During SECOND STAGE LABOR

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2 LABOR SUPPORT During SECOND STAGE LABOR for WOMEN With EPIDURALS BIR T H IN T H I S E R A IS T E C H N O L O G Y D R I V E N. MA N Y W O M E N GIVING B I R T H IN H O S P I T A L S E T T I NG S H AV E E P I D U R A L S F O R PA I N M A N A G E M E N T. YE T L A B O R I N G W O M E N N E E D M O R E T H A N T E C H N O L O G Y TH E Y H AV E B A S I C N E E D S T H A T C A N T B E ADDRESSED BY TECHNOLOGY ALONE. Ann L. Bianchi, RN, MSN Ellise D. Adams, MSN, CNM

3 Zwelling (2008), in her article The Emergence of High-Tech Birthing, suggests that intrapartum (IP) nurses can balance technology in birth by using evidenced-based practice, evaluating their personal birth philosophy, promoting family-centered maternity care and increasing skills in labor support. Increasing labor support skills to comfort women with epidurals during the second stage of labor will be the focus of this article. The practice of labor support includes the provision of nonpharmacologic or comfort methods, called labor support behaviors (LSBs), to address the specific needs of laboring women (Sauls, 2006). Examples of labor support include but aren t limited to back massage, encouragement, instructions for pushing and negotiating a birth plan on behalf of the client. Several authors (Gagnon & Waghorn, 1996; McNiven, Hodnett, & O Brien-Pallas, 1992; Sauls) designated the role of the IP nurse into categories, differentiating between labor support and other nursing interventions such as vaginal examinations, fetal heart rate monitoring, documentation and medication administration. Nursing interventions not categorized as labor support will not be addressed in this article. The Association of Women s Health, Obstetric and Neonatal Nurses (AWHONN) Bottom Line Women with epidurals have unique labor support needs. Labor support behaviors of nurses include physical, emotional, instructional/information and advocacy. Many rewards can be gained from this type of nursing care. (2000) clinical position statement Professional Nursing Support of Laboring Women calls labor support by a professional registered nurse a critical component (necessary) to achieve improved birth outcomes. AWHONN also promotes labor support for women with epidurals in its evidence-based clinical practice guideline Nursing Management of the Second Stage of Labor (AWHONN, 2008). Labor Support Behaviors IP nurses have sophisticated technical skills and complex interpersonal skills to meet the clinical/medical requirements of the labor and delivery unit as well as the physical and psychosocial needs of the woman in labor (Miltner, 2000, p. 491). These skills have been studied extensively by several nurse researchers. Observation work sampling was one technique used to determine Ann L. Bianchi, RN, MSN, and Ellise D. Adams, MSN, CNM, are clinical assistant professors at the University of Alabama in Huntsville, AL. Address correspondence to: ann.bianchi@uah.edu. DOI: /j X x how often IP nurses performed supportive care. Many studies (Gagnon & Waghorn, 1996; Gale, Fothergill- Bourbonnais, & Chamberlain, 2001; McNiven et al., 1992; Miltner, 2002) have found that IP nurses spent between 6.1 percent and 31.5 percent of their time in patient care providing LSBs. In 2000, Miltner interviewed 500 IP nurses and identified 55 nursing interventions that could be characterized as supportive care and were used in both first and second stages of labor. Some of these interventions were coaching pushing or relaxation; offering praise; protecting modesty; reassuring the laboring woman about her progress; and exploring the expectations of the client. Types of Labor Support Behaviors LSBs are specific, nonpharmacologic nursing behaviors that are helpful to women during labor and birth (Bianchi & Adams, 2004). For this article, LSBs useful for second-stage labor are separated into four categories: physical, emotional, instructional/information and advocacy (see Figure 1). Physical LSBs provide the laboring woman with physical comfort, enhance her labor progress and increase her satisfaction with the birth process (Hodnett, Gates, Hofmeyr, & Sakala, 2003; Manogin, Bechtel, & Rami, 2000). Emotional LSBs allow the IP nurse to subjectively be a part of the laboring woman s feelings (Sauls, 2004). Instructional/informational LSBs provide the client with information needed to be a part of the decision-making process during labor and birth (Adams & Bianchi; AWHONN, 2008). Advocacy LSBs protect the client through the establishment of a therapeutic relationship (Foley, Minick, & Kee, 2002). Twenty-one LSBs are listed in Box 1 and are referenced throughout the article. Each LSB corresponds to one of the four colors represented in Figure 1. LSBs are complementary, and creativity is encouraged when constructing combinations of one or more LSB categories. For example, when reassuring the client who feels discouraged with pushing progress (emotional LSB), capitalize on the time between contractions to implement position changes, give a back massage or offer ice chips (physical LSB). Needs of Laboring Women Bowers (2002) reviewed 17 qualitative studies that targeted a woman s expectations of labor support. To analyze labor support from these studies, Bowers categorized labor support into physical comfort, emotional support, informational support and advocacy. Bowers concluded that women have personal expectations of labor support from their caregivers in each of the four categories. An assumption can be made that laboring women s personal expectations may stem from their needs during labor and birth. An understanding of these expectations may provide the IP nurse with an insight into the specific needs of laboring women. Survey results from Listening to Mothers: Report of the First National U.S. Survey of Women s Childbearing Experiences , AWHONN

