DYSFUNCTIONAL LABOR (DYSTOCIA)

Dystocia refers to difficult labor which is usually due to uterine dysfunction, fetal
malpresentation/abnormality, or pelvic abnormality. Dystocia may arise from any
of the four main components of the labor process: the power, or the force that
propels the fetus (uterine contractions); the passenger (the fetus); the
passageway (the birth canal); or the psyche (the woman’s and family’s perception
of the event). In addition, the length of labor may be unusually short or long.

Risk factors for dysfunctional labor include the following:

 Advanced maternal age

 Obesity
 Overdistention of uterus
 Cephalopelvic disproportion (CPD)
 Overstimulation of the uterus
 Maternal fatigue
 Dehydration
 Fear or anxiety
 Lack of analgesic assistance
Dysfunction can occur at any point in labor, but it is generally classified as
primary (occurring at the onset of labor) or secondary (occurring later in labor).
Although the fetus is passive during birth, complications may arise if an infant is
immature or preterm or if the maternal pelvis is so undersized that its diameters
are smaller than the fetal skull. Aside from a concern with the power of labor and
the passenger, the third reason dystocia can occur.

Nursing care plans for dysfunctional labor or dystocia include:

 Risk For Maternal Injury

 Risk For Fetal Injury
 Risk For Fluid Volume Deficit
 Ineffective Individual Coping
 Acute Pain
Risk for Injury (Maternal)
The American College of Obstetricians and Gynecologists (ACOG) practice
bulletins published in 2002 and 2017 noted that maternal complications with
shoulder dystocia include a postpartum hemorrhage rate of 11% and a third- and
fourth-degree perineal laceration in 4% of cases. Health care professionals caring
for women in labor need to be aware of the increased rate of maternal
complications associated with dystocia and be prepared to manage these
(Mendez-Figueroa et al., 2021).

Nursing Diagnosis

 Risk for Injury (Maternal)

Risk factors

 Alteration of muscle tone/contractile pattern

 Maternal fatigue
 Mechanical obstruction to fetal descent
Possibly evidenced by

 [Not applicable]
Desired Outcomes

 The client will accomplish cervix dilation at least 1.2 cm/hr for
primipara, 1.5 cm/hr for multipara in the active phase, with fetal
descent at least 1 cm/hr for primipara, and 2 cm/hr for multipara.
 The client will display vital signs within normal limits.
Nursing Assessment and Rationales

1. Review the history of labor, onset, and duration.

This helps identify possible causes, needed diagnostic studies, and appropriate
interventions. Uterine dysfunction may be caused by an atonic or hypertonic
state. Uterine atony is classified as primary when it occurs before the onset of
labor (latent phase) or secondary when it occurs after well-established labor
(active phase). Prolonged labor appears to result from several factors but is most
likely to occur if the contractions are hypotonic, hypertonic, or uncoordinated.

2. Assess for signs of amnionitis. Note elevated temperature or WBC; odor

and color of vaginal discharge.
The development of amnionitis is directly related to the length of labor, so the
delivery should occur within 24 hr after the rupture of membranes. Observe,
report, and document maternal temperature above 38°C (100.4°F), fetal
tachycardia, and tenderness over the uterine area. These are signs that an
infection has developed.

3. Assess uterine contractile pattern manually (palpation) or electronically

via external or internal monitor with an internal uterine pressure catheter
(IUPC).
Dysfunctional contractions lengthen labor, increasing the risk of maternal/fetal
complications. A hypotonic pattern is reflected by frequent, mild contractions
measuring less than 30 mm Hg via IUPC or “soft as chin” per palpation. A
hypertonic pattern is reflected by increased frequency, an elevated resting tone
per palpation or greater than 15 mm Hg via IUPC, and possibly decreased
intensity of contractions. Note: The intensity of contractions cannot be measured
by an external monitor.

4. Evaluate the current level of fatigue and anxiety, as well as activity and
rest before the onset of labor.
Excess maternal exhaustion contributes to secondary dysfunction or may result
from prolonged labor/false labor. An exhausted client may be unable to gather
her resources to push appropriately. The client may also not push effectively
during the second stage of labor because she fears tearing her perineal tissues.

5. Note effacement, fetal station, and fetal presentation.

These indicators of labor progress may identify a contributing cause of prolonged
labor. For example, breech presentation is not as effective a wedge for cervical
dilation as is vertex presentation. Abnormalities in fetal presentation and position
prevent the smallest diameter of the fetal head from passing through the
smallest diameter of the pelvis for effective labor progress. A prolonged latent
phase may occur if the cervix is not “ripe” at the beginning of labor.

6. Assess and record the client’s pelvic measurements.

Every primigravida should have pelvic measurements taken and recorded before
week 24 of pregnancy so, based on these measurements and the assumption the
fetus will be of average size, a birth decision can be made. Inlet contraction is the
narrowing of the anteroposterior diameter of the pelvis to less than 11 cm or of
the transverse diameter to 12 cm or less.
7. Evaluate the degree of hydration. Note the amount and type of intake.
Prolonged labor can result in a fluid-electrolyte imbalance and depletion of
glucose reserves, resulting in exhaustion and prolonged labor with an increased
risk of uterine infection, postpartal hemorrhage, or precipitous delivery in the
presence of hypertonic labor. Low serum electrolytes or body fluid can occur in
labor for the same reason as a decreased glucose level- there has been a long
interval between eating and the end of labor.

