ICEA Study Guide 6 – The Labor Process

 OBJECTIVES At the completion of Part 6 the learner will:

■ depict pregnancy and birth as a normal, healthy, continuous process in which the body should be trusted

■ outline four sequential stages of labor

■ describe three measures of physiologic progress in birth

■ share common emotional and physical changes associated with each stage of labor

■ describe four hormones that drive physiologic changes in pregnancy, labor, and birth

■ demonstrate the stages of birth using childbirth class props

■ describe the normal pain of birth and its purpose using the acronym P.A.I.N.

■ compare and contrast possible and positive signs of labor

■ describe a contraction and how they are measured

■ conduct a relaxation exercise

■ facilitate a labor rehearsal appropriate for a childbirth class



  1. Normal physiologic labor and birth are presented first.
  2. Relate labor to the familiar and normal

ICEA Position Paper on Physiologic Birth

While technology increases, maternal/infant morbidity/mortality rates have not shown significant improvements. ICEA defines physiologic birth as birth where baby is birthed vaginally following a labor, which has not been modified by medical interventions.

Normal Physiologic Childbirth

  • is characterized by spontaneous onset and progression of labor;
  • includes biological and psychological conditions that promote effective labor;
  • results in the vaginal birth of the infant and placenta;
  • results in physiological blood loss;
  • facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and
    supports early initiation of breastfeeding.

One that is without interference, complications and in line with normal body functions

Factors Influencing Physiologic Birth

The mother’s health status and education are two of the most important factors. A mother’s complicated health history and/or pregnancy may warrant interference.

Benefits of Physiologic Birth

Birth without medical intervention may have many benefits

  • less postpartum pain;
  • quicker physical recovery from the birth;
  • increase in self-esteem as a result of the birth;
  • enhanced bonding with the baby;
  • reduced likelihood of post-natal depression;
  • a calmer, more settled baby;
  • an easier breastfeeding experience;
  • effective respiratory transition for the baby; and
  • more effective gut colonization that prevents allergies in the baby.

Additional benefits of physiologic birth include a reduction in genital tract trauma/need for suturing as well as triggering the production of certain proteins in a newborns’ brain that may improve brain development.

Intervening in a normal physiologic birth process, where there are no complications, increases the risk of complications for the mother and her baby.

Six evidence- based care practices that promote physiologic birth were created by Lamaze International and outline changes in labor care: avoiding medically unnecessary induction of labor, allowing freedom of movement for the laboring woman, providing continuous labor support, avoiding routine interventions and restrictions, encouraging spontaneous pushing in non-supine positions, and keeping mothers and babies together after birth without restrictions on breastfeeding

Expectant parents can optimize their chances for a physiologic birth by becoming educated in childbirth education classes with the latest research. Informed decision making must be at the forefront of our presentation of physiologic childbirth. The goals of prenatal (childbirth) education are to build women’s confidence in their own ability to give birth, to provide knowledge about normal birth, and to help women develop individualized birth plans that provide a road map for keeping birth as normal as possible even if complications occur.

Providing positive sources of media information, such as television shows or web information can assist expectant parents in their quest for knowledge. Referrals to such out-of-classroom materials become necessary especially when limitations are placed on the dissemination of class information.

  1. Introduce anatomical terms


The Last Weeks of Pregnancy – if pregnancy passes due date, try to remember tha labor likely hasn’t begun bc baby isn’t ready to be born. Most normal, healthy births occur after 37the week but before 42nd week. Some preexisting conditions can override the physiological interaction among baby, mom, placenta, leading to births athat aren’t on time. Examples include illness/infection in mom, heavy smoking or other drug use, extremely stressful life circumstances, as well as unknown factors. ~12% occur before 37th week and ~5-10% would occur after 42nd if labor weren’t induced. (effects of labor induction bypasses intricate hormonal processes of normal birth).

Breasts produce more colostrum. Uterus contracts more and more strongly. May have contractions when you exercise, sneeze, bump belly or for no apparent reason.

Pelvic joints relax, allowing room for baby to descend into birth canal. Produce more cervical mucus and vaginal wall becomes more elastic.

Baby is rapidly storing iron, enough to meet his needs for next 6 months (along w iron he’ll consume from breast milk). Becomes able to regulate own temp. lungs mature, preparing him to breathe w out difficulty after birth.

As placenta ages, membrane bw baby’s bloodstream and yours becomes more permeable, permitting large molecules such as antibodies to erach your baby; they protect him against diseases to which you’re resistant/immune and protection lasts for months. If breastfeed baby, protection will continue for as long as you nurse him.

When baby is ready to survive outside body, his body and yours initiate labor.

Events of Late Pregnancy – during last 6-8 weeks of pregnancy, numerous complex interrelated events take place among baby, body and placenta. A change in 1 of these 3 components triggers changes in the other 2.

  • Baby – stores iron, gains weight/fat/strength, capable of temp regulation, secretes CRH and adrenal hormones, gains immunities from mom, breathing movements, lungs mature, assumes birth position, engagement/rotation/descent
  • Mom – increased colostrum, pelvic joints relax, interrupted sleep, lightening, frequent urination, increased vaginal mucus, soft BMs, nesting urge, restless backache, labor pain, pushing
  • Uterus – increased Braxton Hicks, increased sensitivity to oxytocin, cervix ripens and effaces, bloody show, progressing contractions, cervix dilates
  • Placenta and membranes – feto-placental clock influences labor, fetal adrenal hormones converted to estrogen, effects of increased estrogen surpass progesterone effects, increased prostaglandin production, large molecules allowed to cross to baby, transfer of immunities to baby, decreased amniotic fluid, rupture of membranes

Preparations for Baby’s Birth

  1. Birth plan/ review w caregiver. Consider consulting w childbirth educator or doula, who can answer questions. Make sure reflects priorities/preferences
  2. Tour hospital or backup hospital
  3. Preregister at hospital. Sign admission forms, general consent form. During labor, may need to sign addtl consent forms for specific problems.
  4. Arrange for child care if have other children. Arrange for pet care (and for first few days after baby comes home)
  5. Pack 3 bags: 1 for labor, 1 for postpartum stay, 1 for baby. PCNguide has checklist. Partner packs items he/she needs during labor/birth – toothbrush, change of clothes, pajamas and swimsuit (accompany in shower)

Items for Labor: hairband, headband, toothbrush, toothpaste, lip balm, warm socks, massage oil, PCN book, 2 nightgowns or long t shirts (if don’t want hospital gown), hot water bottle (or sock w uncooked rice), rolling pin (back pain), birth pall, favorite juice, tea, frozen fruit bars, snacks, camera/video camera, personal comfort items (pillow, photos, blanket), music, headphones, laptop

Postpartum Stay: nightgowns you can nurse in, robe/slippers, cosmetic and grooming aids, nursing bra, clothes for ride home (wont return to prepregnant size immediately)

Items for Baby: car seat (properly installed), diapers, undershirt or onesie, nightgown or stretch suit, receiving blanket, warm blanket and cap

  1. Provide an overview of the process

Summary of Normal Labor without Pain Medications (if plan to have epidural, use this until receive epidural)


  • Physical Changes: cervix begins to ripen, efface and move forward. Have nonprogressing contractions and may have restless back pain, soft bowel movements and menstrual like cramps; may last for days
  • How you may feel/respond: tired, discouraged, anxious. May be unable to sleep through contractions. May overestimate labor progress, start rituals and go to birthplace. May focus more than necessary on contractions.
  • Ways To Cope: engage in distracting activities and projects; alternate distracting activities with restful ones such as taking a bath, listening to music, lying down, having a massage etc; use labor-stimulating measures (only if you feel pressured to get into labor); eat if hungry (carbs), drink to thirst
  • Ways Partner/Doula Can Help: review route to birthplace; encourage you to eat/drink; pack vehicle and make sure there’s fuel; time contractions (5-6 at a time) every few hours or when labor seems to have changed; ensure you aren’t left alone; help make the time pleasant for you; alert your doula to be ready to come when you need her if she’s not already with you; enhance emotional security and reduce stress by creating a soothing, safe, private and loving atmosphere

First Stage of Labor: Early Labor

  • Physical Changes: denotes time from onset of labor until cervix is dilated 4-5 cm; contractions are progressing, usually mild at first, then becoming longer, stronger and closer together; cervix continues ripening, effacing and begins to dilate; may have bloody show; membranes may rupture (10% chance) but this usually happens later in labor; may have back pain with contractions
  • How you may feel/respond: same as in prelabor plus have mixed feelings – excitement, confidence, and optimism or anxiety and distress – often at same time; as contractions intensify, you can no longer be distracted by them
  • Ways To Cope: begin using planned rituals (relax, breathe, and focus through each contraction) when intensity of contractions stops you from doing distracting activities; use slow breathing, releasing tension with each exhalation; ask doula for help; contact caregiver or birthplace as instructed when contractions have reached 4-1-1 or 5-1-1 pattern; comfort measures for back pain
  • Ways Partner/Doula Can Help: continue timing contractions periodically; call caregiver or birthplace when contractions reach designated intensity, frequency and length or if membranes ruptured; focus on your contractions as soon as you begin doing a planned ritual; give you constructive feedback, not false praise; help you release tension in a selected area of your body with each exhalation; remind you of positions and comfort techniques

First Stage of Labor: Getting into Active Labor

  • Physical Changes: cervix dilated 4-5 cm; contractions intensify and occur every 3-4 min, lasting 1 min or longer; labor progress should begin to speed up at 5 cm
  • How you may feel/respond: head for birthplace or call midwife; may struggle to remain in control and worry that labor is too hard and long; may become serious, withdrawn, and focused on your labor; may recognize that labor isn’t within your control, leaving you feeling trapped – you may weep; you can no longer be distracted during contractions, you need partner or doula’s undivided attention during them; find unnecessary conversation annoying; may want pain meds; can release control and accept your labor if you can move freely, feel safe and uninhibited and have good support
  • Ways To Cope: try to release your need to be in control; let labor happen as you discover what helps you cope (finding your spontaneous ritual); maintain a rhythm with your breathing and movements, letting your partner or doula help as necessary; try to continue slow breathing if you find it restful; remember that labor progress should speed up soon; if planned for early epidural, can probably receive it during this phase
  • Ways Partner/Doula Can Help: drive to birthplace carefully!; use massage (hand or foot), double hip squeeze, counterpressure, slow dancing etc; rhythmically murmur soothing, encouraging words to you; guide you with visualizations, imagery, rhythmic talk or breath-counting – whatever helps you respond well; help you keep a rhythm in your breathing, moaning, swaying, tapping or whatever action you choose; refrain from asking questions during contractions and ask only simple yes or no questions between contractions; help with your ritual (stroking you, holding you, talking to you through contractions) or simply stay by you if that’s all you require; help you follow preferences on pain meds

First Stage of Labor: Active Labor

  • Physical Changes: cervix dilates from 5-8cm; lasts on average 3-5 hours; if baby is OP or her head is tilted to 1 side, dilation of cervix may pause as baby corrects position; may have back pain (30% chance)
  • How you may feel/respond: calmer than before, now that you’ve discovered how to get through contractions; may enter birth zone and become aware or little other than labor
  • Ways To Cope: same as for early labor and getting into active labor plus – take a bath for relaxation and pain relief; stay hydrated by taking frequent sips of water/juice
  • Ways Partner/Doula Can Help: same as for getting into active labor plus stay by you side, offer you liquids, remind you to empty your bladder

First Stage of Labor: Transition

  • Physical Changes: cervix dilates from 8-10 cm; baby begins to descend toward vaginal opening; contractions are long and close together; pain and intensity of labor at its max; lasts less than 2 hours or less than 1 if given birth before; as cervix completes dilation, may have a lip that remains
  • How you may feel/respond: scared/lost; angry/frustrated; may want more help from others; may feel you’ve reached your limit; may lose rhythm and ritual; may cry out, tense, weep or protest; may feel hot, then cold; may tremble; may feel nauseated; may vomit
  • Ways To Cope: Keep a rhythm; follow partner/doula’s lead with Take Charge Routine; Hang in there! ; if want an epidural, can do it at this time as long as labor isn’t moving too fast
  • Ways Partner/Doula Can Help: maintain a confident, calm, optimistic manner; keep eye contact with you; Take Charge Routine; remind you that transition means you’re almost ready to push out baby; hold you tightly if that’s what you want; keep encouraging you and never give up; let you weep while acknowledging your pain

Second Stage of Labor: Resting Phase

  • Physical Changes: time from complete dilation to when begin to push; for up to 20 min, may have few noticeable contractions or have no urge to push; after baby’s head has slipped through cervix, uterus may need time to tighten around rest of baby’s body before you can begin to push
  • How you may feel/respond: feel relief, optimism, confidence and pain-free; have renewed energy, enthusiasm, hope even if you don’t experience a pause in contractions; no longer in the birth zone – your clearheaded, talkative and more aware of your surroundings
  • Ways To Cope: rest or doze, if you can; if want to push spontaneously, remind caregiver of preference, review positions, if resting phase lasts more than 20 min, change to upright positions to encourage an urge to push
  • Ways Partner/Doula Can Help: should match your enthusiasm, use the lull to renew energy (drink beverage, close eyes and rest for a moment, use restroom), help you change positions

Second Stage of Labor: Descent Phase

  • Physical Changes: baby rotates and descends into birth canal; oxytocin surges cause an urge to push, which may be mild at first, but becomes compelling an irresistible. You begin to push reflexively with contractions; contractions aren’t as close together as they were in transition, and they may be shorter; may last for a few min or up to 2 hours; at first, baby’s head can’t be seen then it appears at your vaginal opening when you push and retreats between pushes; your caregiver supports your perineum, applies warm compresses and may direct your pushing
  • How you may feel/respond: may feel inadequate in pushing until you get the hang of it; may find this phase reward, but you may find it painful and tedious. Either way, you’re working hard; may find the pressure in your vagina alarming and fear it will worsen, making you hold back from pushing; may feel less pain as baby’s head repositions
  • Ways To Cope: hold breath and strain when contractions make you feel that you can’t avoid pushing. You may bellow or cry out with effort; try to bulge your pelvic floor; consider touching baby’s head or watching her progress in mirror; if you’re holding back, or if pushing is painful, try to push into the pain and through it. Doing so will feel better than stopping when it hurts. Change your position every 30 min for comfort or to speed up labor progress. Consider directed or prolonged pushing if labor isn’t adequately progressing with spontaneous bearing down; if using directed pushing, follow directions for when and how long to hold your breath and strain
  • Ways Partner/Doula Can Help: encourage and praise your efforts (not yell push); apply cool, damp cloths to forehead, cheeks, neck and chest; report on progress (as soon as baby’s head is visible); remind you to release tension in perineum; remind caregiver of feelings about episiotomy if appropriate; support your position and help you change positions; if pushing is ineffective, remind you to open your eyes and look toward where your baby is emerging (may use a mirror)

Second Stage of Labor: Crowning and Birth

  • Physical Changes: baby’s head emerges; it no longer retracts into your vaginal opening between contractions; perineum and area around urethra are most vulnerable to tearing in this stage; caregiver either supports your perineum (warm compresses) or does episiotomy (unlikely)
  • How you may feel/respond: feel excited because your baby’s birth will be very soon; may feel a burning sensation from vaginal stretching; may have mixed feelings: may be tempted to push hard to get the birth over with or despite the burning. Or you may fear the burning feeling and become reluctant to push.
  • Ways To Cope: recognize the burning as a sign that labor is almost over. Use your partner’s help with positions. To slow the birth of your baby’s head and protect your perineum, stop pushing and pant/blow when your caregiver says; rejoice in baby’s birth!
  • Ways Partner/Doula Can Help: support you as you change positions; refrain from rushing you, help you keep from pushing as needed; say little or nothing when your caregiver is directing you to slow the birth of your baby’s head; rejoice in your baby’s birth!

Third Stage of Labor

  • Physical Changes: lasts up to 30 min; baby’s umbilical cord is clamped and cut; baby’s condition is evaluated using Apgar; if baby is fine and hospital policy allows, baby is placed on bare abdomen or chest; uterus contracts and shrinks, placenta separates from uterine wall. You expel placenta with a few pushes; may briefly tremble uncontrollable (normal); caregiver checks uterus to confirm it’s contraction and checks birth canal for tears
  • How you may feel/respond: feel relief that labor is over; become engrossed with baby; feel concern over trembling; feel alarm if contractions are still painful; feel surprise at discomfort when caregiver examines birth canal or massages your uterus after placenta is expelled
  • Ways To Cope: move away clothing so baby can be skin to skin; don’t rush breastfeeding – baby needs time to acclimate before she’s ready to feed. Let her show you that she’s ready to start suckling; ask for warm blanket to stop trembling; use light breathing and focus on partner or doula during uterine massage and examination or stitching of perineum; try to be patient during postpartum procedures. You’ll have time to focus on baby soon.
  • Ways Partner/Doula Can Help: help you get baby onto bare abdomen; help you breathe and focus through any painful procedures; get you a warm blanket if you’re trembling; open shirt and snuggle skin to skin with baby, if you can’t hold her right away; request that routine newborn procedures be delayed for at least an hour so you can bond with baby; enjoy the time with your new family!


What Childbirth is Really Like

Stages and Phases of Labor

Prelabor may last for days/weeks; cervix moves forward, ripens (softens) and effaces (thins/shortens). Over course of labor, uterus contracts, cervix continues to ripen and efface and begins to dilate; baby moves down birth canal and you give birth to baby, placenta, umbilical cord and amniotic sac. Can take anywhere from a few hours to a day or longer.

Labor divided into 4 stages, each marks a sign of progress. 1st and 2nd further divided into phases, which represent more subtle changes.

  • 1st stage (dilation): begins w contractions that are becoming longer, stronger and more frequent (progressing) and ends when cervix is completely dilated. Has 3 phases: early labor, active labor, and transition.
  • 2nd stage (birth of baby) – begins when cervix is fully dilated and ends when baby is born
  • 3rd stage (delivery of placenta) – begins w birth of baby and ends with delivery of placenta
  • 4th stage (recovery) – begins after placenta is delivered and ends 1 to several hours later, when your condition has stabilized


First Stage of Labor: Dilation – when contractions progressing and ripening, effacing cervix begins to dilate, in first stage of labor. Dilation increases w each phase until cervix 10 cm. in early labor, cervix dilates 4-5 cm. in active labor, dilates to 8 cm and in transition, completely dilates. Each successive phase becomes shorter and more intense. first stage typically lasts bw 2-24 hrs. first time mom avg length 12.5 hrs. for woman who has given birth, first stage lasts half that time (if labor not induced).

Labor Contractions – by end of pregnancy, uterus has become largest and strongest muscle in body. When contracts, hardens and bulges like any other muscle does and muscle fibers shorter and pull ripe, effaced cervix open. Cant control contractions. Follows wavelike pattern. Frequency increases until cervix full dilated.

In early labor, contractions usually feel like dull lower back pain or abdominal cramps. Very early contractions usually short and mild, lasting 30-40 sec and time bw them may be as long as 15-20 min.

By end of 1st stage, contractions usually very intense and last as long as 90 sec – 2 min. time from beginning of one to beginning of next may be as short as 2-3 min, allowing brief rest.

Hormones in Labor – before, during and after labor, body produces several hormones:

  • Oxytocin – love hormone, plays major role in orgasm, breastfeeding and childbirth. In labor, causes contractions and helps w progress
  • Stress hormones (catecholamines) – counteract oxytocin and can slow contractions, leading to prolonged labor
  • Beta-endorphins – body’s painkillers, secreted when you experience pain, stress and physical exertion. Help you transcend pain and enter trance state that’s sometimes called birth zone
  • Prolactin – produced after birth necessary for milk production and calms/elevates mood

To decrease stress hormones and increase oxytocin and beta-endorphins during labor, following are essential: confidence, sense of safety, privacy, quietness, familiar places and faces, supportive interactions w others, and feeling loved (and reciprocating that feeling) through touch, massage, kissing and caressing. Following increase stress hormones and decrease oxytocin and beta-endorphins: anxiety, fear, anger, decision-making, frequent disturbances and feeling watched/judged.

More info: read Gentle Birth, Gentle Mothering by Sarah Buckley/Ina May

First Phase: Early Labor: early labor or latent phase usually longest phase in 1st stage often bc contractions further apart, shorter and less intense than later. During early labor, cervix becomes fully effaced and dilates to 4-5 cm. Spend most time at or near home, keeping busy or relaxing if its day time and resting if nighttime. Waiting and wondering phase. Early labor record can help you decide whether in early labor or in prelabor. (175)

Best way to cope is to ignore phase until mind/body no longer lets you. At that point, use coping techniques. This mind-set can influence the interactions of hormones in a way that optimizes labor progress.

Getting Through Early Labor – avoid assuming labor is progressing faster than it really is. Try to ignore early contractions. Becoming preoccupied w early contractions often has unwelcome effect of making entire labor seem longer.

Rest if tired or if nighttime. Otherwise, try to keep busy doing activities that are fun, calming or distracting (but not exhausting): pack hospital bag, meditate/used guide visualization, have massage (during contractions in early labor, natural to tense specific areas of body or tension spots, which increases perception of pain; will help you get into habit or relaxing muscles in later phases), take long shower (not bath), consume easy to digest foods and drinks (soup, broth, herbal tea, high carb foods – fruit, pasta, toast, rice, waffles), go for walk, visit w friends, listen to music, write in journal, baby photo album – pregnancy photos, watch movie, dance, play cards/games, preplanned early labor project – working on hobby, gardening, laundering, sorting baby’s clothes, preparing 1 dish meals to freeze, baking birthday cake

When to Go to Birthplace/Call Midwife – if first baby, call when membranes rupture or follow 4-1-1 or 5-1-1 rule – contractions intense enough to require you to focus and breathe rhythmically and 4-5 min apart, lasting 1 min for 1 hr. if given birth before, call when membranes rupture or when having progressing contractions and other signs – bloody show, soft bowel movements w contractions; likely shift from early to active labor more quickly so don’t need to wait for 5-1-1 rule; may be advised to go to hospital when contractions 5 min apart.

In have condition that requires hospital observation during early labor, call when suspect labor. Group B strep, herpes sore, high risk conditions.

May call if anxious, live far away.

Be ready to report Early Labor Record – how long contractions last, how many min apart from start of 1 to start of next, how strong – can talk through them or need to use planned ritual, how long contractions have been like this, status of membranes – ruptured? Color/odor. Presence of bloody show.

The Three R’s: After several hours (or even a day or longer), you’ll be unable to ignore your contractions – can’t walk or talk without having to pause at its peak. Activities are no longer distracting or fun. This marks a shift in your coping strategy. Instead of using distracting activities, use the three R’s (p 206).

Partners: Prep hospital bag/gas in car or house (tidy up/enough food) if it’s a homebirth. If mama becomes quiet, become quiet with her. Don’t hover over her or stare. Touch tense areas ~ “Try to breathe away tension in shoulders.” Remind to sip water after every contraction or 2 and follow her rhythm. (Ch 11 relaxation techniques).

Prolonged Prelabor or Early LaborProlonged labor – takes a long time to get started. Can be difficult to distinguish between a long prelabor (in which contractions aren’t’ progressing and cervix isn’t dilating) and a slow early labor (contractions are cervical dilation progressing slower than usual).

Early labor prolonged if regular contractions continue for longer than 20 hours. Many caregivers believe if early labor is taking a physical or psychological toll on woman, it’s prolonged – regardless of time.

Don’t assume entire labor will be slow. Prolonged early labor is NOT a labor complication. In most cases, labor progresses normally as soon as it reaches active phase.

Important to figure out cause; most probably causes:

  • Contractions have begun before cervix has moved forward, ripened or effaced
  • Cervix is scarred from a previous surgery, cone biopsy or another cervical procedure (for cervix to dilate, may require frequent and intense contractions to overcome resistance by scar tissue)
  • Baby is malpositioned, such as occiput posterior or w a raised chin. May also have back pain. Contractions may seem irregular or may couple.
  • You’re tense, anxious or distressed, which increase stress hormones that can hinder labor progress. Previous unresolved emotional/physical trauma, previous difficult birth experience, grief from miscarriage/abortion, stressful relationship or fears about your/baby’s well being

What you can do:

  • When have vaginal exam, ask whether cervix has moved forward and is ripe; ask about effacement
  • Try not to become discouraged or depressed. Visualize contractions bringing cervix forward, then ripening and effacing it
  • Nurture yourself w food, drink and loving support
  • Alternate doing labor stimulating activities with restful, distracting activities
  • Don’t time every contraction. Time 6 in a row, then wait until pattern has changed
  • If have irregular or couple contractions or back pain, assume baby isn’t in ideal position. Once baby is in better position, back pain should dissipate
  • If worried or tense, talk with partner or support person. A good cry can help release any overwhelming sadness/anxiety

Medical care for prolonged labor

If become exhausted or have made little or no progress for more than 24 hrs, need to decide whether to turn to medical interventions. 2 major approaches to speeding up labor medically:

  • Using medications to stop contractions or help you rest, such as tranquilizers, sedatives, uterine relaxants, morphine or alcohol
  • Using medications or procedures to stimulate more effective contractions. Stripping membranes, mechanically ripening or dilating cervix, breaking bag of waters, ripening cervix with prostaglandins or inducing labor with Pitocin

If feel too exhausted or discouraged to continue on own, request medical help.

Rapid Labor – some women, esp those who’ve given birth before – have rapid labors. Start with contractions 3-4 min apart and become increasingly stronger, longer and more frequent than usual.


Second Phase: Active Labor

When cervix dilated 4-5 cm, contractions usually reach 4-1-1 or 5-1-1 pattern. At this point, shifting from early to active labor and dilation usually speeds up and contractions become more painful. Most expectant couples go to hospital at this phase.

Getting Through Active Phase – can manage this phase and cope better after if following true:

  • Allowed to labor in environment that fosters privacy, preserves modesty and minimizes disturbances. When undisturbed, can focus inward and find spontaneous rituals to help get you through contractions
  • Have support people who unconditionally accept your coping style and assist you whenever needed. In this phase, you become serious, quiet and preoccupied. During contractions, your require your partner and others to focus on you – they shouldn’t talk among themselves or to you
  • You have freedom to move and seek comfort in whatever ways you feel helpful

Traveling to birth site during active labor creates a major disturbance in your coping strategy. See Ch 11 for comfort techniques in noisy, busy environment before labor so you can find a coping technique for the ride and can return to ideal focused state once settle in room.

Partners: help her cope with slow dancing, walking with her, stroking her, moaning with her, matching her rhythm by swaying or by moving your hand or head, keeping eye contact with her, or counting her breaths. See Appendix B for suggestions on ways to help partner cope.

Arriving at Hospital/Birth Center: Report info in Early Labor Record (pg 175), make sure have bag, birth plan and any last min items (towel if you bags of water are leaking). Do not drive yourself, have partner drive. Ride to birthplace may be challenging and uncomfortable. Focus your breathing on something in vehicle to give you a rhythm to follow. Go to triage. If think bags of water has broken, nurse may give you sterile speculum exam to obtain a sample of amniotic fluid for diagnosis. If they decide you are in early labor, you may be asked to leave until labor pattern changes. Should follow this advice to keep busy at home. Labor is likely to progress min environment that feels safe, secure and familiar. If don’t want to return home, take a walk nearby or go to cafeteria. When admitted, will take medical history, get urine/blood samples, check baby’s heart rate and progress. Change into hospital gown or bring your own and get an ID bracelet. May have IV catheter inserted at this time. Nurse begins monitoring contractions and baby’s heart rate for 20-30 min, typically with external electronic fetal monitor or possible with hand-held Doppler.

IV Fluids in Normal Labor – in some hospitals, its routine to insert IV catheter in all laboring women shortly after they’re admitted. They carry a few mild risks. See PCNGuide. It can limit mobility in labor because you’re connected to a wheeled pole that holds bag of fluids. Ask if it’s routine at prenatal appointment. If routine, ask whether can have a Hep Lock (Heparin Lock) which involves inserting an IV catheter, but doesn’t require hooking it to an IV bag until IV fluids are needed.

Working with Your Labor – after labor nurse finishes assessing you make yourself as comfortable as possible. Continue/begin spontaneous ritual. Use comfort measures as appropriate, such as placing pressure and cold packs on back or hot compresses on lower abdomen and groin. Empty bladder every hour or so; a full bladder increases discomfort and can slow labor. Make sure to keep self-hydrated by sipping water after a few contractions or by sucking popsicle/ice chips.

Try not to lie in bed throughout labor – may increase pain and slow labor progress. Unless need to rest on contractions are coming so fast you can’t move, try to periodically move about in bed or take advantage of gravity by standing and walking in you room and in the hall.

Continue slow breathing for as long as it helps you relax. Switch to light breathing or one of adaptations if breathing begins to feel labored or If can’t keep breathing rate slow, or if can’t maintain your rhythm. Light breathing may be better suited for demanding contractions than slow breathing, just as short, quick breaths are better suited for demanding physical exercise than long, deep breaths are. By tuning into contractions, you can adapt your breathing rhythm as needed.

Monitoring You and Baby during Normal Labor – as long as labor is normal and baby is doing well, you don’t need medical procedures. PCNGuide has description of techniques if monitoring indicates a complication has developed in labor

  • Monitoring You – regularly checks blood pressure, temp, pulse, urine output, fluid intake, activity and emotional state. Vaginal exams periodically to determine effacement and dilation of cervix and station, presentation and position of baby. recorded on chart which shows labor progress. Observes frequency and intensity of contractions by hand or electronic monitor.
  • Monitoring baby with fetal heart rate monitoring – many things influence baby’s heart rate during labor: your contractions, baby’s activity (fetal movements), medications, body temp, position and other factors. Normal range is 120-160 bpm. Varies in response to changes in amount of oxygen that’s available. If baby is handling labor well, he has a reactive heart rate, which naturally slows down to compensate for temporary reductions in oxygen during a contraction and speeds up between contractions. Indicates he’s compensating well to normal variations in oxygen flow.
    • Depending on maturity/health of baby, ability to compensate varies. If lack of oxygen continues over time, his reserves may become exhausted. May not be able to compensate and might become distressed (also known as nonreassuring fetal heart rate or fetal intolerance of labor). Close observation and further testing help identify those who aren’t tolerating well and may need immediate medical intervention
    • Baby’s heart rate can be monitored by auscultation or by electronic fetal monitoring (EFM). Auscultation – listens during and between contractions with a Doppler, or hand held ultrasound stethoscope. May place a hand on abdomen to feel contractions, then count heartbeats, nothing whether speed up or slow down.
    • Two types of EFM – commonly used external EFM uses belts to place 2 sensor son abdomen and rarely used internal EFM uses 2 sensors placed inside uterus (only used if external isn’t picking up signals). 1 sensor picks up baby’s heartbeat, other picks up changes in uterine tone or pressure. Sensors connected to video screens in room or at nurses station. 2 graphs showing baby’s heart rate and intensity of contractions. All date stored electronically
  1. Studies that compare auscultation and EFM (continuous or intermittent) report each method has similar outcomes. Most caregivers prefer EFM because it monitors many women at same time and frees them from doing it by hand; also saves paper. EFM may limit contact with nurse and may keep you in bed. Auscultation may feel more personal and may work better with your coping strategy.

Caregivers prefer EFM for high risk. If you are healthy and low-risk, shouldn’t have to be monitored continuously. 20 min of EFM when first admitted followed by 15 min each hour is accepted protocol as long as baby’s heart rate remains normal. Also endorsed protocol for 1 minute during and after contraction every 15-30 min in 1st stage and every 5-15 min during 2nd stage.

Check whether hospital uses EFM and if it’s routine for all women; if so, check whether wireless or telemetry is available.

Evaluating Your Amniotic Fluid – When membranes rupture, appearance of amniotic fluid can indicate baby’s condition. Normal fluid is clear and has slightly fleshy odor. If has strong odor of old fish, may have infection. If green/dark, baby has expelled meconium from bowels, which may indicate she’s stresses; occurs in 20% of labors. Caregiver will observe baby’s heart rate frequently to assess well being.

When researching caregiver and birthplace, ask about protocol for treating a newborn who has expelled meconium during labor. Many suction baby’s nose, mouth and trachea when head is born and before first breath. Belief is that suctioning prevents baby from inhaling meconium thereby preventing breathing problems or a rare type of pneumonia called meconium aspiration syndrome. Research hasn’t found that aggressive suctioning prevents meconium aspiration syndrome. Instead, suctioning seems to cause abrasions in membranes of baby’s nose and mouth.


Third Phase: Transition – From 1st to 2nd stage of labor. Cervix is reaching complete dilating and baby is beginning to descend into birth canal. Contractions are longer (90 sec – 2 min) and closer together (2-3 min apart). Labor still technically in 1st stage but showing signs of 2nd stage. Emotions and physical sensations intense. Feel tired, restless, irritable and consumed by efforts to cope. May lose ritual .Body begins secreting high levels of adrenaline, which may lead to a fight or flight response (temp fear, nausea, vomiting, agitation, hot flashes, chills, and trembling) but hormone is beneficial because you become more alert and have renewed strength and energy just when you need to push out baby.

Involuntary spasms (precursors of bearing down) may stimulate diaphragm, causing you to hiccup, grunt or belch. May find self holding breath and straining or grunting during each contraction; this reaction is urge to push. Back or thighs may ache. Increased pressure may cause legs or even whole body to tremble and it may also cause heavy vaginal discharge of bloody mucus. Despite intensity and pain on contractions during transition, you may doze between contractions, as if body is conserving energy for managing them.

Lasts less than an hour (usually bw 5 and 20 contractions).

Getting Through Transition – Become focused only on labor; nothing else matters. Intensity of labor may frighten you. May feel it will last forever and you can’t cope much longer. Encouragement and support from partner, doula and caregivers essential.

Responses to transition (fear, nausea, trembling, despair, crying, dependence on others and difficulty maintaining ritual) are natural and unique to your labor. Goal at this time isn’t necessarily to remain calm, still and relaxed during contractions. Instead, aim to maintain a coping ritual, with the help of your partner or doula if necessary. You may rhythmically sway from side to side, tap your fingers or feet, stroke your belly, or rock back and forth. Or you may want your partner to stroke you or murmur rhythmically in your ear. You may find that moaning during contractions helps release tension. Or you may remain still and quiet during your contractions. Between contractions, try to relax and rest, if only for a few seconds.

Might like partner to hold you close or you might not want to be touched. May want partner to provide only eye contact and verbal encouragement. You may find hot, damp towels on lower abdomen soothing. If sweating, partner can fan you or wipe your face, neck and chest with a cool, damp cloth. If able to doze between contractions, partner can help you focus and begin breathing rhythmically as soon as the next contraction begins so the intensity doesn’t overwhelm you.

