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JOGNN A Practical Approach to Labor Support Ellise D. Adams1 and Ann L. Bianchi2

Correspondence Ellise D. Adams, CNM, MSN, CD (DONA), ICCE, College of Nursing, The University of Alabama in Huntsville, 337 Nursing Building, Huntsville, AL 35899. [email protected]

ABSTRACT In the United States, intrapartum nurses are present at 99% of births. These nurses have a unique opportunity to positively affect a laboring woman’s comfort and labor progress through the use of labor support behaviors. These nonpharmacologic nursing strategies fall into four categories: physical, emotional, instructional/informational, and advocacy. Implementation of these strategies requires special knowledge and a commitment to the enhanced physical and emotional comfort of laboring women.

JOGNN, 37, 106-115; 2008. DOI: 10.1111/J.1552-6909.2007.00213.x Keywords Birth Intrapartum care Intrapartum nurse Labor positions Labor support

1CNM, MSN, CD (DONA), ICCE, is a clinical assistant professor in the College of Nursing, The University of Alabama in Huntsville 2RN,

MSN, ICCE, ICD, is a clinical assistant professor in the College of Nursing, The University of Alabama in Huntsville

Accepted May 2007

Q

uality nursing care for laboring women combines a

advice, advocacy, and supporting the husband/partner.

variety of skills and behaviors to ensure a positive

Sauls (2006) identified professional labor support as

birth experience. Labor support behaviors (LSB) by

having six dimensions: tangible support; advocacy;

nurses provide nonpharmacologic pain relief and support

emotional support—reassurance; emotional support—

to laboring women. Sauls (2004) defined labor support as

creating control, security, and comfort; emotional sup-

the “intentional human interaction between the intrapar-

port—nursing caring behaviors; and informational

tum nurse and the laboring woman that assists the client

support. Hottenstein (2005), based on Watson’s Theory

to cope in a positive manner during the process of giving

of Human Caring, named care modalities as auditory, vi-

birth” (p. 125). Association of Women’s Health, Obstetric

sual, olfactory, tactile, kinesthetic, and caring conscious-

and Neonatal Nurses’ (AWHONN, 2000a) Clinical Position

ness. For this review, the four categories on which several

Statement on this topic stated that “continuously available

research teams agreed were used: physical, emotional,

labor support by a professional registered nurse is a criti-

instructional/informational, and advocacy. Supportive

cal component to achieve improved birth outcomes.” This

care to the laboring woman’s partner is also described

article offers instruction for many supportive behaviors

because partners may need assistance in order to sup-

the intrapartum nurse can implement with laboring

port the laboring woman (Wood & Carr, 2003).

women. Antepartum nurses and childbirth educators may also utilize LSB in preparing clients for labor.

Choosing LSB

Types of Labor Support

Intrapartum nurses use their assessment skills to choose

Nurse researchers have categorized labor support in

Nurses may choose a combination of supportive behav-

a variety of ways. Bianchi and Adams (2004), Gagnon

iors. For example, when assisting women to change po-

and Waghorn (1996), McNiven, Hodnett, and O’Brien-

sitions (physical LSB), the nurse conveys respect by

Pallas (1992), and Gale, Fothergill-Bourbonnais, and

providing privacy and protecting modesty (advocacy

Chamberlain (2001) grouped supportive care into four

LSB). A single LSB may also fall into more than one cat-

areas: physical comfort, emotional support, instructional/

egory. Bryanton, Fraser-Davey, and Sullivan (1994)

informational, and advocacy. Miltner (2002) identified the

noted that praise and encouragement overlap both the

first three categories of nursing support as including en-

emotional and the informational categories.

appropriate LSB for their patients’ varying needs.

couragement, positioning, application of heat and cold, massage, instructions for relaxation and breathing, infor-

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mation regarding labor progress, and negotiating with

Physical LSB

the health care team. Hodnett (1996) identified five types:

Physical support and comfort enhance labor progress

emotional support, comfort measures, informational/

and increase satisfaction with the birth experience

© 2008, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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(Hodnett, Gates, Hofmeyr, & Sakala, 2003; Manogin, Bechtel, & Rami, 2000). A variety of LSB are listed in Table 1.

Proper positioning in labor and birth can reduce pain, analgesia use, and perineal trauma and enable more effective uterine contractions.

