Assessment & Care of the Laboring Woman

Lisa Van Gerpen, CNM, MSN

Initial Rapid Assessment

Presenting complaint (what brings you here)?

Gestational age?Any leaking, bleeding, or unusual discharge?

Time, color, amt?Any problems during your pregnancy?How many babies have you had?Assess labor progress if appears to be in

active labor.

Maternal Admission Assessment Medical History - chronic diseases(ie.

asthma,HTN), surgeries, allergies Obstetrical History (GTPAL) - type of delivery, complications

Gravida (G) - # of times a woman has been pregnant, regardless of the pregnancy outcome T - # pregnancies resulting in term delivery P - # pregnancies resulting in preterm delivery A - # pregnancies resulting in miscarriage or elective termination L - # living children

Parity

Para/Parity: # of pregnancies that reached 20 wks (# pregnancies, NOT # fetuses)

Example: G1 delivers triplets at 32 weeks. Still G1 P1. More helpful if recorded using

GTPAL method: G1 P0103 (0 term pregnancies, 1 preterm pregnancy, 0 aborted pregnancies, 3 living)

What’s their GTPAL?

1. Woman expecting 2nd baby. First baby born at 38.4 weeks, 2 ½ years old,

living.2. Woman expecting 3rd baby. 1st baby

born at 32 wks/living, 2nd baby born at 37.4 wks/died of SIDS.

3. 3rd pregnancy. 1st pregnancy term, 2nd pregnancy 35.6 wks, twins – all living.

Definition of “term”

Term is a pregnancy between 37-42 weeks.Further clarifications recommended byACOG and AWHONN:

Early term: 37 0/7 weeks through 38 6/7 weeks Full term: 39 0/7 weeks through 40 6/7 weeks Late term: 41 0/7 weeks through 41 6/7 weeks Postterm: 42 0/7 weeks and beyond

Maternal Admission Assessment

Current Pregnancy – review/obtain prenatal

record and birth plan

At a minimum, prenatal records should be sent to delivering facility at 36 weeks. This practice still leaves a gap for any visits occurring after this time.

Important to review: GBS status, problems such as substance abuse, gestational diabetes, gestational hypertension, etc.

Maternal Admission Assessment Vital signs (compare to PNR) Systems assessment (apical pulse, lung sounds, extremities- reflexes, clonus, Homan’s, edema, varicosities) Vaginal exam as appropriate – cervical assessment (dilatation, effacement, station), fetal position (lie, presentation, attitude, position), discharge and leaking

Fetal Admission Assessment Gestational age – LNMP,U/S Leopold’s maneuver (fetal position

and presentation) Fetal heart tones Fetal activity Fetal testing/treatments (US’s,NST’s,

genetic screening,etc)-results and reason for testing

Leopold’s Maneuver

Palpate fetal back/position Estimate fetal weight Palpate fetal movement Palpate uterine tone/tenderness

Leopold’s Maneuvers

Fundal Height

Fundal Heights

Fetal Lie

Long axis of fetus relative to mother Vertex (head) Breech Transverse Determine by Leopold’s and vaginal

exam If unable to tell for sure HAVE SOMEONE DOUBLE CHECK!!!

Fetal Lie

Fetal Presentation

Part of fetus entering pelvic inlet first

Fetal Attitude

Relationship of fetal head, shoulder, and legs to one another (flexion or extension) Flexion (normal vertex presentation) Extension (face presentation) Military (brow presentation)

Fetal Position

Note position of fetal denominator occiput sacrum mentum scapula

To maternal pelvis front (anterior) back (posterior) side (transverse)

Fetal Landmarks/denominators

Vertex(Occiput)

Face(Mentum)

Fetal Landmarks/denominators

Breech Shoulder (Sacrum) (Scapula)

Fetal Skull Landmarks

Determining Fetal Position

Molding of Fetal Head

Cervical Assessment

Expose perineum: look for amount of bloody show, wet/glistening perineum, malodorous discharge, ulcerations If blisters or raised vesicles noted, stop

exam and notify provider (may be herpes lesions)

Cervical Assessment

Hold hand sideways and insert fingers gently into vagina

Apply gentle downward pressure as you insert fingers to avoid pressure on anterior vaginal wall or urethra

