Navarro, Ruth Laureen P.

BSN 2 STEM

Stages of Labor Nursing Diagnosis Nursing Interventions

 Assess production of mucus, amount of tearing within

eyes, and skin turgor.
 Risk for Fluid  Monitor intake & output. Note urine specific gravity.
Stage 1 Dilatation Volume Deficit Encourage client to empty bladder at least once every
2-3 hrs.
 Monitor vital signs/FHR as indicated.
 Administer bolus of parenteral fluids, as indicated.

 Monitor and record uterine activity with each

contraction.
 Identify degree of discomfort and its sources.
 Observe for perineal and rectal bulging, opening of
vaginal introitus, and changes in fetal station.
 Acute Pain
Stage 2 Expulsion  Encourage client/couple to manage efforts to bear
down with spontaneous, rather than sustained,
pushing during contractions. Stress importance of
using abdominal muscles and relaxing pelvic floor.
 Encourage client to relax all muscles and rest between
contractions.

 Assess respiratory rhythm and excursion.

 Palpate fundus to note “ballooning” of uterus, and
 Risk for Maternal massage gently.
Stage 3 Placental
Injury  Gently massage fundus after placental expulsion.
 Clean vulva and perineum with sterile water
and antiseptic solution; apply sterile perineal pad.

 Assess psychological and emotional status.

 Use positive terminology; avoid use of terms
that indicate abnormality of procedures or processes.
 Encourage verbalization of feelings.
 Encourage use/continuation of breathing techniques
Stage 4 Immediate
 Anxiety and relaxation exercises.
Post Partum
 Listen to client’s comments that may indicate loss of
self-esteem.
 Provide opportunities for client input into decision-
making process.