Environmental Control

Sims’ Position to Slow Fetal Descent or Facilitate

Environmental control creates a comforting atmo-

Rotation. Sims’ positions can help to slow down fetal

sphere. Adjusting room temperature and lighting while

descent, allowing control over pushing efforts and pre-

decreasing distracting noises contributes to physical

venting perineal lacerations (Albers, 2003; Simkin &

comfort. Therapeutic use of music can have a calming

Bolding, 2004). It can also facilitate anterior rotation of a

effect. Music activates the right brain and can effec-

fetus (Ridley, 2007). This can be accomplished by in-

tively mediate pain (Chang & Chen, 2004; Phumdoung

structing the woman to lie on the side of the fetal spine.

& Good, 2003). Music selection is based on what the

For example, if the fetus is in right occiput posterior po-

woman finds relaxing and comforting. Phumdoung and

sition, the woman lies on her right side. Gravity pulls the

Good found that soft music without lyrics during the ac-

fetal occiput and trunk to the right occiput transverse

tive phase of labor significantly decreased the sensa-

position and eventually to right occiput anterior. Wedge

tion and distress of pain. Antepartum nurses and

a pillow between the woman’s back and bed, and place

childbirth educators can encourage women to bring

a pillow under the abdomen for support (Adams &

music of their choice.

Bianchi, 2006). Once the fetus is in proper alignment for descent, encourage an upright sitting position.

Positioning

Lunge. The lunge is used during labor to decrease

Proper positioning in labor and birth can reduce pain,

back pain and facilitate rotation of a fetus in the occiput

analgesia use, and perineal trauma and enable more

posterior position (Simkin, 2002). If the fetus is in the left

effective uterine contractions (Mayberry et al., 2000).

occiput posterior position, instruct the woman to place

The optimal position is determined by assessment of

her left foot on the chair while turning the left leg outward.

the woman, her phase of labor, fetal position, and the

The femur acts as a lever at the hip joint, prying the is-

woman’s desires. Although only a few positions such as

chium outward creating more space for rotation or cor-

Sim’s, sitting, and squatting have been supported by

rection of asynclitism. While supporting the woman,

research to show a positive effect on client outcomes,

instruct her to lean into the foot on the chair. Hold the

the positions mentioned in this article have been re-

lunge for 3 seconds, then return to upright. Repeat this

ported by laboring women and nurses to provide satis-

motion three to five times during each contraction for sev-

faction during labor and birth.

eral successive contractions (Adams & Bianchi, 2005).

Sitting.

Sitting positions during labor assist the natural

force of gravity to encourage fetal descent, improve the quality and effectiveness of labor contractions, and decrease pain (Gilder, Mayberry, Gennaro, & Clemmens, 2002). Upright positions include sitting in a rocking chair, on a birth ball, or on the toilet. Towel Pull.

The towel pull technique encourages

effective pushing when used in upright positions by involving abdominal muscles in expulsive efforts. As contraction begins, the woman leans forward and pulls on one end of the towel, while the nurse or partner provides resistance. As the woman pulls the towel, abdominal muscles naturally contract, providing external pressure on the uterus.

Dangle. The dangle position assists fetal descent by reducing external pressure on the sacrum or hips (Simkin & Ancheta, 2005). The nurse or partner stands behind the woman, using a wide base of support, and places the arms under the woman’s axillae. When contraction begins, the woman flexes her knees and drops her weight to dangle. The nurse or partner supports the weight of the woman during the contraction. Squatting. Squatting increases the diameter of the pelvis, facilitating rotation and fetal descent (AWHONN, 2000). Women who squatted experienced less pain, less genital tract trauma, and shorter second stage (Albers, 2003; Mayberry, Gennaro, Strange, Williams, & De, 1999; Soong & Barnes, 2005). A squatting bar can

The Sims’ position helps

be attached to the bed to help stabilize and provide bal-

avoid pressure on the sacrum, is gravity neutral, is rest-

ance. As contraction begins, instruct the laboring woman

ful, and provides comfort. If there are no complications

to hold onto the bar for support. Feet should be hip dis-

with fetal heart rate or maternal blood pressure, the la-

tance apart and remain flat. If the woman is too fatigued

boring woman may choose the side that is most com-

to support her weight, kneeling can be encouraged. The

fortable. Instruct the woman to lie on her hip and place

towel pull can also be used to achieve the same benefit.

a pillow between the knees to decrease strain on the

For the woman with epidural analgesia, a modified squat

back. Place a pillow against her back and one under

may be achieved by having the woman sit on a birthing

her upper arm for extra support.

bed with the foot of the bed in the lowest position.

Sims’ Position for Comfort.