Move fingers full length of vagina (do not allow 4th & 5th fingers to touch rectal area

Cervical Assessment

Assess dilatationAssess effacementAssess stationAssess if bulging membranes noted

Fetal StationDetermine relationship of the biparietal

diameter of the fetal head to the ischial spines(estimated in cm above or below)

Press in at sidewall of vagina at 3 & 9 o’clock 0 is at ischial spinesBallotable – head is above ischial spines and not

engagedUsually –1 to +1 during labor; if not, can be a warning sign that baby needs to change position to be able to drop into pelvis

Fetal Station

-3 to +3 -5 to +5

Tests to Confirm ROM

Pooling – visualize fluid w/speculum examNitrazine – pH paperFerning – microscopic examAmnisure- important to obtain prior to SVE if

possible rupture. False positives can occur if significant bleeding. Not been tested with KY jelly, anti-fungal creams. Intercourse should not affect.

Other testing being developed

Amniotic Fluid Testing With Nitrazene Paper

Collected with sterile swab via sterile speculum exam

Amniotic fluid is neutral (pH 7.0) or slightly alkaline (pH 7.25)

Changes the color of the yellow NitrazineNot a definitive test

Amnicators®

Nitrazine Test

Color pH Interpretation

Yellow 5.0

Olive 5.5 Probably not ruptured Olive-green 6.0 Blue-green 6.5 Probably are ruptured Deep blue 7.5 May be caused by

blood or cervical mucus

Fern Test

Obtain fluid sample on 2 swabs with sterile speculum exam (no lubricant) 1st slide from fluid pooled in spec blade, 2nd slide

from back of vagina below the cervixSpread onto clean slide by rotating top tip of

swab onto slide (hold swab vertical, not horizontal)

Allow to dry 5 to 7 minutesView under microscope on low power

Ferning

Positive ferning Negative ferning

Stages of Labor

First stage – 0 to 10 cmSecond stage – 10 cm to deliveryThird stage – delivery to placenta

First Stage (1st phase)

Latent or preparatory phase (0-3 cm)

Extends from onset of regular UCs to the beginning of the active phase when dilation occurs more rapidly

May be several hours, nearly flat line on graph

At end of latent phase, cervix is soft, well effaced, and dilated approximately 3 cm.

First Stage (2nd phase)

Active (dilatational) phase (4-7 cm) Sharp upswing in curve as rate of

dilation increases rapidly Effective labor begins w/this phase Phase of maximum slope – most

dilation occurs at this time 1.2 cm/hour average primips 1.5 cm/hour average multips

First Stage (3rd phase)

Transition, also called “Deceleration Phase” (7-10 cm)

Rate of cervical dilation slowsOccurs just before complete dilation;

phase may be short or not present at all

Active phase ends at complete dilation

Stages of Labor

Second stage (10 cm to birth) Normal up to 2 hours- primip, 1 hour

multip, add an hour if they have an epidural

Pushing stage Remember these are general guidelines;

pay attention to all influencing factors Third stage (placental delivery)

Normal up to 30 minutes

Friedman Curve (Can print from OBix)

First stage new research

“Recent data from the Consortium on Safe Labor have been used to revise the definition of contemporary normal labor progress.”

0.5 cm/h to 0.7 cm/h for nulliparous 0.5 cm/h to 1.3 cm/h for multiparous (the ranges reflect that at more

advanced dilation, labor proceeded more quickly)

First Stage New Research

“Recent data from the Consortium on Safe Labor have been used to revise the definition of contemporary normal labor progress.”

0.5 cm/h to 0.7 cm/h for nulliparous 0.5 cm/h to 1.3 cm/h for multiparous (the ranges reflect that at more

advanced dilation, labor proceeded more quickly)

First Stage New Research

“From 4–6 cm, nulliparous and multiparous women dilated at essentially the same rate, and more slowly than historically described. Beyond 6 cm, multiparous women dilated more rapidly.”

“Second, the maximal slope in the rate of change of cervical dilation over time (ie, the active phase) often did not start until at least 6 cm.”

