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

“For all those committed to supporting birthing people, Simkin’s Labor Progress Handbook is a scientifically grounded and eminently practical resource. At a time of renewed public attention to addressing birth equity across the globe, the authors provide indispensable wisdom to ensure women and families receive the care they deserve.”Dr Neel Shah, MD, MPP, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and an obstetrician-gynecologist at the Beth Israel Deaconess Medical Centre.