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Approach to Labor Support

Table 1: Physical Labor Support Specific Category

Specific Behaviors

Environmental control

Control room temperature; control noise; dim lights; control odors; arrange personal items

Positioning, first stage of labor

Standing; ambulation; abdominal lift; slow dancing; leaning; knee-chest; hand and knees; pelvic rocking; lunge; sitting; dangle; squatting; semi-Fowler’s; Sims’ position

Positioning, second stage of labor

Knee-chest; hands and knees; squatting; Semi-Fowler’s; Sims’ position

Touch

Massage; pressure

Application of cold and heat

Use of ice packs; use of cool washcloths; use of hot packs; use of warm blankets

Hygiene

Provide bath or shower prn; mouth care; perineal care; change bed linens; change gown

Hydrotherapy

Use of shower; use of tub

Urinary elimination

Promote frequent emptying of bladder; encourage ambulation to bathroom

Nourishment

Provide ice chips; provide popsicles

Partner care

Respite; nutrition; physical comfort; environmental control

Touch

both knees with the hands. As contraction begins, the

Touch conveys an attitude of caring and encourages

nurse uses entire body weight to lean in and apply pres-

comfort, but a pat on the hand or shoulder may be ac-

sure against knees. The knee press can be used when

ceptable to some but not to others. Nurses must con-

the woman is in a lateral position. The nurse presses the

sider the client’s personal space and cultural background

upper knee toward her back, while the partner applies

when determining appropriate touch during labor.

pressure over sacrum (Simkin & Ancheta, 2005).

Massage, a form of touch, relaxes muscles and in-

Application of Cold and Heat

creases blood flow (Brown, Douglas, & Flood, 2001)

Pain perception is lowered and muscle spasms de-

and enhances the release of endorphins, promoting

crease when cold and heat are applied to different ar-

comfort while decreasing pain (Simkin & Bolding, 2004).

eas of the body. Temperature of the source should be

Brown et al. found that clients who used pain medica-

monitored to protect the woman’s skin from injury. Cold

tion also found the use of massage and acupressure to

compresses numb an area, slowing transmission of

be more effective than other nonpharmacologic meth-

pain and other impulses over sensory neurons, and last

ods of pain relief. Further investigation is needed to

longer than heat. If the woman is experiencing intense

determine whether massage alone directly decreases

pain in the lower back, an ice pack placed directly over

pain during labor.

the sacral area can be helpful. Cold application to the

Ho-Ku Point Pressure.

The Ho-Ku point is an acupres-

forehead and neck can also provide relief.

sure point which when stimulated can increase fre-

Heat application raises the pain threshold, increases

quency of contractions without increasing pain. The

circulation, and relaxes muscles. A heat pack can be

point is located where the bones of the index finger and

placed over the lower back, groin, or thighs. Warm wa-

thumb join (web of the hand). Apply pressure for 10 to

ter immersion increases relaxation (Benfield, Herman,

60 seconds and repeat six times (Simkin, 1997).

Katz, Wilson, & Davis, 2001) and promotes labor prog-

Double Hip Squeeze. The double hip squeeze changes

needed to determine whether other forms of cold and

the shape of the pelvis and releases tension on the sac-

heat application decrease pain during labor.

ress (Simkin & Bolding, 2004). Further investigation is

roiliac joints. Position the woman on her hands and knees or have her lean over the bed. Standing behind the woman, locate iliac crest and gluteal muscle. Place hands on each side below iliac crest and over gluteal muscle with fingers pointing toward midline. Apply pressure by simultaneously pushing hands toward sacrum throughout the contraction (Simkin & Ancheta, 2005). Knee Press.

Physical labor support can be exhausting for the partner. To maintain the partner’s energy, nurses can offer respite time and encourage nutritional intake. Making the environment comfortable by offering a pillow or blanket is also helpful.

Pressure on the knees pushes the femurs

toward the hips to relieve strain on sacroiliac joints. Po-

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Partner Care

sition the woman in a chair with knees a few inches

Emotional LSB

apart and feet flat on the floor. The nurse faces the

Emotional LSB provide the client with a sense of emo-

woman and locks elbows into his or her sides, cupping

tional comfort (see Table 2). Lazarus and Folkman

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(1984) defined emotional support as contributing to the feeling of being loved or cared about and includes attachment, reassurance, and the ability to rely on and confide in a person. These LSB assist to occupy the client’s mind with positive thoughts and diminish or block feelings of fear, dread, and anxiety. Sauls (2004) defined emotional support in labor as the ability to subjectively participate and share in the laboring client’s feelings.

