The Labor Progress Handbook E-Book

Penny Simkin

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 507

Veröffentlichungsjahr: 2011

Beschreibung

The third edition of The Labor Progress Handbook builds on the success of first two editions and remains an unparalleled resource on simple, non-invasive interventions to prevent or treat difficult labor.  Retaining the hallmark features of previous editions, the book is replete with illustrations showing position, movements, and techniques and is logically organized to facilitate ease of use.

This edition includes two new chapters on third and fourth stage labor management and low-technology interventions, a complete analysis of directed versus spontaneous pushing, and additional information on massage techniques. The authors have updated references throughout, expertly weaving the highest level of evidence with years of experience in clinical practice.

The Labor Progress Handbook continues to be a must-have resource for those involved in all aspects of birth by providing practical instruction on low-cost, low-risk interventions to manage and treat dystocia.

Leseprobe

Table of Contents

Cover

Table of Contents

Half title page

Title page

Copyright page

Dedication

Foreword to the third edition

Foreword to the second edition

Foreword to the first edition

Acknowledgments

Chapter 1 Introduction

SOME IMPORTANT DIFFERENCES IN MATERNITY CARE BETWEEN THE UNITED STATES, THE UNITED KINGDOM, AND CANADA

NOTES ON THIS BOOK

CHANGES IN THIS THIRD EDITION

MATERIAL ON EPIDURALS

CONCLUSION

Chapter 2 Dysfunctional Labor: General Considerations

WHAT IS NORMAL LABOR?

WHAT IS DYSFUNCTIONAL LABOR?

WHY DOES LABOR PROGRESS SLOW DOWN OR STOP?

THE PSYCHOEMOTIONAL STATE OF THE WOMAN: MATERNAL WELL-BEING OR MATERNAL DISTRESS?

WHY FOCUS ON MATERNAL POSITION?

MONITORING THE MOBILE WOMAN’S FETUS

TECHNIQUES TO ELICIT STRONGER CONTRACTIONS

CONCLUSION

Chapter 3 Assessing Progress in Labor

BEFORE LABOR BEGINS

ASSESSMENTS DURING LABOR

ASSESSING THE MOTHER’S CONDITION

ASSESSING THE FETUS

PUTTING IT ALL TOGETHER

CONCLUSION

Chapter 4 Prolonged Prelabor and Latent First Stage

IS IT DYSTOCIA?

THE SIX WAYS TO PROGRESS IN LABOR

SUPPORT MEASURES FOR WOMEN WHO ARE AT HOME IN PRELABOR AND THE LATENT PHASE

SOME REASONS FOR EXCESSIVE PAIN AND DURATION OF PRELABOR OR THE LATENT PHASE

TROUBLESHOOTING MEASURES FOR PAINFUL PROLONGED PRELABOR OR LATENT PHASE

MEASURES TO ALLEVIATE PAINFUL, NONPROGRESSING, NONDILATING CONTRACTIONS IN PRELABOR OR THE LATENT PHASE

CONCLUSION

Chapter 5 Prolonged Active Phase of Labor

WHEN IS ACTIVE LABOR PROLONGED?

CHARACTERISTICS OF PROLONGED ACTIVE LABOR

POSSIBLE CAUSES OF PROLONGED ACTIVE LABOR

MATERNAL POSITIONS AND MOVEMENTS FOR SUSPECTED MALPOSITION, CEPHALOPELVIC DISPROPORTION, OR MACROSOMIA

IF CONTRACTIONS ARE INADEQUATE

IF THERE IS A PERSISTENT ANTERIOR CERVICAL LIP OR A SWOLLEN CERVIX

IF EMOTIONAL DYSTOCIA IS SUSPECTED

CONCLUSION

Chapter 6 Prolonged Second Stage of Labor

DEFINITIONS OF THE SECOND STAGE OF LABOR

PHASES OF THE SECOND STAGE OF LABOR

POSSIBLE ETIOLOGIES AND SOLUTIONS FOR SECOND-STAGE DYSTOCIA

IF EMOTIONAL DYSTOCIA IS SUSPECTED

CONCLUSION

Chapter 7 Optimal Newborn Transition and Third and Fourth Stage Labor Management

OVERVIEW OF THE NORMAL THIRD AND FOURTH STAGES OF LABOR FOR UNMEDICATED MOTHER AND BABY

THIRD STAGE MANAGEMENT: CARE OF THE BABY

THIRD STAGE MANAGEMENT: THE PLACENTA

THE FOURTH STAGE OF LABOR

BABY-FRIENDLY (BREASTFEEDING) PRACTICES

ROUTINE NEWBORN ASSESSMENTS

CONCLUSION

Chapter 8 Low-Technology Clinical Interventions to Promote Labor Progress

INTERMEDIATE-LEVEL INTERVENTIONS FOR MANAGEMENT OF PROBLEM LABORS

WHEN PROGRESS IN PRELABOR OR LATENT PHASE REMAINS INADEQUATE

WHEN PROGRESS IN ACTIVE PHASE REMAINS INADEQUATE

FOSTERING NORMALITY IN BIRTH

WHEN PROGRESS IN SECOND STAGE LABOR REMAINS INADEQUATE

HAND MANEUVERS AND ANTICIPATORY MANAGEMENT OF INTRAPARTUM PROBLEMS

NONPHARMACOLOGIC AND MINIMALLY INVASIVE PHARMACOLOGIC TECHNIQUES FOR INTRAPARTUM PAIN RELIEF

CONCLUSION

Chapter 9 The Labor Progress Toolkit: Part 1. Maternal Positions and Movements

MATERNAL POSITIONS

MATERNAL MOVEMENTS IN FIRST AND SECOND STAGES

Chapter 10 The Labor Progress Toolkit: Part 2. Comfort Measures

GENERAL GUIDELINES FOR COMFORT DURING A SLOW LABOR

NONPHARMACOLOGIC PHYSICAL COMFORT MEASURES

TECHNIQUES AND DEVICES TO REDUCE BACK PAIN

BREATHING FOR RELAXATION AND A SENSE OF MASTERY

BEARING-DOWN TECHNIQUES FOR THE SECOND STAGE

CONCLUSION

Epidural Index

Index

The Labor Progress Handbook

Early Interventions to Prevent and Treat Dystocia

Third Edition

This edition first published 2011 © 2011 by Penny Simkin and Ruth Ancheta and Illustrations by Shanna dela Cruz are Copyright ©Ruth Ancheta

Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing.

Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offices: 2121 State Avenue, Ames, Iowa 50014-8300, USA

The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

9600 Garsington Road, Oxford, OX4 2DQ, UK

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting Service are ISBN-13: 978-1-4443-3771-6/2011.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Simkin, Penny, 1938- author.