If you recognize you’re in transition, you can cope better with this phase. If you think cervix is only 5/6 cm dilated, you may become discouraged and worry that you have hours of demanding contractions to go. When you and partner recognize signs of transition, progress can hearten you. Can see that challenges of transition lead to 2nd stage of labor, when mental state will improve as the birth of baby draws closer.

Pain Medications during Transition- Can get through transition without pain medications, especially if you have the following: a desire for a non-medicated labor, knowledge of what to expect and how to cope in this phase, good support and a labor that’s progressing normally. Some women, however, find that transition is too much for them to handle; the pain is too great, they’re exhausted or they lose control or panic. If this happens to you, pain medications are usually an option.

While there’s no shame in wanting medical help during this phase, don’t take pain medications just because you fear that the intensity of labor is abnormal. Remember that strong emotional responses and challenging contractions are completely normal. Before deciding on pain medications, first find out how far your labor has progressed.   Since it lasts typically an hour , you may decide pain medications not necessary.

Urge to Push in Transition – May develop an urge to push, which may feel as though you need to have a bowel movement (because baby’s head is pressing against your rectum). May also start catching your breath and grunting (making pushing sounds). When you first feel an urge to push, let nurse or caregiver know. Try not to push until she can assist you. If your cervix isn’t completely dilated or is almost dilated except for one thickened area (a “lip” of cervix), you may be asked not to push.

While its okay to bear down in labor, doing so isn’t worthwhile before cervix is fully dilated. Pushing too early may cause cervix to swell and slow labor progress. May find it difficult and uncomfortable to keep from pushing when urge is strong. If asked not to push, try blowing or panting to keep from holding your breath. May be able to relieve a premature urge to push by changing positions, such as to hands and knees, side lying or other positions that neutralize effects of gravity.

Note to Partners- Transition is probably the most difficult challenge you’ll see your laboring partner experience. Her pain and discouragement may trouble you, but remember that her intense sensations and emotions are normal. She and your baby are all right. Nonetheless, you both need reassurance and encouragement from your doula, nurse or caregiver at this time.

Your job during this phase is simple: help her keep a rhythm. Don’t mistake rhythmic moans, groans or other intense sounds for cries of agony; if they rhythmic, she’s coping.

If she beings catching her breath and grunting, she may have an urge to push. Call caregiver – she may be ready to push.

Take Charge Routine for Partners- Use when laboring partner is in despair, weeping, crying out for help, or ready to give up. Also use when she’s overwhelmed with pain, cant relax and cant regain her coping rhythm/ritual

  • Keep composure. Touch should be firm and confident. Voice should be calm and reassuring. Give simple, concise directions. Don’t ask her questions.
  • Stay close to her. Remain by her side with your face near hers
  • Anchor her. Hold her hand or cradle her in your arms
  • Make eye contact. Tell her to open her eyes and look at your or at your hand. This helps her focus
  • Give her a rhythm to follow with her breathing; move your hand or head to set a pace for her to follow (1 breath per second or 2). If she loses rhythm, say “Breathe with me; follow my hand. That’s the way, just like that” nod your head in time with her breathing to reinforce the rhythm
  • Encourage her. Acknowledge the labor is difficult, but not impossible. Remind her that she’s made a lot of progress and that her baby will be here soon. Tell her to look at you the moment she feels the next contraction so you can help her. Immediately set a rhythm for her to follow
  • Repeat yourself. She might not be able to do what you tell her for more than a few seconds, but repeating your instructions will continue to help her.


Short, Fast Labor – 6 hours or less and leads to a precipitate birth. Contractions may have started only 3-4 min apart, lasted a min each and were so intense that a woman couldn’t cope. Rare among 1st time moms, but a few may have labors as short as 3 hours. Much more common for moms who’ve given birth before. Call caregiver if this happens.

Early labor may have passed so fast you have no time to prepare psychologically. First noticeable contractions may be long and painful. May quickly lose faith in ability to handle rest of labor.

What you can do – try not to tense up during contractions and use slow breathing. If slow breathing doesn’t help, use light breathing. Moan or bellow rhythmically. Consent to vaginal exam before making decision about pain medication; cervix may have already dilated to 8-10 cm. anesthesia may be unnecessary or may take effect too late to provide relief before baby’s birth. Rely on partner, doula and staff to help you cope and to reassure you baby’s doing well.

May have urge to push before staff is ready. If so, like on side and pant or gently bear down. Doing so gives your birth canal and perineum more time to stretch, decreasing likelihood of vaginal tearing.

May need to discuss sequence of events with caregiver/partner after so you can process birth and come to terms with it

*Less than 1/1000 babies born on way to hospital/birth center.


Second Stage of Labor: Birth of Your Baby – As soon as cervix has dilated completely, you’re in 2nd stage. Baby gradually leaves uterus, rotates within pelvis, descends through vagina and is born. Typically lasts 15 min- more than 3 hours. First time mom average time is 90 min-2 hours. Second stage faster than previous birth for mom who has given birth before.

Signs of 2nd stage: pain of contractions lessen and interval between them increases. Calm down and can think clear again. Experience renewed energy and become optimistic and aware of those around you.

Urge to Push: most significant sign of 2nd stage. Combination of forceful sensations and reflex (involuntary) actions caused by pressure of baby in vagina during contractions around the time your cervix is fully dilated. Occurs several times within a contraction and indicates that uterine muscles are pushing baby downward. When you have urge to push, you experience a compelling need to grunt or hold your breath and bear down. May feel like a strong urge to have a bowel movement.

When you have urge to push immediately or after a brief rest depends on degree and speed of baby’s descent, her station and position within your pelvis, your body position and other factors. Ask caregiver to check dilation of cervix. If its fully dilated, you can begin pushing when you feel urge. If its not, but is very ripe and effaced, you may be asked to bear down only enough to satisfy urge. If cervix isn’t completely dilated, may be asked not to push. Because urge is involuntary, resisting it may postpone pushing, but only temporarily.

Responding to urge is one of most satisfying aspects of birth experience for many women; some women even orgasm when giving birth. Others find pushing painful and exhausting, while many are simply relieved to start pushing.

Some women don’t feel a strong urge to push in this stage. Usually, time or changing to upright position can strengthen urge. If you receive pain medication, especially epidural, might not feel urge or it might be a vague sensation.

3 Key Concepts for 2nd stage: don’t rush, push when you have urge, use different positions

  • Don’t Rush – bear down or push spontaneously as urge demands and allow time for vagina to stretch open gradually, which decreases likelihood of vaginal bruising or tearing. Don’t use prolonged pushing. Use your energy more efficiently if don’t rush. By holding breath and bearing down only when can’t resist urge, you’re working with uterus and not wasting effort.
  • Push When You Have Urge – different ways to push under certain circumstances
    • Expulsion Breathing and Spontaneous Bearing Down – use when you have urge to push. You naturally bear down or strain for 5-6 sec and take several breaths between efforts. Makes more oxygen available to baby than if you hold breath and bear down for as long as possible. Allows vagina to stretch gradually, reducing risk of tearing
    • Delayed Pushing (passive descent or laboring down with an epidural) – when have epidural, don’t usually have urge to push until baby is close to being born. Uterus continues pushing baby down and into a good position, but you don’t feel need to push in response. With delayed pushing, try to rest and refrain from pushing until baby’s head can be seen at vaginal opening (Crowning) or until you feel urge to push. This way, if baby is occiput posterior or his head is tilted (either a likely occurrence if you have an epidural), you avoid forcing him too deeply into your pelvis before he can reposition himself. Delayed pushing usually means a longer 2nd stage, but as long as baby is doing well, research shows waiting an hour or 2 before pushing with an epidural gives your baby time to gradually reposition until his head is visible. DP is much less tiring for you. It greatly improves chances of a spontaneous vaginal birth (one that doesn’t require vacuum or forceps) and greatly decreases chances of needing cesarean. Caregiver will prob tell you when and how long to push.
    • Directed Pushing – used if you cant feel contractions and delayed pushing isn’t an option of if spontaneous pushing isn’t effective. Caregiver will tell you when, how long and how hard to push
    • Prolonged Pushing – differs from directed pushing in the length of time you’re expected to hold your breath and bear down (10 sec on more, instead of 5-7 sec). not long ago, standard care required women to push as long as hard as they could in order to push the baby out as quickly as possible. Research shows forceful pushing isn’t necessary and may sometimes cause problems that are less likely to occur with spontaneous bearing down, including exhaustion of the mother, overstretching of pelvic ligaments and muscles, possible perineal tears, later urinary incontinence, concerns with baby’s HR and failure of baby to rotate/descend.   Prolonged pushing, esp in supine position can also decrease oxygen to baby and may cause BP to drop, both of which can increase need for faster delivery w episiotomy. 2nd stage may last slightly longer with spontaneous or directed pushing but babies usually remain in good condition throughout process. Best reserved for women w inadequate progress in 2nd stage, even after trying different positions, or for women whose babies are already in distress and may require interventions (such as forceps, vacuum or cesarean) unless they’re pushed out quickly. Discuss with caregiver before due date and include preferences regarding the practice in your birth plan and discuss with staff when you arrive at hospital.
  • Use Different Positions – as long as labor is progressing well in 2nd stage and baby is fine, use whatever positions seem most comfortable to you. If caregiver concerned about progress of baby’s well being, they might suggest a different position. Even if its uncomfortable, it may correct the problem and avoid the need for further interventions. If 2nd stage is rapid, try a position that neutralizes effects of gravity, such as side-lying to help slow labor. If progress is prolonged, try positions that take advantage of gravity. Change positions every 20-30 min. some caregivers comfortable with woman birthing in any position, but most prefer a position they are used to (usually semi-sitting on back). If they only deliver in 1 position, plan to use several other positions during 2nd stage to aid labor progress. If pushing is prolonged, ask whether a change in position might help. If received pain medications, mobility and choice of positions may be limited.


Phases of the 2nd Stage:

3 phases: resting, descent and crowning and birth phase. They share characteristics with the 3 phases of the 1st stage. High spirits, little pain, and slow progress characterize the first phases of both stages. Intense contractions, total mental absorption and steady progress characterize 2nd phases. Lastly, intense sensations and confusion characterize 3rd phases.

  • Resting – after intensity of transition, uterus may stop contracting for 10-20 min, allowing you to rest, clear your head, recoup your energy and grow excited for your baby’s arrival. This is normal and may occur because baby’s head has slipped into birth canal, causing uterus, which had been stretched tightly around baby, to slacken. Your uterus needs a few min to adjust to the change, but once it begins to tighten around the rest of your baby’s body, strong contractions resume and your urge to push becomes powerful. This phase doesn’t occur in all labors. If baby is low in pelvis when 2nd stage begins, or if she’s descending rapidly, your body may skip it or make it brief. Even if this phase doesn’t offer much rest, your probably still become clearheaded and emotionally recharged as you move into 2nd If lasts longer than 15-20 min, caregiver may ask you to try a position that enhances effects of gravity to encourage an urge to push. Or he may direct your pushing, asking you to hold your breath and bear down even if you don’t have an urge to push. Directed pushing may frustrate both you and caregiver, as labor rarely progresses without urge to push. However, directed pushing may be worth trying before medical intervention such as Pitocin.
  • Descent – baby descends into birth canal and likely completes rotation to the occiput anterior position. At this time, powerful contractions make your urge to push irresistible. May find bearing down thrilling and rewarding because you can feel progress. Or you may feel alarmed by the full, bulging, stretching feeling in your perineum. May tense pelvic floor and “hold back” afraid to let baby descend. When pushing, its important to relax pelvic floor and bulge your perineum. Prenatal perineal massage is excellent prep for 2nd stage because it teaches you to relax perineum while its being stretched. Your partner can help you during this phase by reminding you to relax, open up, bulge your bottom, or ease your baby out. This type of encouragement is usually more helpful than hearing “push, push, push”. May need several contractions before you can push effectively. If have trouble trying to figure out where to direct pushing, ask caregiver to perform perineal massage or to use warm compress to give you a location. Using a mirror to watch when push may also help you figure out how to push more effectively. Clenching your jaw and clamping lips together are signs that your tensing muscles in the vagina. By relaxing face/mouth, you may be able to relax vagina. If you let yourself release tension and push despite the pain, you’ll find that pushing feels better than holding back. As this phase progresses, the joy and anticipation you feel give you renewed strength. Perineum begins to bulge, labia part and vagina opens as baby’s head descends each time you bear down. Between pushes, your vagina partially closes and baby’s head retreats. With another contraction, your baby moves farther down, his head becomes clearly visible, and you may be able to see it in a mirror. You may want to reach down and touch his soft, wrinkled head. The normal squeezing of baby’s head by vagina causes scalp to wrinkle until his head moves further down birth canal.
  • Crowning and Birth Phase – begins when baby’s head no longer retreats from vaginal opening between pushes and ends when body completely exits yours. During this phase, vaginal opening stretches to its max, which likely causes a stinging, burning sensation called rim of fire. To reduce risk of vaginal tear or rapid birth, you may need to stop pushing to let vagina and perineum gradually stretch around baby’s head as it emerges. Depending on speed of birth, caregiver may direct you to push only moderately or to push only between contractions. He may ask you not to push at all. Caregiver may support perineum with warm compresses to prevent baby’s head from coming too rapidly and to help your perineum stretch gradually. Research finds clear problems with routine episiotomy to enlarge vaginal opening; nonetheless, some caregivers commonly perform.
    • Protecting Perineum from Large Tear or Episiotomy – many women wear about damaging vaginal tissues or fear that episiotomy will be needed. Research actions to take during pregnancy and labor to protect perineum:
      • Choose caregiver who prefers to avoid episiotomies and has low rate (less than 20%)
      • Good nutrition promotes healthy tissues, so eat well during pregnancy
      • Perform perineal massage regularly for a few weeks before birth
      • When push, use spontaneous bearing down or bear down for only 5-7 sec each time
      • During birth, use positions that put minimal strain on perineum, such as side-lying, kneeling or hands and knees
      • During birth, pant lightly and listen to caregivers directions to avoid pushing while baby’s head and shoulders are born

Holding back during descent phase – may tense pelvic floor in response to stretching sensations you feel when baby’s head is in birth canal. This is normal and usually passes quickly once you feel baby descending. To stop self form holding back, try telling yourself to let go. If successful, pain decreases and you wont have a desire to hold back again. However, you may have trouble letting go for 1 or more of the following reasons

  • Pressure of baby’s head within vagina alarms you and you find it difficult to give in to that pressure – remind self that holding back tends to increase pain and slow progress. You’ll feel much better after letting go. Listen to partner, doula and caregiver when they encourage you to let go. Try sitting on toilet for a few contraction. May help perineal muscles release naturally because its associated with letting go. Warm compresses on perineum can help because moist heat promotes relaxation and relieves stretching sensation. Can also alleviate perineal pain and reduces risks of tearing and urinary incontinence. Also helps reassure you that they will help guide baby out. Discuss with caregiver before due date and include in birth plan. Some caregivers use fingers to stretch woman’s perineum; research finds that this is very painful and no more effective for enlarging vaginal outlet and preventing a tear than use of warm compresses or no treatment.
  • You’re uncomfortable with having people stare at your perineum – they are watching progress of baby, but ask to be covered as much as possible. Warm compresses can conceal perineum
  • You fear you’ll have a bowel movement while pushing – because baby presses on rectum while descending. Caregiver interprets this as progress. May not even be aware of it because caregiver wipes away and removes stool discreetly (perhaps with a warm compress). Sitting on toilet for a few contractions may help you dispel this fear and relax.
  • If you’ve been sexually abused, you fear that the sensation of your baby in your vagina will remind you of your abuse – tell yourself that you’re pushing your pain out of your body as you push out your baby. its important to separate your abuse from the birth of your child. Pg 59

Protecting Your Perineum form a Large tear or an Episiotomy: choose a caregiver who prefers to avoid episiotomies and has a low rate (less than 20%); good nutrition promotes healthy tissues, so eat well during pregnancy; perform perineal massage regularly for a few weeks before birth; when you push, bear down for only 5-7 seconds each time; use positions that put minimal strain on perineum – side lying, kneeling, hands and knees; pant lightly and listen to caregivers directions to avoid pushing while baby’s head and shoulders are being born.

Your Baby’s Birth – 2nd stage of labor ends with baby’s birth. If baby’s position is head down (occiput anterior or posterior), first the crown of his head emerges, followed by his brow and face. His head appears bluish-gray and is soaking wet. After head is out, it rotates to the side to allow shoulders to slip more easily through pelvis. 1 shoulder emerges, followed by rest of body, perhaps rather quickly. You or partner may want to help catch baby.

baby’s body may appear bluish at first and may be streaked with blood, mucus, and vernix caseosa.   With baby’s first breath, skin color quickly becomes normal.

Birthplace policy may require baby to have nose and mouth suctioned after birth. Studies find that healthy vigorous newborns don’t benefit from this procedure. Discuss policy with caregiver and include in birth plan.

While you await delivery of placenta, baby may be dried and immediately placed on abdomen or in arms. Umbilical cord is typically clamped and cut around this time; however, there are long-term advantages for baby if cord clamping is delayed. Custom in some hospitals is to assess newborns well being while in baby warmer in birthing room. Research shows newborns are warmer and begin breastfeeding earlier when kept skin to skin with mothers. Most women report greater satisfaction when they have their babies immediately with them after birth. Before birth, find hospitals custom on use of baby warmers, in birth plan, express preferences to hold baby immediately after birth (if he’s doing well). Nurse or caregiver can assess baby while in your arms or at a later time, after he’s at least had 30 min of skin to skin with you.

Your Reactions After the Birth – first response may be “its over – no more contractions” and may feel grateful and relieved baby is out of body. These may overtake interest in baby especially if you’ve had long, tiring labor.

May temporarily forget about labor and birth the moment you hear/see newborn. May be surprised/awed by baby’s appearance.   May hold breath in suspense until you hear her breathe, smiling with relief and joy when you hear first hearty cry. If caregiver needs to inspect perineum and check for separation of placenta, may find procedures painful and distracting and may be unable to focus completely on baby. After caregiver ahs finished, can return total attention to baby.

Note to Partners: requires great physical effort by partner, even if she had an epidural. To assist her, help her change positions and physically support her as needed. Encourage her to relax her pelvic floor as she pushes. Cheer her on as she pushes, but don’t override caregiver’s directions.

When baby is born, you may experience happiness, exhaustion, relief, wonder, joy and love for partner and baby – all at the same time.. Baby becomes focus of your attention..

If baby cant remain in partners arms immediately after birth (because of concerns for baby’s wellbeing or because staff want to check him in baby warmer), stay with baby so you can report what you see being done to partner. Talk to baby since baby knows your voice and hearing it calms them.

Third Stage of Labor: Delivery of Placenta– lasting between 10 and 30 minutes, 3rd stage is shorter and less painful than earlier stages. Begins with birth of baby and ends when placenta is delivered.

What to Expect– after baby is born, contractions stop briefly, then resume with the purpose of separating the placenta from your uterine wall. Typically less intense than before birth, but may still need relaxation techniques and rhythmic breathing. May be so engrossed with baby that you don’t notice contractions. Caregiver may direct you to give a few small pushes to deliver placenta. May appreciate seeing placenta after delivery as it’s an amazing organ that allowed your baby to thrive in your womb.

Newborn Assessment with Apgar Score– within 1 minute after birth and again at 5 min, caregiver evaluates baby’s well being. As soon as baby is breathing and dried off, caregiver considers 5 factors and gives a score of 0 to 2 points for each. Score of 7-10 indicates baby is in good condition. Score of 6 or less means baby needs additional medical attention and observation.

Can be done while you hold baby. Babies rarely receive a 1- on first score (most babies hands and feet are bluish for a while after birth). If score 6 or less, may have to go to baby warmer or oxygen. 2nd score is usually higher than 1st score, indicating improvement with time or medical assistance.

Helps determine if baby needs immediate medical attention, but can’t predict baby’s overall health or long-term well-being. More thorough exam will be done within 24 hours of birth to more accurately assess baby’s condition.

Apgar Score

  • HR – Absent (0); <100 BPM (1); >100 BPM (2)
  • Respiratory effort– Absent (0); Slow, irregular (1); Good, crying (2)
  • Muscle tone– Limp (0); Arms and legs flexed (1); Active movement (2)
  • Reflex irritability (reaction to something placed in nose) – No response (0); Grimace (2); Sneezing, coughing, pulling away (2)
  • Skin Color– Bluish-gray, pale all over (0); Normal skin color, except for bluish hands and feet (1); Normal color all over (2)


Clamping and Cutting Umbilical Cord– soon after birth, baby’s umbilical cord is clamped and cut with scissors; partner may cut cord

Timing of cord clamping and cutting affects baby’s blood volume. Before birth, baby’s blood circulates via the cord to and from the placenta, allowing the exchange of oxygen, nutrients and other substances. At birth, 1/3 or more of baby’s blood is in placenta, but over the first few minutes, it transfers to your baby. The blood vessels in the cord are gradually compressed by a substance called Wharton’s jelly, which expands when cord is exposed to air. If cord is clamped immediately (which is still common practice), baby doesn’t receive a large portion of the blood from the placenta. Delaying clamping until cord stops pulsating allows baby to receive as much blood as possible. Some blood remains in placenta after pulsation stops.

For years, OBs taught that placenta blood is “extra” and if it got to baby, it could cause jaundice. This belief has been disproved. Delayed clamping benefits baby by helping increase blood levels of iron and reduce anemia from 2-6 months. May also hasten separation and delivery of placenta by decreasing its size.

To achieve optimal blood volume, baby is placed on mother’s abdomen (level with the placenta) until cord stops pulsating. Then it is clamped and cut. Holding baby high above or low below the mother may alter the speed of transfer of blood that passes between placenta and baby, but placement on mother’s abdomen is the most physiologic and seems appropriate under most circumstances.

In challenging situations, baby may benefit even more from delayed cord clamping. Some hospital wait a few minutes to clamp and cut cord after a cesarean. For a baby who needs medical attention or resuscitation, these procedures can often be carried out with the cord intact so the baby, while remaining next to his mother, continues to benefit from oxygenated blood transferring to him. Discuss preference with caregiver and put in birth plan.

Collection and Storage of Umbilical Cord Blood– blood in umbilical cord is rich source of stem cells, which generate and continually renew supplies of red cells, platelets and white cells. Stem cells make it possible for a person to use oxygen, clot blood, and fight infection. Those found in umbilical cord are easier to match to another person’s tissue than mature stem cells found in bone marrow. They can be used to successfully treat people with disease such as immune deficiencies, severe inherited anemia and childhood leukemia and other cancers. They are also used in the search for cures of these diseases.

Some parents consider having babies’ cord blood collected and stored. It’s done after baby’s cord is cut and is accomplished most successfully within 10 minutes of birth, which means that baby still benefits from delayed cord cutting. After collection, stem cells are separated from blood in a lab and stored either in a blood bank for use by the public or in a private storage facility for later use, if needed, by the child or her family.

AAP encourages parents to donate cord blood to public and cautions against using private cord banks because more conditions that they may treat (such as precancerous changes and genetic abnormalities) already exist in baby’s cord blood, which means that her stored cord blood stem cells won’t treat the condition if she develops it later. Its also expensive. Public donated blood is tested for disease and genetic abnormalities before being approved for use. Do research before due date.

Emotions During Labor Chart – How Partner Can Help

1st stage: (2-24 hrs)

  • Early Labor: waiting and wondering – excited, anxious, may overreact. Time contractions. Encourage mom to relax, eat, drink and rest. Use distracting activities. Help her feel safe. Dilation 1; station 1
  • Contractions 4-5 min apart: can no longer be distracted; can’t walk/talk through contractions. Watch for her rhythm and reinforce it. Begin planned ritual: relax, breathe and focus. Dilation 1-2; station 1
  • Active labor: quiet, withdrawn, discouraged, as painful contractions require full attention. Feel need to be move and free to do whatever helps you cope. Follow her lead and move in close. Try bath or shower. Reinforce or adapt ritual. Dilation 4; station 2
  • Transition (peak of pain): may be overwhelmed. Panicky, angry and impatient. Remind her that intensity means labor will progress more quickly. Encourage her. Use take charge routine to help her regain rhythm. Develop new ritual. Dilation: 8; station 1

2nd stage: ½ – 3+ hrs

  • “Lull”: renewed energy, mentally clear; optimistic. Reassure her that lull is normal. Match her mood, discuss spontaneous pushing. Don’t rush. Dilation 9; station 1
  • Descent: may be elated or alarmed by pressure in vagina. May hold back; discouraged if progress is slow. Encourages release of pelvic floor. Assist w pushing positions. Dilation 10 station 0

3rd stage: 10-45 min

  • Crowning: excited. Feel rim of fire. Desire to get it over w. fear of tearing. Encourage her to listen to caregiver. Dilation 10. Station 0.


Fourth Stage of Labor: Recovery– begins just after placenta is delivered and lasts until your condition is stable, typically an hour or 2 after birth. This stage may last longer if you had anesthesia, if you labor was difficult or prolonged, or if you had a cesarean birth.

After delivering placenta, caregiver checks perineum and birth canal for bleeding. If had vaginal tear or episiotomy, tissues are stitched to speed healing (lasts <30 min). Unless given anesthesia in labor, will receive a local anesthetic by injection before perineum is stitched. Should be painless, but injection may sting and may need to use rhythmic breathing. If perineum is intact or have shallow tear, don’t need stitches, but area may become swollen or bruised. Whether have stitches or not, will appreciate an ice pack placed on perineum to reduce any swelling and relieve discomfort.

After birth, uterus begins process of involution (returning to nonpregnant size); it continues to contract, which close blood vessels where placenta was implanted in order to prevent excessive blood loss and to prompt the shedding of the uterine lining that build up during pregnancy. You pass lochia, the heavy red discharge made of the extra blood and fluid that supported your pregnancy and the uterine lining that sustained your baby. Maternity pad is necessary.

Once placenta is delivered, caregiver checks uterus frequently to make sure it remains firm. If uterus is relaxed, she massages it firmly, causing it to contract and preventing excessive blood loss. Uterine (or fundal) massage can be painful, and you may want to do it yourself to control the amount of pressure and perhaps reduce pain to a tolerable level.

How to Massage Uterus – empty bladder. Lie on back and check uterus by pressing on area below navel. If uterus feels as firm as a grapefruit, you don’t need to massage it. If cant feel uterus, it has relaxed and softened. With one hand slightly cupped, massage lower abdomen firmly with small circular movements until you feel you uterus contract and become firm. This action may be painful. If can’t make uterus contract, tell caregiver. Because uterus can bleed excessively if it’s not firm, don’t skip this on the first couple days after birth. Afterward, you may periodically check to see if it needs massage.

Contractions during involution may be painful, especially if have given birth before. Although these afterpains are common and aren’t nearly as intense as labor contractions, you may need to use slow breathing to help manage.

After baby’s birth, legs may tremble, which is normal. Warm blanket may reduce trembling. May have missed meals during labor, so eat and drink to satisfy hunger and thirst.

This stage gives you a chance to get to know your baby without disturbances and to let him nuzzle at your breast. Most babies are ready to suckle within 20-60 minutes after birth.

Baby’s Hormones in 4th Stage– baby’s stress hormones (catecholamines) after birth stimulate her adaptation to life outside womb. They absorb fluid in her lungs so she can breathe easily, jump start her ability to regulate her temperature and make her alert and heighten her reflexes for the first few hours, during which time she begins feeding, exploring her world and seeing you for the first time.

During labor, baby produces beta-endorphins; after birth, she produces prolactin. She also begins producing oxytocin in synchrony with you. These 3 hormones help strengthen the bond between you, increase her interest in breastfeeding, and stimulate you to care for her. Other people can produce oxytocin too – to a lesser degree-by holding baby skin to skin, keeping eye contact and caring for her. By snuggling with baby after birth, skin-to-skin allows for mutual regulation of hormones as you adjust to new life together.

Entering Parenthood– this new role, along with other postpartum changes, may overwhelm you or bewilder you.

Enjoy baby’s first hours of awake time. He’s likely alert, calm and bright-eyed as he begins observing and sensing new sounds, smells, sights, touches and tastes. If light isn’t too bright, he’ll stare, particularly at your face (dim lights if too bright). These moments are time for falling in love with each other. Include partner.

Family-centered and baby-friendly hospitals encourage parents and babies to stay together as much as possible, unless problems develop. Caregiver performs routine observations or procedures while in mom’s arms. Check hospital – if caregivers routinely send healthy newborns to nursery, ask to issue an order to delay or bypass your baby’s admission.

A few hours after birth, baby will fall into a deep sleep. Someone who’s alert should periodically observe baby’s vital signs and yours, including skin color, pulse, respiration, blood pressure and temperature. In the hospital, nurse does this job. At home birth, midwife or birth assistant takes on job before passing on to rested friend or relative.

Processing Birth Experience– it isn’t over until you’ve had a chance to think about and understand it. Will become one of most vivid and poignant memories. Compare and contrast your feelings, thoughts and impressions with those who attended birth, getting answer to any question and look at photos. Write story or draw or paint a picture of it – each is a great way to preserve the special memory for you and your child.

Processing it may takes weeks, months or even years. If it was particularly difficult or disappointing, processing it may take longer. Dealing with a difficult birth may also bring up strong, disturbing feelings. If this is the case for you, talk with your caregiver, doula, childbirth educator or a counselor knowledgeable about childbirth.

Protecting Your Perineum form a Large tear or an Episiotomy: choose a caregiver who prefers to avoid episiotomies and has a low rate (less than 20%); good nutrition promotes healthy tissues, so eat well during pregnancy; perform perineal massage regularly for a few weeks before birth; when you push, bear down for only 5-7 seconds each time; use positions that put minimal strain on perineum – side lying, kneeling, hands and knees; pant lightly and listen to caregivers directions to avoid pushing while baby’s head and shoulders are being born.

Rhythms in first stage of labor: in vast majority of hospital birth, progress is assessed by vaginal examination. This normative mindset is so powerful that few midwives have had opportunity to observe labors where none have occurred. For millions of years, childbirth was not obsessed with labor duration. Gaskin discovered word “pasmo”; labor stopped and everybody went home until it started again.

Friedman’s legacy: Emanuel Friedman was first to graphically record cervical dilation over time. His work in mid 1950s showed understanding of average lengths of labor for primigravid and multigravida women. In 70s, Philpott and Castle gave guidance for what to do if labors were slow. Alert line at 1 cm/hr, transfer line at 2 hours behind alert line and action line 2 hours behind that. O’Driscoll used in his protocol for ‘active management of labor’- artificial rupture of membranes and IV oxytocin if labor didn’t progress at 1 cm/hr. UK studies show up to 57% of low risk primigravid women have their labor augmented with exogenous oxytocin.

Organizational Factors: Martin railed against assembly line childbirth in the 80s but it was not until Perkins critique of USA maternity care citing it as Henry Ford car assembly line. Hospitals still practicing active management of labor are among the largest in Europe with over 8000 births/year.

How Long Will Labor Last & Normal Labor Variations (workbook pgs 34-35)

A short labor isn’t the easiest because of the element of panic involved; her body is racing away from her mind and it’s difficult to feel any sort of control.

Recent research has shown that the Friedman Curve, used to monitor labor progress in the past is now obsolete. Experts say normal labor may take much longer than thought safe in past and are now saying “6 is the new 4” – active labor now defined at beginning at 6 cm- when labor begins to progress more quickly for most woman; they suggest that cesareans for dystocia not be suggested before this time.

Guided Discussion/Q&A:

  • Ask how long students expect labor to last. Remind that them phases don’t always have signs/symptoms when progress; may meld into next
  • Ask about when they have heard to go to the hospital – emphasize importance of staying home in early labor. Women admitted early at increased risk for cesarean. At home, women can eat, drink fluids and change positions easily. May be more relaxed in home and have access to shower/bath (getting in tub too early in labor may slow contractions so wait until they are firmly established). Check with caregiver about when to go
  • Remind students If pregnant woman is sent home, this is to her advantage

Brainstorm – activities you can do in early labor to pass time. Don’t forget rest/sleep

Lecture/Discussion with Visual Aids

  • Illustration of uterus and discuss Braxton Hicks
  • Cut out 2 pregnant shapes of bodies in With Child Conception to Birth Chart Set before and after lightening. Put one on top of other to show difference in fundal height. Point out pressure on bladder, space for diaphragm before and after lightening
  • Baby doll, knitted uterus and pelvis – can show effacement, dilation, cardinal movements etc
  • Poster showing uterus and utero-sacral ligament will help them see why contracting uterus may be felt in the back as the muscles shorter and pull on the sacrum
  • Use poster/PowerPoint to show rupture of membranes, discuss leak vs gush; C-O-A-T (color, odor, amount, time) to report to care provider

DVD: animation of loss of mucous plug, rupture of membranes and contracting/dilating uterus seen in Celebrate Birth! And Stages in Labor

Table 1: How Long is Normal Labor? (previously based on Friedman/ Current ACOG &SMFM)

Latent: beginning with maternal perception of regular contractions

Active: point at which rate of change in cervical dilation significantly increases

  • 1st stage- latent:
    • Previous nulliparous: prolonged if >20 hours (avg 8.6 hrs (+6/- hrs to go from 0-4)
    • Previous multiparous: prolonged if >14 hrs
    • Current: no limits on latent labor since active labor not considered to begin until cervix 6 cm – nothing should be diagnosed before this time
  • 1st stage – active:
    • Previous nulliparous: cervix dilates at least 1.2 cm/hr (avg 4.9 hrs (+/- 4 to go from 4-10)
    • Previous multiparous: cervix dilates at least 1.5 cm/hr
    • Current: cesarean reserved for women beyond 6 cm w ruptured membranes who fail to progress despite 4 hrs of adequate uterine activity or at least 6 hr oxytocin. Women whose cervix dilated to 2 cm upon admission may take up to 20 hrs to reach 10 cm
  • 2nd stage:
    • Previous nulliparous: 2 hours (avg 1 hr (+/- .8 hrs) (extra hr if epidural)
    • Previous multiparous: 1 hour (extra hr if epidural)
    • Current nulliparous: at least 3 hrs pushing
    • Current multiparous: at least 2 hrs pushing
    • Current: specific absolute time has not been identified; longer durations individualized basis – epidural/fetal malposition if progress is being documented
    • Current nulliparous: 95th %: 3.6 hrs with epidural and 2.8 hrs without

How Long Will Labor Last Curve/Graph pg 58: time in stage 1 labor from beg. of active labor

  • Short fast labor: 2 hrs
  • Average 1st labor: 6 hrs
  • Very slow labor: 11 hrs

What’s Going on During Pregnancy?

