First Stage of Labor - Midwifery Today (March 6, 2002)

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Volume 4 Issue 10 March 6, 2002

First Stage of Labor

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In This Week's Issue:

 

1) Quote of the Week

2) The Art of Midwifery

3) News Flashes

4) First Stage of Labor

5) Check It Out!

6) Midwifery Today Online Forum: Herbs for Fertility

7) Question of the Week: Broken Coccyx

8) Question of the Week Responses: Group B Strep, bipolar, stroke

9) Switchboard

10) Classifieds

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1) " Just as a woman's heart knows how and when to pump, her lungs to

inhale, and her hand to pull back from fire, so she knows when and how

to give birth. "

-Virginia Di Orio

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2) The Art of Midwifery

 

When you begin nipple stimulation for a client, check the prenatal

record to see what her normal blood pressure (BP) is. One of the ways

you can tell whether or not she is truly kicking into labor is that

her BP will rise. If it doesn't, you're going to be doing nipple

stimulation for a long, long time. But remember, there is a

pathological rise in BP as well, so I have decided on a cutoff of 140

over 90. I don't want to see any pressures higher than that.

-Sr. Angela Murdaugh, CNM, Midwifery Today Issue 31

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3) News Flashes

 

More than 8,000 pregnant Danish women were surveyed about how often

they had eaten fish during pregnancy. The occurrence of preterm

delivery fell from 7.1% in women never eating fish to 1.9% in those

eating fish at least once a week. Overall, low birth weight and

preterm birth tended to decrease with increasing fish consumption, and

average birth weight and length of gestation tended to increase with

increasing fish consumption. This correlation applied to a daily

intake of as much as 15 g fish. These findings agree with previous

trials showing that consumption of fish oil in pregnancy can increase

birth weight by prolonging gestation and can prevent recurrence of

preterm delivery. The authors suggest that for women with zero or low

fish intake, small amounts of omega-3 fatty acids -- provided as fish

or fish oil -- may protect against preterm delivery.

-British Journal of Medicine, 2002;324:447

http://bmj.com/cgi/content/full/324/7335/447

 

 

4) First Stage of Labor

 

First Stage, Homebirths

When I arrive at a client's home, I do the following:

-Assess the attitude and acclimate

-Find out how long the mother feels she has been in labor

-Assess if she is truly in labor (check for ROM, lost mucus plug,

bloody show, regular strong contractions, etc.)

-Start labor records

-Check fetal heart tones (get an initial baseline by listening through

three consecutive contractions

-Take blood pressure and pulse

-Do palpation (check fluid amounts and position of baby by feeling the

uterus)

-Take the woman's temperature

-Do a urine test in long labors (check for protein, glucose, ketones

so fluid and food intake can be adjusted if needed)

-Do an internal exam (effacement, dilation, station, position)

-Check frequency and duration of contractions

-Check fluid amount (color, smell, and amount of ruptured membranes)

-Note the attitude and tolerance of mom/partner/others present. (Do

they need to be alone? Do they need encouragement -- position changes,

relaxation techniques?)

-Clean house, do the dishes, vacuum, clean the bathroom, prepare the

birth bed, boil water.

(Note: The order of assessment may change depending on the situation.)

-Jill Cohen, lay midwife

 

In-Hospital First Stage Assessment and Management of Low-Risk Women

-Support and observation are the hallmarks of managing normal labor.

Remember the 4 Ps: Powers, Passenger, Pelvis, Psyche

-Evaluate maternal emotional support, energy level, relaxation

ability, coping with pain/fears. Discuss options/preferences. Review

birth plans, answer questions.

-Do initial physical exam, take vital signs: Blood pressure, pulse,

temperature, respirations, input and output, uterine contractions,

fetal heart rate, fetal position/station, estimated fetal weight,

labs, cervical status/membranes.

-Evaluate for latent phase/active phase in term primip/multip, labor

progress, maternal well being, stability of fetus, fetal well being.

