Simkin's Labor Progress Handbook

List of Contributors xvi Foreword xviii Chapter 1: Introduction 1 Lisa Hanson, PhD, CNM, FACNM, FAAN and Emily Malloy, PhD, CNM Causes and prevention of labor dystocia: a systematic approach 1 Notes on this book 4 Note from the authors on the use of gender-inclusive language 5 Conclusion 5 References 5 Chapter 2: Respectful Care 7 Amber Price DNP, CNM, MSN, RN 7 Health system conditions and constraints 8 LGBTQ birth care 9 RMC and pregnant people in larger bodies 9 Shared decision-making 10 Expectations 11 The impact of culture on the birth experience 12 Traumatic births 12 Trauma survivors and prevention of PTSD 13 Trauma-informed care as a universal precaution 15 Obstetric violence 16 Patient rights 17 Consent 17 Maternal mortality 18 References 19 Chapter 3: Normal Labor and Labor Dystocia: General Considerations 22 Lisa Hanson, PhD, CNM, FACNM, FAAN, Venus Standard, MSN, CNM, LCCE, FACNM, andPenny Simkin, BA, PT, CCE, CD(DONA) What is normal labor? 22 What is labor dystocia? 26 What is normal labor progress and what practices promote it? 26 Why does labor progress slow or stop? 28 Prostaglandins and hormonal influences on emotions and labor progress 29 Disruptions to the hormonal physiology of labor 30 Hormonal responses and gender 30 “Fight‐or‐flight” and “tend‐and‐befriend” responses to distress and fear during labor 31 Optimizing the environment for birth 32 The psycho‐emotional state of the pregnant person: wellbeing or distress? 33 Pain versus suffering 33 Assessment of pain and coping 34 Emotional dystocia 34 Psycho‐emotional measures to reduce suffering, fear, and anxiety 34 Before labor, what the caregiver can do 34 During labor: tips for caregivers and doulas, especially if meeting the laboring client for the first time in labor 37 Conclusion 38 References 38 Chapter 4: Assessing Progress in Labor 41 Wendy Gordon, DM, MPH, CPM, LM, with contributions by Gail Tully, BS, CPM, andLisa Hanson, PhD, CNM, FACNM, FAAN Before labor begins 42 Fetal presentation and position 42 Abdominal contour 42 Location of the point of maximum intensity (PMI) of the fetal heart tones via auscultation 42 Leopold’s maneuvers for identifying fetal presentation and position 46 Abdominal palpation using Leopold’s maneuvers 46 Estimating engagement: The rule of fifths 49 Malposition 53 Other assessments prior to labor 53 Estimating fetal weight 53 Assessing the cervix prior to labor 54 Assessing prelabor 55 Six ways to progress 55 Assessments during labor 55 Visual and verbal assessments 55 Hydration and nourishment 55 Psychology 56 Quality of contractions 56 Vital signs 57 Purple line 58 Assessing the fetus 58 Fetal movements 58 Gestational age 58 Meconium 59 Fetal heart rate (FHR) 59 Internal assessments 67 Vaginal examinations: indications and timing 68 Performing a vaginal examination during labor 68 Assessing the cervix 69 Assessing the presenting part 70 Identifying those fetuses likely to persist in an OP position throughout labor 75 The vagina and bony pelvis 76 Putting it all together 76 Assessing progress in the first stage 76 Features of normal latent phase 76 Features of normal active phase 76 Assessing progress in the second stage 77 Features of normal second stage 77 Conclusion 77 References 77 Chapter 5: Role of Physiologic and Pharmacologic Oxytocin in Labor Progress 82 Elise Erickson, PhD, CNM, FACNM and Nicole Carlson, PhD, CNM, FACNM, FAAN History of oxytocin discovery and use in human labor 83 Structure and function of oxytocin 83 Oxytocin receptors 83 Oxytocin and spontaneous labor onset and progression 84 Promoting endogenous oxytocin function in spontaneous labor 85 Ethical considerations in oxytocin administration 85 Oxytocin use 86 Oxytocin use during latent phase labor 87 Oxytocin use during active phase labor 87 Oxytocin use during second stage labor 88 Changes in contemporary