Chart on pg 4 in handbook helps to keep expectant parents focused on development of baby, along with physical and emotional changes they themselves are experiencing. Discussions of pregnancy discomforts, exercise and nutrition can easily tie into the changes noted in the 3 trimesters of pregnancy.

Update: Birth Hormones. Childbirth Connection is to publish online Hormonal Physiology of Childbearing by Dr. Sarah Buckley, author of Gentle Birth, Gentle Mothering. Evidence based info on orchestration of labor, birth, breastfeeding and attachment by “Birth hormones” – oxytocin, endorphins, catecholamines, and prolactin. Receptors for oxytocin, endorphins, and prolactin increase throughout pregnancy in preparation for labor, birth and the postpartum period. Believed that prolactin during pregnancy helps pregnant women deal with stress.

Small group activity/learning task – if male/female couples, divide by sex into small groups. Give each flip chart and markers. Ask to discuss and record answer on chart – how have you changed during this pregnancy? How has your partner changed during this pregnancy? Make own notes to ensure important parts you wish to make are covered. (Pg 4 in workbook)

Guided discussion with visual aids – Emotions During Pregnancy graph pg IV-5. Video teaching fetal growth and evelopment, especially helpful for early pregnant class to relate own physical/emotional experiences to growth/development of baby. Milner Fenwick’s “A Nine Month’s Journey” – short, comprehensive and visually appealing.

Books – A Child is Born, Understanding your moods when you’re expecting; In the Womb

DVDs: A nine-month journey; in the womb

Video Clip: the VisualMD “From conception to birth

Websites Stress and pregnancy Fetal Development


Emotions During Labor Chart – How Partner Can Help

1st stage: (2-24 hrs)

  • Early Labor: waiting and wondering – excited, anxious, may overreact. Time contractions. Encourage mom to relax, eat, drink and rest. Use distracting activities. Help her feel safe. Dilation 1; station 1
  • Contractions 4-5 min apart: can no longer be distracted; can’t walk/talk through contractions. Watch for her rhythm and reinforce it. Begin planned ritual: relax, breathe and focus. Dilation 1-2; station 1
  • Active labor: quiet, withdrawn, discouraged as painful contractions require full attention. Feel need to be move and free to do whatever helps you cope. Follow her lead and move in close. Try bath or shower. Reinforce or adapt ritual. Dilation 4; station 2
  • Transition (peak of pain): may be overwhelmed. Panicky, angry and impatient. Remind her that intensity means labor will progress more quickly. Encourage her. Use take charge routine to help her regain rhythm. Develop new ritual. Dilation: 8; station 1

2nd stage: ½ – 3+ hrs

  • “Lull”: renewed energy, mentally clear; optimistic. Reassure her that lull is normal. Match her mood -discuss spontaneous pushing. Don’t rush. Dilation 9; station 1
  • Descent: may be elated or alarmed by pressure in vagina. May hold back; discouraged if progress is slow. Encourages release of pelvic floor. Assist w pushing positions. Dilation 10 station 0

3rd stage: 10-45 min

  • Crowning: excited. Feel rim of fire. Desire to get it over w. fear of tearing. Encourage her to listen to caregiver. Dilation 10. Station 0.
  1. Four stages of labor
  2. First stage
  3. Second stage
  4. Third stage
  5. Fourth stage
  6. Stages of labor flow together in one process, unique to every woman.



Rhythms in first stage of labor: in vast majority of hospital birth, progress is assessed by vaginal examination. This normative mindset is so powerful that few midwives have had opportunity to observe labors where none have occurred. For millions of years, childbirth was not obsessed with labor duration. Gaskin discovered word “pasmo”; labor stopped and everybody went home until it started again.

Friedman’s legacy: Emanuel Friedman was first to graphically record cervical dilation over time. His work in mid 1950s showed understanding of average lengths of labor for primigravid and multigravida women. In 70s, Philpott and Castle gave guidance for what to do if labors were slow. Alert line at 1 cm/hr, transfer line at 2 hours behind alert line and action line 2 hours behind that. O’Driscoll used in his protocol for ‘active management of labor’- artificial rupture of membranes and IV oxytocin if labor didn’t progress at 1 cm/hr. UK studies show up to 57% of low risk primigravid women have their labor augmented with exogenous oxytocin.

Organizational Factors: Martin railed against assembly line childbirth in the 80s but it was not until Perkins critique of USA maternity care citing it as Henry Ford car assembly line. Hospitals still practicing active management of labor are among the largest in Europe with over 8000 births/year.

An Emergent Critique: Albers concluded from her research in 90s that nulliparous women’s labors than Friedman had said (17.5 hours vs. 8.5 hours for nulliparas and 13.8 vs 7 for multiparas). Primiparous women remained in first stage for 26 hours and multiparous women for 23 hours without adverse effects. The acceleratory phase occurred after 5 cm in multiparous women and after 6 cm in many nulliparous women and labor did not decelerate toward full dilation as Friedman had suggested. They restated their view that a parabolic curve of labor was much more realistic than linear versions of cervical dilation.

Oxytocin – “the benevolent queen” – direct on uterine contractions and in generation feelings of nurture, protection and altruism towards baby. Adrenaline – (fight or flight) – noradrenaline (peacemaker) prepare and empower a woman for hard labor of birthing by mobilizing her strengths and inner resources. Complete removal of pain with epidural stimulates noradrenaline, which wrongly interprets labor is stopping so feeds back to stop the release of oxytocin so labor is becalmed again. Inner high of endogenous endorphins, secreted when body is in chronic pain.

Rhythms in early labor– we can’t validate woman who had labor pains for 7 days because we dare not record a length of labor longer than 24 hours. Less than 60% experienced contractions at the starting point of their labors. The remainder described fluid loss (38%), constant pain (24%), blood stained loss (16%), gastrointestinal symptoms (6%), emotional upheaval (6%) and sleep alterations (4%) as heralding the start of labor, none of which fit the textbook definition.

6000 women showed no differences in cesarean section rates and other morbidities between partogram and no partogram.

“Pasmo” – physiological delays were known about in 19th century.

Now recommends a cervical dilation rate of .5cm/hr in nulliparous women and this has been endorsed by NICE intrapartum guideline.

Alternative Skills for Sussing Out Labor: Intuition – midwife’s need to defecate, ebb and flow of tide. Pets, farm animals.

Prolonged Labor: encourage mobility and posture change. Acupuncture. Hypnosis. Acupressure. Nipple stimulation. ARM has for decades been first option but does not shorten labor and may contribute to higher cesarean rate. Oxytocin’s propensity to hyperstimulate uterus and link between it and poor neonatal outcome, so use only minimum amount. Lactic acid levels in women with prolonged labor may help distinguish those likely to respond to oxytocin and those who will not. Dystocia over diagnosed and over treated in Western world.

“Being with not doing to laboring women”: Most important.

Conclusion: greater focus on birth environment and role of birth companions. Help mom discover labor rhythm. Care for prolonged labor should prioritize physiological/psychological/social support before medical interventions. Exogenous oxytocin should be reserved for dystocia that does not respond to any other intervention and then used sparingly. Services should review their use of vaginal examinations in labor.

Rhythms in 2nd stage of labor – origins of medicalization of 2nd stage date back to 1600s – one obvious concern w coached pushing is tendency to reinforce professional hegemony while undermining women’s confidence in own physiology. Widespread collapse in current generation of women to instinctively do 2nd stage w out professional instruction.

Research evidence – prolonged breath-holding in 2nd stage decreased placental perfusion resulting in fetal hypoxia. Coached pushing involving prolonged breath-holding decreased fetal cerebral oxygenation. If coached pushing in 2nd stage lasted longer than an hour, babies had lower pH at birth. Coached pushing results in a longer 2nd stage than spontaneous pushing with no differences in type of birth, fetal outcome and perineal outcome.. # of other concerns:

  • Maternal exhaustion
  • More assisted vaginal births
  • More episiotomies and perineal tears
  • Deleterious impact on pelvic floor, in particular urinary stress incontinence

When spontaneous pushing combined with upright posture, 2nd stage shorted by 45 min compared with coaching and semi-recumbent position in low risk primiparous women. Women also said they experienced less pain, less fatigue and were more satisfied

Spontaneous pushing:

  • Breathing pattern during contraction and pushing is self-directed
  • Tie of initiating push is irregular (women initiates push independently and pushing often begins once contraction is well established)
  • Pushing may be characterized by grunting with pushing, short and more frequent bearing-down efforts with each contraction or both
  • Open-glottis pushing (Grunting noise while pushing)
  • Patient follows cues from body
  • No verbal instruction as to how to push
  • No non-verbal instruction is given (deep breaths)
  • Caregivers offer encouragement and praise only, not instruction

Directed pushing – following verbal direction, demonstration or instruction from caregivers regarding:

  • Time of pushing (when to start/stop)
  • Length of pushing (how long to push)
  • Position for pushing
  • Breathing during pushing
  • Strength of push
  • Specific direction on how to push
  • Instruction to make no noise with pushing efforts
  • Actively positioning woman in a certain way for pushing or verbally directing her to position herself in a certain way
  • Vaginal examination w concurrent direction such as push my finger out
  • Vaginal examination actively stimulating Ferguson’s reflex or manipulating or stretching cervix or perineum
  • Following any non-verbal instructions on how to push

Concluded from examination of 10 studies of Valsalva’s maneuver (pushing while breath-holding) that practice should be discontinues because of negative effects on fetal heart and perineum. All forms unlikely to beneficial included routine directed pushing, pushing by sustained bearing down and breath-holding.

Epidurals and 2nd stage – compared immediate coached pushing with delayed open-glottis pushing in nulliparous women with epidurals, demonstrating that latter group had better fetal outcomes and less perineal trauma. No difference in length of 2nd stage. Open-glottis pushing (pushing w out breath holding) demonstrated by women audibly grunting, shorter periods of breath-holding (6-8 sec) and no more than 3 pushes per contraction. Good practice to combine open-glottis pushing w upright posture, achievable now w low-dose epidurals.

Definition of 2nd stage – it is an esp brave midwife who will record 6 hr 2nd stage that included several hrs of latency; its far more comfortable to assign the start so that time comes in under whatever guideline locally requires.   Most have been there and adopted visualization of presenting part as reference marker for start of 2nd stage.

Midwifes known that women’s bodies don’t fit template of biomedical definition, because they have rest and be thankful phase after full dilation or they involuntarily push before. Both of these fall outside the normative physiology. Ascertaining the start of the 2nd stage even w a confirmatory vaginal examination was always problematic anyway. If there is no cervix palpable on examination, you are already too late – full dilation occurred some time before. Occasionally midwives, fed up with confines of biomedical model, may deliberately record full dilation at 9 or 11 cm because they argue the improbability that ever woman in world has a cervix that dilates to 10 cm exactly. They are facetiously commenting on the nonsense that birth anatomy and physiology is uniform across all women.

1st to stage transition: that mysterious phenomenon, virtually ignored by childbirth textbooks, yet transition is one of the earliest observed labor behaviors by students on birth suites. For women who experience transition, the notion that it is rather enigmatic and of little relevance would be laughable.

Spectrum of experiences/emotions (From inner calm to acute distress) in latter half of labor just prior to pushing. If time frames take on less significance, then midwives will be freer to work with the lived experience of transition and 2nd stage and arguably offer better individualized care. Women spoke of:

  • Paradox of being in control and letting go
  • Altered state of consciousness
  • Sense of timelessness
  • Wanting midwife to be a safe anchor, someone to put trust in, with a calm, quiet, unobtrusive presence
  • Unhelpful aspects of care were being treated as a naughty schoolgirl, being told off, intrusive interventions (fetal monitoring, requiring to be on bed, interruptions and being undermined)

One way out of this temporality bind is to adjust definition of start of 2nd stage. redefining this by changing criterion of full dilation of cervix to “when presenting part has passed through the cervix and is below the ischial spines. This alteration would allow for physiological variations observed in practice of latent episodes after reaching full dilation. Once presenting part has descended beyond ischial spines, then bearing down will occur as the fetus enters the perineal phase or women experience the fetal ejection reflex.

Acknowledgment of latent element and subsequent lengthening of the time frame has appeared in OB journals in recent years. Anesthetists and OBS became alarmed at assisted vaginal birth rates w epidurals and at fetal hypoxia associated with prolonged coached pushing. They began researching passive descent, in some studies up to 5 hours before active pushing was commenced. Now, its common practice to wait at least 2 hours in many consultant units. Blatant double standard exists where women without epidurals are allowed only 1 hr.

Concerns for baby when labor is exposed to oxytocin augmentation during 2nd stage have been raised; it’s a risk factor for fetal acidaemia.

  1. Time and fetal health – many OBs believe direct link between length of 2nd stage and fetal health and this primarily drives time restrictions on 2nd stage

Examined 25k women and found length of 2nd stage not associated with low Apgar scores or neonatal unit admissions. 6000 nulliparous women – some who had 2nd stages lasting longer than 5 hours and concluded non increase in low 5 min Apgar scores, neonatal seizures or neonatal unit admission. No association between length of 2nd stage and neonatal morbidity. Some found links to maternal morbidity such as infection and bleeding, but these were explained by labor practices or 1st stage factors.

2 papers that suggest neonates might be at more risk form long 2nd stages. Those whose 2nd stages were longer than 3 hours, babies at greater risk. Babies exposed to long 2nd stages had lower 5 min Apgars and more admission to neonatal units. Both confounded by high rates of epidural in samples. Maternal outcomes, principally postpartum hemorrhage, assisted vaginal birth, infection and perineal trauma were worse in this group. Some of maternal outcomes can be explained by compounded effects of more forcep births.

In summary, long 2nd stage has links with some maternal morbidities but link w fetal compromise more speculative. Some evidence when presenting part is on pelvic floor, fetal lactic acid begins to accumulate and this may be reflected in deterioration in fetal heart patterns.

2nd stage of labor does not need to be terminated for duration alone but on individual assessment of mom/baby in each case. Encourage upright posture and spontaneous pushing, both of which will optimize fetal/maternal health.

Early pushing – unlikely to be beneficial. Student midwives have been told it will lead an oadematous lip of cervix which, if left untreated, will slough off leading to hemorrhage. Focuses mind of midwife – to get woman lying on side breathing on entonox or, if that fails, sitting an epidural.

Posterior Position in 2nd stage – link between persistent posterior position and range of maternal outcomes including prolonged 1st and 2nd stage labor, oxytocin augmentation, epidural, assisted vag birth, sphincter tears, cesareans and postpartum hemorrhage.

Evidence base of 9 prevailing concepts that guide current labor management for posterior position concluded that only 2 proven: ultrasound diagnosis to identify fetal position and digital or manual rotation in 2nd stage to correct malposition. In terms of birth outcome, it is the position of the baby at commencement of 2nd stage that is best predictor of outcome. Back pain is unreliable marker of OP position as it can occur in OA labors and not occur in OP ones. A delay in labor without back pain could still be related to an OP position. Vaginal examinations were found to be unreliable in diagnosing OP. Some evidence that changes of position may help OP position to rotate and certainly many midwives advocate lunge maneuver (creating disequilibrium in hips by stepping up and down) as well as pelvic squeeze (pressing inwards on iliac crests). Trent towards OA rotation in OP labors as well as a successful treatment of backache with h ands/knees position. Good section on OP in Holistic Midwifery Volume II.

Tips for delay in 2nd stage: these are experiential, based on general good practice principles, anecdotal or sometimes counter-intuitive; little research on physiological interventions for this scenario:

  • Variety of upright postures
  • Psychological barriers
  • Empty bowel/bladder
  • Offer water immersion
  • Suggest nipple/clitoral stimulation
  • Change of voice tone or carer, if possible
  • Recumbent postures, including McRoberts
  • Coached pushing but for short time frames
  • Agree a time frame before initiating an assisted vaginal birth or transfer out of home or birth centers – sometimes mentioning the end point of forceps or transfer to labor ward seems to bring a reward

Attitudes and philosophy – resist temptation after experience above to always do a confirmatory vaginal examination when signs of 2nd stage appear, takes experience and a supportive environment

Attitudinal change to enhance woman’s autonomy is imperative; a move from:

  • Loss of autonomy to being in control
  • Passive to active
  • Dependence to independence

For midwives, movement from:

  • Control to facilitation
  • Dominance to masterly inactivity
  • Surveillance and monitoring to watchful expectancy
  • More to less

Attitudes and philosophy – resist temptation after experience above to always do a confirmatory vaginal examination when signs of 2nd stage appear, takes experience and a supportive environment

Attitudinal change to enhance woman’s autonomy is imperative; a move from:

  • Loss of autonomy to being in control
  • Passive to active
  • Dependence to independence

For midwives, movement from:

  • Control to facilitation
  • Dominance to masterly inactivity
  • Surveillance and monitoring to watchful expectancy
  • More to less

Then the space is made for sensitive, intuitive support hat really does make a difference when needed in the 2nd stage

Practice recommendations – care should be based on:

  • Rehabilitating women’s confidence in their own ability to do the 2nd stage
  • Fetal and maternal condition
  • Evidence of descent of presenting part in the presence of expulsive contractions and spontaneous pushing
  • Time restrictions for duration of a physiological 2nd stage should be as flexible as they are for women w epidurals in 2nd stage
  • Women should be encouraged to follow their instincts
  • Midwives’ role is to affirm physiology, not control it or deny it
  • Routine coached pushing should be abandoned
  • Coaching for women w epidurals should mimic physiological behaviors regarding shorter periods of breath-holding, open-glottis pushing and vocalizing
  • Combine deregulated approach w upright postures
  • Transition and early bearing down are part of a spectrum of physiological labor behaviors
  • In content of delay, counter-intuitive measures may have a place


Rhythms in 3rd stage of labor – 3rd stage of labor presents the ultimate challenge to the advocates of birth physiology bc this is the area where active management is routinely practiced. 73% of midwives in UK always or usually use active management. 12 countries used prophylactic oxytocins bw 72-100% of the time. Active management reduces risk of major hemorrhage (blood loss >1000 ml) in resource-rich countries but that needs to be weighed against a number of adverse effects. Bc of horrendous mortality in developing world from PPH (>500 ml), WHO recommends active mgmt. w prophylactic uterotonics in those settings.

Since distillation of synthetic oxytocin in 1950s, its use in 3rd stage of labor has become routine in maternity hospitals.

History of uterotonics – ergot was first described in 1582 but its use was discontinued in 1828 except for PPH bc of deaths of moms and babies, principally due to uterine rupture. Oxytocin was first synthesized in 1955 and was enthusiastically adopted bc it did not have nasty side-effects or ergot. Became extremely popular to use in combination w ergot as prophylaxis for 3rd stage of labor in West. Ergot preparations are very powerful uterotonics. Currently its use is on its own for control of PPH or in combination w syntocinon as a prophylaxis for 3rd stage. Oxytocin replaced ergot in many European countries, and UK is unusual in opting for syntometrine (combination of ergometrine and syntocinon).

PPH is major cause of maternal mortality in developing world, mainly bc poverty and ill-health leave women profoundly anaemic. Millions are able to withstand small blood lossess in labor. WHO advocates active management in these settings.

Components of active and physiological 3rd stage care – active mgmt. includes:

  • Prophylactic oxytocics
  • Early cord clamping and cutting
  • And/or waiting for signs of separation
  • Delivery by controlled cort traction
  • Usually completed w/in 15 min

Physiologic care includes:

  • No oxytocic prophylaxis
  • Cutting of cord after delivery of placenta or after cord pulsation stops
  • Delivered by maternal effort and gravity
  • Usually completed w/in 45 min
  • Suckling at the breast if mother breastfeeding

In active mgmt, midwife delivers placenta and must disturb immediate post birth period to do this; referral to OB if 45 min and no placenta. In contrast, woman births her placenta in physiological care and she can be left undisturbed in early post birth period. Referral to OB not considered until at least an hr passed.

RCTs on active or physiological mgmt. – need to weigh advantage of reducing major hemorrhage in active group w:

  • Significantly increased diastolic bp in moms
  • After pains
  • Use of analgesia
  • More women returning to hospital w bleeding

Lower birth weight in babies, presumable bc of early cord clamping.

No statistically significant increase in major hemorrhage in women at low risk of bleeding.

Syntometrine associated w significant reduction of PPH compared w oxytocin 5 units, though less so w oxytocin 10 unites. Syntometrine caused more nausea, vomiting and raised bp. Timing of umbilical cord clamping found non difference in hemorrhage rates. Timing of oxytocin (Before or after expulsion of placenta) – no impact on hemorrhage rates. Later timing would reduce risk of hyper-transfusion to neonate and potentially reduce risk of retained placenta, though trials too small to show any difference in latter outcome.

Misoprostol has advantage of being stable in warmer temps, oral in prep and inexpensive compared w conventional injectable uterotonic; less effective for controlling blood loss in excess of 1 liter and had does related side effects of shivering and raised temp.

Trial evidence pointing towards being more selective about active mgmt. and to revising traditions around timing of oxytocin admin and cord clamping.

More recent research in midwifery-led environments – 3 studies that physiological 4d stage safe in midwifery-led settings and even desirable. 30,000 women New Zealand 5 yr period – 48% physiological 3rd stage: blood loss amounts lower at both thresholds up to 500 ml and up to 100 ml. Netherlands – no difference in PPH rate found between low-risk nulliparous women who received active or physiological care. Australia – active mgmt. actually predisposed to PPH at all thresholds bw 500 and 1500 ml.

Those at low obstetric risk and labor physiologically during 1st and 2nd stage appear to complete a physiological 3rd stage safely and may even be exposed to less risk of PPH.

Defining benchmark for PPH – healthy women w normal labors can tolerate a blood loss of ~1000 ml w out decompensating (~20% of blood).

Physiological 3rd stage and maternal physiology -– the process of returning to pre-pregnant physiology, which haemodynamically means reducing the circulating blood volume, commences immediately after birth. Active management postpones passage of blood per vagina to heavier lochia on days 2 and 3 and, if total blood loss could be compared between active and physiological methods at 3 days, the amounts would be very similar. The extra circulating blood has to be excreted – it is just the timing that differs according to 3rd stage care.

The extra bleeding of physiological care cleanses the uterine cavity, flushing out the placenta in the process. Active management, where bleeding is reduced, would result in more retained placentas. Early cord clamping results in blood being trapped in placental body causing baulking. Detachment from uterine wall is then more difficult. Only one trial of active management revealed more retained placentas.

Unclamping the maternal end to allow drainage of blood after severing the cord may reduce the incidence of retained placentas. This practice mimics physiological care where blood continues to flow, via the cord, out of the placental body after birth.

Early skin to skin showed benefits on duration of breastfeeding, mother infant attachment, less infant crying and cardio-respiratory stability. Active management does compromise immediate skin to skin a little. The cord has to be cut and placenta delivered by controlled cord traction all within minutes of birth. This may require the mother to move to a bed and a semi-recumbent position and this further disturbs skin to skin.

Physiological 3rd stage and neonatal transition – cord issues dominate recent thinking on neonatal transition physiology. Delaying cord clamping up to 2 min in preterm infants associated w less need for transfusion and less intraventricular hemorrhage. These babies may also be less prone to respiratory distress syndrome. Delaying in term infants can provide an additional 30% extra blood and up to 60% more red blood cells; this allows baby to start extra uterine life w peak hematocrit, hemoglobin and ferritin levels, less anemia, better perfusion of vital organs, better cardio pulmonary adaptation and increased duration of breastfeeding.

Successful neonatal transition dependent upon newborn having an adequate blood volume to recruit the lung for respiratory function through capillary erection and an adequate red cell volume to provide enough oxygen delivery to stimulate and maintain respiration. Usually complete within 3 minutes of birth. Immediate crying efforts are not effective at gaseous exchange within the lungs because blood flow has not had time to initiate capillary erection.

Mammalian birth always includes a rest period after the birth when the cord is left alone. One min Apgar score is not useful for assessing respirations because this may take up to 3 min to be established. No-touch technique combines with warm water medium combine to make babies often peaceful and quiet at birth.

Cutting cord early is effectively starving baby of oxygen seems an unnecessarily aggressive and harsh method of facilitating neonatal transition and of welcoming a new baby.

Cutting cord on ‘flat’ baby so that resuscitation can take place on a resucitaire should be challenged. It makes no sense at all to cut this lifeline when the baby is already compromised. The placenta is a resuscitative organ and it should be harnessed for this purpose.

Stress importance of not disturbing the immediate post-birth period when optimum hormonal conditions exist for bonding. Endorphins are at high levels in both mother and baby, contributing to the baby’s alertness and the mother’s attentiveness. In the mother, an oxytocin surge is triggered to contract the uterus and help separate the placenta. This surge is augmented by skin to skin contact and breast-suckling. The drop in circulating catecholamines at birth facilitates oxytocin secretion which is more likely to be inhibited if the immediate post-birth period is disturbed and hurried. Time pressures on birthing rooms. Post-birth tasks of checking, weighing, administering drugs and dressing baby all have to be completed, along with readying mother for transfer out. The ‘luxury’ of allowing an undisturbed 30-60 min post-birth bonding time would be difficult to achieve.

Language games – there is a chance of hemorrhage if we leave 3rd stage happen naturally. With injection, it will be quicker and cleaner. Or if the rest of the labor is normal, it is worth considering a normal 3rd stage. There may be a little more bleeding but you can have uninterrupted time with your baby and no drugs.

Some found shorter and less bleeding with natural 3rd stage rather than active management.

Practice Recommendations:

  • A physiological approach is the appropriate care when labor is normal
  • If an active approach is chosen, then syntocinon ten units is the uterotonic of choice
  • There may be advantages in delaying administration of uterotonic until after birth of placenta, but this requires more research.


Signs Preceding Labor – in 1st time pregnancies, uterus sinks downward and forward ~ 2 weeks before term, when fetus’s presenting part (usually fetal head) descends into true pelvis – aka “lightening” or “Dropping”. Happens gradually. Feel less pressure below ribcage and breathe more easily afterwards but more bladder pressure. Return of urinary frequency occurs. In multiparous woman, lightening may not take place until after uterine contractions are established and true labor is in progress.

Woman may complain of persistent low backache and sacroiliac distress as a result of relaxation of pelvic joints. Braxton Hick contractions.

Vaginal mucus becomes more profuse in response to extreme congestion of vaginal mucous membranes. Brownish or blood-tinged cervical mucus (bloody show) may be passed. Cervix becomes soft (ripens), and partially effaced and may begin to dilate. Membranes may rupture spontaneously.

Common in days preceding labor: weight loss of 1-3.5 lbs, caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels and surge of energy. Burst of energy to clean house, put everything in order. Less commonly: diarrhea, nausea, vomiting, and indigestion.

Signs Preceding Labor

  • Lightening
  • Return of urinary frequency
  • Backache
  • Stronger Braxton Hicks contractions
  • Weight loss of 1-3.5 lbs
  • Surge of energy
  • Increased vaginal discharge, bloody show
  • Cervical ripening
  • Possible rupture of membranes

Onset of Labor – Cannot be ascribed to single cause. Many factors – changes in maternal uterus, cervix and pituitary gland. Hormones produced by normal fetal hypothalamus, pituitary and adrenal cortex probably contribute. Progressive uterine distention, increasing intrauterine pressure and gaining of placenta seem to be associated with increasing myometrial irritability. This is a result of increased concentrations of estrogen and prostaglandins, as well as decreasing progesterone levels. Effects of these result in strong, regular, rhythmic uterine contractions.

Stages of Labor – in women w out complications and vertex presentation 1) regular progression of uterine contractions 2) effacement and progressive dilation of cervix 3) progress in descent of presenting part.

  • 1st stage of labor – onset of regular contractions to full effacement and dilation of cervix. Much longer than 2nd and 3rd stages combined. Great variability is the rule. Traditionally divided into 3 phases: latent, active and transition phase. Women w epidural may not notice transition phase. During latent phase, there is more progress in effacement of cervix and little increase in descent. Active and transition phases – more rapid dilation of cervix and increased rate of descent of presenting part.
  • 2nd stage of labor – cervix fully dilated to birth of fetus. Composed of 2 phases: latent (passive fetal descent) and active pushing. Latent phase – fetus continues to descent and rotate to OA. Urge to bear down not strong and some women do not experience. Active pushing – strong urges to bear down ad presenting part descents and presses on stretch receptors of pelvic floor.
  • 3rd stage – birth of fetus until placenta delivered. Placenta normally separates with 3rd or 4th strong contraction after infant born. After separated, can be delivered with next contraction.
  • 4th stage – delivery of placenta and 2 hrs post birth. Recover physically, observe for complications such as abnormal bleeding.

Mechanism of Labor – Turns and other adjustments necessary in human birth. female pelvis has varied contours and diameters at different levels. 2 cardinal movements that occur in vertex presentation: engagement, descent, flexion, internal rotation, extension, external rotation (restitution) and birth by expulsion. Combination of movements occur simultaneously. Engagement involves both descent and flexion.


Engagement– when biparietal diameter of head passes pelvic inlet, head is said to be engaged. In most nulliparous women, occurs before onset of active labor because firmer abdominal muscles direct presenting part into pelvis. In multiparous women, because abdominal musculature is more relaxed, head often remains freely movable above pelvic brim until labor is established.

III. Physiologic progress

The Six Ways to Progress in Labor

Significant dilation can occur only when cervix has already undergone preparatory changes. When cervix has not undergone first 3 steps (ripening, effacement and anterior movement), significant dilation (beyond 4 cm in nullipara, more in multipara) rarely occurs. If such progress is ignored, an incorrect diagnosis of dysfunctional labor may be made before the woman is even in labor.

For most women, first 3 steps take place gradually, simultaneously and almost unnoticed over a period of weeks before labor begins. For a minority, hours or days of nonprogressing prelabor contractions are necessary. Sometimes, they are intense enough to prevent sleep and woman becomes discouraged and exhausted.

6 ways to progress:

  • Cervix movers from posterior to anterior position
  • Cervix ripens or softens
  • Cervix effaces
  • Cervix dilates
  • Fetal head rotates, flexes and molds
  • Fetus descends, rotates further and is born.

Encourage her to engage in distracting activities to help her accept slow progress of early labor as a normal variation, preventing exhaustion, meeting her nutritional needs and keeping her comfortable.

Rotation, flexion, molding, and descent of fetal head take place in active labor and 2nd stage.

Support Measures for Women who are at Home in Prelabor and the Latent Phase

  • Continue normal activities- restful activities (even if can’t sleep) at night, avoiding overexertion
  • Have partner, friend, relative or doula with her
  • If nighttime and can rest, lie down or relax in bathtub (immersion in water in early labor may temporarily stop contractions and give woman some rest. Advantage if she needs rest but disadvantages if conditions exist that make it important her labor progresses (prolonged pregnant or prolonged rupture of membranes)
  • If unable to rest, or its daytime, she should try distraction measures:
    • Go for walk of have someone take her for a drive
    • Visit friends/family
    • Go to a movie or other entertainment, shopping
    • Read aloud to a companion, being read to
    • Prepare meals for after birth or bake bread
    • Prepare baby’s clothing, bedding
    • Watch videotapes, TV
    • Do a project – sorting photographs, writing in journal, clean closet, draw, paint
    • Play games
  • Eat when hungry, unless knows she is having cesarean. Best food choices are easily digested complex carbs (starchy foods, fruits, veggies). Avoid greasy or spicy foods
  • Drink to thirst. Water, broth, fruit juice, caffeine free tee or electrolyte balanced beverages. Women have a lower tolerance for water during labor and shouldn’t drink excessively. Prolonged 2nd stage, instrumental delivery and cesarean are some risks of hyponatremia
  • Use labor coping techniques during contractions when distraction no longer possible and can’t walk or talk through them without pausing at peaks. Relaxation and self-calming techniques, slow breathing (Sighing) and attention-focusing are appropriate
  • Time 4-5 contractions in a row for duration, frequency and interval to see if they are progressing. Apps available.
  • Know provider guidelines on when to come to hospital

A lot of women crushed when expected to be 5-6 cm and are only found to be 1-2 cm.

  1. Overview

YouTube: Vaginal Childbirth 
(Birth) (47 seconds) Animation of baby coming out of vagina

  1. Rotation of baby through pelvis: Cardinal movements

Key Vocabulary for Late Pregnancy and Labor – during late pregnancy/early labor, cervix changes so it can dilate and baby assumes birth position (usually head down).

Parity – describes condition of having given birth. Primigravidas are women who are pregnant for 1st time, nulliparas have never given birth and primiparas have given birth once (often wrongly used to refer to nulliparas). Multiparas are women who have given birth more than once.

Presentation and Position – Babies can situate themselves in the uterus in several ways, some more suitable for an easy birth than others. Presentation or presenting part describes the part of your baby that’s lying over your cervix and will emerge from your body first. Most favorable and most common presentation (95% of births) is vertex, in which the top of your baby’s head is down over your cervix. Other presentations are frank breech (buttocks down), breech (one or 2 feet down), complete breech (buttocks and feet down), and shoulder, face or brow presentations.

Position refers to direction toward which back of baby’s head (occiput) or other presenting part lies. Possible positions are anterior (towards front), posterior (towards back) and transverse (towards side).

Occiput anterior (OA) – back of baby’s head is pointing toward anterior (front). Left or right occiput anterior – LOA/ROA – back of baby’s head toward left or right front.

Occiput posterior (OP) – back of baby’s head is toward back. Right or left occiput posterior (ROP/LOP) – back of baby’s head toward right/left back. Right or left occiput transverse (ROT/LOT) – back of baby’s head toward right or left side.

Baby’s positions may change during labor among OA, OT and OP, although by birth most babies are OA.

Six Steps to Birth – occur before a vaginal birth. First 3 begin days or weeks before labor starts (prelabor) and last 3 happen during labor:

  1. Cervix moves forward
  2. Cervix ripens
  3. Cervix effaces
  4. Cervix dilates
  5. Baby’s head rotates and tucks (chin to chest)
  6. Baby’s head molds, descends through pelvis and is born

Station and Descent – Station refers to location of top of baby’s head (or other presenting part) within pelvis. Measured in centimeters, in relation to middle of pelvis (ischial spines), which is referred to as 0 station. If top baby’s head at 0 station, descended to middle of pelvis. If head floating above level of pubic level, may be as high as -4. If head at +1 or +2, 1 or 2 cm below middle of pelvis. When head at vaginal opening and on its way out, +4 station.

Downward movement of baby into pelvis is called descent. During late pregnancy and birth, baby moves from highest station (-4) to lowest station (+4) and is then born. For Primigravidas, some descent – either gradual or sudden – usually takes place several weeks before onset of labor. Women may begin labor at -1 or 0 station. For multiparas, common for labor to begin w babies still floating. Most descent, takes place during pushing in late labor.

