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Midwifery management of prodromal labor
MIDWIFERYMANAGEMENTOFPRODROMALLABOR
INTRODUCTION Melissa is a 28-year-old gravida, para 0, abortus 1, who had a normal prenatal course. She is 41 weeks’ pregnant. On June 1 at 10:00 PM she calls to say she has had some bloody show and a slight backache. At 2:00 AM she phones again to say she is having contractions every 10 minutes lasting 30 to 45 seconds. You ask her to call again when the contractions are stronger and closer, if the membranes rupture, or if she should have any questions. At 11:OO AM (June 2) Melissa calls and says the contractions are stronger and about 7 minutes apart. She would like to know what is happening with her labor. Your abdominal examination reveals that the baby is vertex, the back is on the right side, and the head seems to be entering the pelvis. Estimated fetal weight is 8 lbs (3584 g) and fetal heart rate is 140 beats per minute. Vaginal examination findings are as follows: the cervix is posterior, 70% effaced, and a finger-tip dilated. The head is at a - 2 to - 1 station, the membranes are intact. The contractions are of fair quality every 7 to 8 minutes. You offer suggestions and ask her to call when labor changes. At 2:00 AM (June 3) you are called. The contractions are every 5 minutes and seem somewhat stronger. When you see Melissa the abdominal examination is the same and the cervix is 2- to 3-cm dilated. 80% effaced, head - 1 station. How would you manage this situation?
Name:
Margaret
Schaefer-Turner
MSN, CNM
Date of graduation from nurse-midwifery school: 1977 School of nurse-midwifery: Yale University Institution now practicing in: Group private practice-CNM/OB/GYN Type of setting: Hospital with birth rooms, Children’s Hospital of Buffalo, NY This scenario often is found in primigravid posterior labors. I would admit Melissa to the birth room and reassure her that she is making progress. The contractions are closer. She is beginning the ac-
tive stage of labor. Assuming the fetal rhythm-strip is normal and Melissa is well hydrated, I would encourage ambulation, a hot shower, and clear liquids. Labor possibly could be improved with nipple stimulation. If she is exhausted and/or dehydrated intravenous fluids and sedation would be preferable to the above. Most likely the vertex is posterior, therefore side-lying or the handsand-knees position would be recommended. I would expect slow, steady dilatation of the cervix. If there is no change after several hours I would consult with an obstetrician regarding Pitocin augmentation to improve the strength, frequency, and effectiveness of the contractions. In
342 Copyright
Journal of Nurse-Midwifery 0 1985 by the American
College of Nurse-Midwives
??
most cases, I find that maximal patience and minimal intervention is required. Name: Melody Caton Urban, CNM, MSN
Date of graduation from nurse-midwifey program: 1982 School of nurse-midwifery: sity of Miami
Univer-
Institution now practicing in: Home births and hospital births at St. May’s Hospital in Rochester, NY Type of setting: Private hospital and home In addition to the information given, I would want to know how much
Melissa has rested
in the last 72
Vol. 30, No. 6, November/December
1985
0091-2182/85/$03.30
hours, how much she has eaten, and what she has eaten. I would want to know how she is tolerating labor, her attitude toward labor, and what support system she has. If Melissa is tired and in need of nourishment, I would have her eat a moderate portion of a high protein, easily digested meal. A small glass of wine may relax her. I would remain with her unless she had a good support person and then I would be nearby. Resting on her left side for 2 to 3 hours would be suggested. The baby and mother would be monitored during this time. I would reevaluate the status of Melissa’s labor. If labor is not progressing, nipple stimulation or walking could help strengthen the contractions. At 7:00 or 8:00 AM I would check Melissa for progress. If progress is not being made, I would discuss the situation with Melissa and her support person. Consultation would be obtained and I would most likely proceed to the hospital for labor augmentation. Name: Marguerite Grindrod Date of graduation from nurse-midwifery program: 1981 School of nurse-midwifery: Downstate Medical Center Midwifery Program Institution now practicing in: Private practice Type of setting: Home and hospital births at St. Mary’s Hospital in Rochester, NY I would ask Melissa how she is feeling about her labor; is she discouraged or exhausted? Fears or anxieties could be contributing to the slow progress. I also would evaluate what she has been eating and drinking. Assuming that she is physically in good shape and willing to keep trying, I would try to “energize” the situation. When the attending persons at a birth get bored and dis-
Journal of Nurse-Midwifery
??