populations and labor progress 88 Oxytocin dosing 89 High dose/low dose 89 Variation in oxytocin dosing among special populations 89 Higher body mass index 89 Nullipara 90 Maternal age 90 Epidural 91 Problems associated with higher doses or longer oxytocin infusion 91 Postpartum hemorrhage 91 Fetal Intolerance to labor 92 Oxytocin holiday 92 Breastfeeding and beyond 92 New areas of oxytocin research 93 Conclusion 93 References 93 Chapter 6: Prolonged Prelabor and Latent First Stage 101 Ellen L. Tilden, PhD, RN, CNM, FACNM, Jesse Remer, BS, CD(DONA),BDT(DONA), LCCE, FACCE, and Joyce K. Edmonds, PhD, MPH, RN The onset of labor: key elements of recognition and response 102 Defining labor onset 102 Signs of impending labor 103 Prelabor 103 Prelabor vs labor: the dilemma 103 Delaying latent labor hospital admissions 103 Anticipatory guidance 104 Anticipatory guidance for coping prior in prelabor 105 Sommer’s New Year’s Eve technique 106 Prolonged prelabor and the latent phase of labor 106 Fetal factors that may prolong early labor 107 Optimal fetal positioning: prenatal features 107 Miles circuit 109 Support measures for pregnant people who are at home in prelabor and the latent phase 110 Some reasons for excessive pain and duration of prelabor or the latent phase 111 Iatrogenic factors 112 Cervical factors 112 Management of cervical stenosis or the “zipper” cervix 112 Other soft tissue (ligaments, muscles, fascia) factors 112 Emotional dystocia 113 Troubleshooting Measures for Painful Prolonged Prelabor or Latent Phase 113 Measures to Alleviate Painful, Non‐progressing, Non‐dilating Contractions in Prelabor or Latent Phase 114 Synclitism and asynclitism 114 Open knee–chest position 118 Closed knee–chest position 119 Side‐lying release 119 When progress in prelabor or latent phase remains inadequate 120 Therapeutic rest 120 Nipple stimulation 120 Membrane sweeping 121 Artificial rupture of membranes in latent labor 121 Can prenatal actions prevent some postdates pregnancies, prolonged prelabors, or early labors? 121 Prenatal preparation of the cervix for dilation 121 References 125 Chapter 7: Prolonged Active Phase 130 Amy Marowitz, DNP, CNM What is active labor? Description, definition, diagnosis 131 When is active labor prolonged or arrested? 131 Possible causes of prolonged active labor 132 Treatment of prolonged labor 132 Fetopelvic factors 132 How fetal malpositions and malpresentation delay labor progress 134 Determining fetopelvic relationships 134 Malpositions 134 Malpresentations 134 Use of ultrasound 135 Artificial rupture of the membranes (amniotomy) when there is a fetal malposition or malpresentation 135 Epidural analgesia and malposition or malpresentation 135 Maternal positions and movements for suspected malposition, malpresentation, or any “poor fit” 136 Overview and evidence 136 Positions to encourage optimal fetal positioning 137 Forward‐leaning positions 137 Side‐lying positions 137 Asymmetrical positions and movements 137 Abdominal lifting 142 “Walcher’s” position 142 Flying cowgirl 142 Low technology clinical approaches to alter fetal position 144 Digital or manual rotation of the fetal head 144 Digital rotation 145 Manual rotation 146 Early urge to push, cervical edema, and persistent cervical lip 147 Manual reduction of a persistent cervical lip 148 Reducing swelling of the cervix or anterior lip 148 Disruptions to the hormonal physiology of labor 150 Overview 150 If emotional dystocia is suspected 150 Predisposing factors theorized to contribute to emotional dystocia 151 Possible indicators of emotional dystocia during active labor 151 Measures to help cope with expressed fears 151 Hypocontractile uterine activity 152 Factors that can contribute to contractions of inadequate intensity and/or frequency 152 Immobility 152 Environmental and emotional factors 152 Uterine lactate production in long labors 152 Sodium