LABOR Stage I—Active Phase

As contractions increase to moderate intensity in the active phase, and as the cervix dilates from 4 to 8 cm, the
client becomes more involved and focused on the labor process. The active phase lasts approximately 1–2 hr in the
multipara and 3–4 hr in the nullipara. The fetus descends in the birth canal at approximately 2 cm/hr in the multipara
and 1 cm/hr in the nullipara.

CLIENT ASSESSMENT DATA BASE

Activity/Rest
May show evidence of fatigue

Ego Integrity
May appear more serious and absorbed with labor process
Apprehensive about ability to control breathing and/or perform relaxation techniques

Pain/Discomfort
Contractions are moderate, occurring every 2.5–5 min and lasting 45–60 sec.

Safety
Fetal heart tones (FHTs) detected slightly below umbilicus in vertex position
FHR variability and periodic changes commonly noted in response to contractions, abdominal palpation, and fetal
movement

Sexuality
Cervix dilates from approximately 4–8 cm (1.5 cm/hr multipara, 1.2 cm/hr nullipara).
Moderate amount of bloody show present.
Fetus descends to 11–12 cm below ischial spines.

NURSING PRIORITIES
1. Promote and facilitate normal progression of labor.
2. Support client’s/couple’s coping abilities.
3. Promote maternal and fetal well-being.

NURSING DIAGNOSIS: Pain [acute]

May Be Related To: Tissue dilation/muscle hypoxia, pressure on adja- cent structures,
stimulation of both parasympathetic and sympathetic nerve endings
Possibly Evidenced By: Verbalizations, distraction behaviors (restlessness), muscle tension
DESIRED OUTCOMES/EVALUATION Identify/use techniques to control pain/
CRITERIA—CLIENT WILL: discomfort.
Report discomfort is minimized.
Appear relaxed/resting between contractions.
Be free of untoward side effects if analgesia/anesthetic agents are
administered.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess degree of discomfort through verbal and Attitudes and reactions to pain are individual and
nonverbal cues; note cultural influences on based on past experiences, understanding of
pain response. physiological changes, and cultural expectations.
Assist in use of appropriate breathing/relaxation May block pain impulses within the cerebral
techniques and in abdominal effleurage. cortex through conditioned responses and cutaneous
stimulation. Facilitates progression of normal labor.
Assist with comfort measures (e.g., back/leg rubs, Promotes relaxation and hygiene; enhances feeling
sacral pressure, back rest, mouth care, repositioning, of well-being. Note: Lateral recumbent position
shower/hot tub use, perineal care, and linen changes). reduces uterine pressure on the vena cava, but
periodic repositioning prevents tissue ischemia
and/or muscle stiffness, and promotes comfort.
Encourage client to void every 1–2 hr. Palpate above Keeps bladder free of distension, which can
symphysis pubis to determine distension, especially increase discomfort, result in possible trauma,
after nerve block. interfere with fetal descent, and prolong labor.
Epidural or pudendal analgesia may interfere with
sensations of fullness.
Provide information about available analgesics, Allows client to make informed choice about
usual responses/side effects (client and fetal), and means of pain control. Note: If conservative
duration of analgesic effect in light of current situation. measures are not effective and increasing muscle
tension impedes progress of labor, minimal use of
medication may enhance relaxation, shorten labor,
limit fatigue, and prevent complications.
Support client’s decision about the use or nonuse Helps reduce feelings of failure in the client/
of medication in a nonjudgmental manner. couple who may have anticipated an unmedicated
Continue encouragement for efforts and use of birth and did not follow through with that plan.
relaxation techniques. Enhances sense of control and may prevent/
decrease need for medication.
Time and record the frequency, intensity, and Monitors labor progress and provides information
duration of uterine contractile pattern per protocol. for client. Note: Anesthetic agents may alter uterine
contractile pattern. (Refer to CP: Dysfunctional
Labor/Dystocia.)
Assess nature and amount of vaginal show, Cervical dilation should be approximately
cervical dilation, effacement, fetal station, 1.2 cm/hr in the nullipara and 1.5 cm/hr in the
and fetal descent. multipara; vaginal show increases with fetal descent.
Choice and timing of medication is affected by
degree of dilation and contractile pattern.
Provide safety measures; e.g., encourage client Regional block anesthesia produces vasomotor
to move slowly, keep siderails up after drug paralysis, so that sudden movement may
administration, and support legs with precipitate hypotension. Analgesics alter
position changes. perception, and client may fall trying to get out of
bed.
Assess BP and pulse every 1–2 min after regional Maternal hypotension, the most common side
injection for first 15 min, then every 10–15 min effect of regional block anesthesia, may interfere
for remainder of labor. Elevate head approximately with fetal oxygenation. Elevating head prevents
30 degrees, alternate position by turning side to block from migrating up and causing respiratory
side and use of hip roll. depression. Lateral positioning increases venous
return and enhances placental circulation.
Monitor FHR variability. Agents such as bupivacaine (Marcaine) and fentanyl
(Sublimaze) reportedly have little effect on FHR
variability (but in practice may decrease variability);
alterations should be investigated thoroughly. Note:
Risks associated with caudal anesthesia include
perforation of fetal scalp, as well as maternal rectum,
and is rarely used.