8. Graph cervical dilation and fetal descent against time (i.e., Friedman
curve).
This may be used on occasion to record progress/ prolongation of labor. The
Friedman curve represents the basis for presenting labor progression graphically.
It aimed to identify the abnormal progress of labor. It monitors cervical dilatation
and includes observations of necessary intrapartum details (Lavender & Bernitz,
2020).

9. Palpate the abdomen of a thin client for the presence of a pathological

retraction ring between uterine segments.
Two distinct swellings will be visible on the client’s abdomen: the retracted uterus
and the extrauterine fetus. These rings are not palpable through the vagina or the
abdomen in the obese client. In obstructed labor, a depressed pathological ring
(Bandl’s ring) may develop at the juncture of lower and upper uterine segments,
indicating an impending uterine rupture.

10. Investigate reports of severe abdominal pain. Note signs of fetal

distress, cessation of contractions, and presence of vaginal bleeding.
This may indicate developing uterine tears/acute rupture necessitating
emergency surgery. Note: Hemorrhage is usually occult since it is intraperitoneal
with hematomas of the broad ligament. If a uterus should rupture, the client
experiences a sudden, severe pain during a strong labor contraction, which she
may report as a “tearing” sensation. Hemorrhage from the torn uterine arteries
floods into the abdominal cavity and possibly into the vagina.

Nursing Interventions and Rationales

1. Encourage the client to void every two hours. Assess for bladder fullness
over the symphysis pubis.
A full bladder may inhibit uterine activity and interfere with fetal descent. Urge
the client in labor to void every two hours to keep the bladder empty, so this
does not add to the slow progress caused by hypotensive or hypertensive
contractions.

2. Place the client in a lateral recumbent position and encourage bed rest or
sitting position/ambulation, as tolerated.
Relaxation and increased uterine perfusion may correct a hypertonic pattern.
Ambulation may assist gravitational forces in stimulating normal labor patterns
and cervical dilation. Contractions are usually stronger and more effective when
the client assumes an upright position or lies on her side. Walking or nipple
stimulation may intensify contractions.

3. Assist the client in positioning if shoulder dystocia is suspected.

Asking or assisting the client to flex her thighs sharply on her abdomen
(McRoberts maneuver) widens the pelvic outlet and may allow the anterior
shoulder to be born. Applying suprapubic pressure may also help the shoulder
escape from beneath the symphysis pubis and be born. These are the first two of
a series of maneuvers that help resolve shoulder dystocia.

4. Have an emergency delivery kit available.

This may be needed in the event of precipitous labor and delivery, which are
associated with uterine hypertonicity. If decelerations in the FHR, an abnormally
long first stage of labor, or lack of progress with pushing occurs, cesarean birth
may be necessary. Be certain that the client and her partner understand that,
although contractions are strong, they are ineffective and are not achieving
cervical dilatation.

5. Remain with the client if possible, or arrange for the presence of a doula
as appropriate.
A doula is a second support person in labor. The doula does not replace the
client’s partner and does much more than time contractions. The use of a doula is
an individual choice. Although research on the subject is not extensive, there are
suggestions that rates of oxytocin augmentation, epidural anesthesia, and
cesarean birth can all be reduced by doula support. With specific education,
many nurses participate as either doula or special support nurses to clients in
labor.
6. Provide a quiet environment as indicated.
Decreasing external stimuli may be important to allow sleep after medication
administration to a client in a hypertonic state. It is also helpful in decreasing the
level of anxiety, which can contribute to both primary and secondary uterine
dysfunction. Providing dim lights and providing a warm temperature could be
given more consideration in most institutions.

7. Prepare the client for amniotomy, and assist with the procedure, when
the cervix is 3–4 cm dilated.
Rupture of membranes relieves uterine overdistension (a cause of both primary
and secondary dysfunction) and allows presenting part to engage and labor to
progress in the absence of cephalopelvic disproportion (CPD). Note: Active
management of labor (AML) protocols may support amniotomy once the
presenting part is engaged to accelerate labor/help prevent dystocia. The nurse
assists the health care provider with the procedure and cares for the client and
fetus afterward. Amniotomy stimulates prostaglandin secretion, which stimulates
labor.

8. Avoid administration of narcotics or epidural block anesthetics until the

cervix is 4 cm dilated.
A hypertonic contractile pattern may occur in response to oxytocin stimulation;
sedation/analgesia given too early (or more than the client’s needs) can inhibit or
arrest labor. Epidural or subarachnoid blocks may depress or eliminate the
natural urge to push. The use of narcotic analgesics is also avoided if birth is
expected within an hour.

9. Administer narcotic or sedative, such as morphine, pentobarbital

(Nembutal), or secobarbital (Seconal), for sleep as indicated.
Morphine helps promote heavy sedation and eliminate hypertonic contractile
patterns. Hypertonic contractions may occur more because more than one
uterine pacemaker is stimulating contractions. They tend to be more painful than
usual because the myometrium becomes tender from constant lack of relaxation
and the anoxia of uterine cells that results. A period of rest conserves energy and
reduces the utilization of glucose to relieve fatigue.

10. Use nipple stimulation to produce endogenous oxytocin.

This helps the client to use natural methods to stimulate contractions, such as
nipple stimulation. Nipple stimulation causes the client’s posterior pituitary gland
to secrete natural oxytocin, strengthening contractions.

