Simkin's Labor Progress Handbook

Lisa Hanson PhD, CNM, FACNM, FAAN is Klein Professor and Associate Director of the Marquette University College of Nursing, Midwifery Program, Milwaukee, WI, USA. She practiced as a midwife for 30 years in Milwaukee, WI, USA. Lisa is an active midwifery researcher who has authored numerous scientific articles.

Emily Malloy PhD, CNM is a nurse-midwife in full scope midwifery practice and a midwife researcher who conducts clinical research in Milwaukee, WI, USA. She is a participating faculty at Marquette University College of Nursing, Midwifery program.

Penny Simkin BA, PT, CCE, CD(DONA) is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 15,000 pregnant people, couples, and siblings for childbirth, and assisted hundreds as a doula. She is author of several books for both parents and professionals.

List of Contributors xvi

Foreword xviii

Chapter 1: Introduction 1
Lisa Hanson, PhD, CNM, FACNM, FAAN and Emily Malloy, PhD, CNM

Causes and prevention of labor dystocia: a systematic approach 1

Notes on this book 4

Note from the authors on the use of gender-inclusive language 5

Conclusion 5

References 5

Chapter 2: Respectful Care 7
Amber Price DNP, CNM, MSN, RN 7

Health system conditions and constraints 8

LGBTQ birth care 9

RMC and pregnant people in larger bodies 9

Shared decision-making 10

Expectations 11

The impact of culture on the birth experience 12

Traumatic births 12

Trauma survivors and prevention of PTSD 13

Trauma-informed care as a universal precaution 15

Obstetric violence 16

Patient rights 17

Consent 17

Maternal mortality 18

References 19

Chapter 3: Normal Labor and Labor Dystocia: General Considerations 22
Lisa Hanson, PhD, CNM, FACNM, FAAN, Venus Standard, MSN, CNM, LCCE, FACNM, andPenny Simkin, BA, PT, CCE, CD(DONA)

What is normal labor? 22

What is labor dystocia? 26

What is normal labor progress and what practices promote it? 26

Why does labor progress slow or stop? 28

Prostaglandins and hormonal influences on emotions and labor progress 29

Disruptions to the hormonal physiology of labor 30

Hormonal responses and gender 30

“Fight‐or‐flight” and “tend‐and‐befriend” responses to distress and fear during labor 31

Optimizing the environment for birth 32

The psycho‐emotional state of the pregnant person: wellbeing or distress? 33

Pain versus suffering 33

Assessment of pain and coping 34

Emotional dystocia 34

Psycho‐emotional measures to reduce suffering, fear, and anxiety 34

Before labor, what the caregiver can do 34

During labor: tips for caregivers and doulas, especially if meeting the laboring client for the first time in labor 37

Conclusion 38

References 38

Chapter 4: Assessing Progress in Labor 41
Wendy Gordon, DM, MPH, CPM, LM, with contributions by Gail Tully, BS, CPM, andLisa Hanson, PhD, CNM, FACNM, FAAN

Before labor begins 42

Fetal presentation and position 42

Abdominal contour 42

Location of the point of maximum intensity (PMI) of the fetal heart tones via auscultation 42

Leopold’s maneuvers for identifying fetal presentation and position 46

Abdominal palpation using Leopold’s maneuvers 46

Estimating engagement: The rule of fifths 49

Malposition 53

Other assessments prior to labor 53

Estimating fetal weight 53

Assessing the cervix prior to labor 54

Assessing prelabor 55

Six ways to progress 55

Assessments during labor 55

Visual and verbal assessments 55

Hydration and nourishment 55

Psychology 56

Quality of contractions 56

Vital signs 57

Purple line 58

Assessing the fetus 58

Fetal movements 58

Gestational age 58

Meconium 59

Fetal heart rate (FHR) 59

Internal assessments 67

Vaginal examinations: indications and timing 68

Performing a vaginal examination during labor 68

Assessing the cervix 69

Assessing the presenting part 70

Identifying those fetuses likely to persist in an OP position throughout labor 75

