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The Labor Progress Handbook


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Table of Contents

Foreword to the Fourth Edition xvii Acknowledgments xx Chapter 1: Introduction 1 Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA) Causes and prevention of labor dystocia: a systematic approach 1 Differences in maternity care providers and practices in the united kingdom, the united states, and canada 5 Notes on this book 5 Changes in this fourth edition 6 A note from the authors on the use of gender?specific language 6 Conclusion 7 References 7 Chapter 2: Normal Labor and Labor Dystocia: General Considerations 9 Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA) What is normal labor? 10 What is labor dystocia? 14 Why does labor progress slow down or stop? 15 Prostaglandins and hormonal influences on emotions and labor progress 17 "Fight?or?flight" and "tend?and?befriend" responses to distress and fear during labor 19 Optimizing the environment for birth 21 The psycho?emotional state of the woman: wellbeing or distress? 21 Pain versus suffering 21 Assessment of pain and distress in labor 22 Assessment of women's ability to cope with the pain 23 Psycho?emotional measures to reduce suffering, fear, and anxiety 24 Before labor, what the caregiver can do 24 During labor: tips for caregivers and doulas, especially if meeting the laboring client for the first time in labor 26 An integrated philosophy on caring for trauma survivors 27 Trauma histories: why they matter 27 Childhood sexual abuse (CSA) and trauma in adulthood 27 Traumatic births 28 Trauma?informed care as a universal precaution 31 Physical and physiologic measures to promote comfort and labor progress 32 During labor: physical comfort measures 32 During labor: physiologic measures 32 Why focus on maternal position? 33 Techniques to elicit stronger contractions 35 Maintaining maternal mobility while monitoring contractions and fetal heart 36 Auscultation 36 When EFM is required: options to enhance maternal mobility 37 Continuous EFM 37 Intermittent EFM 39 Wireless telemetry 40 Conclusion 42 References 42 Chapter 3: Assessing Progress in Labor 49 Wendy Gordon, LM, CPM, MPH, Suzy Myers, LM, CPM, MPH, with contributions by Gail Tully, BS, CPM, CD(DONA) and Lisa Hanson, PhD, CNM, FACNM Before labor begins 50 Fetal presentation and position 50 Abdominal contour 52 Location of the point of maximum intensity (PMI) of the fetal heart tones via auscultation 53 Leopold's maneuvers for identifying fetal presentation and position 55 Abdominal palpation using Leopold's maneuvers 55 Estimating engagement 58 Malposition 62 Influencing fetal position prior to labor 62 Identifying those fetuses likely to persist in an OP position throughout labor 63 Influencing fetal position during labor 63 Other assessments prior to labor 64 Estimating fetal weight 64 Assessing the cervix prior to labor 64 The Bishop scoring system 65 Assessments during labor 66 Visual and verbal assessments 66 Hydration and nourishment 66 Psychology 67 Quality of contractions 68 External assessments 69 Vital signs 69 Quality of contractions 69 Abdominal palpation (Leopold's maneuvers) 70 Assessing the fetus 70 Gestational age 71 Meconium 71 Fetal heart rate (FHR) 71 Internal assessments 75 Vaginal examinations: indications and timing 77 Performing a vaginal examination during labor 77 Assessing the cervix 79 Assessing the presenting part 81 The vagina and bony pelvis 87 Putting it all together 87 Assessing progress in the first stage 87 Features of normal latent phase 88 Features of normal active phase 88 Assessing progress in the second stage 88 Features of normal second stage 88 Conclusion 89 References 89 Chapter 4: Prolonged Prelabor and Latent First Stage 95 Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA) The onset of labor: key elements in diagnosis 96 Prelabor vs labor: the dilemma for expectant parents 96 Symptoms that differentiate prelabor from early labor 97 The six ways to progress in labor-prelabor to birth 99 The Bishop Score 100 Use of the "Six Ways to Progress" and the Bishop Score to help parents differentiate prelabor from labor 100 Prolonged prelabor and latent phase of labor 101 Can prenatal actions prevent some postdates pregnancies, prolonged prelabors, or early labors? 