4 FIGURE 1 Labor Support Behaviors (LSB) Artwork by Wade Pettus. (Declercq, Sakala, Corry, Applebaum, & Risher, 2002) showed that women had positive views of their care during labor and birth. Most women strongly agreed that while in labor and during birth they were able to understand information provided to them, were treated with kindness and understanding, were comfortable discussing their concerns and asking questions, got the attention they needed, were not hurried and were free to take the time they needed to get through labor and birth, and were as involved in making decisions as they wanted to be (Declercq et al., p. 30). Women are more likely to report positive views of their labor and birth experiences when their needs for supportive care have been met. Women s physical needs include upright or lateral positions for comfort, a home-like environment and relief of discomfort and pain. Emotional needs include continuous support, attention to cultural needs, having a sense of control, being treated with kindness and receiving unhurried care. Instructional/ informational needs include understandable information, information about the course of labor and instructions pertaining to procedures that occur during labor. Advocacy needs include staff that listen to her needs, provision of a trusting environment where concerns can be expressed and involvement in decisions about care (Declercq et al., 2002; Hodnett, 2002). Corbett and Callister (2000) surveyed women 72 hours after birth using the Bryanton Adaptation of the Nursing Support in Labor Questionnaire. Findings indicated that women perceived emotional support more helpful than other types of labor support. It s important to note that 93 percent of the women in the study had epidural anesthesia. Even when physical pain is relieved, the other needs of laboring women are still present. epidurals in SeCoNd Stage Choosing LSBs for women with epidurals requires the IP nurse to incorporate knowledge of the maternal and fetal effects of the epidural. While epidurals provide pain relief for laboring women, side effects may alter the course of labor and birth outcomes. Laboring women must also fully understand these effects in order to give accurate informed consent. The IP nurse plays an important role in helping laboring women understand the information given to her. Due to motor blockade, an epidural has an effect on maternal positioning during labor. Impaired motor ability most often requires confinement to bed. The client may also have fewer position change options with an epidural. Immobility hinders fetal descent and may lead to an increased incidence of instrumental vaginal delivery (Lieberman & O Donoghue, 2002; Mayberry, Clemmens, & De, 2002; Minato, 2000). In a systematic review, Lieberman and O Donoghue found lower rates of spontaneous vaginal births among nulliparas with epidurals. They also noted increased instrumental vaginal births among women with epidurals independent of parity. Instrumental vaginal births are associated with third- and fourthdegree perineal lacerations; therefore, an association between epidurals and these lacerations is likely (see LSB1). Fraser et al. (2002), in a multicenter randomized-controlled trial, sought to determine risk factors in second stage for difficult delivery among nulliparas with epidural analgesia. Abnormal fetal position and fetal station higher than +2, measured at complete dilation, were associated with difficult births. Lieberman and O Donoghue (2002) also found that abnormal fetal position could be a leading cause of the increase in cesarean and operative vaginal births in mothers with epidurals. The maternal upright position uses gravity and encourages appropriate fetal positioning. In a meta-analysis of seven studies on the effects of the epidural, Leighton and Halpern (2002) found that the length of second stage is increased with an epidural. Maternal overexertion, exhaustion and fatigue are, therefore, more common due to these extended stages of labor (Minato, 2000). Not only are laboring women mentally fatigued, but muscle fatigue occurs also. Muscle fatigue can lead to decreased uterine contractility and inadequate maternal oxygenation and, therefore, inadequate fetal oxygenation (Mayberry, Gennaro, Strange, Williams, & De, 1999) (see LSB2). Goetzl et al. (2001) found that mothers with epidurals experience low-grade fevers of 99.6 o F to o F. Leighton and Halpern (2002) reported women with an epidural for longer than five hours who also experienced shivering were more likely to have increased maternal temperature. Lieberman and O Donoghue (2002) also found an increase in maternal temperature to be associated with epidural use in labor. These February March 2009 Nursing for Women s Health 41

