GOVERNMENT COLLEGE OF NURSING,

JODHPUR(RAJ.)

NCP
On
Normal Labor- Latent Phase
Subject-Obstetrics & Gynecology Specialty-I

SUBMITTED TO - SUBMITTED BY-

Mrs. ANNMA SUMON HEMLATA BHANWARIA
NURSING LECTURER M.sc (N) Pre. year
GCON, Jodhpur GCON, Jodhpur
Identification data:
 Name of the patient : Sapna Chauhan
 Husband’s name : Lalit Chauhan
 Age :20 year
 Address : Madhuban,Saraswati Nagar, HB, Jodhpur.
 Religion : Hindu
 Education status : Graduate
 Occupation :Housewife
 Date of admission :04/07/19
 Hospital reg no :254863
 Ward :ANW
 Obstetric score :G1
 L.M.P. : 25/09/18
 E.D.D. : 05/07/19
 Date of Delivery : 05/07/19

ADMISSION HISTORY:

On admission complain:
Amenorrhoea for 9 months and constipation from last 2 days.

Personal history:
She is non- vegetarian, nonalcoholic, no smoker, and have no drug allergy.

Medical History:
No H/o HTN, DM, and lungs diseases.

Surgical History:
NoH/o any previous caesarean operation.

Family history:
No history of hereditary and genetic disorder.
Obstetric history:
G1 (Primi)
An alive Mch delivered by normal delivery.
Child is alive normal and healthy.

Previous labor history: Full term normal delivery with episiotomy.

Menstrual history: Regular normal flow 3-5 days cycles 26-28 days.

CONDUCTION ON ADMISSION:

General examination:
Temp- 37.2c
Pulse- 98/min
B.P. 120/80 mm of Hg
Resp.- 24/min
Anaemia- No
Hydration- Adequate
Oedema- Nil
Heart- NAD
Lungs- NAD
Liver- NAD
 ABDOMINAL AND PELVIC EXAMINATION:
By inspection:
1. Gravid uterus.
2. Fetal movement present.
3. Linea nigra is prominent and Straie Gravidarum seen.
4. Fundal height is 28cm.
5. Presence of previous caesarian scar.

By palpitation:
Softer consistency and indefinite out line in fundal grip.
Continuous flat and smooth surface feel in left lateral and irregular small knob on other side- lateral grip hard and round structure feel in lower pole of uterus by
superficial pelvic grip.Head is not fixed yet.

By auscultation:
F.H.S. 140/min

Vaginal examination: No leaking and bleeding per vagina, no any scar found around the vagina.

INVESTIGATION AND SPECIAL OBSERVATION:

Hb -10gm%
ABORH -B+ve
Blood sugar-80gm/dl
Urine sugar-Nil
Albumin - Nil
HBAsg -non-reactive

Ultra-sonography: USG show the fluid is adequate and fetal heart sound is 160.
 NURSING CARE PLAN

Labor is defined as a series of rhythmic, involuntary, progressive uterine contraction that causes effacement and dilation of the uterine cervix. The process
of labor and birth is divided into three stage.

The first stage of labor is the longest and involves three phases namely latent, active, and transition. The latent phase begins with the onset of regular uterine
contractions until cervical dilatation. The active phase occurs when cervical dilatation is at 4 to 7 cm and contractions last from 40 to 60 seconds with 3 to 5
minutes interval and the last phase which is transition phase occurs when contractions reach their peak with intervals of 2 to 3 minutes and dilatation of 8 to 10
cm.

The second stage of labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered.
Lastly, the third stage or the placental stage begins right after the birth of the baby and ends with the delivery of the placenta.
There are instances where labor doesn’t start on it’s own so when the risks of waiting for labor to start are higher than the risks of having a procedure to get
labor going, inducing labor may be necessary to keep the woman and baby healthy. This may be the case when certain situations such as premature rupture of
the membranes, overdue pregnancy, hypertension, preeclampsia, heart disease, gestational diabetes, or bleeding during pregnancy are present.