Distraction includes providing laboring women with specific activities so that conscious thoughts and anxieties are reduced. maternal satisfaction with the birth process was not related to relief of pain but more closely related to the attitudes and behaviors of caregivers. Communicating caring, competence, and advocacy early in the nurseclient relationship fosters the development of a trusting relationship through which emotional and physical

Nursing Presence Jackson (2004) defined nursing presence as being with

needs can be met.

the client rather than performing tasks on the client and as

Distraction

complete physical, emotional, psychological, and spiri-

Focal Point. Distraction includes providing laboring

tual engagement between nurse and client. MacKinnon,

women with specific activities so that conscious thoughts

McIntyre, and Quance (2005) identified physical pres-

and anxieties are reduced. During the contraction, the

ence, developing a trusting relationship and emotional

focal point assists the laboring woman to tune out painful

presence as essential components of nursing presence.

stimuli by focusing on visual stimuli. When using an in-

Nursing presence includes portraying a high level of

ternal focal point such as a thought or visual image, the

nursing skill; being open, honest, and nonjudgmental with

woman closes her eyes and uses mental images to pro-

the client; listening intently to her needs and concerns;

vide distraction from the pain of labor.

understanding the privilege of being part of the client’s life; and the client’s perception of the meaningfulness of

Guided Imagery.

the relationship with the nurse (Hunter, 2002; Jackson).

has not been reported within the nursing literature; how-

The effectiveness of guided imagery

ever, the usefulness in clinical practice has been freThe optimum staffing for labor and delivery units is one

quently reported (Jacobson, 2006). This technique uses

nurse to one client. Although most unit staffing matrices

the mind to create a pleasant image and enhance relax-

will not allow for continuous presence, choosing when

ation in early labor. It is important to keep the environ-

to be at the bedside, demonstrating a caring, effective

ment free of distractions and the client comfortable. Use

attitude, and being fully present when in the room are

a script meaningful to the client. Make a suggestion to

important. Nursing tasks can be clustered to provide

picture a scene and engage each of her senses to ex-

longer periods of physical and emotional presence.

perience the scene. See Table 3.

Effective Caring Attitude

Spirituality

Nurse theorist Leininger (2001) called caring the es-

The laboring woman’s spirituality or faith may serve as a

sence of nursing. In Bowers’ (2002) review of 17 studies

source of inner strength and comfort during labor (Breen,

of perceived labor support, clients described a caring

Price, & Lake, 2006). To provide effective spiritual care,

nurse as calm, warm, and open. Supportive nurses

the nurse must attend to the client’s spiritual well-being

bestowed praise and encouragement upon the client,

and detect and address spiritual distress (Jackson,

were concerned, respectful, and competent, and pro-

2004). Questions such as “Tell me about your sources of

vided a constant presence. Hodnett (2002) found that

inner strength” or “In what ways can I assist you to rely on

Table 2: Emotional Labor Support Specific Category

Type of Behavior

Distraction Effective caring attitude

Specific Behaviors Visual focal point; guided imagery; visualization; hypnosis; encourage client rituals; engage in social conversation

Verbal expression

Affirming words or phrases; soft tone; calm voice; confident voice; encouraging words; reassuring praise

Nonverbal expression

Undivided attention; eye contact; flexible, noninterfering, unobtrusive care; pleasant facial expression

Nursing presence

Physical presence; emotional presence; cluster tasks; establish trusting relationship early; convey expertise

Therapeutic use of humor

Assist client to focus on the comic elements of labor; ensure humor is used appropriately

Refocusing

Simkin’s (2002) take charge routine; reframe negative thoughts into positive

Spirituality

Acknowledge spirituality; prayer; meditation; chanting; quoting scripture

Partner care

Encouragement; praise; reassurance; presence

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Approach to Labor Support

Table 3: Supportive Distraction Through Guided Imagery: Beach Scene Preparation

Assist the client to a comfortable position; remove distractions from the room; ask the client to close her eyes and practice abdominal breathing.

Read this script in a calm, quiet voice

“You have arrived at the beach. It is early in the day and there are no people in sight. You are alone. With your eyes closed, raise your head toward the sun. Feel how warm the sun feels against your skin. You slowly move toward the edge of the sand. With bare feet you feel the sand and it is soft and warm against your toes. You stand for a moment, to experience your surroundings. The day is fair and bright. There is a light, warm breeze that moves in little swirls around your body. It moves your hair and you feel free. You can smell the seashore and you hear the seagulls a short distance away. Listen to the gentle waves as they move along the edge of the sand. You can see them roll in and out. There is a rhythm to the waves and it matches your breathing. You move closer and feel the coolness of the water around your legs. As you float in the coolness of the water, match your breathing with the waves and let it relax you. You are totally relaxed. The sun rays feel warm upon your face. The water is refreshing and you feel peaceful.”

