
  2. Effacement of the cervix. Effacement describes the thinning of the cervix to allow the baby to pass through the birth canal.
  3. Delivery of the placenta. Once the baby is delivered, the placenta will pass through the uterus and finally out of the vagina.

Depending on the circumstances, babies are delivered via vaginal delivery or cesarean section. The most common and preferred method is vaginally because it carries the lowest risk for complications and results in a faster recovery.

A C-section is done by an obstetrician making surgical incisions in the abdomen and uterus. It can be planned in advance or may occur during labor if an emergency arises, such as fetal distress, placental abruption, umbilical cord prolapse, or excessive bleeding.

Nursing Process

Labor and delivery nurses take care of women and their babies before, during, and after the delivery. They serve as the connection between the patient and the doctor. The nurse is a source of support for the mother and provides education, comfort measures, and updates about the progress of their labor, and about any possible interventions that may be needed further on. During C-section delivery, the nurse may also scrub in to assist in the surgery.

Nursing Care Plans Related to Labor and Delivery

Acute Pain

Labor and delivery is an extremely painful process, and the duration and intensity vary for each individual. The pain is caused by muscle contractions in the uterus and immense pressure on the cervix. It will present itself as intense cramps in multiple parts of the body, such as the abdomen, groin, and back.

Nursing Diagnosis: Acute Pain

Related to:

  • Muscle contractions
  • Tissue trauma

As evidenced by:

  • Restlessness
  • Moaning, crying, wincing
  • Verbalization of pain
  • Facial mask of pain
  • Diaphoresis
  • Tachycardia and tachypnea

Expected outcomes:

  • Patient will verbalize a decrease in pain.
  • Patient will show signs of being at ease and comfort, as evidenced by resting and breathing even and unlabored.
  • Patient will demonstrate and utilize practices that will help reduce the pain, such as relaxation and breathing techniques and changes in body positioning.

Assessment:

1. Assess the patient’s level of pain using the numeric pain scale.
Pain is always subjective. Finding out how much pain the patient is experiencing is important to drive further interventions.

2. Screen pain along with assessing vital signs.
Pain is often considered the fifth vital sign. In addition to this, blood pressure, pulse, and respiratory rates can elevate when experiencing pain.

Interventions:

1. Establish a rapport with the patient and their significant other.
Entertaining any questions they may have will reduce barriers in communication, ultimately easing any fears and promoting trust and relaxation.

2. Instruct the patient on breathing techniques.
Breathing can help distract from pain. The nurse can instruct on breathing techniques such as belly breathing or pant-pant-blow breathing through contractions.

3. Discuss pain relief options.
The mother should be in charge of her labor plan. The nurse can discuss and explain options for pain relief and help the mother decide what is best for them.

4. Assist the patient in positioning.
Adjusting the body’s positioning will help limit fatigue and enhance circulation. Allow the mother to decide which positions relieve pain, such as side-lying, leaning, or on all fours.

5. Provide comfort measures.
Back rubs, pillows for better positioning, and ice cubes can provide short-term relief.

6. Administer analgesics if ordered.
An epidural can be placed to block pain below the waist. The nurse assists the anesthesiologist with positioning and preparing the site for epidural insertion in the lower back.


Risk for Infection

The risk of infection increases due to the ability of some pathogens to invade after the rupture of amniotic membranes. Puerperal sepsis is an infection in the genital tract that can occur after giving birth and spread throughout the body.

Nursing Diagnosis: Risk for Infection

Related to:

  • Repetitive vaginal examinations
  • Rupture of amniotic membranes
  • Fecal contamination
  • Umbilical cord prolapse

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.

Expected outcomes:

  • The patient will verbalize signs and symptoms of infection to notify the nurse and/or provider of.
  • The patient will demonstrate keeping their environment clean, safe, and aseptic.
  • The patient will show no signs of infection.

Assessment:

1. Assess vaginal secretions and amniotic fluid.
If the secretions are tested using Nitrazine paper, an alkaline reaction (blue) will confirm the presence of amniotic fluid. The color, odor, amount, and character should be recorded. Discoloration and foul odor will indicate possible infection as normal fluids should appear clear, with some specks of vernix (protective layer on baby’s skin) and lanugo (hair covering the baby’s body).

2. Monitor and record fetal heart rate.
A rate greater than 160 beats per minute (fetal tachycardia) may indicate infection. Poor oxygenation may also occur, especially during abnormal labor.