Using alcohol pad or cotton swab on both sides of Increasing loss of sensation following when
abdomen, assess and record level of sensation epidural block indicates migration of anesthesia.
q 30 min. Level above T-9 may alter respiratory function while
loss of sensation at level of breastbone
(approximately 7–6) increases risk of profound
hypotension.

Engage client in conversation to assess sensorium; Systemic toxic responses with altered sensorium
monitor breathing patterns and pulse. occur if medication is absorbed into the vascular
system. Altered sensorium may also be an early
indicator of developing hypoxia. Interference with
respiratory functioning occurs if analgesia is too high,
paralyzing the diaphragm.

Assess for warmth, redness of large toe or ball of Ensures proper placement of catheter for
foot, and equal distribution of spinal medication continuous block and adequate levels of
if used. anesthetic agent.

Monitor FHR electronically, and note decreased Decreased FHR variability is a common side effect
variability or bradycardia. of many anesthetics/analgesics. These side effects
can begin 2–10 min after administration of anesthetic,
and may last for 5–10 min, on occasion.

Collaborative
Assist with complimentary therapies as indicated, Some clients and healthcare providers may prefer
e.g., acupressure/acupuncture. a trial of alternative therapies to mediate pain before
pursuing invasive techniques.
Administer analgesic such as butorphanol tartrate IV route is preferred because it ensures more rapid
(Stadol) or meperidine hydrochloride (Demerol) and equal absorption of analgesic. Medication
by IV or deep intramuscular (IM) during administered by IM route may require up to 45
contractions, if indicated. min to reach adequate plasma levels, and maternal
uptake may be variable, especially if drug is injected
into subcutaneous fat instead of muscle.
Administering IV drug during uterine contraction
decreases amount of medication that immediately
reaches the fetus. Note: Stadol is used with caution
when drug dependence is suspected, and is
contraindicated for clients with opiate dependency
because drug interaction may precipitate withdrawal
in drug-dependent clients.
Administer oxygen, and increase plain fluid intake Increases circulating fluid volume, placental
if systolic pressure falls below 100 mm Hg or falls perfusion, and oxygen available for fetal uptake.
more than 30% below baseline pressure.
Obtain fetal scalp sample if bradycardia persists Prolonged fetal bradycardia may indicate need to
for 30 min or more per electronic monitor. determine pH for evaluation of hypoxia.
Administer IV bolus of 500–1000 ml of lactated Increased circulating fluid level helps prevent side
Ringer’s solution just before administration of effects of hypotension associated with block.
lumbar epidural block.
Assist with epidural or caudal block anesthesia Provides relief once active labor is established;
using an indwelling catheter. reinforcement through catheter provides sustained
comfort during delivery. Such analgesia does not
interfere with uterine activity and/or Ferguson
reflex. While it relaxes the cervix and facilitates the
labor process, it may alter internal fetal rotation and
diminish client’s ability to bear down when needed.
Note: A new technique of ultra–low-dose epidural is
being used to achieve pain control without negative
effect on client’s ability to sense contractions and
push effectively. With this approach, the client is not
restricted to bedrest but may even be up walking as
able.