Nursing Care Plans

The nursing care plan for a woman in labor includes providing information regarding labor and birth, providing comfort and pain relief measures, monitoring
mother’s vital signs and fetal heart rate, facilitating postpartum care, and preventing complications after birth.

Labor Stage IA: Latent Phase

1. Deficient Knowledge
2. Risk for Fluid Volume Deficit
3. Risk For Fetal Injury
4. Risk For Maternal Infection
5. Risk For Ineffective Coping
6. Risk For Anxiety
 Nursing Nursing Nursing Intervention Implementation Nursing
Assessment Diagnosis Goal Evaluation
Subjective I- Deficient To enhance - Assess client’s baseline knowledge - Assessed client’s data and - Client will verbalize
Data- Knowledge knowledge and expectations during pregnancy. knowledge about labour process. understanding of
Client says, related to about psychological
“Is everything Information birthing - Provide and discuss options for care - Information about labour process and physiological
will be misinterpretation, process. during the labor process. Provide given. changes.
alright.” Lack of information about birthing alternatives,
exposure/recall as if available and appropriate. - Client will
Objective evidenced by participate in decision-
Data- Inaccurate - Provide information about procedures - Information given about any type of making process.
Client asks follow-through of (especially fetal monitor and telemetry) procedure done on client.
questions instruction, and normal progression of labor. - Client will
again and Questions, demonstrate
again. Statements of - Review appropriate activity levels and - Activities reviewed and safety appropriate breathing
misconception. safety precautions, whether client precautions taken. and relaxation
remains in hospital or returns home. techniques.

- Obtain informed consent for - Informed consent taken from client

procedures, e.g., and family members.
forceps delivery, episiotomy.
Explain the procedures and the possible
risks associated with labor
and delivery.

- Educate the client about breathing and - Education given to the client about
relaxation techniques appropriate to relaxation techniques.
each phase of labor; teach and review
pushing positions for stage II.

Nursing Nursing Nursing Intervention Implementation Nursing

Assessment Diagnosis Goal Evaluation

Objective II- Risk for Fluid To maintain - Assess production of mucus, amount - Assessment of client done. - Client will maintain
Data- Volume altered level of tearing within eyes, and skin turgor. fluid intake as able.
Client looks Deficitrelated of fluid
very toDecreased volume - Monitor intake & output. Note urine - Intake and output are monitored. - Client will
dehydrated. intake, increased specific gravity. Encourage client to demonstrate adequate
losses (e.g., empty bladder at least once every 1 1/2– hydration (e.g., moist
nausea & 2 hr. mucous membranes,
vomiting, mouth yellow/amber urine of
breathing, - Monitor vital signs/FHR as indicated. - Monitored Vitals. appropriate amount,
hormonal shifts) absence of thirst,
- Monitor Hematocrit level. - Monitored hematocrit level. afebrile, stable vital
signs/FHR).
- Provide mouth care and hard candy, - Mouth care provided.
as appropriate.

- Provide clear fluids (e.g., clear broth, - Clear fluids provided.

tea, fruit juices) and ice chips, as
permitted.

- Administer bolus of parenteral fluids, - Administered bolus to client.

as indicated.

Nursing Nursing Nursing Intervention Implementation Nursing

Assessment Diagnosis Goal Evaluation

Objective III- Risk for fetal To reduced -Note progress of labor. -Noted progress of labor. - Fetus will display
Data- Injuryrelated the risk for FHR and beat-to-beat
Continues toHypercapnia, fetal injury. - Monitor baseline FHR manually - Monitored basic data to plan variability within
fetal heart Infection, Tissue and/or electronically. Evaluate nursing care. normal limits, with no
monitoring hypoxia frequently per protocol. Note ominous periodic
done to FHR variability and periodic changes changes in response to
observe any in response to uterine contractions. uterine contractions.
type heart rate
abnormality. - Monitor FHR during rupture of - FHR monitored.
membranes, reassess per protocol,
obtain 30-min EFM strip for record.
Evaluate periodic changes in FHR.