5 Box 1 Labor Support Behaviors for the IP Nurse LSB1 Use Effective Verbal Communication Techniques. Discuss the impact of the epidural on second stage with the laboring woman as early in labor as possible, before she chooses her method of pain relief. This frank discussion allows the IP nurse and the laboring woman to develop a plan that will minimize the negative effects of the epidural and maximize potential positive effects. For example, discuss the benefits of upright positioning on fetal descent. LSB2 Implement Periods of Push and Rest. To avoid excessive fatigue, implement rest periods during second-stage pushing efforts. Mayberry, Gennaro, Strange, and De (1999) observed five different patterns of pushing and resting: (1) pushing with each contraction, no rest except between contractions; (2) one rest period every 10 minutes; (3) two to three rest periods every 10 minutes; (4) pushing every other contraction with one rest period every 10 to 15 minutes; and (5) greater than four rest periods in less than 10 minutes. Advantages to greater periods of rest during second stage seem obvious but must be studied more fully. LSB3 Control Environmental Temperatures. To avoid maternal temperature extremes, ensure that the thermostat in the LDR is moderately cool, and provide personal cooling methods such as removing heavy blankets, using cool washcloths or providing portable fans. Once the birth has occurred, cooling methods may have to be discontinued to avoid newborn heat loss. LSB4 Provide Information About Second Stage. Information that will assist the woman to feel at ease with laboring down may include explaining that progress will continue with each contraction and the fetus will continue to make descent into the birth canal; describing the sensation of pressure that may be felt during laboring down; and updating progress, by saying you are moving the baby down. Use pelvic and fetal models to demonstrate the current location of the fetus and the path of fetal descent to help the laboring woman visualize what must occur before pushing. This information provides the woman with the knowledge she needs to increase her confidence that her body is functioning in a positive way. LSB5 Communicate Second Stage Progress Effectively to the Health Care Team and to the Client. Descriptive details concerning client progress must be effectively delivered in a truthful and positive manner. Voice tone and choice of words are important. For example, when relaying information to the physician, use statements such as, I m encouraged because the fetal head has rotated to an anterior position and the baby has good variability without decelerations. Mom has lots of energy and is still smiling. This statement is encouraging and offers information about fetal position and well-being plus added information on how the woman is coping. The laboring woman will also be encouraged if the information is upbeat and delivered in an unhurried manner. LSB6 Promote Rest During Second Stage. Offer reassurance about fetal well-being and labor progress to put the laboring woman s mind at ease so that rest is enhanced. It s important to point out that laboring down provides an opportunity for rest and peacefulness and is also a time to regain energy while the fetus descends. During this time, assess for signs of uneasiness or restlessness and investigate what will make the woman more comfortable. LSB7 Offer Undivided Attention (Nursing Presence). MacKinnon, McIntyre, and Quance (2005) studied the meaning of presence in birth. They discovered that women expected their nurse to be present and there for them. This includes being available and emotionally involved, listening, being an advocate and creating a trusting environment, especially during second stage. The nurse-client relationship, developed in the first stage of labor, allows the woman to rely on the IP nurse for comfort and support and may empower women in labor to trust their bodies to do the work required in the birth process. LSB8 Ask for Feedback About Emotions, Fears and Feelings. Laboring women can create a perceived reality much worse than the truth. We know that pent-up emotions must be released at some point. Simkin (2002a) encourages the use of the question, What s going through your mind? Once these thoughts are voiced by the woman, the IP nurse should address them quickly. LSB9 For Partners: Assess Desires and Encourage Involvement. The plan of care should always include the birth partner. Role model LSBs to the partner. Find out some of the things the partner specifically wants to do, such as cutting the cord or telling mom the gender of the baby. Showing concern to the birth partner often comforts the laboring woman. LSB10 Negotiate With the Health Care Team. Advocate for the client by negotiating with the health care team to promote the client s desires. Negotiation may take a formal approach by encouraging the health care team to uphold the client s birth plan. An informal approach may simply be conveying the client s request using appropriate timing and respectful communication (Adams & Bianchi, 2008). LSB11 Implement the Modified Squat. With clients who have an epidural, the modified squatting position during second stage can be offered once the woman has reached 0 station. With the foot of the bed lowered, the woman can place her feet on the lowest part of the bed to assume a modified squatting position. A squatting bar can be placed across the bed to help stabilize the woman during a contraction. When the contraction begins, assist the woman to pull forward. Assess frequently for fatigue. The modified squatting position 42 Nursing for Women s Health Volume 13 Issue 1

