Introduction

Fetal Development

The Danger Signs of Pregnancy

The Pregnant Patient's

Sexual Intimacy

Communication Skills

Labor Coping Strategies

Birth Options and Preferences

What to Take to the Hospital

Labor

Addendum

Labor Continued

Stages of Labor

First Stage of Labor
That stage when uterine contractions of sufficient frequency, intensity and duration cause the cervix to dilate from 1 to 10 centimeters, or to sufficient dilation to allow passage of the fetal head down into 3 phases of labor: early, active, and transition.

Second Stage of Labor
Begins when dilation of the cervix is complete and ends with delivery of the infant.

Third Stage of Labor
Begins with delivery of the infant and ends with delivery of the placenta and fetal membranes.

Fourth Stage of Labor
Begins with delivery of the placenta and lasts for an hour or so after delivery during which time uterine “after contractions” act to control bleeding from the placental implantation site.

Labor Chart

First Stage of Labor

Early Phase

Descent
Station of presenting part……-2 or -1

Bloody Show

Emotional and Behavioral Changes in the Woman

• Denial
• Surprise
• Excited
• Talkative or mute
• Calm or tense
• Apprehensive, anxious
• Thoughts center on self, labor and baby
• Impatient
• Energetic, confident
• Sociable
• Pain usually controlled well
• Alert
• Follows directions well
• Open to instructions

Coach Activities and Responsibilities

• Finish packing bags
• Finalize arrangements of care for children and pets
• Prepare “coach’s snack”
• Practice relaxation skills
• Use distraction
• Encourage only light activity alternating with rest and relaxation. Resist “spurt of  energy”
• Encourage clear fluids and light, easily digested meals
• Time contractions
• Call doctor and hospital when appropriate
• Assist with relaxation and breathing skills when necessary
• Accept behavior
• Praise efforts
• Encourage
• Provide support and comfort measures (massage, positioning, ice chips, fanning etc.)
• Provide privacy
• Remember favorite music/tape player

Active Phase

Cervix

Contractions

Descent
Station of presenting part       -2, -1 or 0

Bloody Show

Emotional and Behavioral Changes in the Woman

• More introverted
• Less talkative
• More apprehensive
• Serious
• Requires more support, companionship & encouragement
• May evidence fatigue
• Doubts ability to control pain
• Les self-confidence
• Must concentrate more during contractions
• May have some difficulty following directions
• May be restless
• May hyperventilate
• Knows she’s in true labor

Coach Activities and Responsibilities

• Assist with relaxation & breathing techniques
• Remind her of focal point & effleurage
• Favorite music in background
• Anticipate physical needs:
• Encourage ambulation and/or position changes
• Hourly urination
• Use of lip balm
• Ice chips
• Cool, damp washcloth to forehead or back of neck
• Fanning
• Low back counter-pressure
• Massage
• Shower, if permitted
• Encourage.  Speak to mother or give her instructions using simple, positive and direct statements between contractions.  Inform her of dilation.
• Time & record contractions
• Use trigger words from previous practices such as “Relax”, “Let go”, “Release tension”, “Concentrate”, “You are wonderful”, “You can do this”, “I love  you”, and so on.
  Stay with mother as much as possible. Take short breaks only as necessary.
  Interpret staff communiqués to mother. Collaborate on decisions with mother and            health team.

Transition

Cervix

Contractions

Descent
Station of presenting part       -1 to +1

Bloody Show

Emotional and Behavioral Changes in the Woman

• Irritable
• Anxious
• Feeling of panic
• Susceptible to suggestions, vulnerable, dependent
• Mood change. Apprehensive, “I can’t do this”
• Disoriented, loses sense of time
• May fear losing control
• May dislike being touched
• May find odors offensive
• May resist position changes
• Loss of inhibitions
• Low, descending backache
• Trembling
• Hot flashes, chills, or both
• Amnesia or confusion
• May feel nauseous and/or vomit
• Sleepy between contractions
• Vague in communications
• Vocalizations (noises), groaning, grunting
• May be calm, almost meditative
• Or, none of the above
• Rectal pressure, urge to push