Risk factors/concerns (review prenatal chart)

-Encourage alternating ambulation/rest, frequent position changes,

showers/baths, massage, music, imagery, breathing, frequent urination,

hydration/nutrition. IV meds/epidural as needed per mother's informed

choice in active labor. Support the family. Enhance the mother's

feeling of safety at all times. Try to avoid admitting mom until she

is in active labor.

-Sharon Glass, CNM (Midwifery Today Issue 31)

====

 

Sometimes you'll get the feeling that stronger contractions and hard

labor are impending, but the woman is keeping them at bay. Up to about

4 or 5 cm (and sometimes beyond), women have the power to control

labor's ebb and flow, and can choose the time when they let the forces

of birth take over. Difficulties occur if the uterus has worked up to

a certain intensity and the mother begins to fight against it. This is

often the case when a woman is groaning and rocking at only 2 or 3 cm

dilation.

 

Women often need special guidance at this point. To move into active

labor, the mother must give up notions of how labor is " supposed to

be. " She may no longer find slow, deep breathing effective; if her

breathing sounds ragged or jerky, introduce slightly more accelerated

but relaxed chest breathing. Movement during contractions (even pelvic

rocking) can create muscular tension; show her how to be still and let

her body " melt " while focusing on the rhythm of her breath. Enable the

mother to make this shift and frantic agitation will be replaced with

peaceful resignation that permeates the environment and sets a tone of

readiness for harder labor...

 

Some women feel vulnerable lying down, particularly those who like

being in control. Sitting cross-legged, with shoulders and hands

loose, can give the mother a sense of steering herself through

contractions, and a straight spine can keep tension from stacking up

her back. Have someone sit behind her and squeeze her shoulders or

push on her lower back periodically to help her stay loose in this

position. If the baby is posterior and not yet descended, the mother

can try the hands-and-knees position with pelvic rocks to encourage

rotation. If she likes, you can massage her buttocks using long,

downward strokes. This helps her focus low in her body and encourages

her to relax her breathing.

-Elizabeth Davis, Heart and Hands 3rd ed., Celestial Arts, Berkeley,

CA 1997

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MIDWIFERY TODAY ISSUE 31 (Theme: First Stage)

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5) Check It Out!

 

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CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME

 

Strategies for Keeping Birth Normal in First Stage

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First Stage Difficulties: Global Sharing

http://www.midwiferytoday.com/products/952T178.htm

First Stage Difficulties: Approaches from Different Cultures and

Modalities

http://www.midwiferytoday.com/products/972T574.htm

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6) Midwifery Today's Online Forums

 

I'm looking for information about herbs to use to increase fertility.

I am ready to conceive again and would like to facilitate it any way I

can. Easily obtained teas and such would be easiest. -Amy

====

 

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7) Question of the Week

 

Q: A friend pregnant with her first child was told she must have a

caesarean because her coccyx has a noticeable, abnormal curve and that

in a vaginal birth, the baby would break it. I've heard of a sprained

or bruised coccyx but never broken. Is a broken coccyx possible and

avoidable? Is a trial of labor desirable in this case?

-Elizabeth Cheron

====

 

SEND YOUR RESPONSE to mtensubmit with " Question of

the Week " in the subject line.

 

 

8) Question of the Week Responses

 

Q: A friend was just diagnosed, by urinalysis, with Group B strep. She

is planning to have her baby at home (this will be her third

successful homebirth). She has been told she will need IV antibiotic

intrapartum. Is it safe to have a homebirth and if so what

precautionary measures should be taken? She is due March 20.

-Colleen

====

 

A: I have had several moms with strep B. I encourage the moms to avoid

refined sugars and junk food. I also suggest they eat lots of leafy

green vegetables and fresh fruit. Having a more alkaline diet will

discourage the strep B. Liquid oxygen helps to alkaline the system as

well. This can be purchased in most health food stores. The medical

profession has really terrified mothers. I have had no problems with

moms who tested positive. They all had a fine birth.

 

All of us have strep B -- some have it more under control. Cleaning up

the diet really helps. Most moms who have upgraded the diet will then

test negative for strep B. The doctors will tell them they will still

have the antibiotics regardless, since they had tested positive for it

at a previous time. That is very discouraging.

-Anon.