Lightening and dropping also refer to baby’s descent before labor or decreased pressure in chest and upper abdomen and increased pressure on bladder. Engagement describes condition in which top of baby’s head (or other presenting part) is engaged or at 0 station and fixed in pelvis. Can be determined by palpating abdomen or by vaginal exam.

Cervical Changes – changing levels and interactions of hormones cause cervix to change gradually, beginning before labor and ending just before baby’s birth. Caregiver can assess during vaginal exam.   Because subjective, may vary if more than 1 person examines you. Exam can’t predict when will go into labor or how long labor will last. If have very ripe, effaced cervix, may go into labor right away or in several weeks. Same true if have thick, firm cervix.

Changes cervix undergoes during labor process:

  • Cervix moves forward – usually weeks before labor begins, cervix is high and posterior (pointing towards back); as labor approaches, cervix gradually moves down to anterior position (pointing towards front).
  • Cervix effaces (thins/shortens) – cervix of primigravida usually effaces a lot before it dilates. Cervix of multigravida typically effaces and dilates at same time.
    • Effacement measured as % or length in cm. 0% effacement means cervix 3-4 cm long and hasn’t begun to thin. 50% or 2 cm means cervix has thinned hallway; 100% or paper-thin means that cervix has thinned completely. Make sure don’t confuse cm of effacement w cm of dilation.
  • Cervix dilates (opens) – cervix usually dilates before labor begins (1-2 cm in Primigravidas or up to 4 cm in multigravidas), most occurs during labor. When cervix has opened width of fingertip, 1 cm dilated; when fully dilated – 10 cm.


  1. Dilation of cervix

Assessing Progress in Labor – Many important assessments help determine when labor is progressing normally and when it is not. Readers who do not have professional training do not use hands-on assessment techniques because they are outside their scope of practice. The following address progress with a full-term singleton in a longitudinal lie and a cephalic presentation.

Before Labor Begins

Malposition – primary cause of dysfunctional labor; OP is most common.

2 questions: can fetal position be assessed accurately before labor begins? If so, does doing so provide an opportunity to correct some problems before labor begins?

Can malposition accurately be determined antenatally?

Clues to location/orientation of fetal back, which is presumed to correlate with position of fetal head in maternal pelvis

Assessments include: 1) observing contour of maternal abdomen 2) locating point of maximum intensity (PMI) of fetal heart tones via auscultation 3) performing abdominal palpation using Leopold’s maneuvers

  • Reliability of neither maternal abdominal contour nor PMI of fetal heart tones has been assessment with well-designed studies
  • Abdominal contour – when fetus is lying with back anterior, maternal abdominal wall looks convex and umbilicus may appear “popped out”. Mother reports fetal movement predominantly in upper quadrant opposite fetal back. When fetal back is oriented posteriorly, abdomen looks concave, especially depressed in region of umbilicus or below. Mother reports fetal movement in midline or everywhere. Fetus more likely to enter maternal pelvis in less favorable OP position. Observations may be difficult in obese women.
  • Location of PMI of fetal heart tones via auscultation – loudest sounds heard through fetal back at approx. level of scapula or shoulders. Best tool is fetoscope rather than Doppler (which uses ultrasound to create artificial sound not affected by proximity to heart valves). When fetus has curved back toward mother’s front, heart tones are crisp and clear below maternal umbilicus and several cm from midline. When fetus curved back is toward mother’s spine, PMI is in right or left lateral area of maternal abdomen (LOP or ROP_. If fetal back in concave position, may be heard through fetal chest, sounding muffled, distant and difficult to hear.
  • Does knowing location of fetal back predict position of fetal head? Not necessarily. Makes sense when we appreciate that fetus can turn her neck to orient her head differently in pelvis.

Leopold’s maneuvers – accuracy in identifying fetal position has not received adequate study; some say accurate 68% of time.

  • When fetal back is anterior, the side of maternal abdomen where back is located (left or right) feels smooth and firm, while on opposite side, fetal limbs “small parts” are easily felt
  • When fetal back is posterior, may be difficult to palpate any smooth back. Fetal limbs may be palpated on either side of midline.
  • 4 step method to determine fetal lie, presentation, position and engagement in pelvis. Uterine tone and estimated fetal weight also obtained by careful abdominal palpation in late pregnancy or labor.
  • Technique: woman should empty bladder and then recline. Relax abs by bending knees slightly or resting them on pillow. Right-handed people on woman’s right…
  • 4 steps: order not important
    • Identify what part of fetus is in fundus (top of uterus). Facing woman’s head, caregiver places both hands on woman’s upper abdomen and, using firm but gentle pressure, feel fundus and height, shape, size and consistency of fetal parts in that area.   When lie is longitudinal and presentation is cephalic, breech is palpated in fundus. May feel bony and relatively large but is differentiated from head by feeling continuous w spine and moving w it. When head is in fundus (breech), usually feels ballotable – bounces between palpating hands bc it can be moved independently from fetal back. When lie is transverse, neither head nor breech can be palpated in fundus.
    • Helps determine location of fetal back – still facing woman’s head, place hands palm down on either side of abdomen. Keep both hands in contact and alternate pressure from 1 hand to other. Caregiver can palpate shape and bulk of fetal parts on either side of torso and around toward spine. Caregiver may differentiate feel of smooth back form knobby limbs (small parts) and amniotic fluid from fetal body parts. When lie is transverse, head or breech may be palpated on one or other side of torso.
    • Use to confirm presentation/lie and to assess presenting part and descent into pelvis – use thumb and forefinger of dominant hand to gently palpate lower pole of uterus, just above symphysis. Nondominant hand may be used to grasp fundus at same time. If lie is longitudinal and presenting part is cephalic, examiner should feel large bony skull, which is often mobile if not yet deeply engaged. If presenting part is breech, although may not feel bony, its much smaller than head and does not move independent of body. When lie is transverse, lower pole, like fundus, feels empty of fetal parts.
    • Used to confirm presentation/lie and to assess presenting part and descent into pelvis – examiner turns to face woman’s feet and places 1 hand on each side of abdomen. W fingers pointing toward woman’s feet, caregiver presses fingertips gently and firmly toward spine and around presenting part.
  • Term head that is floating above pelvic brim is easily palpated. Feels round, large and mobile. As head descends into bowl of pelvic inlet, it becomes more difficult to palpate. When fetal head is deeply engaged prior to labor, it may be nearly impossible to feel w external palpation and sometimes requires internal assessment or ultrasound to confirm cephalic presentation.
  • Not only do we need to know more about utility of ultrasound as tool to assess fetal position, need more info about low-tech methods. Gap in research addressing whether observation, auscultation and palpation by caretakers can aid in determining fetal position. Does ability to determine position make a difference in labor? Only 2 published trials examined whether OP could be changed by prenatal maneuvers – could change to OA for short periods but no evidence that maintained during labor/birth.
  • Bellymapping – 3-step process by Gail Tully to identify fetal position, integrating mom’s observations, palpation and auscultation of fetal heart. Can combine w Leopold’s maneuvers to involve women in care. Belly Mapping Workbook:
    • Step 1: Make a pie – divide abdomen into quadrants (pie pieces) and draw on paper – which side of belly is firm, where she feels big bulge of fetal buttocks or head, where feels stronger kicks (fetal feet or knees), where she feels stretching from fetal leg movements, where she feels smaller movements (hands, elbows).
    • Step 2: Visualize baby – when certain of fetal position, some draw outline of fetus on abdomen w nontoxic marker. Or may position doll over belly
    • Name position – if provider identifies unfavorable position in late pregnancy, mother may be able to use maternal positioning and exercises to reposition fetus before labor. May be more successful in last weeks before head is engaged. Optimum fetal positioning – OFP – combines late pregnancy and intrapartum positions to facilitate and maintain favorable positions. Spinning Babies uses OFP concepts plus other positions, movements, devices learned from midwives, PTs, chiropractors or own discoveries while working w laboring women.

Other assessments prior to labor

  • Estimating fetal weight – most women w large babies deliver without difficulty, fetal macrosomia can complicate labor. When fetus is large, problems associated w malposition may be compounded. Methods estimating are imprecise. Fundal height measurement poor predictor. Ultrasound assessments and palpation have estimated margin of error of 10-20%. Accuracy of palpation significantly increased when examiner is experienced but reduced when fetus is macrosomic. Inaccurate prediction may influence diagnosis of labor dysfunction, leading to cesarean.
  • Birth weight prediction equation – predicts birth weight of term, healthy Caucasian infants w avg of +-/-8%, better than ultrasound. For predicting macrosomia, equation equivalent to ultrasound. Value of estimating is questionable bc: current methods not reliable; impact macrosomia variable; not possible to reverse fetal weight at or near term. When labor progress poor, estimation and one of many variables factored into labor help resolve dysfunctional labors.
  • Assessing cervix prior to labor – during pregnancy, cervix composed of dense collagen fibers providing firm, inelastic tubular structure that helps keep uterine contents safely contained. In labor, role of cervix is reversed. Must become elastic enough for muscular activity of uterus to open it and expel fetus. Hormonal changes cause alterations in composition of cervical tissue. Collagen fibers break down; elastin fibers in internal os provide stretch; and water content of connective tissue increases, making cervix soft and stretchy. Cervical ripening begins weeks before labor’s onset and caused by hormonal influence distinct form mechanisms of effacement and dilation. Some labor problems, both preterm and prolonged labors at term, may be result of cervical dysfunction rather than uterine dysfunction, when cervix undergoes changes too soon or does not complete them. Some reasons for cervical dystocia are scarring from procedures such as cautery, cryosurgery or other surgery or congenital abnormalities.
  • Bishops 15 point scoring system – induce-ability based on 5 factors: cervical dilation, effacement, consistency, position in vagina and station of head. Ripe of favorable for induction cervix has score 6-8. Also used to assess need of pre-induction cervical ripening agents.
  • Some caregivers use for women not necessarily candidates for induction, sometimes w weekly routine exams in last month of pregnancy. Assessing prelabor cervix in women at term may help identify those more likely to experience short or prolonged latent phases. Nulliparas – women who begin labor w cervices long, firm, closes and posterior more likely to experience prolonged latent phases, while those whose cervixes are thin, stretchy and partially dilated likely to progress more rapidly to active phase. Value of assessment in predicting onset of labor not substantial.
  • Condition of cervix late in pregnancy does not predict when labor will begin or how it will progress.

Assessments during labor – that influence labor progress – position, attitude (whether fetal chin well flexed toward chest), station, cervical change over time, quality of contractions, condition of mom/fetus

  • Position, attitude, and station of fetus- assessed primarily via internal vaginal exams.
  • Vaginal examinations: indications and timing – rather than being down at predetermined interval or according to protocol, done as need for info arises. Reasons that justify:
    • At beginning of caring for woman to establish baseline
    • When period of time in active labor has elapsed, usually more than 3 hrs and labor does not seem to be progressing or when no other signs of progress (mothers affect, spontaneous bearing down), decision must be made about interventions
    • After intervention implemented for some time (period stair climbing to aid in rotation of fetal head or time in bath)
    • Woman requests or expresses discouragement or desire for pain meds
    • Spontaneous urge to push w out other signs of fetal descent
    • When FHR nonreassuring or other concerning signs (excess vaginal bleeding)
    • Internal monitor (scalp lead or intrauterine pressure catheter) needed
  • Performing a vaginal examination during labor
    • Preparing to do exam – observe woman’s labor pattern and her responses –frequency, duration, quality of contractions, how woman is coping, if woman is moving w or bw contractions, positions spontaneously assumed
    • Ask woman to empty bladder. Should lie down comfortable surface, preferably on back w head supported by not more than a pillow. Mother’s legs supported w knees flexed and wide apart and soles of feet together or flat on bed. If back not comfortable, can rest in supported semiprone w pillow wedged under 1 hip w upper knee and hip flexed and supported. Some experienced caregivers can do other positions but more challenging to find position of presenting part. Some may experience fear if have experienced previous trauma.
    • Vaginal exam and other assessments, step by step – wash and warm hands. Start w firm, gently abdominal palpation – basic Leopold’s. Determine location of fetal back. Estimate fetal weight. Assess uterine tone bw and during contractions by gently palpating at fundus w fingertips. Good time to assess FHR and maternal vital signs.
    • Ask permission. If not granted, don’t do it.
    • Between contractions, caregiver inserts first one (forefinger) and then 2 fingers (middle) into vagina, putting firm but gentle pressure on posterior vaginal wall and avoiding pressure on urethra. Ask mom to relax vaginal muscles.
    • If fingers inserted w pads down, when reached bulbocavernosus muscle or ~3-4 cm into vagina, examiner explains she will rotate fingers so wrist is face up – allows for better assessment of cervix, presenting part, vagina and pelvis.
  • Assessing the cervix
    • Position – is os anterior, posterior or midline? When cervical os is posterior, sometimes its just barely possible to reach it but not enough to assess dilation. Caregiver may be able, by applying gentle, steady pressure to reach the os and manually pull it forward. Can ask woman to place fist under each buttock to help tilt pelvis.
    • Consistency – are cervical tissue and os stretchy and soft or firm? As labor progresses, cervix should become softer and more yielding. Thick, rigid cervix is abnormal.
    • Effacement – how long is cervical canal? Its difficult, if not impossible to assess effacement digitally w out being able to insert at least 1 finger into cervix. Since length of cervix prior to labor varies from 1-4 cm, its best expressed in terms of length of cervical canal (rather than %). Completely effaced is paper thin
    • Dilation – how open in cervix, in cm, without manual stretching. First 6-7 cm assessed by evaluating how open cervix is. Takes practice to know approx. # of finger breadths, or distance bw fingers and corresponding dilation. Practice w plastic models or household objects – jars w various sized mouths. Last 3 cm easier to assess bc measured by evaluating how much of cervix remains on 1 side, between open edge of os and where cervix meets lower uterine segment. Measurable full dilation could vary bw 9-12 cm depending on diameters of head
  • Unusual cervical findings
    • Zipper cervix: while cervix is quite thin, os is adherent and closed. Sometimes, after near complete effacement is achieved, this can be overcome by inserting 1-2 fingers and massaging os open during contraction. As adhesion releases, os opens like a zipper, sometimes dilating from 1-4 cm in 1 contraction. Expect bloody show as capillaries rupture w stretching.
    • Rigid os – cervix may be partially dilated but has thickness and lacks a feeling of elasticity. Does not yield easily w contractions. May be a sign of primary cervical dysfunction or a consequence of edema in cervix caused by poorly fitting head or uneven pressure on cervix during contractions. In former, cervix never softens and effaces; in latter, cervix may be thinned and dilated during latent phase or early active phase but becomes swollen in late active phase
    • Os is not palpable at all – lower uterine segment is thinned, head is well-applied w a low station and exam findings may mimic full dilation. Sometimes, possible to find small depression where os is
    • Persistent anterior cervical lip – occurs when most of cervix has retracted behind head (no rim of cervix is palpated around lateral or posterior aspects of head) but anterior portion of cervix is caught bw head and symphysis pubis. Position changes, time and patience usually resolve situation. If tissue feels stretch, may be reduced manually.

The presenting part – is it a head? May not be a head; can risk missing undiagnosed breech presentation. Frank breech may mimic those w extremely malpositioned head: no sutures or fontanelles are felt and leading part feels soft and spongy, as w a caput. Perform speculum exam. Presence of hair confirms cephalic presentation.

Fetal station – in relation to imaginary transverse plane bw ischial spines, where is leading edge of bony skull? To assess station by vaginal exam:

  • Stations expressed in cm above or below ischial spines – zero station. When head has not yet entered pelvis, leading edge is said to be floating.
  • Examiner first finds appropriate location of 1 ischial spine. Easiest to do by reaching w 1 dominant hand diagonally across mother’s pelvis (right hand will palpate right maternal spine). In woman w normal midpelvis, spine will be blunt and not easily palpated, so approximating location takes practice. Helps to find sacrospinous ligament and follow it w 2 fingers from midline to place of insertion on sidewall. Bc insertion point is also location of pudendal nerve, mother may report achy sensation when pressed there.
  • Second, examiner compares level of leading edge of head w level of ischial spines. Use enough pressure to feel bone, to avoid mistaking a large, spongy caput for head at lower station.
  • To assess station by abdominal palpation – according to WHO, when significant degree of caput of molding, assessment by ab palpation more useful than by vaginal exam. Can assess descent w minimum of intrusion, avoid infection risks, make more accurate assessments. Mentally divide fetal head into 5 sections, each about width of 1 finger. When entire fetal head above pubic symphysis, can be palpated w all 5 fingers and is said to be five fifths palpable (at this height, head is mobile). When head can only be felt w 2 fingers – said to be two fifths palpable. When head entirely below symphysis, zero fifths palpable.
  • Less precise measure – how deeply fingers may be inserted before reaching head. If station floating, fingers will be inserted completely and not reach leading edge of head. W station -4 to -2, fingers will be inserted completely and will be able to palpate head w tips of fingers. 0 station – fingers inserted halfway before meeting head. Lower stations – fingers reach head easily.
  • In slow 2nd stage, progress may be in mm rather than cm.
  • High station in active phase, esp in nullipara may suggest malposition or true cephalopelvic disproportion (CPD).
  • Evaluating fetal positing is perhaps single most difficult assessment to make during vaginal exams. Commonly determined by palpating bony landmarks on fetal head through reasonably dilated cervix to determine location of occiput in relation to maternal pelvis. Accuracy of digital id of bony landmarks has been studies and found low level of accuracy w digital exams (w/in 45 degrees). Misdiagnosis of fetal position may cause more harm than no diagnosis.
  • Digital assessment of position of fetal skull: find most easily palpated landmark – sagittal suture. Some degree of asynclitism is normal as head comes into pelvic brim in early labor. W well-positioned head, throughout most of labor sagittal suture usually in right or left oblique diameter and roughly in middle of pelvis. May also be in transverse diameter. During 2nd stage when internal rotation normally occurs, it rotates 45-90 degrees to anterior=posterior diameter of pelvis. If sagittal suture is palpated just below pubic arch, indicates asynclitism. If sagittal suture cannot be felt at all, there prob is significant asynclitism, usually posterior, w posterior parietal bone (parietal bone next to woman’s back) leading and sagittal suture tucked under symphysis pubis
  • Fontanelles are assessed by following sagittal suture line in both directions from midline. Posterior fontanelle is smaller and has 3 points. Does not actually feel like a triangular space as much as joining of 3 suture lines. Anterior fontanelle is much larger; has 4 pts and shaped like diamond.
  • Even when not possible to accurate locate fontanelles, malposition can be detected. Important to notice whether head fits more or less symmetrically. When fetal head malpositioned, does not fill pelvis. Head feels tight in front of pelvis, as if sitting over pubic symphysis, while there is room in back of pelvis
  • Studies show digital assessment of position often impossible, esp in 1st stage. Digital assessment useless for determining fetal position and advocates ultrasound as gold standard. 10% of intrapartum ultrasound exams, scans were uninterpretable.
  • Evaluating flexion of fetal head – w well-flexed head in OA position, small posterior fontanelle is palpable in right or left oblique diameter of pelvis while anterior fontanelle is not. When large fontanelle is easily palpated, fetus is usually in posterior, deflexed position.
    • Evaluating presence of molding – molding, the overlap of bones of head as response to pressure during labor, permits fetal head to better accommodate tight fit through maternal pelvis. Often necessary for fetal descend. If excessive and occurring early in labor, molding may be a sign of difficulty. Evaluating degree of molding, w stage of labor, station, est fetal size and other variables can aid in assessment of dysfunctional labor. Molding obscures fontanelles and makes sutures feel more prominent.
  • Evaluating caput – caput formation, accumulation of fluid in tissue of scalp, also a result of pressure on fetal head. Normally occurs in 2nd stage labor w active descent but may be present in active phase of 1st stage if membranes have rupture. Finding of caput formation w high station could represent undiagnosed breech (soft and spongy) rather than caput. Might also signify OP position or disproportion. Extensive caput also makes assessment of position and state more difficult and is sometimes mistaken for descent. As caput forms, swelling expands lower in pelvis, but fetal head may not have descended at all.
  • Evaluating application of head to cervix – is head well applied to cervix or does cervix feel like empty sleeve? W malpositioned head, common to find cervix soft and stretch but during contractions, head does not press against it. Gives impression of poor fit rather than rigid cervix.

The vagina and bony pelvis – do vaginal muscles feel soft and stretchy or tight and unyielding? Are there any obvious bony abnormalities (flat sacrum, short diagonal conjugate, prominent ischial spines, narrow pubic arch or rigid, prominent coccyx), or does pelvis feel general normal?

Quality of contractions – normal labor characterized by involuntary and intermittent contractions that increase in frequency, duration and intensity over time. Can be visualized as bell-shaped curve consisting of 3 phases: increment (intensity builds), acme (peak), decrement (relaxation as intensity diminishes).

  • Normal coordination of myometrium during labor causes uterus to differentiate into thick, muscular upper segment and a thinning, stretchy lower segment. Retraction, continual shortening of vertical muscle fibers, enables uterus to decrease intrauterine space, thus opening cervix and pushing fetus down and out.
  • When labor dysfunctional, important to evaluate uterine activity. Poor uterine activity can be primary cause of dysfunctional labor or may be effect of other problem such as malpositioned fetus. “uterus has a brain” describes this interplay. When fetus does not fit well thorough the pelvis, contractions often diminish in response to this relative obstruction.
  • Frequency: measured from start of 1 contraction to start of next. Some note # of min from onset to onset. Others record # in 10 min period. Contractions active labor – 2-5 in 10 min. concerns arise when more frequency than 5 in 10 min (tachysystole). Bc placental blood flow is markedly diminished during most intense contractions of labor, min rest of 30 sec between contractions essential for adequate fetal oxygenation. When >5 in 10 min, fetus may not have time to recover. Rarely problem in spontaneous labor but must be considered when labor is induced or augmented, part w high doses of misoprostol and is potential risk w any uterine stimulant
  • Duration – assessed as time from start of contraction to its end. Varies considerably depending on stage/phase of labor. Early labor – 20-30 sec. Active labor 60-90 sec
  • Resting time – subtract duration from frequency.
  • Can be measured using palpation or objectively by electronic monitoring using tocodynamometer (external pressure sensitive device) or intrauterine pressure catheter.
  • Resting tone – degree to which uterus relaxes bw contractions. Normal resting tone <15 mm Hg. High resting tone abnormal and potentially hazardous for mom and fetus. Could lead to uterine dystocia and to fetal intolerance of labor due to inadequate capillary refilling and oxygen transfer at placenta site.
  • Intensity – rise in intrauterine pressure above resting tone w each contractions. Contractions capable of dilating cervix are 30-50 mm Hg above resting tone at acme. Become stronger in 2nd stage and reach max magnitude in 3rd stage, although not perceived to be painful.
  • Although resting tone/intensity can be assessed w external palpation, precise measurements only possible w intrauterine pressure catheter. External monitor’s measurements of resting tone and intensity depend on placement of tocodynamometer and therefore less reliable than palpation by experienced OB. When not using external;/internal devices:
  • External palpation – use watch w sweep 2nd hand and firm pressure of fingers on fundus, assess frequency, duration and resting time. Resting tone and and intensity can be estimated. Bw contractions, fundus should feel soft and relax. Onset of contraction may be palpated before woman feels it. At peak of adequate contraction, woman’s fundus is not indentable and feels wood hard. May detect relaxation phase and end of contraction before woman’s pain sensation abates. This is bc woman still perceives the stimulation of nerve fibers in cervix and lower uterine segment. Use nose, chin, forehead analogy. If uterus feels like nose when pressed, intensity mild; chin – moderate; forehead –intense.
    • Women w substantial adipose tissue over uterine wall will be more difficult to assess.
  • Internal assessment – if caregiver suspects contractions not intense enough to dilate cervix, examining cervix during contraction can help evaluate contraction strength. Much more uncomfortable for woman than cervical assessment done bw contractions, so ask permission. Insert finger before contraction begins and hold fingertips against cervix. W onset of good contraction, edges of cervical os stretch, and head descends, pressing against cervix. If forebag w intact membranes, becomes tight and full. Inadequate contractions are not strong enough to produce these changes, and little stretch is palpated. Cervix may have the empty sleeve feel bc head is not brought into contact w it.
  • Mothers perception – poor indicator of contraction quality since pain perception varies. She is able to report if becoming more intense over time. Dysfunctional labor – less frequent, lasting less time or feeling less intense.

Assessing the mother’s condition

  • Hydration and nourishment – adverse effects of dehydration during labor. Women in labor require approx. 50-100 kcal/hr to maintain adequate muscle function. Research supports free use of oral intake –both fluids and solids. Some will naturally take in calories; some need to be reminded. Prolonged labor may be both a cause and effect of dehydration and insufficient calorie intake. Focus on prevention. Have nonacidic, easy to digest carb snacks and drinks available (broth, electrolyte sports drinks, fruit, honey, toast), offer beverages, encourage to drink to thirst to prevent hyponatremia (may cause prolonged labor due to overhydration from forced oral fluids) and maternal exhaustion by dehydration and poor caloric intake.
    • Urine – void at least every 2 hrs and produce urine light in color. Dark, concentrated or scant urine suggests inadequate fluid
    • Ketonuria – ketosis, accumulation of ketones as result of metabolizing stored fat in absence of adequate carb available, occurs normally in response to both exertion and fasting. Controversy exists whether presence of ketone bodies in urine during labor is sign of maternal compromise
    • Temperature – slight rise in temp normal; if elevated more than 1F and labor prolonged, may signal dehydration. Significant increase in temp (>100.4F) esp in presence of ruptured membranes may signal infection, a serious intrapartum complication
    • Emesis – vomiting common in labor. When prolonged/persistent, dehydration may result. Replacing fluids lost requires additional intake, either oral or IV
    • Fluid loss through perspiration – women laboring in warm conditions, esp in baths, need addtl fluids. Remind to drink to thirst. Offer, but not push, after each contraction or two
    • Maternal distress – inadequate intake may cause anxiety, exhaustion and sickness. Severe dehydration can exacerbate nausea and vomiting. IV may be needed
  • Vital signs – prolonged labor – maternal vital signs should be assessed at regular intervals bw contractions. Presence of elevated blood pressure, pulse or abnormal respiration rate must be noted.
  • Psychology – positive effects of confidence and well being and adverse effects of psychological distress on progress of labor. When no apparent physical reason for poor progress, psychological source should be considered. Minimize stress, support labor environment, assess emotional state, build trust through good communication

Assessing the fetus – most of time, term fetus of otherwise healthy woman tolerates prolonged or dysfunctional labor well. When signs of fetal compromise are present, resolving distress becomes paramount. Fetal Heart Rate, gestational age and presence/absence of meconium in amniotic fluid are elements of fetal assessment.

  • Fetal heart rate – primary source of info about fetal well-being during labor is FHR and fetus’ response to contractions. IA is method of fetal assessment used in home and freestanding birth centers. In many hospitals, auscultation has largely been abandoned, although it is a reliable method of monitoring. Telemetry can be employed or EFM can be used intermittently in order to promote mobility.
    • Appropriate candidates for intermittent auscultation – healthy full term pregnancy, absence of medical interventions such as oxytocin or epidural
  • How to perform intermittent auscultation – handheld Doppler or fetal stethoscope may be used. Ultrasound detects motion of heart valves and converts this into manufactured sound that replicates fetal heartbeat. Fetal stethoscope specially designed ot use bone conduction of examiners skull to transmit subtle sounds of fetal cardiac activity through ear pieces. Doppler offers these advantages:
    • Easier auscultation in a variety of positions
    • Auscultation during contractions
    • Parents and others to hear
    • Does not require pressure on woman’s abdomen, so more comfortable
    • Can be adapted for use in water (requires special waterproof probe)
    • Some studies show improved neonatal outcome compared to fetoscope

Fetal stethoscope offers these advantages:

  • Detects true sounds of fetal heart, including dysrhythmias, avoiding risks of artifact or detecting maternal pulse in error
  • Provides no additional ultrasound exposure
  • Requires no battery or mechanical parts that can malfunction
  • Can also be used to help verify fetal position

General principles of IA

  • Frequency of auscultation: monitor approx. every hr during latent labor. During active first stage, every 15-30 min and every 5 min w active bearing down during 2nd If abnormality detected, more frequent auscultation.
  • Timing of auscultation: between contractions, counting FHR for 60 sec
  • Method of counting: full 60 sec provides most accurate rate. Maternal pulse should be evaluated periodically to ensure rate being counted is fetal and not maternal

Intermittent auscultation technique

  • Use Leopold’s maneuvers to locate fetal back, point of maximal ability to auscultate FHR
  • Palpate for contractions
  • Palpate maternal pulse
  • Place over fetal back
  • Determine baseline by listening for 60 sec
  • Record findings

Reassuring signs of fetal well-being that can be assessed w out CEFM

  • Normal baseline FHR
  • Absence of decelerations
  • Absence of FHR arrhythmia
  • Accelerations of FHR w or w out fetal scalp or vibroacoustical stimulation
  • Fetal movement reported by woman or palpated by examiner
  • Clear amniotic fluid

When using continuous electronic fetal monitoring – critical to establish FHR not mothers that’s being recorded.

  • Baseline FHR definitions: normal FHR baseline rate 110-160 bpm; tachycardia baseline rate >160 bpm; bradycardia less than 110 bpm
  • Variability defined – fluctuations irregular in amplitude and frequency – can only be assessed w CEFM, not through use of IA
    • Absent: no variability
    • Minimal: less than 5 bpm
    • Moderate: 6-25 bpm
    • Marked: >35 bpm
  • Accelerations defined – visually apparent abrupt increase of 15+ beats for 15 sec+. in preterm fetus (32 weeks), 10+ beats for 10 sec+. accelerations considered sign of fetal well-being. Can be counted for 5-15 sec duration. Can and should be listened for and documented during IA
  • Decelerations defined: fall below baseline and defined by onset, timing and shape on CEFM tracing. Not well-distinguished by use of IA
    • Early decelerations are considered normal finding during labor – symmetrical, gradual declines w lowest point occurring >30 sec from onset of contraction. Mirror shape of contraction.   Associated w compression of fetal head that leads to vagal nerve stimulation. Most common in late active and 2nd stage labor
    • Variable decelerations – irregularly shaped and timed occurring <30 sec from onset of contraction. Indicate mechanical compression of umbilical cord that may lead to fetal compromise. Changing mom’s position often reduces pressure on umbilical cord and is 1st step in appropriate care. Significance depends on entire context of CEFM tracing according to 3-tiered system.
    • Late decelerations – gradual uniform declines in FHR w lowest point of deceleration occurring >30 sec from onset of contraction. Defining characteristic is timing bc they occur late in contraction and return to baseline following end of contraction. Consider an indication of potential uteroplacental insufficiency (diminished blood and oxygen flow to baby). Significance depends on 3-tired system.

The 3-tiered fetal heart rate interpretation system

  • Category I – baseline 110-160 bpm; variability moderate. Late or variable decelerations absent.
    • Implications – normal, strongly predictive of normal acid-base status at time of observations; no specific action required
  • Category II – baseline variability – minimal variability, absent variability not accompanied by recurrent decelerations, marked variability
    • Accelerations – absence of induced accelerations after fetal stimulation
    • Periodic or episodic decelerations – recurrent variable decelerations w minimal or moderate BLV; prolonged deceleration (<2 min but <10 min); recurrent late decelerations w moderate BLV; variable decelerations w other characteristics, such as slow return to baseline, overshoots or shoulders
    • Implications: indeterminate, not predictive of abnormal fetal acid-base status; requires evaluation, continued surveillance and reevaluation; take into account the entire associated clinical circumstance

Brief overview of gestational age, meconium and indications for consultation

  • Gestational age: both preterm and post term more vulnerable to stress of labor
    • Premature – decelerations of FHR more ominous
      • Additional risks may be related to etiology of preterm labor (infection/placental abruption)
    • Post-term – increased risks of oligohydramnios, meconium passage, meconium aspiration syndrome and cord compression. Increased likelihood of macrosomia, w attendant labor risks (cephalopelvic disproportion and malposition)
      • Some studies show link bw postdates and shoulder dystocia; others have not confirmed except when macrosomia.
      • Increased risk for placental insufficiency, resulting in growth restriction and higher rates of stillbirth
    • Meconium – may occur when brief episode of hypoxia that causes relaxation of anal sphincter. May indicate compromise in fetal oxygenation. More often a normal maturational event, occurring more frequently as gestational age reaches and exceeds 40 weeks and in 35-50% of all post-term pregnancies. Should be considered sign of fetal compromise if:
      • Associated w nonreassuring FHR pattern
      • Associated w maternal fever or other signs of infection
      • Thick, dark colored, or particulate (containing discrete pieces or chunks)
      • Transfer to hospital – nonreassuring FHR, <37 weeks, >42 wks, significant (dark, thick or particulate) meconium in amniotic fluid

Putting it all together

  • Assessing progress in the 1st stage – latent phase characterized by persistent contractions that do effect change, albeit slow and sometimes subtle. Active phase when more intense/frequent and rate of change becomes more accelerated.
    • Normal latent phase:
      • Cervix softens, effaces slowly but progressively
      • Fetal station may/may not change
      • Dilation slow, up to 4-5 cm
      • Contractions may be regular or irregular, w varying frequency and duration, but usually mild to moderate in intensity
      • Normal duration 20-24 hrs (longest phase for most nulliparas). Woman may be distractible during contractions and carry on normal activities bw contractions
      • Mother does not become exhausted
    • Normal active phase:
      • Cervical effacement becomes complete, later in multiparas than nulliparas
      • Rate of cervical change increase over time, although progress may not be uniform from hour to hour
      • Dilation progresses over time to full dilation, but rate of dilation varies tremendously bw women
      • Fetal head engages, particularly in nullipara
      • Fetal head descends to lower stations, esp toward completion of first stage
      • Woman’s behavior becomes serious and focused, both during and bw contractions. Her coping behaviors may become more dramatic
      • If there is back pain, the place that hurts moves downward over time
      • Normal symptoms during rapid dilation may include an increase in bloody show, nausea, vomiting, shaking, irritability, anger, or feelings of desperation
      • This phase lasts longer for nulliparas than for multiparas
      • The upper limits of normal duration vary from author to author
      • Mother and fetus fare well w the work of labor
    • Assessing progress in the 2nd stage – often a latent phase after full dilation and before fetus descends enough to trigger a pushing urge. If active phase of 2nd stage includes full dilation and spontaneous active pushing efforts, active 2nd stage progress assessed by linear descent of head and concludes w birth of baby
      • Mother has spontaneous pushing urges (unless regional anesthesia)
      • Contractions increase or remain strong and intense, though they may be shorter or less frequent than those in late first stage
      • Fetal head may rotate, mold and form a caput
      • All of mechanisms of labor are accomplished: descent, flexion, internal rotation, birth of head, restitution, external rotation, and birth of shoulders and body of fetus
      • Upper limits of normal duration vary but are longer for nulliparas than for multiparas
      • Mother and fetus fare well w pushing


Mechanism of Labor

  • Asynclitism – head usually engages in pelvis in a synclitic position – one that is parallel to anteroposterior plane of pelvis. Frequently asynclitism occurs (head is deflected anterioroly or posteriorly in pelvis), which can facilitate descent bc head is being positioned to accommodate to pelvic cavity. Extreme asynclitism can cause cephalopelvic disproportion so that it cannot descent.
  • Descent – refers to progress of presenting part through pelvis. Dpends on at least 4 forces: pressure exerted by amniotic fluid, direct pressure exerted by the contracting fundush on the fetus, force of the contraction of the maternal diaphragm and abdominal muscles in 2nd stage of labor and extension and straightening of fetal body. Effects of these forces are modified by size and shape of maternal pelvic planes and size of fetal head and its capacity to mold
    • Degree measured by station. Little descent occurs during latent phase of 1st It accelerates in active phase when cervix has dilated 5-6 cm. especially apparent when membranes have ruptured.
    • In first time pregnancy, descent usually slow but steady; in subsequent pregnancies, may be rapid. Progress in descent of presenting part assessed by abdominal palpation and vaginal exam until presenting part can be seen at introitus
  • Flexion – as soon as descending head meets resistance from cervix, pelvic wall, or pelvic floor, it normally flexes so that chin is brought into closer contact w fetal chest. Permits smaller suboccipititobregmatic diameter (9.5cm) rather than large diameters to present to outlet
  • Internal rotation– maternal pelvic inlet widest in transverse diameter; therefore, fetal head passes inlet into true pelvis in occipitotransverse position. Outlet is widest in anteroposterior diameter; for fetus to exist, head must rotate. Internal rotation begins at level of ischial spines but is not completed until presenting part reaches the lower pelvis. As occiput rotates anteriorly, face rotates posteriorly. W each contraction, fetal head is guided by bony pelvis and muscles of pelvic floor. Eventually occiput will be in midline beneath pubic arch. Head is almost always rotated by the time it reaches the pelvic floor. Both levator ani muscles and bony pelvis are important for achieving anterior rotation. Previous childbirth injury or regional anesthesia may compromise function of levator sling
  • Extension– when fetal head reaches perineum for birth, its deflected anteriorly by perineum. Occiput passes under lower border of symphysis pubis first and then the head emerges by extension: first the occiput, then the face, and finally the chin
  • Restitution and external rotation– after head is born, it rotates briefly to position it occupied when it was engaged in inlet. 45 degree turn realigns infant’s head w back and shoulders. Head can then be seen to rotate further. This external rotation occurs as shoulders engage and descend in maneuvers similar to those of the head. Anterior shoulder descends first. When it reaches the outlet, it rotates to the midline and is delivered from under the pubic arch. Posterior shoulder is guided over perineum until its free of vaginal introuitus.
  • Expulsion– after birth of shoulders, head and shoulders are lifted up toward mother’s pubic bone and trunk of body is born by flexing it laterally in direction of symphysis pubis. When baby has completely emerged, birth is complete, and 2nd stage of labor ends.

