NCP LABOR Induced/Augmented

This plan of care concerns the induction of labor for maternal health problems, fetal compromise, or postmaturity (medically indicated inductions), and the augmentation of labor in uterine dysfunction. For optimal use of this plan of care, combine it with the previous plans of care in this chapter, concerning the normal stages of labor and dysfunctional labor, as appropriate.

CLIENT ASSESSMENT DATA BASE

Circulation

BP elevation (possibly anxiety or pregnancy-induced hypertension [PIH]); decrease (suggests supine hypotension or dehydration)

Food/Fluid

Maternal weight loss of 2.5–3 lb (may be associated with postmaturity or fetal weight loss)

Neurosensory

Deep tendon reflexes may be brisk 3+ with PIH; presence of clonus indicates severe excitability.

Pain/Discomfort

Uterine palpation may reveal dysfunctional contractile pattern.

Safety

May experience SROM without contractions.
Elevated temperature (infection in presence of prolonged rupture of membranes).
FHR may be greater than 160 bpm if preterm, hypoxic, or septic.
Fetal size may indicate weight loss; fetal demise.
Greenish amniotic fluid (fetal distress in vertex presentation).
Presenting part below the pelvic inlet.
Fundus may be lower than anticipated for term, with intrauterine growth retardation/restriction (IUGR) associated with maternal vascular involvement.
History/presence of Rh isoimmunization, chorioamnionitis, diabetes, PIH not controlled by medical therapy, chronic hypertension, postmaturity, cyanotic maternal cardiac disease, or renal disease; or previous cesarean delivery with low transverse incision (vertical incision is contraindication).

Sexuality

Precipitous (or rapid) labor with previous pregnancy; client lives a distance from the hospital.
Cervix may be ripe (approximately 50% effacement and 2–3 cm dilated).
Uterine inertia may occur.
Bloody show may be present with dilation.
Increased vaginal bleeding (placenta previa or abruptio placentae are contraindications).
May be 42 weeks’ gestational age or more.

DIAGNOSTIC STUDIES

Complete Blood Count with Differential (CBCD): Determines presence of anemia and infection, as well as level of hydration.
Blood type and Rh factor, if not previously done.
Urinalysis: Reveals urinary tract infection, protein, or glucose.
Lecithin to Sphingomyelin Ratio: Determines fetal maturity.
Nitrazine Paper and/or Fern Test: Confirms rupture of membranes.
Scalp pH: Indicates degree of fetal hypoxia/fetal metabolic reserves.
Ultrasonography: Determines gestational age, fetal size, presence of fetal heart motion, and location of the placenta.
Pelvimetry: Identifies deformities of the pelvis, CPD, or fetal malposition (all of which are contraindications for induction/augmentation).
Nonstress Test (NST) or Contraction Stress Test (CST): Evaluates fetal/placental functioning.

NURSING PRIORITIES

1. Promote maternal and fetal well-being.
2. Provide client/couple with information about induction and augmentation of labor.
3. Provide emotional support.
4. Promote comfort.