 The labor progress handbook : early interventions to prevent and treat dystocia / Penny Simkin, BA, PT, CCE, CD(DONA), Senior Faculty, Simkin Center for Allied Birth Vocations at Bastyr University, Independent Practice of Childbirth Education and Labor Support, Ruth Ancheta, BA, ICCE, CD(DONA), DONA-Approved Doula Trainer, Independent Practice of Childbirth Education and Labor Support; with contributions by Lisa Hanson, PhD, CNM, FACNM, Suzy Myers, LM, CPM, MPH, Gail Tully, BS, CPM, CD(DONA); illustrated by Shanna dela Cruz. – Third Edition.

p. ; cm.

 Includes bibliographical references and index.

ISBN 978-1-4443-3771-6 (pbk. : alk. paper) 1. Labor (Obstetrics)–Complications–Prevention–Handbooks, manuals, etc. 2. Birth injuries–Prevention–Handbooks, manuals, etc. I. Ancheta, Ruth, author. II. Title.

 [DNLM: 1. Dystocia–prevention & control–Handbooks. 2. Birth Injuries–prevention & control–Handbooks. 3. Labor, Obstetric–Handbooks. WQ 39]

 RG701.S57 2011

 618.4–dc22

2010049407

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9780470959367; ePub 9780470959374

We dedicate this book to childbearing women and their caregivers in the hope that some of our suggestions will reduce the likelihood of cesarean delivery for dystocia; also to the wise, patient, and observant midwives, nurses, doulas, family doctors, and obstetricians whose actions and writings have inspired and taught us.

Foreword to the third edition

Writing the foreword to the third edition of a successful book is a simple yet daunting task. Ellen Hodnett and Michael Klein so extolled the merits of the previous editions that there is little left to say. The core of the Labor Progress Handbook remains the same: a detailed description of labor as a physiologic process entwined with practical advice on how to help keep it that way. However, the third edition has been updated and newly referenced with some important additions: more practical guidance such as detailed descriptions of massage techniques and a complete analysis of directed versus spontaneous pushing. A beautifully written new chapter on the third and fourth stages of labor dispenses neatly with routine newborn suctioning and early cord clamping and gives a balanced discussion of active versus physiological third stage management. Another describes “intermediate interventions”—manual techniques and relatively low-level interventions to help avoid the need for medical or surgical management when labor is not progressing.

Labor is a dynamic neurohormonal dance and dramatic physical transition that transforms a woman’s body, psyche, and soul. Labor is defined by dynamic and complex processes: psychological phenomena such as privacy and inhibition; the endocrine enigma of pulsatile oxytocin and endorphin surges; even the more tangible physiologic and anatomic changes of Ferguson’s reflex and molding of the fetal skull. From a deductive scientific perspective, these remain poorly understood, even in 2011. Where science can no longer inform us, we must rely upon the experience, insight, and art of generations of skilled midwives and labor attendants, and this is where the Labor Progress Handbook is so helpful.

The authors demonstrate an excellent understanding of modern evidence-based practice; however, unlike in most medical texts, they are not constrained by the limits of science. Throughout the book, the highest level of evidence is sought and a multitude of current randomized trials are cited, yet the discussions weave seamlessly from Cochrane reviews and randomized controls trials through formal cohort evidence when available to anecdotal observations and midwifery lore when not. For a phenomenon as complex as labor, the latter are often more informative than the former. A Cochrane review of randomized trials demonstrates the effectiveness of doulas in avoiding analgesia and operative birth. However, to understand why, one is left with observations of the roles of “privacy” and “support” to facilitate “disinhibition” of the “instinctual brain” integral to normal labor and key to avoiding “emotional dystocia.” These concepts are neither easily definable nor amenable to reductionist analysis, yet they are understood by any experienced birth attendant.

When I was a young medical student first learning about labor, evidence-based medicine had not yet been born, yet I was lucky enough to have skeptical mentors who had dispensed with routine enemas, shave preps, and episiotomies. Without Cochrane reviews and meta-analyses to distract us, we were taught to unobtrusively observe and support women in normal labor (since most women did not have an epidural). Had it existed then, the Labor Progress Handbook would have been a very helpful guide.

In today’s obstetric environment, where the majority of laboring women receive epidurals and where information and knowledge have largely replaced wisdom and art, the Labor Progress Handbook is that much more important—an invaluable asset to any birth attendant and essential reading for any student of birth—whether nurse, midwife, doctor, or doula.

Andrew Kotaska, MD, FRCSC

Clinical Director of Obstetrics

Stanton Territorial Hospital

Yellowknife, Northwest Territories

Canada

Foreword to the second edition

In Canada, where we pride ourselves on having an integrated system of maternity care, where obstetricians, family doctors, nurses, and midwives work collaboratively, a recent national study nevertheless reported that three out of four women receive one or more major interventions in labor. How can this be? Could it be because we have forgotten how to look after women in labor?

The second edition of this thoughtful and practical book will be a gift to the full range of practitioners and trainees from the sister disciplines of obstetrics and gynecology, family practice, midwifery and nursing. It is a skillful blend of classical obstetrical teaching, quoting liberally from conventional textbooks and scientific literature, to “new” information gleaned from the long experience of midwives.

Generations of medical students have learned a huge amount about the pathology of childbirth, with the result that they tend to fear labor and have learned to intervene with the “big guns,” like oxytocin augmentation and various forms of expedited birth. We learned as students that childbirth could be reduced to a little plumbing: the “three Ps.” And if we regurgitated this in an exam, we received a sure pass.

(1) The Passage or pelvis: size, shape, angles.

(2) The Power or strength of contractions.

(3) The Passenger or fetus, meaning principally the size of fetal head but also position and attitude.

Unfortunately, while plumbing is important in childbirth and in life (especially for those of us in advancing years), there is so much more to labor and life. Responding to the complexity and simplicity of labor so well described in this book, some of us have invented another “seven Ps,” and I was pleased to find that many of them have been enumerated by the authors:

(4) The Person—the woman: her beliefs, preparation, knowledge, and “capacity” for doing the work of labor and birth.

(5) The Partner—how the woman is supported and the partner”s knowledge, beliefs, and preparation for the labor.

(6) The People—the “entourage”—others who may be involved in the pregnancy, labor, and birth process, and who are working with the woman. The entourage also have their beliefs, preparation, and knowledge of the process, and this interacts positively or negatively with those of the woman and her partner.

(7) The Pain—the influence and experience of pain and the sociocultural beliefs of the woman and her support system and her personal psychological environment. All this influences the woman’s capacity for coping with labor and birth. Clearly pain interpretation and pain control impacts the progress of labor.

(8) The Professionals—the manner in which all members of the health care team support, inform and collaborate in care and information-sharing with the woman and her partner and support people, significantly influences the woman’s response to the labor and birth process.

(9) The Passion—the journey of pregnancy, labor and birth, is one that is special and unique for all women. It is crucial for all involved in the care of women to recognize and honor this passion and allow this concept to guide us in our practice as we appreciate and guard the intimacy of this life-changing experience. And we need to control our anxiety and need for perfection so that the woman can fully experience the passion even when the birth is complex and requires considerable help from us.

(10) The Politics—You know it’s true!