6 is the new 4

Mild………………………….Chin Tense fundus but easy to indent

Moderate…………………. Nose Firm fundus, difficult to indent with

fingertips Strong………………………. Forehead

Rigid, board-like fundus, almost impossible to indent with fingertips

Analogy of Contraction Intensity

Maternal AssessmentsTemperature and pulse – per hospital

guidelines-increase frequency if ROM,fetal tachycardia

Blood pressure – per hospital guidelinesOxytocin use - at a minimum assess BP

before each increaseBladder status (enc. void q 2 hours)Amniotic fluidVaginal discharge/bleeding

Maternal Assessments

Intake and output if indicatedProgress of labor Response to laborPain level and relief measuresLabor support

Essential Forces of Labor

Original Model (3 P’s) Identified 3 things that were thought

to affect length of labor/type of delivery: Powers – contractions, abdominal

pressure from pushing Passageway – size, shape of pelvis,

ability of cervix to dilate and stretch Passenger – fetus (size, position of

head, presentation, gestation)

Expanded Model (1978 – 1996)

Added 2 additional P’s:Psyche (maternal)

Previous experiences, emotional readiness

Cultural/ethnic heritage Support systems

Positioning – will discuss later

13 Essential Forces of Labor(13 P’s that affect a woman’s L&D)

Internal physical forces – originate from within the woman:

Powers – UCs, a major internal forcePassageway – pelvisPassenger – babyPhysiology (other sensations)

Physiologic responses to intensity of labor (large muscle shaking, vomiting, etc.)

Internal Forces (cognitive/emotional)

Psychology of mother – ability of mother to influence her birth; “I knew I’d have a c/s”

Preparation by mother – prenatal classes, choosing provider, preparing home for new baby, birth plans, visualizing how they wanted the birth to be

Position of delivery – changing positions to help baby turn, help labor progress normally

External Forces

External forces – originating from outside the mother

Professional provider – some perceived to be “agents of control”; ability to advocate/support the patient

Place of birth – can affect labor by imposing external requirements; environment

Procedures – contribute to the feeling of control or lack of control over labor (enemas if not needed, continuous EFM, having to use bedpan). May make women feel powerless or humiliated

External ForcesPeople – women reported their labors being

affected by other people (office staff, friends, relatives, educators). Often provided support, distraction; some helpful, some non-helpful

Politics – societal influences that were external to woman but affected her labor experience; affects her self-esteem and confidence (interchanges between provider & nurse, etc.)

Pressure interface – decision-making; when involved in decision making, women were pleased with their birth experience. When not involved, felt things were “done to them”

Supporting the WomanIn Labor

Nursing Presence

Numerous studies show a sustaining human presence decreases the anxiety, pain, and fear a woman may experience during labor ↑ catecholamines from pain & anxiety reduce

uterine and placental blood flow, slow dilation rates

Nursing Support: Effect on Labor

Women with continuous labor support areless likely to: have regional analgesia have any analgesia/anesthesia give birth with vacuum extraction or forceps give birth by cesarean have a baby with a low 5-minute Apgar score report dissatisfaction or a negative rating of

their experience

Positioning in Labor

Nonphysiologic Positioning

Lying supine - reduction in cardiac output and UC intensity

Recumbent Position

A Western tradition for the convenience of the provider, began when women were hospitalized for childbirth pelvis tilted and fetus directed toward coccyx weight on coccyx/sacrum, restricts posterior

movement & ↓ pelvic outlet dimensions tightens perineum & narrows vaginal opening active phase 33% longer

Physiologic Positioning- Upright Positioning

Gravity adds 10-35 mmHg to UC pressureContractions less painful, more productiveFetus well aligned with angle of pelvisMay speed up labor if woman has been

recumbentMay increase urge to push Relieves back pain, good for backrubCan use any type of fetal monitoring

Physiologic Positioning

Standing/Leaning Restful, good for backrubs Curving or leaning forward creates a

C-shaped sacral curve instead of S-shaped curve, easier for fetus to negotiate

Can embrace partner, feeling of well-being & being cared for

Ambulating, Lunge Ambulating

Movement changes pelvic joints, enc. rotation

May provide distraction May ↑ woman’s sense of personal control

Lunge – “lunge” to one side Widens pelvis Encourages rotation of OP fetus Do for ~ 5 sec. at a time