your faith?” are useful in assessing the client’s reliance

birth experience for all (see Table 4). Effective verbal

upon this source of strength. Nurses also must critically

and nonverbal communication is vital when delivering

assess their own comfort with providing spiritual care. If

instructional and informational support to clients. Verbal

a spiritual need is identified that the assigned nurse is

and nonverbal communication is delivered simultane-

unable to meet, a reassignment may be necessary.

ously, and the message is stronger when these are con-

Labor support behaviors that incorporate spirituality include prayer, meditation, chanting, reading or reciting from scriptures, and the use of rituals or sacraments. Prayer or meditation can be facilitated by a quiet and respectful environment. Nurses can read scripture or prayers on request of the client. Spiritual rituals or sacraments are typically administered by clergy.

gruent (Adams & Bianchi, 2005). Verbal communication must be culturally sensitive, taking into consideration how instruction or information is understood by the woman. When an interpreter is used, the nurse should face the woman and direct questions to her instead of the interpreter (Trivasse, 2006).

Instruction for Relaxation The ideal time to provide instruction for relaxation is

Partner Care Nurses must be aware of the emotional status of the laboring woman’s partner and provide the partner with encouragement, praise, reassurance, and nursing presence. Relieving the emotional stress of the partner can in turn alleviate maternal stress.

prior to labor. At the time of labor admission, the intrapartum nurse should assess knowledge and comfort with relaxation techniques. When instructions are provided during labor, a demonstration may be necessary. Instruction presented to the laboring woman should also be directed to the partner. The nurse can encourage relaxation by offering instructions on pro-

Instructional/Informational LSB

gressive relaxation and touch relaxation (see Table 5).

Instruction and information on all aspects of labor and

Instruction for Breathing

birth provide clients with an opportunity to be a part of

Breathing patterns are a learned technique of controlling

the decision-making process, which fosters a positive

the depth and rate of respiration to match the intensity

Table 4: Instructional/Informational Labor Support Specific Category

Type of Behavior

Specific Behaviors

Effective communication techniques

Verbal

Reflecting; reframing; choosing appropriate words and phrases; choosing culturally sensitive words; using interpreter

Nonverbal

Gestures; body language; eye contact; culturally sensitive behaviors

Instructional

Breathing patterns

Cleansing breath; abdominal breathing; patterned breathing; breathing levels

Informational

Partner care

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Relaxation techniques

Progressive; physiological; passive; touch; selective relaxation

Pushing techniques

Open glottis; closed glottis

Routines

Familiarize with surroundings; plan of care; interpret medical jargon; labor and birth process

Procedures

Nonpharmacologic pain relief; pharmacologic pain relief; routine hospital procedures; electronic fetal monitoring Explain procedures; update on client progress; role model support behaviors

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Table 5: Instructions for Relaxation Type

Purpose

Instructions

Progressive relaxation

Allows the woman to differentiate between tense muscles and relaxed muscles. Once this distinction is made, the woman will be more aware of tension and able to consciously relax muscles.

Instruct laboring woman 1. Progressively contract each of the following sets of muscle groups beginning with face and neck; shoulders, arms, and hands; chest, back, and buttocks; ending with the legs, feet, and toes. 2. Become aware of how it feels when all muscle groups are contracted. 3. Progressively release tension in each muscle group in reverse order: toes, feet, and legs; buttocks, back, and chest; hands, arms, and shoulders; neck and face. 4. Pay attention to how it feels when all muscle groups are relaxed.

Touch relaxation

Touch brings awareness of tense muscles and signals the woman to release tension. Touch can be applied to the forehead, back of neck, shoulders, arms, hands, back, legs, or feet.

Nursing actions 1. Determine whether woman prefers a light touch or a firm touch. 2. Place hand flat over the muscle group or if possible, wrap hand around the muscle. 3. Apply a light touch or firm touch over muscle. 4. Instruct the woman to release tension into the touch. 5. Continue to apply touch until the muscle is relaxed.

of the contraction. Breathing awareness and use of dif-

woman becomes aware of her breathing rhythm and

ferent breathing levels can increase a laboring woman’s

depth as she inhales and exhales, she is better able to

confidence and ability to cope with contractions and re-

adjust her breathing levels as labor progresses. (See

duce discomfort. Breathing patterns are most effective

Table 6.) As labor becomes more difficult, a woman may

when learned and practiced before labor begins (Ad-

state that she feels overwhelmed by the contractions.

ams & Bianchi, 2005). Antepartum nurses have an op-

When the laboring woman is unable to maintain her

portunity to increase the confidence of pregnant women

concentration, the intrapartum nurse can suggest

and their ability to learn breathing and relaxation skills

switching to the next breathing level, one that has a

before labor begins, and they can encourage clients to

faster pace and requires more concentration (Adams &

attend childbirth classes that incorporate breathing and

Bianchi, 2005).

relaxation.