bicarbonate 153 Calcium carbonate 154 When the cause of inadequate contractions is unknown 154 Breast stimulation 154 Walking and changes in position 154 Acupressure or acupuncture 154 Coping and comfort issues 155 Individual coping styles 155 Simkin’s 3 Rs: Relaxation, rhythm, and ritual: The essence of coping during the first stage of labor 156 Hydrotherapy: Warm water immersion or warm shower 156 Comfort measures for back pain 156 Exhaustion 157 Sterile water injections 158 Procedure for subcutaneous sterile water injections 159 Hydration and nutrition 160 Conclusion 160 References 160 Chapter 8: Prevention and Treatment of Prolonged Second Stage of Labor 166 Kathryn Osborne, PhD, CNM, FACNM and Lisa Hanson, PhD, CNM, FACNM, FAAN Definitions of the second stage of labor 167 Phases of the second stage of labor 167 The latent phase of the second stage 168 Evidence-based support during the latent phase of second stage labor 169 What if the latent phase of the second stage persists? 169 The active phase of the second stage 169 Physiologic effects of prolonged breath‐holding and straining 170 Effects on the birth giver 170 Effects on the fetus 170 Spontaneous expulsive efforts 171 Diffuse pushing 172 Second stage time limits 173 Possible causes and physiologic solutions for second stage dystocia 174 Position changes and other strategies for suspected occiput posterior or persistent occiput transverse fetuses 174 The use of supine positions 174 Why not the supine position? 176 Use of the exaggerated lithotomy position 177 Differentiating between pushing positions and birth positions 178 Knees together pushing 178 Leaning forward while kneeling, standing, or sitting 178 Squatting positions 178 Asymmetrical positions 180 Lateral positions 181 Supported squat or “dangle” positions 181 Other strategies for malposition and back pain 182 Early interventions for suspected persistent asynclitism 183 Positions and movements for persistent asynclitism in second stage 188 Nuchal hand or hands at vertex delivery 190 If cephalopelvic disproportion or macrosomia (“poor fit”) is suspected 190 The influence of time on cephalopelvic disproportion 191 Fetal head descent 191 Verbal support of spontaneous bearing‐down efforts 192 Guiding the birthing person through crowning of the fetal head 192 Hand skills to protect the perineum 192 Perineal management during second stage 194 Topical anesthetic applied to the perineum 194 Differentiating perineal massage from other interventions 194 Waterbirth 194 Positions for suspected “cephalopelvic disproportion” (CPD) in second stage 197 Shoulder dystocia 197 Precautionary measures 202 Two step delivery of the fetal head 204 Warning signs 204 Shoulder dystocia maneuvers 205 The McRoberts’ maneuver 206 Suprapubic pressure 206 Hands and knees position, or the Gaskin maneuver 207 Shrug maneuver 207 Posterior axilla sling traction (PAST) 208 Tully’s FlipFLOP pneumonic 208 Somersault maneuver 208 Decreased contraction frequency and intensity 210 If emotional dystocia is suspected 211 The essence of coping during the second stage of labor 211 Signs of emotional distress in second stage 211 Triggers of emotional distress unique to the second stage 211 Conclusion 213 References 213 Chapter 9: Optimal Newborn Transition and Third and Fourth Stage Labor Management 219 Emily Malloy, PhD, CNM, Lisa Hanson, PhD, CNM, FACNM, and Karen Robinson, PhD, Cnm, Facnm Overview of the normal third and fourth stages of labor for unmedicated mother and baby 219 Third stage management: care of the baby 220 Oral and nasopharynx suctioning 220 Delayed clamping and cutting of the umbilical cord 221 Management of delivery of an infant with a tight nuchal cord 222 Third stage management: the placenta 222 Physiologic (expectant) management of the third stage of labor 223 Active management of the third stage of labor 224 The fourth stage