Dangle - same effect

Can put foot up on chair, or just “lunge” to side and stand for short time

Lunge

Dangle Raise bed, remove

foot sectionPartner sits on bed,

woman’s weight supported on partner’s legs

During UC, woman relaxes & dangles

Lack of weight-bearing allows pelvis to shift/move to accommodate fetus

Pelvic Rocking

Movement should be small, try to keep back flat/straight & not curved towards floor

Encourages fetal descent & rotation, relieves pain

Sitting Position

UC’s more frequent, greater duration and intensity

Good resting positionSome gravity advantageFetal descent improves when upright 30

degrees or more (shorter 2nd stage)May assist with bearing down effortsVaginal exams possible, can use EFM or

auscultation

Sitting vs Recumbent

Primips: 1st stage 23% shorter, 2nd stage 48% shorter; less likely to have forceps

Multips: Active phase 42% shorter, 2nd stage no difference

Sitting Alternatives

Sitting, leaning forward

Relieves backache, good position for back rub

Opens pelvisRelaxes perineum

Birth Ball

Allows for pelvic rocking, bouncing

Semi-squat widens pelvis

Movement & distraction reduces pain – gives mom something to do during painful UC

Sitting: toilet/commode, birth stool

May relax perineum for effective bearing down

May feel more natural to push/bear down

Semi-squat position widens pelvis, shortens 2nd stage

Hands and Knees

Relieves back pain, pressure off sacrumAssists rotation of baby in OPAllows for pelvic rockingVaginal exams possiblePressure off of hemorrhoidsMay be used to correct FHR decelerationsRecommend H&K for 15 min., rest; repeat

The Occiput Posterior Baby (OP)

Back of baby’s head towards mother’s back

Linked with longer labors, delays dilatation and descent

Causes considerable back pain

OP Position & Back Pain

Change position q. 20-30 minutes to facilitate baby’s turning; take advantage of gravity & movement

Stand or walk to help align fetus in pelvis and ease rotation

Pelvic rockingCounter pressure, massageHeat/cold packsShowers with spray on painful areaHands & Knees (H&K)

H&K - Physiology

When mom flips, occiput no longer crowding the sacrum

Increases diameter of pelvisBack is heaviest part of the baby (like a

wooden boat) and as the uterus falls forward the angle between the uterus and spine increases

Gravity and buoyancy turn the fetal back, head will rotate & follow

Intact membranes helps rotation as more bouyancy

Study on H&K

100 healthy primips not in labor @ 38 wks with fetuses in OP position. Randomly divided into 5 groups of 20 per group:1 – H&K position2 – H&K with pelvic rocking3 – H&K w/mother stroking baby downward4 – H&K w/pelvic rocking & stroking5 – control group, no H&K

Results

Successful rotation to OA occurred in 12-18 of the 20 women in each of the 1st 4 groups No significant differences found between

the 4 methods (H&K only or w/some other action)

However, none of the fetuses in the control group rotated.

Study on H&KAnother study showed decreased back

pain along with trends toward a benefit for several other outcomes, including operative delivery, fetal head position at delivery, 1-minute Apgar scores, and time to delivery

Eleven women (16%) allocated to use hands-and-knees positioning had fetal heads in occipitoanterior position following the study period compared with 5 (7%) in the control group

Knee Chest

Modification of H&K, but tush is higher than shouldersBegin by getting into H&K and then

slowly lower head to comfortable resting position

Many same benefits as H&K, but less tiring on arms/wrists

Good resting position, good for counter-pressure or massage

Modified Knee-ChestHands & Knees

Side Lying

Good resting positionConvenient for many interventionsHelps lower blood pressureGreater UC intensity than when supineSafe if pain medications usedMay promote progress of labor when

alternated with walkingGravity neutralCan slow a very rapid second stage Easier to relax between pushing effortsAllows posterior sacral movement in 2nd

stage

Squatting

Tilts pelvis & uterus forwardHelps align fetus for enhanced rotation and

descent↑ strength of UCs (squat instead of pitocin!)Works with gravity for smooth descent of

babyEncourages dilation of cervixRelieves back pressureSupports abdominal muscles by placing

thighs pressure against abdomenShortens birth canal

Squatting

Relaxes & evenly stretches pelvic floor muscles

Reduces need for episiotomyDecreases need for forcepsShortens 2nd stageWidens pelvic outlet (0.5-2 cms) –

pelvic outlet 28% greater in squat position compared to side-lying

Allows freedom to shift weightRequires less bearing down effort and ↑urgePrevents supine hypotension