- Monitor FHR and periodic changes if - FHR monitored.

a problem is detected with fetoscopy or
external monitor. Note presence of
bradycardia/tachycardia or sinusoidal
pattern.

- Assess maternal perineum for - Assessment of maternal perineum

chlamydial discharges, vaginal warts, done.
or herpetic lesions.

Nursing Nursing Nursing Intervention Implementation Nursing

Assessment Diagnosis Goal Evaluation

Objective IV- Risk for To reduce - Monitor vital signs, and white blood - Monitored vital signs. - Client will
Data- Maternal the maternal cell (WBC) count, as indicated. demonstrate
Procedures Infectionrelated risk for techniques to
can cause to Fecal infection. - Perform initial vaginal examination; - Performed vaginal examination. minimize risk of
vaginal contamination, repeat only during contractile pattern or infection.
infections. Invasive client’s behavior indicates significant
procedures, progress of labor. - Client will be free of
Repeat vaginal signs of infection (e.g.,
examinations, - Use aseptic technique during a - Used aseptic technique during a afebrile; amniotic fluid
Rupture of vaginal examination. vaginal examination. clear, nearly colorless
amniotic and odorless).
membranes. - Demonstrate good hand washing - Demonstrated for good hand
techniques. washing techniques.

- Assess vaginal secretions - Assess vaginal secretions

usingphenaphthazine (nitrazine paper). usingphenaphthazine.
Perform microscopic examination for
positive ferning.

- Monitor and describe the character of - Monitored character of amniotic

amniotic fluid. fluid.

- Provide oral and parenteral fluids, as - Provided oral and parenteral fluids.
indicated.

- Encourage perineal care after - Encouraged for perineal care after

elimination and prn as indicated; elimination.
change underpad/ linen when wet.

- Carry out perineal preparation, as -Perineal preparation done.

appropriate.

- Obtain blood cultures if symptoms of - Blood culturesObtained.

sepsis are present.

- Administer cleansing enema, if - Administered cleansing enema.

indicated.

- Administer prophylactic antibiotic IV, - Administered prophylactic

if indicated. antibiotic IV.

- Administer oxytocin infusion, as - Administered oxytocin infusion.

 ordered.

Nursing Nursing Nursing Intervention Implementation Nursing

Assessment Diagnosis Goal Evaluation

Objective V- Risk To reduce - Assess uterine contraction/relaxation - Assessment of uterine contraction - Client will identify
Data- For Ineffective ineffective pattern, fetal status, vaginal bleeding, done. individually
Pregnancy is Coping related to coping and cervical dilatation. appropriate behaviors
type of crises Inadequate mechanism. to maintain
and effective support systems - Determine client’s cultural - Proper history taking done. control.
coping and/or coping background, coping abilities, and
mechanism is methods verbal and nonverbal responses to pain. - Client will verbalize
required. Personal Determine previous experiences awareness of own
vulnerability and ante-partal preparation. coping abilities.
Situational crisis.
- Establish rapport and accept behavior - Established rapport and accepted - Client will use
without judgment. Make verbal behavior of client. medication
contract about expected behaviors of appropriately
client and nurse.

- Stay with/provide companion (e.g.,

doula [woman’s servant]) for a client
who is alone.

- Reinforcing breathing and relaxation - Reinforcing breathing and

techniques during contractions. relaxation techniques during
contractions given.

- Discuss types of systemic/regional - Discussionabout types of

analgesics or anesthetics when systemic/regional analgesics.
available in the birth setting.