6 facilitates fetal descent by increasing the diameter of the pelvis (Mayberry et al., 2000). LSB12 Implement the Towel Pull. Position the mother into a semi-reclining or squatting position. Attach the squatting bar to the bed. Knot one end of the towel or sheet and give to the client after looping the towel around the squatting bar. Instruct the client to pull the towel or sheet toward her while pushing (Injoy Videos, 2006). The nurse may also assist with the towel pull method by holding one end of towel and providing resistance while the laboring woman pulls on the other end of the towel during a contraction (Adams & Bianchi, 2008). For safety measures, the woman and the nurse should be assisted by another support person to maintain balance and promote safety. LSB13 Provide Physical Safety/Security. Safety is a high priority when a client s mobility is impaired. The labor process poses a physical risk to mother and fetus. Providing safety/ security in a physical manner includes protecting the laboring woman from injury. Side rails on the labor bed provide protection against falls. When the foot of the bed is lowered, it may become unstable if the laboring woman is large. Therefore, avoid using the foot of the bed in this situation. LSB14 Implement Sims Lateral for Comfort. To increase comfort, assist the woman into Sims Lateral, making sure the hip and knee resting on the bed are flexed. Pillows help to stabilize and cushion the body while in this position. A pillow may be placed between her knees to decrease strain on the lower back muscles and a pillow may also be placed behind the woman to help stabilize her while she is resting. LSB15 Implement Sims Lateral to Facilitate Rotation. Based on continual assessment of second stage, the IP nurse may purposely instruct the woman to lie on a particular side to help facilitate anterior fetal rotation. To rotate a fetus, the laboring woman is positioned on the side in which the fetal spine is located. If the nurse s assessment indicates the fetus is right occiput posterior, the woman lies on her right side. Gravity will pull the fetal occiput and trunk toward right occiput transverse and then eventually right occiput anterior (Adams & Bianchi, 2008). Once the woman is placed on her side a pillow is wedged between her back and the bed with another pillow under the abdomen for support. An upright position can be encouraged once the IP nurse s assessment reveals the fetus is in proper alignment (Adams & Bianchi, 2008). The use of a pelvis and fetal model will help the laboring woman visualize the birthing process. LSB16 Provide Affirmation. Whether there is an expressed need or not, a laboring woman with an epidural needs affirmation during second stage. She needs regular updates regarding her progress. She needs a connection to her contractions. She needs to hear that the baby is tolerating the pushing well. These affirmations need to be repeated numerous times. LSB17 Establish Eye Contact. Eye contact from the IP nurse assists the laboring woman in pushing effectively. The IP nurse can role model pushing. Eye contact is established by maintaining a face to face position and locking eyes. Statements such as look at me, stay with it, you can do it, and breathe with me, are effective in keeping the client focused. LSB18 Provide Encouragement. Women with epidurals need more encouragement to push. These women can t feel the progress they re making and often express despair. Encouragement also provides women with the emotional energy to continue. IP nurses can develop methods of encouragement other than the default cheerleading routine often used. During second stage, laboring women need to be encouraged to follow their instincts. Words are important tools of encouragement. Be specific about progress, cheerful and hopeful in communication. Implement bearing down efforts. Between contractions, it s effective to encourage the laboring woman to try alternate LSB to promote comfort. Some helpful encouragements may include let s try a different position, why don t you rest through the next three contractions, let me get you some ice, or I ll massage your shoulders while you rest. LSB19 Use Effective Verbal and Nonverbal Communication Techniques. When assisting a client to use open glottis pushing, communicate, both verbally and nonverbally, that this method is efficient and effective. Helpful statements include, Don t be concerned about the noise you make, I ve got the door closed, and this noise makes you push more effectively. Supportive nonverbal communication includes