Comfort Techniques For Labor Support

Counter Pressure

Localized pressure to reduce back pain Steady strong force applied to a spot on

the low back during UCs using the fist, heel of hand, or a firm object

Other hand placed in front over hip bone to offset the pressure on her back

Mom should designate where the pressure feels best and amount of pressure to use

May gentle rotate/massage fist into area

Bilateral (Double) Hip Squeeze

Type of pressure massage that can relieve back pain, help open pelvic outlet

During labor, baby’s head stretches the pelvis; the hip squeeze helps to relax the

stretched musclesWoman in position where her hip

joints are flexed (hands/knees, standing and leaning forward, etc.)

Begin by placing hands on hip bones, then slide hands back

Double Hip Squeeze

Keep one hand on each bone and your thumbs pointed toward the spine forming a "W". Push the hipbones "in and up" towards the mothers body, and at the same time towards the mothers shoulders as if you needed to press on the bones and slide them up her back.

Steady pressure with the whole palms of hands (not heels of hands), directed diagonally toward the center of pelvis

Double Knee Press

Localized pressure to reduce back painWoman sits upright in chair with support

behind lower back, knees a few inches apart, feet flat

Partner kneels in front, cupping knees with both hands (heel of hand on top of tibia)

Steadily press knees straight back toward woman’s hip joints by leaning towards her duing UC

Can also be done with woman side-lying

Measures to Inhibit/Compete with Pain Awareness

Superficial Heat

Soothing, pain-relieving effects↑ uterine activity (local application of heat

to abdominal wall over upper uterine segment)

Hot compresses to groin, perineum Caution with heat of hot pack!

Warm blankets

Superficial Cold

Slows transmission of impulses over sensory neurons leading to decreased sensation/pain

Useful for musculoskeletal and joint pain (so back labor usually responds well to cold)

Ice packs on low back, anus, perineumTo perineum after birth to reduce swelling

Superficial Cold - Cautions

Protective layer should be placed between woman’s skin and source of cold

Don’t use if woman already chilled or shivering

Be aware of cultural variations, may have strong avoidance of cold

Hydrotherapy

Bath/shower ancient treatment for many ailments

Relaxing, stress reducingRelief of pain, enhanced blood flow to

exposed area, less use analgesiaMay accelerate labor, improved UCs

In 1 study, half as many in the bath required augmentation of labor

Decrease in BPHigh patient satisfaction

Physiologic Effects

Weight of water (hydrostatic pressure) moves tissue fluid into intravascular space ↑ plasma volume, cardiac output, urinary output In early labor, could slow labor (dilutes circulating

oxytocin)Causes vasodilation of peripheral blood

vessels, decreases BPBuoyancy reduces pressure on abdominal

muscles and decreases pain of UCs

Nursing Considerations

Water temp should be 96 – 98 degrees to prevent maternal hyperthermia and fetal tachycardia

Can remain in tub as long as desired unless clinical reason exists to leave tub (fetal distress, bleeding, advanced labor) Monitor fetus w/fetoscope or water-resistant

doppler or U/S toco (Note – toco NOT water-proof!)

Monitor maternal temperatureOkay w/ROM if fetal head engaged

Touch

Pat of reassurance, stroking – all signs of caring/comfortTouch or massage stimulates

different sensory receptors that can compete with pain receptors

Be sure to use “caring touch” in addition to “clinical touch”

Study: Clinical vs Caring Touch

Looked at work activities of OB nurses in a large teaching hospital

Detected only 2 instances of caring touch in 616 observations of work activities

Less than 10% of their activities were categorized as supportive; most were giving instructions or information to mom; touch for clinical work (take pulse, help with positioning, check cervix, apply/re-adjust EFM, etc.)