11. Initiate infusion of exogenous oxytocin (Pitocin) or prostaglandins.

Oxytocin may be necessary to increase or institute myometrial activity for a
hypotonic uterine pattern. It is usually contraindicated in hypertonic labor
patterns because it can accentuate the hypertonicity but may be tried with
amniotomy if the latent phase is prolonged and if CPD and malpositions are
ruled out. Oxytocin is an effective uterine stimulant, but there is a thin line
between adequate stimulation and hyperstimulation, so careful observation
during the entire infusion time is an important nursing responsibility.

12. Prepare for forceps delivery, as necessary.

Excessive maternal fatigue, resulting in ineffective bearing-down efforts in stage II
labor, necessitates the use of forceps. Today, the technique is rarely used (in only
about 4% to 8% of births) because it can lead to rectal sphincter tears in the
client, leading to dyspareunia, anal incontinence, or increased urinary stress
incontinence.

13. Assist with preparation for cesarean delivery, as indicated, e.g.,

malposition, CPD, or Bandl’s ring.
Immediate cesarean birth is indicated for Bandl’s ring or fetal distress due to CPD.
Note: Once labor is diagnosed, if delivery has not occurred within 12 hours, and
amniotomy and oxytocin have been used appropriately, then a cesarean delivery
is recommended by some protocols. Assist in preparing the client for a possible
laparotomy as an emergency measure to control bleeding and the birth of the
fetus. The fetus’s viability depends on the extent of the rupture and the time
elapsed between rupture and abdominal extraction.

Risk For Injury (Fetal)

Although the fetus is passive during birth, complications may arise if an infant is
immature or preterm or if the maternal pelvis is so undersized that its diameters
are smaller than the fetal skull, such as occurs in early adolescence or women
with altered bone growth from a disease such as rickets. It can also occur if the
umbilical cord prolapses, if more than one fetus is present, or if a fetus is
malpositioned or too large for the birth canal.
Nursing Diagnosis

 Risk for Injury (Fetal)

Risk Factors

 Abnormalities of the maternal pelvis

 Cephalopelvic disproportion (CPD)
 Fetal malpresentation
 Tissue hypoxia/acidosis
 Prolonged labor
Possibly evidenced by

 [Not applicable]
Desired Outcomes

 The client will participate in interventions to improve labor patterns

and/or reduce identified risk factors.
 The client will display FHR within normal limits, with good variability
and no late decelerations noted.
 The fetus will be free of injury and complications.
Nursing Assessment and Rationales

1. Assess FHR manually or electronically. Note variability, periodic changes,

and baseline rate.
This detects abnormal responses, such as exaggerated variability, bradycardia,
and tachycardia, which may be caused by stress, hypoxia, acidosis, or sepsis. If in
a free-standing birth center, check the fetal heart tone between contractions
using a Doptone. Count for 10 min, break for 5 min, and count again for 10 min.
Continue this pattern throughout the contraction to midway between it and the
following contraction. To rule out cord prolapse, always assess fetal heart sounds
immediately after rupture of the membranes, whether this occurs spontaneously
or by amniotomy.

2. Note the frequency of uterine contractions. Notify the healthcare

provider if the frequency is two minutes or less.
Hypertonic uterine contractions are marked by an increase in resting tone to
more than 15 mm Hg. A danger of hypertonic contractions is that the lack of
relaxation between contractions may not allow optimal uterine artery filling; this
can lead to fetal anoxia early in the latent phase of labor.
3. Note uterine pressures during resting and contractile phases via
intrauterine pressure catheter, if available.
Resting pressure greater than 30 mm Hg or contractile pressure greater than 50
mm Hg reduces or compromises oxygenation within intervillous spaces.
Contractions should occur no more often than every two minutes, should not be
stronger than 50 mm Hg pressure, and should last no longer than 70 seconds.
The resting pressure between contractions should not exceed 15 mm Hg by
monitoring.

4. Identify maternal factors such as dehydration, acidosis, anxiety, or vena

caval syndrome.
Sometimes, simple procedures (such as turning the client to a lateral recumbent
position) can increase circulating blood and oxygen to the uterus and placenta
and may prevent or correct fetal hypoxia. The client with increased uterine muscle
tone is uncomfortable and frustrated. Anxiety about the lack of progress and
fatigue impair their ability to tolerate pain.

5. Monitor fetal descent in the birth canal concerning ischial spines.

A descent that is less than 1 cm/hr for a primipara, or less than 2 cm/hr for a
multipara, may indicate CPD or malposition. The arrest of descent results when
no descent occurs for two hours in a nullipara or one hour in a multipara. Failure
of descent occurs when the expected descent of the fetus does not begin, or
engagement or movement beyond 0 station does not occur. Cesarean birth
usually is necessary.

6. Assess for malpositioning using Leopold’s maneuvers and findings on

internal examination (location of fontanelles and cranial sutures). Review
results of ultrasonography.
Determining the fetal lie, position, and presentation may identify the factor(s)
contributing to dysfunctional labor. Leopold maneuvers and a vaginal
examination usually reveal the presentation. If the presentation is unclear,
ultrasound confirms the presentation. A head that feels more prominent than
normal, with no engagement apparent on Leopold’s maneuvers, suggests a face
presentation. It is also suggested that the head and the back are both felt on the
same side of the uterus with Leopold maneuvers.
7. Assess for the deep transverse arrest of the fetal head.
Failure of the vertex to rotate fully from an OP to an occiput OA position may
result in a transverse position, arrested labor, and the need for cesarean delivery.
A mature fetus cannot be born vaginally from this presentation. Because there is
no firm presenting part, the cord or an arm may prolapse, or the shoulder may
obstruct the cervix.

