First Stage of Labor
First Stage, Homebirths
When I arrive at a client's home, I do the following:
- Assess the attitude and acclimate
- Find out how long the mother feels she has been in labor
- Assess if she is truly in labor (check for ROM, lost mucus plug, bloody show, regular strong contractions, etc.)
- Start labor records
- Check fetal heart tones (get an initial baseline by listening through three consecutive contractions)
- Take blood pressure and pulse
- Do palpation (check fluid amounts and position of baby by feeling the uterus)
- Take the woman's temperature
- Do a urine test in long labors (check for protein, glucose, ketones so fluid and food intake can be adjusted if needed)
- Do an internal exam (effacement, dilation, station, position)
- Check frequency and duration of contractions
- Check fluid amount (color, smell, and amount of ruptured membranes)
- Note the attitude and tolerance of mom/partner/others present. (Do they need to be alone? Do they need encouragement -- position changes, relaxation techniques?)
- Clean house, do the dishes, vacuum, clean the bathroom, prepare the birth bed, boil water.
(Note: The order of assessment may change depending on the situation.)
- Jill Cohen, lay midwife
In-Hospital First Stage Assessment and Management of Low-Risk Women
- Support and observation are the hallmarks of managing normal labor. Remember the 4 Ps: Powers, Passenger, Pelvis, Psyche
- Evaluate maternal emotional support, energy level, relaxation ability, coping with pain/fears. Discuss options/preferences. Review birth plans, answer questions.
- Do initial physical exam, take vital signs: Blood pressure, pulse, temperature, respirations, input and output, uterine contractions, fetal heart rate, fetal position/station, estimated fetal weight, labs, cervical status/membranes.
- Evaluate for latent phase/active phase in term primip/multip, labor progress, maternal well-being, stability of fetus, fetal well-being. Risk factors/concerns (review prenatal chart).
- Encourage alternating ambulation/rest, frequent position changes, showers/baths, massage, music, imagery, breathing, frequent urination, hydration/nutrition. IV meds/epidural as needed per mother's informed choice in active labor. Support the family. Enhance the mother's feeling of safety at all times. Try to avoid admitting mom until she is in active labor.
- Sharon Glass, CNM (Midwifery Today Issue 31)
Sometimes you'll get the feeling that stronger contractions and hard labor are impending, but the woman is keeping them at bay. Up to about 4 or 5 cm (and sometimes beyond), women have the power to control labor's ebb and flow, and can choose the time when they let the forces of birth take over. Difficulties occur if the uterus has worked up to a certain intensity and the mother begins to fight against it. This is often the case when a woman is groaning and rocking at only 2 or 3 cm dilation.
Women often need special guidance at this point. To move into active labor, the mother must give up notions of how labor is "supposed to be." She may no longer find slow, deep breathing effective; if her breathing sounds ragged or jerky, introduce slightly more accelerated but relaxed chest breathing. Movement during contractions (even pelvic rocking) can create muscular tension; show her how to be still and let her body "melt" while focusing on the rhythm of her breath. Enable the mother to make this shift and frantic agitation will be replaced with peaceful resignation that permeates the environment and sets a tone of readiness for harder labor....
Some women feel vulnerable lying down, particularly those who like being in control. Sitting cross-legged, with shoulders and hands loose, can give the mother a sense of steering herself through contractions, and a straight spine can keep tension from stacking up her back. Have someone sit behind her and squeeze her shoulders or push on her lower back periodically to help her stay loose in this position. If the baby is posterior and not yet descended, the mother can try the hands-and-knees position with pelvic rocks to encourage rotation. If she likes, you can massage her buttocks using long, downward strokes. This helps her focus low in her body and encourages her to relax her breathing.
- Elizabeth Davis, Heart and Hands 3rd ed.,
Celestial Arts, Berkeley, CA 1997
To order Midwifery Today issue 31 (First Stage), click here.
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Question of the Week: Broken Coccyx
Q: A friend pregnant with her first child was told she must have a caesarean because her coccyx has a noticeable, abnormal curve and that in a vaginal birth, the baby would break it. I've heard of a sprained or bruised coccyx but never broken. Is a broken coccyx possible and avoidable? Is a trial of labor desirable in this case?
