The latent phase, or the first phase of stage I labor, begins with the onset of true labor and ends with the cervix dilated 4 cm. The phase averages approximately 8–10 hr, up to 20 hr for nulliparas and 3–6 hr, up to 14 hr for multiparas. It usually occurs with client at home, unless specific concerns necessitate inpatient care, e.g., spontaneous rupture of membranes (SROM), history of rapid labor, unsafe weather conditions/distance from facility.
1. Enhance client’s/couple’s/other involved family members’ emotional and physical preparedness for labor.
2. Promote and facilitate normal labor progress.
3. Support client’s/couple’s/involved family members’ coping abilities.
4. Prevent maternal/fetal complications.
(Inpatient care is not required in early labor, unless complications develop necessitating hospitalization.)
1. Displays only early, or no, signs of active progression of labor.
2. Demonstrates appropriate coping behaviors.
3. Understands self-care needs and signs of labor progression requiring re-evaluation.
Nursing diagnosis of labor stage I - latent phase: Risk for Anxiety may be related to situational crisis, interpersonal transmission, unmet needs.
Nursing care plan, intervention with rationale
1. Provide primary nurse orcontinuous intrapartum professional support as indicated.
Rationale: Continuity of care and assessment may decrease stress. Research studies suggest that these clients require less pain medication, which may result in shorter labor.
2. Orient client to environment, staff, and procedures. Provide information about psychological and physiological changes in labor, as needed.
Rationale: Education may reduce stress and anxiety and promote labor progress.
3. Assess level and causes of anxiety, preparedness for childbirth, cultural background, and role of significant other/partner.
Rationale: Provides baseline information. Anxiety magnifies pain perception, interferes with use of coping techniques, and stimulates the release of aldosterone, which may increase sodium and water resorption.
4. Monitor BP and pulse as indicated. (If BP is elevated on admission, repeat procedure in 30 min to obtain true reading once client is relaxed.)
Rationale: Stress activates the hypothalamic-pituitary adrenocortical system, which increases retention and resorption of sodium and water and increases excretion of potassium. Sodium and water resorption may contribute to development of intrapartal toxemia/hypertension. Loss of potassium may contribute to reduction of myometrial activity.
5. Monitor uterine contractile pattern; report dysfunctional labor.
Rationale: A hypertonic or hypotonic contractile pattern may develop if stress persists and causes prolonged catecholamine.
6. Encourage client to verbalize feelings, concerns, and fears.
Rationale: Stress, fear, and anxiety have a profound effect on the labor process, often prolonging the first phase because of utilization of glucose reserves; causing excess epinephrine release from adrenal stimulation, which inhibits myometrial activity; and increasing norepinephrine levels, which tends to increase uterine activity. Such an imbalance of epinephrine and norepinephrine can create a dysfunctional labor pattern.
7. Demonstrate breathing and relaxation methods. Provide comfort measures.
Rationale: Reduces stressors that might contribute to anxiety; provides coping strategies.
8. Promote privacy and respect for modesty; reduce unnecessary exposure. Use draping during vaginal examination.
Rationale: Modesty is a concern in most cultures. Support person may or may not desire to be present while client is examined or care provided.
9. Be aware of client’s need or preference for female caregivers/support persons.
Rationale: Cultural practices may prohibit presence of men (even father of the child) during labor and/or delivery.