YouTube: Childbirth Stations (1:54)

Shows animation of baby going from -3 to +3


Nursing Care of Family During Postpartum Period- Assist mother with rest and recovery from labor and birth. 4th trimester – first 3 months after birth.

Information that must be communicated to postpartum nurse include woman’s name, age, identify of health care provider; gravidity and parity; anesthetic used; any medications given; duration of labor and time of rupture of membranes; whether labor was induced or augmented; type of birth and perineal repair; blood type and Rh status; group B streptococcus (GBS) status; statue of rubella immunity; HIV; Hep B and syphilis serology test results; other infections identified during pregnancy (gonorrhea, chlamydia) and whether these were treated; type and amount of IV fluids, physiologic status since birth; description of fundus, lochia, bladder, and perineum; sex and weight of infant; time of birth; name of pediatric care provider; chose method of feeding; any abnormalities noted and assessment of initial parent-infant interaction. Newborn’s Apgar scores, weight, stooling and whether fed since birth. Nursing interventions done (eye prophylaxis, vit K injection) as well as ID procedures (footprints, armbands) must be recorded.

Bedside reporting is increasingly being used instead of traditional report given at nurses’ station. Bedside reporting has been show to improve client safety and client satisfaction. Clients freel more involved in their plan of care, which increases their satisfaction. Holding report at bedside has enabled many nurses to both visualize and communicate w client at time of report, which improves client safety.


  1. Descent though the pelvis
  2. Ferguson’s Reflex


Secondary Powers – as soon as presenting part reaches pelvic floor, contractions change in character and become expulsive. Involuntary urge to push. Bearing down efforts or secondary powers used to aid in expulsion of fetus as she contracts her diaphragm and abdominal muscles and pushes. These result in increased intra-abdominal pressure that compresses uterus on all sides and adds to power of expulsive forces. Secondary powers have no effect on cervical dilation. When and how woman pushes much-debated topic.

Positioning of Laboring Woman – position affects woman’s anatomic and physiologic adaptations to labor. Frequent changes relieve fatigue, increase comfort, and improve circulation. Woman should be encouraged to find positions most comfortable.

Fig 16-11 Cervical Effacement and Dilation. Cervix is drawn up and around presenting part (internal os). Membranes intact, and head is not well applied cervix.

Process of Labor – term labor refers to process of moving fetus, placenta and membranes out of uterus and through birth canal.


Second Stage of Labor – when infant is born. Begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with baby’s birth. Force exerted by uterine contractions, gravity and maternal bearing-down efforts facilitates achievement of expected outcome of a spontaneous, uncomplicated vaginal birth. Median duration 50-60 minutes in nulliparous women and 20-30 min in multiparous women.   In addition to parity, maternal size and fetal weight, position, and descent influence the length of this stage. Use of epidural often increases length of stage because it blocks or reduces woman’s urge to bear down and limits her ability to attain an upright position to push.

Upper limits for duration of normal 2nd stage: nulliparous – 2 hrs w no regional anesthesia or 3 hours with anesthesia; multiparous women – 1 hr w no regional anesthesia, 2 hours with. Prolonged 2nd stage diagnosed after these time limits reached.

2nd stage composed of 2 phases: latent and active pushing phase. Maternal verbal and nonverbal behaviors, uterine activity, urge to bear down and fetal descent characterize these phases.

Latent (“laboring down”) phase – period of rest and relative calm. Fetus continues to descend passively through birth canal and rotate to an anterior position as a result of ongoing uterine contractions. Woman is quiet and often relaxes w her eyes closed between contractions. Urge to bear down is not strong, and some women do not experience it at all or only during acme (peak) of a contraction. Delayed pushing shown to result in significant decreases in pushing time, significant increase in during of 2nd stage, and a reduction in number of operative vaginal births. No differences in # of cesareans, perineal lacerations or episiotomies, or fetal complications linked to delayed pushing. Allowing a woman to rest during this phase and waiting until urge intensified significantly reduced time spent pushing but did not significantly increase total length of stage. Maternal fatigue scores, perineal injuries, and FHR decelerations were similar in immediate and delayed pushing groups. Another study found significant decrease in pushing time in nulliparous women with epidural who practice delayed pushing.

Careful monitoring with assurance of normal fetal status should be used during delayed pushing. If descent is slow and woman becomes anxious, she should be encouraged to change positions frequently or to stand by bedside to use advantage of gravity and movement to facilitate descent and progress to active pushing phase signaled by perception of need to bear down.

During active pushing (descent) phase the woman has strong urges to bear down as Ferguson reflex is activated when presenting part presses on stretch receptors of pelvic floor. Fetal station is usually +1 and position is anterior. Stimulation causes release of oxytocin from posterior pituitary gland, which provokes stronger expulsive uterine contractions. Woman becomes more focused on bearing down efforts, which become rhythmic. She changes positions frequently to find a more comfortable pushing position. Woman often announces onset of contractions and becomes more vocal as she bears down. Urge to bear down intensifies as descent progresses and presenting part reaches perineum. Woman may be more verbal about pain she is experiencing; she may scream or swear and may act out of control.

Validate woman’s experience of pressure, stretching and straining as normal and a signal that descent of fetus is progressing. Tell her to listen to her own body.

  1. Emotional changes in each stage of labor


Etiologies and risk factors for dysfunctional labor (dystocia):

  • Cervical dystocia – posterior unripe cervix at labor onset, scarred, fibrous cervix or “rigid os,” “tense cervix” or thick uterine segment. Unripe cervix may prolong latent phase. Surgical scarring, damage from disease or structural abnormality may increase cervical resistance.
  • Emotional dystocia– maternal distress or fear, exhaustion, severe pain. Increased catecholamine production may inhibit contractions
  • Fetal dystocia– malposition, asynclitism, large or deflexed head, lack of engagement. Pendulous abdomen, size and shape of pelvis or fetal head may predispose fetus to malposition.
  • Iatrogenic dystocia– misdiagnose of labor or 2nd stage, elective induction (nulliparous), inappropriate oxytocin use, maternal immobility, drugs, dehydration, disturbance. Misdiagnosis or unneeded interventions or restrictions can slow or interfere with labor progress.
  • Pelvic dystocia – malformation, pelvic shape other than gynecoid, small dimensions. Maternal movement and upright positions increase pelvic dimensions.
  • Uterine dystocia – inadequate or inefficient contractions. May 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 vs Suffering- Pain is unpleasant bodily sensation that one wishes to avoid/relieve. Suffering is a distressing psychological state that includes feelings of helplessness, fear, panic, loss of control and aloneness. It’s an inability to cope with pain that is at root of the concern. Women say pain affecting behavior (losing control, crying out, writhing, showing weakness or behaving shamefully) and whether they will find themselves in a state of helplessness. Suffering is similar in definition to trauma and can lead to emotional distress (even PTSD) that sometimes continues long after birth.

2 main approaches to pain management: medication & nonpharmacologic methods

Women asked periodically to assess pain; woman offered medication if it reaches certain level.

More important than assessment of pain is assessment of ability to cope with it.  Can use visual scale or ask after contraction “could you tell me what was going through your mind during that contraction” – her answer will indicate whether she is coping, in distress or both. If coping, all she needs is patience, encouragement and approval. If in distress (crying out, whimpering, struggling or giving up) or has lost rhythm, or if answer indicates emotional distress, it may lead to suffering and she will need intensive emotional/physical support and guidance in different comfort measures to recover a sense that she can cope. If she cannot response to more intensive guidance, she is probably a candidate for pain meds. No woman should remain in a state of suffering.

Labor progress and prevention of dystocia depend on harmonious interactions among a variety of psychoemotional, interpersonal, physical and physiologic factors. Progress is facilitate when a woman feels safe, respected, and cared for by caregivers; when she can remain active, mobile and upright; and when pain is adequate and safely managed. Sense of wellbeing enhanced by caring attentive partner or loved ones; and a calm comfortable and well-equipped birthplace.

Hormones oxytocin, endorphins, catecholamines and prolactin have specific effects; its that balance of hormones that determines net effect on labor progress as well as maternal postpartum mental health, mother-infant interaction, and initiation of breastfeeding.

When neocortex (newer, more uniquely human part of brain – the thinking, reasoning part) is overstimulated, birth process is inhibited. Birth involves coordinated activity within endocrine system and older, more primitive parts of brain that humans share with other mammals.   So minimize stimulation of neocortex. Other mammals seek privacy in comfortable, cozy, quiet space with dim light. In today’s maternity facilities, neocortex constantly stimulated with birth lights, strangers, many questions, unfamiliar sights and sounds and other disturbances inhibiting primate brain function and contributing to dystocia.

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

  • Oxytocin- hormone of “calm and connection” or “love” hormone, contributes to uterine contractions, the urge to push, and fetal ejection reflex, letdown of breastmilk, maternal behavior and feelings of well-being and love. Has opposite effects of catecholamines
  • Endorphinsmorphine like hormones increase with pain, exertion, tress and fear and counteract unpleasant feelings. Create trance-like state in labor (withdrawn, dreamy and instinctual behavior). Contribute to high feelings that many unmedicated women have after birth. Once stress/pain ends, woman has leftover euphoric effects of endorphins
  • Catecholamines stress hormones (adrenalin or epinephrine, noradrenalin or norepinephrine, cortisol and others) secreted when a person is frightened/angry, in danger or feels she is in danger. Hormones of “fight or flight”. Physiologic effect enables person’s body to endure, defend against, or flee a dangerous situation. Counteract effects of oxytocin and endorphins. 1st stage labor contractions may slow down/stop, fetal heart rate may slow, woman becomes tense, alert, fearful and protective of unborn child. Recent studies of female behavior show its better described as “tend and befriend” – protecting offspring and reaching out for support.   In 2nd stage, surge of catecholamines is physiologic and helps mobilize strength, effort and alertness needed to push out baby
  • Prolactin- “nesting hormone” prepares breasts for breastfeeding during pregnancy and after birth; promotes synthesis of milk and has mood-elevating and calming effects on mother. Seems to play a role in altruistic behavior of new mother – ability to put baby’s needs before her own

*Fetus/newborn also produce these hormones, which contribute to fetal well-being during labor, neonatal adaptation, initiation of breastfeeding etc

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

“Fight or flight” response is a physiologic process that promotes survival of endangered or frightened animal/human and is triggered by outpouring of catecholamines or stress hormones. Triggered by physical danger, fear, anxiety or other forms of distress, it has potential of slowing labor progress. During most of 1st stage, excessively high levels of circulating catecholamines cause maternal blood to be shunted away from uterus, placenta and other organs not essential for immediate survival to the heart, lungs, brain and skeletal muscle, the organs essential to fight or flight. Decreased blood supply to uterus/placenta slows uterine contractions and decreases availability of oxygen to fetus.

Fear/anxiety also causes woman to interpret caregivers’ words or labor events in a pessimistic or negative way. High levels of catecholamines prevent woman from entering instinctual mental state, sometimes called “the zone”

As woman nears 2nd stage of labor, which requires alertness and great physical effort, outpouring of catecholamines normally occurs and has beneficial effect of speeding birth by causing fetal ejection reflex. Many women briefly exhibit fear, anger or even euphoria, typical catecholamine responses, just before birth.

Although physiology of fight or flight response is similar in men and women, behavioral differences exist between the two sexes. Males’ responses follow fight or flight pattern (fight to protect self, family, village or country against dangerous attackers, or flee from danger if odds are too great), females’ behavioral responses characterized by pattern of “tend and befriend” which refers to protecting their young from harm and reaching out for help or affiliating with others to reduce risks to themselves and their offspring. Women want and need supportive people around them during labor. In face, absence of this kind is one of the most frequently mentioned reasons for later dissatisfaction with childbirth and is associated with PTSD after childbirth. A woman’s protectiveness toward her child is evident when she is told by a respected caregiver that her baby is in danger. She will quickly agree to whatever treatment is suggested; however, if she does not trust caregiver, she may try to protect child by resisting suggested treatment.

Maternal Effects of Anxiety (Tend and Befriend Response) in Labor

Excessive maternal catecholamine levels in 1st stage of labor:

  • Physiologic response in mother: decreased blood flow to uterus, suppression of oxytocin effects, decreased uterine contractions, increased duration of 1st stage of labor, decreased blood flow to placenta
  • Maternal psychological response: increased negative or pessimistic perception of events and words of others, increased need for reassurance and support, protectiveness toward fetus
  • Physiologic response in fetus: increased fetal production of catecholamines, fetal conservation of oxygen, fetal heart rate decelerations

Excessive catecholamine levels in 2nd stage labor:

  • Maternal effects: alertness, renewed energy and strength
  • Fetal effects: same as listed above; fetal ejection reflex (rapid expulsion of fetus)

To enhance woman’s feelings of security/trust and reduce likelihood of emotional distress:

  • Environment for birth: hospital is an alienating environment for most women, in which institutionalized routines and lack of privacy can contribute to feelings of loss of control. Women more likely to labor out of bed and avoid common OB interventions in environments designed to promote normal birth
  • Psychoemotional measures:
    • Before labor, what caregiver can do: encourage women to think about comforting things she and her partner might have during labor – fav music, scents, pictures, loved ones or a doula, hew own clothing to wear during labor, visualizations, aromatherapy, massage or relaxation techniques. Encourage parents to write birth plan, introducing selves and describing concerns, fears, preferences and choices.
    • During labor: tips for nurses and midwives, esp if meeting woman for first time:
      • Introduce self by name and call her by her name. greet her and her support team. Introduce her to unit (room, lighting, use of bed, bath/shower, call buttons, kitchen, nurses station, lounge)
      • Ask her about plans and preferences
      • Encourage atmosphere of privacy, comfort and intimacy between her and support people:
        • Knock before entering, keep door closes
        • Do not leave body exposed
        • Share comfort devices available (ice pack, hot pack, warm blankets, birth ball, beanbag chair, bath, shower, squatting bar, birth stool, music tapes, juices, tea, others)
        • Encourage cuddling, hugging, slow dancing
        • Encourage and reassure woman and try to remain with her as much as she wishes and as much as other responsibilities allow
      • Explain clinical procedures/tests. Giver her results, if woman’s vital signs, labor progress and fetal heart rate appear normal, tell her
      • Inform her of signs of progress as you identify them (6 ways)
      • Suggest comfort measures
      • Reassure her not only with words but also praise, smiles, touch, hand-holding, gestures of kindness/respect

Physical Comfort Measures – may reduce woman’s stress and likelihood of labor-slowing fight or flight response:

  • Create atmosphere (privacy, no sudden noises, dim light) that encourages woman’s spontaneous self-comforting behaviors and those learned in childbirth class
    • Relaxation techniques/rhythmic movements
    • Calming vocalizations (moans, sighs)
    • Rhythmic breathing
    • Guided imagery/visualization
  • Give her partner suggestions
    • Massage and pressure techniques
    • Timing contractions or counting breaths to help her know where she is in contraction
    • Encourage rhythm in movements, breathing, moaning and even in mental activities
    • Wiping her face and neck with cool damp cloth
    • Giving words of praise and encouragement
    • Speaking rhythmically in a soothing low tone of voice
  • Encourage use of available amenities
    • Hot/cold packs
    • Bath/shower
    • Birth ball
    • Cold/hot beverages, ice chips
    • Lounge
    • Music player, TV


Some Reasons for Excessive Pain and Duration of Prelabor or Latent Phase

  • Iatrogenic factors – oxytocin-induced contractions sometimes painful and debilitating, esp when cervix is unripe or when contractions come every 2-3 min and cervix only 1-2 cm dilated. May be policies that restrict woman to bed; reasons given include ruptured membranes, continuous EFM, pregnancy induced hypertension or hospital custom. In many cases, its not require, but woman is encouraged not to get out of bed.
  • Cervical factors – unripe cervix at term may indicate insufficient remodeling of connective tissues, which causes cervical resistance to increasing intrauterine pressures or presence of muscle fibers in cervix, which cause cervical contractions during uterine contractions. Scar tissue in cervix sometimes increases resistance of cervix to effacement and first few cm of dilation. Contractions of great intensity for many hrs/days, cervical massage or manual dilation may be required to overcome this resistance, after which dilation often proceeds normally
  • Fetal factors – OP position of fetus/brow, face presentation or large unengaged fetal head
  • *Emotional factors – extreme fear, anxiety, loneliness, stress or anger before or during labor may lead to a buildup of catecholamines and a resulting slowdown in progress. Women not supported emotionally or who have experienced previous difficult childbirths; traumatic experiences such as emotional, physical, or sexual abuse; substance abuse; multiple hospitalizations or other experiences may find early labor unexpectedly painful or traumatic. Exhaustion, discouragement, and feelings of hopelessness may result for long prelabor or latent phase. Woman’s optimism and coping ability diminish and her pain worsens as time goes on and without apparent progress. Sometimes helpful to ask woman about her emotional state during latent labor. Between contractions ask “What was going through your mind during that contraction?” or “How are you feeling right now?” or “Why do you think this labor is going slowly right now?” may reveal that mother is distressed or worried over specific concerns. Women having painful nonprogressing prelabor or early labor often appear to be much further along in labor than they truly are. Contractions may be so intense that women must rely on coping strategies that others might now use until late in 1st


Troubleshooting Measures for Painful Prolonged Prelabor or Latent Phase

Validation, intense emotional support, and physical comfort. Try not to contribute to her self-doubt or worries by suggesting something is wrong:

  • If she is discouraged over slow dilation or nonprogressing contractions, remind her that before her cervix can dilate, it must move forward, ripen and efface – each of which is a positive sign of progress.   Disclose any progress (see 6 ways to progress)
  • Avoid term “false labor”
  • Encourage her to use positions that she finds more comfortable
  • Offer bath, shower, or massage as temporary relaxer and pain reliever
  • TENS may be especially useful to relieve back pain during early labor. More useful for back pain than other pain. Do not restrict woman to bed. Before restricting woman with ruptured membranes to bed, caregiver might auscultate fetal heart and assess fetal movement with woman in upright position. Sometimes upright position actually protects against prolapsed cord, as gravity may keep head applied to the cervix, thus preventing cord from slipping through.
  • Many caregivers restrict woman with pregnancy induced hypertension to bed because bp lowers when woman is on left side. Help her focus on comfort measures she can do in bed – relaxation, rhythmic breathing, vocalization, guided imagery, visualizations, other attention focusing measures and massage of back/feet. If limited walking acceptable, can walk to bathroom, to use shower/bath (lower bp). Having choices boosts morale
  • Assess woman’s emotional state
  • For exhaustion, discouragement, and hopelessness, suggest a change: wash face, comb hair, brush teeth, take walk, play some upbeat music. Especially effective as sun comes up after a long night with little progress. New day can renew spirits
  • Have good talk with her and partner, encouraging them to express feelings. May benefit from a good cry, followed by pep talk and perhaps visit from friend/family member
  • If above unsuccessful, drug-induced rest with alcohol, sleep medication or pain reliever may be appropriate choice.


Variations in Prenatal Care – variations that influence care include culture, maternal age, medical and OB history and # of fetuses.

Cultural Influences – standards of care at early prenatal care in not only unfamiliar but also seems strange to women of other cultures. Lack of $, transportation and language barriers, women from diverse cultures may not see care until late in pregnancy or may not participate at al. concern for modesty can be deterrent. For some, exposing body parts, esp to male, considered serious violation of modesty. Invasive procedures such as vaginal exam so threatening they cant discuss it, even w own husbands. Many women prefer females.

Many cultural groups regard care to be necessary only in times of illness. Not considered appropriate during pregnancy.

Cultural prescriptions tell women what to do and cultural proscriptions establish taboos. Purpose of theses practices are to prevent maternal illness resulting from pregnancy-induced imbalanced state and to protect vulnerable fetus. They regulate woman’s emotional response, clothing, activity, rest, sexual activity and dietary practices.

Emotional Response – some cultural proscriptions involve forms of magic. Some Mexicans believe pregnant women should not be allowed to witness an eclipse of the moon because it can cause a cleft palate. Exposure to earthquake can precipitate preterm birth, miscarriage or breech. In some cultures, pregnant women must not ridicule someone with an affliction for fear her child might be born with same handicap.   Mother should not hate a person lest her child resemble that person. Dental work shouldn’t be performed because may cause baby to have cleft lip. Folk belief widely held is that woman should refrain from raising arms above head and from tying knots because they tie knots in umbilical cord and can cause it to wrap around baby’s neck. Placing knife under bed of laboring woman will “cut” her pain.

Physical Activity and Rest – norms that regulate physical activity of pregnancy vary tremendously. Some encourage women to be active, to walk and to engage in normal, not strenuous activities to ensure baby is healthy and not too large. Some believe any activity is dangerous and family members willingly take over work of pregnant woman, believing inactivity protects mom and child. Mother encouraged imply to produce succeeding generation. If health care professionals unaware, they may misinterpret as laziness or nonadherence with desired regimen. Important to find out views on activity and rest.

Clothing – modesty an expectation of many. Amulets, medals and beads women by women from some cultures to promote health or protect woman and fetus from danger. Some Mexican women of U.S. SW and Central America wear cord beneath breasts and knotted over umbilicus. Called a muneco, thought to prevent morning sickness and ensure safe birth.

Sexual Activity – most cultures do not prohibit until end of pregnancy. Some view it as necessary to keep birth canal lubricated.


Emotions during pregnancy chart

Ambivalence about pregnancy, acceptance of pregnancy, physical changes, pride (growing bond with baby), mood swings, concern over partner, quickening, fear of injury, feeling unattractive, nightmares, fulfillment, LABOR, numbness, BIRTH (relief, joy)

  1. Graph of emotional changes for the laboring client
  2. Emotional changes partners may experience during labor and birth
  3. Four hormones of labor and birth


Hormonal Changes During Pregnancy – placenta is the major source of hormones

  • hCG – ensures ovaries produce estrogen and progesterone for first 2-3 months of pregnancy, until your placenta matures and produces appropriate amount
  • Estrogen – promotes growth of uterine muscles and their blood supply, encourages production of vaginal mucus, and stimulates development of the ductal system and blood supply in breasts. Changes in water retention, body fat buildup and skin pigmentation are related to estrogen levels. In late pregnancy, rising estrogen levels increase uterus’s sensitivity to oxytocin and help start labor.
  • Progesterone – relaxes uterus during pregnancy, keeping it from contracting too much. Helps maintain healthy blood pressure, greater absorption of nutrients/sometimes causing constipation. In late pregnancy, it has less effect on your uterus, letting contractions increase and start labor.
  • Relaxin – from ovaries relaxes and softens ligaments, cartilage and cervix, making them more stretchable during pregnancy and letting pelvic joints spread during birth
  • Prostaglandins – produced in amniotic membrane, increase in level during late pregnancy. They soften and ripen cervix in prep for labor and stimulate muscles in uterus and bowels.
  • Corticotropin-releasing hormone (CRG)- comes from baby, placenta, and tissues within your uterus. Increased levels in late pregnancy change ratio of estrogen to progesterone
  • Oxytocin – produced in pituitary gland, stimulates uterine contractions to help trigger onset of labor and promote labor progress. Responsible for urge to push at end of labor and for let-down reflex during breastfeeding.

First Trimester Changes for You and Your Baby – first trimester is “formation” period because by end of it baby’s organ systems are formed and functioning.

First 4 Weeks

  • Changes in Baby – normal human cell 46 chromosomes; blueprint at conception determines baby’s sex, blood type, eye and hair color, nose and ear shape and some personality traits and mental capabilities; also guides baby’s growth and development throughout her life. After conceptions, fertilized egg quickly divides from 1 cell into 2, then 4, 8, 16, and so on until it becomes a multicellular structure called a blastocyst. It makes it way along fallopian tube and implants in uterine lining in upper part of uterus. By 2 weeks, baby is an embryo and another part of the fertilized egg develops into placenta.
  • Changes in You – breast tenderness, slight ache in belly.

PCN 56 Father: Changes in Relationship – may feel left out at times. Instead of you, sher turns to friends and relatives for emotional support. May feel you’re expected to care more for her and your relationship but that she’s less available to you emotionally, physically and sexually.

Role during labor and birth – take a childbirth prep class, watch DVDs or read books and discuss and worries with other fathers and partner. Consider having a friend, relative or doula at birth.

Role as Father – hormone levels in expectant fathers change during pregnancy – lower levels of testosterone and cortisol and higher levels of estradiol.

Hormonal Interactions That Start Labor – if had normal pregnancy, labor typically begins when baby has grown enough to thrive outside body and has needs that placenta can’t meet. A complex interplay of biochemical events signals to both body and baby that it’s time to start labor.

  1. In baby’s brain, hypothalamus (main control center of autonomic nervous system) secretes corticotropin-releasing hormone (CRH), which sets in motion a cascade of hormonal interactions
  2. CRH goes to pituitary gland (which influences hormone secretion) in baby’s brain, stimulating gland to secrete adrenocorticotropic hormone (ACTH), which makes his adrenal glands secrete large amounts of steroid hormone androgen into his blood stream and onto placenta
  3. In placenta, androgen is converted into estrogen, which overrides the calming effects of the hormone progesterone on uterus. Estrogen also causes uterus, membranes, and placenta to produce prostaglandins, which may lead to cervical ripening and uterine contractions. It further causes changes to uterine muscles, increasing the # of oxytocin receptors by 100-200%. This greater # of receptors makes uterus more sensitive to oxytocin, which increases the frequency of contractions.
  4. As uterus contracts, it places pressure on your cervix and causes it to stretch. Never fibers carry impulses from cervix up spinal cord to pituitary gland.
  5. Stimulation of pituitary gland causes it to release more oxytocin, further increasing frequency of contractions
  6. Process gains momentum, and contractions intensify and speed up throughout labor.

How To Distinguish Between Prelabor and Early Labor – most women ~ shift from prelabor (Braxton Hicks which intermittently tighten uterus)) and labor contractions (dilate cervix) subtle and gradual. For a few women, shift is obvious if membranes rupture (bag of waters breaks) w a gush before contractions begin or if contractions begin suddenly and intensely.

Hormones in Labor – before, during and after labor, body produces several hormones:

  • Oxytocin – love hormone, plays major role in orgasm, breastfeeding and childbirth. In labor, causes contractions and helps w progress
  • Stress hormones (catecholamines) – counteract oxytocin and can slow contractions, leading to prolonged labor
  • Beta-endorphins – body’s painkillers, secreted when you experience pain, stress and physical exertion. Help you transcend pain and enter trance state that’s sometimes called birth zone
  • Prolactin – produced after birth necessary for milk production and calms/elevates mood

To decrease stress hormones and increase oxytocin and beta-endorphins during labor, following are essential: confidence, sense of safety, privacy, quietness, familiar places and faces, supportive interactions w others, and feeling loved (and reciprocating that feeling) through touch, massage, kissing and caressing. Following increase stress hormones and decrease oxytocin and beta-endorphins: anxiety, fear, anger, decision-making, frequent disturbances and feeling watched/judged.

More info: read Gentle Birth, Gentle Mothering by Sarah Buckley/Ina May

First Phase: Early Labor: early labor or latent phase usually longest phase in 1st stage often bc contractions further apart, shorter and less intense than later. During early labor, cervix becomes fully effaced and dilates to 4-5 cm. Spend most time at or near home, keeping busy or relaxing if its day time and resting if nighttime. Waiting and wondering phase. Early labor record can help you decide whether in early labor or in prelabor. (175)

Best way to cope is to ignore phase until mind/body no longer lets you. At that point, use coping techniques. This mind-set can influence the interactions of hormones in a way that optimizes labor progress.

The hormones of labor and their functions in labor and early post partum:

  • Oxytocin- hormone of “calm and connection” or “love” hormone, contributes to uterine contractions, the urge to push, and fetal ejection reflex, letdown of breastmilk, maternal behavior and feelings of well-being and love. Has opposite effects of catecholamines
  • Endorphinsmorphine like hormones increase with pain, exertion, tress and fear and counteract unpleasant feelings. Create trance-like state in labor (withdrawn, dreamy and instinctual behavior). Contribute to high feelings that many unmedicated women have after birth. Once stress/pain ends, woman has leftover euphoric effects of endorphins
  • Catecholamines stress hormones (adrenalin or epinephrine, noradrenalin or norepinephrine, cortisol and others) secreted when a person is frightened/angry, in danger or feels she is in danger. Hormones of “fight or flight”. Physiologic effect enables person’s body to endure, defend against, or flee a dangerous situation. Counteract effects of oxytocin and endorphins. 1st stage labor contractions may slow down/stop, fetal heart rate may slow, woman becomes tense, alert, fearful and protective of unborn child. Recent studies of female behavior show its better described as “tend and befriend” – protecting offspring and reaching out for support.   In 2nd stage, surge of catecholamines is physiologic and helps mobilize strength, effort and alertness needed to push out baby
  • Prolactin- “nesting hormone” prepares breasts for breastfeeding during pregnancy and after birth; promotes synthesis of milk and has mood-elevating and calming effects on mother. Seems to play a role in altruistic behavior of new mother – ability to put baby’s needs before her own

*Fetus/newborn also produce these hormones, which contribute to fetal well-being during labor, neonatal adaptation, initiation of breastfeeding etc

How Birth Hormones Prepare Mother and Baby for Birth: Online -The Hormonal Physiology of Childbearing by Dr. Sarah Buckley.

Roles of hormones in preparing pregnant woman and fetus for birth (oxytocin, endorphins, catecholamines, prolactin). Receptors for these hormones increase throughout pregnancy. Best when labor begins on its own and receptors are at ideal numbers. Receptors for catecholamines do not increase, but surge of endogenous steroids and catecholamines in days before onset of spontaneous labor – this prepares fetal lungs for extrauterine life by clearing fetal lung fluid, increasing lung elasticity and increasing lung surfactant. In ~24 hours around time of spontaneous labor, oxytocin reduces oxygen requirements in fetal brain, which protects fetal brain for duration of labor and birth. In animal studies, this neuro-protective effect was reversed when high doses of Pitocin were given, making fetal brain more vulnerable to hypoxia during labor.

Immediate and uninterrupted skin to skin after birth can help restore flow of birth hormones for those who had interventions.