- Discuss administration of sedatives

such as secobarbital (Seconal),
pentobarbital (Nembutal), or
hydroxyzine (Vistaril).
 Nursing Nursing Nursing Intervention Implementation Nursing
Assessment Diagnosis Goal Evaluation
Objective VI- Risk for To reduce -Assess level and causes of anxiety, - Assessment of level and causes of -Client will report
Data- Anxiety related to anxiety of preparedness for childbirth, cultural anxiety. anxiety is at a
Client seems Interpersonal the patient. background, and role of significant manageable level.
anxious by transmission, other/partner.
her facial Situational crisis, -Client will use
expression. Unmet needs. - Monitor pattern of uterine -Monitored pattern of uterine breathing and
contraction. contraction. relaxation techniques
proficiently.
- Monitor BP and pulse as indicated. (If - Monitored BP and pulse.
BP is elevated on admission, repeat the -Client will appear
procedure in 30 min to obtain true relaxed appropriate to
reading once the client is relaxed.) the labor situation.
Client will remain
- Orient client to environment, staff, -Orientated client to environment. normotensive.
and procedures. Provide information
about psychological and physiological
changes in labor, as needed.

- Promote privacy and respect for -Promoted privacy.

modesty; reduce unnecessary exposure.
Use draping during a vaginal
examination.

- Encourage client to verbalize feelings, - Encouragement about client to

concerns, and fears. verbalize feelings.

- Provide primary nurse or continuous - Provided supported.

intrapartum professional support as
indicated.

- Be aware of client’s need or

preference for female
caregivers/support persons.
 - Determine diversional needs; - Determined about diversional
encourage a variety of activities (e.g., needs.
music, books, cards, walking, rocking,
showering, massage, painting,
aromatherapy).

- Demonstrate breathing and relaxation -Demonstrated breathing and

methods. Provide comfort measures. relaxation methods.

- Provide an opportunity for - Provided an opportunity for

conversation to include choice of infant conversation.
names, expectations of labor and
perceptions/fears during pregnancy.

- Prepare for, and/or assist with,

discharge from hospital setting, as
indicated.

HEALTH EDUCATION
First Stage of Labor
 Admit the mother in labor room and complete procedures such as changing to hospital gown, applying identification band, obtaining history and
completing chart forms
 Orient patient to labor and delivery rooms
 Explain admission protocol, labor process and management plans
 Carry out perineal shave and administer enema if not contraindicated
 Start an I.V. line if indicated and administer fluids
  Provide bodily care and attend to comfort needs
 Monitor and evaluate maternal well-being, fetal well-being and progress of labor (vital signs of mother, fetal heart sounds, uterine contractions, cervical
dilation and fetal descend)
 Encourage to use coping skills such as breathing, relaxation and positioning
— During latent phase (1-4 cm dilation) review breathing techniques she can use as labor progress and
encourage ambulation and comfortable position.
— During active phase (4-8 cm dilation) provide comfortable position, assist with breathing exercises, provide
backup and sacral pressure and analgesia.
— During transitional phase (8-10 cm dilation), assist with deep breathing during contractions and shallow
breathing and relaxation between contractions.
 Provide information about progress of labor, fetal well-being and how she is coping.

Second Stage of Labor

 Continue to monitor maternal well-being including vital signs, bladder care, hydration and analgesia
 Encourage maternal pushing efforts
 Evaluate perineal integrity and perform episiotomy if appropriate
 Deliver the baby and reassure mother about neonate's condition.

Third Stage of Labor

 Encourage patient to maintain position to facilitate delivery of placenta
 Allow mother to hold and feed the baby if she desires
 Deliver placenta and membranes
 Monitor maternal vital signs, bleeding and consistency of uterus
 Administer oxytocin if required
 Examine placenta and membranes for completeness
 Perform episiotomy suturing if one was made.

Fourth Stage of Labor

 Provide clean gown, perineal pads and comfortable position
 Check vital signs regularly
 Palpate fundus of uterus for contractility
 Massage the fundus and express any clots present
 Inspect the perineum, bladder and change pads
 Offer food and fluids if not contraindicated