102 Prenatal preparation of the cervix for dilation 102 Attention to fetal factors that may prolong early labor 107 Optimal fetal positioning: prenatal features 107 Prenatal assessment and correction of suboptimal maternal musculoskeletal variations 109 The woman who has hours of latent labor contractions without dilation 109 Support measures for women who are at home in prelabor and the latent phase 109 Some reasons for excessive pain and duration of prelabor or the latent phase 112 Iatrogenic factors 112 Cervical factors 112 Other soft tissue (ligaments, muscles, fascia) factors 113 Emotional factors 113 Troubleshooting measures for painful prolonged prelabor or latent phase 114 Measures to alleviate painful, non?progressing, non?dilating contractions in prelabor or the latent phase 115 Synclitism and asynclitism 116 Open knee-chest position 119 Closed knee-chest position 120 Side?lying release 120 Conclusion 121 References 121 Chapter 5 Prolonged Active Phase of Labor 125 Penny Simkin, BA, PT, CCE, CD(DONA), Ruth Ancheta, MA, ICCE, CD(DONA), and Lisa Hanson, PhD, CNM, FACNM What is active labor? Description, definition, diagnosis 126 When is active labor prolonged? 127 Observable characteristics of prolonged active labor 127 Possible causes of prolonged active labor 128 Fetal and fetopelvic factors 129 Malposition, macrosomia, malpresentation, and cephalopelvic disproportion 129 Persistent asynclitism 130 Occiput posterior 130 How fetal malpositions delay labor progress 132 Problems in diagnosis of fetal position during labor 133 Artificial rupture of the membranes with a malpositioned fetus 134 Specific measures to address and correct problems associated with a "poor fit"-malposition, cephalopelvic disproportion, and macrosomia 135 Maternal positions and movements for suspected malposition, cephalopelvic disproportion, or macrosomia 135 Forward?leaning positions 136 Side?lying positions 138 Asymmetrical positions and movements 140 Abdominal lifting 142 An uncontrollable premature urge to push 143 If contractions are inadequate 145 Immobility 145 Medication 147 Dehydration and fear of dehydration 147 Overhydration-excessive oral and/or intravenous fluids 148 Exhaustion 149 Uterine lactic acidosis as a cause of inadequate contractions 149 When the cause of inadequate contractions is unknown 150 Breast stimulation 150 Walking and changes in position 151 Acupressure or acupuncture 151 Hydrotherapy (baths and showers) 151 If there is a persistent anterior cervical lip or a swollen cervix 153 Positions to reduce an anterior cervical lip or a swollen cervix 153 Other methods 154 Manual reduction of a persistent cervical lip 155 If emotional dystocia is suspected 155 Assessing the woman's coping 155 Western cultural attitudes on coping with labor 155 Relaxation, Rhythm, and Ritual: The essence of "coping" during the first stage of labor 155 Indicators of emotional dystocia during active labor 156 Predisposing factors for emotional dystocia 157 Helping the woman state her fears 157 How to help a laboring woman in distress 158 Special needs of childhood abuse survivors 159 Incompatibility or poor relationship with staff 161 If the source of the woman's anxiety cannot be identified 161 Conclusion 162 References 162 Chapter 6 Prevention and Treatment of Prolonged Second Stage of Labor 167 Penny Simkin, BA, PT, CCE, CD(DONA), Lisa Hanson, PhD, CNM, FACNM, and Ruth Ancheta, MA, ICCE, CD(DONA) Definitions of the second stage of labor 168 Phases of the second stage of labor 168 The latent phase of the second stage 169 Avoid directing the woman to push during the latent phase of the second stage 170 What if the latent phase of the second stage persists? 