This book focuses on these concepts, while providing concrete information to help us facilitate the natural processes that are ready to be released, if we but give them time.

How refreshing to find a book that teaches how to stay out of trouble, how to prevent dysfunctional labors (and even to do so well before labor occurs) during prenatal care. It is liberating to have information on how to shift a fetus from an unfavorable to a favorable position, rather than waiting pessimistically to see an antenatal fetal malposition turn into an intrapartum OT or OP. New learners will benefit from the detailed descriptions of asynclitism and how to diagnose and treat it, as well as excellent descriptions of how to diagnose a flexed or extended head.

I have seen Penny teach these techniques in workshops for maternity caregivers, and seen the “Aha!” experience that results in the statement, “I can’t wait to try these techniques in my next clinic or labor.”

And now the information is available in accessible form to share with trainees and the women themselves. Thus, this book complements and augments the materials conventionally taught to medical students and specialist trainees. It will empower them with information that they can use in the labor suite. It will make them feel useful.

Epidural analgesia: the new reality. Who can argue with good pain relief ? But at what price? And do women know, and have they been taught the full picture? The Cochrane Collaboration clearly demonstrates that it increases the length of the first and second stages of labor, increases the use of instrumentation and leads to excess perineal trauma. And while Cochrane reports no increase in cesarean section, most of us know that to be untrue. When used early and often (not the conditions of the major new trials in Cochrane)1, epidural analgesia usually requires oxytocin augmentation (which is generally given in low dose regimes). Epidural analgesia clearly increases the frequency of cesarean section.

Therefore, I was particularly impressed with the way that the authors explained the influence of epidural analgesia on the course of labor. In fact, epidural analgesia is now so pervasive that we have forgotten how the entire shape of labor has been altered by its availability and omnipresence. Not to overstate the issue, there are places in North America and elsewhere where the staff either do not know or have forgotten how to look after women who do not have an epidural.

Unfortunately, it is this sad situation that makes it so necessary to describe how epidural analgesia alters labor and what techniques are needed to assist women who have an epidural. The authors have therefore elaborated on this new reality and provided the cautions and tools to assist caregivers do their best to let labor unfold in the presence of an epidural.

This little text, which will fit nicely in a back pocket or “lab coat,” provides practical diagrams of normal and abnormal fetal positions that can be identified well before labor, and more importantly, corrected, so as to lessen the malpositions of labor that unleash the “cascade” of interventions that characterize the experience of so many women having their first babies. It will take much to turn society back from thinking of childbirth as an accident waiting to happen and to help women realize their power and competence, but the authors have given us a tool to help in that process, to help us keep normal birth normal. I am grateful that this book is available and entering its second edition.

Michael C. Klein, MD, CCFP,

FAAP(Neonatal-Perinatal), FCFP, ABFP

Emeritus Professor of Family Practice and Pediatrics

University of British Columbia

REFERENCE

1. Howell C. (2000). Epidural versus non-epidural analgesia for pain relief in labour. Cochrane Database Syst Rev (3), CD000331. doi:10.1002/14651858.CD000331.

Foreword to the first edition

At last, a book that offers practical advice for nurses and midwives who wish to help to prevent and treat dysfunctional labor! Penny Simkin and Ruth Ancheta have done a superb job of interweaving the clinical wisdom of observant, expert practitioners with the best available research evidence about what helps and does not help women during labor.

I wish this book had been available a long time ago. In the early 1970s when I was a novice labor and delivery nurse, I observed a common but puzzling problem. In those days we subjected women to an admission routine that included a variety of very unpleasant procedures. (Thankfully the worst of these procedures—perineal shaves, enemas, and rectal exams—have since been recognized as useless or harmful and have been eliminated from common practice.) Part of the admission routine involved assessment of the quality and strength of contractions. When I inquired about the contractions, I was often told, “My contractions were frequent and strong at home, but they seem to have gotten a lot weaker and further apart since I arrived.”

I would reply, “Do not worry, this happens a lot. After we finish the admission procedures and you are settled in here, your labor will probably get going again.”

Why did I say this? I believed it. I had observed it often and had overheard experienced colleagues reassure their patients in this way.

At some intuitive level I felt the decrease in labor intensity was caused by the woman’s reaction to the stress of the hospital admission routine. But at the time almost nothing had been written about the role of stress hormones on uterine function, nor about the relationships between maternal anxiety, environmental influences, stress hormones, and labor complications. And the randomized controlled trials showing the substantial benefits of labor support had not even been conducted yet1.

What about the instances in which labor did not return spontaneously to the strong, regular pattern that had been occurring prior to admission? Our repertoire of nursing interventions was limited primarily to advising the woman either to ambulate or to rest and wait. (Currently, in some settings the options may be even fewer, with ambulation restricted by the routine use of electronic fetal monitors.)

These women frequently ended up with a cascade of medical interventions—IV oxytocin, amniotomy, epidural analgesia, and forceps or cesarean delivery.

I now believe that there is much more I could have done to prevent or treat the problem of dysfunctional labor. Penny Simkin and Ruth Ancheta have described how “emotional dystocia” and stressful environmental influences may lead to complications, and they offer simple but potentially powerful nursing measures to ameliorate these problems. They have also persuaded me that many instances of dystocia or prolonged labor may be caused by subtle malpositions of the fetal head, potentially correctable with simple positioning techniques.

I can only imagine how much more effective I would have been if this book had been available when I was a labor and delivery nurse.

As a researcher, I am inspired to study these simple but potentially very powerful labor support techniques. Dystocia or dysfunctional labor is the most common reason for primary cesarean delivery. Given the high rates of cesarean delivery in North America and the United Kingdom, and the limitations and risks of medical treatments for dystocia, it seems long overdue that nurses and midwives take an active role in preventing and treating this common clinical problem. This book contains a wealth of information about and practical suggestions for preventing and correcting dysfunctional labor. It should be required reading for all who care for women in labor, and a reference text in every labor and birthing unit.

Ellen D. Hodnett, RN, PhD

Professor and Heather M. Reisman Chair

Perinatal Nursing Research

University of Toronto

REFERENCE

1. Hodnett E. (1998). Support from caregivers during childbirth (Cochrane Review). In: The Cochrane Library, Issue 3. Update Software, Oxford.