of labor 226 Baby‐friendly (breastfeeding) practices 227 Supporting microbial health of the infant 228 Routine newborn assessments 229 Conclusion 230 References 230 Chapter 10: Epidural and Other Forms of Neuraxial Analgesia for Labor: Review of Effects, with Emphasis on Preventing Dystocia 235 Sharon Muza, BS, CD/BDT(DONA), LCCE, FACCE, CLE and Robin Elise Weiss,Ph.D., MPH, CLC, LCCE, FACCE, AdvCD/BDT(DONA) Introduction: analgesia and anesthesia—an integral part of maternity care in many countries 235 Neuraxial (epidural and spinal) analgesia—new terms for old approaches to labor pain? 236 Physiological adjustments that support maternal-fetal wellbeing 237 Multisystem effects of epidural analgesia on labor progress 237 The endocrine system 237 The musculoskeletal system 238 The genitourinary system 239 Can changes in labor management reduce problems of epidural analgesia? 239 Descent vaginal birth 243 Guided physiologic pushing with an epidural 244 Centering the pregnant person during labor 245 Conclusion 246 References 246 Chapter 11: Guide to Positions and Movements 249 Lisa Hanson, PhD, CNM, FACNM, FAAN and Emily Malloy, PhD, CNM Maternal positions and how they affect labor 250 Side‐lying positions 250 Pure side‐lying and semiprone (exaggerated Sims’) 250 The “semiprone lunge” 256 Side‐lying release 257 Sitting positions 259 Semisitting 259 Sitting upright 261 Sitting, leaning forward with support 262 Standing, leaning forward 263 Kneeling positions 264 Kneeling, leaning forward with support 264 Hands and knees 266 Open knee–chest position 266 Closed knee–chest position 269 Asymmetrical upright (standing, kneeling, sitting) positions 269 Squatting positions 270 Squatting 270 Supported squatting (“dangling”) positions 272 Half‐squatting, lunging, and swaying 274 Lap squatting 274 Supine positions 277 Supine 277 Sheet “pull‐to‐push” 278 Exaggerated lithotomy (McRoberts’ position) 279 Maternal movements in first and second stages 280 Pelvic rocking (also called pelvic tilt) and other movements of the pelvis 281 Hip sifting 282 Flexion of hips and knees in hands and knees position 283 The lunge 284 Walking or stair climbing 285 Slow dancing 286 Abdominal lifting 288 Abdominal jiggling with a shawl 289 The pelvic press 290 Other rhythmic movements 292 References 293 Chapter 12: Guide to Comfort Measures 294 Emily Malloy, PhD, CNM and Lisa Hanson, PhD, CNM, FACNM, FAAN Introduction: the state of the science regarding non‐pharmacologic, complementary, and alternative methods to relieve labor pain 295 General guidelines for comfort during a slow labor 295 Non‐pharmacologic physical comfort measures 296 Heat 296 Cold 297 Hydrotherapy 299 How to monitor the fetus in or around water 301 Touch and massage 302 How to give simple brief massages for shoulders and back, hands, and feet 302 Acupuncture 307 Acupressure 307 Continuous labor support from a doula, nurse, or midwife 307 How the doula helps 308 What about staff nurses and midwives as labor support providers? 309 Assessing the laboring person’s emotional state 310 Techniques and devices to reduce back pain 312 Counterpressure 312 The double hip squeeze 312 The knee press 314 Cook’s counterpressure technique No. 1: ischial tuberosities (IT) 315 Cook’s counterpressure technique No. 2: perilabial pressure 316 Techniques and devices to reduce back pain 318 Cold and heat 318 Cold and rolling cold 318 Warm compresses 319 Maternal movement and positions 319 Birth ball 320 Transcutaneous electrical nerve stimulation (TENS) 321 Sterile water injections for back labor 323 Procedure for subcutaneous sterile water injections 324 Breathing for relaxation and a sense of mastery 324 Simple breathing rhythms to teach on the spot in labor 325 Bearing‐down techniques for the second stage 325 Spontaneous bearing down (pushing) 325 Self‐directed pushing 326 Conclusion 326 References 326 Index 329