Instruction During Pushing Breathing awareness and breathing patterns enable a

During the second stage, the nurse can support the

woman to better control her response to labor. When the

woman to use open-glottis pushing and follow her own

Table 6: Instructions for Breathing Breathing Technique

Purpose

Instructions to Laboring Woman

Breathing awareness

Allows client to identify normal breathing pattern

1. Sit up, place one hand palm down over abdomen, and the other hand on top of the first hand. 2. Breathe in and out normally, paying attention to how the abdomen rises and falls, like having a balloon in your abdomen. Each time a breath is taken in, the abdomen expands. Each time a breath is let out, the abdomen collapses.

Cleansing breath at start and end of contraction

Serves as a signal to begin the contraction, initiate breathing patterns, and end the contraction

1. Take an exaggerated inhalation of air through the nose and exhale through the mouth.

Level 1 breathing

Promotes relaxation

1. Place hands over lower abdomen and inhale until lower abdomen expands.

Level 2 breathing

Promotes relaxation

1. Place hands on waist and inhale until waist expands.

Level 3 breathing

Promotes concentration

1. Place hands above the breast area at the level of shoulder blades and inhale until that area expands.

Level 4 breathing

Promotes maximum concentration during transition

2. Breathe in and out slowly at a rate that is half your normal respiratory rate. 2. Breathe in and out at a rate slightly faster than normal.

2. Breathe in and out at a rate that is double your normal rate. 1. Place hands at the level of the clavicle and inhale to that level. 2. Breathe in and out in a shallow fashion, as in a pant. 3. Alternation: Take three short breaths in and out, then blow out quickly, and inhale quickly again, in a three-inhale to one-exhale pattern.

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Approach to Labor Support

Table 7: Advocacy Labor Support Specific Category

Type of Behavior

Specific Behaviors

Conveying respect

Ensure privacy; protect modesty; provide complete information; provide nonjudgmental care; protect patient rights; respect existing relationships

Ensuring security

Support client to express both positive and negative emotions; provide physical safety/security; provide emotional safety/security

Acknowledging mother’s expectations for labor and birth

Listening to her wishes

Encourage woman to verbalize her needs, fears, anxiety; convey that she has the right to choose; give her time to consider choices

Assisting with making informed choices

Explain risks and benefits; periodically offer reevaluation and reflection

Birth planning

Support her wishes with words and actions; negotiate with health care team on her behalf; communicate birth plan to others

Conflict resolution

Encourage problem-solving behavior; intervenes if others interfere

Partner care

Determine partner’s expectations; convey respect; encourage partner to be an advocate for the client

urges to push, reminding the woman and her partner

care, and protecting client rights. Nurses ensure privacy

that her body will respond appropriately. The closed-

and protect modesty by keeping unnecessary people

glottis method of pushing has been linked to negative

from the room, securing the door during procedures,

effects on the fetus, such as fetal heart decelerations

providing gowns that adequately cover her while ambu-

associated with prolonged second stage (Thomson,

lating, and covering her with drapes when appropriate.

1993). Despite this evidence, rising rates of epidural

Lothian (2004) noted that feeling respected allows women

anesthesia have contributed to the continuation of the

to “tap into inner wisdom and dig deep to find the strength

closed-glottis method (Simpson & James, 2005).

needed to give birth” (p. 6). Nonjudgmental care includes putting self aside and providing competent care

Information Regarding Patient Care

in all situations. Being an advocate means providing the

Informing women of the plan of care and interpreting

same quality of care to the client at 28 weeks in preterm

medical jargon can ease anxiety. As labor progresses,

labor who refuses tocolytic therapy as to the previously

the woman must be updated on fetal status and cervical

infertile couple pregnant with their first child.

change. Allow time for information to be assimilated. The laboring woman and her partner may want time alone to discuss health care decisions. The nurse should follow up to make sure they understand the information that has been provided.

Partner Care Nurses can ease the partner’s anxiety and provide support by offering information concerning the woman’s labor progress. Taking time to demonstrate and explain supportive measures allows the partner to effectively participate in labor support.