couraged by slow progress we tend to advise the woman to call when things are more active. The laboring woman may feel deserted or ignored, or that she is letting everybody down, The labor often slows further. I would spend some time sitting with Melissa, talking about her birth plans and paying attention to the fact that she is in labor. I might suggest that the couple spend some time alone, trying nipple stimulation, hugging, kissing, and physical closeness. A long walk outside can be helpful. A hypertonic saline enema can do wonders to stimulate a sluggish labor. If friends and relatives are there waiting for something to happen, 1 might suggest sending everybody away for a while and taking the phone off the hook. This is a way to decrease pressure on the laboring woman to perform. Suggesting a dose of castor oil in this situation may help. 1 have never had much success using black or blue cohosh in a tincture or a tea to stimulate labor. There has been progress, albeit slow, in this labor. The baby is doing well. The fetal heart tones are good and there is no sign of distress. If the mother is able to eat, drink, and rest so that she is not becoming physically and emotionally drained, my inclination would be to provide support and encouragement and continue to try to get things moving.
home, stay with the patient, palpating each contraction for quality, quantity, consistency, and screening for evidence of dysfunctional labor patterns. The fetal heart rate should be auscultated every 15 minutes from the beginning of one contraction through the next contraction. Fluids should be increased to hydrate the patient. A warm shower and hot packs to the back and abdomen should be tried. If by vaginal examination I find her muscles to be very tense, I would suggest a glass of wine and two Tylenol or aspirin; then repeat the warm shower or bath. If in 2 hours the examination is unchanged, I would call the attending physician and have her admitted for fetal monitoring and observation. If she is making progress, I would plan a birthing room birth. However, if in 2 hours after admission she is unchanged, with fetal heart rate within normal limits, I again would consult and discuss artificial rupture of membranes and possible Pitocin augmentation.
Name: Elaine Mielcarski, CNM
Type of setting: Hospital
Date of graduation from nurse-midwifery program: 1979 School of nurse-midwifery: Medical University of South Carolina Institution now practicing in: Private practice with physician Type of setting: Hospital with birthing rooms I am assuming
this family plans a home birth. Since Melissa has a prolonged latent phase of labor, I would consult. If clinical pelvimetry seems adequate, I would go to the patient’s
Vol. 30, No. 6, November/December
1985
Name: Eleanor Price McLees, CNM Date of graduation from nurse-midwifery school: 1980 School of nurse-midwifery: State University of New York at Downstate Medical Center Institution now practicing in: Private practice, Syracuse, NY
The prolonged latent phase is one of the most anxiety-producing labor patterns for women and midwives, both wondering how long the labor will go on, and hoping that maybe at the next pelvic examination the cervix will be 5 or 6 cm dilated. At this point, I would feel much more comfortable with Melissa in the hospital. I would spend some time with her, see how she is coping, and assess the contractions. I also would need more information for my data base. I will assume that the client’s
343
previous history and clinical findings are within normal limits. However, I would want some very specific information from the pelvic examination. Is the cervix now anterior? How well applied is the head to the cervix? Can the position be ascertained? How do the membranes feel? How does this assessment of the pelvis compare to the initial evaluation? The midwife must ask herself, “Has this woman made progress?” (At one time or another, haven’t we all assessed dilatation to be what we might Ike it to be?) In addition to spending time with Melissa, external fetal monitoring would tell how the baby has been dealing with the last few daysnoting baseline, variability, and periodic rate changes. I have found three conditions need to be addressed in the management of the prolonged latent phase of labor: 1) dehydration, 2) exhaustion, and 3) frustration. Dehydration. The woman who has consumed food and fluids continuously since the onset of labor still may be unable to keep up with the energy demands of this phase. I have found an intravenous of 1000 D,LR in addition to oral fluids to be satisfactory for treating dehydration. This often improves fetal heart baseline, variability, and eliminates a late deceleration pattern. After half the liter has infused, the woman will frequently comment that she feels more energetic, even though the intravenous is a nuisance. I encourage support people to keep nourished, too. Exhaustion. There is a very good possibility that Melissa has not slept one night, now going on two. An assessment of the quantity and quality of rest she has had in the last few days is important in determining how her energy will hold out for the hours ahead. If those suggestions offered for trying wine, warm bath, and massage were unsuccessful in allowing Melissa to get some sleep, I am in favor of therapeutic rest, despite my usual reluctance to use medications in labor. I have found oral Seconal
344