171 The active phase of the second stage 171 Support of spontaneous bearing down 171 Physiologic effects of prolonged breath?holding and straining 172 Effects on the woman 172 Effects on the fetus 172 Spontaneous expulsive efforts 172 Diffuse pushing 174 Second stage time limits 175 Possible etiologies and solutions for second stage dystocia 176 Maternal positions and other strategies for suspected occiput posterior or persistent occiput transverse fetuses 178 Why not the supine position? 179 Differentiating between pushing positions and birth positions 179 Leaning forward while kneeling, standing, or sitting 179 Squatting positions 179 Asymmetrical positions 179 Lateral positions 182 Supported squat or "dangle" positions 183 Other strategies for malposition and back pain 183 Manual interventions to reposition the occiput posterior fetus 187 Early interventions for suspected persistent asynclitism 190 Positions and movements for persistent asynclitism in second stage 192 Nuchal hand or hands at vertex delivery 193 If cephalopelvic disproportion or macrosomia ("poor fit") is suspected 193 The influence of time on cephalopelvic disproportion 194 Fetal head descent 194 Positions for suspected "cephalopelvic disproportion" (CPD) in second stage 194 The use of supine positions 200 Use of the exaggerated lithotomy position 202 Shoulder dystocia 203 If contractions are inadequate 203 If emotional dystocia is suspected 204 The essence of coping during the second stage of labor 204 Signs of emotional distress in second stage 205 Triggers of emotional distress unique to the second stage 205 Conclusion 207 References 207 Chapter 7 Optimal Newborn Transition and Third and Fourth Stage Labor Management 211 Lisa Hanson, PhD, CNM, FACNM, and Penny Simkin, BA, PT, CCE, CD(DONA) Overview of the normal third and fourth stages of labor for unmedicated mother and baby 211 Third stage management: care of the baby 213 Oral and nasopharynx suctioning 213 Delayed clamping and cutting of the umbilical cord 214 Management of delivery of an infant with a tight nuchal cord 216 Third stage management: the placenta 216 Physiologic (expectant) management of the third stage of labor 217 Active management of the third stage of labor 218 The fourth stage of labor 221 Keeping the mother and baby together 221 Baby?friendly (breastfeeding) practices 222 Supporting microbial health of the infant 223 Routine newborn assessments 225 Conclusion 226 References 227 Chapter 8 Low?Technology Clinical Interventions to Promote Labor Progress 231 Lisa Hanson, PhD, CNM, FACNM Intermediate?level interventions for management of problem labors 232 When progress in prelabor or latent phase remains inadequate 232 Therapeutic rest 232 Nipple stimulation 233 Management of cervical stenosis or the "zipper" cervix 233 When progress in active phase remains inadequate 234 Artificial rupture of the membranes (AROM) 234 Digital or manual rotation of the fetal head 235 Digital rotation 236 Manual rotation 237 Manual reduction of a persistent cervical lip 238 Reducing swelling of the cervix or anterior lip 238 Fostering normality in birth 239 Perineal management 239 Prenatal perineal massage 239 Perineal management during second stage 240 Verbal support of spontaneous bearing?down efforts 240 Maternal birth positions 241 Guiding women through crowning of the fetal head 241 Hand skills to protect the perineum 242 Differentiating perineal massage from other interventions 243 When progress in second stage labor remains inadequate 243 Duration of second stage labor 243 Precautionary measures 245 Warning signs 246 Shoulder dystocia maneuvers 246 The McRoberts' maneuver 247 Suprapubic pressure 248 The Gaskin maneuver 249 Somersault maneuver 249 Non?pharmacologic and minimally invasive pharmacologic techniques for intrapartum pain relief 251 Acupuncture 251 Sterile Water Injections 252 Procedure for subcutaneous sterile water injections 253 Nitrous oxide 254 Topical anesthetic applied to the perineum 254 Conclusion 254 References 255 Chapter 9 Epidural and Other Forms of Neuraxial Analgesia for Labor: Review of Effects, with Emphasis on Preventing Dystocia 260 Penny Simkin, BA, PT, CCE, CD(DONA) Introduction: analgesia and anesthesia-an integral part of maternity care in many countries 261 Neuraxial (epidural and spinal) analgesia-new terms for old approaches to labor pain? 261 Physiological adjustments that support fetal growth and wellbeing 262 Multisystem effects of epidural analgesia on labor progress 263 The endocrine system 263 The central nervous system and peripheral nervous system (sensory, motor, and autonomic, including the sympathetic and parasympathetic nervous systems) 264 The musculoskeletal system 265 The genitourinary system 266 Can changes in labor management reduce problems of epidural analgesia? 