Acknowledgments

We have been helped in writing this book by many wonderful people, especially:

Sally Avenson, Fredrik Broekhuizen, Roberta Gehrke, Joan Hintz, Lynn Diulio, Mary Mazul, Ann Neal, Jean Sutton, Karen Hillegas, Barbara Kalmen, Karen Kohls, Ann Krigbaum, and Karen Lupa for their helpful suggestionsJohn Carroll, Alicia Huntley, Shauna Leinbach, Jenn McAllister, Sara Wickham, and Lisa Hanson for reviewing the text and giving us useful feedbackDiony Young, for her assistance and supportAnne Frye, midwife and author of Holistic Midwifery, for her stimulating conversation and generous sharing of ideasShanna dela Cruz, our dedicated and meticulous illustratorThe mother and child depicted in the cover photoThe dozens of women and men who posed for our illustrations, including Robin Block, Asela Calhoun, Vic dela Cruz, Helen Vella Dentice, Carissa and Zsolt Farkas, Katie Rohs, Maureen Wahhab, Bob Meidl, and Lori Meidl Zahorodney, and class members in Penny Simkin’s childbirth classes, staff members of Waukesha Memorial Hospital, Aurora Sinai Hospital, and St. Mary’s Hospital of Milwaukee, Wisconsin, USACelia Bannenberg, for permission to redraw the deBy birthing stoolJan Dowers, Lesley James, Tracy Sachtjen, and Heather Snookal, who provided support and assistance with manuscript preparation of previous editions, and Tanya Baer, Candace Halverson, and Molly Kirkpatrick, who provided extraordinary assistance in the preparation of this edition.Last but not least, we wish to acknowledge our families who have helped us in countless ways as we devoted ourselves to this larger than expected task.

Chapter 1

Introduction

Penny Simkin, BA, PT, CCE, CD(DONA), and Ruth Ancheta, BA, ICCE, CD(DONA)

Some important differences in maternity care between the United States, the United Kingdom, and Canada

Notes on this book

Changes in this third edition

Material on epidurals

Conclusion

References

Labor dystocia, dysfunctional labor, failure to progress, arrest of labor, arrested descent—all these terms refer to slow or no progress in labor, which is one of the most vexing, complex, and unpredictable complications of labor. Labor dystocia is the most common medical indication for primary cesarean sections. Dystocia also contributes indirectly to the number of repeat cesareans, especially in countries where rates of vaginal births after previous cesareans (VBAC) are low. In fact, The American College of Obstetricians and Gynecologists (ACOG) estimates that 60% of all cesareans (primary and repeat) in the United States are attributable to the diagnosis of dystocia.1 Thus, reducing the need for cesareans for dystocia is a strategic way to reduce the overall cesarean rate. Prevention of dystocia also reduces the need for many other costly and risky corrective obstetric measures and spares numerous women from the discouragement and disappointment that often accompany a prolonged or complicated birth.

The possible causes of labor dystocia are numerous. Some are intrinsic:

The powers (the uterine contractions)The passage (size, shape, and joint mobility of the pelvis and the stretch and resilience of the vaginal canal)The passenger (size and shape of fetal head, fetal presentation and position)The pain (and the woman’s ability to cope with it)The psyche (anxiety, emotional state of the woman).

Others are extrinsic:

Environment (the feelings of physical and emotional safety generated by the setting and the people surrounding the woman)Ethnocultural factors (the degree of sensitivity and respect for the woman’s culture-based needs and preferences)Hospital or caregiver policies (how flexible, family- or woman-centered, how evidence based)Psychoemotional care (the priority given to nonmedical aspects of the childbirth experience)

Please see Michael Klein’s Foreword to the second edition (page xviii) for his discussion of factors influencing labor progress.

The Labor Progress Handbook focuses on prevention, differential diagnosis, and early interventions to use with dysfunctional labor (dystocia). The emphasis is on relatively simple and sensible care measures or interventions designed to help maintain normal labor progress and to manage and correct minor complications before they become serious enough to require major interventions. We believe this approach is consistent with worldwide efforts, including those of the World Health Organization, to reserve the use of medical interventions for situations in which they are needed: “The aim of the care [in normal birth] is to achieve a healthy mother and baby with the least possible level of intervention that is compatible with safety.”

2

The suggestions in this book are based on the following premises:

Progress may slow or stop for any of a number of reasons at any time in labor—prelabor, early labor, active labor, or during the second or third stage.The timing of the delay is an important consideration when establishing cause and selecting interventions.Sometimes several causal factors occur at one time.Caregivers and others are often able to enhance or maintain labor progress with simple nonsurgical, nonpharmacologic physical and psychological interventions. Such interventions have the following advantages:compared to most obstetric interventions for dystocia, they carry less risk of harm or undesirable side effects to mother or baby.they treat the woman as the key to the solution, not the key to the problem.they build or strengthen the cooperation between the woman, her support people (loved ones, doula [trained labor support provider]), and her caregivers.they reduce the need for riskier, costlier, more complex interventions.they may increase the woman’s emotional satisfaction with her experience of birth. The choice of solutions depends on the causal factors, if known, but trial and error is sometimes necessary when the cause is unclear. The greatest drawbacks are that the woman may not want to try these interventions; they sometimes take time; or they may not correct the problem.Time is usually an ally, not an enemy. With time, many problems in labor progress are resolved. In the absence of clear medical or psychological contraindications, patience, reassurance, and low or no risk interventions may constitute the most appropriate course of management.The caregiver may use the following to determine the cause of the problem(s):objective observations: woman’s vital signs; fetal heart rate patterns; fetal presentation, position, and size; cervical assessments; assessments of contraction strength, frequency, and duration; membrane status; and timesubjective observations: woman’s affect, description of pain, level of fatigue, ability to cope with self-calming techniques.direct questions of the woman and collaboration with her in decisions regarding treatment:

“What was going through your mind during that contraction?”

“Please rate your pain during your previous contraction.”

“Why do you think labor has slowed down?”

“Which options for treatment do you prefer?”

Once the probable cause and the woman’s perceptions and views are determined, appropriate primary interventions are instituted and labor progress is further observed. The problem may be solved with no further interventions.If the primary interventions are medically contraindicated or if they are unsuccessful, then secondary, relatively low-technology interventions are used, and only if those are not successful are the tertiary, high-technology obstetric interventions instituted under the guidance of the doctor or midwife.

Chart 1.1 illustrates the approach described in this book. Other, similar flow charts appear throughout this book to illustrate the application of this approach to a variety of specific causes of dysfunctional labor.

Chart 1.1. Care plan for the problem of “little or no labor progress.”

Many of the interventions described here are derived from the medical, midwifery, nursing, and childbirth education literature. Others come from the psychology, sociology, and anthropology literature. We have provided references for these, when available. Some suggestions have come from the extensive experience of nurses, midwives, doctors, and doulas. Many are applications of physical therapy principles and practices. Some items fall into the category of “shared wisdom,” where the original sources are unknown. We apologize if we neglect to mention the originator of an idea that has become sufficiently widespread to fall into this category. Finally, some ideas originated with one, some, or all of the authors who have used them successfully in their work with laboring women.

With today’s emphasis on evidence-based practice, many rather entrenched maternity care customs are falling out of favor because they have been proven ineffective or harmful. Routine practices, such as enemas, pubic shaving, continuous electronic fetal monitoring, maternal supine and lithotomy positions in the second stage of labor, episiotomy, immediate clamping of the umbilical cord, and routine suctioning of the baby’s airway after birth are examples of forms of care that became widespread before they were scientifically evaluated. Then, once well-controlled trials of safety and effectiveness had been performed and the results combined in meta-analyses, these common practices were found to be ineffective and to increase risks.3

Where possible, we will base our suggestions on scientific evidence and will cite appropriate references. However, numerous simple and apparently risk-free practices have never been scientifically studied. Some of these are based on an understanding of the emotional and physiologic processes taking place during childbirth. Others are applications of anatomy, kinesiology, and body mechanics to enhance the relationships between such separate but interdependent forces as pelvic shape, maternal posture, fetal position and station, uterine activity, and the force of gravity. Still others are based on a recognition of the importance of each laboring woman’s personal and cultural values.