to be lip service only for therapeutic rest. The mothers do not sleep well but the babies do. Morphine sulfate l/4 grain given subcutaneously, and 100 mg of Nembutal intramuscularly has been highly successful in providing several hours of well-deserved sleep. I previously shuddered at this combination but eventually saw its merits when women would either wake in transition, or sleep undisturbed for four or five hours and awake well rested to face whatever the day may have in store. Should the former occur, I would give Narcan to the mother; otherwise I suggest a light breakfast, enema, and encourage nipple stimulation, depending on the status of the cervix and the contractions. Frustration. This phase of labor is one of the times the midwife must be “with woman” emotionally. Women are depressed and discouraged at their slow pace. A pep talk is in order, with double doses of empathy and lots of encouragement (even if the midwife is not). Emphasizing her progress, no matter how small it has been, and relating how well the baby is doing, may keep the woman and her support persons feeling positive. The phrase “entertainment phase” should be eliminated from the vocabularies of childbirth educators and birth attendants. For many laboring women there is nothing entertaining about it. Especially for the primigravida, this term only seems to confuse and discourage her when she feels her dilatation is so insignificant in relation to her pain. Lastly, Melissa should be reassured that there is an end to the process; the active phase not taking anywhere near the amount of time consumed by the earlier phase. When the only deviation from the norm is a prolonged latent phase of labor, I would discuss Melissa’s case with my associate physician after evaluating her response to the management plan previously implemented. Should the client and I be leaning towards Pitocin, I would con-
Journal of Nurse-Midwifery
??
sult the physician and request his evaluation before its administration. ASSISTANT EDITOR’S COMMENTS The prolonged latent phase of labor can be confusing and overwhelming to the woman experiencing it. Without careful management the resulting exhaustion, dehydration, and discouragement can affect progress and the patient may have more intervention surrounding her birth. The latent phase of labor is barely mentioned in the obstetric and midwifery textbooks. The beginning of the latent phase of labor is difficult to define because of individual variations in the onset of labor and the perception of the onset. One study defined the onset of the latent phase from the point when painful contractions are 10 minutes apart. The end of the latent phase of labor is when the cervix is from 3- to 4-cm dilated. Looking at the subject in a totally objective way, without consideration of the psychological effect on the patient it can be said that: “The duration of the latent phase has little bearing on the subsequent course of labor, whereas the characteristics of the accelerated phase usually are predictive of the outcome of a particular labor.“l 0kun2 reported a study of the latent phase in 716 Nigerian parturients. Primigravidas with a latent phase of over 20 hours and multiparas with a latent phase of over 14 hours were considered to have a prolonged latent phase. The longest latent phase in the study was 70 hours. No significant correlation was found between the duration of the latent phase and the active phase of labor. A weak correlation was seen in relation to the duration of membrane rupture and mode of delivery. The study failed to demonstrate any correlation between a prolonged latent phase and complications. The responses of the midwives to this description of Melissa’s labor
Vol. 30, No. 6, November/December 1985
were varied and yet similar. All of the midwives felt the individual woman and her situation needed to be evaluated carefully. Once this was accomplished, some varied approaches to this type of labor were mentioned. In reading the responses it is clear that some or all of the techniques mentioned have been used by midwives at one time or another. Although we are not always sure what particular suggestion was helpful, there seems to be reason to believe that many of these approaches are valid and reasonable solutions to the prolonged latent phase. I was surprised to see how many of the suggestions made by the midwives had been researched and the effectiveness documented. The effect of ambulation on labor has been studied: “Since freedom of movement and upright positions have been advocated repeatedly, our initial studies compared the conventional position, dorsal recumbency, with standing. The results were very much in favor of using standing instead of dorsal recumbency.“3 Roberts and Mendez-Bauer4 in their article on the effects of lateral recumbency and sitting on the first stage of labor have shown that frequent changes of position are helpful. The woman’s comfort has to be balanced with progress in cervical dilation. Their research showed the most favorable position to be standing, then sitting, then side lying: “Labor in the sitting-lateral series averaged about twice the length of that in the dorsal-standing. This discrepancy can be explained by the higher frequency of the contractions recorded in the dorsal-standing study. In other words, since the contractions were more frequent in standing than in the lateral position, a similar number of contractions could be accumulated in a shorter period of time.” Hydration is mentioned by all the midwives and although many ob-
Journal of Nurse-Midwifery
??