Hormones and Effects of Changes During Pregnancy

Hormone/Source/Effects of Changes During Pregnancy

  • Human chorionic gonadotropin (hCG) – fertilized ovum and chorionic villi; maintains corpus luteum production of estrogen and progesterone until placenta takes over function
  • Progesterone – corpus luteum until 14 wks, then placenta – suppresses secretions of FSH and LH by anterior pituitary; maintains pregnancy by relaxing smooth muscles, decreasing uterine contractibility; causes fat to deposit in subcutaneous tissues over maternal abdomen, back, and upper thighs; decreases mother’s ability to use insulin
  • Estrogen – corpus luteum until 14 wks, then placenta – suppresses secretions of FSH and LH by anterior pituitary; causes fat to deposit in subcutaneous tissues over maternal abdomen, back, and upper thighs; promotes enlargement of genitals, uterus and breasts; increases vascularity; relaxes pelvic ligaments and joints; interferes with folic acid metabolism; increases level of total body proteins; promotes retention of sodium and water; decreases secretion of hydrochloric acid and pepsin; decreases mother’s ability to use insulin
  • Serum prolactin – anterior pituitary – prepares breasts for lactation
  • Oxytocin – posterior pituitary – stimulates uterine contractions; stimulates milk ejection from breasts
  • Human chorionic somatomammotropin (previously called human placental lactogen) – placenta – acts as growth hormone; contributes to breast development; decreases maternal metabolism of glucose; increases amount of fatty acids for metabolic needs
  • Thyroxine-binding globulin, throxine, triiodothyronine – thyroid – with adequate iodine intake, little or no enlargement of thyroid gland. Total T3 and T4 levels are slightly increased, peak by mid-pregnancy, by term are 10-15% lower than nonpregnant
  • Parathyroid – parathyroid – controls calcium and magnesium metabolism
  • Insulin– pancreas – increases production of insulin to compensate for insulin antagonism caused by placental hormones; effect of insulin antagonists is to decrease tissue sensitivity to insulin or ability to use insulin
  • Cortisol – adrenal glands – stimulates production of insulin; increases peripheral resistance to insulin
  • Aldosterone – adrenal glands – stimulates reabsorption of excess sodium rom renal tubules

Hormonal Physiology of Childbearing by Sarah Buckley –  225 pages –

  1. Oxytocin
  2. Catecholamines
  3. Beta-endorphins
  4. Prolactin
  5. Using props

First Stage of Labor and Comfort Strategies: one phase of labor flows into the next. Pg 39-42 in Prepared Childbirth – The Family Way frequently used by students to remind them of things they may try. 6 is the new 4 – active labor now being defined at beginning at 6 cm. Strongly recommended that cesareans for dystocia NOT be suggested before 6 cm.  (pgs 39-42 workbook)

Visual Aids – effacement and dilation. When using doll, treat as a baby. Can use foods from cheerios to bagels or dilation chart. Remember, cervix is a soft, supple organ designed to stretch and open.

Progress in Labor poster from Birth International shows soft, rounded images of baby’s head causing cervix to thin and open

Knitted uterus or turtleneck sweater creates a realistic image of how uterus pulls back and opens the cervix for the baby to come through. (Baby’s head or your own head)

Model of a pelvis and baby doll, show how baby navigates canal as it flexes, rotates and extents

Rubber bands in various diameters and thickness (ones that come on veggies).

Charts – ICEA and Childbirth Graphics.

Graphics – color copies of illustrations on pages 7 and 39-42 of PowerPoint CD

  • Cervix pg 7. Follow effacement and dilation as it progresses through 2nd stage
  • Notice rotation of baby from transverse to anterior
  • Notice how position of baby moves from flexion to extension
  • Refer to pg 7 for discussion of presentation and positions
  • Project illustrations of uterus with different stages of dilation. When played quickly on PowerPoint slide slow, movement and rotation of baby with dilation of cervix are emphasized


  • Notice representation of waves of contractions on pages 39-42 as peaks become higher and closer together as contractions intensify
  • A discussion of labor support is reinforced by these charts which provide a cheat sheet for partner in labor
  • Use labor road map graphic by Penny Simkin while discussing variations of labor, partner roles and comfort measures. Cart and tear sheets available through childbirth graphics

Storytelling: personal stories – tell of women who coped effectively with several days of prelabor contractions. Tell stories of coping with transition. Have former students tell stories. Always ask permission, change names, times, locations to protect identity.

Show one water birth/ labor. Music during labor (play variety so people can see what they like; partner songs).

Simple story of birth – 2 weeks prior to baby’s birth for 1st time moms and closer to baby’s birth for 2nd/subsequent babies, baby drops down into mothers pelvis. When baby’s lungs full mature, baby releases protein that signals moms baby to begin labor. Oxytocin, endorphins, adrenalin all prepare mom and baby for transition to outside world

Small Group activities/learning tasks

  • Give each group a card with scenario of pregnant woman, can use handbook to look up answers.   See 3 scenarios in overview of labor pg 82 or on CD
  • Labor time line game and role play

DVDs: show labor and birth in positive light

  • Celebrate birth! – an inside look at labor; excellent view of 2nd stage in Connie’s birth and poetic segment of women giving birth in Everyday Miracles
  • Of nature and birth – 3 min DVD with inspiring chant “Beautiful Baby”

Game: labor time line – groups 2-4 ppl; give pics of phases of labor and put in timeline – before labor begins, early labor, active labor, transition, pushing. Put things such as rupture of membranes, nausea, panic, hot/cold, leg cramps, anxiety, walk, eat, drink, empty bladder, turn off TV, dim lights etc. can put things in more than one category

Role play: contraction with vocalization, movement, moaning with focal point, loss of focus and panic. After role play, discuss ways partner helped or could have helped. Other role-play is to demonstrate baby’s trip through pelvis, showing cardinal movements (tuck chin, rotate, extend etc)

Pain Management Strategies and comfort measures – don’t underestimate comfort measures

Waterbirth – so effective people call it aquadural. Show at least 1 DVD with women laboring or giving birth in labor

Music During Labor – play wide variety;

Goody bag demonstration – pg 96. Ask them to pack one for last class. Have each person pick an item and guess its use.

Tool belt demonstration – Teri Shilling’s Staying Energized card set

Massage tool circle – small, hand held massage tools. Ask people to bring a tool from home.

Rehearsals/ role playing – having them role-play the same situation at the same time decreases performance anxiety. Discuss what strategies were used.

For final labor rehearsal of series, set up labor stations. Position/activity. Have as many stations as students. Can make posters. Birth Companion pamphlet by Childbirth Graphics. Childbirth Skills Teaching Kit. Add massage toys, music player, warm/ice pack etc to stations. Sample rehearsals on pg 83, 84. Aromatherapy. Rebozo.

Possible Labor Stations: Sensory Station. Hot/cold pack. Vibrators/massages. Focal point, music, aromatherapy suggestions. Ideas for goody bag. Standing Station: birth ball or lean over on table. Against wall. Rebozo, ice wrap, massage tool. Slow dancing. Standing, leaning forward or back. Abdominal lifting. Sitting Station: chair, birth ball, massage tools. Sitting upright, sitting leaning forward, sitting leaning back. Kneeling and all fours station: mat, chair, ball. Side lying with relaxing images station: mat/blanket. Side lying picture. Relaxing images. Touch relaxation station: mats/chairs. Handout for hand massage. Touch relaxation. Movement station: chair/ball. Pictures of movements: birth ball swaying, rocking, swaying, stepping, dancing, knee press, hip squeeze, lunge. Other stations: pushing, breath awareness, birth art, mom’s choice, partner’s choice.

Handouts on Web:; 3 R’s;

Handouts for purchase: Penny Simkin’s road map of labor.

Breathing strategies: (scroll to correct journal)

Collection of Labor Stories: a midwifes story; ill never have sex with you again; birthing a better way; orgasmic birth; belly button bliss; labor of love; adventures in natural childbirth; baby catcher

Labor station card sets: childbirth skills teaching kit. Labor lab-interactive learning for labor coping skills. ICEA stations of labor.

Creative teaching strategies: The idea box and staying energized by T. Shilling on

  1. The baby, plastic pelvis, and knitted uterus with placenta
  2. Using props to model parenting skills


VII. Normal pain

  1. P.A.I.N. – Purposeful, Anticipated, Intermittent, Normal


P: purposeful

A: anticipated

I: intermittent

N: normal

  1. Fear-Tension-Pain Cycle

Lecture/Discussion: Pain Management Theories

The Fear-Tension-Pain cycle is an old standard that still gives good rationale for what we teach. Draw the circle on a board or poster or display the Powerpoint slide. Show how the cycle can be changed:

  • Reduce fear of unknown and fear due to prior conditioning and misinformation, with education. Show images of women coping well with labor and birth, and discuss positive birth stories
  • Reduce tension by teaching relaxation techniques, the benefits of warm showers and baths, and active birth strategies such as walking, changing positions, and rhythmic movements
  • Reduce pain by reducing the fear and tension, and by teaching coping strategies and how they work

Fight or flight response is normal, protective response for fear. Its not helpful to fight or flee from labor; instead we try to elicit relaxation response. Ask students to name which:

Fight or flight or sympathetic system/relaxation or parasympathetic system

  • Pupils dilate/ pupils constrict
  • Mouth dry/ mouth moist
  • Rapid breathing and heart rate/ breathing and heart rate slow
  • Cold sweat/warm sweat or none
  • Blood to extremities/ blood to internal organs
  • Digestion slows; digestion efficient
  • Adrenaline increases and oxytocin decreases/adrenal secretions decrease
  • Muscle tension increases/muscle tension decreases
  • Bp increases/ bp decreases
  • Extremities cold/ extremities warm
  • Body odor increases/ no body odor

Endorphins: long distance runners familiar with these chemically similar to morphine; produced in response to pain and levels increase during pregnancy, then dramatically rise during labor as contractions increase in intensity, peaking with birth of baby. women who exercise during pregnancy have even greater levels. Massage and TENs during labor stimulate production

Sensory stimulation and gate control theory – understanding of neurophysiologic basis for pain reducing strategies is important (see article nonpharmaceutical pain relief by Suzanna Hilbers) alternating various comfort measures such as heat, cold, pressure and movement, pregnancy woman can modify painful stimuli. Painful internal stimuli travel along small diameter nerve fibers while more pleasant tactile sensations travel along faster moving larger diameter fibers. Pain relief is achieved when gate is closed to painful stimuli due to processing of positive stimuli by brain. Brainstorm various ideas that may work; involve all senses and rehearse.

Simulating contractions:

  • Clothespin for muscle fatigue – thumb and first finger to pinch and release the clothespin rapidly for 60 seconds. Lactic acid is formed when oxygen to muscle is depleted. This demonstrates one reason to relax all voluntary muscles in labor while the uterus contracts.
  • Ice as pain stimulus – use various techniques – breathing, vocalizing, moving, focusing, massage etc to block painful stimulations. Can be put in zip lock, in bowls for hands to be immerged, small balloons (can be reused – latex can cause allergy).
  • Wall Squat – when thigh muscles begin to feel tense, a cleansing breath and breathing pattern is begun. They will see the progress in the length of the “contraction” they can handle if they practice this with various coping techniques.

For those who plan natural/unmedicated childbirth: Lamaze has defined 6 healthy birth practices that promote safe and healthy birth:

  • Let labor begins on its own
  • Walk, move around and change positions
  • Bring a loved one, friend or doula for continuous support
  • Avoid interventions not medially necessary
  • Avoid giving birth on back and follow body’s urges to push
  • Keep baby and mom together –best for mom, baby and breastfeeding

Can download at or Show short video clips during class or assign as homework.

Code word – some use a code word for pain medications

YouTube: Pain vs suffering during labor

DVDs: 3 R’s, Natural born babies

References: official Lamaze guide, deliver me from pain

Why Labor is Painful:

  • Reduced oxygen to uterine muscles during contraction, which creates a buildup of waste products such as lactic acid, that in turn causes pain
  • Stretching of the cervix as it dilates
  • Pressure of the baby on nerves in and near the cervix and vagina
  • Tension and stretching of ligaments of uterus and pelvic joints during contractions and baby’s descent
  • Pressure of baby on urethra, bladder and rectum
  • Stretching of pelvic floor muscles and vaginal tissues during birth

Your Perception of Pain – simply understanding they physical reasons helps many women cope. Labor pain is normal and temporary. By changing the way you think of pain, you can alter perception of it and reduce its severity.

Gate Control Theory of Pain – helps explain why people feel more pain in some cases and les sin others and why some people feel it more than others. Think of following experiences: stubbed toe that hurts less when you dance, a bruise that goes unnoticed until after game, pain of physical exertion eased when you focus on a rhythm (counting, chanting or singing a song in your head)

Although pain never goes away, your awareness of it decreases when brain receives other stimuli that are non-painful or pleasant (pain modifiers). Helps explain why distractions help relieve pain. Can make pain more manageable during labor by increasing pleasant stimuli (massage, music, cold packs, heating pad or other distractions and focusing on them).

  1. Gate-Control Theory of Pain

The Labor Progress Toolkit: Part 2. Comfort Measures: Nonpharmacologic methods to relieve pain. Want to acknowledge the benefits of a well-time epidural in serious cases of dystocia: as a precursor to painful interventions; as an aid for an exhausted mother to get some sleep and possibly to create a mind-body split where deep-seated fear or anxiety is cause of dystocia.

General Guidelines for comfort during a slow labor:

  • Frequent position changes (every 20-30 min)
  • Rhythmic movement reduces both pain and anxiety
  • Pressure techniques
  • Heat and cold
  • Hydrotherapy
  • Relaxation, rhythmic breathing, moaning patters, bearing down efforts
  • Experienced doula or labor support brings continuous emotional support

Nonpharmacologic Physical Comfort Measures

  • Heat: use any time she shows pain, anxiety, muscle tension, when she’s chilled or in 2nd stage for perineum to enhance relaxation of pelvic floor. warm moist towel, heating pad, gel pack, rice pack or hot water bottle to lower abdomen, groin, thighs, lower back, shoulders or perineum. Or warm shower on shoulders, abdomen, lower back or immerse. Warmed blanket. Rice filled microwaveable packs can be made by filling large tube sock with 1.5 pounds of dry uncooked rice. Place in microwave 3-5 min; can add lavender seeds or flowers. Be careful of contamination with woman’s body fluids. Can also be used as cold pack. Caution: side effect of epidural is alteration in thermoregulation. She also lacks sensation.
  • Cold: cold compresses to lower back, perineum using ice bag, gel pack, rick pack, latex glove filled with ice chips, frozen wet washcloth, cold soda an, plastic bottle of water etc. use for woman’s face. Use against anus to relieve painful hemorrhoids in 2nd Put layer between. Helps musculoskeletal and joint pain. Decreases muscle spasm (works longer than heat). Slows transmission of pain and other impulses. Caution if woman has epidural
  • Hydrotherapy: shower, bath (caution: water temp no more than 100 degrees – can cause fetal tachycardia). Leave back after 1.5 hours for 30 minutes. Can return after 30 minutes. Can use hand held Doppler designed for underwater use or have woman lift abdomen out of water or step out of shower as needed for intermittent monitoring. Possible alternative to bed rest for women with pregnancy-induced hypertension. Shower can be used in any phase of 1st stage or early 2nd Bath should be used after active labor is established because can slow contractions in early labor. Can be used to stop preterm contractions or give woman temporary rest. Entrance into water before 5 cm is associated with longer labor and greater need for oxytocin augmentation. Don’t use bath if bleeding or fetal distress, on narcotic medications or using epidural.
  • Touch and massage: hands, feet, scalp, shoulders, back. Light, firm stroking, kneading, still pressure. Hands or massage devices. With or without oils, lotions, powders. When woman seems tense, frightened, anxious. Don’t use if not culturally acceptable or is uncomfortable. Can improve blood pressure. Always ask for permission and make sure hands are clean and warm. Use unscented massage oil. Once begin, don’t remove both hands until you are done – unsettling to know when hands will reappear.
    • Shoulder Massage: place hands on shoulders. Stroke firmly from neck to shoulders, then over shoulders to upper arms. Knead upper arms a few times, and stroke firmly toward neck. 3-4x. knead or squeeze and release shoulder muscles 1-2 min. make brief deep circles on tops of her shoulders and along spine with middle three fingers – 15-30 sec each spot.
    • Criss-cross massage – notice where waist is narrowest – one hand on each side, below her ribs; hands pointing opposite directions. Stroke hands firmly up and across her back toward each other. Cross one hand over the other and move to the original starting spots.
    • Hand Massage – if clenches fists, grabs bedrail etc. thumbs placed side by side on back of wrist. Pads of fingers press into palm. Slowly slide thumbs apart and off her hand. Repeat 10x. be careful with swollen hands or carpal tunnel
    • 3 part food massage: sitting on bed – grab one feet with both hands. Have thumbs touch each other and press into sole of foot. Squeeze until it’s firm enough. Slowly slide thumbs apart and off foot. 10x. “Squeeze Apple”= press heel of hand firmly into arch of her foot and grasp her heel; squeeze and release several times as if squeezing tennis ball. Deep circle massage in magic spot – top of foot just below ankle. 30-60 sec.
  • Acupressure: press firmly on point for 10-60 seconds. Rest for equal time. Repeat up to 6x. contractions may speed up during this time. Can also apply ice filled washcloth to Hoku for 20 min at a time. Helps clear blockage of energy flow along particular meridians in body. Good when poor progress so smooth functioning occurs. Don’t use before term.
  • Acupuncture: can turn breech babies, relieve labor pain and induce labor

Continuous support from doula, nurse, midwife – only if she wants one. Doula results in 26% cesareans, 41% fewer instrumental delivers, 28% of mothers less likely to receive pain medication; 33% less likely to be dissatisfied. Support in early labor better than in active labor. 8% births in US attended by midwives and 3% have doulas. Needs to be non-nursing staff for greatest benefit.

Psychosocial comfort measures: excessive production of stress hormones (Catecholamines) can affect uterine and placental function

Assessing Woman’s Emotional State: Sometimes best way is to ask her “What was going through your head during the last contraction?” When distressed during latent phase, more risk of prolonged labor, nonreassuring fetal tones, intolerance of labor and all interventions that accompany such problems – not true of women in active labor/transition. Provide reassuring or comforting sensory stimuli: music the woman likes; massage, backrub, touch; lighting; juice or frozen bars in a flavor she likes; pleasant smelling massage lotion; electronic fetal monitoring audible if it reassures her. Provide reassurance and praise – ask what sensations she’s having and reassure her they are normal – “your body knows just what it’s doing” “it won’t be that much longer” compliment her “you’re doing so well” don’t change a thing “you’re doing perfect” help her reframe distressing thoughts “Can you imagine your strong contractions doing exactly what they are supposed to do – opening your cervix and bringing baby to you?” tell her to go to bathroom (remind her of call light in bathroom if she feels urge to push). Confirm rhythmic motions “you’re great at finding what works for you”. Ask her if it helps to do something during a contraction if not sure. If she is silent, in her own world, do not distract her.

Techniques and Devices to Reduce Back Pain

  • Counterpressure – on woman’s sacrum with the heel or fist of one hand. Place other hand on woman’s hip to help her keep balance.
  • Double hip squeeze – one or two people may do. If 1: place hands on outsides of woman’s hips, over gluteal muscles – over meatiest part of her butt and press inward toward center of her pelvis with whole palms steadily through contraction. 2 person is easier – woman kneels over birth ball, seat of a chair over lowered foot portion of birthing bed over a pile of pillows.
  • Knee press: if woman is seated, press hand over knees, lean towards woman through each contraction. If side lying, two partners are needed – only upper knee is pressed, other partner presses sacrum during contractions to stabilize her. Press knee toward hip joint.
  • Cook’s Counterpressure Technique No 1: ischial tuberosities – woman lies on side or on hands and knees, and apply pressure on both spots with thumbs, heels of hands, fists or tennis balls to sit bones. In Chinese medicine, its acupuncture points UB36 (Urinary Bladder). Can use when woman has a premature urge to push before complete dilation with a cervical lip or swelling. Don’t do if has a preexisting symphysis pubis problems or past pelvic trauma.
  • Cook’s Perilabial Counterpressure Technique No. 2 – late in 2nd stage, caregiver presses externally with thumbs or fingers just outside woman’s labia against both inferior pubic rami to counteract forces of fetal head against pubic arch and pelvic musculature. ***Not appropriate for doula unless she is asked by caregiver. Do when has uncontrollable premature urge to push before complete dilation. When woman is pushing and head is approaching crowning. At crowning when woman is trying not to push in order to protect perineum. Caution as above approach.
  • Cold and heat – pressing and rolling a cold can of juice over woman’s low back is sometimes more appreciated than steady pressure in one area. Use a layer in between. Warm compress if has low back pain. Use caution if had epidural
  • Hydrotherapy – shower/bath
  • Movement – lunge, slow dancing, walking, pelvic rocking, pelvic tilt, swaying, rocking, open knee chest position, abdominal lift and abdominal stroking all encourage fetal rotation and relieve back pain
  • Birth ball – sitting, swaying on birth ball, kneeling on birth ball with knee pads, standing, swaying with balls
  • TENs – Transcutaneous electrical nerve stimulation – hand held battery operated device that causes transmission of mild electrical impulses through skin where they stimulate nerve fibers. 4 pads place d on low back on paraspinal muscles on either side of the spine, two with top edges at level of lowest ribs and two with bottom edges slightly above level of gluteal cleft. Alternating mode after a contraction helps keep woman from habituation to one kind of stimulation. Increase intensity during contractions. It inhibits awareness of pain as described in Gate Control Theory of Pain. May also increase local endorphin production. Greatest benefit if started early in labor, especially if has back pain. Gives her a sense of control. Don’t use with hydrotherapy.
  • Sterile water injections for back pain – intracutaneous or subcutaneous (sometimes called sterile water blocks) reduce back pain and easily performed by clinical personnel. Saline injections do not have same effect.
  • Breathing techniques – see pg 373 further down in document
  • Bearing down techniques for 2nd stage: spontaneous bearing down (pushing) – she bears down when she has the reflexive urge, usually 5-7 seconds. May hold her breath, moan, release air or bellow. Breathe quickly and lightly for several seconds in between.
  • Self directed pushing – when bearing down is unfocused, ineffective and diffuse, without progress for 30 minutes. Eyes clenched shut. Encourage woman to try new position. Gravity enhancing positions. Have her open eyes and gaze at vaginal outlet.
  • Directed pushing – directed how, when and how long to push. Usually holds breath for 10 seconds with 1 short breath in between. Aka purple pushing. Use when anxious and asks for help or if has epidural but should be delayed until fetal head visible or woman feels urge to push.

MWHC 381-384
Ch 17 – Maximizing Comfort for Laboring Woman – pain is a highly individualized phenomenon with sensory and emotional components. It’s the intensity of discomfort that is unique to individual. Pharmacologic and nonpharmacologic methods available – method choses depends on situation, availability, and preferences of women, partner and health care provider.

Pain During Labor and Birth- Neurologic Origins2 origins: visceral and somatic. During 1st stage, uterine contractions cause cervical dilation and effacement. Uterine ischemia (decreased blood flow and therefore local oxygen deficit) results from compression of arteries supplying myometrium during uterine contractions. Pain impulses during 1st stage are transmitted via T1 to T12 spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves. These nerves originate in uterine body and cervix.

Pain from distention of lower uterine segment, stretching of cervical tissue as it effaces and dilates, pressure and traction on adjacent structures (uterine tubes, ovaries, ligaments) and nerves, and uterine ischemia during 1st stage is visceral pain. Its located over lower portion of abdomen. Referred pain occurs when pain that originates in uterus radiates to abdominal wall, lumbosacral area of back, iliac crests, gluteal area, thighs and lower back.

During most of 1st stage, woman usually only has discomfort during contractions. Some women, esp those w fetus in posterior position, experience continuous contraction-related low back pain, even in interval between contractions. As labor progresses and pain becomes more intense and persistent, women become fatigues and discouraged, often experiencing difficulty coping with contractions.

During 2nd stage, woman has somatic pain, which is often described as intense, sharp, burning, and well localized. Pain results from:

  • Distention and traction on peritoneum and uterocervical supports during contractions
  • Pressure against bladder and rectum
  • Stretching and distention of perineal tissues and pelvic floor to allow passage of fetus
  • Lacerations of soft tissue (cervix, vagina and perineum)

As women concentrate on work of bearing down to give birth, may report a decrease in pain intensity. Pain impulses during 2nd stage are transmitted via pudendal nerve through S2 to S4 spinal nerve segments and parasympathetic system.

Pain experienced during 3rd stage and afterpains of early postpartum period are uterine, similar to pain experienced in first stage. Areas of discomfort shown in Fig 17-1

Fig 17-1 Discomfort during labor. A Distribution of labor pain during first stage (lower belly, lower back, hips). B Distribution of pain during transition and early phase of 2nd stage – lower belly, lower back. C. Distribution of pain during late 2nd stage and actual birth (Gray areas indicate mild discomfort; light pink areas indicate moderate discomfort; dark red indicates intense discomfort). Less in lower belly and back. Lot in vaginal area.

Perception of Pain – pain threshold remarkedly similar in everyone regardless of gender and social, ethnic or cultural differences, theses differences play a definite role in person’s perception and behavioral responses. Fear and lack of info can increase pain and discomfort. Knowledge, a positive attitude and support result in decreased pain perception and less use of medication during labor.

Pain tolerance refers to level of pain woman is willing to endure. When level is exceeded, she will seek measures to relieve pain. Factors that influence pain tolerance level and request for pain relief: level of anxiety, nature of support during labor and willingness and ability to participate in nonpharmacologic measures.

Expression of Pain – pain results in physiologic effects and sensory and emotional (affective) responses. Sympathetic nervous system activity stimulated in response to intensifying pain, resulting in increased catecholamine levels.   BP and HR increase. Maternal respiratory patterns change in response to increase in oxygen consumption. Hyperventilation, sometimes accompanied by respiratory alkalosis, can occur as pain intensifies and more rapid, shallow breathing techniques used during contractions. Pallor and diaphoresis may be seen. Gastric acidity increases and nausea and vomiting are common in active and transition phases of 1st stage. Placental perfusion may decrease, and uterine activity may diminish, potentially prolonging labor and affecting fetal well-being.

Certain emotional (affective) expressions of pain often seen. Changes include increasing anxiety with lessened perceptual field, writhing, crying, groaning, gesturing (hand clenching and wringing) and excessive muscular excitability throughout body.

Factors Influencing Pain Response – influenced by variety of physiologic, psychologic, emotional, social, cultural, and environmental factors.

Physiologic Factors – uterine contractions, cervical dilation, and effacement can be cause of discomfort and pain. Fatigue, anxiety, interval and duration of contractions, fetal size and position, rapidity of fetal descent, maternal position, and maternal mobility during labor also affect woman’s perception of intensity of childbirth contractions.

Beta-endorphins are endogenous opioids secreted by pituitary gland that act on central and peripheral nervous systems to reduce pain. Levels increase during pregnancy and birth. Associated w feelings of euphoria and analgesia. Pain threshold may rise as beta-endorphin levels increase, enabling women in labor to tolerate acute pain.

Culture – culture and religious belief system determines how they will perceive, interpret, respond to, and manage pain. Cultural influences may impose certain behavioral expectations regarding acceptable and unacceptable behavior. Women with strong religious beliefs often accept pain as a necessary and inevitable part of bringing a new life into the world, whereas others tend to vocalize their pain by moaning, breathing rhythmically or shouting.

Recognize that woman’s response to pain may vary according to background and may not accurately reflect intensity of pain. Listen to words she uses to describe sensory and affective qualities of pain.

Cultural Considerations – Some Cultural Beliefs About Childbirth and Pain:

  • Chinese women may not exhibit reactions to pain, although exhibiting pain during childbirth is accepted. They consider accepting something when it is first offered as impolite; therefore, pain interventions must be offered more than once. Acupuncture may be used.
  • Arab or Middle Eastern may be vocal in response to labor pain. May prefer medications.
  • Japanese may be stoic, but may request medications when pain becomes severe
  • SE Asian may endure sever pain before requesting relief
  • Hispanic may be stoic until late in labor, when may become vocal and request relief
  • Native American may use medications or remedies made from indigenous plants. Often stoic in response to pain
  • African American may express pain openly. Use of medication varies.

Anxiety – commonly associated with increased pain. Mild anxiety considered normal. Excessive anxiety and fear cause more catecholamine secretion, which increases stimuli to brain from pelvis because of decreased blood flow and increased muscle tension. This action magnifies pain perception. As anxiety and fear heighten, muscle tension increases, effectiveness of uterine contractions decreases, experience of discomfort increase and cycle of increase fear and anxiety begins. Cycle will slow progress of labor. Woman’s’ confidence in her ability to cope with pain will be diminished potential resulting in reduced effectiveness of pain relief measures being used.

Previous Experience – childbirth for healthy young woman may be first experience with significant pain so may not have developed pain coping strategies. For women who have had a difficult and painful previous birth experience, anxiety and fear may lead to increased pain perception.

Sensory labor pain for nulliparous women often grater than for multiparous women during early labor (dilation less than 5 cm) because reproductive tract structures are less flexible. During transition of 1st stage and during 2nd stage, multiparous women may experience greater sensory pain because flexible tissue increases speed of fetal descent. Firmer tissue of nulliparous women results in slower, more gradual descent.

Parity may affect perception of labor pain because nulliparous women often have longer labors and therefore greater fatigue. Fatigue magnifies pain, thus causing many women to have an increased perception of intensity of pain during labor.

Gate-Control Theory of Pain – intense pain stimuli can at times be ignored. Possible because certain nerve cell groupings within spinal cord, brainstem, and cerebral cortex have ability to modulate the pain impulse through a blocking mechanism. Helps explain way hypnosis and pain relief techniques taught in childbirth prep classes. Pain sensations travel along sensory nerve pathways to brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Using distractions techniques such as massage or effleurage, stroking, music, focal points, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. These distractions are though to work by closing down a hypothetic gate in spinal cord, thus preventing pain signals from reaching brain. Perception of pain thereby diminished.

When laboring woman engages in neuromuscular and motor activity, activity within spinal cord itself further modifies transmission of pain. Cognitive work involving concentration on breathing and relaxation requires selective and directed cortical activity that activates and closes the gating mechanism as well. As labor intensifies, more complex cognitive techniques are required to maintain effectiveness. Main impetus behind gate-control theory as it relates to pain is to introduce the pain to a positive stimulus by using all 5 senses. B rain then begins to accept more positive stimulus, while paying less attention to negative stimuli such as discomfort of pain. Stimulating senses will not create a pain-free environment, but can help decrease it.

Comfort – predominant medical approach is that labor is painful and must be removed. Alternate view is labor is a natural process in which women can experience comfort and transcend the discomfort or pain to reach the joyful outcome of birth. Having needs/desires met promotes a feeling of comfort. Most helpful interventions are a caring nursing approach and supportive presence.

Support – evidence indicates woman’s satisfaction with labor/birth experience determined by how well her personal expectations of childbirth were met and quality of support and interaction she received from caregivers and partners. Satisfaction influenced by degree to which she was able to stay in control and participate in decision-making, including pain relief measures.

Value of continuous presence of person who provides physical comforting, facilitates communication and offers info and guidance has been long known. Emotional support demonstrated by giving praise and reassurance and conveying positive, calm and confident demeanor when caring for woman. Women w continuous support beginning early in labor less likely to use pain meds or epidural and more likely to experience spontaneous vaginal birth and express satisfaction with experience. Research concluded that a more positive effect achieved when continuous support provided by people other than hospital staff.

Environment – quality of environment can contribute to her having more positive experience. Woman’s environment includes individuals present (how they communicate, their philosophy of care, including a belief in value of nonpharmacologic pain relief; practices policies and quality of support) and physical space in which labor occurs. Women in supportive environment feel more in control and therefor more likely to have better experience. Studies show correlation between control and increased satisfaction.

Women prefer to be cared for by familiar caregivers in comfortable, homelike setting. Should be safe and private, allowing a woman to feel free to be herself as she tries out difference comfort measures. Stimuli such as light, noise and temp should be adjusted according to her preferences. Should have space for movement, position changes, ambulation, and equipment such as birthing balls. Comfortable chairs, tubs and showers should be readily available to facilitate participation in a variety of nonpharmacologic pain relief measures. Bringing items from home such as pillows, objects for a focal point, music, iPad, or DVDS can enhance familiarity of environment.

  1. Neuromatrix theory of pain

Neuromatrix Theory of Pain – expansion of Gate Control Theory and takes into account all possible factors that can influence how pain is felt and interpreted. Helps explain why women differ in reactions to labor pain and why some women find comfort measures more helpful that others. Past experiences of pain or trauma are factors, as are preexisting factors such as chronic pain or painful medical conditions, anxiety, personality or temperament, physiological factors such as central nervous system’s and endocrine system’s reactions to stress and cultural or familiar attitudes toward pain. Some of these are genetically determined; others are formed earlier in life.

Factors That Increase Labor Pain:

  • Physical: hunger/thirst, fatigue, muscle tension, full bladder, discomfort from staying in same position
  • Emotional/Mental: fear, anxiety, loneliness, or feeling watched or judged (all can release stress hormones); lack of confidence and preparation; ignorance or misinformation about labor/birth; unsupportive staff or relatives; feeling powerless to make decisions or feeling that your decisions aren’t being respected
  • Variations during labor: frequent long contractions or coupling contractions; baby that’s malpositioned; prolonged, tiring labor; exhaustion; rapid intense labor, with little breaks in between contractions; expectations for labor and birth that don’t match actual experience; hospital policies/procedures/interventions that limit mobility or ability to use coping techniques

Measures that make labor pain more manageable – to minimize factors that increase labor pain, be aware of them in advance, make plans to manage them and ensure that your support people are aware of them and work to minimize their impact on you: eat and drink enough to stave off hunger and thirst; dim lights and arrange for minimal interruptions; if have past trauma, get counseling before

Think of what comforts you: what comforts you when sick, what did parents do to make you feel better, what do you do during physical exertion to keep going, what soothes pain of headache/sore muscles, what helps you feel safe in unfamiliar situations, what calms you when stressed/scared, what kind of support from others best helps you. Download worksheet from PCNguide.

Pain vs Suffering in Labor: pain is a mild to unpleasant physical sensation that might or might not be associated with physical damage; suffering is a debilitating emotional state that might be associated with pain or with another cause, such as grief, humiliation or defeat. Can have pain without suffering (strenuous workout). Suffering includes: perceived threat to body/psyche, helplessness and loss of control; distress; inability to cope with distressing situation; fear of dying or death of baby

If don’t have enough stimuli that help reduce perceptions of pain (massage, movement, baths, encouraging words) or if have too many factors increasing it (fear, loneliness, ignorance of what’s happening, immobility, unkind/insensitive treatment, anxiety/depression), more likely to be overwhelmed by pain and feel as if suffering.