Coach Activities and Responsibilities

• Provide perspective encouragement. This is the most difficult part of labor but also the shortest.
• Remain supportive. Tell her she is “Doing great”, “I love you”, “It’s almost over”,  “The baby’s almost here”, Help her focus on only one contraction at a time. 
• Always be positive.
• Take nothing personally at this pint. 
• Don’t overreact to her moodiness.
• Don’t leave during this phase (no matter what she may say).
• Have her urinate at the onset of transition
• Encourage position changes 1-2 times per hour
• Decisions with mother and health team
• Actively support her relaxation as much as possible, and breathe with her as necessary. 
• Use eye-to-eye contact. 
• Help her drain tension between contractions.
• Help her visualize the cervix opening, the baby coming down.
• If you must ask her questions, ask ones that can be  answered “Yes” or “No”.
• Observe for signs of hyperventilation.
• Provide a cool washcloth for her forehead or back  of neck. 
• Use fan. 
• Give low back counter-pressure as desired.
• Massage as desired.
• Use lip balm.
• Give ice chips.
• Vary breathing patterns for maximum concentration.
• Provide warm blankets and/or socks, if desired.
• Remove cover if too warm.
• Low groaning noises are okay.
• Observe for urge to push. Use appropriate breathing to prevent urge to push when it  occurs, until pushing is allowed.

Birth or Expulsion

Contractions

Descent
From mid-pelvis to expulsion (birth)

Bloody Show

Emotional and Behavioral Changes in the Woman

• Awake and alert, gets a “second wind”
• Initial inability to remember how to push
• Totally involved with pushing during contractions but eager for interaction  between contractions
• Feels more in control
• May be excited, euphoric, elated
• Has strong urge to push (unless has deep regional block such as epidural). Relief at being able to push.
• Pushing with contractions usually felt as a great relief due to pressure from the baby’s head causing a natural numbing of the nerves in the mother’s pelvic area (a small number of women find pushing painful, however, if they fail to relax the pelvic floor muscles or in the infant’s head is still rotating).
• Pressure on tailbone, rectum and pelvic floor with rectal bulging, flattening of the perineum and heavy bloody show.
• Stretching or burning sensation felt briefly as baby’s head emerges and if mother not anesthetized
• May be overwhelmed with emotions with birth of infant
• May feel relief, love, joy, satisfaction, strength
• May be exhausted
• May feel disappointment with self, labor, and/or the baby

Coach Activities and Responsibilities

• Assist woman with proper positioning for expulsion efforts (pushing)
• Participate with pushing including physical support and counting for woman’s bearing down efforts
• Help her relax between contractions and remind her to relax her pelvic floor muscles (Kegels)
• Cool washcloth to forehead
• Ice chips and lip balm
• Be encouraging
• Share in the experience
• May be overwhelmed with emotions with birth of infant
• May feel relief, love, joy, satisfaction, strength
• May be exhausted
• May feel disappointment with self, labor, and/or baby

Placental

Contractions

Emotional, Physical and Behavioral Changes in the Woman

• Contractions temporarily cease with birth of the infant then resume.  In primips, these contractions are typically mild.  In multips, the uterus often contracts vigorously at intervals giving rise to painful sensations known as “after contractions”.  Oral analgesics can be helpful.
• Detachment of placenta typically occurs within 5-30 minutes after birth of infant.
• After delivery of placenta, Pitocin is often added to the intravenous solution.  This is done to assist the uterus to contract efficiently to reduce the amount of vaginal bleeding thereby minimizing the possibility of postpartum hemorrhage.
• Lochia (vaginal discharge of blood and tissue) begins after delivery of the placenta and, initially, is bright red in color and large in quantity.
• Episiotomy and/or any vaginal or perineal tears are repaired
• Woman experiences generalized body trembling (“shakes”) due to circulatory changes which can be misinterpreted as chills or as being cold
• Woman is typically alert, euphoric, tired, emotional, laughing, and/or crying
• She seeks reassurance that the infant is normal.  Woman seeks contact with the infant
• She expresses emotion with significant others
• Woman asks questions about labor and delivery, recalls events vividly, and/or may express apology for labor behavior

