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LABOR Stage I Latent Phase

LABOR Stage I Latent Phase

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Published by mardsz

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Published by: mardsz on Jan 01, 2009
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09/14/2012

 
LABOR Stage I—Latent Phase
The latent phase, or the first phase of stage I labor, begins with the onset of true labor and ends with the cervixdilated 4 cm. The phase averages approximately 8–10 hr, up to 20 hr for nulliparas and 3–6 hr, up to 14 hr formultiparas. It usually occurs with client at home, unless specific concerns necessitate inpatient care, e.g., spontaneousrupture of membranes (SROM), history of rapid labor, unsafe weather conditions/distance from facility.
CLIENT ASSESSMENT DATA BASEEgo Integrity
May be excited or anxious
Pain/Discomfort
Regular contractions, increasing in frequency, duration, and severity.Contractions are mild to moderate, 10–20 min apart, progressing to 5–7 min apart, lasting15–20 sec, progressing to 30–40 sec.
Safety
Fetal heart tones best heard below level of umbilicus (dependent on fetal position)
Sexuality
Membranes may or may not have ruptured.Cervix dilates from 0 to 4cm.Fetus may be at station1 to 0 (primigravida) or from 0 to +2 cm (multigravida).Scant vaginal discharge, may be pink or brownish mucus (“show”), or may consist of mucous plug.
NURSING PRIORITIES
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.
DISCHARGE GOALS
(Inpatient care is not required in early labor, unless complications develop necessitatinghospitalization.)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:Anxiety, risk forRisk Factors May Include:
Situational crisis, interpersonal transmission, unmet needs
Possibly Evidenced By:
[Not applicable; presence of signs/symptoms establishes an
actual
diagnosis]
 
DESIRED OUTCOMES/EVALUATION
Report anxiety is at a manageable level.
CRITERIA—CLIENT WILL
Use breathing and relaxation techniques proficiently.Appear relaxed appropriate to the labor situation.Remain normotensive.
ACTIONS/INTERVENTIONSRATIONALEIndependent
Provide primary nurse orcontinuous intrapartum Continuity of care and assessment may decreaseprofessional support as indicated.stress. Research studies suggest that these clientsrequire less pain medication, which may result inshorter labor.Orient client to environment, staff, and procedures. Education may reduce stress and anxiety andProvide information about psychological and promote labor progress.physiological changes in labor, as needed.Assess level and causes of anxiety, preparedness Provides baseline information. Anxiety magnifiesfor childbirth, cultural background, and role of pain perception, interferes with use of copingsignificant other/partner.techniques, and stimulates the release of aldosterone,which may increase sodium and water resorption.Monitor BP and pulse as indicated. (If BP is elevated Stress activates the hypothalamic-pituitary-on admission, repeat procedure in 30 min to obtain adrenocortical system, which increases retentiontrue reading once client is relaxed.)and resorption of sodium and water and increasesexcretion of potassium. Sodium and water resorptionmay contribute to development of intrapartaltoxemia/hypertension. Loss of potassium maycontribute to reduction of myometrial activity.Monitor uterine contractile pattern; report A hypertonic or hypotonic contractile pattern maydysfunctional labor. (Refer to CP: develop if stress persists and causes prolongedDysfunctional Labor/Dystocia.)catecholaminerelease.Encourage client to verbalize feelings, concerns, Stress, fear, and anxiety have a profound effect onand fears.the labor process, often prolonging the first phasebecause of utilization of glucose reserves; causingexcess epinephrine release from adrenal stimulation,which inhibits myometrial activity; and increasingnorepinephrine levels, which tends to increaseuterine activity. Such an imbalance of epinephrineand norepinephrine can create a dysfunctional laborpattern.Demonstrate breathing and relaxation methods. Reduces stressors that might contribute to anxiety;Provide comfort measures. (Refer to CP: Labor: provides coping strategies.Stage I—Active Phase; ND: Pain [acute].)Promote privacy and respect for modesty; Modesty is a concern in most cultures. Supportreduce unnecessary exposure. Use draping person may or may not desire to be present whileduring vaginal examination.client is examined or care provided.Be aware of client’s need or preference for Cultural practices may prohibit presence of menfemale caregivers/support persons.(even father of the child) during labor and/ordelivery.
 
Provide opportunity for conversation to include Presents opportunity for client to verbalizechoice of infant names, expectations of labor, excitement about herself, the pregnancy, and herand perceptions/fears during pregnancy.baby. Serves as a diversion to help pass time duringwhat is commonly the longest phase of labor.Determine diversional needs; encourage variety Helps divert attention away from labor, makingof activities (e.g., television, books, cards, walking, time pass more quickly. If condition permits,rocking, showering, massage, music, aroma therapy).walking usually promotes cervical dilatation,shortens labor, and lowers the incidence of fetal heartrate (FHR) abnormalities.Prepare for, and/or assist with, discharge from During very early latent phase with no apparenthospital setting, as indicated.progress of labor, the comfort and familiarity of thehome environment may decrease anxiety and allowopportunity for a variety of acceptable diversionalactivities, thereby hastening the labor process.
NURSING DIAGNOSIS:Knowledge deficit [Learning Need], regarding progression olabor, available optionsMay Be Related To:
Lack of exposure/recall, information misinterpretation
Possibly Evidenced By:
Questions, statements of misconception, inaccurate follow-through of instruction
DESIRED OUTCOMES/EVALUATION
Verbalize understanding of psychological and
CRITERIA—CLIENT WILL:
physiological changes.Participate in decision-making process.Demonstrate appropriate breathing and relaxation techniques.
ACTIONS/INTERVENTIONSRATIONALEIndependent
Assess client’s preparation, knowledge level, Helps establish information/learning needs andand expectations/birth plan.set priorities.Provide information about procedures (especially Antepartal education can facilitate the labor andfetal monitor and telemetry) and normal delivery process, assist the client in maintainingprogression of labor.control during labor, help promote a positive attitudeand/or sense of control, and may decrease relianceon medication.Discuss options for care during the labor/Necessary for the client/couple to participatedelivery process. Provide information about actively in the decision-making process.birthing alternatives, if available and appropriate.Review roles of staff members.Identifies resources for specific needs/situations.Demonstrate breathing/relaxation techniques Unprepared couples need to learn copingappropriate to each phase of labor; teach and mechanisms on admission to help reduce stressreview pushing positions for stage II.and anxiety. Couples with prior preparation canbenefit from review and reinforcement.

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