- Elizabeth Cheron
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Question of the Week Responses: Group B Strep, Bipolar, Stroke
Q: A friend was just diagnosed, by urinalysis, with Group B strep. She is planning to have her baby at home (this will be her third successful homebirth). She has been told she will need IV antibiotic intrapartum. Is it safe to have a homebirth and if so what precautionary measures should be taken? She is due March 20.
A: I have had several moms with strep B. I encourage the moms to avoid refined sugars and junk food. I also suggest they eat lots of leafy green vegetables and fresh fruit. Having a more alkaline diet will discourage the strep B. Liquid oxygen helps to alkaline the system as well. This can be purchased in most health food stores. The medical profession has really terrified mothers. I have had no problems with moms who tested positive. They all had a fine birth.
All of us have strep B -- some have it more under control. Cleaning up the diet really helps. Most moms who have upgraded the diet will then test negative for strep B. The doctors will tell them they will still have the antibiotics regardless, since they had tested positive for it at a previous time. That is very discouraging.
A: In our country (The Netherlands) women with group B streps can deliver at home but with a few restrictions and depending if the obstetrician in charge is in favour of homebirth or not. I have had a case like this only two times. I asked for a second opinion from an obstetrician who I knew is not afraid of home delivery, and we agreed on the following:
Have the woman get another checkup (at 36 weeks gestation) and see if the bacteria are still present. If so, she can get antibiotics and be tested after the antibiotic treatment. If she is still infected she needs intrapartum IV antibiotics -- if she delivers after 4 hours. If she's a "flying multipara," as we say, and delivers within 4 hours, the IV antibiotics are too slow to work and then I think a shot of 50,000 units of penicillin for the baby postpartum will do (in the hospital I work with, this therapy is done, and after a day of observation most mothers and babys go home without problems).
If there are no strep B left after the antibiotic treatment in pregnancy, the woman can deliver at home, but stay aware of the fact that nobody knows how long after the treatment with antibiotics in pregnancy the strep will be eliminated. So close observation of mother and child is still needed, and the baby must be transferred to hospital to get treated if even the slightest sign of infection occurs.
In my opinion this shot of preventive antibiotics also can be given at home to the baby (we are allowed to give the first vaccination against hepatitis B within two hours of birth to the baby at home as well, so why not antibiotics?).
Thorough observations for signs of illness in mother and child also can be done at home, but I never got a GP to give me the antibiotics for the baby because it is not "regular protocol." Still I think it could be an option (maybe that's my opinion about delivering in the most natural environment; I think you need a hospital only if there's nothing you can do anymore at home).
Remember that this woman already had two babies at home without complications and that close and thorough observations for signs of infection are more important than antibiotics -- because there still is no hard evidence this preventive antibiotic treatment really helps.
A: I have attended a homebirth where the mother needed GBS prophylaxis. If the labor is progressing rapidly, start an IV site and administer penicillin-G 500 million units or 2 grams of ampicillin if allergic to penicillin. Then give Clindamycin 900 mg or Erythromycin 500 mg. If the labor is going to take a while, start a saline lock instead, tape it nicely, and give her additional doses every 4 hours of Pen-G 2.5 million units or 1 gram ampicillin, or half doses of the other -mycins. I did not consult the ACNM Homebirth Handbook, but that is what I have seen and it worked out well. Now that the mother has had the screening and is known GBS positive, the CDC guidelines suggest she receive intrapartum prophylaxis. If a midwife is not familiar with doing it, she may be able to find a supportive RN in her community. The mother should still have a homebirth if she wants it, but we should remember that a baby with GBS sepsis often will die and we all should carefully do what we can to prevent that.
-Carla Cleary, RN SNM
A: During my research into homebirth, I came across several articles that support giving antibiotics IM during the last 4 weeks of pregnancy as an alternative to intrapartum antibiotics. Recommended dosage is (1) 1.2 ml shot of penicillin G benzathine per week for 4 weeks.
