CBL 2_Active Labour and Non-Pharmacological Pain Management Flashcards
Mechanisms of labour for OA?
ROA
1. Babes head enters inlet of pelvis (in transverse diameter – oval to oval)
2. Fetal axis pressure – makes babes head flex (smallest diameter of fetal head presenting)
3. Increased pressure on fetal axis – causes descent of fetus through pelvis
4. Occiput meets resistance of maternal pelvic floor – occipate rotates anteriorly by 1/8 (babe head OA) – but shoulders Do Not rotate
5. Increasing fetal descent, occipate slips beneath suprapubic arch (top of pelvic brim) CROWNING
6. Babes head extends (releases face and chin)- sweep perinium
7. Restitution – fetal head and fetal shoulders re-align – anterior shoulder meets suprabupic arch and 1/8 rotates
9. Anterior shoulder sweeps under the pubic arch and posterior shoulder sweeps under the curve of the pelvis (hollow of the sacrum) = lateral flexion of fetus**BUT NOW RESEARCH IS SAYING POSTERIOR SHOULDER IDK?
Mechanisms of labour for OP?
ROP – long rotation, only difference to ROA is head goes long way around
- Babes head enters inlet of pelvis (similar position of OA)
- Fetal axis pressure – makes babes head flex (smallest diameter of fetal head presenting)
- Increased pressure on fetal axis – causes descent of fetus through pelvis
4.Occiput meets resistance of maternal pelvic floor – occipat rotates anteriorly by 3/8 – and shoulders rotate 2/8 (same misalignment of OA position) - Increasing fetal descent, occiput slips beneath suprapubic arch (top of pelvic brim) CROWNING
- Babes head extends (releases face and chin)- sweep perinium
- Restitution – fetal head and fetal shoulders re-align – anterior shoulder meets suprabupic arch and 1/8 rotates
- Anterior shoulder sweeps under the pubic arch and posterior shoulder sweeps under the curve of the pelvis (hollow of the sacrum) = lateral flexion of fetus
How can we avoid causing iatrogenic hyponatremia? (4)
DRINK PER THIRST
-Isotonic drinks
-Know the symptoms of hyponatremia (Nausea and vomiting)
-Have standards in place on fluid intake in labour
What are heightened levels of fear associated with in birth?(7)
- C/S
- Epidural
- Neg birth exp
- Neg prenatal exp
- Neg pp exp
- Less confidence as a parent pp
- nreased anxiety
What is the midwife’s role with fear and birth?
● Address client beliefs, attitudes, and previous experiences to foster feelings of autonomy and reduced anxiety
● Prenatal discussions
● Providers who do not value vaginal birth, and who seem to make decisions based on fear instead of evidence, are associated with higher cesarean rates for clients
Can hyponatremia occur in the absence of IV fluids?
Yes sometimes
Key factors to support physiological first stage? (4 Ps)
- Power
- Passenger
- Passage
- Psyche
(POSITION)
How do we support Power?
- INCREASE NATURAL OXY - safe environment
- Dim lighting, minimal sounds, with limited disturbances and strangers.
- Foster a sense of safety – whatever that means to them.
How do we support Passenger?
- Movement and position changes can assist the contractions in positioning the fetus through the pelvis
- Some examples: side-lying release, lunges, sitting on toilet with one foot on stool and the other foot on the floor, and continuing to move during a contraction without “freezing” the body with tension
How do we support the Passage?
Empty bladder
Opren the pelvis - squatting, kneeling, hands and knees
Support intuitive positioning - don’t boss client around
How do we support the psyche?
- The emotional wellbeing of the birthing person relates to labour progress
- Fear and anxiety produce beta-endorphins, adrenocorticotropic hormone, cortisol, and epinephrine (stress hormones)
- These hormones act on the uterus’s smooth muscle causing decreased blood flow resulting in contractions to become weaker, shorter, and further apart which can also impact dilation progress (4).
- Continuous support i
- safety
- music, aromatherapy, encouragement
Routine care for active 1st stage? (4)
● Assess birther and fetal well-being
● Monitor progress of labour
● Offering support /recommendations for non-pharmacological pain management
● Facilitating access to pharmacological pain management when requested/ appropriate
How often birther vital measured in active first stage?
Every 4 hours (BP, temp, HR, RR)
Is high HR common in labour?
Yes, but we don’t want it persistently above 100 – that’s tachy.
How often FHS in active 1st stage?
Every 15 min – 30 mins
When extra FHS in active 1st stage? (6)
- Before meds
- Before and after AROM
- After SROM
- Before and after VE
- Before starting epidural
- concerning reading
What should we observe about the birther in labour? (4)
●Coping/pain
●Emotions
●Energy/fatigue
●Fluid intake and output
Cervical dilation rates for active first stage (Zhang et al)?