open and patient body language. LSB20 Provide Instructions for Open Glottis Pushing. Although this is a client-directed method of pushing, the client with an epidural may need some instruction. Ideally, pushing methods are taught before second stage. Teaching should include a discussion of upright positions that use the effects of gravity, the concept of laboring down and a demonstration of the method. Teaching aids include a fetal descent poster, a plastic pelvis and a fetal model. LSB21 Implement the Take Charge Routine. The Take Charge Routine was first promoted by Penny Simkin (Simkin, 2002b). Implement this LSB to focus the client and return her attention to BDEs. The Take Charge Routine involves making eye contact with the client, making physical contact, often by holding her shoulders, and encouraging her to pant and breathe until the contraction ends. Between contractions, you may need to talk fast and in a slightly raised voice to gain her attention. During the next BDE, an effective way to use this LSB is to actively push with the client, mimicking the open glottis method of pushing. February March 2009 Nursing for Women s Health 43

7 Women are more likely to report positive views of their labor and birth experiences when their needs for supportive care have been met newborns were also more likely to endure sepsis evaluation even if the mother was afebrile. Newborns born to mothers with fevers are also at greater risk to receive prophylactic antibiotic administration (Lieberman & O Donoghue) (see LSB3). Supportive Care Laboring down has been referred to in the literature as rest and descend (Hansen, Clark, & Foster, 2002; Mayberry et al., 2002; Minato, 2000). The use of this terminology upholds the philosophy that labor progression continues to occur while women rest and wait for the fetus to descend. Laboring down does not promote the need to watch the clock, nor does it require initiation of pushing efforts solely based on dilation. When the focus is directed toward progression of fetal descent, there is less emphasis on time limits. Roberts (2003) states that laboring down works on the premise that the woman s pushing efforts are delayed until objective evidence of fetal rotation and descent is documented by the nurse. If the epidural has blocked the urge to push, the IP nurse continues surveillance of fetal position and station. Although the woman is not actively pushing, uterine contractions continue to aid in fetal descent allowing the body to rest until the fetus has entered the birth canal. Many benefits related to laboring down have been reported in the literature. A study conducted by Hansen et al. (2002) concluded that women who began second-stage labor by resting during descent experienced less overall fatigue, a decreased amount of time pushing and fewer fetal heart rate decelerations. Simpson and James (2005) studied 45 nulliparous women with epidurals and found that the fetal oxygen saturation was improved in women who delayed pushing until the urge was felt, compared with women who pushed immediately at 10 cm. Their study also showed evidence that perineal lacerations were decreased with delayed pushing. Laboring women are more likely to have their fears alleviated when information concerning labor progress is offered (Chen, Wang, & Chang, 2001). This is especially true when the woman begins to labor down. The woman s confidence level can be increased when she understands how her body will work naturally and how progress can be made even though her body is not ready to actively push (see LSB4). The IP nurse identifies the following six elements during assessment of labor progress in the second stage: (1) cervical dilation, (2) maternal and fetal well-being, (3) rotation of fetal head, (4) descent of presenting part, (5) intensity of contractions and (6) the involuntary urge to push (Adams & Bianchi, 2006). When the health care team is evaluating the options for birth or reviewing criteria relating to the progression of labor, these assessment data become vitally important in order to support laboring down efforts, and could make a difference when determining the length of time allowed for second stage. How IP nurses communicate these assessment findings to the health care team may be the pivotal point that will support continued laboring down efforts (see LSB5). When labor pain is minimized or removed with an epidural, the woman s concerns shift (Simkin, 2002a). Laboring women begin to focus on other areas such as the well-being of the fetus, often asking Is my baby alright? They also become more concerned about labor progression. If they have a good concept and understanding of the birth process, they re able to rest without increased anxiety or concern (Chen et al., 2001) (see LSB6). Emotional Care Emotional care is vital for all women in labor, including those with epidurals, and IP nurses are in an ideal position to provide it (AWHONN, 2000). Effective pain relief may reduce anxiety, but laboring women with epidurals may have other sources of stress. Additionally, epidurals don t always provide effective pain relief, and even when they do, they usually don t block all sensation. During second stage, the woman can experience different sensations, such as difficulty breathing or extreme numbness, 44 Nursing for Women s Health Volume 13 Issue 1