stetric units disagree with oral intake during labor, it seems there is etidence that oral intake may be the safest approach. A commentary in the British Journal of Obstetrics and Gynecology,5 states that small amounts of ketones in the urine are normal during labor. The author of this commentary questions the wisdom of giving large amounts of intravenous solutions, especially those that are high in glucose and salt free. He says hyperinsulinism could be caused in the fetus as a direct result of the infusion of too much glucose. The use of salt-free solutions could cause hyponatremia in both the baby and mother. Neonatal jaundice and a slowing down of labor with the use of high concentrations of glucose are mentioned. The same author feels that laboring women have a decreased ability to excrete water during labor and an intravenous intake of 1200 mL per day is adequate for laboring women. Based on this and other research, we who have told our patients to eat and drink during labor, rather than depending on the use of intravenous fluids in the prolonged labor situation, were promoting health and avoiding complications for the mother and baby. All of the midwives mentioned nipple stimulation as a possible aid to progress in labor. Elliott et al6 state: “Breast stimulation activates the milk ejection reflex. Stimulation of the nipple and areola causes sensory impulses to be relayed to the supraoptic and paraventricular nuclei in the hypothalmus. Efferent impulses cause the release of oxytocin from the postenor pituitary. Oxytocin acts on the end organ, the breast, to cause milk letdown and is known to cause uterine contractions.” In studies done by Elliott et al6 relating to the use of breast stimulation to prevent postdates pregnancy and to improve the Bishop score, it was suggested that women stimulate their breasts for a total of 3 hours per day.
Vol. 30, No. 6, November/December
1985
They found that cervical dilatation and effacement and station of the fetal head are significantly changed by breast stimulation. The use of the shower was mentioned by several of the midwives because the warmth of the shower and bath are soothing and relaxing. Brown7 agrees: “Immersing the body in water is an effective method of relieving pain, promoting muscular relaxation, and reducing psychological tension due to the hydrothermal and hydrokinetic properties of water.” The use of castor oil for labor induction was very common until the introduction of Pitocin in the mid 1950s. Castor oil is taken from the castor bean plant, which is an herb. “The Chinese value castor oil as a laxative, but also use it in cases of difficult childbirth, facial deformities, and stomach cancer.“8 The stimulation of the smooth muscle of the bowel seems to stimulate the smooth muscle of the uterus. Since Meg mentioned two other herbs, black and blue cohosh, I would like to share what information I found on them: “Most prominent as a medicinal plant, black cohosh was widely used by the American Indians, and was particularly important to the Indian midwives. An Indian medicine guide of the late eighteenth century called it ‘one of our very best remedies in a great many womb troubles,’ ‘and devoted considerable space to its virtues as an emmenagogue. “8 Regarding the blue cohosh: “It partakes of the nature of ginseng and seneka. The Indian women use it successfully in cases of lingering parturition. It appears to be particularly suited to female complaints. It is a powerful emmenagogue, and promotes delivery, the menstrual flux, and dropsical discharges.“8 There are many references to herbs and their use in the case of prolonged labor. It is difficult to find dosages and possible side effects, but it certainly is interesting to explore
345
the possibility of these herbs being helpful in promoting labor. Prolonged latent phase always presents the question of stimulation versus rest. The use of wine is an alternative to the use of drugs for sedation. It may or may not slow or stop contractions. Alcohol may cause nausea, but “Ethanol may have a direct depressant action on the myometrium.“g Sedation with morphine or Seconal has been used with reported success. The idea is to give the mother some much needed rest with the hope that when she wakes up she will be in strong, effective labor. There does come a point when the use of Pitocin becomes the indicated measure. The decision of when it is necessary will depend on the physical and emotional condition of the mother.