8. Note odor and change in color of amniotic fluid with prolonged rupture
of membranes or when the membranes rupture.
Ascending infection and sepsis accompanying fetal tachycardia may occur with
prolonged rupture of membranes. Excess amniotic fluid causing uterine
overdistention is associated with fetal anomalies. Meconium-stained amniotic
fluid in a vertex presentation results from hypoxia, which causes vagal stimulation
and relaxation of the anal sphincter. Noting characteristics of amniotic fluid alerts
staff to potential needs of newborns, e.g., airway/ventilatory support.

9. Assist with the assessment of pelvic size or clinical pelvimetry.

Digital evaluation or clinical pelvimetry is an essential part of the overall physical
examination. In general, the size of the pelvis can be determined to be large or
ample, small, or borderline. Examining the essential landmarks and
measurements should allow one to decide on normality or abnormality. The
inability to determine size or morphology should elevate one’s index of suspicion
and thus demand a more careful intrapartum assessment or possible consultation
(O’Leary, 2009).

Nursing Interventions and Rationales

1. Instruct the client to void regularly every two hours.

During long labor, be certain that the client voids approximately every two hours
to keep her bladder empty because a full bladder could further impede the
descent of the fetus.

2. Arrange transfer to an acute care setting if malposition is detected in the

client in a free-standing birth center without adequate surgical/high-risk
neonatal capabilities.
The risk of fetal or neonatal injury or demise increases with vaginal delivery if the
presentation is other than vertex. Caution a multiparous client by week 28 of
pregnancy that because past labor was so brief, her labor this time also may be
brief so that she has time to plan for adequate transportation to the hospital or
alternative birthing center. Both grand multiparas and clients with histories of
precipitous labor should have a birthing room converted to birth readiness
before full dilatation is obtained. Then, even if a sudden birth should occur, it can
be accomplished in a controlled surrounding.

3. Prepare the client for the most expedient method of delivery if the fetus
is in the brow, face, or chin presentation.
Such presentations increase the risk of CPD, owing to a larger diameter of the
fetal skull entering the pelvis (11 cm in brow or face presentation, 13 cm in chin
presentation, versus 9.5 cm for vertex presentation), often necessitating assisted
delivery via forceps or vacuum, or cesarean delivery because of failure to
progress and ineffective labor pattern. If the chin is posterior, cesarean birth is
usually the method of choice; otherwise, it would be necessary to wait for a long
posterior-to-anterior rotation to occur. Such rotation could result in uterine
dysfunction or a transverse arrest.

4. Observe for visible cord prolapse or occult cord prolapse as indicated by

variable decelerations on the monitor strip.
Cord prolapse is more likely to occur in the breech presentation because the
presenting part is not firmly engaged, nor is it blocking the os, as in vertex
presentation. Because the umbilicus precedes the head, a cord loop passes down
alongside the head. The pressure of the head against the pelvic brim
automatically causes compression on this loop of the cord.

5. Have the client assume the hands-and-knees position or lateral Sims’

position on the side opposite that to which fetal occiput is directed.
These positions encourage anterior rotation by allowing the fetal spine to fall
toward the client’s anterior abdominal wall (70% of fetuses in the OP position
rotate spontaneously). The client may lie on her side (on her left side if the fetus
is in right occipitoposterior position (ROP) or on her right side if the fetus is in the
left occipitoposterior position). Theoretically, shifting the weight from right to left
or “lunging” or swinging her body right to left while elevating her left foot on a
chair widens the pelvic path and makes fetal rotations easier. Study findings,
however, observed no efficacy of the hands and knees position, but it was
associated with increased maternal comfort (Guittier et al., 2016).
6. Assist in the birthing of the head in a fetus with breech presentation.
To aid in the birth of the head, the infant’s trunk is usually straddled over the
primary care provider’s right forearm. Two fingers of the right hand are then
placed in the infant’s mouth. The left hand is slid into the client’s vagina, palm
down, along the infant’s back, and pressure is applied to the occiput to flex the
head fully. The gentle traction applied to the shoulders (upward and outward)
delivers the head.

7. Assist in relieving cord pressure in umbilical cord prolapse.

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. Management aims to relieve pressure on the cord,
thereby relieving the compression and the resulting fetal anoxia. This may be
done by placing a gloved hand in the vagina and manually elevating the fetal
head off the cord or by placing the client in a knee-chest or Trendelenburg
position to cause the fetal head to fall back from the cord.

8. Cover the exposed cord with sterile saline compress.

If the cord has prolapsed to the extent it is exposed to room air, drying will begin,
leading to constriction and atrophy of the umbilical vessels. Do not attempt to
push any exposed cord back into the vagina because this could add to the
compression by causing knotting or kinking. Instead, cover any exposed portion
with a sterile saline compress to prevent drying.

9. Administer antibiotics to the client, as indicated.

This prevents or treats ascending infection and will protect the fetus as well.
Vaginal or cervical infections may cause prematurely ruptured membranes.
Treatment of premature rupture of membranes is based on weighing the risks of
early delivery of the fetus against the risks of infection in the mother and sepsis in
the newborn.