The vagina and bony pelvis 76

Putting it all together 76

Assessing progress in the first stage 76

Features of normal latent phase 76

Features of normal active phase 76

Assessing progress in the second stage 77

Features of normal second stage 77

Conclusion 77

References 77

Chapter 5: Role of Physiologic and Pharmacologic Oxytocin in Labor Progress 82
Elise Erickson, PhD, CNM, FACNM and Nicole Carlson, PhD, CNM, FACNM, FAAN

History of oxytocin discovery and use in human labor 83

Structure and function of oxytocin 83

Oxytocin receptors 83

Oxytocin and spontaneous labor onset and progression 84

Promoting endogenous oxytocin function in spontaneous labor 85

Ethical considerations in oxytocin administration 85

Oxytocin use 86

Oxytocin use during latent phase labor 87

Oxytocin use during active phase labor 87

Oxytocin use during second stage labor 88

Changes in contemporary populations and labor progress 88

Oxytocin dosing 89

High dose/low dose 89

Variation in oxytocin dosing among special populations 89

Higher body mass index 89

Nullipara 90

Maternal age 90

Epidural 91

Problems associated with higher doses or longer oxytocin infusion 91

Postpartum hemorrhage 91

Fetal Intolerance to labor 92

Oxytocin holiday 92

Breastfeeding and beyond 92

New areas of oxytocin research 93

Conclusion 93

References 93

Chapter 6: Prolonged Prelabor and Latent First Stage 101
Ellen L. Tilden, PhD, RN, CNM, FACNM, Jesse Remer, BS, CD(DONA),BDT(DONA), LCCE, FACCE, and Joyce K. Edmonds, PhD, MPH, RN

The onset of labor: key elements of recognition and response 102

Defining labor onset 102

Signs of impending labor 103

Prelabor 103

Prelabor vs labor: the dilemma 103

Delaying latent labor hospital admissions 103

Anticipatory guidance 104

Anticipatory guidance for coping prior in prelabor 105

Sommer’s New Year’s Eve technique 106

Prolonged prelabor and the latent phase of labor 106

Fetal factors that may prolong early labor 107

Optimal fetal positioning: prenatal features 107

Miles circuit 109

Support measures for pregnant people who are at home in prelabor and the latent phase 110

Some reasons for excessive pain and duration of prelabor or the latent phase 111

Iatrogenic factors 112

Cervical factors 112

Management of cervical stenosis or the “zipper” cervix 112

Other soft tissue (ligaments, muscles, fascia) factors 112

Emotional dystocia 113

Troubleshooting Measures for Painful Prolonged Prelabor or Latent Phase 113

Measures to Alleviate Painful, Non‐progressing, Non‐dilating Contractions in Prelabor or Latent Phase 114

Synclitism and asynclitism 114

Open knee–chest position 118

Closed knee–chest position 119

Side‐lying release 119

When progress in prelabor or latent phase remains inadequate 120

Therapeutic rest 120

Nipple stimulation 120

Membrane sweeping 121

Artificial rupture of membranes in latent labor 121

Can prenatal actions prevent some postdates pregnancies, prolonged prelabors, or early labors? 121

Prenatal preparation of the cervix for dilation 121

References 125

Chapter 7: Prolonged Active Phase 130
Amy Marowitz, DNP, CNM

What is active labor? Description, definition, diagnosis 131

When is active labor prolonged or arrested? 131

Possible causes of prolonged active labor 132

Treatment of prolonged labor 132

Fetopelvic factors 132

How fetal malpositions and malpresentation delay labor progress 134

Determining fetopelvic relationships 134

Malpositions 134

Malpresentations 134

Use of ultrasound 135

Artificial rupture of the membranes (amniotomy) when there is a fetal malposition or malpresentation 135

Epidural analgesia and malposition or malpresentation 135

Maternal positions and movements for suspected malposition, malpresentation, or any “poor fit” 136

Overview and evidence 136

Positions to encourage optimal fetal positioning 137

Forward‐leaning positions 137

Side‐lying positions 137

Asymmetrical positions and movements 137

Abdominal lifting 142

“Walcher’s” position 142

Flying cowgirl 142

Low technology clinical approaches to alter fetal position 144

Digital or manual rotation of the fetal head 144

Digital rotation 145

Manual rotation 146

Early urge to push, cervical edema, and persistent cervical lip 147

Manual reduction of a persistent cervical lip 148

Reducing swelling of the cervix or anterior lip 148

Disruptions to the hormonal physiology of labor 150

Overview 150

If emotional dystocia is suspected 150

Predisposing factors theorized to contribute to emotional dystocia 151

Possible indicators of emotional dystocia during active labor 151

Measures to help cope with expressed fears 151

Hypocontractile uterine activity 152

Factors that can contribute to contractions of inadequate intensity and/or frequency 152

