The Labor Progress Handbook Early Interventions to Prevent and Treat Dystocia

Praise for the previous edition:

"This…edition is timely, useful, well organized, and should be in the bags of all doulas, nurses, midwives, physicians, and students involved in childbirth."
–Journal of Midwifery and Women's Health

The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia is an unparalleled resource on simple, non-invasive interventions to prevent or treat difficult or prolonged labor. Thoroughly updated and highly illustrated, the book shows how to tailor one’s care to the suspected etiology of the problem, using the least complex interventions first, followed by more complex interventions if necessary.

This new edition now includes a new chapter on reducing dystocia in labors with epidurals, new material on the microbiome, as well as information on new counselling approaches specially designed for midwives to assist those who have had traumatic childbirths.

Fully referenced and full of practical instructions throughout, The Labor Progress Handbook continues to be an indispensable guide for novices and experts alike who will benefit from its concise and accessible content.

Penny Simkin, Senior Faculty at Simkin Center for Allied Birth, Vocations at Bastyr University, Independent Practice of Childbirth Education and Labor Support, USA.

Lisa Hanson, Professor and Director, Midwifery Program, College of Nursing, Marquette University, USA.

Ruth Ancheta, DONA-Approved Doula Trainer, Independent Practice of Childbirth Education and Labor Support, USA.

Foreword to the Fourth Edition xvii

Acknowledgments xx

Chapter 1: Introduction 1
Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA)

Causes and prevention of labor dystocia: a systematic approach 1

Differences in maternity care providers and practices in the united kingdom, the united states, and canada 5

Notes on this book 5

Changes in this fourth edition 6

A note from the authors on the use of gender‐specific language 6

Conclusion 7

References 7

Chapter 2: Normal Labor and Labor Dystocia: General Considerations 9
Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA)

What is normal labor? 10

What is labor dystocia? 14

Why does labor progress slow down or stop? 15

Prostaglandins and hormonal influences on emotions and labor progress 17

“Fight‐or‐flight” and “tend‐and‐befriend” responses to distress and fear during labor 19

Optimizing the environment for birth 21

The psycho‐emotional state of the woman: wellbeing or distress? 21

Pain versus suffering 21

Assessment of pain and distress in labor 22

Assessment of women’s ability to cope with the pain 23

Psycho‐emotional measures to reduce suffering, fear, and anxiety 24

Before labor, what the caregiver can do 24

During labor: tips for caregivers and doulas, especially if meeting the laboring client for the first time in labor 26

An integrated philosophy on caring for trauma survivors 27

Trauma histories: why they matter 27

Childhood sexual abuse (CSA) and trauma in adulthood 27

Traumatic births 28

Trauma‐informed care as a universal precaution 31

Physical and physiologic measures to promote comfort and labor progress 32

During labor: physical comfort measures 32

During labor: physiologic measures 32

Why focus on maternal position? 33

Techniques to elicit stronger contractions 35

Maintaining maternal mobility while monitoring contractions and fetal heart 36

Auscultation 36

When EFM is required: options to enhance maternal mobility 37

Continuous EFM 37

Intermittent EFM 39

Wireless telemetry 40

Conclusion 42

References 42

Chapter 3: Assessing Progress in Labor 49
Wendy Gordon, LM, CPM, MPH, Suzy Myers, LM, CPM, MPH, with contributions by Gail Tully, BS, CPM, CD(DONA) and Lisa Hanson, PhD, CNM, FACNM

Before labor begins 50

Fetal presentation and position 50

Abdominal contour 52

Location of the point of maximum intensity (PMI) of the fetal heart tones via auscultation 53

Leopold’s maneuvers for identifying fetal presentation and position 55

Abdominal palpation using Leopold’s maneuvers 55

Estimating engagement 58

Malposition 62

Influencing fetal position prior to labor 62

Identifying those fetuses likely to persist in an OP position throughout labor 63