10. Prepare for and assist in amnioinfusion.

Amnioinfusion is the addition of sterile fluid into the uterus to supplement the
amniotic fluid and reduce compression on the cord. For this, a sterile double-
lumen catheter is introduced through the cervix into the uterus. Attach the client
to an FHR monitor and urge her to lie in a lateral recumbent position to prevent
supine hypotension syndrome. This procedure can also be performed daily for
clients diagnosed with oligohydramnios.

11. Assist and prepare for external cephalic version (ECV), as indicated.
The external cephalic version is the turning of the fetus from a breech to a
cephalic position before birth. The evidence for the effectiveness of ECV in
reducing breech vaginal and cesarean births is strong. ECV is considered the first-
line option in most Western countries. Although ECV is a safe procedure with few
complications, it should be performed in a setting where fetal monitoring and
surgical delivery are available (Savchenko et al., 2020).

12. Prepare for delivery or a vacuum extraction in the posterior position.

Delivering the fetus in a posterior position results in a higher incidence of
maternal lacerations. A vacuum extractor may be used to rotate and expedite the
delivery of the fetus. A fetus, if positioned far enough down the birth canal, may
be born by vacuum extraction. With the fetal head at the perineum, a soft, disk-
shaped cup is pressed against the fetal scalp and over the posterior fontanelle.
When the vacuum pressure is applied, the air beneath the cup is suctioned out,
and the cup then adheres so tightly to the fetal scalp that traction on the vacuum
cord leading to the cup extracts the fetus.

13. Prepare for cesarean delivery of breech presentation if fetus fails to

descend, labor progress ceases, or CPD is identified.
Vaginal delivery of an infant in breech position is associated with injury to the
fetal spinal column, brachial plexus, clavicle, and brain structures, increasing
neonatal mortality and morbidity. The risk of hypoxia caused by prolonged vagal
stimulation with head compression, and trauma such as intracranial hemorrhage,
can be alleviated or prevented if CPD is identified and surgical intervention
follows immediately.

Risk For Fluid Volume Deficit

Adequate maternal hydration during labor is fundamental to ensure efficient

contractions. Some investigators propose that extrapolating the data of the
physiological effects of uterine smooth muscle exertion might give an idea as to
why some women could be inadequately hydrated if they experience prolonged
labor. Inadequate hydration during labor can stimulate alterations in the acid-
base balance of the myometrium provoking a reduction in contractility and
prolonging labor, as well as increasing the probability of cesarean delivery (Lopez
et al., 2019).

Nursing Diagnosis

 Risk for Fluid Volume Deficit

Risk factors

 Hypermetabolic state
 Vomiting
 Profuse diaphoresis
 Restricted oral intake
 Mild diuresis associated with oxytocin administration
 Length and work of labor
Possibly evidenced by

 [Not applicable]
Desired Outcomes

 The client will maintain fluid balance, as evidenced by moist mucous

membranes and palpable pulses.
 The client’s urine will be adequate, free of ketones, and the specific
gravity is maintained between 1.003 and 1.030.
 The client will be free of complications.
 The client’s serum electrolyte results will be within acceptable
parameters.
Nursing Assessment and Rationales

1. Monitor vital signs. Note reports of dizziness with a change of position.

Increased pulse rate and temperature and orthostatic BP changes may indicate a
decrease in circulating volume. Maternal intrapartum fever, defined as a
temperature of 38℃ (100.4℉) or above, commonly complicates labor. Its
appearance is frequently considered a sign of chorioamnionitis, which
necessitates the administration of antibiotics. Intrapartum fever is not only
associated with increased use of antibiotics, but also with increased risk of
cesarean births, respiratory distress syndrome, seizures during the first week of
life, tachycardia, low Apgar score, and even the need for admittance to the NICU
(Lopez et al., 2019).
2. Assess for vomiting and diarrhea.
Vomiting and diarrhea occasionally accompany labor; if these occur, they can add
to fluid and electrolyte loss. Maternal hyponatremia (sodium level <135 mEq/l)
can provoke nausea, vomiting, headaches, and even seizures. The fetus receives
water from the mother’s circulation via the placenta, which, in such cases, can
produce mild transplacental hyponatremia. This can provoke seizures in the
newborn (Lopez et al., 2019).

3. Assess lips and oral mucous membranes and degree of salivation, as well
as skin turgor.
Dry oral mucous membranes or lips and decreased salivation indicate
dehydration. Dehydration is also evidenced by a dry tongue and decreased
turgor (elasticity) of the skin.

4. Note abnormal FHR response.

This may reflect the effects of maternal dehydration and decreased perfusion.
Fetal tachycardia is a baseline of FHR greater than 160 beats/minute that lasts 2
to 10 minutes or longer. It can be caused by maternal fever or maternal
dehydration. When fetal tachycardia occurs along with loss of baseline variability
or late decelerations, immediate intervention is required.

5. Keep accurate intake/output, test urine for ketones, and assess breath for
fruity odor.
Decreased urine output and increased urine specific gravity reflect dehydration.
Inadequate glucose intake results in a breakdown of fats and the presence of
ketones. Test the urine each time the client voids during labor for glucose,
protein, ketones, and specific gravity. Ketones in the urine suggest starvation
ketosis. A concentrated specific gravity suggests a lack of fluid.