Immobility 152

Environmental and emotional factors 152

Uterine lactate production in long labors 152

Sodium bicarbonate 153

Calcium carbonate 154

When the cause of inadequate contractions is unknown 154

Breast stimulation 154

Walking and changes in position 154

Acupressure or acupuncture 154

Coping and comfort issues 155

Individual coping styles 155

Simkin’s 3 Rs: Relaxation, rhythm, and ritual: The essence of coping during the first stage of labor 156

Hydrotherapy: Warm water immersion or warm shower 156

Comfort measures for back pain 156

Exhaustion 157

Sterile water injections 158

Procedure for subcutaneous sterile water injections 159

Hydration and nutrition 160

Conclusion 160

References 160

Chapter 8: Prevention and Treatment of Prolonged Second Stage of Labor 166
Kathryn Osborne, PhD, CNM, FACNM and Lisa Hanson, PhD, CNM, FACNM, FAAN

Definitions of the second stage of labor 167

Phases of the second stage of labor 167

The latent phase of the second stage 168

Evidence-based support during the latent phase of second stage labor 169

What if the latent phase of the second stage persists? 169

The active phase of the second stage 169

Physiologic effects of prolonged breath‐holding and straining 170

Effects on the birth giver 170

Effects on the fetus 170

Spontaneous expulsive efforts 171

Diffuse pushing 172

Second stage time limits 173

Possible causes and physiologic solutions for second stage dystocia 174

Position changes and other strategies for suspected occiput posterior or persistent occiput transverse fetuses 174

The use of supine positions 174

Why not the supine position? 176

Use of the exaggerated lithotomy position 177

Differentiating between pushing positions and birth positions 178

Knees together pushing 178

Leaning forward while kneeling, standing, or sitting 178

Squatting positions 178

Asymmetrical positions 180

Lateral positions 181

Supported squat or “dangle” positions 181

Other strategies for malposition and back pain 182

Early interventions for suspected persistent asynclitism 183

Positions and movements for persistent asynclitism in second stage 188

Nuchal hand or hands at vertex delivery 190

If cephalopelvic disproportion or macrosomia (“poor fit”) is suspected 190

The influence of time on cephalopelvic disproportion 191

Fetal head descent 191

Verbal support of spontaneous bearing‐down efforts 192

Guiding the birthing person through crowning of the fetal head 192

Hand skills to protect the perineum 192

Perineal management during second stage 194

Topical anesthetic applied to the perineum 194

Differentiating perineal massage from other interventions 194

Waterbirth 194

Positions for suspected “cephalopelvic disproportion” (CPD) in second stage 197

Shoulder dystocia 197

Precautionary measures 202

Two step delivery of the fetal head 204

Warning signs 204

Shoulder dystocia maneuvers 205

The McRoberts’ maneuver 206

Suprapubic pressure 206

Hands and knees position, or the Gaskin maneuver 207

Shrug maneuver 207

Posterior axilla sling traction (PAST) 208

Tully’s FlipFLOP pneumonic 208

Somersault maneuver 208

Decreased contraction frequency and intensity 210

If emotional dystocia is suspected 211

The essence of coping during the second stage of labor 211

Signs of emotional distress in second stage 211

Triggers of emotional distress unique to the second stage 211

Conclusion 213

References 213

Chapter 9: Optimal Newborn Transition and Third and Fourth Stage Labor Management 219
Emily Malloy, PhD, CNM, Lisa Hanson, PhD, CNM, FACNM, and Karen Robinson, PhD,

Cnm, Facnm

Overview of the normal third and fourth stages of labor for unmedicated mother and baby 219