Some of the strategies suggested in this book will lend themselves to randomized controlled trials, while others may not. Perhaps readers will gather ideas for scientific study as they read this book and apply its suggestions.

SOME IMPORTANT DIFFERENCES IN MATERNITY CARE BETWEEN THE UNITED STATES, THE UNITED KINGDOM, AND CANADA

This book is being published simultaneously in North America and the United Kingdom, where the approaches to maternity care are quite different from one another. It may surprise the reader to learn about some of those differences, and it may also be interesting to learn that practices that are considered essential for safety in one country are considered ineffective or archaic in another. We hope that one indirect effect of our book will be to encourage a willingness to reconsider practices that are either entrenched or avoided in one’s own workplace.

Table 1.1 compares some basic features of maternity care between the United States, Canada, and the United Kingdom. Because of such differences in maternity care as those listed in Table 1.1, the willingness to introduce new practices and the power to do so will vary among caregivers in different countries. We hope our readers will begin to use the simplest, most innocuous measures immediately and to educate themselves and change policies where necessary.

Table 1.1. Comparison of maternity care in the United States, Canada, and the United Kingdom

NOTES ON THIS BOOK

This book is directed toward midwives, nurses, and doctors who want to support and enhance the physiologic process of labor with the objective of avoiding complex, costly, more risky interventions. It will also be helpful for students in obstetrics, midwifery, and maternity nursing; for childbirth educators who can teach many of these techniques to expectant parents; and for doulas, who are qualified and skilled in the use of many of the techniques. The chapters are arranged chronologically according to the phases and stages of labor.

Because a particular maternal position or movement is useful for the same problem during more than one phase of labor, we have included illustrations of these positions in more than one chapter. This will allow the reader to find position ideas at a glance when working with a laboring woman. Complete descriptions of all the positions, movements, and other measures can be found in the “Toolkit,” Chapters 9 and 10.

The terms “caregiver” and “birth attendant” are used most commonly to refer to the maternity care professionals who provide care and support for the woman in labor.

CHANGES IN THIS THIRD EDITION

Besides updating the information, and adding new suggestions, 32 new illustrations, and references throughout this edition, we have asked Lisa Hanson, PhD, CNM, FACNM, associate professor at Marquette University College of Nursing, to author a chapter on intermediate interventions for use by midwives and doctors to enhance labor progress. This includes techniques for manually dilating a rigid cervix; digital or manual rotation of a malpositioned fetus in late labor or second stage; management of shoulder dystocia; the “somersault maneuver” for delivering a baby with a tight nuchal cord; and many others.

We also asked Lisa Hanson to co-author (with Penny Simkin) the new Chapter 7, “Optimal Newborn Transition and Third and Fourth Stage Labor Management,” which includes a critical discussion of routine postpartum care practices in the context of holistic definitions of the third and fourth stages that are based on immediate and maximum skin-to-skin contact between mother and baby to foster family integration and facilitate breastfeeding and maternal behavior.

Suzy Myers, LM, CPM, MPH, chairperson of the Department of Midwifery at Bastyr University, near Seattle, Washington, has updated Chapter 3, “Assessing Progress in Labor.” The innovative concept of “belly mapping,” developed by Minnesota midwife and artist, Gail Tully, is also presented in this chapter. Gail Tully supplied the content and drawings for the “belly mapping” segment of the chapter, which is also coauthored by Lisa Hanson.

All of these midwives’ contributions provide techniques and practical tips that are not taught in many schools of medicine, midwifery, and nursing.

MATERIAL ON EPIDURALS

In acknowledgment of the widespread use of epidural analgesia, we address the needs of readers who work extensively with women who have them and are unable to use many of the measures shown in this book. Labors with epidural analgesia are frequently accompanied by slow progress, maternal hypotension, maternal fever, the necessity for synthetic oxytocin, instrumental delivery, episiotomy, cesarean, prophylactic antibiotics for the newborn, and other undesired side effects. Usual care of women who have an epidural during a normally progressing labor (restriction to bed, limited movement, large amounts of intravenous fluids, supine position, and prolonged directed maximal bearing down during second stage) may actually add to the undesired effects of the epidural medication itself and increase the likelihood of labor dystocia. With that possibility in mind, we encourage our readers to treat a woman with an epidural as much as possible (within the realm of safety) like a woman who does not have an epidural. We have prepared a special “Epidural Index” (page 379) to help readers quickly identify measures that can safely be used for women with epidural analgesia to correct side effects and fetal malpositions and to aid progress.

CONCLUSION

The current emphasis in obstetrics is to find better ways to treat dystocia once it occurs. This book advocates prevention and a stepwise approach to interventions beginning with the least invasive approaches possible that will result in safe delivery. This approach is the focus of this book.

To our knowledge, this is the first book that compiles labor progress strategies that can be used by a variety of caregivers in a variety of locations. Most of the strategies described can be used for births occurring in hospitals, at home, and in freestanding birth centers.

We hope this book will make your work more effective and more rewarding. Your knowledge of appropriate early interventions may spare many women from long, discouraging, or exhausting labors; reduce the need for major interventions; and contribute to safer and more satisfying outcomes. The women may not even recognize what you have done for them, but they will appreciate and always remember your attentiveness, expertise, and support, which contribute so much to their satisfaction4 and positive long-term memories of their childbirths.5

We wish you much success and fulfillment in your important work.

REFERENCES

1. American College of Obstetricians and Gynecologists (ACOG). (2003). Dystocia and augmentation of labor. ACOG Practice Bulletin No. 49. Obstet Gynecol 102, 1445–1454.

2. World Health Organization. (1996). Care in normal birth: A practical guide. In Safe Motherhood. Geneva, Author.

3. Hofmeyr GJ, Neilson JP, Alfirevic Z, et al. (2008). Pregnancy and Childbirth: A Cochrane Pocketbook. West Sussex, England, Wiley.

4. Hodnett E. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol 186(5), s160–s172.

5. Simkin P. (1990) Just another day in a woman’s life? Women’s long term perceptions of their first birth experience. Part I. Birth 18(4), 203–210.

Chapter 2

Dysfunctional Labor: General Considerations

Penny Simkin, BA, PT, CCE, CD(DONA), and Ruth Ancheta, BA, ICCE, CD(DONA)

What is normal labor?

What is dysfunctional labor?

Why does labor progress slow down or stop?

A role for the fetus in regulating labor?

The psychoemotional state of the woman: maternal well-being or maternal distress?