Coach Activities and Responses

• Typically focuses attention on infant
• Visually examines infant, esp. as nurse is giving initial cares to infant (drying,  suctioning, putting on arm bands, etc.)
• Desires to touch and hold infant
• May be apprehensive about holding infant
• Feels protective of infant.  Often thinks nurses and doctor handle infant without proper tenderness
• Bring baby to mother once infant has been dried and wrapped in clean, dry blankets (or nurse will bring baby to mother)
• Enjoy baby’s behaviors with mother (squinting, opening eyes, moving lips and   tongue, crying, etc.)
• Feels overwhelming emotion
• May be tearful
• May be tired
• May be initially disappointed, as with sex of child
• Stay with infant as baby goes to nursery for vital signs, to be weighed, bathed, etc. (if not in a LDR/P or birthing room)

Recovery

Contractions

Emotional, Physical and Behavioral Changes in the Woman

• Vital signs are monitored regularly (every 15 mins.) and tend to return to normal within one hour
• Immediately after delivery, placental site is approximately the size of the palm of the hand (by the 13th to 14 day after delivery, the placental site is 3-4 cm. in diameter)
• The lochia (vaginal blood and tissue discharge ) is bright red and large in quantity for the first few days after delivery (after 3-4 days, the lochia becomes progressively paler to a more pinkish color and smaller in quantity. 
• After the 10th day, the lochia assumes a yellowish-white color as is scant in amount. 
• Lochia tends to disappear in 3-4 weeks after delivery but can persist for up to 6 weeks with early resumption of activities)
• Fundus is massaged every 15 minutes for first hour after delivery to assess uterine firmness and amount of lochia flow
• The bladder postpartum has an increased volume capacity and a relative insensitivity to increased fluid pressure. 
• Overdistention of the bladder can dislocate the uterus causing hypotonus leading to excessive bleeding. 
• Incomplete urine emptying and excessive urine retention can lead to bladder infections.  For these reasons, the woman’s ability to empty her bladder with the first 4 hours after delivery is carefully observed.  If she cannot void adequately, she can expect to be catheterized.
• The “shakes” continue for 1-2 hours
• An ice pack to the perineum can be soothing and may reduce swelling at the episiotomy site
• If the episiotomy site or “after-contractions” are painful, oral medications can be given
• The woman is usually thirsty and may claim to be hungry as well due to calories expended during labor and missed meals
• The woman may feel relief, elation, excitement or exhaustion
• The woman may desire to recount the labor experience with family members and visitors

Coach Activities and Responses

• Desires to show off baby
• Enjoys telling others about baby, what has been done to the infant thus far, how the infant has responded, and about the baby’s behaviors.
• Retells own account of labor
• May feel relief, elation, excitement or exhaustion
• May be hungry due to missed meals while participating in the labor.

The primary consideration in choosing an expulsive position is its ability to promote the optimal progress of labor. The position of the mother, the position of the baby, and whether the mother is anesthetized or not can affect the efficiency of the maternal bearing down effort during second stage labor. This, in turn, can effect the length of time spent, and the amount of effort expended in second stage labor or expulsion of the baby.

Technique for Pushing

This technique may be adapted to any of the pushing positions previously described.