346
The wisdom and sensitivity of the midwife will help her make decisions that are right for the individual situation and for the individual patient. Patricia Deibel, CNM JNM Assistant Editor, Region 2 Practicing midwifery at Family Maternity Service Rochester, NY
3. Mendez-Bauer C, Arroyo J, GarciaRamos C, et al: Effects of the standing position on spontaneous uterine contractility and other aspects of labor. J Perinat Med 3:89,1975. 4. Roberts JE, Mendez-Bauer C, et al: Effects of lateral recumbency and sitting on the first stage of labor. J Reprod Med 7:477,1984. 5. Dumoulin JC: Ketonuria during labor. Br J Obstet Gynaecol 91:1,1984, p. 97. 6. Elliott JP, Flaherty JF: Breast stimulation to ripen the cervix. Am J Obstet Gynecol 1949:583,1984.
REFERENCES 1. Friedman EA: Labor: Clinical eualuation and management, 2nd ed. New York: Appleton, 1978. 2. Okun A: Characteristics and significance of the latent phase in the outcome of labor among Nigerian parturients. J Natl Med Assoc 76(6):609,1984.
Journal of Nurse-Midwifery
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7. Brown C: Therapeutic effects of bathing during labor. J Nurs-Midwif 27:13,1982. 8. Hylton W (ed): The Rodale herb book, 1st ed. Pennsylvania. Rodale Press, 1974, p. 397. 9. Pritchard JA, Macdonald PC (eds): Williams obstetrics, 16th ed. New York: Appleton-Century-Crofts, 1980, p. 933.
Vol. 30, No. 6, November/December
1985
INTRODUCTION Melissa is a 28-year-old gravida, para 0, abortus 1, who had a normal prenatal course. She is 41 weeks’ pregnant. On June 1 at 10:00 PM she calls to say she has had some bloody show and a slight backache. At 2:00 AM she phones again to say she is having contractions every 10 minutes lasting 30 to 45 seconds. You ask her to call again when the contractions are stronger and closer, if the membranes rupture, or if she should have any questions. At 11:OO AM (June 2) Melissa calls and says the contractions are stronger and about 7 minutes apart. She would like to know what is happening with her labor. Your abdominal examination reveals that the baby is vertex, the back is on the right side, and the head seems to be entering the pelvis. Estimated fetal weight is 8 lbs (3584 g) and fetal heart rate is 140 beats per minute. Vaginal examination findings are as follows: the cervix is posterior, 70% effaced, and a finger-tip dilated. The head is at a - 2 to - 1 station, the membranes are intact. The contractions are of fair quality every 7 to 8 minutes. You offer suggestions and ask her to call when labor changes. At 2:00 AM (June 3) you are called. The contractions are every 5 minutes and seem somewhat stronger. When you see Melissa the abdominal examination is the same and the cervix is 2- to 3-cm dilated. 80% effaced, head - 1 station. How would you manage this situation?
Name:
Margaret
Schaefer-Turner
MSN, CNM
Date of graduation from nurse-midwifery school: 1977 School of nurse-midwifery: Yale University Institution now practicing in: Group private practice-CNM/OB/GYN Type of setting: Hospital with birth rooms, Children’s Hospital of Buffalo, NY This scenario often is found in primigravid posterior labors. I would admit Melissa to the birth room and reassure her that she is making progress. The contractions are closer. She is beginning the ac-
tive stage of labor. Assuming the fetal rhythm-strip is normal and Melissa is well hydrated, I would encourage ambulation, a hot shower, and clear liquids. Labor possibly could be improved with nipple stimulation. If she is exhausted and/or dehydrated intravenous fluids and sedation would be preferable to the above. Most likely the vertex is posterior, therefore side-lying or the handsand-knees position would be recommended. I would expect slow, steady dilatation of the cervix. If there is no change after several hours I would consult with an obstetrician regarding Pitocin augmentation to improve the strength, frequency, and effectiveness of the contractions. In
342 Copyright
Journal of Nurse-Midwifery 0 1985 by the American
College of Nurse-Midwives
??