Pain versus suffering

The “fight-or-flight” and “tend-and-befriend” responses to distress and fear in labor

The environment for birth

Psychoemotional measures

Physical comfort measures

Physiologic measures

Why focus on maternal position?

Monitoring the mobile woman’s fetus

Auscultation

When EFM is required: options to enhance maternal mobility

Continuous EFM

Intermittent EFM

Telemetry

Techniques to elicit stronger contractions

Conclusion

References

WHAT IS NORMAL LABOR?

Normal labors may be long or short. They may very painful or hardly painful. They may occur after a high-risk or a low-risk pregnancy. They may result in the birth of a small or a large baby. They may take place within or outside the hospital.

Despite these variations, all such labors, if they meet the following criteria, would be considered normal by the World Health Organization (WHO),1 which defines normal labor as having the following features:

spontaneous onset of labor between 37 and 42 completed weeks of pregnancylow risk at the start, and remaining so throughout labor and deliveryspontaneous birth of an infant in the vertex presentationmother and baby in good condition after birth

It is often stated that one can diagnose normal labor only in retrospect, leading many to conclude that it is preferable to treat all labors as high risk, even though WHO estimates that “between 70 and 80% of all pregnant women may be considered as low-risk at the start of labour.”1,chap1,p3 Because of the great expense, intensive training, and inherent risks of treating all labors as high risk, WHO states, “In normal birth there should be a valid reason to interfere with the normal process.”1,chap1,p3 However, assessment of risk must continue throughout pregnancy and labor: “At any moment early complications may become apparent and induce the decision to refer the woman to a higher level of care. …”1,chap1,p2 By emphasizing the need for ongoing surveillance of maternal and fetal well-being, WHO answers many of the concerns resulting from the impossibility of predicting which low-risk women will remain low risk throughout labor and birth.

Influential organizations and working groups in North America and Europe have taken up the challenge of defining normal labor.2–7 Table 2.1 describes some of these efforts. Many others have taken on the task of developing tools to evaluate providers of maternity care (individuals and institutions) on how well or how poorly they promote normal birth.8–12

Table 2.1. Many ways to define “normal birth”

Defining Organization or IndividualDefinitionCommentsWorld Health Organization (WHO), 19961“Spontaneous in onset, low-risk at the start of labor and remaining so throughout labor and delivery. The infant is born spontaneously [without help] in the vertex position [head down] between 37 and 42 completed weeks of pregnancy. After birth mother and baby are in good condition.”This retrospective definition normal labor is based on healthy outcomes. Normal labor can only be diagnosed in retrospectSociety of Obstetricians and Gynecologists of Canada (SOGC), Association of Women’s Health, Obstetric and Neonatal Nursing of Canada (AWHONN), Canadian Association of Midwives (CAM), College of Family Physicians of Canada (CFPC), and Society of Rural Physicians of Canada (SRPC)2Same as WHO, above, plus:“Normal birth includes the opportunity for skin–skin holding and breastfeeding in the first hour after the birth.A normal birth does not preclude possible complications such as postpartum hemorrhage, perineal trauma and repair, and admission to the neonatal intensive care unit.Normal birth may also include evidence-based intervention in appropriate circumstances to facilitate labor progress and normal vaginal delivery; for example: Augmentation of labor and artificial rupture of the membranes (ARM) if it is not part of medical induction of labor Non-pharmacologic and pharmacologic pain relief (nitrous oxide, opioids and/or epidural) Managed third stage of labor Intermittent fetal auscultationA normal birth does not include: Elective induction of labor prior to 41+0 weeks Spinal analgesia, general anesthetic Instrumental delivery Cesarean delivery Routine episiotomy Continuous electronic fetal monitoring for low risk birth Fetal malpresentation”This is a prospective process-based definition of normal labor. With this definition, one may have a normal labor, but a poor outcome.The group advocates• Spontaneous of labor• Freedom to move throughout• Continuous labor support• No routine intervention• Spontaneous pushing in woman’s preferred position• Fetal surveillance by auscultation• Good information for women• Education on normal birth for childbirth educators and care providersUK Maternity Care Working Party (MCWP), 2007, including the Royal College of Midwives (RCM), Royal College of Obstetricians and Gynecologists (RCOG), and National Childbirth Trust (NCT)3The “normal delivery” group includeswomen whose labor starts spontaneously, progresses spontaneously without drugs, and who give birth spontaneously;AND women who experience any of the following, provided they do not meet the exclusion criteria (see below):augmentation of labor, artificial rupture of the membranes (ARM) if not part of medical induction of labor,nitrous oxide/oxygen,opioids,electronic fetal monitoring,managed third stage of labor,antenatal, intrapartum, or postnatal complications (postpartum hemorrhage, perineal tear, repair of perineal trauma, admission to SCBU or NICU).The “normal delivery” group excludeswomen who experience any one or more of the following:induction of labor (with prostaglandins, oxytocics or ARM),epidural or spinal, general anesthetic,forceps or vacuum,caesarean section, or episiotomy“Some MCWP members would like the Information Centre definition tightened in future to also exclude procedures like augmentation of labor, use of opioid drugs, artificial rupture of membranes or managed third stage. This would depend on the necessary statistics being routinely collected. Alternatively, a tighter definition could lead to the establishment of a separate definition of ‘physiological’ or ‘natural’ birth.”Similar to SOGC definition above, this is another Prospective Process-based definition except it does not include epidural, and does include electronic fetal monitoring in the definition of “normal.”Lamaze International, 20074“Six Care Practices that Support Healthy BirthLabor begins on its ownFreedom of movement throughout laborContinuous labor supportNo routine interventionsSpontaneous pushing in upright or gravity-neutral positionsNo separation of mother and baby after birth, with unlimited opportunities for breastfeeding”This Prescriptive Process-based definition describes evidence-based practices that are necessary for a normal birth. Outcomes are not part of the definition; rather the process is emphasized.Listening to Mothers 2:USA Survey, 20065…“Technology-intensive childbirth care is the norm.” For example, survey mothers experienced the following interventions: induction of labor (41%); electronic fetal monitoring (94%); intravenous fluids (83%); epidural or spinal analgesia (76%). These were usually done without medical indication.Used in this way, “normal” refers to most common, or usual, and has nothing to do with health.This Descriptive survey provided information on practices that constitute statistical norms, that is, usual practicesCoalition for the Improvement of Maternity Services (CIMS), 19966“Normalcy of the Birthing ProcessBirth is a normal, natural, and healthy process.Women and babies have the inherent wisdom necessary for birth.Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such.Breastfeeding provides the optimum nourishment for newborns and infants.Birth can safely take place in hospitals, birth centers, and homes.The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth.”CIMS published a Physiologic definition of normal birth. CIMS has published its TEN Steps to Mother-Friendly Childbirth, which are similar to the Lamaze Six Care Practices that Support Healthy Birth.Debbie Gould, 2000 (7)Who definition, plus:• Labor and birth involves strenuous physical work by mother,• Includes movement by mother (seeking comfort and progress), and• Movement by fetus through the birth canal• “Movement and the notion of hard work are crucial to a midwifery understanding of normal labor.”PLUS:• A healthy mother and baby who are ready to adjust together to their new roles;• Empowerment of the woman• Sense of achievement from her own productive efforts and her ACTIVE control (rather than passive role) in the birth.This holistic definition includes references to the mother’s and fetus’s physical effort and emphasizes their shared roles in accomplishing the birth and postpartum adjustment together. With this definition, normal birth also includes psychological benefits for the mother.