  1. Simkin ‘Pain Coping Scale’

Rating Intensity of Pain and Ability to Cope – Pain intensity scale vs pain coping scale

Releasing Control in Labor vs Losing Control – Although you can’t consciously control your contractions, you can control how you respond to them. To help avoid feeling discounted, passive, powerless, learn about options for childbirth well before they begin. Read about interventions you are considering and make sure decisions are reflected in birth plan

Options for Pain Relief – Essential to have a “toolbox” of coping options:

  • Coping skills you’ve used throughout life to comfort yourself when sick, tired, worried, in pain or physically exerting yourself;
  • Self help skills you practice during pregnancy such as breathing techniques, relaxation, visualization and attention focus
  • Comfort items to bring to birthplace such as own pillow or clothes, snacks and beverages, heating pads, cold packs, birth ball, shower/bathtub
  • Hands on support from doula/partner – massage, gentle stroking, acupressure
  • Changes to environment to make it more comfortable such as dimming lights, playing music, aromatherapy, asking for minimal disruptions

Availability of Pain-Relief Options – Options depend on where you give birth. If birth at birth center, won’t have access to epidural. Hospital policies, care practice and available equipment might/might not support various comfort techniques such as eating, mobility, baths/showers, birth balls, acupuncture and aromatherapy. Anesthesiologist may not be available at all times

Effectiveness of Various Pain Relief Options % used, % helpful

  • Epidural 76%, 81%
  • Bathtub 6%, 48%
  • Massage 20%, 40%
  • Iv narcotics 22%, 40%
  • Birth ball 7%, 34%
  • Heat/cold 6%, 31%
  • Relaxation 25%, 28%
  • Position changes 42%, 23%
  • Changes to environment 4%, 21%
  • Breathing techniques 49%, 21%

Although pain medications – especially epidural – can effectively minimize or eliminate pain, they’re also expensive and carry risks and disadvantages that may complicate labor. Consider trying various nun drug methods first to see if they can help you manage effectively. Even if planning to receive epidural or pain meds, still wise to know comfort techniques to cope on way to hospital or while waiting for pain medication.

Determining Your Preferences for Pain Relief – do you prefer to give birth without drugs or do you prefer to use medications? How strongly do you feel about this? May be influenced by past experiences or expectations about labor.   Better able to cope if have info on all available options. More likely to avoid, postpone or minimize if you have a partner or doula who encourages you and helps with self-help comfort measures, supportive staff, caregiver who’s patient/encouraging. The more uncomplicated your labor, the better your chances for non-medicated labor. If labor is prolonged, complicated or includes painful interventions, you’re more likely to need medications.

Pain Medication Preference Scale – PMPS

Being Flexible with Plan for Pain Relief – labor may progress faster than expected, leaving no time for medications or you may be one of unlucky few for whom medications don’t provide adequate pain relief. Partner should remember pain medication preference. If plan to delay, he/she should suggest trying another coping technique for 4-5 contractions before helping you get drugs. Can also use a code word

Preparing to Labor without Pain Medications – if having drug free labor is your goal

  • Confirm partner agrees with goal and helping you achieve it
  • Choose birthplace that supports non-medicated birth and has non-medical tools such as birth balls and large bathtubs. Choose caregiver experienced in supporting women without pain medications. Ask what percentage of clients use pain meds
  • Learn comfort techniques
  • Take childbirth prep classes
  • Consider hiring a doula
  • State wishes in birth plan
  • Avoid/minimize interventions that can increase labor pain (induction and augmentation) or ones that limit mobility (EFM)
  • Consider having code word
  • As move from early labor to active (305 cm), contractions will become painful. Try to adapt breathing, movements or activities to help cope. When cervix dilates 6-7 cm, contraction may become intense. if you can relax between contractions and maintain a rhythm, you’ll be coping well. As move from active labor to transition (7-8 cm), may need to rely on support. Partner can remind you contractions are as painful as they’ll become. If have gone this far, can probably manage rest of labor without pain meds
  • Note to Partners – stay hydrated and keep up energy by eating nutritious snacks.   Conserve strength when physically supporting partner. Use good body mechanics.

The Invaluable Birth Doula – don’t overlook services a birth doula can provide. Unlike nursing staff who must concentrate on completing clinical tasks while providing care, a doula can focus solely on you and your partner. She’ll know your birth plan, likes and dislikes, hopes for birth and pain medication preferences. One woman without a partner hired a doula. Another woman whose mother had died wanted feminine energy of someone who had given birth. Another wanted someone to help her and her partner with comfort measures.

Some couples hire a doula just as much for the partner as for laboring woman, especially if partner isn’t completely comfortable with demands of labor support and needs a guide or helper, or wants someone to take over the role of primary support person. Doula can provide backup support if partner has medical condition such as hypoglycemia (which necessitates getting regular food and rest), becomes queasy at sight of blood, has physical limitations or simply wants to avoid pressure of having to learn and remember all comfort measures.

Can also do necessary tasks for partner so they can focus on primary support such as run errands, fetch food, beverages and comfort items such as ice packs. Can take photos, report progress and developments to couple’s friends and family. Can massage woman’s back while partner helps her maintain rhythm or can continue support so partner can eat, get some air or take much needed nap.

If doula isn’t available or allowed in birthplace (or don’t want one), trusted relatives or friends can do many of the things a doula can do, especially if they attend childbirth prep classes with you and partner.

Contingency Plan – if struggling to cope but still don’t want to receive drugs, ideas to try:

  • Change environment. Take a walk, shower, dim lights or put on relaxing music
  • Change ritual or breathing techniques
  • Eat something or drink a sugary beverage. Sometimes all you need is quick energy boost
  • Find out how far cervix has dilated. Labor may be difficult because you’re making rapid progress
  • Don’t base decision on pain medication on one hard contraction. Find new comfort technique for 4-5 contractions. Endorphins may kick in and may make it manageable.

Preparing to Labor with Pain Medications – Learn about pain medications during pregnancy whether or not you plan to use them. That way, if need arises, you have knowledge about them and can make an informed decision. Both you and baby are affected if you take pain medications so know all possible risks and benefits.

Weighing Risks/Benefits of Pain Medications – benefits include increased ability to relax and sleep, reduction or elimination of pain. Side effects are often mild, manageable and familiar to hospital staff. All interventions have potential risks – decreased blood pressure in mom, prolonged labor, forceps delivery or vacuum extraction, fever in mom or baby and variations in baby’s heart rate. While risks are moderate, may require additional interventions that have their own potential side effects.

  • While medications can minimize or eliminate pain, they generally can’t prevent you from experiencing any.
  • Any medication you receive affects baby. since baby’s liver and kidneys are immature, effects of some drugs last longer than for you. Medication effect depends on drug, amount received, how and when it’s given and other factors. Pcnguide
  • Pain medications affect labor progress. They slow contractions and may increase need for other medical interventions. If labor progress is abnormally slow, drugs may speed up progress by letting you relax
  • Some require restrictions: to bed, of eating and drinking, IV fluids, Pitocin augmentation, administration of oxygen, frequent monitoring of blood pressure and blood oxygen levels, bladder catheterization, EFM, vacuum extraction and cesarean.

Key Vocabulary of Pain Medications

  • Route of administration – oral is a pill or liquid you swallow; inhalation is a gas you breathe; intramuscular is a shot given into muscle; intravenous is an injection into a vein – often through IV catheter; neuraxial are drugs injected into space surrounding spinal cord such as epidurals and spinal blocks. How quickly it takes effect depends on route
  • Areas of effect – systemic (Affecting entire body), regional (large area) or local (specific, relatively small part of body). Need more medication to get desired results with systemic than regional or local
  • Type of effect – analgesia reduces perception of pain while anesthesia indicates loss of sensation including pain sensation; anesthetics block nerve endings from sending pain impulses to brain

Systemic Medications – Pills, injections, gases. They are carried in bloodstream and may affect baby as well because placenta can’t screen them out. Magnitude depends on type and amount used and time between last dose and birth. Other factors include baby’s maturity, health and response during labor.

Medication or its byproducts might not disappear from baby’s bloodstream for hours or days and neurobehavioral changes may be present during first few days. Changes may be obvious or only noticeable to professionals who use highly sensitive tests.

General anesthesia is systemic medication that causes total loss of sensation and consciousness. Its used only for a small % of cesarean births. IV narcotics are systemic medications used most commonly in labor, although IM narcotics are sometimes given.

IV Narcotics or Narcotic-like Medications – reduce transmission of pain messages to pain receptors in brain.

  • Benefits – takes the edge off pain. May take you longer to notice a contraction has started and may seem to fade away sooner. Peak may still be intense enough to feel pain. May work well if you can handle peak but want to have longer break between contractions so you can rest; may even be able to doze between contractions and wake up to manage peak.
  • Tradeoffs – IV fluids, EFM and restriction to bed. May cause sleepiness or lethargy and may cause hazy feeling, disorientation or euphoria. Some find feeling relaxing/pleasant while others feel out on control.
  • Possible side effects – itching, nausea, vomiting. May slow labor and cause variations in baby’s heart rate. Can receive narcotic antagonist to reduce side effects, but it’ll reduce pain relief. After birth, narcotics in baby’s bloodstream may cause her to breathe slowly and have poor muscle tone. She can receive a narcotic antagonist if needed.
  • Timing – effects last 60-90 min. used in early labor when its believed birth is at least 2 hours away. Timing allows effects on baby to fade before birth.

Local and Regional Anesthetics – often called blocks reduce feeling or numbness in particular area of body. When injected near specific nerves, it blocks transmission of sensations along them. Affects muscle control, blood flow and temperature in affected area. Most drug names end with suffix –caine such as lidocaine and bupivacaine.

Local Anesthetics (Perineal Block) – block sensation in small area near nerve endings. Injected into skin, mucous membranes or muscles. During labor, typically injected in perineum (perineal block). Can be injected in cervix (paracervical block) or vagina (pudendal block) but they aren’t often used.

  • Benefits: perineal block numbs perineum and is necessary for repair of episiotomy or lacerations. May numb perineum before episiotomy or forceps delivery.
  • Tradeoff: injections may be painful
  • Possible side effects: if perineal block given during repair of episiotomy or lacerations, side effects minimal. If given early in 2nd stage (rare), medication may affect baby’s heart rate during labor or his reflexes at birth
  • Timing – given during 2nd stage or episiotomy or forceps delivery is necessary. Given in 3rd stage for repair of episiotomy or lacerations.

Regional (Neuraxial) Analgesia and Anesthesia: Epidural and Spinal Blocks – neuraxial medications are injected in your lower back near nerve roots in spinal column. They affect the region of your body to which these nerves and their branches go. The region can be as small as your abdomen and lower back, or as large as the area from your chest to your toes. Medications are often a combination of of an anesthetic fentanyl, which enhances the overall numbing effect. A spinal block is an injection that takes effect quickly and lasts for an hour or two. An epidural catheter is a tube through which medication is given for as long as it’s needed.

  • Benefits – ACOG stated among all options for medicated pain relief, the epidural is the most effective for reducing pain, while allowing the woman to stay alert and actively participate in her labor. 98.8% have significant pain relief. Typically provides relief for rest of labor. Because of locations of injection sites, much smaller amounts of neuraxial can be used than needed for local or systemic analgesia. Fewer mental and respiratory side effects and higher level of satisfaction. Babies are more alert, breathe better and better muscle tone than babies born with higher doses of systemic narcotic like medications.
  • Tradeoffs – accompanied by IV fluids, bladder catheter, continuous monitoring of blood pressure, contractions and baby’s heart rate. Eating/drinking restriction and confined to bed. Reduces mobility. Feeling birth has become a medical event.
  • Possible side effects: most common include decreased blood pressure, longer labor, longer pushing stage and fever. Effects may lead to further interventions (Pitocin augmentation, vacuum extraction or forceps) and secondary side effects on both you and baby (uterine hyperstimulation or variations in baby’s heart rate). Itching/nausea. Some women worry about risk of paralysis or even death but this is so rare its nearly nonexistent. Experience wont depend solely on skills of anesthesiologist; many factors including your and your baby’s physical state and well-being as well as how your body reacts to medications. Postpartum side effect may be shortened duration of breastfeeding. Woman is likely to stop breastfeeding sooner, partly because she might have taken longer after birth to begin holding and nursing her baby and partly because of a mistaken perception that she might not make enough milk. Problems can be overcome by early and frequent skin to skin and by starting breastfeeding within first hour. The earlier a woman initiates breastfeeding and the more often she nurses, the more milk she makes and the more likely she is to have breastfeeding success.
  • Timing – some caregivers require a woman be in active labor (4-5 cm dilated and strong, regular contractions). Epidurals given in early labor likely to slow or stall labor. Others give at any point in labor based on conflicting research that says it doesn’t prolong labor. Others give combined spinal-epidural (CSE), spinal narcotics early in labor and an epidural later on.

Procedure for Epidural and Spinal Blocks – as wait for anesthesiologist, contractions may be intense so may need to cope. Receive IV fluids to reduce risk of drop in blood pressure and to allow for administration of additional medications if needed. Procedures can take 10-20 min. if you have IV in already, nurse can increase flow to give you ¼ to 1 liter of fluid quickly. When anesthesiologist arrives, asked to lie curled on side or sit up and lean forward to curve back. Cleans lower back with antiseptic and numbs skin with local anesthetic. Prep can take 10 min or longer. May need support to help you sit or lie still during contractions. Where and how he places needed or catheter in back depends on type of block:

  • Spinal Block – inserted through dura (tough membrane that surrounds spinal cord) into the intrathecal space, which is filled with cerebrospinal fluid. Drugs given this way called intrathecal medications. Takes affect within minutes and lasts a few hours
  • Epidural catheter – inserted into epidural space, just outside dura. Thin plastic tube (Catheter) threaded through needle, needle is removed, catheter is taped to back, and test dose of medications is given through catheter to ensure you don’t react poorly to the drugs. Catheter is attached to a pump devise that steadily releases small amounts of anesthetic or analgesia. Within a few min, tingling and numbness are noticeable; within 15 min, likely to be completely numb from top of uterus to pelvis or even from chest to toes. Catheter remains in place and pain relief continues throughout labor. May receive doses by continuous drip, series of doses or from when you need them.
  • Combined spinalepidural (CSE)- epidural needle is inserted, then smaller spinal needle is inserted thought it and into intrathecal space for admin of spinal narcotic. Spinal needle is removed and epidural catheter is inserted. No medication is added to epidural at this time. Effects of spinal narcotic last a few hours or until cervix has dilated to 4-6 cm and intensifying contractions cause you to feel pain. When you need more relief, epidural medication is given through catheter.

Temp, blood pressure, pulse and blood oxygen levels are checked frequently.   May also have electrocardiogram (EKG). Many women receive excellent pain relief and don’t experience any side effects. If monitoring indicates that you or your baby are reacting poorly to neuraxial medications, then more interventions may be necessary.

If blood pressures drops significantly, baby’s heart rate will also decrease. Caregiver may turn you onto your side, place an oxygen mask on your face and ask you to breathe deeply. May be given medications or additional IV fluids to raise BP. Managing side effects often causes a cascade of interventions. If epidural causes contractions to slow down, may receive Pitocin to stimulate them – which may overstimulate your uterus, which can lead to variations in baby’s heart rate, which may increase need for cesarean.

Chances of fever increase since medication alters ability to regulate your temp. the longer it’s in place, the higher your risk. When you have a fever, baby’s heart rate may increase to a worrisome level and cesarean may be necessary. Epidural wont cause an infection in baby, but may increase chance shell be treated for one. If you have a fever during labor, baby may have one at birth but it can’t be assumed its because of epidural since it’s associated with infection so baby will be checked for infection with blood tests and possibly a spinal tap. She may be kept in special care nursery and given antibiotics for 2 days until test results are known. It will separate you from baby and can be worrisome.

Options for Epidurals:

  • Patient controlled epidural analgesia (PCEA) – allows you to press a button to give yourself more medication when you need it. Women tend to use less and are more satisfied than when dosage is controlled for them. Although you have some control, device has a timer that limits number of doses which are carefully measured so you cant overdose
  • Combined spinal-epidural (CSE) – uses spinal narcotic in early labor then an epidural in later labor, when you need more pain relief
  • Light or late epidural – reduce side effects by delaying epidural until in active labor and requesting low concentration
  • Policies vary among hospitals
    • Movement – ask whether you’re able to move and whether movement in bed is encouraged
    • Food and drink – some allow only ice chips but may be allowed clear fluids
    • Delayed pushing – may wait to push until baby’s head is visible at vaginal outlet. Has been proven to reduce vaginal tears, forceps delivery, vacuum extraction and need for cesarean.
    • Lowering dosage or discontinuing – by slowing/stopping at beginning of 2nd stage, may be able to bear down more effectively.

Note to Partners: stay with mom and relax together when she has an epidural. It may leave her feeling disconnected from her body and the birth experience; talk with her about the labor and your baby to help her reconnect with events. Help her change positions as much as possible; if she has a light epidural, she may be able to get on hands and knees.

Occasional challenges with epidurals – partner might not initially receive sufficient pain relief; she might experience windows of pain or pain might return after initial relief.

Might have discomforts such as itching, nausea and feeling overheated or chilled. Give her a massage, help her change positions, cover her with a warm blanket, place a cool cloth on her forehead or giver her ice chips or sips of water if allowed. Do not place heating pads or ice packs on any part of her body that’s affected by epidural.

Partner still may experience intense pressure or burning during pushing stage. Reassure her that these sensations are normal and signal that baby will be born soon. If holding one of her legs as she pushes, be careful not to pull back too far – think about her hips normal range of motion and don’t force beyond that point to avoid straining hips, thighs or lower back.

Help partner get lots of skin-to-skin contact with baby so breastfeeding can begin in first hour.

Failed Epidurals – 12% don’t provide complete pain relief when first inserted, while 7% may provide good pain relief initially but fade over time. Some only provide minimal pain relief, others allow for windows of pain. Staff may be able to fix it by changing your position, increasing medication or repositioning epidural catheter – these measures have resulted in good pain relief for nearly all women with epidurals (98.8%).

Key Points – no one should suffer in labor; see PCN guide for pain medications


VIII. Signs of labor

  1. Possible signs of labor


Prelabor – contractions can last 30-40 seconds each and occur 10-20 min apart or may last up to 2 min each and occur 5 min apart. Some women barely notice, while others need to use distraction, slow breathing, tension release etc.

Distinguishing feature is nonprogressing – change very little in length, frequency and intensity over time. May even subside for a while and resume later. May last for a few hours to a day. If lasts longer than a day, consider prolonged prelabor, which can be tiring and discouraging.

Status of labor determines when you can be admitted to hospital/birth centre. If arrive w cervix dilated 3-4 cm, will probably be sent home. Home birth – midwife won’t stay but birth attendant may. Try to focus on helpful ways to get through prelabor – restful, distracting, pleasant activities to make prelabor and early labor positive experiences.

Fathers/Partners: join pregnant partner in distracting activities and try to remain patient, cheerful and attentive. If confused/frustrated, contact doula or friend who has been through labor.

Signs of Labor – recognizing signs is best way to ensure that you don’t’ mistake prelabor contractions for labor contractions. Signs divided into 3 categories: possible, prelabor and positive signs. Might or might not experience all categories.

Possible signs occur in late pregnancy and may indicate hormonal changes underway (but cervical changes aren’t yet occurring). Occur intermittently for days/weeks, but don’t indicate labor.

Possible Signs

  • Restless back pain that comes and goes – vague, nagging back pain often accompanied by feeling of uneasiness or restlessness. Unable to be comfortable in any position for long.   Pain differs from postural back pain that may feel after standing/sitting for a while. May resemble back pain felt before menstrual period and may occur off/on for days. If restless back pain is only symptom, don’t get too excited. By itself, doesn’t indicate labor/prelabor
  • Mild to moderate abdominal cramping – cramps may be similar to menstrual cramps and may be accompanied by discomfort in thighs. With time, may progress into contractions or may stop
  • Frequent, soft bowel movements – may be accompanied by intestinal cramps of upset stomach. Prob due to increased levels of prostaglandins, which cause lower digestive tract to clear itself in order to make room for baby as she descends
  • Nesting urge – sudden burst of energy – scrub floor in home, shop extensively, tie up loose ends at work or spruce up baby’s room – w sense of urgency. Behavior may seem reasonable to you at time, but it may surprise others. May not realize it as sign until after birth. Try to avoid exhausting activities

Prelabor signs indicate labor is probably moving forward, ripening or effacing. May progress into positive labor signs the same day they begin or may simply alert you that labor will begin in a few days/weeks.

Prelabor Signs

  • Nonprogressing contractions – occur regularly and may continue for hrs w/out changing in intensity, frequency or duration. Don’t dilate cervix, but prob prepare it for dilation. Although can be strong, long and frequent, most likely to be milk and occur 8-20 min apart. May last for short time or continue for hrs before disappear/begin to progress. Try to be patient and maintain normal activity – eat, drink and alternate between resting and doing distracting activities.
  • Bloody show – throughout pregnancy, cervix contains thick mucus, which may be loosened or released when cervix begins effacing and dilating. May appear as sticky plug. More often, it becomes thin and liquid (leukorrhea). May be tinged w blood from small blood vessels in cervix that broke as cervix thinned and opened. Can appear before any other labor sign or might not appear until hrs after contractions. Continue to pass bloody show throughout labor.
    • If bloody show is more mucus than blood, you’re fine. If more blood than mucus or vagina is dripping blood, may have broken larger broken blood vessel or more serious problem – call caregiver
    • In late pregnancy, may pass brownish, bloody discharge w/in 24 hrs after vaginal exam or sex, both which can cause harmless cervical bleeding. Easy to mistake for bloody show. If pink or bright red and mixed w mucus, its bloody show. After exam/intercourse, its usually brownish, like dried blood
  • Leaking of amniotic fluid – membranes (bag of waters or amniotic sac) may begin to leak before labor. Leaking fluid before labor occurs in ~10% of pregnancies (in more than half of those, its gush rather than trickle). Leaking may mean you’ve developed small hole in bag high in uterus – underwear feels damp and notice when walking/changing position. Let caregiver known – they may want to confirm it’s amniotic fluid (may be urine or liquid mucus). If have Group B Strep – GBS – she may want to give you antibiotics.

Positive signs – contractions that become longer, strong and more frequent (progressing) and rupture of membranes in gush of amniotic fluid (bag of water bursts, not leaks). Only reliable signs that labor has begun (w few exceptions) is cervix dilating. Although most labors start w progressing contractions but w out rupture of membranes in gush of fluid, ~6% start w latter sign (if happens, you’ll almost certainly begin having contractions w/in min or hours). *if less than 37 weeks and have 2+ possible signs along w 6 contractions in an hr (or 8 contractions in 2 hrs), call caregiver – may be in preterm labor. Rest, bath, drink water to stop contractions; if they don’t stop, will prob be asked to go to hospital.

  • Progressing contractions – purpose is to dilate cervix and push baby down and out of uterus. Become longer, stronger and more frequent (or at least 2).
    • In early labor, prob feel like abdominal tightening w some back pain. As labor advances, likely become painful. If given birth before, may have contractions that come and go for several hrs until pattern becomes continual and progressive. Intermittent contractions can make it difficult to determine whether contractions are progressing so time and keep record.
  • Rupture of membranes w gush of amniotic fluid – water breaking – ROM doesn’t occur in most pregnancies until active phase or labor or later. Some labors begin when ROM occurs w gush of 1/2 -1 cup amniotic fluid. If it does occur, may think wet self or hear popping sound before feeling wetness. Contractions usually start w/in hrs. if membranes rupture before contractions:
    • Note time/color/odor of fluid. Describe amt. Amniotic fluid normally clear and odorless. Strong foul odor may mean infection. Brownish/greenish – baby experienced stress
    • Notify caregiver or call hospital immediately – caregiver may recommend inducing labor soon after ROM if occurs at term and if tested positive for GBS. Caregiver may wait to see if go into labor spontaneously or if can get labor to start. If occurs before term, caregiver may takes steps to prevent labor
    • After ROM, don’t put anything in vagina (tampons/fingers) – increases chance of infection. Vaginal exams also increase risk of infection, so try to limit # of exams. Fine to take a bath – research found doesn’t cause infection. If GBS positive, will prob receive antibiotics to prevent infection in baby.
      • *Rare occasions (<5/1000), babies umbilical cord prolapses (slips through mothers cervix into vagina) when membranes rupture w gush – requires immediate medical intervention bc baby may press against cord and cut off oxygen supply
    • Changes in cervix confirmed by vaginal exam – caregiver checks for cervical position, ripening, effacement or dilation (>4 cm indicates labor). After ROM, caregiver should postpone exam until clear, positive signs of active labor to reduce chance of infection.

Signs of Labor

Possible – Restless back pain, Cramps, Diarrhea, Nesting urge

Prelabor- Nonprogressing contractions, Bloody show, Leaking or trickle of amniotic fluid

Positive- Progressing contractions, Cervix dilated >4cm, Rupture of membranes in a gush of amniotic fluid

Early Labor Record – PCNGuide has template. Apps.

  • Helps decide when to call caregiver or go to hospital/birth center. (4-1-1/5-1-1 rule). Many begin timing when can’t walk or talk through one or when need to use slow/light breathing.
  • Write down time it began, duration – how many seconds it lasted, length of time from beginning of 1 to beginning of next (interval). Include comments about intensity of contractions, appetite and foods you’ve eaten, breathing rhythms used, blood show, status of membranes.
  • Time 5-6 in a row. Stop timing until pattern changes (may take many hrs or just a few). If progressing, prob in labor. If not, prob in prelabor.

Key Points – most reliable signs of labor – progressing contractions and rupture of membranes in gush of amniotic fluid. To confirm, caregiver may check for cervical dilation.

Signs of Labor; Discussion/Q&A

  • What heard from friends/family about onset of labor?
  • What might expect in weeks leading to labor? Lightening, nesting, show/plug
  • Hours preceding birth? Flu like symptoms, backache, contractions, rupture of membranes
  • How likely bag of waters breaking first sign? Note it most often breaks when sleeping rather than running errands or when in hospital in active labor
  • Discuss different feelings of uterine contractions – cramps low in front, pain in back, pressure in groin, tidal waves. Assure them very few women didn’t know they were having a contractions
  • Emphasize importance of staying at home in early labor
  • Reassure students sent home its to their advantage – can eat, drink, change positions, use bath

Lecture/Discussion with Visual Aids

  • Illustration of uterus and discuss Braxton Hicks
  • Cut out 2 pregnant shapes of bodies in With Child Conception to Birth Chart Set before and after lightening. Put one on top of other to show difference in fundal height. Point out pressure on bladder, space for diaphragm before and after lightening
  • Baby doll, knitted uterus and pelvis – can show effacement, dilation, cardinal movements etc
  • Poster showing uterus and utero-sacral ligament will help them see why contracting uterus may be felt in the back as the muscles shorter and pull on the sacrum
  • Use poster/PowerPoint to show rupture of membranes, discuss leak vs gush; C-O-A-T (color, odor, amount, time) to report to care provider; use graphics on family way PowerPoint slide to show mucus plug and rupture of membranes

DVD: good animation of loss of mucus plug, rupture of membranes and contracting/dilating uterus in celebrate birth! And Stages of Labor

How To Time Contractions (graph):

  • Duration – beginning to end of 1 contraction
  • Frequency – beginning of 1 contraction to beginning of next
  1. Positive signs of labor

First Stage of Labor – begins w onset of regular uterine contractions and ends w full cervical effacement and dilation. Consists of 3 phases: latent (early – through 3 cm), active (4-7), and transition (8-10 cm).

Care Management – most nulliparous women seek admission in latent phases because not sure of right time to come in. multiparous women usually do not come until in active phases of 1st stage. Women who have given birth before often less anxious about process, unless experience was negative before.

Assessment – many women call hospital/birthing center first for validation that it’s alright to come in for evaluation or admission or that they remain at home. Many hospitals discourage nurse from giving advice regarding what to do because of legal liability. Nurses often instructed to tell women to call their midwife or to come to hospital if they feel need to be checked. Conversation should be documented in woman’s record.

Woman may first call midwife or go to hospital when in false labor or early in latent phase of 1st stage. May feel discouraged, angry or confused on learning that contractions feel so strong to here but are not true contractions because not causing cervical dilation or still not strong/frequent enough for admission. During 3rd trimester, women should be instructed about stages of labor and signs indicating onset. Should be informed that they will usually not be admitted if cervix is dilated 3cm or less.

If woman lives near hospital and has adequate support and transportation, she may be encouraged to stay at home or return home to allow labor to progress. Ideal setting for low risk women is familiar environment of home, where she can move around freely and eat and drink at will. Woman who lives considerable distance form hospital, who lacks support and transportation or who has history or rapid labors may be admitted in latent labor.

Warm shower is often relaxing during early labor. Warm baths before labor is well established could inhibit uterine contractions and prolong labor process. Soothing back, foot and hand massage or warm drink of preferred liquids such as tea or milk can help woman rest and even sleep, esp if false or early labor is occurring at night. Diversional activities such as walking outdoors or in house, reading, watching TV, playing on computer or smart phone, or talking w friends can reduce perception of early discomfort, help time pass and decrease anxiety.

When woman arrives at hospital, assessment is top priority. Nurse performs screening assessment by using techniques of interview and physical assessment and reviews lab and diagnostic test findings to determine health status of woman and fetus and progress of her labor. Nurse notifies physician. If woman is admitted, a detailed systems assessment is done.

When woman is admitted, she is moved from observation area to labor room: LDR room or LDRP room. Woman can include partner in assessment/admission process if she wishes. Nurse can direct others not participating in this process to waiting area. Woman undresses and puts on her gown or hospital gown. Nurse places ID band on woman’s wrist. Personal belongings put away or given to family members. Some women bring birth bag or Lamaze bag. Nurse shows woman/partner layout of room, how to use call light and phone system, how to adjust lighting and different bed positions.

Hot To Distinguish True Labor from False Labor

True Labor Contractions

  • Occur regularly, becoming stronger, lasting longer and occurring closer together
  • Become more intense with walking
  • Are usually felt in lower back, radiating to lower portion of abdomen
  • Continue despite use of comfort measures

Cervix (by vaginal examination)

  • Shows progressive change (softening, effacement and dilation signaled by appearance of bloody show)
  • Moves to an increasingly anterior position


  • Presenting part usually becomes engaged in pelvis, which results in increased ease of breathing; at same time, presenting part presses downward and compresses the bladder, resulting in urinary frequency

False Labor Contractions

  • Occur irregularly or become regular only temporarily
  • Often stop with walking or position change
  • Can be fest in back or abdomen above umbilicus
  • Can often be stopped through use of comfort measures

Cervix (by vaginal examination)

  • May be soft but with no significant change in effacement or dilation or evidence of bloody show
  • Is often in a posterior position


  • Presenting part is usually not engaged in pelvis
  1. Contractions

Signs of Labor


  • What heard from friends/family about onset of labor?
  • What might expect in weeks leading to labor? Lightening, nesting, show/plug
  • Hours preceding birth? Flu like symptoms, backache, contractions, rupture of membranes
  • How likely bag of waters breaking first sign? Note it most often breaks when sleeping rather than running errands or when in hospital in active labor
  • Discuss different feelings of uterine contractions – cramps low in front, pain in back, pressure in groin, tidal waves. Assure them very few women didn’t know they were having a contractions
  • Emphasize importance of staying at home in early labor
  • Reassure students sent home its to their advantage – can eat, drink, change positions, use bath

Lecture/Discussion with Visual Aids

  • Illustration of uterus and discuss Braxton Hicks
  • Cut out 2 pregnant shapes of bodies in With Child Conception to Birth Chart Set before and after lightening. Put one on top of other to show difference in fundal height. Point out pressure on bladder, space for diaphragm before and after lightening
  • Baby doll, knitted uterus and pelvis – can show effacement, dilation, cardinal movements etc
  • Poster showing uterus and utero-sacral ligament will help them see why contracting uterus may be felt in the back as the muscles shorter and pull on the sacrum
  • Use poster/PowerPoint to show rupture of membranes, discuss leak vs gush; C-O-A-T (color, odor, amount, time) to report to care provider; use graphics on family way PowerPoint slide to show mucus plug and rupture of membranes

DVD: good animation of loss of mucus plug, rupture of membranes and contracting/dilating uterus in celebrate birth! And Stages of Labor

How To Time Contractions (graph):

  • Duration – beginning to end of 1 contraction
  • Frequency – beginning of 1 contraction to beginning of next
  1. Relaxation exercises for the classroom

Teaching Relaxation: first learn to relax yourself, then it will be much easier to teach others. Begin with a recorded session that you play for your class as you join them in relaxing. Model a relaxing position as you introduce session with a soft, relaxing voice. Dim lights, play soft music and shut out distracting noises. Scripts in Prepared Childbirth – The Family Way (pgs 104-106). Begin and end sessions with time to slowly lead in and out of relaxed state – do not rush! Offer a variety of techniques for releasing tension as not everyone responds to the same method. Give time for couples to give feed back to each other. If they can’t communicate their needs now, they won’t be able to in a time of tension. Open discussion after.

Various relaxation techniques:

  • Progressive relaxation helps students become aware of how a muscle feels when it is contracted, stretch and released. Work 1 muscle at a time from head to toe. Ask students if its easier to release a muscle after tensing, stretching or neither (pg 104 handbook)
  • Selective relaxation reinforces muscle isolation. not all muscles are tense or all released at the same time. In labor, it is beneficial for some women to focus on relaxing other muscles as the uterus contracts
  • Touch and massage techniques should be demonstrated and practiced so each student learns to perform them. Different types of massage are described on pg 26 in handbook. Allow time for each to be the giver and receiver of the massage, and to feed back to one another they type of touch each prefers. Practicing massage is a popular homework assignment
  • Visual imagery is a useful tool to help a woman reduce stress, relax, cope with her pain, and to think positively. It can even help labor progress. When using imagery, remember to: consider environment (space, music, lights, temp, pillows); suggest distractions are fewer if they close their eyes; begin the image in the room where they are grounded and safe; address distracting thoughts – they may put them away and have them back after the exercise; suggest a range of sensations they may experience; end the image envisioning the same scenes passed as they left the room; follow up with class discussion of the experiences of those who will share

Biodots: small temperature sensitive pads which may be placed on each student’s hand before a relaxation session. Extremities warm as relaxation occurs, causing the Biodot on the hand to change color. Remind students to check the color of their dot, both before and after the relaxation exercise. A color key is usually included. ICEA bookstore sells. Can wear the next day to see how it changes according to activity/stress levels.

