Module 5: The Onset of Labor and Early Labor Flashcards
Understand the lack of consensus on defining the onset of labor.
Friedman’s observations led to conceptualizing functional divisions of labor, with a preparatory phase, a dilation phase and a expulsive phase. These roughly correspond to latent phase of the first stage of labor, active phase of the first phase of labor, and second stage. These functional divisions mirror physiology and ring true to those who observe women in labor. However, our ability to accurately determine what phase of labor an individual woman is experiencing based on clinical data such as contractions pattern and cervical status is limited.
Understand the debate on defining the onset of active labor. Know Friedman’s definition, how his research resulted in the use of common criterion of 3- or 4-centimeters dilation to define active labor, and how contemporary research informs our current understanding of when active labor begins.
*Friedman defined this as the time when the RATE of dilation increases. However, Friedman himself points out that is not accurate to define active labor based on a particular dilation as there is considerable variation among women
*Contemporary research shows that many women are not in active labor until 5 or 6 centimeters. Several authors have proposed a rate of at least 0.5 cm per hour in the absence of other problems as an alternative minimum for normal labor progress.
*This is an important clinical issue because expectations for labor progress are very different in active as compared to latent phase, and mistakenly diagnosing active labor results in unnecessary interventions.
Describe anticipatory guidance related to labor onset and early labor.
*Anticipatory guidance emphasizes that labor onset is a gradual process, and it is often difficult to distinguish from the contractions and common discomforts of late pregnancy.
*The variability in women’s experience of labor onset should be explained. The normalcy of a lengthy preparatory phase and common experience of contractions that stop and start over days and weeks should also be discussed.
*Finally, anticipatory guidance includes an explanation of the reasons to delay admission to the birth site until active labor begins.
List the subjective components of the evaluation of a woman for the possible onset of labor.
- What is the time of day and the weather?
- How far away from the birth site does the woman live?
- Does she have access to transportation?
- Is home a quiet place she can rest if needed?
- Uterine Ctx
- Vaginal bleeding/spotting
- Bloody show
- Fluid leaking
- Fetal Status
- Fatigue
- Hydration/Nutrition
- Coping
List the objective components of the evaluation of a woman for the possible onset of labor.
- Maternal vital signs
- Fetal heart rate assessment
- Urine dipstick for proteinuria and ketonuria, assess specific gravity as needed
- Leopold’s maneuvers to determine fetal lie, presentation, position, and estimated fetal weight.
- Abdominal palpation for uterine tone and contraction frequency.
- Digital vaginal exam
Analyze methods for diagnosing the spontaneous rupture of the membranes including: Observation of fluid coming from the cervical os
*Is fluid obviously leaking out of the vagina?
*What is the appearance and smell of the fluid?
*Visualization
*Is there fluid coming out of cervical os?
*If obvious may be best data for definitive diagnosis
*Collect fluid from posterior fornix of vagina
*Have the woman lie down on her back for 15-30 minutes first so fluid collects
Analyze methods for diagnosing the spontaneous rupture of the membranes including: pH testing (nitrazine test)
*Amniotic fluid is alkaline, so turns paper dark blue
*If fluid is collected with cotton swab from posterior fornix, swab onto a piece of pH paper
*Can also touch paper to labia or perineum or wherever you see some fluid
*False positive: blood, semen, urine, bacterial vaginosis, trichomonis
*False negative: not enough residual amniotic fluid present
Analyze methods for diagnosing the spontaneous rupture of the membranes including: Arborization (fern test)
*Dried amniotic fluid has a characteristic “ferning” appearance under the microscope
*Collect fluid from posterior fornix with cotton swab and and transfer to slide.
*Let dry 10 minutes then look under microscope
*False positive: possibly fingerprints, cervical mucus, semen, significant amount of blood
*False negative: not enough residual amniotic fluid present
Analyze methods for diagnosing the spontaneous rupture of the membranes including: Rapid immunoassays
*Detect different biomarkers found in amniotic fluid
*Vaginal fluid is collected with swab, specimen swab swished in a tube with solvent then strip inserted into vial-2 lines positive, 1 line negative
*No speculum exam needed, RN may perform
*Seems to be commonly used now
*Manufacturers report high specificity and sensitivity, as do some studies
*Other studies show high false positive rate if any symptoms of labor
*Comparison to evaluation with diagnosis combining other methods unclear
*Cost comparison also unclear
*False positive: possibly significant bleeding, higher vaginal concentration of biomarker with labor?
*False negative: error in testing procedure, not enough residual fluid present
Evaluate the importance of an accurate diagnosis of ruptured membranes in different clinical circumstances.
*There are risks associated with ROM and theses include:
o Infection
o Preterm birth in the case of PPROM
o Prolapsed cord
*It would be important to have an accurate diagnosis if it will change management.
o No labor
o Preterm gestation
o Maternal group B strep (GBS) positive status
* False positive may lead to unnecessary intervention
* False negative may increase risk of complications
Understand the reasons for the recommendation of delaying admission until active labor.
*Increased rate of
o Cesarean birth
o Oxytocin augmentation
o Epidural analgesia
o Other interventions such as fetal scalp electrodes and intrauterine pressure catheters
Analyze the evidence on programs to reduce early labor admissions and the associated interventions.
3 randomized trials
*All slightly different–women either presenting for care in early labor or called for advice and were randomized to “usual care” or some type of special program.
*These studies focus on group of women seeking care in early labor, not on all women
*In all 3 studies, women in the special care groups were more satisfied
*Specialized care did not make a statistically significant different in cesarean births
*Other findings varied (can read more in JMWH article)
*Conclusions-
o Women in these studies liked more care during early labor
o Studies not hugely helpful in figuring out how to reduce early admissions and associated risks
o Perhaps different “special care” would make a bigger difference in outcomes
Discuss the qualitative research on women’s experience of early labor and consider the contrast between what we tell women and what they experience.
*In every study, women described the difficulty they had coping at home in early labor. Many women expressed surprise over the severity of pain, and this prompted some to seek care.
*They worried about how they would cope with active labor which they assumed would be much more painful.
*Some women felt the degree of pain they signaled abnormality.
*Women described considerable uncertainty about whether or not they were in labor, and the right time seek care once labor began. This caused significant anxiety as they worried about going to the hospital too soon and being sent home.
*Women also expressed anxiety over assuming responsibility for the well-being of themselves and their fetus. They recounted that their family members and other support people also experienced this anxiety, and many women felt pressured to go to the birth facility by loved ones.
*Significant fatigue contributed to poor coping for women as well.
*Many expressed feelings of vulnerability and the need to have their experiences validated by health care providers.
*Some women felt the need to convince care providers they were experiencing real labor.
*So, what can we do? Make our anticipatory guidance more realistic!
o Listen to women
o Realistic anticipatory guidance
o Normalize early labor
o Recognize when women really our help in early labor
Discuss strategies helpful for coping with early labor.
*Support
*Reassure and encourage normalcy
*Aromatherapy
*Acupressure
*Rest and or activity that helps.
*3Bs (Benadryl, booze, and warm bath)
*Pharmacological
Discuss the importance of self-care in early labor including adequate fluid, calories and rest and strategies for fatigue and nausea and vomiting.
It helps minimize fatigue the body prepare for active labor.
