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.
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: Acute Pain 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.
1. Identify/use techniques to control pain/discomfort.
2. Report discomfort is minimized.
3. Appear relaxed/resting between contractions.
4. Be free of untoward side effects if analgesia/anesthetic agents are administered.
Nursing Care Plan with intervention and rationale
1. Assess degree of discomfort through verbal and nonverbal cues; note cultural influences on pain response.
Rationale: Attitudes and reactions to pain are individual andbased on past experiences, understanding of physiological changes, and cultural expectations.
2. Assist in use of appropriate breathing/relaxation techniques and in abdominal effleurage.
Rationale: May block pain impulses within the cerebral cortex through conditioned responses and cutaneous stimulation. Facilitates progression of normal labor.
3. Assist with comfort measures (e.g., back/leg rubs, sacral pressure, back rest, mouth care, repositioning, shower/hot tub use, perineal care, and linen changes).
Rationale: Promotes relaxation and hygiene; enhances feeling of well-being. Note: Lateral recumbent position reduces uterine pressure on the vena cava, but periodic repositioning prevents tissue ischemia and/or muscle stiffness, and promotes comfort.
4. Encourage client to void every 1–2 hr. Palpate above symphysis pubis to determine distension, especially after nerve block.
Rationale: Keeps bladder free of distension, which can increase discomfort, result in possible trauma, interfere with fetal descent, and prolong labor. Epidural or pudendal analgesia may interfere with sensations of fullness.
5. Provide information about available analgesics, usual responses/side effects (client and fetal), and duration of analgesic effect in light of current situation.
Rationale: Allows client to make informed choice about means of pain control. Note: If conservative 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.
6. Support client’s decision about the use or nonuse of medication in a nonjudgmental manner. Continue encouragement for efforts and use of relaxation techniques.
Rationale: Helps reduce feelings of failure in the client/couple who may have anticipated an unmedicated birth and did not follow through with that plan. Enhances sense of control and may prevent/ decrease need for medication.
7. Time and record the frequency, intensity, and duration of uterine contractile pattern per protocol.
Rationale: Monitors labor progress and provides information for client. Note: Anesthetic agents may alter uterine contractile pattern.
8. Assess nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent.
Rationale: Cervical dilation should be approximately1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with fetal descent. Choice and timing of medication is affected by degree of dilation and contractile pattern.
9. Provide safety measures; e.g., encourage client to move slowly, keep siderails up after drug administration, and support legs with position changes.
Rationale: Regional block anesthesia produces vasomotorparalysis, so that sudden movement may precipitate hypotension. Analgesics alter perception, and client may fall trying to get out of bed.
10. Assess BP and pulse every 1–2 min after regional injection for first 15 min, then every 10–15 min for remainder of labor. Elevate head approximately 30 degrees, alternate position by turning side to side and use of hip roll.
Rationale: Maternal hypotension, the most common side effect of regional block anesthesia, may interfere with fetal oxygenation. Elevating head prevents block from migrating up and causing respiratory depression. Lateral positioning increases venous return and enhances placental circulation.