1. In the semi-reclining position, lean back to a 30 degree angle with knees out, ankles down and soles of feet touching.  For comfort, place pillows or blanket rolls under knees.
2. As the contraction begins and builds in intensity, inhale and exhale two cleansing breaths.  As the urge to push builds, take in the third breath and  hold it.
3. Contract your abdominal muscles in a good pelvic tilt (letter “C” slump position). As you round your back in a “C”-curve, do not sit up over the baby.  Instead, pull your knees out gently with your hands under your knees and your elbows out.  This position of the hands and elbows maintains the rounded curve of the back.
4. Relax the pelvic floor muscles.  Think, “Open, out, release.”
5. Hold your breath and bear down as the coach counts 1-10 (no longer than 8-10 seconds of breath holding per cycle as prolonged breath holding can cause a drop in the fetal heart tones).  The coach should support your head forward as you push.
6. Let your breath out and inhale your next breath quickly while maintaining abdominal pressure and pushing effort to your coach’s count of 1-10.  Do this again and again until the contraction ends.
7. Push only when the uterus is contracting. Relax between contractions. Take deep, relaxing breaths.  Release all muscle tension.
8. When the baby’s head bulges the perineum, your doctor or midwife will instruct you to stop pushing to allow the baby’s head to birth through the vaginal opening slowly.  When instructed to stop pushing, relax and blow lightly to prevent pushing.
9. Enjoy your baby!

Back Labor

The most common presenting position of a baby during labor is in the vertex (head down) and anterior (occiput, or back of head, toward maternal pubic bone) position.  In as many as 20% of labors, however, the infant may present in the vertex and posterior (occiput, or back of head, toward the maternal tailbone-sacrum and coccyx bones) position.  In this posterior presentation, the mother experiences great back pressures radiating from the back forward abdominally with each contraction.  Due to the extension of the infant’s head in this position, and because of the diameter of the cranium which the baby is presenting, the infant’s station tends to remain higher longer thus prolonging the progress of labor.

Most posterior presenting babies rotate to the anterior position in late first stage, or second stage, labor so that they are born in an anterior and more common position.

Following are useful comfort measures which may be helpful for the laboring woman experiencing back labor.  Some techniques may help to rotate the baby from posterior to anterior position.

Positioning
To keep the baby’s weight off of the maternal uterus and back:

1. Left or right side-lying.
2. Hands and knees pelvic tilt.
3. Tailor sit with the upper torso leaning somewhat forward.
4. Sitting on the side of the bed with the arms and upper torso over the pulled-up bedside table.
5. Leaning forward on a backwards-straddled chair.
6. Leaning forward while standing with the mother’s arms reaching upward and around the coach’s neck, and the coach’s arms are around the mother reaching to the small of her back to give counter-pressure or massage.
7. Sitting on the toilet and leaning forward.
8. Positioned on the side toward which the baby is turning which may speed                          rotation.

Counter-pressure
Firm external pressure against the internal pressure of the fetus’ head to the mother’s sacrum and coccyx with uterine contractions:

1. Lower back pressure or massage by the coach to the woman’s tailbone area (where the “fork–in-the-road” area is).
2. Firm pressure applied with flat of hand; padded first in a kitchen mitt; tennis balls; soda can; Tupperware (hollow, fillable) rolling pin; small paint roller; wooden back massager; etc.
3. Interchange temperature with constant counter-pressure to decrease nervous interpretation of pain.  Example: Apply initial counter-pressure with a crushed ice compress or Blue Ice compress for approximately 30 minutes; then 30 minutes of counter-pressure with no hot or cold; 30 minutes of counter-pressure with a warm compress to the back; then an additional 30 minutes of counter-pressure with no hot or cold; repeat the cycle.
4. Use powder or lotion for massage to reduce friction.

Emotional Support and Encouragement

1. Give constant, positive encouragement and praise as this is usually a longer, harder labor than if the infant were in the anterior position.  Remind the laboring woman to focus on only one contraction at a time.
2. The coach can expect to give constant, external counter-pressure.
3. Remind the laboring woman to reposition herself regularly for comfort. Maternal repositioning may have the added benefit of encouraging a position change by the fetus from posterior to anterior thus alleviating the woman’s back pain with each contraction.