Influencing fetal position during labor 63

Other assessments prior to labor 64

Estimating fetal weight 64

Assessing the cervix prior to labor 64

The Bishop scoring system 65

Assessments during labor 66

Visual and verbal assessments 66

Hydration and nourishment 66

Psychology 67

Quality of contractions 68

External assessments 69

Vital signs 69

Quality of contractions 69

Abdominal palpation (Leopold’s maneuvers) 70

Assessing the fetus 70

Gestational age 71

Meconium 71

Fetal heart rate (FHR) 71

Internal assessments 75

Vaginal examinations: indications and timing 77

Performing a vaginal examination during labor 77

Assessing the cervix 79

Assessing the presenting part 81

The vagina and bony pelvis 87

Putting it all together 87

Assessing progress in the first stage 87

Features of normal latent phase 88

Features of normal active phase 88

Assessing progress in the second stage 88

Features of normal second stage 88

Conclusion 89

References 89

Chapter 4: Prolonged Prelabor and Latent First Stage 95
Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA)

The onset of labor: key elements in diagnosis 96

Prelabor vs labor: the dilemma for expectant parents 96

Symptoms that differentiate prelabor from early labor 97

The six ways to progress in labor—prelabor to birth 99

The Bishop Score 100

Use of the “Six Ways to Progress” and the Bishop Score to help parents differentiate prelabor from labor 100

Prolonged prelabor and latent phase of labor 101

Can prenatal actions prevent some postdates pregnancies, prolonged prelabors, or early labors? 102

Prenatal preparation of the cervix for dilation 102

Attention to fetal factors that may prolong early labor 107

Optimal fetal positioning: prenatal features 107

Prenatal assessment and correction of suboptimal maternal musculoskeletal variations 109

The woman who has hours of latent labor contractions without dilation 109

Support measures for women who are at home in prelabor and the latent phase 109

Some reasons for excessive pain and duration of prelabor or the latent phase 112

Iatrogenic factors 112

Cervical factors 112

Other soft tissue (ligaments, muscles, fascia) factors 113

Emotional factors 113

Troubleshooting measures for painful prolonged prelabor or latent phase 114

Measures to alleviate painful, non‐progressing, non‐dilating contractions in prelabor or the latent phase 115

Synclitism and asynclitism 116

Open knee–chest position 119

Closed knee-chest position 120

Side‐lying release 120

Conclusion 121

References 121

Chapter 5 Prolonged Active Phase of Labor 125
Penny Simkin, BA, PT, CCE, CD(DONA), Ruth Ancheta, MA, ICCE, CD(DONA), and Lisa Hanson, PhD, CNM, FACNM

What is active labor? Description, definition, diagnosis 126

When is active labor prolonged? 127

Observable characteristics of prolonged active labor 127

Possible causes of prolonged active labor 128

Fetal and fetopelvic factors 129

Malposition, macrosomia, malpresentation, and cephalopelvic disproportion 129

Persistent asynclitism 130

Occiput posterior 130

How fetal malpositions delay labor progress 132

Problems in diagnosis of fetal position during labor 133

Artificial rupture of the membranes with a malpositioned fetus 134

Specific measures to address and correct problems associated with a “poor fit”—malposition, cephalopelvic disproportion, and macrosomia 135

Maternal positions and movements for suspected malposition, cephalopelvic disproportion, or macrosomia 135

Forward‐leaning positions 136

Side‐lying positions 138

Asymmetrical positions and movements 140

Abdominal lifting 142

An uncontrollable premature urge to push 143

If contractions are inadequate 145

Immobility 145

Medication 147

Dehydration and fear of dehydration 147

Overhydration—excessive oral and/or intravenous fluids 148

Exhaustion 149

Uterine lactic acidosis as a cause of inadequate contractions 149

When the cause of inadequate contractions is unknown 150

Breast stimulation 150

Walking and changes in position 151

Acupressure or acupuncture 151

Hydrotherapy (baths and showers) 151

If there is a persistent anterior cervical lip or a swollen cervix 153

Positions to reduce an anterior cervical lip or a swollen cervix 153

Other methods 154

Manual reduction of a persistent cervical lip 155

If emotional dystocia is suspected 155

Assessing the woman’s coping 155

Western cultural attitudes on coping with labor 155

Relaxation, Rhythm, and Ritual: The essence of “coping” during the first stage of labor 155

Indicators of emotional dystocia during active labor 156

Predisposing factors for emotional dystocia 157

Helping the woman state her fears 157

How to help a laboring woman in distress 158

Special needs of childhood abuse survivors 159

Incompatibility or poor relationship with staff 161

If the source of the woman’s anxiety cannot be identified 161

Conclusion 162

References 162

Chapter 6 Prevention and Treatment of Prolonged Second Stage of Labor 167
Penny Simkin, BA, PT, CCE, CD(DONA), Lisa Hanson, PhD, CNM, FACNM, and Ruth Ancheta, MA, ICCE, CD(DONA)