Administer emergency medications as indicated, Narcan is used to reverse opiate-induced

e.g., nalaxone (Narcan) or ephedrine (Ephedra). respiratory depression. Adrenalin may be required
for hypotensive episodes not responsive to IV fluid
bolus.

Succinylcholine chloride, and assist with intubation, Systemic toxic reaction to epidural anesthetic may
as appropriate. alter sensorium or cause convulsions if medication is
absorbed into the vascular system.

NURSING DIAGNOSIS: Urinary Elimination, altered

May Be Related To: Altered intake, fluid shifts, hormonal changes, mechanical
compression of bladder, effects of regional anesthesia

Possibly Evidenced By: Changes in amount/frequency of voiding, urinary urgency, urine

retention, slowed progression of labor

DESIRED OUTCOMES/EVALUATION Empty bladder appropriately.

CRITERIA—CLIENT WILL: Be free of bladder injury.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Palpate above symphysis pubis. Detects presence of urine in bladder and degree of
fullness. Incomplete emptying of the bladder may
occur because of decreased sensation and tone.
Record and compare intake and output. Note Output should approximate intake. Increased
amount, color, concentration, and specific output may reflect excessive fluid retention prior
gravity of urine. to the onset of labor and/or effects of bedrest; i.e.,
increased glomerular filtration rate and decreased
adrenal stimulation. Specific gravity reflects kidney’s
ability to concentrate urine and the client’s hydration
status. Decreased output may occur with
dehydration, hemorrhage, and pregnancy-induced
hypertension (PIH). (Refer to CP: Intrapartal
Hypertension.)

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

Position client upright, run water from the faucet, Facilitates voiding/enhances emptying of bladder.
pour warm water over the perineum, or have client
blow bubbles through a straw.
Take temperature and pulse, noting increases. Helps monitor degree of hydration.
Assess dryness of skin and mucous membranes.

Collaborative
Catheterize as indicated. An overdistended bladder can cause atony, impede
fetal descent, or become traumatized by presenting
part of the fetus.

NURSING DIAGNOSIS: Anxiety, risk for

Risk Factors May Include: Situational crisis, interpersonal transmission from other(s), unmet
needs
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Report anxiety minimized/manageable.
CRITERIA—CLIENT WILL: Appear relaxed and/or in control.
Self-initiate breathing/relaxation techniques.
Follow instructions of partner/nurse.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess client’s anxiety level through verbal and Identifies level of intervention necessary. Excess
nonverbal cues. anxiety increases pain perception and can have
negative impact on the outcome of labor.
Provide continuous intrapartal professional Fear of abandonment can intensify as labor
support/doula. Inform client that she will not progresses. The client may experience increased
be left alone. anxiety and/or loss of control when left unattended.
Doulas can provide client with emotional, physical,
and informational support as an adjunct to primary
nurse.
Encourage use of breathing and relaxation Assists in reduction of anxiety and of perception of
techniques. Breathe with client/couple as necessary. pain within the cerebral cortex, enhancing sense of
control.
Monitor FHR and its variability; monitor maternal BP. Prolonged anxiety can result in endocrine
imbalances, with excess release of epinephrine and
norepinephrine, elevating BP and pulse. Note:
Medications relaxing smooth muscle may reduce
FHR variability and maternal BP.
Evaluate contractile pattern/progression of labor. Increasing force/intensity of uterine contractions
can heighten client’s concerns about personal
capabilities and outcome of labor. In addition,
increased levels of epinephrine may also inhibit
myometrial activity. Excess anxiety and stress levels
can deplete glucose reserves, thereby decreasing the
amount available for adenosine triphosphate (ATP)
synthesis, which is necessary for uterine contractions.
Refer to CP: Labor: Stage I—Latent Phase; ND: If client is admitted during the active phase,
Anxiety, risk for. interventions usually accomplished during the latent
phase need to be addressed at this time.

Collaborative
Administer combination of narcotic and sedative Addition of mild sedative potentiates the action of
(e.g., meperidine hydrochloride [Demerol] and the narcotic, reducing anxiety, and assisting client
promethazine [Phenergan] IM. in focusing on breathing/relaxation techniques.

