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 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.
CLIENT ASSESSMENT DATA BASE
Ego 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, lasting
15–20 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 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.
Full Nuring Care Plan Labor Stage 1
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.
CLIENT ASSESSMENT DATA BASE
Ego 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, lasting
15–20 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 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.
Full Nuring Care Plan Labor Stage 1
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