Third stage management: care of the baby 220

Oral and nasopharynx suctioning 220

Delayed clamping and cutting of the umbilical cord 221

Management of delivery of an infant with a tight nuchal cord 222

Third stage management: the placenta 222

Physiologic (expectant) management of the third stage of labor 223

Active management of the third stage of labor 224

The fourth stage of labor 226

Baby‐friendly (breastfeeding) practices 227

Supporting microbial health of the infant 228

Routine newborn assessments 229

Conclusion 230

References 230

Chapter 10: Epidural and Other Forms of Neuraxial Analgesia for Labor: Review of Effects, with Emphasis on Preventing Dystocia 235
Sharon Muza, BS, CD/BDT(DONA), LCCE, FACCE, CLE and Robin Elise Weiss,Ph.D., MPH, CLC, LCCE, FACCE, AdvCD/BDT(DONA)

Introduction: analgesia and anesthesia—an integral part of maternity care in many countries 235

Neuraxial (epidural and spinal) analgesia—new terms for old approaches to labor pain? 236

Physiological adjustments that support maternal-fetal wellbeing 237

Multisystem effects of epidural analgesia on labor progress 237

The endocrine system 237

The musculoskeletal system 238

The genitourinary system 239

Can changes in labor management reduce problems of epidural analgesia? 239

Descent vaginal birth 243

Guided physiologic pushing with an epidural 244

Centering the pregnant person during labor 245

Conclusion 246

References 246

Chapter 11: Guide to Positions and Movements 249
Lisa Hanson, PhD, CNM, FACNM, FAAN and Emily Malloy, PhD, CNM

Maternal positions and how they affect labor 250

Side‐lying positions 250

Pure side‐lying and semiprone (exaggerated Sims’) 250

The “semiprone lunge” 256

Side‐lying release 257

Sitting positions 259

Semisitting 259

Sitting upright 261

Sitting, leaning forward with support 262

Standing, leaning forward 263

Kneeling positions 264

Kneeling, leaning forward with support 264

Hands and knees 266

Open knee–chest position 266

Closed knee–chest position 269

Asymmetrical upright (standing, kneeling, sitting) positions 269

Squatting positions 270

Squatting 270

Supported squatting (“dangling”) positions 272

Half‐squatting, lunging, and swaying 274

Lap squatting 274

Supine positions 277

Supine 277

Sheet “pull‐to‐push” 278

Exaggerated lithotomy (McRoberts’ position) 279

Maternal movements in first and second stages 280

Pelvic rocking (also called pelvic tilt) and other movements of the pelvis 281

Hip sifting 282

Flexion of hips and knees in hands and knees position 283

The lunge 284

Walking or stair climbing 285

Slow dancing 286

Abdominal lifting 288

Abdominal jiggling with a shawl 289

The pelvic press 290

Other rhythmic movements 292

References 293

Chapter 12: Guide to Comfort Measures 294
Emily Malloy, PhD, CNM and Lisa Hanson, PhD, CNM, FACNM, FAAN

Introduction: the state of the science regarding non‐pharmacologic, complementary, and alternative

methods to relieve labor pain 295

General guidelines for comfort during a slow labor 295

Non‐pharmacologic physical comfort measures 296

Heat 296

Cold 297

Hydrotherapy 299

How to monitor the fetus in or around water 301

Touch and massage 302

How to give simple brief massages for shoulders and back, hands, and feet 302

Acupuncture 307

Acupressure 307

Continuous labor support from a doula, nurse, or midwife 307

How the doula helps 308

What about staff nurses and midwives as labor support providers? 309

Assessing the laboring person’s emotional state 310

Techniques and devices to reduce back pain 312

Counterpressure 312

The double hip squeeze 312

The knee press 314

Cook’s counterpressure technique No. 1: ischial tuberosities (IT) 315

Cook’s counterpressure technique No. 2: perilabial pressure 316

Techniques and devices to reduce back pain 318

Cold and heat 318

Cold and rolling cold 318

Warm compresses 319

Maternal movement and positions 319

Birth ball 320

Transcutaneous electrical nerve stimulation (TENS) 321

Sterile water injections for back labor 323

Procedure for subcutaneous sterile water injections 324

Breathing for relaxation and a sense of mastery 324

Simple breathing rhythms to teach on the spot in labor 325

Bearing‐down techniques for the second stage 325

Spontaneous bearing down (pushing) 325

Self‐directed pushing 326

Conclusion 326

References 326

Index 329