How caregivers manage pain and distress in second-stage labor.

Innovative care interactions are needed when helping a woman who exhibits severe pain or distress during the second stage of labor. We describe how caregivers and laboring women interacted during second-stage labor, with particular attention to how caregivers managed pain and distress. We used observational methods to perform a microanalysis of behaviors from video-recorded data. Pain occurred during labor contractions, and distress (an emotional response to pain) manifested primarily between contractions. Four patterns of women's behavior were identified: 1) no pain or distress, 2) low-level pain and/or distress, 3) focused working, and 4) severe pain and/or distress. Successful care was identified as enabling the woman to maintain herself in any state other than severe pain and/or distress. Particular modes of speech used by the caregiver enabled the attainment of successful care when the woman was not in severe pain or distress. When severe pain or distress existed, innovative caregiving transitioned the woman to another state. Successful intervention strategies included 1) giving innovative directions and 2) "talking down." Ordinary modes of "birth talk" can be used when severe pain or distress is not manifested and when the primary care problem is to assist women with bearing down. Innovative care interactions are needed when faced with severe pain or distress. Managing labor pain is an ongoing focus of clinicians who provide care to women in labor. In addition to pain, women might also experience distress, an emotional response to the labor experience. Whether from choice or necessity, caregivers for laboring women need nonpharmacologic interventions and interpersonal skills that can help women endure labor and give birth. Labor is hard work, and even in precipitous labors most women require assistance. Care given to a laboring woman consists of employing comforting strategies that help her cope with the pain of uterine contractions. The purpose of these comfort strategies is to help the woman find needed resilience during labor. Most cultures have mechanisms for providing this kind of support. In this article, we identify patterns of behavior used by laboring women and describe successful and unsuccessful strategies used by caregivers to help these women deal with pain and distress during the second stage of labor.

A critical appraisal of guidelines for antenatal care: components of care and priorities in prenatal education.

There are a variety of published prenatal care (PNC) guidelines that claim a scientific basis for the information included. Four sets of PNC guidelines published between 2005 and 2009 were examined and critiqued. The recommendations for assessment procedures, laboratory testing, and education/counseling topics were analyzed within and between these guidelines. The PNC components were synthesized to provide an organized, comprehensive appendix that can guide providers of antepartum care. The appendix may be used to locate which guidelines addressed which topics to assist practitioners to identify evidence sources. The suggested timing for introducing and reinforcing specific topics is also presented in the appendix. Although education is often assumed to be a vital component of PNC, it was inconsistently included in the guidelines that were reviewed. Even when education was included, important detail was lacking. Addressing each woman's needs as the first priority was suggested historically and remains relevant in current practice to systematically provide care while maintaining the woman as the central player. More attention to gaps in current research is important for the development of comprehensive prenatal guidelines that contribute effectively to the long-term health and well-being of women, families, and their communities.

Birth talk in second stage labor.

In this secondary analysis of videotape data, we describe birth talk demonstrated by caregivers to women during the second stage of labor. Birth talk is a distinctive verbal register or a set of linguistic features that are used with particular behaviors during specific situations, has a particular communication purpose, and is characterized by distinctive language features. Birth talk is found cross-culturally among speakers of diverse languages. Our findings show that birth talk occurred mainly during contractions and co-occurred with two general styles of caregiving: "directed toward forced bearing down" and "supportive of physiologic bearing down." We also describe talk that occurred during rest periods, which was similar across the two styles. Caregivers' use of language tended to be either procedural (giving directions, instructions) or comfort related (encouraging and supporting). Linguistic features of the talk consisted of utterances of short duration, level pitch patterns with no sudden pitch shifts, and a restricted pitch range.

Best practices in second stage labor care: maternal bearing down and positioning.

Despite evidence of adverse fetal and maternal outcomes from the use of sustained Valsalva bearing down efforts, current second-stage care practices are still characterized by uniform directions to "push" forcefully upon complete dilatation of the cervix while the woman is in a supine position. Directed pushing might slightly shorten the duration of second stage labor, but can also contribute to deoxygenation of the fetus; cause damage to urinary, pelvic, and perineal structures; and challenge a woman's confidence in her body. Research on the second stage of labor care is reviewed, with a focus on recent literature on maternal bearing down efforts, the "laboring down" approach to care, second-stage duration, and maternal position. Clinicians can apply the scientific evidence regarding the detrimental effects of sustained Valsalva bearing down efforts and supine positioning by individualizing second stage labor care and supporting women's involuntary bearing down sensations that can serve to guide her behaviors.