Acknowledgment of Mothers’ Expectations Simkin (2002) suggested that when laboring women are distressed, nurses can ask, “What’s going through your mind?” (p. 729). Wuitchik, Bakal, and Lipshitz (1989) found that distressing thoughts in latent labor increased the likelihood of prolonged labor, fetal distress, and medical intervention. Nurses can help relieve distress by determining the woman’s concerns and giving accurate information. Birth Planning. A motto promoted by the American College of Nurse-Midwives is “listen to women” (Kathryn,

Advocacy LSB

1993). Listening enables the nurse to hear the woman’s

Advocacy includes protecting the client, attending to

birth, and the postpartum period. Constructing a care-

needs, and assisting in making choices related to health

fully executed birth plan requires a thorough assessment

care; this requires the establishment of a therapeutic re-

of the client’s needs and desires. Clients’ needs and de-

lationship (Foley, Minick, & Kee, 2002). Advocacy may

sires may require the nurse to negotiate with members of

require being the client’s voice when she is vulnerable

the health care team or her family, or both. Negotiation

or unable to speak for herself. In being an advocate for

requires clear delineation of the client’s desires, appro-

the client, the nurse empowers the client to give birth

priate timing, and respectful communication skills.

intuitive wisdom on her needs and desires for labor,

with dignity (see Table 7). Development of a standard birth plan form can diminish

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Conveying Respect

duplication of effort and promote continuity among

Conveying respect to the laboring woman means ensur-

health care providers. The birth plan form should be de-

ing privacy, protecting modesty, providing nonjudgmental

veloped by an interdisciplinary team. Consent forms

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and waivers are necessary when families make requests that are outside the usual care provided at the facility. Many facilities require the birth plan form to be signed by each physician or certified nurse-midwife in the

The intrapartum nurse must step in quickly when the client’s needs, desires, or safety is compromised and promote problem-solving behaviors.

practice. This formality may assist in ensuring that the laboring woman’s needs are met. In a Swedish study (Lundgren, Berg, & Lindmark, 2003), midwives assisted one group of women in development of a birth plan, while the control group did

sion, outline the client’s plan of action regarding pain management.

Partner Care

not use a birth plan. There was no improvement in the

While the laboring woman’s wishes and needs must

birth plan mothers’ relationship to caregivers, fear and

have priority, it is appropriate for the intrapartum nurse

pain related to childbirth, perceived control over child-

to determine the partner’s expectations related to la-

birth, or concerns for the unborn child, and their rela-

bor and birth. If these are not in conflict with the client’s

tionship with the caregivers was less satisfying. Lothian

wishes, every attempt should be made to honor them.

(2006) suggested that birth plans may increase tension when clients and providers hold conflicting views of birth: as a normal natural process that could occur

Implementing LSB in Practice

safely without intervention or as full of risk, requiring in-

As obstetric nursing content in nursing school curricula

terventions to avoid negative outcomes. For clients or

decreases (AWHONN, 2006a), there is less emphasis

providers who hold the second view, birth plans repre-

on LSB and less value placed on this type of hands-on

sent a request to remove the safeguards put in place to

nursing care. Therefore, in addition to training in elec-

avoid risk.

tronic fetal monitoring, neonatal resuscitation, and surgical scrub techniques, extensive hands-on training in

The intrapartum nurse must be aware of personal views in order to set them aside to support a client’s decisions. Once a woman makes an informed health care decision, the nurse has a responsibility to support the deci-

LSB should be a required element of labor and delivery orientation. When intrapartum nurses have knowledge and confidence in their LSB skill, they more effectively provide this care (Kardong-Edgren, 2001).

sion rather than adhering only to the nurse’s personal belief structure. For example, a nurse’s approach to al-

Mentoring is an effective means to pass on the skill of

leviating pain in labor may be a reflection of a personal

labor support. One way to implement this is to desig-

philosophy of pain in labor. If the nurse believes that

nate a day of the month as Labor Support Day. The LSB

pain in labor is pathologic, a pharmacologic approach

expert is not assigned a client but rotates between labor

to pain relief may be the first line of defense. However,

rooms and provides hands-on instruction and support

nurses who believe that pain in labor is normal or physi-

in LSB to the labor and delivery staff.

ological may offer a variety of nonpharmacologic LSB (Lowe, 2002).

Conflict Resolution Labor rooms are not conflict-free zones. The stress of labor can promote conflict that may have negative effects on labor progress. The intrapartum nurse must step in quickly when the client’s needs, desires, or

Intrapartum nurses need time to develop into expert caregivers. It takes time, most likely more than 5 years, in a consistent setting to develop expertise (Benner, 2001). Experts should be studied closely. What characteristics or traits does this nurse exhibit? If these traits could be identified, nurse managers could more easily identify prospective staff members.

safety is compromised and promote problem-solving

All nurses must have access to current nursing literature

behaviors. Steps of problem solving include defining

to develop evidence-based practice (Romano &

the problem, looking for potential causes, identifying al-

Lothian, 2004). Hanson (1998) found that nurse-mid-

ternative solutions, choosing the best approach, and

wives who spent time reading professional journals

carefully implementing that approach.