A British midwife scholar, Debby Gould, has proposed a holistic definition of normal labor7 that includes the WHO criteria but adds these other attributes:

strenuous physical work by the mothermovement by the mother (seeking comfort and progress)movement by the fetus (through the birth canal)

Gould believes “movement and the notion of hard physical work to be crucial to a midwifery understanding of normal labor.”7,p424 The consequences of a normal labor as defined by Gould include psychosocial outcomes:

a healthy mother and baby who are ready to adjust together to their new roles in continuing the lifecycle of the woman and the familyempowerment of the womana sense of achievement that comes from the mother’s productive efforts and her active central (rather than passive) role in her child’s birth

Gould believes that acceptance of this definition of normal birth would lead to improved care of women and a reversal of the prevailing cultural trend of increasing passivity of women and medicalization of birth.7 Gould’s definition most closely embodies the approach to labor put forth in this book.

Although none of the organizations and individuals that have defined normal birth specifies rates of labor progress in their definitions, numerous authors consider adequate labor progress to be a defining characteristic of normality and a major focus of intrapartum care, along with monitoring and maintaining the well-being of mother and fetus. Given the wide range of normality, however, it is not surprising that there are many points of view on the meaning of abnormal progress and on how to prevent, identify, and correct this troublesome problem.

WHAT IS DYSFUNCTIONAL LABOR?

The term “dysfunctional labor” is a catch-all term that refers to protracted or arrested progress in cervical dilation during the active phase of labor, or protracted or arrested descent during the second stage. Other terms, such as “labor dystocia,” “uterine inertia,” “persistent malposition,” “cephalo-pelvic disproportion,” “failure to progress,” “protracted labor,” and, as some clinicians have said in frustration, “WCO” (“won’t come out!”), have been used to refer to dysfunctional labor. In fact, Friedman compiled a list of 65 terms used to describe abnormal labor!13 Some caregivers are less patient than others and make the diagnosis of dysfunctional labor more quickly.

Diagnosis and management of dysfunctional labor vary, depending on the philosophy of the care provider.14 For example, proponents of “active management of labor” begin high-dose oxytocin augmentation of nulliparas any time after labor is diagnosed, if the rate of dilation is less than 1 cm/hr for 2 hours.15 Friedman’s graphic analyses of labor progress, published between the mid-1950s and the 1970s, have profoundly influenced obstetrics in America and elsewhere for decades. He defined dysfunctional labor as a rate of dilation less than 1.2 cm/hr in nulliparas and less than 1.5 cm/hr in multiparas during the active phase of labor, which he defined as dilation from 3 to 10 cm.13 This work still carries great influence, although more recent research shows that the mean rate of dilation is markedly slower.

Zhang and colleagues16 replicated Friedman’s graphic analyses of labor with 1200 contemporary women, who typically are larger and have larger babies than the women in Friedman’s time. They also receive oxytocin augmentation and epidural analgesia more often. Zhang and colleagues concluded that new criteria are needed to allow a slower rate of dilation before resorting to cesarean delivery. They found that between 4 and 6 cm, the median rate of dilation was 1.2 cm/hr with contemporary women—a rate that Friedman would have diagnosed as “dysfunctional.” Furthermore, the average duration of active labor (from 4 to 10 cm) was 5.5 hours, as opposed to Friedman’s 2.5 hours.13

Albers and colleagues17,18 conducted two studies of the length of labor in a total of 3984 midwife-attended healthy women at term who did not receive oxytocin or epidural analgesia. Their mean duration of active labor was 7.7 hours in nulliparas and 5.6 hours in multiparas. Active phase labors lasting as long as 19.4 hours in nulliparas and 13.8 hours in multiparas were associated with healthy outcomes. Along with Zhang et al., Albers and her colleagues call for revision of clinical expectations for the length of active labor.16–18

Other researchers report lower cesarean rates without additional risks to mother or baby when the diagnosis of dystocia is postponed until a delay in dilation exceeding at least 4 hours has occurred.14,18,19 If the woman can be made comfortable and the fetus’s status appears reassuring, these researchers feel less urgency to speed progress. Unfortunately, nonclinical factors often dictate the caregiver’s decision on when, whether, and how to intervene. For example, these factors may include the adequacy of staffing now and later, their own availability, their personal threshold for patience, and the woman’s needs or desires.

Many midwives and others embrace a “tolerance for wide variations in normal labor.”18 They try to preserve normality and avoid the need for augmentation with oxytocin by ensuring the privacy of the woman, remaining physically present but unobtrusive, nourishing the woman, supporting and reassuring her, using nonpharmacologic interventions (bath, movements, etc.), and exercising patience and watchful waiting while allowing the labor process to unfold at its own pace.

WHY DOES LABOR PROGRESS SLOW DOWN OR STOP?

Most cases of labor dystocia are caused by one or a combination of specific conditions, as listed in Table 2.2. Some of these etiologies disappear with changes in labor management. Others are corrected with skilled diagnosis and appropriate treatments based on the diagnosis. With time, patience, and trial and error, others may self-correct. And last, some will not respond and obstetric interventions will be indicated.

A Role for the Fetus in Regulating Labor?

Although scientific evidence is lacking, many maternity care professionals relate anecdotes of slow-progressing labors, which, when augmented with oxytocin, resulted in fetal intolerance of labor (also known as fetal distress and nonreassuring fetal heart rate tracings) and cesareans. One wonders whether practitioners who tolerate slower progress without augmentation are able to avoid cesareans for fetal distress that might be caused by augmentation with oxytocin. The intriguing question of whether the fetus, perhaps through catecholamine production or some other means, influences the labor pattern merits further scientific investigation.

Table 2.2. Etiologies and risk factors for dysfunctional labor (dystocia)

EtiologyDescriptionCommentsCervical dystociaPosterior unripe cervix at labor onset, scarred, fibrous cervix or “rigid os,”“tense cervix” or thick lower uterine segmentUnripe cervix may prolong latent phase. Surgical scarring, damage from disease, or structural abnormality may increase cervical resistanceEmotional dystociaMaternal distress or fear, exhaustion, severe painIncreased catecholamine production may inhibit contractionsFetal dystociaMalposition, asynclitism, large or deflexed head, lack of engagementPendulous abdomen, size and shape of pelvis or fetal head may predispose fetus to malpositionIatrogenic dystociaMisdiagnosis of labor or second stage, elective induction (nulliparous), inappropriate oxytocin use, maternal immobility, drugs, dehydration, disturbanceMisdiagnosis or unneeded interventions or restrictions can slow or interfere with labor progressPelvic dystociaMalformation, pelvic shape other than gynecoid, small dimensionsMaternal movement and upright positions increase pelvic dimensionsUterine dystociaInadequate or inefficient contractionsMay be secondary to fear, fasting, dehydration, supine position, cephalopelvic disproportion, lactic acidosis in myometrium, or structural abnormalities

THE PSYCHOEMOTIONAL STATE OF THE WOMAN: MATERNAL WELL-BEING OR MATERNAL DISTRESS?