Massage

Firm or light stroking, vibration, kneading, deep circular pressure, continual steady pressure, joint manipulation

Stimulates variety of receptors in skin & deeper tissues

Hand massage easy to do, almost always accepted by laboring woman

Very soothing to women who grip their hands during labor

Nursing Presence & Teaching Education on what is happening & what to

expect – knowledge is power! Information on options Information on discomfort/sensation – what

to expect and what they can do about itWomen supported in labor have shorter

labors, require less pain meds, and more likely to have a vaginal birth

Positive affirmations You can do this, you’re doing great That’s one less contraction you’ll never see again

Continuous Intrapartum Support

Less likely to have intrapartum analgesiaLess operative birthLess likely to report dissatisfaction with

their childbirth experienceFewer perinatal complicationsFewer NBs with 5 min. apgar score < 7Fewer NBs admitted to NICUShorter labors

Distraction

Conscious mind-diverting activities can reduce pain Patterned breathing Visualization Concentration on a visual (focal point),

auditory, or tactile item

TENS (Transcutaneous Electrical Nerve Stimulator)

Non-invasiveLow voltage electric current

transmitted to skin with electrodes; buzzing or tingling sensation Don’t place electrodes on abdomen –

possible effects of TENS on fetal heart function; less concern on back

Can vary intensity, pulse frequency, & patterns of stimulation

Can ↑ intensity during UC, ↓ after UC

Intradermal Water Injections

For back pain in labor Equipment – sterile H20, TB syringe,

25 gauge needleTakes ~ 20-30 seconds to administer,

relief within 2-5 minutes, lasts 1-4 hours Can be repeated in 1-2 hours if needed

RN injects 0.1 ml sterile H20 intradermally at 4 sites

Mark injection sites. Find posterior iliac spines, palpated by

feeling the bony prominences just lateral to the sacrum and below the iliac crest; then measure 2-3 cm below and 1-2 cm medical from the spines

Swab sites with alcohol, inject 0.1 ml sterile H20 into each site, forming small bleb

Patient feels intense stinging, followed by relief of back labor

Birth Ball

During pregnancy, stimulates postural reflexes and keeps supportive muscles of spine in good working order.

Facilitates physiologic positions for laborEnhances labor through optimal fetal

positioning in relation to woman’s pelvis Encourages pelvic motion which aids

rotation of posterior babyPromotes squatting without knee strain

Allows mother to shift weight and support pelvic region for greater comfort during labor

Facilitate fetal descent when labor may not be progressing

Allows gravity to help with birthCan support a woman if she wants to try

different positionsAllows woman to move with supportProvides easy access to mother’s back for massage

Relieves nervous tension- provides comfort and relaxation for woman

Easy to useEasy to cleanVersatile- Can be used in bed,

shower, on floor, against wall or for partner support

Comfortable for postpartum use Babies enjoy bouncing and rocking

motion provided by Mom on birth ball

Birth Ball PositionsSitting

May gently rock side to side or back and forth

May gently bounce

Access to back for partner massage

Kneeling Kneel on pillow and lean over ball Sit on ball and lean over bed Place ball on bed, kneel in bed and

lean over ball

Leaning Position ball behind mothers back

against wall and mother leans back onto ball

Position ball on bed behind mothers back and mother leans into ball

Provides “piston” action

Peanut ball Position ball between legs (often used

with epidural) Frequent repositioning required Recent study showed 2 hour reduction

in length of labor, as well as decreased vacuum and forceps use

Mom should be barefoot or wearing non-slip socks when on ball

A spotter should always be near when Mom attempts to sit on the ball

When sitting down on the ball Mom should hold the ball with her hand as

she sits downFeet should be flat on the floor and

approx 2 feet apart to help stabilize her

Other considerations when using the Birth Ball:

Carrying strap should be removed when in use by Mom

Cover the ball when in use with towel, blanket, Chux pad for Mom’s comfort and for absorption

Birth ball covers are available and have a handle built in for ease in carrying. (I’m not sure how you clean these?)

Types of Birth BallsRound balls:

Come in several different sizes Guide to use:

Woman’s Ht Ball Ht Ball Size Cost

4’8” – 5’2” 22” or 55 cm

Medium $24

5’3” – 5’8” 26” or 65 cm

Large $24

5’9” – 6’5” 30” or 75 cm

Extra-large

$32

Oval Balls Also called egg-shaped or kidney

shaped These are the newest models of birth

balls Give more stability to mom Moms are more comfortable on them The shape encourages a deep squat Cost: ~ $30

Peanut Balls Help provide positioning for bedrest

women May be usedto improve comfort and helpopen pelvis

The 3 “R’s” for Labor Pain Management

Relaxation

Rhythm breathing

Rituals

Relaxation

Psychological benefits Helps you to remain emotionally calm during labor You have more control and can communicate more

effectively with those around youPhysical benefits

Relaxed muscles use less oxygen, more O2 for you & baby

Uterus can contract more effectively Decreases fatigue Increases pain threshold Diverts focus to a positive action

Rhythmic Breathing

Benefits Helps laboring woman relax, especially if

she has learned/practiced the techniques (provide practice time in early labor)

Calming effect Provides measure of control for woman Can be used when other comfort measures

not available (i.e., unable to get up to shower or whirlpool, use birth ball, etc.)

