Simkin's Labor Progress Handbook
Description
Get ready to enhance your expertise in the world of childbirth with Simkin's Labor Progress Handbook -- a trusted resource tailored for childbirth medical practitioners
This invaluable guide unravels the complexities of labor, equipping you with practical strategies to overcome challenges encountered along the way. Inside this comprehensive book, you'll discover a wealth of low-technology, evidence-based interventions designed to prevent and manage difficult or prolonged labors. Grounded in research and practical experience, these approaches are tailored by doulas and clinicians to provide optimal care and achieve successful outcomes.
The fifth edition of this prestigious text includes information on:
* Labor dystocia causes and early interventions and strategies promoting normal labor and birth
* Application of fetal heart rate monitoring (intermittent auscultation, continuous electronic fetal monitoring, and wireless telemetry) while promoting movement and labor progress
* The role of oxytocin and labor progress, and ethical considerations in oxytocin administration
* Prolonged prelabor and latent first through fourth stage labor, addressing factors associated with dystocia
* Positions, comfort measures and respectful care
With meticulous referencing and clear, practical instructions throughout, Simkin's Labor Progress Handbook continues to be a timely and accessible guide for novices and experts alike, including doulas, nurses, midwives, physicians, and students.
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Persons
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.
Content
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
Chapter 1
Introduction
Lisa Hanson, PhD, CNM, FACNM, FAAN and Emily Malloy, PhD, CNM
- Causes and prevention of labor dystocia: a systematic approach
- Notes on this book
- Note from the authors on the use of gender-inclusive language
- Conclusion
- References
CAUSES AND PREVENTION OF LABOR DYSTOCIA: A SYSTEMATIC APPROACH
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.1 Some have suggested that the use of the term "dystocia" be abandoned in favor of more precise definitions since one clear explanation is lacking.1 The modern course of labor is very different than in the past, and optimal strategies to reduce unnecessary interventions while providing interventions when needed and appropriate are still under investigation.2 Dystocia also contributes indirectly to the number of repeat cesareans, especially in countries where rates of vaginal births after previous cesareans (VBAC) are low. Thus, preventing primary cesareans for dystocia decreases the total number of cesareans. The prevention of dystocia also reduces the need for many other costly, time-intensive, and possibly risky interventions, and spares the laboring person from discouragement and disappointment that often accompany a prolonged or complicated birth.3
The possible causes of labor dystocia are numerous. Some are intrinsic:
- The powers (uterine contractions).
- The passage (size, shape, and joint mobility of the pelvis and the stretch and resilience of the vaginal canal).
- The passenger (size, shape, and flexion of fetal head, fetal presentation, and position).
- The pain (and the laboring person's ability to cope with it).
- The psyche (emotional state of the laboring person).
Others are extrinsic:
- Environment (the feelings of physical and emotional safety generated by the setting and the people surrounding the laboring person).
- Ethno-cultural factors (the degree of sensitivity and respect for the person's culture-based needs and preferences).
- Hospital or caregiver policies (how flexible, family- or person-centered, how evidence-based).
- Psycho-emotional care (the priority given to non-medical aspects of the childbirth experience).
The focus of Simkin's Labor Progress Handbook is on prevention, differential diagnosis, and early interventions to use to prevent labor dystocia. We emphasize relatively simple care measures and low technology approaches designed to help maintain normal labor progress, and to manage and correct minor deviations before they become serious enough to require technologic 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 [birth parent] and baby with the least possible level of intervention that is compatible with safety."4
The suggestions in this book are based on the following premises:
- The timing of dystocia is an important consideration when establishing cause and selecting interventions.
- Sometimes several causal factors can occur simultaneously.
- Clinicians and caregivers are often able to enhance or maintain labor progress with simple non-surgical, non-pharmacological 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 laboring person or fetus;
- The laboring persons is autonomous with the right to accept or refuse interventions. These suggestions treat the laboring person as the key to the solution, not part of the problem;
- They build or strengthen the cooperation between the laboring person, their support people (loved ones, doula), and their clinicians;
- they reduce the need for riskier, costlier, more complex interventions;
- They may increase the person's emotional satisfaction with their 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 laboring person may not want to try some interventions; they may take time; and/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 medical or psychological contraindications, patience, reassurance, and low- or no-risk interventions may constitute the most appropriate course of management.
- The clinician may use the following to determine the cause of the problem(s):
- Objective data: vital signs; fetal heart rate patterns; fetal presentation, position, and size; cervical assessments; assessments of contraction strength, frequency, and duration; membrane status; and time;
- Subjective data: person's affect, description of pain, level of fatigue, ability to cope using self-calming techniques:
- Essential components:
- - Attentive listening
- - Informed consent and refusal
- - Shared decision-making with the laboring person
Chart 1.1 illustrates the step-by-step approach followed in this book-from detection of little or no labor progress through graduating levels of interventions (from simple to complex) to correct the problem.
Chart 1.1. Care plan for the problem of "little or no labor progress."
If the primary physiologic interventions are contraindicated or if they are unsuccessful, then secondary-relatively low-technology-interventions are used, and only if those are unsuccessful are tertiary, high-technology obstetrical interventions instituted under the guidance of the physician or midwife. Other similar flow charts appear throughout this book showing how to apply this approach to a variety of specific causes of dysfunctional labor.
Many of the interventions described here are derived from the medical, midwifery, nursing, and childbirth education literature. Some of the strategies described in this book lend themselves to randomized controlled trials, others do not. Others come from the psychology, sociology, and anthropology literature. Suggestions also come from the extensive wisdom and experience of nurses, midwives, physicians, and doulas and other labor support providers. Many are applications of physical therapy principles and practices. The fields of therapeutic massage and chiropractic provide methods to assess and correct soft tissue tension and imbalance that can impair labor progress. We have provided references for these, when available. Some items fall into the category of "shared wisdom," where the original sources are unknown.
During the past half-century, extensive scientific evaluation of numerous entrenched medical customs, policies, and practices, intended to improve birth outcomes, has determined that many are ineffective or even harmful. Routine practices, such as enemas, pubic shaving, routine continuous electronic fetal monitoring, maternal supine and lithotomy positions in the second stage of labor, routine episiotomy, immediate clamping of the umbilical cord, routine suctioning of the newborn's airway after birth, and separation of the newborn from parent/s are examples of care practices that became widespread before they were scientifically evaluated. Scientific study now shows that these common practices were not only ineffective, they increased the risks for the birthing person and neonate.5
Other valid considerations, such as the laboring person's needs, preferences, and values, also play a large role in the selection of approaches to their care. Our paradigm is one of respectful maternity care, although we recognize that throughout history and around the world, laboring people have been subject to racism, sexism, gender discrimination, disrespect, and other abusive and harmful behaviors. It is our expectation that laboring people are treated using a respectful maternity care and human rights model.
Racism and white supremacy are pervasive in obstetric care. Scholars have identified that many of the people identified as early founders of obstetrics and gynecology learned their skills through experimentation, coercion, and abuse of black, brown, and poor birthing people.6 Therefore, in this book, we will avoid using the names of those early experimenters in favor of descriptive terminology, for example, left side lying, or runner's lunge for the position formerly called by a gynecologist's name. Additionally, for one hundred years, nurses, midwives, and physicians were taught a system of pelvic classification with the aim of predicting difficult births that was overtly racist, and based only on pseudoscience.7 Therefore, in this book, we recognize that humans and pelvises are dynamic, and there is not one perfect pelvis. Rather, our goal...