Why do supportive birth attendants become directive of maternal bearing-down efforts in second-stage labor?

A supportive approach to care for women during the second stage of labor that primarily relies on the laboring woman's involuntary expulsive urges has been advocated. We aimed to learn about the clinical circumstances surrounding the caregiver shift from being primarily supportive to directing women regarding their bearing-down efforts. This research analyzed the communications of 10 birth attendants and women during the expulsive phase of labor using videotapes recorded from two studies carried out between 1986 and the present. The occasions when a birth attendant shifted verbalizations were identified, and categories of the rationales that may have influenced the modification in caregiver behavior were developed. Birth attendants most frequently provided directions to help the woman push effectively, that is, to focus the woman's bearing-down efforts during maternal distress, fatigue, fear, and pain to expedite the labor process (38% of the occasions of caregiver change in verbalizations). The next most frequent clinical situations when caregivers offered directions about "pushing" were diminished urge to bear-down with epidural analgesia (10%), routine arbitrary practices (9% caregiver and 6% by supportive companion), and fetal distress (<1%). A category of "supportive direction" (20%) was identified. This care strategy has not been previously reported. It combined direction with support in a way that was supportive rather than overriding the woman's involuntary efforts.

A new understanding of the second stage of labor: implications for nursing care.

A reconceptualization of the second stage of labor is proposed, with an early phase of descent and a later phase of active pushing, as the basis for nursing care related to direction or support of expectant mother's bearing-down efforts. This reconceptualization challenges the rules that have accompanied second stage by providing criteria for the obstetric conditions optimal for fetal descent that develop during the initial phase of second stage as the fetal head rotates to an anterior position and descends to at least a 1+ station. The phase of active pushing is accompanied by a decline in fetal pH and should be shortened, not only by assisting the woman with effective bearing-down but also by allowing a longer early phase of second stage and encouraging the woman to push only when the obstetric conditions are optimal.

Changes in postpartum perineal muscle function in women with and without episiotomies.

This report presents results of a comparison perineal muscle function between antepartum and postpartum measurements in a cohort of women with different perineal conditions after childbirth. Data were obtained by using prospective electromyographic perineometry measurements to objectively determine perineal muscle function before and after delivery in 102 women. In addition, 24 nulliparous, non-pregnant women were studied to determine the effect of pregnancy on perineal muscle function. Pregnancy is associated with a decrease in perineal muscle strength and endurance compared with the postpartum state. The degree to which women improved or did not improve perineal muscle function after birth was related to perineal trauma at delivery. After controlling for parity, maternal age, birthweight, smoking status, and antepartum scores, the order of best to worst performance was cesarean birth, intact perineum, first-degree perineal injury, second- or third-degree perineal injury, and episiotomy. Pre- and post-delivery scores were compared for each woman and analyzed according to perineal outcome. Although all other perineal outcome groups increased muscle function by 6 months postpartum, women with an episiotomy had a mean net loss of perineal muscle performance after birth. These observations do not support the use of episiotomy for the purpose of preserving perineal muscle function.

The "push" for evidence: management of the second stage.

Recognition that the available evidence does not support arbitrary time limits for the second stage of labor has led to reconsideration of the influence of maternal bearing down efforts on fetal/newborn status as well as on maternal pelvic structural integrity. The evidence that the duration of 'active' pushing is associated with fetal acidosis and denervation injury to maternal perineal musculature has contributed to the delineation of at least two phases during second stage, an early phase of continued fetal descent, and a phase of "active" pushing. The basis for the recommendation that the early phase of passive descent be prolonged and the phase of active pushing shortened by strategies to achieve effective, but non-detrimental pushing efforts is reviewed. The rational includes an emphasis on the obstetric factors that are optimal for birth and conducive to efficient maternal bearing down. Explicit assessment of these obstetric factors and observation of maternal behavior, particularly evidence of an involuntary urge to push, should be coupled with the use of maternal positions that will promote fetal descent as well as reduce maternal pain. The use of epidural analgesia for pain relief can also be accompanied by these same principles, although further research is needed to verify the strategies of "delayed pushing" and maintenance of pain relief along with a reconceptualization of the second stage of labor.