Nursing Interventions and Rationales

1. Encourage oral fluids as appropriate.

Clear liquids such as fruit juices and broths provide not only fluids but also
calories for energy production. Note: Oral fluids are not recommended if surgical
intervention is contemplated. The client is also encouraged to drink bottled
mineral water or isotonic drinks at a rate of 100 ml/hr until delivery (Lopez et al.,
2019).
2. Review laboratory data, e.g., Hb/Hct, serum electrolytes, and serum
glucose.
Increased hematocrit suggests dehydration. Low levels of serum electrolytes or
body fluid can occur in labor for the same reason as a decreased glucose level-
there has been a long interval between eating and the end of labor. Dilutional
hyponatremia is a condition in which the serum concentration of sodium is
reduced due to excessive water retention. Excessive oral water intake during labor
and circulatory overload through the use of sodium-free solutions, together with
the use of oxytocin, predisposes the development of dilutional hyponatremia
(Lopez et al., 2019).

3. Administer fluids intravenously.

It is suggested that optimal hydration for clients in labor should include a mixed
volume of solutions (crystalloid and mineral water) at the rate of 300 ml/hr. The
administration of crystalloid solutions in continuous perfusion is initiated at a rate
of 200 ml/hr, alternating normal saline and Ringer’s lactate solution. The
perfusion rate is increased (at 300 ml/hr) if the client has diuresis lower than
35ml/hr or has a temperature higher than 37.8℃ (100.04℉) (Lopez et al., 2019).

4. Assist the client in managing her IV lines appropriately.

When inserting the IV catheter, try to use an insertion site in the client’s
nondominant hand and, if necessary, only a small “reminder” board. Use long
tubing or attach extensions so that the client can move about freely and her
mobility is not limited or restricted by the short length of IV tubing. Assure the
client that being out of bed and walking, turning freely, squatting, sitting, or
using whatever position she prefers during labor will not disrupt the IV line of the
infusion.

5. Ensure that the fluid volume infused into the client is accurate.
Researchers in other studies have evaluated the relationship between the number
of solutions administered to mothers and newborn weight loss. Excessive
newborn weight loss occurs when the volume of maternal fluids during the first
stage of labor exceeds 200 ml/hr compared to 100 ml/hr. Weight loss in the
newborn is considered to be excessive when greater than 10% between the first
70-98 hours of life (Lopez et al., 2019).
Ineffective Individual Coping

Labor and birth are unique events, requiring the client to employ all the
psychological and physical coping methods she has available. The most common
factors that can increase stress and cause dystocia include lack of analgesic
control of excessive pain, absence of a support person or coach to assist with
nonpharmacological pain relief measures, immobility and restriction to bed, and
a lack of the ability to carry out cultural traditions.

Nursing Diagnosis

 Ineffective Individual Coping

May be related to

 Inadequate/exhausted support systems

 Personal vulnerability
 Situational crisis
 Unrealistic expectations/perceptions
 Inadequate coping methods
Possibly evidenced by

 Verbalizations and behavior indicative of an inability to cope

 Inability to meet role expectations, basic needs, or problem-solve
 Lack of appetite
 Sleep disturbances
 Withdrawn demeanor
 Depression
Desired Outcomes

 The client will verbalize understanding of the current situation.

 The client will identify and use effective coping techniques.
 The client will verbalize awareness of their coping abilities and
strengths.
 The client will identify potentially stressful situations and steps to
avoid or modify them.
Nursing Assessment and Rationales

1. Determine the progress of labor.

Labor progress and prevention of dystocia depend on harmonious interactions
among various psycho-emotional, interpersonal, physical, and physiologic factors
(Hanson et al., 2017). Prolonged labor with resultant fatigue can reduce the
client’s ability to cope or manage contractions. Increasing pain when the cervix is
not dilating or effacing can indicate developing dysfunction. Extreme pain may
indicate developing anoxia of the uterine cells.

2. Assess degree of pain in relation to dilation/effacement.

In many hospitals, laboring clients are asked periodically to assess their pain,
using a visual analog scale of 0 to 10. It also includes images of faces indicating
expressions ranging from smiling to somber to agony. The client indicates her
pain level and is offered pain medications if it reaches a particular level (Hanson
et al., 2017).

3. Determine the anxiety level of the client and partner. Note evidence of
frustration.
Excess anxiety increases the adrenal activity or the release of catecholamines,
causing endocrine imbalance. High levels of catecholamines during labor
suppress the usual endorphin effects that would otherwise alter the client’s state
of consciousness and help her enter an instinctual mental state. Excess
epinephrine inhibits myometrial activity. Stress also depletes glycogen stores,
reducing glucose available for adenosine triphosphate (ATP) synthesis, which is
needed for uterine contraction (Hanson et al., 2017).

4. Assess the effectiveness of past or present coping strategies by observing

behaviors.
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 client may have had past coping strategies that could help her
go through the labor dysfunction. Two tools can be used to assess the client’s
ability to cope with labor pain. The Pain Coping Scale is a visual analog scale,
which ranges from 10 to 0. The mid-range denotes the ability to cope, without or
with help. The second tool, the Coping Algorithm for assessing a client’s coping
during labor, assesses the broader context of the experience of pain and coping
(Hanson et al., 2017).