Benefits of Breathing Patterns

May enhance oxygen to mom, uterus, baby

Provides distraction Brings purpose to contractions,

makes them more productive

Strategies to Use With Breathing

Count breathsUse light massage such as effleurageCount to 4 or 5 as you inhale and exhaleUse music via headphonesVisualize - close your eyes and "see" an

image, or place, that you find relaxingGet on all fours and rockWalk, rocking chair, birth ballHave a focal point (internal or external)

Strategies to Use w/Breathing

Sing a tune in your headUse repetitive phrase: "I am safe...I am

sound," "Breath in oxygen, breathe out tension.“

Stand and rock your pelvis from side to sideBath, shower, or whirlpoolChange the way you inhale/exhale Inhale/exhale through your nose Inhale/exhale through your mouth.

Other Strategies

Focal point – picture, partner’s face, tile on ceiling, etc. – helps to distract from UCs

Cleansing or relaxing breath – big sigh Helps you to signal your body to relax and

prepare for coming contraction Releasing breath at end helps get rid of

any lingering tension

Remember…

Even if they have been to Childbirth classes, they look to you to assist, coach, lead them

Be present for your patients and be an active participant in their labor and birth

Types of Breathing Patterns

The following are taught in prenatal classes: Slow paced breathing Slow modified paced breathing Modified paced breathing Patterned paced

Slow Paced Breathing

Start with relaxing breathSlow easy breaths in & out, ~ ½ normal

rate (in nose, out mouth; whatever most comfortable)

End with relaxing breathReview next breathing pattern with mom

prior to this pattern no longer working (i.e., prepare her for what is next)

Use until it is no longer working for mom

Slow Modified Paced

Start with relaxing breath Begin with slow paced breathing When the slow breathing doesn’t work,

speed up the breaths during the harder part of the UC

Slow to slow paced breathing when able End with relaxing breath

Modified Paced Breathing

Can use prior to Slow-Modified Paced (previous pattern) if works better for pt.

Start & end with relaxing breath Quick, shorter breaths throughout UC (~ 2x normal

breathing rate) In through nose, out through mouth may help prevent

hyperventilating

Modified Paced Breathing

Can use any combination of breathing patterns that work, various rhythms Breathing in & out with each word:

“HA-HA-HA-WHOOOO” “HE-HE-HE-WHOOOO”

Patterned Paced (Pant/Blow)

Relaxing breath pre & post UC Pant blow

Gentle Pushing

Relaxing breath pre & post UC Gentle bearing down with urge,

breathe as desired

Basic Patient Care Considerations

HydrationIV therapyChange soiled/damp linen promptlyFrequent mouth carePerineal careGood ventilation/fansControl the labor environment

Second Stage LaborManagement

2nd Stage Labor – 3 phases

Latent phase – time following full dilation until urge to push is established

Active phase – ↑ urge to bear down Fergeson’s reflex – presenting part

stretches pelvic floor muscles, causes release of endogenous oxytocin

Supports theory that urge to push is more dependent on station than dilation

Transition stage – begins when baby’s head bulges the perineum, crowns, and baby is born

Length of 2nd Stage

Efforts to limit length of 2nd stage have been documented since 1861

Rationale was to ↓ risk of hypoxia to fetus

Led to practices such as directed pushing; strong, sustained pushing; and pushing before urge to push

No research has been documented to support these practices

“Traditional” 2nd Stage

Breath holding Duration of labor not significantly different May lower pH and apgar scores