Pain Versus Suffering

Maternal well-being in labor is associated with numerous factors, but after safety for mother and baby, pain is probably the chief concern of women and their caregivers. What is it about pain that causes such concern? The distinction between pain and suffering is crucial to our understanding of women’s emotional well-being in labor. For our purposes, the pain of labor might be defined as an unpleasant bodily sensation that one wishes to avoid or relieve. Suffering, however, is a distressing psychological state that includes feelings of helplessness, fear, panic, loss of control, and aloneness. Suffering may or may not be associated with pain, and pain may or may not be associated with suffering.

We postulate that it is not pain, but an inability to cope with pain that is at the root of the concern. In fact, in our discussions with pregnant women, it is not the pain of labor that worries them as much as how the pain will affect their behavior (losing control, crying out, writhing, showing weakness, or behaving shamefully) and whether they will find themselves in a state of helplessness (not knowing how long the pain will go on and being unable to do anything to reduce it). In other words, they are afraid of suffering. Suffering is similar in definition to trauma and can lead to emotional distress (even posttraumatic stress disorder) that sometimes continues long after the birth.

There are two main approaches to pain management: (1) use of medication to modify or eliminate the sensation of pain and (2) use of nonpharmacologic methods to keep the pain manageable, with the primary goal being the prevention of suffering.

In many hospitals, laboring women (and all other hospital patients) are asked periodically to assess their pain, using a visual analog scale of 0 (“no pain”) to 10 (“worst pain imaginable”); it also includes images of faces indicating expressions ranging from smiling to somber to agony (Fig. 2.1). The woman indicates her pain level and is offered pain medications if it reaches a particular level.

Fig. 2.1. Pain intensity scale.

More important than assessment of pain, however, is assessment of her ability to cope with it (Fig. 2.2). Here, the visual analog scale ranges from 10 (“no need to cope—very easy”) to 0 (“totally unable to cope”). The mid-range denotes ability to cope, without or with help—usually demonstrated by maintaining some kind of rhythmic ritual during contractions and relaxing between (see page 160 for more on using relaxation, rhythm, and ritual—the “3Rs”—to cope with pain). The caregiver observes the woman’s responses to her contractions. Another good way for the caregiver to assess coping is to occasionally ask the woman, after a contraction, “Could you tell me what was going through your mind during that contraction?” Her answer will indicate whether she is coping, is in distress, or some of both. If she is coping, all she needs is patience, encouragement, and approval. If her behavior indicates that she is in some degree of distress (crying out, whimpering, struggling, or giving up) or has lost her rhythm, or if her answers to your question indicate emotional distress (“This is much harder than I expected”; “I don’t know how much longer I can go on”; “Please don’t make me do this!”; “I don’t know. I hate this;” or “That’s it. I’m done!”), it may indicate or lead to suffering, and she will need intensive emotional and physical support and guidance in different comfort measures to recover a sense that she can cope. If she cannot respond to more intensive guidance, then she is probably a candidate for pain medications. The bottom line is that no woman should remain in a state of suffering. Chapters 9 and 10 (“Toolkits 1 and 2”) offer numerous measures to enhance a woman’s ability to cope with the pain and unpredictability of labor.

Fig. 2.2. Pain coping scale.

Labor progress and prevention of dystocia depend on harmonious interactions among a variety of psychoemotional, interpersonal, physical, and physiologic factors. As we shall see, progress is facilitated when a woman feels safe, respected, and cared for by her expert caregivers; when she can remain active, mobile, and upright; and when her pain is adequately and safely managed. Her sense of well-being is enhanced by a caring attentive partner or loved ones; competent, confident, compassionate caregivers and doulas; and a calm comfortable, and well-equipped birthplace. If these are not available to her, she may feel ashamed, embarrassed, inhibited, incompetent, alone, judged, unsafe, restricted, disrespected, ignored, or insignificant.20 Such feelings may elicit a psychobiological reaction that interferes with efficient progress in labor.

The complex interplay of a variety of hormones influences—and is influenced by—the labor process as well as by the factors just named. These hormones—oxytocin, endorphins, catecholamines, and prolactin—have specific effects, which may either inhibit the effects of the others or facilitate them. It is the balance of hormones that determines the net effect on labor progress as well as maternal postpartum mental health, mother–infant interaction, and the initiation of breastfeeding. See Table 2.3.

Table 2.3. The hormones of labor and their functions in labor and early post partum

The following description of key hormones is synthesized from the published works of several prominent experts.21–23Oxytocin. Known as the hormone of “calm and connection” or the “love” hormone, oxytocin contributes to uterine contractions, the urge to push, and the “fetal ejection reflex,”24 the “letdown” of breastmilk, maternal behavior, and feelings of well-being and love. It has opposite effects of catecholamines, as described later.Endorphins. These morphine-like hormones increase with pain, exertion, stress, and fear and tend to counteract associated unpleasant feelings. During labor, they are instrumental in creating the trance-like state (withdrawn, dreamy, and instinctual behavior) characteristic of women in active labor. They contribute to the “high” feelings that many unmedicated women have after birth. Once the stress or pain ends, the woman has the leftover euphoric effects of the endorphins.Catecholamines. These stress hormones (adrenalin or epinephrine, noradrenalin or norepinephrine, cortisol, and others) are secreted when a person is frightened or angry, is in danger, or feels she is in danger. These are the hormones of “fight-or-flight.” Their physiologic effects enable the person’s body to endure, defend against, or flee a dangerous situation. Catecholamines tend to counteract the effects of oxytocin and endorphins. First stage labor contractions may slow down or stop, the fetal heart rate may slow, and the woman becomes tense, alert, fearful, and protective of her unborn child. The term “fight-or-flight” accurately describes the physiologic response to danger of all mammals, as well as the behavioral response of males. Recent studies of female behavior when in fear or danger have shown that female behavior is often better described as “tend-and-befriend”—that is, protecting their offspring and reaching out for support.25 In the second stage, a surge of catecholamines is physiologic and helps mobilize the strength, effort, and alertness needed to push out the baby. See pages 29–30 for further discussion of “tend-and-befriend.”Prolactin. This “nesting hormone” prepares the breasts for breastfeeding during pregnancy and after birth, it promotes the synthesis of milk and has mood-elevating and calming effects on the mother. It seems to play a role in the altruistic behavior of a new mother—the ability to put the baby’s needs before her own.

It is notable that the fetus and newborn also produce these hormones, which contribute to fetal well-being during labor, neonatal adaptation, initiation of breastfeeding, and other possible functions.