Nursing Interventions and Rationales

1. Acknowledge the reality of the client’s reports of pain/discomfort.
Discomfort and pain may be misunderstood because of a lack of progression that
is not recognized as a dysfunctional problem. Usually, anyone can tolerate a little
discomfort from a backache, feeling thirsty, having dry lips, or having a leg
cramp. However, few people can tolerate having all these discomforts
simultaneously or feeling even one of them while experiencing a labor
contraction. Feeling listened to and supported can help the client relax, reducing
discomfort and enhancing the ability to cope with the situation.

2. Maintain a calm manner and environment.

A calm manner calms the parents and reduces anxieties and tension that can
elevate pain perception. Provide a comfortable environment: clean sheets, a cool
washcloth to the forehead, closed room door. A comfortable environment aids in
relaxation, promoting effective coping.

3. Discuss the possibility of discharge of client to home until active labor is

established.
Too early admission fosters a sense of a longer or prolonged labor for the client.
The client may be able to relax better in familiar surroundings. This also provides
an opportunity to divert or refocus attention and to attend to tasks that may be
contributing to the level of anxiety or frustration. Based on research examining
the progression of labor, ACOG recommended delaying admission until the onset
of active labor (6 cm). The admission decision can influence subsequent clinical
processes because admission in early labor compared with active labor is
associated with a greater risk of medical interventions and cesarean birth
(Breman et al., 2019).

4. Encourage the efforts of the client or the couple to date.

This may be useful in correcting the misconception that the client is overreacting
to labor or is somehow to blame for the alteration of the anticipated birth plan.
Encouragement is a powerful tool for intrapartum nursing care because it helps
the client to summon inner strength and gives her courage to continue Liberal
praise is given if she successfully uses techniques to cope with labor.

5. Provide comfort measures and reposition the client.

Assist the client’s support person in providing the usual comfort measures that
are helpful for anyone with pain, such as reassurance, massage, or a change in
position. For dry lips, ice chips to suck on, moistening the lips with a wet cloth, or
using a moisturizing jelly or balm can be helpful. A cool cloth to wipe perspiration
from the forehead, neck, and chest can keep the client from feeling overheated.
Change the client’s sheets, offer her a clean gown, and ask if she’d like to bathe
or take a shower. These measures can help her feel clean and refreshed, with a
ready-to-go-again feeling.

6. Encourage ambulation as appropriate.

If there is no contraindication, encourage the client to walk or sit upright in a bed
or chair. Upright positions enhance fetal descent. Walking strengthens labor
contractions. Walking may not be advisable if the membranes are ruptured and
the fetus is high because it could lead to umbilical cord prolapse.

7. Provide factual information about what is happening.

This reduces the “unknowns” to assist with the reduction of anxiety and provides
data necessary to make informed decisions. Explain how each method is
expected to help her labor advance. Inform her any time she is making progress,
either with improved contractions or with increasing cervical dilation. If the client
understands the reason for any interventions, she will more likely cooperate with
them and feel more in control. Knowing that her efforts are having the desired
effect encourages her to continue with her learned coping methods.

8. Assist the client’s support person with their comfort measures as well.
Think of comfort measures for the client’s support person. Is the chair by the side
of the bed comfortable? Does he or she need to stretch or take a beverage or
bathroom break? Could you serve as the coach while the support person makes
some phone calls? Breaks such as these allow a partner to come back rested and
ready to give support again.

9. Help the client identify coping strategies.

Because pain is not a new phenomenon for a client of childbearing age, it can be
helpful to ask her to recall methods she usually uses to combat pain or anxiety,
such as meditation or applying a cool cloth. Associating labor pain with usual
circumstances can go a long way toward helping her collect her resources and
decide on a workable pain relief strategy.
10. Assist with oxytocin augmentation if ordered.
The primary risks of oxytocin augmentation or induction of labor relate to
overstimulating the uterus. Observe contractions for excessive frequency (more
frequent than every two minutes), duration (>90 seconds), or inadequate rest
interval (<60 seconds). Excessive contractions can reduce fetal oxygen supply.
Observe fetal heart rate for rates outside the normal range of 110-160 mm Hg.
These are signs of potential uterine overstimulation.

Acute Pain

Maternal well-being in labor is associated with numerous factors, among which

the survival of a healthy mother and baby are unquestionably the most
important. Besides safety, labor pain, and the fear of that pain and associated
damage, are probably the next greatest concerns of both women and their
caregivers. The distinction between pain and suffering is crucial to the
understanding of the client’s emotional well-being in labor (Hanson et al., 2017).

Nursing Diagnosis

 Acute Pain
May be related to

 Decreased coping ability

 Intense labor contractions
 The slow progress of labor
 The arrest of fetal descent
Possibly evidenced by

 Verbalizations of pain and discomfort

 Facial grimacing, distraction behaviors
 Narrowed focus, withdrawal
 Anxiety
 Restlessness, irritability
 Tachycardia, tachypnea, changes in BP
Desired Outcomes

 The client will verbalize a reduced or tolerable level of pain.

 The client will display a relaxed facial and body appearance between
contractions.
  The client will be able to utilize techniques to handle contractions.
 The client will demonstrate the ability to listen and respond to
questions and instructions.
Nursing Assessment and Rationales

1. Assess the nature of pain, such as location, intensity, and whether it is

intermittent or constant.
Assessment enables the nurse to identify if the pain is normal for the client’s
labor status and to choose the best interventions for pain relief. Assess pain by
using a visual analog scale of 0 (“no pain”) to 10 (“worst pain imaginable”); it also
includes images of faces indicating expressions ranging from smiling to somber
to agony (Hanson et al., 2017).