Definitions of the second stage of labor 168

Phases of the second stage of labor 168

The latent phase of the second stage 169

Avoid directing the woman to push during the latent phase of the second stage 170

What if the latent phase of the second stage persists? 171

The active phase of the second stage 171

Support of spontaneous bearing down 171

Physiologic effects of prolonged breath‐holding and straining 172

Effects on the woman 172

Effects on the fetus 172

Spontaneous expulsive efforts 172

Diffuse pushing 174

Second stage time limits 175

Possible etiologies and solutions for second stage dystocia 176

Maternal positions and other strategies for suspected occiput posterior or persistent occiput transverse fetuses 178

Why not the supine position? 179

Differentiating between pushing positions and birth positions 179

Leaning forward while kneeling, standing, or sitting 179

Squatting positions 179

Asymmetrical positions 179

Lateral positions 182

Supported squat or “dangle” positions 183

Other strategies for malposition and back pain 183

Manual interventions to reposition the occiput posterior fetus 187

Early interventions for suspected persistent asynclitism 190

Positions and movements for persistent asynclitism in second stage 192

Nuchal hand or hands at vertex delivery 193

If cephalopelvic disproportion or macrosomia (“poor fit”) is suspected 193

The influence of time on cephalopelvic disproportion 194

Fetal head descent 194

Positions for suspected “cephalopelvic disproportion” (CPD) in second stage 194

The use of supine positions 200

Use of the exaggerated lithotomy position 202

Shoulder dystocia 203

If contractions are inadequate 203

If emotional dystocia is suspected 204

The essence of coping during the second stage of labor 204

Signs of emotional distress in second stage 205

Triggers of emotional distress unique to the second stage 205

Conclusion 207

References 207

Chapter 7 Optimal Newborn Transition and Third and Fourth Stage Labor Management 211
Lisa Hanson, PhD, CNM, FACNM, and Penny Simkin, BA, PT, CCE, CD(DONA)

Overview of the normal third and fourth stages of labor for unmedicated mother and baby 211

Third stage management: care of the baby 213

Oral and nasopharynx suctioning 213

Delayed clamping and cutting of the umbilical cord 214

Management of delivery of an infant with a tight nuchal cord 216

Third stage management: the placenta 216

Physiologic (expectant) management of the third stage of labor 217

Active management of the third stage of labor 218

The fourth stage of labor 221

Keeping the mother and baby together 221

Baby‐friendly (breastfeeding) practices 222

Supporting microbial health of the infant 223

Routine newborn assessments 225

Conclusion 226

References 227

Chapter 8 Low‐Technology Clinical Interventions to Promote Labor Progress 231
Lisa Hanson, PhD, CNM, FACNM

Intermediate‐level interventions for management of problem labors 232

When progress in prelabor or latent phase remains inadequate 232

Therapeutic rest 232

Nipple stimulation 233

Management of cervical stenosis or the “zipper” cervix 233

When progress in active phase remains inadequate 234

Artificial rupture of the membranes (AROM) 234

Digital or manual rotation of the fetal head 235

Digital rotation 236

Manual rotation 237

Manual reduction of a persistent cervical lip 238

Reducing swelling of the cervix or anterior lip 238

Fostering normality in birth 239

Perineal management 239

Prenatal perineal massage 239

Perineal management during second stage 240

Verbal support of spontaneous bearing‐down efforts 240

Maternal birth positions 241

Guiding women through crowning of the fetal head 241

Hand skills to protect the perineum 242

Differentiating perineal massage from other interventions 243

When progress in second stage labor remains inadequate 243

Duration of second stage labor 243

Precautionary measures 245

Warning signs 246

Shoulder dystocia maneuvers 246

The McRoberts’ maneuver 247

Suprapubic pressure 248

The Gaskin maneuver 249

Somersault maneuver 249

Non‐pharmacologic and minimally invasive pharmacologic techniques for intrapartum pain relief 251