8 that may cause her mental stress and concern (Simkin, 2002a). It s also common for her support system to become less attentive following the epidural, leaving her feeling abandoned and insignificant (Simkin, 2003). IP nurses may also provide fewer LSBs and spend more time outside of the room following the epidural, which may be interpreted as lack of concern by the laboring woman (Adams & Bianchi, 2006) (see LSB7). Women may describe feeling detached from the birth process and the baby following an epidural (Simkin, 2002a). When contractions aren t felt, they may be perceived as gone (Simkin). Women can become impatient, bored and worried. Physical concerns such as losing permanent feeling in the lower extremities or the side effects of the epidural may produce significant worries (see LSB8). Chapman (2000) found that male birth partners described two emotions when their partners had an epidural. Before the epidural, they felt they were losing her. Her pain was intense, she was exhausted and he was less able to communicate with her. This created feelings of anxiety, frustration and helplessness among male birth partners. After the epidural assisted with pain relief, birth partners felt she was back. Birth partners expressed relief, worried less and enjoyed labor more. This information can assist the IP nurse in providing care to the partner (see LSB9). Positioning for Second Stage Proper positioning during second stage of labor enhances the comfort of laboring women and has the ability to promote fetal rotation and descent (Mayberry et al., 2000). When mobility is limited because of an epidural, the IP nurse makes adjustments in the care provided. Under some circumstances, barriers exist that decrease the IP nurse s quest to promote upright positions and frequent position changes. Gilder, Mayberry, Gennaro, and Clemmens (2002) surveyed nurse s current practices and the use of upright positioning during labor. They found that some barriers were due to maternal reasons, such as lower extremity weakness, fatigue and general passivity, which in turn led to women refusing position changes. The study also discovered barriers to upright positions were related to the preference of health care provider, as some health care providers weren t open to upright positions and preferred the low Fowler s position for their own convenience (see LSB10). Upright positions, such as modified squat and towel pull, during the second stage of labor for a woman with an epidural have been linked to increased participation in the birth process (Hanson, 1998). Benefits of upright positions include increased satisfaction with the birth process and decreased pain during birth (Gilder et al., 2002). Upright positions may also play a part in the effectiveness of contractions (Gilder et al.) (see LSB11). The towel pull method allows the woman to assume a semireclining or squatting position. Using the towel pull method can assist the woman to assume a correct position. The towel pull uses abdominal muscles to assist with expulsive efforts (Mayberry et al., 2000) (see LSB12). Security and safety are important needs of the laboring woman. Many threats to the woman s physical safety can occur during second stage. Examples to promote physical safety include making sure the bed remains in a locked position and ensuring that equipment, such as the squatting bar is in proper working order. The IP nurse consistently evaluates the safety and security of the client as she progresses through the second stage of labor (see LSB13). The Sims lateral position is considered gravity-neutral and it relieves pressure on the sacral area (see LSB14). Albers (2003) and Simkin and Bolding (2004) found that the Sims lateral position increases the woman s control over pushing, which slows a rapid second stage and may decrease the possibility of perineal lacerations. Ridley (2007) recommends the Sims lateral to facilitate anterior rotation of the fetal head (see LSB15). Methods for Pushing Once the fetus has descended, it s appropriate for women with an epidural to begin bearing down efforts (BDEs). The IP nurse should assist these efforts utilizing a method that will be effective and safe for mother and baby. Two methods of BDEs are presented here closed glottis and open glottis. Closed Glottis Closed glottis pushing is also called valsalva maneuver, directed or voluntary pushing. This method is initiated and directed by someone other than the laboring woman, often the IP nurse. Typical BDEs involve instruction to take a deep breath and hold it for a count of 10 at the beginning of each contraction. A quick breath is exhaled, followed by another deep breath and BDEs. The laboring woman is encouraged to push forcefully at least three times per contraction (see LSB16 and LSB17). Many health care providers may feel that closed glottis pushing shortens second stage, although research does not support this assumption (Minato, 2000; Roberts, 2003). The literature cites many risks associated with this type of pushing (see Box 2). Open Glottis The second type of BDE is called open glottis, or spontaneous or involuntary pushing. This pushing effort is initiated by the laboring woman once the Ferguson reflex is elicited. While this reflex may not be felt by the client with an epidural, the IP nurse can encourage the client to push in this manner (see LSB18 and LSB19). Benefits of open glottis pushing are listed in Box 3. The typical BDEs with open glottis pushing are several short pushes, accompanied by breath holding no longer than four to six seconds at a time. Expiratory grunting and other vocalizations are common and may be encouraged by the IP nurse February March 2009 Nursing for Women s Health 45