most cases, I find that maximal patience and minimal intervention is required. Name: Melody Caton Urban, CNM, MSN
Date of graduation from nurse-midwifey program: 1982 School of nurse-midwifery: sity of Miami
Univer-
Institution now practicing in: Home births and hospital births at St. May’s Hospital in Rochester, NY Type of setting: Private hospital and home In addition to the information given, I would want to know how much
Melissa has rested
in the last 72
Vol. 30, No. 6, November/December
1985
0091-2182/85/$03.30
hours, how much she has eaten, and what she has eaten. I would want to know how she is tolerating labor, her attitude toward labor, and what support system she has. If Melissa is tired and in need of nourishment, I would have her eat a moderate portion of a high protein, easily digested meal. A small glass of wine may relax her. I would remain with her unless she had a good support person and then I would be nearby. Resting on her left side for 2 to 3 hours would be suggested. The baby and mother would be monitored during this time. I would reevaluate the status of Melissa’s labor. If labor is not progressing, nipple stimulation or walking could help strengthen the contractions. At 7:00 or 8:00 AM I would check Melissa for progress. If progress is not being made, I would discuss the situation with Melissa and her support person. Consultation would be obtained and I would most likely proceed to the hospital for labor augmentation. Name: Marguerite Grindrod Date of graduation from nurse-midwifery program: 1981 School of nurse-midwifery: Downstate Medical Center Midwifery Program Institution now practicing in: Private practice Type of setting: Home and hospital births at St. Mary’s Hospital in Rochester, NY I would ask Melissa how she is feeling about her labor; is she discouraged or exhausted? Fears or anxieties could be contributing to the slow progress. I also would evaluate what she has been eating and drinking. Assuming that she is physically in good shape and willing to keep trying, I would try to “energize” the situation. When the attending persons at a birth get bored and dis-
Journal of Nurse-Midwifery
??
couraged by slow progress we tend to advise the woman to call when things are more active. The laboring woman may feel deserted or ignored, or that she is letting everybody down, The labor often slows further. I would spend some time sitting with Melissa, talking about her birth plans and paying attention to the fact that she is in labor. I might suggest that the couple spend some time alone, trying nipple stimulation, hugging, kissing, and physical closeness. A long walk outside can be helpful. A hypertonic saline enema can do wonders to stimulate a sluggish labor. If friends and relatives are there waiting for something to happen, 1 might suggest sending everybody away for a while and taking the phone off the hook. This is a way to decrease pressure on the laboring woman to perform. Suggesting a dose of castor oil in this situation may help. 1 have never had much success using black or blue cohosh in a tincture or a tea to stimulate labor. There has been progress, albeit slow, in this labor. The baby is doing well. The fetal heart tones are good and there is no sign of distress. If the mother is able to eat, drink, and rest so that she is not becoming physically and emotionally drained, my inclination would be to provide support and encouragement and continue to try to get things moving.
home, stay with the patient, palpating each contraction for quality, quantity, consistency, and screening for evidence of dysfunctional labor patterns. The fetal heart rate should be auscultated every 15 minutes from the beginning of one contraction through the next contraction. Fluids should be increased to hydrate the patient. A warm shower and hot packs to the back and abdomen should be tried. If by vaginal examination I find her muscles to be very tense, I would suggest a glass of wine and two Tylenol or aspirin; then repeat the warm shower or bath. If in 2 hours the examination is unchanged, I would call the attending physician and have her admitted for fetal monitoring and observation. If she is making progress, I would plan a birthing room birth. However, if in 2 hours after admission she is unchanged, with fetal heart rate within normal limits, I again would consult and discuss artificial rupture of membranes and possible Pitocin augmentation.