266 1. Inform the woman ahead of time 266 2. Shorten the duration of exposure 267 3. Treat the woman as much as possible like a person who does not have an epidural 267 4. Attend to the woman's emotional needs 272 Restoring women to a central role 273 Conclusion 274 References 274 Chapter 10 The Labor Progress Toolkit Part 1: Positions and Movements 277 Penny Simkin BA, PT, CCE, CD(DONA) and Ruth Ancheta MA, ICCE, CD(DONA) Maternal positions and how they affect labor 278 Side?lying positions 279 Pure side?lying and semiprone (exaggerated Sims') 279 The "semiprone lunge" 284 Side?lying release 285 Sitting positions 288 Semisitting 288 Sitting upright 289 Sitting leaning forward with support 290 Standing, leaning forward 292 Kneeling positions 293 Kneeling, leaning forward with support 293 Hands and knees 295 Open knee-chest position 296 Closed knee-chest position 298 Asymmetrical upright (standing, kneeling, sitting) positions 299 Squatting positions 300 Squatting 300 Supported squatting ("dangling") positions 302 Half?squatting, lunging, and swaying 304 Lap squatting 306 Supine positions 308 Supine 308 Sheet"pull?to?push"309 Exaggerated lithotomy (McRoberts' position) 310 Maternal movements in first and second stages 312 Pelvic rocking (also called pelvic tilt) and other movements of the pelvis 312 Hip sifting 314 Flexion of hips and knees in hands and knees position 315 The lunge 316 Walking or stair climbing 317 Slow dancing 318 Abdominal lifting 320 Abdominal jiggling with a rebozo 321 The pelvic press 323 Other rhythmic movements 324 References 326 Chapter 11 The Labor Progress Toolkit Part 2: Comfort Measures 327 Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA) Introduction: the state of the science regarding non?pharmacologic, complementary, and alternative methods to relieve labor pain 328 General guidelines for comfort during a slow labor 328 Non?pharmacologic methods to relieve labor pain 328 Non?pharmacologic physical comfort measures 330 Heat 330 Cold 331 Hydrotherapy 333 Touch and massage 337 How to give simple brief massages for shoulders and back, hands, and feet 338 Acupressure 343 Acupuncture 344 Continuous labor support from a doula, nurse, or midwife 345 How the doula helps 345 What about staff nurses and midwives as labor support providers? 346 Psychosocial comfort measures 347 Assessing the woman's emotional state 348 Techniques and devices to reduce back pain 350 Counterpressure 350 The double hip squeeze 351 The knee press 353 Cook's counterpressure technique No. 1: ischial tuberosities (IT) 354 Cook's counterpressure technique No. 2: perilabial pressure 355 Techniques and devices to reduce back pain 357 Cold and heat 357 Cold and rolling cold 358 Warm compresses 359 Hydrotherapy 359 Maternal movement and positions 360 Birth ball 360 Transcutaneous electrical nerve stimulation (TENS) 362 Sterile water injections for back pain 364 Breathing for relaxation and a sense of mastery 364 Simple breathing rhythms to teach on the spot in labor 365 Bearing?down techniques for the second stage 366 Spontaneous bearing down (pushing) 366 Self?directed pushing 367 Directed pushing 367 Conclusion 367 References 368 Index 371

About the Author

Penny Simkin, Senior Faculty at Simkin Center for Allied Birth, Vocations at Bastyr University, Independent Practice of Childbirth Education and Labor Support, USA. Lisa Hanson, Professor and Director, Midwifery Program, College of Nursing, Marquette University, USA. Ruth Ancheta, DONA-Approved Doula Trainer, Independent Practice of Childbirth Education and Labor Support, USA.

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