NURSING DIAGNOSIS: Coping, Individual/Couple, risk for ineffective

Risk Factors May Include: Situational crises, personal vulnerability, inadequate support systems
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Identify effective coping behaviors.
CRITERIA—CLIENT/COUPLE WILL: Engage in activities to maintain/enhance control.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Ascertain client’s understanding and expectations The client’s/couple’s coping skills are most
of the labor process. challenged during the active and transition phases as
contractions become increasingly intense. Lack of
knowledge, misconceptions, or unrealistic expectations
can have a negative impact on coping abilities.
Encourage verbalization of feelings. Helps nurse gain insight into individual needs, and
assists client/couple to deal with concerns.
Reinforce use of positive coping mechanisms and Assists client in maintaining or gaining control.
relaxation techniques. Enhances feelings of competence, and fosters self-
esteem. The stressors that accompany labor can be
threatening to a woman’s self-esteem, especially if she
has not coped positively with past experiences and/or
successfully accomplished the tasks of pregnancy.
Note withdrawn behavior. Adolescents, in particular, may become withdrawn
and not express needs to be nurtured. This may also
be true for some cultures (such as Native American
or Vietnamese) where the woman is encouraged to be
stoic/suffer in silence.
Assess effectiveness of labor partner. Provide role The client is influenced by those around her and
modeling as indicated. may respond positively when others remain calm
and in control.
Demonstrate behaviors and techniques partner can Encourages choice of multiple options, enhances
use to assist with pain control and relaxation. Provide coping and self-esteem of partner/couple.
information regarding water, music, imagery,
aromatherapy, and correct misconceptions.
Limit verbalization/instruction during contractions Allows client to focus attention and may enhance
to a single “coach.” ability to follow directions. Multiple coaches may
actually result in decreased concentration, confusion,
and loss of control.
Provide positive reinforcement for efforts. Use Encourages repetition of appropriate behaviors.
touch and soothing words of encouragement. Enhances individual’s confidence in own ability to
cope with or handle labor, while also meeting her
needs for dependency.

NURSING DIAGNOSIS: Injury, risk for maternal

Risk Factors May Include: Effects of medication, delayed gastric motility, physiological urges
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Verbalize understanding of individual risks and
CRITERIA—CLIENT WILL: reasons for specific interventions.
Follow directions to protect self/fetus from injury.
Be free of preventable injury/complications.

ACTIONS/INTERVENTIONS RATIONALE
Independent
Monitor uterine activity manually and/or The uterus is susceptible to possible rupture if a
electronically, noting frequency, duration, and hypertonic contractile pattern develops
intensity of contraction. (Refer to CP: Dysfunctional spontaneously or in response to oxytocin
Labor/Dystocia.) administration. Placental separation and hemorrhage
can also occur if contraction persists.

Institute bedrest and use of siderails (as labor Promotes safety should dizziness or precipitous
intensifies) or following administration of delivery occur following administration of
medication. Avoid leaving client unattended. medication.

Place client in lateral recumbent or semi- Increases placental perfusion and reduces supine
upright position. hypotensive syndrome. Note: Some women may
prefer an upright position during the phase of
maximum slope of labor (i.e., 4–9 cm dilation).
Studies suggest this position may shorten this phase
of labor without increasing discomfort or producing
adverse effects on fetal well-being.

Administer perineal care after defecating or urinating. Reduces risk of ascending infection, which can occur,
especially with prolonged rupture of membranes.

Monitor temperature and pulse. Elevations are indicators of developing infection.

Offer client clear liquids or ice chips, as appropriate; Delayed gastric motility inhibits digestion during
avoid solid foods. labor, placing the client at risk for aspiration.
However, client can benefit from intake of calories in
PO fluids to help generate energy for work of labor.

Monitor urine for ketones. Urinary ketones indicate metabolic acidosis resulting
from a deficiency in glucose metabolism, which may
reduce uterine activity and cause myometrial
fatigue that prolongs labor.

Note time of rupture of membranes and The incidence of ascending infection increases with
characteristics of amniotic fluid. the passage of time.
Have client pant or blow out if she feels the Panting during the active phase or the transition
premature urge to bear down. phase prevents bearing down too early and can
thereby reduce risk of lacerations or edema of the
cervix/birth canal.