0.1 cm hour to 2.4 cm hour
When does active labour occur SOGC?
3-4 nulip
4-5 multip
AND cervical length 1 cm
(not evidence based cummon SOGC)
What does active labour look like?
-Regular, intense contractions
-Progressive cervical change
-Stopping to focus on contractions
When does active labour occur ACOG and SMFM?
6 cm dilation
What are we always assessing in labour?
1- Maternal condition and coping
2- Fetal condition
3-labour status
What does the evidence tell us about going to the hospital too soon in labour?
Avoid early admission when not in active labour – because it will lead to more interventions
How often should someone be drinking in labour?
As per thirst
What are the risk factors of developing peripartum hyponatraemia? (8)
- Lower baseline sodium in pregnancy
- Labour-related nausea, vomiting, stress, pain, starvation
- Physiological oliguria and antidiuresis
- Prolonged labour
- Oxytocin IOL
- Excess of oral/intravenous fluids/positive fluid balance >1500 ml
- Epidural
- Dextrose infusion
What are the early signs of peripartum hyponatraemia?(4)
headache
anorexia
nausea
lethargy and apathy
What are the clinical signs of moderate to severe hyponatraemia?(7)
disorientation
agitation
seizures
depressed reflexes,
coma
respiratory arrest
noncardiogenic pulmonary oedema.
When start partogram?
ACTIVE LABOUR not before
Evidence based: 6 cm and beyond with regular cx pattern
How does the textbook define active labour?
regular, painful contraction
progressive cervical dilation
combination of contractions AND cervical change that define active labour
Ctx don’t change with position change
When does ACOG recommend waiting till lack of progress should be defined?
After 6 cm dilation
Should hospital admission CBC be routine for all low risk labouring people?
No, but is required for C/S
How often VEs in labour?
Every 4 hours, however there should always be a justification if it’s necessary
(Some do every 2-4 hours)
What should we consider when doing VEs?
Is it necessary to do right now?
Is there another way of getting this information?
What is ‘normal’ labour modelled after in midwifery?
Specific pelvic morphology that is common in European women
What should we think about when considering pelvic shape?
-Normalizing white centered anatomy in birth can disadvantage non-European birthers, leading to classifications of abnormal and increased intervention
-human birth canal is variable in shape and mechanisms of labour
What is the difference in fetal presentation with gynacoid pelvis vs anthropid pelvis
GP – babe born often facing posterior (more common in European and more discussed in midwifery textbooks)
AP – babe commonly born facing anterior
Therefore the ‘normal’ mechanisms of labour differ for different pelvises
What is the role of the midwife sometimes?
Masterly inactivity lol
What does Zhang say about labour curve compared to Freidman curve?
average labor curve differs markedly from the Friedman curve. The cervix dilated substantially slower in the active phase. It took approximately 5.5 hours from 4 cm to 10 cm, compared with 2.5 hours under the Friedman curve. The diagnostic criteria for protraction and arrest disorders of labor may be too stringent in nulliparous women
Why does Denis Walsh question current intrapartum care (incl 4 hour VEs)?
Walsh mentions evidence raised by Gurewitsch et al (2002) showing that grand multips latent phase could last up til 6cm and that progression beyond that mimics lower parity (challenging the convention that multips clients labor more quickly). THERE IS PHYSIOLOGICAL VARIATION= NORMAL. Homogenizing people towards an average is unhelpful. Routine 4 hourly VE for every client is inextricably linked to the progress paradigm, custom and practice. What of clients who have been abused, PTSD? Labor rhythms vs labor progress models of care?
What does Zhang say about labour progress?
criteria used today are too stringent and many nullip clients will deliver safely with progress at less than 0.5cm/hr (3-7cms) and less than 1cm/hr (7-10cms).
Simkin and Acheta low intervention approach to prolonged active labour? (5)
- Note progress in Fetal position, descent, rotation (precursor to further progress)
- Tend to Emotional distress, nurture and encourage, positional changes, activity, empty bladder, music & restone rhythm
- Nipple stim, acupuncture (evidence base exists), reflexology, herbs where expertise exists
- Bath/shower, hydration and nutrition (evidence that water immersion can help labor progress)
- If maternal and fetal condition allow - TIME!
What does Walsh say on VE and labour progress?
-questions current intrapartum care practice (incl routine 4 hrly VEs) which has become so normal in our intrapartum care..
-Walsh mentions evidence raised by Gurewitsch et al (2002) showing that grand multips latent phase could last up til 6cm and that progression beyond that mimics lower parity (challenging the convention that multips clients labor more quickly). THERE IS PHYSIOLOGICAL VARIATION= NORMAL.
-Homogenizing people towards an average is unhelpful.