Acupuncture 251

Sterile Water Injections 252

Procedure for subcutaneous sterile water injections 253

Nitrous oxide 254

Topical anesthetic applied to the perineum 254

Conclusion 254

References 255

Chapter 9 Epidural and Other Forms of Neuraxial Analgesia for Labor: Review of Effects, with Emphasis on Preventing Dystocia 260
Penny Simkin, BA, PT, CCE, CD(DONA)

Introduction: analgesia and anesthesia—an integral part of maternity care in many countries 261

Neuraxial (epidural and spinal) analgesia—new terms for old approaches to labor pain? 261

Physiological adjustments that support fetal growth and wellbeing 262

Multisystem effects of epidural analgesia on labor progress 263

The endocrine system 263

The central nervous system and peripheral nervous system (sensory, motor, and autonomic, including the sympathetic and parasympathetic nervous systems) 264

The musculoskeletal system 265

The genitourinary system 266

Can changes in labor management reduce problems of epidural analgesia? 266

1. Inform the woman ahead of time 266

2. Shorten the duration of exposure 267

3. Treat the woman as much as possible like a person who does not have an epidural 267

4. Attend to the woman’s emotional needs 272

Restoring women to a central role 273

Conclusion 274

References 274

Chapter 10 The Labor Progress Toolkit

Part 1: Positions and Movements 277
Penny Simkin BA, PT, CCE, CD(DONA) and Ruth Ancheta MA, ICCE, CD(DONA)

Maternal positions and how they affect labor 278

Side‐lying positions 279

Pure side‐lying and semiprone (exaggerated Sims’) 279

The “semiprone lunge” 284

Side‐lying release 285

Sitting positions 288

Semisitting 288

Sitting upright 289

Sitting leaning forward with support 290

Standing, leaning forward 292

Kneeling positions 293

Kneeling, leaning forward with support 293

Hands and knees 295

Open knee–chest position 296

Closed knee–chest position 298

Asymmetrical upright (standing, kneeling, sitting) positions 299

Squatting positions 300

Squatting 300

Supported squatting (“dangling”) positions 302

Half‐squatting, lunging, and swaying 304

Lap squatting 306

Supine positions 308

Supine 308

Sheet“pull‐to‐push”309

Exaggerated lithotomy (McRoberts’ position) 310

Maternal movements in first and second stages 312

Pelvic rocking (also called pelvic tilt) and other movements of the pelvis 312

Hip sifting 314

Flexion of hips and knees in hands and knees position 315

The lunge 316

Walking or stair climbing 317

Slow dancing 318

Abdominal lifting 320

Abdominal jiggling with a rebozo 321

The pelvic press 323

Other rhythmic movements 324

References 326

Chapter 11 The Labor Progress Toolkit

Part 2: Comfort Measures 327
Penny Simkin, BA, PT, CCE, CD(DONA) and Ruth Ancheta, MA, ICCE, CD(DONA)

Introduction: the state of the science regarding non‐pharmacologic, complementary, and alternative methods to relieve labor pain 328

General guidelines for comfort during a slow labor 328

Non‐pharmacologic methods to relieve labor pain 328

Non‐pharmacologic physical comfort measures 330

Heat 330

Cold 331

Hydrotherapy 333

Touch and massage 337

How to give simple brief massages for shoulders and back, hands, and feet 338

Acupressure 343

Acupuncture 344

Continuous labor support from a doula, nurse, or midwife 345

How the doula helps 345

What about staff nurses and midwives as labor support providers? 346

Psychosocial comfort measures 347

Assessing the woman’s emotional state 348

Techniques and devices to reduce back pain 350

Counterpressure 350

The double hip squeeze 351

The knee press 353

Cook’s counterpressure technique No. 1: ischial tuberosities (IT) 354

Cook’s counterpressure technique No. 2: perilabial pressure 355

Techniques and devices to reduce back pain 357

Cold and heat 357

Cold and rolling cold 358

Warm compresses 359

Hydrotherapy 359

Maternal movement and positions 360

Birth ball 360

Transcutaneous electrical nerve stimulation (TENS) 362

Sterile water injections for back pain 364

Breathing for relaxation and a sense of mastery 364

Simple breathing rhythms to teach on the spot in labor 365

Bearing‐down techniques for the second stage 366

Spontaneous bearing down (pushing) 366

Self‐directed pushing 367

Directed pushing 367

Conclusion 367

References 368

Index 371

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