====

 

A: In our country (The Netherlands) women with group B streps can

deliver at home but with a few restrictions and depending if the

obstetrician in charge is in favour of homebirth or not. I have had a

case like this only two times. I asked for a second opinion from an

obstetrician who I knew is not afraid of home delivery, and we agreed

on the following:

 

Have the woman get another checkup (at 36 weeks gestation) and see if

the bacteria are still present. If so, she can get antibiotics and be

tested after the antibiotic treatment. If she is still infected she

needs intrapartum IV antibiotics -- if she delivers after 4 hours. If

she's a " flying multipara, " as we say, and delivers within 4 hours,

the IV antibiotics are too slow to work and then I think a shot of

50.000 units of penicillin for the baby postpartum will do (in the

hospital I work with, this therapy is done, and after a day of

observation mother and baby mostly go home without problems).

 

If there are no strep B left after the antibiotic treatment in

pregnancy, the woman can deliver at home, but stay aware of the fact

that nobody knows how long after the treatment with antibiotics in

pregnancy the strep will be eliminated. So close observation of mother

and child is still needed, and the baby must be transferred to

hospital to get treated when only the slightest sign of infection

occurs.

 

In my opinion this shot of preventive antibiotics also can be given at

home to the baby (we are allowed to give the first vaccination against

hepatitis B within two hours of birth to the baby at home as well, so

why not antibiotics?).

 

Thorough observations of signs of illness of mother and child also can

be done at home, but I never got a GP to give me the antibiotics for

the baby because it is not " regular protocol. " Still I think it could

be an option (maybe that's my opinion about delivering in the most

natural environment; I think you need a hospital only if there's

nothing you can do anymore at home).

 

Remember that this woman already had two babies at home without

complications and that close and thorough observations for signs of

infection are more important than antibiotics - because there still is

no hard evidence this preventive antibiotic treatment really helps.

-Mieke

====

 

A: I have attended a homebirth where the mother needed GBS

prophylaxis. If the labor is progressing rapidly, start an IV site and

administer penicillin-G 500 million units or 2 grams of ampicillin if

allergic to penicillin. Then give Clindamycin 900 mg or Erythromycin

500 mg. If the labor is going to take a while, start a saline lock

instead, tape it nicely, and give her additional doses every 4 hours

of Pen-G 2.5 million units or 1 gram ampicillin, or half doses of the

other -mycins. I did not consult the ACNM Homebirth Handbook, but that

is what I have seen and it worked out well. Now that the mother has

had the screening and is known GBS positive, the CDC guidelines

suggest she receive intrapartum prophylaxis. If a midwife is not

familiar with doing it, she may be able to find a supportive RN in her

community. The mother should still have a homebirth if she wants it,

but we should remember that a baby with GBS sepsis often will die and

we all should carefully do what we can to prevent that.

-Carla Cleary, RN SNM

====

 

A: During my research into homebirth, I came across several articles

that support giving antibiotics IM during the last 4 weeks of

pregnancy as an alternative to intrapartum antibiotics. Recommended

dosage is (1) 1.2 ml shot of penicillin G benzathine per week for 4

weeks.

-Erika O.

====

 

A: I recently had a woman test positive with GBS from a yoni/rectum

culture sent into a lab for testing at about 36 1/2 weeks. After

getting the results, the mother was informed of her choices: the

protocols of a hospital birth with a GBS+ test and what we would do at

home with a GBS+ homebirth. She decided that she would like to stay at

home and try to work on the GBS using herbs, positive thinking, and a

chance to retest after a few days of herbal treatment. It seems to me

that GBS can come and go on a daily basis. My own feeling is that GBS

has to do with pH balance and allowing it to grow if this balance is

out of whack. We had a remedy: First, we used a light herbal douche

made of comfrey, calendula, a bit of goldenseal, 3 drops of

Nutri-biotic diluted in warm water. She was advised to administer the

douche just at the vaginal opening and not to push the herbal water

too high or with force. She did this 2-3 times a day. Also, she drank

3 glasses of water infused with Nutri-biotic daily and ate lots of

veggies, fruit, and simple grains. After 5 days of this remedy, we

retested. Her test came back GBS negative. She was ecstatic! I truly

believe the herbs worked and the retesting was crucial. Her homebirth

was wonderful!