used the most effective positions for second stage la-

For instance, if the client’s father voices concern that his daughter’s pain is not managed appropriately, the nurse can step in quickly and address this issue, sparing the client the distress of trying to manage her father’s anxi-

bor. Maintaining subscriptions to professional journals and attending regular continuing education activities on current research will assist the intrapartum nurse to maintain practice that is supported by science.

ety. The nurse can ask for a clearer understanding of

Labor support behaviors must be faithfully documented,

the father’s concern, provide an explanation of comfort

even if a narrative note is required. Consistent terminology

measures that have been implemented, describe the

for LSB will increase their value and better define the prac-

stages and phases of labor, and with the client’s permis-

tice of intrapartum nursing. Specific LSB can be added

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Approach to Labor Support

to the preprogrammed list of annotations of electronic

Association of Women’s Health, Obstetric and Neonatal Nurses.

monitoring systems. This may make charting easier and

(2006). Policy position statement: Inclusion of maternal/newborn nursing content in schools of nursing. Washington, DC:

assist in data collection for future research related to LSB.

Author.

Improving LSB Definition and Developing Certification

Benfield, R. D., Herman, J., Katz, V. L., Wilson, S. P., & Davis, J. M.

While many researchers have studied labor support,

Benner, P. (2001). From novice to expert: Excellence and power in

there is no “acceptable or agreed upon definition (that)

clinical nursing practice (Commemorative Ed.). New Jersey,

(2001). Hydrotherapy in labor. Research in Nursing & Health, 24, 57-67.

NJ: Prentice Hall.

exists for professional labor support and its underlying components and attributes” (Sauls, 2006, p. 38). Concepts, definitions, components, and attributes need to be developed by a consortium of nursing leaders who have

Bianchi, A. L., & Adams, E. D. (2004). Doulas, labor support, and nurses. International Journal of Childbirth Education, 19(4), 24-30. Bowers, B. B. (2002). Mothers’ experiences of labor support: Exploration of qualitative research. Journal of Obstetric, Gynecologic,

proven to be knowledgeable in the field of labor support. This work can produce standards, policies and proce-

and Neonatal Nursing, 13, 742-752. Breen, G. V., Price, S., & Lake, M. (2006). Spirituality and high-risk preg-

dures, competencies, and plans for a comprehensive

nancy: Another aspect of patient care. Lifelines, 10, 467-473.

certification program. Credentialing lends authority to any

Brown, S. T., Douglas, C., & Flood, L. P. (2001). Women’s evaluation of

discipline. Designing and implementing a certification

intrapartum nonpharmacological pain relief methods used dur-

program in labor support would lend importance and credibility to this discipline. Kardong-Edgren (2001)

ing labor. Journal of Perinatal Education, 10(3), 1-8. Bryanton, J., Fraser-Davey, H., & Sullivan, P. (1994). Women’s perceptions of nursing support during labor. Journal of Obstetric,

stated that this type of certification should be required just as certification in electronic fetal monitoring is required.

Gynecologic, and Neonatal Nursing, 23, 638-644. Chang, S., & Chen, C. (2004). The application of music therapy in

For the program to be comprehensive, it should include a workshop with opportunities for hands-on practice of

maternity nursing. Journal of Nursing, 51(5), 61-66. Foley, B. J., Minick, M. P., & Kee, C. C. (2002). How nurses learn advocacy. Journal of Nursing Scholarship, 34, 181-186.

each LSB, a training manual, and an exit examination.

Gagnon, A. J., & Waghorn, K. (1996). Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth,

Conclusion

23, 1-6. Gale, J., Fothergill-Bourbonnais, F., & Chamberlain, M. (2001). Mea-

Intrapartum nurses can use a multitude of nonpharma-

suring nursing support during childbirth. Maternal Child Nurs-

cologic pain relief methods to assist laboring women.

ing, 26, 264-271.

Labor support behaviors can be enhanced when the in-

Gilder, K., Mayberry, L. J., Gennaro, S., & Clemmens, D. (2002). Ma-

trapartum nurse taps into more than one labor support

ternal positioning in labor with epidural analgesia. Results from

category at a time. The nurse who is committed to labor support will positively affect birth experiences (Adams

a multi-site survey. Lifelines, 6, 41-45. Hanson, L. (1998). Second-stage positioning in nurse-midwifery practices, part 2: Factors affecting use. Journal of Nurse-Midwifery,

et al., 2006). Every effort should be made to position a nurse who is skilled and committed to labor support at

43, 326-330. Hodnett, E. (2002). Pain and women’s satisfaction with the experience

the bedside of all laboring women.

of childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186S, 160-172.

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