-Routine 4 hourly VE for every client is inextricably linked to the progress paradigm, custom and practice. What of clients who have been abused, PTSD? Labor rhythms vs labor progress models of care?
What does the research say about offering non-pharm pain mgmt. first? (3)
- increased satisfaction
- fewer interventions (epidurals, CS, forceps, vacuums, Pitocin)
- shorter labours.
Most effective if tailored to individual and with labour support.
ACOG recommends that non-pharm methods be offered first as there are no adverse effects/side effects.
Low intervention approach to prolonged labour (Simkin and Acheta)?
Low intervention approach (pg 105-107); more holistic assessment may include (prior to further medical intervention)
- Note progress in Fetal position, descent, rotation (precursor to further progress)
- Tend to Emotional distress, nurture and encourage, positional changes, activity, empty bladder, music & restone rhythm
- Nipple stim, acupuncture (evidence base exists), reflexology, herbs where expertise exists
- Bath/shower, hydration and nutrition (evidence that water immersion can help labor progress)
- If maternal and fetal condition allow - TIME
Denis Walsh criteria for VEs?
Is it necessary to do right now?
Is there another way of getting this information?
Different ways of viewing pain in labour?
Pain relief approach and working with pain approach
What is pain relief approach? (4)
-Many doctors and nurses align with this approach
-Pain is unnecessary
-That we should eliminate pain in labour
-The benefits of pain relief medication outweigh the risk of using them
What is working with pain approach? (4)
-Pain/intensity is a normal part of labour
-Pain incentivises you to move around in labour to get comfortable aiding the birth progress
-Labour pain can be better coped with an environment that feels safe, supported, and private
-Supports natural pain relieving hormones aka endorphins to be released
Pain vs Suffering (Simkin)?
You can have pain without suffering (ex. training for a marathon) – prepared with lots of support You can have suffering without pain (ex. epidural suffering emotionally – isolated, worried)
Sometimes pain and suffering happens at the same time.
What are some things that might reduce suffering with pain in labour? (5)
- Birth Education
-Companionship/doula - Reassurance
- Touch
- Feelings of Safety
What are the pain management strategies? (1-4, 2-2)
Pharmacological –
* epidural
* spinals
* NO
* IV drugs/IM drugs
Non-pharmacological
* gate control theory
* central nervous system-controlled pain method
What is the gate control theory approach to pain?
If you activate nerves in non-painful way blocks pain signals from reaching brain – limited amount of info can go to brain.
What are some examples of gate control theory? (5)
Labouring in a warm tub of water
Massage
Positioning/mvmnt
TENS MACHINE
Sterile water injections
What is central nervous system control pain method?
-controlling mind and what you’re thinking you can control the unpleasentness of pain
What are some examples of central nervous system control pain method? (5)
- childbirth education
- hypnobirthing
- continous support (doula)
- aromatherapy
- deep breathing
Are non-pharm approaches to pain effective?
Yes, gate controlled theory and central nervous system controlled pain method decreased chance of needing an epidural and being satisfied with your birth.
What were the results of offering central nervous system approach first (before pharm)? (4)
Fewer c/s
Fewer vaccum/forceps
Less use of oxytocin in late labour
Shorter labour
What is the most effective approach to pain? (2)
Different approaches tailored to the individual
Continous labour support from a doula
How do we perceive pain?
Intensity and unpleasantness
When people are coping well in labour what do they usually have? (3)
Rythym
Relaxation
Ritual
7 cardinal movements?
- Descent
- Engagement
- Flexion
- Rotation
OA - occipate rotates anteriorly by 1/8
OP - occipat rotates anteriorly by 3/8 – and shoulders rotate 2/8 (same misalignment of OA position) - Extension
- Restitution
Anterior (or often posterior) shoulder delivery - Expulsion
Fluid and nutrition guidelines for labour?
Low risk
no restrictions
Documentation in labour output/input? (3)
oral intake
voids
emesis
How many people fear childbirth enough to lose sleep/have anxiety?
25 %
What is transition?
period when active 1st stage of labour ends and beginning of 2nd stage begins; difficult to differentiate; may be characterized by a dip in contraction duration and interval length
What is latent 2nd stage?
period of respite before onset of urge to push; pause in pushing efforts, despite continued contractions; ctx patterns change, ctx shorter, longer interval between; can last between 5min to 1 hour
Recognizing transition and 2nd stage of labour without VE? (9)
Involuntary pushing
Increased bloody show
Passing stool
engorgement/distension of vulva
Anal dilation
Fetal presenting part visible at introitus
Increased rectal pressure
Trembling/shivering
Feeling sudden loss of control in transition
What is valsava pushing?
Act of holding one’s breath and straining, closed glottis
What is Diffuse Noxious Inhibitory Control ?
Doing gate controlled pain theory with painful stimulus (ex. sterile water injecitons)