Collaborative
Discontinue or decrease flow rate of oxytocin when Helps to prevent hypertonic contractile pattern
used if contraction lasts longer than 90 sec, or if the with resultant decreased placental blood flow and
uterus fails to relax completely between risk of uterine rupture. (Refer to CP: Dysfunctional
contractions. Labor/Dystocia.)
Administer IV antibiotics, if indicated. Administration of antibiotics during labor is
controversial, but on occasion may protect against
infection in cases of prolonged rupture of
membranes.

NURSING DIAGNOSIS: Gas Exchange, risk for impaired fetal

Risk Factors May Include: Altered oxygen supply/blood flow
 Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Display FHR and beat-to-beat variability within
CRITERIA—FETUS WILL: normal limits (WNL).
Be free of adverse effects of hypoxia during labor.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess for presence of maternal factors or High-risk situations that negatively affect
conditions that compromise uteroplacental circulation are likely to be manifested in late
circulation (e.g., diabetes, PIH, kidney or decelerations and fetal hypoxia.
cardiac disorders). Note prenatal testing of
placental functioning by nonstress test (NST)
or contraction stress test (CST).
Monitor FHR every 15–30 min if WNL. Monitor Fetal tachycardia or bradycardia is indicative of
FHR electronically if it is less than 120 bpm, or possible compromise, which may necessitate
greater than 160 bpm. Periodically compare intervention. Note: Ext ernal monitoring device
client’s apical heart rate with FHR. may inadvertently record maternal rather than fetal
heart activity.
Check FHR immediately if membranes rupture, Detects fetal distress due to visible or occult cord
and then again 5 min later. Observe maternal prolapse.
perineum for visible cord prolapse.
Instruct client to remain on bedrest if presenting Reduces risk of cord prolapse.
part does not fill the pelvis (station 14).
Note and record color, amount, and odor of In a vertex presentation, prolonged hypoxia results
amniotic fluid and time of membrane rupture. in meconium-stained amniotic fluid owing to vagal
stimulation, which relaxes the fetal anal sphincter.
Hydramnios may be associated with fetal anomalies
and poorly controlled maternal diabetes.
Monitor fetal descent in birth canal through Prolonged head compression stimulates vagal
vaginal examination. In cases of breech presentation, responses and may result in fetal bradycardia if
assess FHR more frequently. the rate of descent is not at least 1 cm/hr for
primiparas or 1.5 cm/hr for multiparas. Fundal
pressure in breech presentation may cause vagal
stimulation and head compression.
Assess FHR changes during a contraction, noting Detects severity of hypoxia and possible cause.
decelerations and accelerations. The fetus is vulnerable to potential injury during
labor, owing to situations that reduce oxygen levels,
such as cord prolapse, prolonged head compression,
or uteroplacental insufficiency.
Monitor uterine activity manually or electronically. Development of hypertonicity can compromise
uteroplacental circulation and fetal oxygenation.
Talk to client/couple as care is being given, and Provides psychological support and assurance to
provide information about situation, as appropriate. reduce anxiety related to increased monitoring.
Collaborative
If late or persistent variable decelerations occur:
Transfer to level 2 or 3 hospital setting as May require specialized monitoring/interventions.
indicated:
Discontinue oxytocin if it is being administered; Strong contractions caused by oxytocin may inhibit
or reduce uterine relaxation and lower fetal oxygen levels.
Place client in lateral recumbent position; Increases placental perfusion, which may correct
problem if caused by uteroplacental insufficiency.
Turn client from side to side as indicated; Helps take pressure from the presenting part off the
umbilical cord, if cord is being compressed.
Increase plain IV infusion rate; Increases circulating fluid volume and placental
perfusion.
Administer oxygen to client via mask; Increases available oxygen for placental transfer.
Prepare for and assist with fetal scalp sampling, Prolonged, decreased variability may indicate
repeating as indicated; acidosis. On occasion, determining fetal pH value
may be helpful in identifying fetal respiratory
acidosis and metabolic reserves.
Prepare for delivery by the most expeditious Repetitive late decelerations over a 30-min period
means or by surgical intervention, if no accompanied by decreased variability may warrant
improvement occurs. a cesarean birth to prevent fetal injury and/or
death from hypoxia.
(Refer to CP: Labor Stage I—Latent Phase; NDs: Knowledge deficit [Learning Need]; Infection, risk for maternal; Injury, risk for fetal;
and Fluid Volume risk for deficit.)