Valsalva maneuver ↑ intrathoracic pressure & intracranial pressure Impairs blood return from lower extremities,

results in ↓ in uteroplacental flow Can cause FHR decelerations Tightens pelvic floor muscles, may ↑ perineal

damage

Traditional Birthing

Lithotomy position, lying on back with legs up in stirrups – decreases maternal PaO2. Not found to occur if pushed in upright

positionIf women are in lithotomy & also hold their

breath when they push, risk of maternal & fetal PaO2 reduction increases When not instructed how to push, average

pushing effort lasted 5 seconds w/an average of 4.29 pushing efforts per contraction

“Count to Ten” Pushing

May create fetal hypoxemiaAlternate technique is to moan, create the

sound of “oh” or a deep humming sound with pushing May decrease interventions, improve fetal

status, decrease maternal fatigue, improve neonatal status

Rest prior to pushing if no urge (primips up to 2 hours, multips up to 1 hr) Fewer variable decels, less maternal fatigue,

decrease in pushing time, and trend towards higher apgar scores

2 Studies

Cohen (1977) found no significant ↑ in frequency of perinatal mortality or neonatal mortality when 2nd stage lasted longer ↑ in PP hemorrhage noted related to obstetric

interventions used to limit length 2nd stage

Study replicated in 1995, retrospective study over 5 years of 6,041 primips – no adverse outcomes found in closely monitored pts, even when 2nd stage exceeded 5 hrs in 2.7% of patients (Menticoglou, Manning, Harman, & Morrison)

Physiologic Second Stage “Laboring Down”

Urge to push may be at, before or after 10 cm

Don’t have patient push if no urge – can cause asynclitic presentation

Duration of labor not significantly different; directed pushing does cause negative changes in mother and fetus (apgars, lacerations, BP’s, etc.)

Upright Positioning

Benefits in 2nd stage similar to 1st stage – improves uterine contractility, reduced muscle hypoxia, reduced pain

Less perineal trauma, fewer episiotomiesHigher fetal oxygenation saturation

during labor; higher pH & pO2 and lower pCO2 levels at birth for newborns

Squatting

Best position for 2nd stage laborUterus elevates, directing fetus

towards pelvic outlet, fetal descent enhanced

Golay, Vedam, Sorger (1993) – mean length of 2nd stage shortened by 23 min. for primips and 13 min. for multips who pushed while squatting compared to women who pushed in semi-recumbent position

Pharmacologic Pain Control in Labor

Medications - various oral, IM, or IV meds depending on stage of labor and desired effect

EpiduralIntrathecal Narcotics

Sedatives/ Tranquilizers

Decrease anxiety, inhibit contractions, allow rest or sleep

Use only in early labor due to possible negative maternal/neonatal effects

Does not help for painCan be given with opioids or narcoticsSeconal, NembutalPhenergan, Vistaril, Largon

Parenteral OpioidsDemerol, morphine, fentanylDecreased perception of painMay decrease UC’s in early laborNeonatal effects r/t dose and timingPotential for neonatal depression- birth

should occur < 1 hour or > 4 hours afterAlteration in NB behavioral effects

possible for several days4 studies showed women who had 3 doses

or more of narcotics within last 10 hrs of labor, had ↑ risk of child having addiction problems later in life (6% without, 29% with)

Parenteral Opioids

FHR variability may decrease IV/IM or combination IV onset 5-10 minutes, IM onset 20-40

minutesDuration 2-4 hoursGive all IV meds at beginning of UC when

blood vessels of uterus & placenta are constricted; minimizes drug transfer to fetus

Narcan (narcotic antagonist)

Agonist/Antagonist

Stadol, Nubain, TalwinBlock receptors responsible for respiratory

depressionStimulate receptors that block painful

sensationsEqual to opioids (for pain relief & potential

for maternal and neonatal respiratory depression)

Less N/V

Anesthesia

Local infiltrateParacervical blockPudendal blockEpidural blockSpinal blockIntrathecal narcoticsGeneral anesthesia

References

American College of Obstetricians and Gynecologists. Definition of Term Pregnancy. ACOG Committee Opinion. Washington, DC: ACOG;2013

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth (Review). The Cochrane Collaboration. 2012

Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Wilian AR. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. PubMed. 2005

References

Tussey C, Botsios E. Decrease the Length of Labor with the Use of a Labor Ball with Patients That Receive An Epidural. AWHONN Convention Presentation. 2011