A: I recently had a woman test positive with GBS from a yoni/rectum culture sent into a lab for testing at about 36 1/2 weeks. After getting the results, the mother was informed of her choices: the protocols of a hospital birth with a GBS+ test and what we would do at home with a GBS+ homebirth. She decided that she would like to stay at home and try to work on the GBS using herbs, positive thinking, and a chance to retest after a few days of herbal treatment. It seems to me that GBS can come and go on a daily basis. My own feeling is that GBS has to do with pH balance and allowing it to grow if this balance is out of whack. We had a remedy: First, we used a light herbal douche made of comfrey, calendula, a bit of goldenseal, 3 drops of Nutri-biotic diluted in warm water. She was advised to administer the douche just at the vaginal opening and not to push the herbal water too high or with force. She did this 2-3 times a day. Also, she drank 3 glasses of water infused with Nutri-biotic daily and ate lots of veggies, fruit, and simple grains. After 5 days of this remedy, we retested. Her test came back GBS negative. She was ecstatic! I truly believe the herbs worked and the retesting was crucial. Her homebirth was wonderful!
A: A UK support group for Group B Strep offers loads of evidence-based information. The Web site address is www.gbss.org.uk.
National Childbirth Trust, UK
More about bipolar condition [Issue 4:9]:
I assisted a woman with severe bipolar disorder who was on Venlafaxine. It was not even a question of getting off the meds -- her behavior would be harmful. No amount of trust, counseling, and praise would have abated her illness. She had experienced an unmedicated pregnancy, birth, and postpartum 5 years earlier. It was hell for her. We researched as much as we could but couldn't find much info. We were more worried about the drug for the infant with breastfeeding. She tried taking an antidepressant plus an antianxiety for a bit postpartum but it didn't work very efficiently for her. Her homebirth was beautiful, with a nice healthy boy.
More about stroke [Issue 4:8]:
Several years ago our hospital had a lady who had a stroke at about 28 weeks. She stayed in the hospital and received tube feedings and physical therapy. She responded very little and could not communicate verbally at all. Near term she became restless. OB nurses were called to the floor and we determined that she was in labor. It progressed very well and she pushed spontaneously when the baby started moving down. When we put the baby on her chest a single tear rolled down her cheek. Of course the baby was watched closely for growth and well-being throughout the pregnancy, but she didn't have any further problems.
New Zealand College of Midwives
Celebrating Diversity within Unity
4-6 July 2002
Dunedin Centre, Dunedin, New Zealand
Pre-conference workshop, 3 July 2002, featuring internationally renowned speakers:
- Beatrijs Smulders, Midwife from The Netherlands
- Wendy Savage, Obstetrician from the United Kingdom
For further information contact:
Mary Whitham, Convener
Phone: 03 466 7945
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
A woman I am looking after has hepatitis B. The results came like this:
- Hep B surface antigen: not detected
- Hep B surface antibody: 0 IU/L
- Hep B core antibody: detected
Is she infectious? Are there any alternatives to giving the baby a vaccination and immunoglobulin?
Regarding pregnancy massage [Issue 4:9]:
Massage has been shown to reduce the likelihood of preterm labor and reduce blood pressure issues. Also, when administered during labor, it reduces trauma, the need for drugs, pain, and later, postpartum depression. See the Touch Research Institute Web site for more information.
I am certified in prenatal and postpartum massage and a member of NAPMT (National Association of Pregnancy Massage Therapists). I recommend contacting them (firstname.lastname@example.org) for information about a practitioner in your area, as all members are certified.
In terms of the benefits, here are but a few:
- increases maternal circulation
- improves maternal and fetal oxygen circulation
- improves blood and lymph flow (reducing swelling)
- relieves pain, muscle soreness and fatigue
- improves sleep
- improves outcomes of labor (including a reduction in premature birth)
- and provides a woman with the experience of loving, nurturing touch so she is better able to touch her baby in a loving, nurturing way.
All these benefits are supported by research. I would recommend contacting Kate Jordan (she can be reached through NAPMT) for information about research and sources.
- Teri Brickey, LMT, NAPMT, CIMI
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The International School of Traditional Midwifery in Ashland, Oregon is accepting enrollment for 2002 classes that start in May. For information contact: ISTM Catalog-MTEN, 3607 Hwy 66, Ashland, OR 97520 or call 541-488-8273.
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