Spiraling relaxation into each class:

Class 1) progressive relaxation and tension awareness; hand massage

Class 2) Selective relaxation; release to touch; autogenic phrases

Class 3) Massage, stroking in various positions

Class 4) Visual imagery; positive affirmations

Class 5) Partners find mom’s “hidden tension” and help her to release it

Class 6) Review all relaxation skills in a labor rehearsal

References: The relaxation and stress reduction workbook; Mother massage – a handbook for relieving the discomforts of pregnancy; Massage during pregnancy by B. Waters

DVD: Penny Simkin’s Comfort measures for childbirth

Relaxation: Awareness Exercise: (sitting in chairs or on floor). Teach tuning into bodies and awareness of bodies early in pregnancy. Script summary “awareness of tension is mastered by consciously focusing on each area of your body – how it moves and how it feels and how it relates to the space around it. 1st, focus on surroundings, then move inward. Feel eye muscles as you look around – what do you see (colors of light, walls, ceiling). Be aware of what you see. What you hear (fan, outside noises). Smell (air, aromas, fragrances, like/dislike, think of smell comforting to you and remember it), feel your presence in this room – you are with others, in a building on this ground on this earth, which you are apart of. Can have eyes focus on point in room or inward. Take a cleansing breath and signal body to let go. Acknowledge thoughts and let them pass. Concentrate on head – tension may cause headaches or may be present with a busy mind. Many muscles and nerves in face and scalp. Think of a pleasant sensation for your head – good hair brush, shampoo/scalp massage, warm hair dryer, cool wind blowing through hair. Try to IMAGINE those you find pleasant (pause for several breaths). Lift fingers and run them through your hair in a way that feels good to you (pressing, massaging, scratching, stroking). EXPERIENCE that sensation now. Try to wiggle scalp. Find the muscles in your scalp – move them – then concentrate on the tension leaving as you allow them to release. Breathe air in through nose – feel it go to lungs and expand your chest/rib cage. Feel release of tension as you sign air out through mouth. Tune into how you breath. Movement of chest/belly. Feel cool air as you breathe in and warm air go to lungs. Can picture a color of the air. May breathe in relaxing color and release a different color. Try for several breaths. Consider jaw – is it tight with clenched teeth? Stretch it open wide, drag it down, yawn, let it go. Let it remain loose with teeth not touching. Move focus to shoulders. Rub them. Feel for tight muscles. Pull shoulders down toward feet to stretch tension away. Release. Drop chin to chest. Feel stretch in back of neck. Feel it with hands. Hold for several seconds. Lift head and look forward. Put right hand on left side of head and pull. Hold. Change hands. Put hands in lap. Think about hands and fingers. Stretch and release stretch. Think of all the wonderful things hands do for you. Cleansing breath and feel release in head, neck, shoulders, arms and down your back. Readjust sitting position. Rock pelvis to be sure you are sitting on “sit bones”. Let tension go from pelvis and let legs flow to your toes. Scan body from head to toe, paying attention to how each of you feels when tension has been released – head, scalp, face, eyes, jaw, tongue, shoulders, neck, arm hands, fingers, back, hips, legs, feet, toes. When you feel tension in any of these during the day, send a relaxing breath to that part. Breathe softy, consciously, with awareness. Return to a state of alertness, slowly increasing pace of breaths. Look around. Move hands and arms, feet, legs. Discuss experience with partner.

At home review of following on page 104 in handbook

Progressive Relaxation Script: If lying on floor: “Get as comfortable as you can. If pregnant, lie on side. Place pillow under head, between knees and under upper arm so you can release into pillows, feeling well supported. Partners – can place pillow on back and under knees. Legs uncrossed. Lying on floor and seated “Purpose of exercise is to learn how a muscle group feels when tense and when it is released. Let go of any worries in your mind. Allow a deep, soothing relaxation to come over your body. Take a deep breath in and let it out. Take breath in and let tension release with a sigh. Think about forehead – is it released or tense? Raise eyebrows in a look of surprise. Release. Frown and feel deep furrows in brow. Hold and release. Imagine someone smoothing your brow, with a warm hand or cool cloth. Move eyes slowly and hold briefly in each direction – look up, down, right, left. Feel tension in your eyes as you move them, then close softly, peering into darkness. Press lips in a tight pucker. Release. Part lips after moistening with tongue. Stretch an exaggerated smile and then release to a soft, relaxed smile. Press tongue to top of mouth – feel what a strong muscle it is – even it can carry tension. Release it to fall loosely in mouth. Bite teeth together gently. Feel tension in jaw as you hold even a gentle bite. Allow jaw to fall open so teeth do not touch. Stretch your jaw by dragging it down, wide open. Yawn if you wish. Allow jaw to close but keep it loose and slack. Pull head into shoulders like a turtle. Release. Let chin drop to chest. Hold. Arc chin to right shoulder. To left. Back to center. Clench fists – hold tight. Release. Be aware of the sensation. Stretch fingers long. Relax. Round shoulders forward. Feel stretch across back as you hold. Release. Pull shoulders back and down. Release. Pull arms tightly against your body. Hold. Now let rest loosely by side. Breathe deeply- filling lungs with air. Blow air out of mouth in a deep sigh. Feel belly rise and pull belly inward as you slowly exhale. Moms body will hug baby with the breath out. Release hug as you inhale and allow baby to float peacefully. Pinch buttocks together. Feel tightness. Release. Push feet and legs together. Release. Push hips and knees outward. Hold. Release. Flex right foot and stretch your leg. Drop foot and leg. Repeat with opposite. Curl toes gently without pointing foot. Hold feel. Release. Wiggle toes. Scan body, thinking of each muscle we just worked. Release them all. Concentrate on this feeling of relaxation. As your practice, the time required to reach this state will shorten.” With more energy “Now it’s time to leave this relaxed state. Do not move quickly. Take time to readjust. Think about the room you are in and the people around you. Be read for the lights to brighten. Slowly move arms and legs. When you are ready, return to a state of alertness. You will feel quite refreshed.”

Illustrations of following on pg 22-24 handbook

Release to Touch – practice in a variety of positions. Refer to illustrations on pg 22-24 in Prepared Childbirth – The Family Way.

Can be done in slow dance, walking and supported standing, but ideal positions are side lying, which provides partner with easy access to mom’s arms, legs, hips and back while she is fully supported and supported sitting, which allows partner to reach limbs, belly, face and neck, while maintaining eye contact.

Script: “Moms, take shoes off and find a comfortable position so you will feel fully supported as you learn to release to touch. Partners, take your place facing her if she is on her side or in front of her or to the side of her if she is sitting so you can reach her shoulders and arms, then hips and legs. Try to keep space on both sides of her as you will have to move around during this sequence. Partners- rubs hands briskly together to warm, then place both hands- warm and relaxed – on mom’s shoulder nearest you. Hold them there, allowing her time to release her tension toward the warmth of your hands. Both of you take a cleansing breath together as a signal to let go of your tension. Partner’s hands should be loose. Gently stroke down her arm with both your hands – all the way to the fingertips, “pulling” the tension from her body. Do not allow her hand to fall. Gently place it back where it was as your hands leave hers. Ask her if she wants more or less pressure. Repeat that motion on the same arm, adjusting pressure to suit her. Hands pause on her shoulder, stroke down the arm, off the hand. Her arm should now feel very loose and relaxed. Notice the difference in the feeling of relaxation in her two arms. Now, place your hands on the crest of her hip. Mom, release to the touch of warm hands as your partner strokes down the top and sides of the leg with both hands…slowly, gently, firmly…all the way to the foot. Pull all her tension out her toes. Ask her about pressure. Adjust it, then repeat stroking the leg from the hip, to the knee, ankle and off the foot. Move to opposite side and repeat the entire sequence. Hands pause on shoulder, stroke down the arm, off the hand. Move to hip, stroke down leg, all the way to her foot and out her toes. Now move to a position behind mom, so you can comfortably reach her shoulders and head. Place both hands together at base of her neck, with your fingers spreading to the tops of her shoulders. Gently press down with the heel of your hands. Mom, release your tension to the pressure of warm hands. Partners, move your touch to a new point on top of her shoulders and press down gently, firmly. Before we move on, ask mom if she likes having her head touched. If she does not, you can massage her shoulders again. Place hands on her head with your fingers touching and the heels of your hands above her ears. Moms, imagine that your partner’s hands are magnets that attract tension and pull it away. Partners, press in very gently with your hands, then just hold slight pressure on her head. Partner’s hand very slowly begin to release pressure, then barely touch your hair. Pull away slowly into the space around the head. Your tension has gone with your partner’s hands. Partners, shake your hands out, then repeat, adjusting again for pressure as she desires. If you are comfortable on side, back is open for touch. If sitting, lean forward so partner may touch and stroke down your back. When doing long strokes on the back, be sure that one of your hands maintains contact with her body at all times. Begin with the heel of your hand near her left shoulder. Stroke firmly with your open palm all the way down her back and hip. Before you release that hand from her hip, place your other hand near her shoulder, just to the right of your last stroke. When that hand begins to move, release the first hand from her hip. Slowly work across her back, hand over hand, stroke after stroke- until you reach her left shoulder. Keep your strokes firm and slow. Discuss your reaction with your partner. Did it help you release tension? Was any touch more irritating than relaxing? Then, reverse roles. Mom, stroke, press or massage partner in a manner to show him how you like to be touched. Demonstrate the pressure and speed you like, then listen to your partner’s feedback. You will probably find you like different types of touch. In the future, you will know how to touch your partner according to their desire, not yours.

Hand Massage: position partner’s hand so it is supported for relaxation, and for you to work comfortably with it. If you choose to use a massage oil or lotion, pour it on your hands, then rub it together to warm it before touching your partner’s hand.

Squeeze and hold gentle pressure with both hands, moving to various positions around the hand. Turning the palm up, use both thumbs to apply pressure in the middle of the palm, just under the knuckles, using counter-pressure on the back of the hand with your fingers. Hold for about 10 seconds. Slowly walk the thumbs randomly throughout the palm of the hand with slow, firm presses or circling motions. One finger at a time, rub on all sides of each finger from the palm to the fingertip. Turn the hand over. Grasp the hand with your thumbs together on the back of the hand. Pull your thumbs firmly to each side as if “breaking a popsicle”. Repeat several time. Supporting your partner’s hand with one of your hands, use your free hand to stroke from the wrist down to the tip of each finger and thumb. Massage and gently pull each finger. With your fingers toward the wrist, place one of your hands on top and one on the bottom of the hand begin massaged. Squeeze firmly and hold to a count of 5, then lighten the pressure and slowly pull your hands down the wrist and of the fingers. Repeat 3x.

Foot Massage: Position the foot so that it is supported in a relaxed position, and it is comfortable for you to work with it. Socks may be left on the feet or, if barefooted, you may choose to use a massage oil or lotion. Pour the oil or lotion on your hands and rub them together to warm it before touching the foot. Use firm strokes and both hands to massage the foot.

Squeeze and hold gently pressure with both hands, moving to various positions around the foot. Press just under the ball of the foot with your thumbs and hold for about 10 seconds. Walk the thumbs around the bottom of the foot with slow presses or circling motions. Use your knuckles to massage the instep and the outer edges of the heel. Use your fingertips to make small circles around the top of the foot. Stroke from the top of the ankle down between each toe. Massage and gently pull or wiggle each toe. Squeeze and release the top of the foot with both hands several times.   Squeeze and release the bottom of the foot with both hands several times. With fingers pointing towards the ankle, place one hand on top and one on the bottom of the foot. Squeeze firmly and hold to a count of 5, then lighten the pressure and pull hands down the foot and off the toes slowly. Repeat 3x.

Visual Imagery: House of Colors – Discuss how colors affected them after this exercise. Did they learn anything about how colors make them feel? Were any colors more stimulating, stressful or relaxing than others? Can be a cue for colors to use in labor, nursery, or in home.

Script: Spend a few moments making yourself as comfortable as possible. Let go of any worries or concerns that may be in your mind. You can have them back when this exercise is over…but let the next few minutes be your time…to experience colors.

As you participate in this imagery session, you may discover how different colors affect you. Some colors you may find relaxing, others more alerting; some may make you feel the sensation of warmth and others may cool you; some colors are pleasant and comfortable and others are not. First, notice this room. Think of the colors you see, and the textures and temperature you feel around you. Then you may wish to close your eyes and take a brief journey in your mind to the remarkable House of Colors.

Imagine if you will, walking up the sidewalk to a fascinating old Victorian style house. Now imagine walking up to the front door. You turn the door handle and enter the first room of the house. This room has been completely decorated in the color red. The ceiling is red, the walls are red, the floor is red, everything in the room is red. What objects do you see in your red room? Pause. Notice how you feel in the red room. Notice how you feel being completely surrounded by the color red. Even the air you breathe is red. Pause. Now prepare to leave the red room behind and open the door to the next room – the orange room.

Repeat with rooms of other colors – Yellow, Green, Blue, Purple, White. The room has been completely decorated in the color ____. The ceiling is _____, the walls are _______, the floor is _______, everything in the room is ______. What objects do you see in your _____ room? Pause. Notice how you feel in the _____ room. Notice how you feel being completely surrounded by the color ______. Even the air you breath is ____.

Now it is time to leave the House of Colors. Imagine yourself leaving the white room, going out the back door, and walking around the front walk, to the sidewalk.   Pause. Now it is time to return to this classroom. Remember the colors and lights in this room. Feel the floor under you. Move your arms and legs a little. When you are ready, let your eyes open.

Visual Imagery: Your Special Place

Script: Spend a few moments making yourself as comfortable as possible in any position you choose. You may take off your shoes, glasses, and put them safely aside. Settle into your pillows, and let the next few minutes be your special time. Visual imagery is really just directed daydreaming. I will ask you to imagine a place where you can become very relaxed. This can be a place that really exists, or simply a place in your imagination. Perhaps you will remember a special vacation – sunning on a warm, sandy beach; enjoying a fireplace in a cabin in the woods; or lounging in a hammock by a cool mountain lake. Or, this can be a place where you have never been, but perhaps have dreamed about. It doesn’t even have to be a real place. In your own imagination you can even be floating on a cloud. It doesn’t matter. The important thing is that this place can become very special to you – it is a place where you can totally relax and enjoy yourself now, and can return to at any time.

Now, if you have settled in, allow a deep, soothing relaxation to come over you as you participate in this imagery exercise. Take a deep breath in…and gently let it out. Take another deep breath in…and gently let it out. As you take a third deep breath in, feel yourself release comfortably into your pillows. And as you breathe out again, let any remaining tension flow away with your exhalation. You may wish to let your eyes close, to shut out distractions. Picture yourself now, leaving this room…and the are where you live. Your imagination takes you to a road. Walk along this road until you come to a spot where you can see forever. Look out from this spot and find an inviting and comforting place…a place in your mind that will become your special place… Pause

Now imagine that you are there in your special place. Pause. Are you by yourself? Or is there someone with you? Pause. What are you doing? Pause. When you look around, what do you see? Pause. Are you indoors? Or outdoors? Pause. What does the air feel like around you? Pause. Are there any special smells in this place? If so, take a moment to enjoy them. Pause. When you listen, what sounds do you hear? Pause. Are there any special sensations that you feel? Take a few moments to enjoy all the sensations that you are feeling in your special place. Enjoy the feeling of relaxation. Pause.

Remember, that anytime you want to, you can return to your special place in your mind, and you can feel the peaceful relaxation that you are enjoying now. Pause.

Look around you before you say goodbye. Now it is time to leave your special place and return to the spot where you could see forever. Walk along the road in your mind, until you return to this room. Feel the floor beneath you. Remember the colors and the lights in this room. Begin to stretch your arms and legs a little. And when you are ready, let your eyes open and come to a sitting position.

Visual Imagery: Birth (for all relaxation and imagery exercises, speak slowly and clearly)

Script: Spend a few moments making yourself as comfortable as possible. You may wish to take off your shoes, and if you wear glasses, you may take them off and put them safely aside. Choose the position that is most comfortable for you. Your arms and legs should be bent at every joint and separate with pillows so that you can be totally release. Let go of any worries or concerns that may be in your mind. You can have them back when this exercise is over…but let the next few minutes be *your* time. Do nothing at all except allow a deep, soothing relaxation to come over you as you participate in this imagery session.

Although this exercise is directed to the pregnant women, I would like the partners to imagine what is happening to her and how you will be able to best support her when it comes time for the baby to be born.

Take a deep breath in, and gently let it out. Take another deep breath in, and gently let it out. As you take a third deep breath in, feel yourself release comfortable into your pillows. And as you breathe out again, let any remaining tension flow away with your exhalation. You may wish to let your eyes close, to shut out distractions.

For this exercise, I would like you to imagine your baby’s birth. It may occur a few days before, or after your due date, or even exactly on the day that you have been expecting your baby. In this exercise, you will think about the sensations that I will be describing, but you will not actually experience these sensations until it is time for your baby to be born.

Think for a moment about the positive aspects of your pregnancy…the amazing way that your belly has grown to make room for your growing baby…the way your breast have gotten bigger to prepare for nursing your infant…the way that your baby communicates with you by kicking and moving around. Many scientists think that when the time is right, your baby will release tiny amounts of a hormone that will instruct your uterus to being contracting. Pregnancy is an amazing, natural process. You are feeling strong, healthy, and confident about giving birth.

Toward the end of your pregnancy, your hormones will instruct your body to prepare for birth. Your cervix may move from a position tilting towards your back to facing forward, right into the birth canal. Your cervix will soften, “ripen”. Periodically you may feel the uterus tighten, as it begins to prepare for labor. These contractions will come and go intermittently, whether or not you feel them. Your baby will settle down into your pelvis. On the day of your baby’s birth, these contractions will gradually become stronger, longer, and closer together…and they will continue to occur…instead of stopping as they have done on previous days. The cervix will stretch and open: 3 cm, 5 cm, 7 cm…this process takes time. Each contraction sends a signal to your brain to release oxytocin. The oxytocin will cause contraction to increase in strength,. And, as the strength increases, labor will progress, and you will be that much closer to holding your baby.

You will find that the pain of labor has a purpose. It will help you discover ways to help your labor progress. You will move and change positions in response to pain. You may walk…slow dance to the music you bring with you…stand under warm water in the shower…or do pelvic tilts on all fours r on your bed. Moving in response to the pain of contractions will actually help you…and will encourage your baby to move into position and down the birth canal. Narcotic-like endorphins are released by your brain in response to pain…to decrease your perception of pain. High levels of endorphins also allow you to “go into yourself,” and tune into your natural instincts, which will help you to manage your labor. Your internal focus on your labor will become more important to you that the surrounding environment. But you will want to have people with you who will encourage you quietly and patiently, so that you will not be afraid. You will feel totally supported, and comforted, as you flow with your labor. Even if labor is long, you will have the energy you need to persevere. You will rest between contractions, paying no attention to the time. Even 30 seconds of rest is a gift. Surround yourself with people who trust the birthing process and who will know that you have the strength and the confidence to give birth. Labor is hard work, but you can do it.

Finally, your cervix will open to 10 cm. your body will rest for a few minutes, then you will begin to feel an urge to push. You tune into the strong sensations that you are feeling, and bear down with your contractions. Your baby will move and rotate, find a way through the birth canal.

After your final push, you will reach out to hold your baby. You will feel joy, excitement, relief, and pride. You and your baby will gaze at one another…in awe of one another. Slowly your baby will nuzzle at your breast, then begin to suck. Sucking will cause oxytocin to be released, and the uterus to tighten. You will then push out the placenta with very little effort. It is a perfect design. The miracle of birth will overwhelm you. A new star in your family constellation will change you forever.

As we end this birth visualization, I would like you to return your mind to the classroom. While you are still relaxed, take a moment to think about what you need to make your birth experience what you want it to be. Pause.

Over the next week, talk to your partner, and to those who will be with you during labor and birth…about those things that will help you to give birth as you wish. Will you have the support and encouragement you need? …the freedom to move around and choose the comfort strategies that best help you? … The patience to let the miracle of birth take place as rapidly or as slowly as it is meant to happen for you? Pause

When you feel ready, slowly begin to increase your breathing rate, move or stretch your arms and legs, then come to a sitting position.

Practice time as a Rehearsal for Labor – learn how to work with partner to use techniques effectively. Practice enough so you’re comfortable with them and review periodically. Visit. for a practice guide. Practicing these exercises, breathing rhythms, and relaxation techniques will increase your confidence in your ability to handle labor and birth.

  • Conditioning exercises (pg 95). Continue practicing until birth
  • Comfort measures for discomforts (pg 103). Use as needed
  • Body awareness exercises (pg 215)
  • Passive relaxation (pg 216)
  • Relaxation countdown (pg 218). At first, use several breaths to relax, then work toward relaxing with one breath
  • Perineal massage (pg 235). During last 5-6 weeks of pregnancy, do 5-6x a week
  • Slow breathing (224)
  • Touch relaxation (219)
  • Roving body check (219) practice by self and with partner
  • Slow breathing with roving body check (224, 219)
  • Attention focusing (208)
  • Crisscross back massage (213)
  • Possible positions for 1st stage of labor (221-222). Practice slow breathing in each position
  • Light breathing (pg 225). Experiment with depth and rate of you breathing
  • Adaptations of slow and light breathing – contraction-tailored, vocal, slide and variable breathing (226-227)
  • Variety of positions for first stage of labor (221-222) while practicing breathing adaptations
  • Ways to decrease back pain in labor (229-232). Double hip squeeze, counterpressure, abdominal lift, open knee-chest position, knee press and lunge. Combing with breathing patterns
  • Ways to avoid pushing (228)
  • Spontaneous bearing down and directed pushing (232-234). Practice gently bearing down and incorporate the bulging exercise (p 96). Occasionally, practice panting to avoid pushing in middle of practice contraction
  • Positions for 2nd stage of labor (222-223). Try while practicing spontaneous bearing down (expulsion breathing)
  • Labor rehearsal: practice all the coping techniques during a series of pretend contractions. Partner can help by observing and helping your fully relax in all positions.
  1. Labor rehearsal – a classroom tool


XII. ICEA Teaching Papers

  1. ICEA Teaching Papers
Using the Body as a Teaching Tool

The Body as the Teaching Tool – ICEA Teaching Idea Sheet #6

Best teaching tool is own body.

  • Fertilization – Form ovary with left hand clenched slightly. Suddenly ovulation takes place, your fist opens releasing the egg into the waiting fallopian tube. The fimbria are the moving fingers of your right hand; the egg travels up the tube (which is your right arm) and finally implants itself in the uterus, formed as your head drops forward and your upper body becomes the waiting uterus.
  • Relaxation: Tension and relaxation can be presented by tightening face, then smoothing out tension with fingers to demonstrate progressive relaxation and the use of touch.
  • Effacement: Nose can serve to illustrate consistency of the cervix before labor begins, firm but flexible and not at all effaced. Tug on your nose with your thumb and forefinger to illustrate this; contrast this with an image of full effacement by using the skin tightly stretched between your thumb and index finger. How thin and stretchy!
  • Contractions: Can use your nose again to give the class the idea of how the abdomen feels with a mild contraction. The forehead can be the consistency of the abdomen when the contractions become stronger.
  • Dilation: Dilating the cervix from 0-10 cm can be pictured by using closed, pursed lips, then stretching your mouth wide open to simulate full dilation. Everyone in the class can see the difference in each other as they return the demonstration. Slide your index finger along the dilated cervix that is your open mouth to demonstrate a vaginal examination during labor.
  • Pelvis: Let’s build a pelvis! Place your thumbs together for the pubic arch; your index fingers touch to form the oval shape of the inlet. Now bend the remaining three fingers on each hand to represent the ischial spines. Ask the class to do this with you and then have everyone look down into the pelvis just as the baby does when labor begins. They can see the wider transverse diameter of the pelvic inlet and the roomier anterior-posterior diameters of the outlet. The explanation of the internal rotation of the head to fit into the pelvis, past the spines and under the pubic arch is easier to visualize.
  • Progress of Labor: Clench fingers tightly into a fist to show the cervix at the beginning of labor, allowing only a fingertip to pass through. As labor progresses and the contractions become stronger and more effective, the thumb and the forefinger of the fist begin to relax and show progressive dilation. Both hands together now with thumbs and index fingers overlapped, you can progress from 0-10 cm.
  • Pushing: Use your body to form the J, demonstrating the angle which will produce the most effective pushing. Start the pushing demonstration sitting flat on the floor, using an over-turned straight-back chair as your backrest to simulate being semi-reclined in a hospital bed. Ask for suggestions from the class about improving your pushing. They could tell you to get out of bed, squat, turn to the right or left lateral positions. Have someone support you as you push. Demonstrate everything they suggest, illustrating that there are many ways to push and no one “right” way that works for every birth
  • Perineum: Have each class member pull his/her forefingers to the outside corners of the fully opened mouth. The burning sensation will simulate the feeling in the perineum just before the head is born. Remember the stretched skin between the thumb and index finger? Use this now to demonstrate the taut perineum. If an episiotomy is indicated, you can show the difference between the midline and mediolateral episiotomy by drawing two lines down from the vaginal opening across the stretched perineum.


Using a Pelvic Model – ICEA Teaching Idea Sheet #1: Using a Pelvic Model

Pelvic Model Can Be Used:

  • Female anatomical structure and function – important parts of pelvis, such as inlet, outlet, ischial spines, coccyx etc. Effects of hormone relaxin on joints, as well as increased size of pelvic outlet can be illustrated by loosening screws on plastic model. Station, descent, cardinal movements, process of birth, fetal positions and presentation can be demonstrated by using w a fetal doll or fist
  • Positions for pushing – use flexible clothes dryer (part which leads from dryer to outside vent; right angle – can purchase ad hardware store) elbow to show advantages and disadvantages of various positions. Insert elbow directly into pelvis to demonstrate “down-up-and-out” dynamics of pushing. Gives visual explanation of value of upright position.
    1. Available in 2 forms: metal and plastic (recommended). Discussion of elasticity of vagina important.
  • Posterior position and back labor – point out coccyx and sacrum. Physiological reasons for back massage, counter measure and effleurage.
  • Good posture and body mechanics – place pelvis in carious positions. Teach pelvic rocking by tilting pelvis forward and backward.
  • Causes of common discomforts of pregnancy – swelling, sciatic pain, decreased circulation in extremities, pelvic distention and hemorrhoids can be illustrated by using pieces of ribbon, rope or yarn to portray abdominal sorta (1 red piece), sciatic nerves (2 green pieces), and pelvic veins (2 blue movies). Place them in pelvis as they appear anatomically. Ribbons may be taped. Inflate medium sized balloon until shaped like uterus. Place neck down into pelvis to show effect of weight of gravid uterus on arteries, veins and nerves. Shows graphic of supine position on laboring woman. Use neutral colored balloon and under-inflate.
  • Relationship of fetus, uterus and pelvis during childbirth – place fetal doll in knitted uterus and place in pelvic model.
  • Location and function of pelvic floor muscles – stretch 2 wide rubber bands around screws of pelvic model, 1 on right, 1 on left. Will illustrate sling effect of perineal floor. Discuss importance of pelvic floor. When teaching Kegels, press rubber bands down and up to demonstrate strength, function and muscle tone of perineal floor. Contrast between good and slack pelvic musculature can be demonstrated by using smaller, tighter rubber bands and then larger ones.
  • Hold pelvis forward, not up and down. It tips quite far forward in normal woman


Using a Knitted Uterus – Teaching Idea Sheet #2

Desirable qualities – can include uterus w fundus indicated and detachable vagina. Features such as stripes/jarring color contrasts may distract. Colors/texture should enhance perception of uterus as warm, soft environment.

How To Use – effacement, dilation and crowning, passed around class

  • Effacement and dilation – weave elastic threads through cervical yarn at both internal OS and external OS so that cervix is held closed. This illustrates cervix in noneffaced way. As slowly push dolls head down toward cervix, elastic at internal OS will open, showing effacement but no dilation. Continuing pressure against external OS will illustrate gradual dilation of cervix.
  • Difference bw dilation and crowning – This is a common area of confusion for students in childbirth classes. Be sure to emphasize the difference between dilation of the cervix during the first stage of labor (which is invisible externally) and the visible dilation of the vaginal opening at the end of the second stage. When the cervix is fully dilated around the doll’s head, attach the knitted vagina to show the progress still needed before birth occurs.
  • Demonstrate These Conditions:
    • Conditions of the cervix: station, a “lip” or “rim” of the cervix, edematous cervix
    • Potential effects of maternal positioning
    • What happens during an internal exam
    • What happens when membranes are stripped
    • Fundal massage during recovery
    • Effects of fetal hiccups and other movements
    • Difference between a firm uterus and a boggy one
    • Manual extraction of placenta
    • Involution
    • External examination to determine fetal position

Special Doll needed? A life-sized doll or fetal model that is floppy or bendable is most workable. Doll’s head should be ~ 10 cm diameter; the length of the doll between 18-20 inches.

Contents of uterus can also be a ball used with padding to “flesh out” the uterus. If ball used, it should be similar in size to a baby’s head. A model of a placenta with umbilical cord and attached membranes is available for purchase. If this is not available, a doll can be placed inside a clear plastic bag. This will serve two purposes – bag can represent the amniotic sac. When protruding through the cervix, it can be “ruptured” to demonstrate amniotomy. Also the plastic bag will allow the doll to slide through the cervix more easily for insertion prior to and expulsion during the demonstration.
Whenever a doll or fetal model is used for teaching or demonstration, it is important to treat the doll as if it were a real baby. In that way a message of gentleness, warmth and caring is transmitted along the factual content of the lesson.

  1. Knitted Uterus and Vagina Instructions for Knitting a Model Uterus and Vagina – ICEA Teaching Ideas Sheet #5


  1. Suggestions for Labor Rehearsals ICEA Teaching Idea Sheet #4

Use the labor rehearsal to review information taught in previous classes. They describe a situation or phase of labor and couples are asked what they would do.

If they have actually gone through the body movements needed to respond to a proposed situation, they are more likely to respond in a similar manner in the real situation.

Encourage thinking about the alternatives to a given situation. What are several ways that they could cope with this development? What tools, what skills what knowledge do they have that could be used here? Arrange your labor rehearsals so that there are positive outcomes. Present them with problems and difficulties, but make the results successful.

Use a timer to indicate the beginning of each contraction. During transition, set the timer to go off every two minutes for four or five contractions, each lasting at least ninety seconds; don’t allow discussion to interrupt the contractions.

  1. Mom and her support person are walking across the parking lot to the hospital and a hard contraction begins.
  2. In transition, they are coping well when the fetal heart rate drops and the electronic monitor’s alarm goes off; no nurse comes into the room.
  3. While driving to the hospital and breathing though a contraction, the bag of water ruptures.
  4. After six hours of hard labor, the cervix is still at 2 cm and the fetus has had short periods of distress. The physician says, “Ms. Smith, you need a cesarean.”
  5. During active labor, using high chest breathing, the mother begins to feel short of breath and has tingling sensations around her lips and tongue.
  6. In transition, the mother develops the shakes, nausea and vomiting. She says, “I can’t go on. I can’t. I just can’t.”
  7. Analgesics are given and cause heavy drowsiness.
  8. The mother is experiencing continuous low back pain.
  9. On admission to the hospital, hard contractions are coming every three minutes and the mother is feeling the urge to push. The admission clerk says, “Now Mr. Smith, I need you to stay here and fill out these forms. The nurse will take Mrs. Smith to the labor area in the wheel chair.”
  10. The bag of water ruptures but labor has not begun. After six hours the physician says they will order a Pitocin drip to induce labor.
  11. In active labor, the anesthesiologist comes into the room during a contraction and immediately says, “Are you ready for your epidural?”
  12. It is 3:00 AM; they are asleep at home. The mother wakes up to go to the bathroom and has some diarrhea. She goes back to bed and is up again at 3:15 AM with another bathroom trip. She feels different and cannot go back to sleep; backache.
  13. It is now 6:00 AM and contractions have been coming every twenty minutes since 3:15 AM, but they are very mild, requiring only conscious release for comfort.
  14. During active labor in the hospital, a contraction begins; the nurse enter the room and asks, “How are things going, Ms. Smith? How often are your contractions coming? Would you like some medication to take the edge off?” (Contraction is on- going)
  15. Half an hour ago, the mother was at 5 cm. On the next contraction, “Oh I have to go to the bathroom.”
  16. Two hours ago she was at 4 cm; she is still at 4 cm currently. The instructor role plays the nurse who says she will need to examine the mother during a contraction and does so; she is still at 4 cm.
  17. Labor begins when the couple is not together and she cannot get in touch with the partner.
  18. When they get to the hospital after ten hours of labor at home, her cervix is dilated to 1 cm.
  19. They are at home; it is midnight and contractions have been coming every five minutes for an hour but they are mild. What now? If they suggest calling the doctor, the instructor role-plays the doctor on the telephone.
  20. After pushing for two hours, the baby is still high in the pelvis. The doctor suggests that a cesarean may be needed.
  21. She finds it very difficult not to push during the birth of the head.


  1. ICEA Teaching Sheets 

  2. Labor, Delivery, Recovery, (Birthing) Postpartum (LDRP) rooms


XIII. ICEA Position Papers

  1. Position Papers: Physiologic Birth

ICEA Position Paper on Physiologic Birth

While technology increases, maternal/infant morbidity/mortality rates have not shown significant improvements. ICEA defines physiologic birth as birth where baby is birthed vaginally following a labor, which has not been modified by medical interventions.

Normal Physiologic Childbirth

  • Is characterized by spontaneous onset and progression of labor;
  • Includes biological and psychological conditions that promote effective labor;
  • Results in the vaginal birth of the infant and placenta;
  • Results in physiological blood loss;
  • Facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and
    supports early initiation of breastfeeding.

One that is without interference, complications and in line with normal body functions

Factors Influencing Physiologic Birth

The mother’s health status and education are two of the most important factors. A mother’s complicated health history and/or pregnancy may warrant interference.

Benefits of Physiologic Birth

Birth without medical intervention may have many benefits:

  • Less postpartum pain;
  • Quicker physical recovery from the birth;
  • Increase in self-esteem as a result of the birth;
  • Enhanced bonding with the baby;
  • Reduced likelihood of post-natal depression;
  • A calmer, more settled baby;
  • An easier breastfeeding experience;
  • Effective respiratory transition for the baby; and
  • More effective gut colonization that prevents allergies in the baby.

Additional benefits of physiologic birth include a reduction in genital tract trauma/need for suturing as well as triggering the production of certain proteins in a newborns’ brain that may improve brain development.

Intervening in a normal physiologic birth process, where there are no complications, increases the risk of complications for the mother and her baby.

Six evidence- based care practices that promote physiologic birth were created by Lamaze International and outline changes in labor care: avoiding medically unnecessary induction of labor, allowing freedom of movement for the laboring woman, providing continuous labor support, avoiding routine interventions and restrictions, encouraging spontaneous pushing in non-supine positions, and keeping mothers and babies together after birth without restrictions on breastfeeding

Expectant parents can optimize their chances for a physiologic birth by becoming educated in childbirth education classes with the latest research. Informed decision-making must be at the forefront of our presentation of physiologic childbirth. The goals of prenatal (childbirth) education are to build women’s confidence in their own ability to give birth, to provide knowledge about normal birth, and to help women develop individualized birth plans that provide a road map for keeping birth as normal as possible even if complications occur.

Providing positive sources of media information, such as television shows or web information, can assist expectant parents in their quest for knowledge. Referrals to such out-of-classroom materials become necessary especially when limitations are placed on the dissemination of class information.

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