Name: Elaine Mielcarski, CNM
Type of setting: Hospital
Date of graduation from nurse-midwifery program: 1979 School of nurse-midwifery: Medical University of South Carolina Institution now practicing in: Private practice with physician Type of setting: Hospital with birthing rooms I am assuming
this family plans a home birth. Since Melissa has a prolonged latent phase of labor, I would consult. If clinical pelvimetry seems adequate, I would go to the patient’s
Vol. 30, No. 6, November/December
1985
Name: Eleanor Price McLees, CNM Date of graduation from nurse-midwifery school: 1980 School of nurse-midwifery: State University of New York at Downstate Medical Center Institution now practicing in: Private practice, Syracuse, NY
The prolonged latent phase is one of the most anxiety-producing labor patterns for women and midwives, both wondering how long the labor will go on, and hoping that maybe at the next pelvic examination the cervix will be 5 or 6 cm dilated. At this point, I would feel much more comfortable with Melissa in the hospital. I would spend some time with her, see how she is coping, and assess the contractions. I also would need more information for my data base. I will assume that the client’s
343
previous history and clinical findings are within normal limits. However, I would want some very specific information from the pelvic examination. Is the cervix now anterior? How well applied is the head to the cervix? Can the position be ascertained? How do the membranes feel? How does this assessment of the pelvis compare to the initial evaluation? The midwife must ask herself, “Has this woman made progress?” (At one time or another, haven’t we all assessed dilatation to be what we might Ike it to be?) In addition to spending time with Melissa, external fetal monitoring would tell how the baby has been dealing with the last few daysnoting baseline, variability, and periodic rate changes. I have found three conditions need to be addressed in the management of the prolonged latent phase of labor: 1) dehydration, 2) exhaustion, and 3) frustration. Dehydration. The woman who has consumed food and fluids continuously since the onset of labor still may be unable to keep up with the energy demands of this phase. I have found an intravenous of 1000 D,LR in addition to oral fluids to be satisfactory for treating dehydration. This often improves fetal heart baseline, variability, and eliminates a late deceleration pattern. After half the liter has infused, the woman will frequently comment that she feels more energetic, even though the intravenous is a nuisance. I encourage support people to keep nourished, too. Exhaustion. There is a very good possibility that Melissa has not slept one night, now going on two. An assessment of the quantity and quality of rest she has had in the last few days is important in determining how her energy will hold out for the hours ahead. If those suggestions offered for trying wine, warm bath, and massage were unsuccessful in allowing Melissa to get some sleep, I am in favor of therapeutic rest, despite my usual reluctance to use medications in labor. I have found oral Seconal
344
to be lip service only for therapeutic rest. The mothers do not sleep well but the babies do. Morphine sulfate l/4 grain given subcutaneously, and 100 mg of Nembutal intramuscularly has been highly successful in providing several hours of well-deserved sleep. I previously shuddered at this combination but eventually saw its merits when women would either wake in transition, or sleep undisturbed for four or five hours and awake well rested to face whatever the day may have in store. Should the former occur, I would give Narcan to the mother; otherwise I suggest a light breakfast, enema, and encourage nipple stimulation, depending on the status of the cervix and the contractions. Frustration. This phase of labor is one of the times the midwife must be “with woman” emotionally. Women are depressed and discouraged at their slow pace. A pep talk is in order, with double doses of empathy and lots of encouragement (even if the midwife is not). Emphasizing her progress, no matter how small it has been, and relating how well the baby is doing, may keep the woman and her support persons feeling positive. The phrase “entertainment phase” should be eliminated from the vocabularies of childbirth educators and birth attendants. For many laboring women there is nothing entertaining about it. Especially for the primigravida, this term only seems to confuse and discourage her when she feels her dilatation is so insignificant in relation to her pain. Lastly, Melissa should be reassured that there is an end to the process; the active phase not taking anywhere near the amount of time consumed by the earlier phase. When the only deviation from the norm is a prolonged latent phase of labor, I would discuss Melissa’s case with my associate physician after evaluating her response to the management plan previously implemented. Should the client and I be leaning towards Pitocin, I would con-
Journal of Nurse-Midwifery
??
sult the physician and request his evaluation before its administration. ASSISTANT EDITOR’S COMMENTS The prolonged latent phase of labor can be confusing and overwhelming to the woman experiencing it. Without careful management the resulting exhaustion, dehydration, and discouragement can affect progress and the patient may have more intervention surrounding her birth. The latent phase of labor is barely mentioned in the obstetric and midwifery textbooks. The beginning of the latent phase of labor is difficult to define because of individual variations in the onset of labor and the perception of the onset. One study defined the onset of the latent phase from the point when painful contractions are 10 minutes apart. The end of the latent phase of labor is when the cervix is from 3- to 4-cm dilated. Looking at the subject in a totally objective way, without consideration of the psychological effect on the patient it can be said that: “The duration of the latent phase has little bearing on the subsequent course of labor, whereas the characteristics of the accelerated phase usually are predictive of the outcome of a particular labor.“l 0kun2 reported a study of the latent phase in 716 Nigerian parturients. Primigravidas with a latent phase of over 20 hours and multiparas with a latent phase of over 14 hours were considered to have a prolonged latent phase. The longest latent phase in the study was 70 hours. No significant correlation was found between the duration of the latent phase and the active phase of labor. A weak correlation was seen in relation to the duration of membrane rupture and mode of delivery. The study failed to demonstrate any correlation between a prolonged latent phase and complications. The responses of the midwives to this description of Melissa’s labor