3. Monitor vital signs and white blood cell count.
An elevation of WBC count and abnormal vital signs can indicate infection (maternal temperatures of 38℃/100°F or higher and a WBC count of more than 18,000-20,000/mm³). There is an increased risk for intra-amniotic infection (chorioamnionitis) within 4 hours of membrane rupture.

Interventions:

1. Limit vaginal examinations.
Repeated vaginal examinations increase the risk of introducing pathogens into the vagina and birth canal.

3. Utilize aseptic technique during invasive procedures.
The use of aseptic technique will help in preventing and limiting the growth of bacteria, such as during IV or urinary catheter insertions.

4. Demonstrate proper perineal care and good handwashing techniques.
Proper handwashing reduces the risk of infection. Proper perineal hygiene, such as wiping from front to back after giving birth, will help lessen the possibility of introducing pathogens into perineal lacerations. Keeping the site clean after birth will also aid in faster wound recovery.

5. Administer antibiotics as prescribed.
The administration of antibiotics during labor is controversial as the medication may affect the baby. Still, when needed, it may protect against infection, such as in case of prolonged rupture of membranes.

6. Administer oxytocin as prescribed.
Oxytocin is a natural hormone used to induce labor by causing the uterus to contract. The longer it takes for the baby to come out, the more susceptible the mother and the baby are to infections.


Anxiety

Anxiety is normal and can begin long before labor and delivery. Especially with first-time mothers, childbearing comes with the fear of not knowing how the delivery will turn out and worries regarding the baby’s health and the pain of childbirth. The possible use of epidurals and the need for a C-section also contribute to the fear.

Nursing Diagnosis: Anxiety

Related to:

  • Perceived threat to baby
  • Fear of unexpected outcomes
  • Surgical intervention (C-section)
  • Threat to health
  • Fear of pain

As evidenced by:

  • Increased tension
  • Feelings of inadequacy
  • Expression of concerns
  • Alterations in vital signs
  • Restlessness

Expected outcomes:

  • Patient will verbalize ease of worries and stress.
  • Patient will express feelings of concern and anxiety.
  • Patient will utilize support systems effectively.

Assessment:

1. Assess psychological and emotional state.
Emotions related to anxiety and uncertainty can affect the labor and delivery process and interfere with the patient’s willingness to cooperate.

2. Assess the patient’s specific concerns.
Inquiring about the patient’s causes of anxiety can open up a dialogue that allows the nurse to potentially clarify and assuage feelings of fear or the unknown.

Interventions:

1. Acknowledge the patient’s feelings and verbalizations that may indicate guilt.
Knowing how the patient feels towards the process will help gauge how they understand why interventions can sometimes be required during labor and delivery and that these choices are available because they may be medically necessary and not because they are lacking personally.

2. Acknowledge and include their support system.
Keeping the significant other/s involved during the process, as well as praising them for any progress, will help establish rapport and trust, leading to a more relaxed environment during childbirth.

3. Maintain a calm demeanor, giving clear and concise explanations.
During emergency deliveries, anxiety may occur due to the process not meeting their expectations. The nurse should remain calm and assertive to maintain control of the situation.

4. Encourage relaxation techniques.
To keep the abdominal wall from becoming tense, the patient needs to be instructed in proper relaxation techniques such as deep-breathing exercises, effleurage (light, rhythmic, circular strokes on the abdomen), and gentle massages of the shoulders and limbs. This will allow the uterus to rise with contractions without pressing against the hard abdominal wall.

5. Provide a calm environment.
Labor can be a long process. When appropriate, keep lighting dim and noises and interruptions to a minimum to allow for rest.


References

  1. Standford Medicine Children’s Health. Labor and Delivery. https://www.stanfordchildrens.org/en/topic/default?id=labor-and-delivery-138-W1314. Accessed Nov. 26, 2022
  2. Johns Hopkins Medicine. Labor. https://www.hopkinsmedicine.org/health/wellness-and-prevention/labor. Accessed Nov. 26, 2022
  3. Hutchison, J., Mahdy, H., Hutchison, J. (2022). Stages of Labor. StatPearls Publishing LLC.
  4. Mayo Clinic. Labor induction. https://www.mayoclinic.org/tests-procedures/labor-induction/about/pac-20385141. Accessed Nov. 26, 2022
  5. Cleveland Clinic. Types of Delivery. https://my.clevelandclinic.org/health/articles/9675-pregnancy-types-of-delivery. Accessed on Nov. 27, 2022
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.