9 (see LSB20). Laboring women may become fatigued and develop emotional distress during second stage. The IP nurse can implement LSBs to focus the client and return her attention to BDEs (see LSB21). Because there s an increase in body fluids, including the possibility of unintentional defecation, during Box 2 Risks Associated with Closed Glottis Pushing Maternal, During Labor Increased intrathoracic and abdominal pressure Vasoconstriction, hypotension and decreased cardiac output, which in turn decreases maternal blood flow Petechial hemorrhages of the face, neck and eyes Increased fatigue Decreased blood flow to the fetus second stage, the IP nurse provides perineal and anal care to promote physical comfort. The bladder must also be assessed frequently to ensure that it is not distended during an extended second stage. These strategies promote hygiene, comfort and privacy and convey respect for the laboring woman. Co n c l u s i o n Women who elect epidural anesthesia for their labor and birth present with different needs than women who give birth without regional anesthesia. A comprehensive approach to the nursing management of these women requires the IP nurse to incorporate the use of LSBs into practice. Many rewards can be gained through this type of challenging nursing care. The IP nurse gains the satisfaction of contributing to a laboring woman s self-confidence and sense of empowerment, while mothers and their partners gain a positive birth experience in which their efforts are recognized and valued. NWH Maternal, After Birth Diminished first urge to void following birth Decreased bladder capacity Increased symptoms of urge incontinence Increased risk of pelvic organ prolapse Fetal Alterations in perfusion, causing acid-base imbalances and heart rate decelerations Tightened pelvic floor muscles, which hamper fetal rotation and descent Sources: Mayberry et al., 2000; Schaffer et al., 2005 Box 3 Benefits of Open Glottis Pushing Facilitation of maternal/fetal circulation (Roberts, 2002) Less maternal fatigue (Mayberry et al., 1999) Unaltered bladder function (Schaffer et al., 2005) Decreased incidence of perineal tears due to gradual fetal descent (Simpson & James, 2005) References Adams, E., & Bianchi, A. (2008). A practical guide to labor support. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(1), Adams, E. D., & Bianchi, A. L. (2006, June). She s having an epidural: The innovative nurse s guide to labor support. Session presented at the Association of Women s Health, Obstetric and Neonatal Nurses 2006 Convention, Baltimore, MD. Albers, L. (2003). Reducing genital tract trauma at birth: Launching a clinical trial in midwifery. Journal of Midwifery and Women s Health, 48(2), Association of Women s Health, Obstetric and Neonatal Nurses. (2000).Clinical position statement: Professional nursing support of laboring women. Washington, DC: Author. Association of Women s Health, Obstetric and Neonatal Nurses. (2008). Evidence-based clinical practice guideline: Nursing management of the second stage of labor. Washington, DC: Author. Bianchi, A., & Adams, E. (2004). Doulas, labor support, and nurses. International Journal of Childbirth Education, 19(4), Bowers, B. B. (2002). Mothers experiences of labor support: Exploration of qualitative research. Journal of Obstetric, Gynecologic and Neonatal Nursing, 31(6), Chapman, L. (2000). Expectant fathers and labor epidurals. Maternal-Child Nursing, 25, Chen, C. H., Wang, S. Y., & Chang, M. Y. (2001). Women s perception of helpful and unhelpful nursing behaviors during labor: A study in Taiwan. Birth, 28(3), Corbett, C. A., & Callister, L. C. (2000). Nursing support during labor. Clinical Nursing Research, 9(1), Nursing for Women s Health Volume 13 Issue 1

10 Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s childbearing experiences. New York: Maternity Center Association. Foley, B. J., Minick, M. P., & Kee, C. C. (2002). How nurses learn advocacy. Journal of Nursing Scholarship, 34(2), Fraser, W. D., Cayer, M., Soedor, B. M., Turcot, L., Marcoux, S., & for the PEOPLE (Pushing Early or Pushing Late with Epidural Study) Group. (2002). Risk factors for difficult delivery in nulliparas with epidural analgesia in second stage of labor. Obstetrics & Gynecology, 99(3), Gagnon, A. J., & Waghorn, K. (1996). Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth, 23(1), 1 6. Gale, J., Fothergill-Bourbonnais, F., & Chamberlain, M. (2001). Measuring nursing support during childbirth. Maternal Child Nursing, 26(5), Gilder, K., Mayberry, L., Gennaro, S., & Clemmens, D. (2002). 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