2. Assess the client’s ability to cope with pain.

More important than pain assessment is the assessment of the client’s distress-
an inability to cope with the pain. The Pain Coping Scale is a visual analog scale,
which ranges from 10 (“no need to cope- very easy”) to 0 (“totally unable to
cope”). The nurse may ask her after a contraction, “Could you tell me what was
going through your mind during that contraction?” Her answer will indicate
whether she is coping or is in distress, neutral, or some of each. The Coping
Algorithm involves asking the laboring woman periodically, “how are you coping
with your labor?” and observations for clues that she is not coping (e.g., crying,
inability to focus, panic, thrashing in bed, clawing, biting) (Hanson et al., 2017).

3. Assess for nonverbal cues of pain.

Crying, moaning during and/or between contractions, thrashing with contractions
or tense, guarded body posture, and “mask of pain” facial expression are
common verbal and nonverbal signs of pain. Evaluating verbal and nonverbal
communication helps the nurse evaluate the need for pain relief in clients who
may not directly communicate their need for it or do not speak the prevailing
language.

Nursing Interventions and Rationales

1. Provide general comfort measures.

Adjust the room temperature and light level according to the client’s preference.
Reduce irritants such as wet underpads. Provide ice chips, Popsicles, or juices to
relieve the client’s dry mouth. Avoid bumping or moving the bed. These general
measures reduce outside irritants that could make it harder for the client to use
childbirth preparation techniques and are themselves a source of discomfort. A
comfortable environment is conducive to relaxation.

2. Encourage and assist the client in assuming comfortable positions.

Position changes promote comfort and help the fetus adapt to the size and
shape of the client’s pelvis. An upright position, sitting, walking, or swaying with a
partner may be most comfortable for the client in early labor and aids in
contractions and descent through gravity. Leaning forward against a birthing ball
or pelvic rocking between contractions may relieve tense back muscles.

3. Enforce bed rest as appropriate, but avoid the supine position.

If the client must remain in bed because of a situation such as her membranes
have ruptured and the fetal head is not engaged, urge her to keep active within
the limits of bed rest and not to lie on her back to avoid supine hypotension
syndrome. Move bedclothes or monitor leads, if any are attached, as needed to
allow her to be able to turn and remain active.

4. Promote the use of techniques learned in childbirth preparation.

Depending on the type of childbirth preparation the client and her support
person have had, the method may include breathing exercises, distraction by
focusing on an external object, acupressure, therapeutic touch, music therapy,
guided imagery, self-hypnosis, or a combination of these methods.

5. Review learned breathing exercises with the client.

Even though the client conscientiously practiced breathing or focusing in a
relaxed, fun setting of an antepartal class, the discomfort and stress of labor may
make it easy for her to forget what she learned. As necessary, review previously
learned breathing exercises with her. Urge her to begin using these early in labor,
before contractions become so strong, so she gains confidence that they can
effectively diminish pain. If the client has had no prior training in breathing
exercises, sit with her and teach her a simple breathing pattern, so she can begin
to utilize this to relieve some of her pain.

6. Assist the client experiencing signs of hyperventilation.

If the client has signs of hyperventilations (dizziness, numbness or tingling
sensations, spasms of hands and feet), have her breathe into her cupped hands, a
small bag, or a washcloth placed over her mouth and nose. Hyperventilation
often occurs when the client uses rapid breathing patterns because she exhales
too much carbon dioxide. These measures help her to conserve carbon dioxide
and rebreathe it to correct for excess loss.

7. Explain to the client and her partner how the labor progresses.
Knowing that her efforts are having the desired results gives her courage and
helps her to tolerate pain. Be certain to explain the characteristics of contractions
and reinstruct them as necessary. Do not assume the client is aware of this simply
because she is experiencing the contractions. Sometimes, knowing can help the
client tolerate the pain even as it increases in intensity.

8. Teach the client and her support person about the benefits of massage.
Massage is another pain relief method that can be taught to a client and her
support person during labor. This may be especially useful if the client is
experiencing back pain because rubbing or massaging the sacral area often
alleviates that. A firm massage on her shoulders can provide a relaxing distraction
from the sensation of internal pressure and pain.

9. Observe for a full bladder every one to two hours or more.

If the client receives large amounts of oral or intravenous fluids, a full bladder
may be a source of discomfort and can prolong labor by inhibiting fetal descent.
It may cause pain that lingers after epidural analgesia is begun.

10. Allow the client to decide if she needs pharmacological relief or not.
Helping the client decide if and when medication for pain relief should be used
requires an in-depth understanding of the available drugs, their effects on the
mother and the fetus, and their mechanism and duration of action. Many clients
come into labor wishing to avoid drugs entirely. Once in labor, they may change
their minds but hesitate to say so, especially if their partners also believe a birth
without the use of drugs is ideal. Maintain a supportive presence to help the
client make the best decision for herself and her baby.

11. Assist in administering pharmacological relief for the client.

All obstetric anesthesia must be supervised by a registered nurse who is prepared
to manage unexpected responses in the mother or the newborn. The client
should be questioned closely about allergies to foods, drugs, and latex to identify
pain relief measures that may not be advisable. She should be questioned about
her preferences for pain relief.