-Anon.

===

 

A: A UK support group for Group B Strep offers loads of evidence-based

information. The Web address is www.gbss.org.uk.

-Zana, CBE

National Childbirth Trust, UK

====

 

A: Group B Strep is carried as normal flora by approximately 20% of

women. Having said that, the consequence of neonatal/perinatal

infection can be fatal. Here in Austalia the normal hospital practice

is IV antibiotics in established labour, usually 2 g ampicillin

initially, followed by 1 g fourth hourly till delivery. If your

midwife is able to canulate I see no reason why you should not have a

homebirth, with an interval of no less than 4 hours from the first

dose till delivery. This may seem interventionist but is actually

evidence-based care.

-Jaz

====

 

More about bipolar condition [issue 4:9]:

 

I assisted a woman with severe bipolar disorder who was on

Venlafaxine. It was not even a question of getting off the meds -- her

behavior would be harmful. No amount of trust, counseling, and praise

would have abated her illness. She had experienced an unmedicated

pregnancy, birth, and postpartum 5 years earlier. It was hell for her.

We researched as much as we could but couldn't find much info. We were

more worried about the drug for the infant with breastfeeding. She

tried taking an antidepressant plus an antianxiety for a bit

postpartum but it didn't work very efficiently for her. Her homebirth

was beautiful, with a nice healthy boy.

-Ruth

====

 

More about stroke [issue 4:8]:

 

Several years ago our hospital had a lady who had a stroke at about 28

weeks. She stayed in the hospital and received tube feedings and

physical therapy. She responded very little and could not communicate

verbally at all. Near term she became restless. OB nurses were called

to the floor and we determined that she was in labor. It progressed

very well and she pushed spontaneously when the baby started moving

down. When we put the baby on her chest a single tear rolled down her

cheek. Of course the baby was watched closely for growth and well

being throughout the pregnancy, but she didn't have any further

problems.

-Anon.

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New Zealand College of Midwives

7th Biennial National Conference

 

Celebrating Diversity within Unity

4-6 July 2002

Dunedin Centre, Dunedin, New Zealand

 

Pre-conference workshop, 3 July 2002, featuring internationally

renowned speakers:

-Beatrijs Smulders, Midwife from The Netherlands

-Wendy Savage, Obstetrician from the United Kingdom

http://www.nzcom.org.nz

 

For further information contact:

Mary Whitham, Convener Phone - 03 466 7945

Email: marywhitham 9) Switchboard

 

A woman I am looking after has hepatitis B. The results came like

this:

Hep B surface antigen: not detected

Hep B surface antibody: 0 IU/L

Hep B core antibody: detected

Is she infectious? Are there any alternatives to giving the baby a

vaccination and immunoglobulin?

-Anon.

====

 

Regarding pregnancy massage [issue 4:9]:

 

Massage has been shown to reduce the likelihood of preterm labor and

reduce blood pressure issues. Also, when administered during labor, it

reduces trauma, the need for drugs, and pain, and later, postpartum

depression. See the Touch Research Institute Web site for more

information: http://www.miami.edu/touch-research/index.html

-Michelle

====

 

I am certified in prenatal and postpartum massage and a member of

NAPMT (National Association of Pregnancy Massage Therapists). I

recommend contacting them (napmt) for information about a

practitioner in your area, as all members are certified.

In terms of the benefits, here are but a few: increases maternal

circulation, improves maternal and fetal oxygen circulation, improves

blood and lymph flow (reducing swelling); relieves pain, muscle

soreness and fatigue; improves sleep; improves outcomes of labor

(including a reduction in premature birth); and provides a woman with

the experience of loving, nurturing touch so she is better able to

touch her baby in a loving, nurturing way.

All these benefits are supported by research. I would recommend

contacting Kate Jordan (she can be reached through NAPMT) for

information about research and sources.

-Teri Brickey, LMT, NAPMT, CIMI

====

 

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or call 541-488-8273.

 

 

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