Vol. 30, No. 6, November/December 1985
were varied and yet similar. All of the midwives felt the individual woman and her situation needed to be evaluated carefully. Once this was accomplished, some varied approaches to this type of labor were mentioned. In reading the responses it is clear that some or all of the techniques mentioned have been used by midwives at one time or another. Although we are not always sure what particular suggestion was helpful, there seems to be reason to believe that many of these approaches are valid and reasonable solutions to the prolonged latent phase. I was surprised to see how many of the suggestions made by the midwives had been researched and the effectiveness documented. The effect of ambulation on labor has been studied: “Since freedom of movement and upright positions have been advocated repeatedly, our initial studies compared the conventional position, dorsal recumbency, with standing. The results were very much in favor of using standing instead of dorsal recumbency.“3 Roberts and Mendez-Bauer4 in their article on the effects of lateral recumbency and sitting on the first stage of labor have shown that frequent changes of position are helpful. The woman’s comfort has to be balanced with progress in cervical dilation. Their research showed the most favorable position to be standing, then sitting, then side lying: “Labor in the sitting-lateral series averaged about twice the length of that in the dorsal-standing. This discrepancy can be explained by the higher frequency of the contractions recorded in the dorsal-standing study. In other words, since the contractions were more frequent in standing than in the lateral position, a similar number of contractions could be accumulated in a shorter period of time.” Hydration is mentioned by all the midwives and although many ob-
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stetric units disagree with oral intake during labor, it seems there is etidence that oral intake may be the safest approach. A commentary in the British Journal of Obstetrics and Gynecology,5 states that small amounts of ketones in the urine are normal during labor. The author of this commentary questions the wisdom of giving large amounts of intravenous solutions, especially those that are high in glucose and salt free. He says hyperinsulinism could be caused in the fetus as a direct result of the infusion of too much glucose. The use of salt-free solutions could cause hyponatremia in both the baby and mother. Neonatal jaundice and a slowing down of labor with the use of high concentrations of glucose are mentioned. The same author feels that laboring women have a decreased ability to excrete water during labor and an intravenous intake of 1200 mL per day is adequate for laboring women. Based on this and other research, we who have told our patients to eat and drink during labor, rather than depending on the use of intravenous fluids in the prolonged labor situation, were promoting health and avoiding complications for the mother and baby. All of the midwives mentioned nipple stimulation as a possible aid to progress in labor. Elliott et al6 state: “Breast stimulation activates the milk ejection reflex. Stimulation of the nipple and areola causes sensory impulses to be relayed to the supraoptic and paraventricular nuclei in the hypothalmus. Efferent impulses cause the release of oxytocin from the postenor pituitary. Oxytocin acts on the end organ, the breast, to cause milk letdown and is known to cause uterine contractions.” In studies done by Elliott et al6 relating to the use of breast stimulation to prevent postdates pregnancy and to improve the Bishop score, it was suggested that women stimulate their breasts for a total of 3 hours per day.
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They found that cervical dilatation and effacement and station of the fetal head are significantly changed by breast stimulation. The use of the shower was mentioned by several of the midwives because the warmth of the shower and bath are soothing and relaxing. Brown7 agrees: “Immersing the body in water is an effective method of relieving pain, promoting muscular relaxation, and reducing psychological tension due to the hydrothermal and hydrokinetic properties of water.” The use of castor oil for labor induction was very common until the introduction of Pitocin in the mid 1950s. Castor oil is taken from the castor bean plant, which is an herb. “The Chinese value castor oil as a laxative, but also use it in cases of difficult childbirth, facial deformities, and stomach cancer.“8 The stimulation of the smooth muscle of the bowel seems to stimulate the smooth muscle of the uterus. Since Meg mentioned two other herbs, black and blue cohosh, I would like to share what information I found on them: “Most prominent as a medicinal plant, black cohosh was widely used by the American Indians, and was particularly important to the Indian midwives. An Indian medicine guide of the late eighteenth century called it ‘one of our very best remedies in a great many womb troubles,’ ‘and devoted considerable space to its virtues as an emmenagogue. “8 Regarding the blue cohosh: “It partakes of the nature of ginseng and seneka. The Indian women use it successfully in cases of lingering parturition. It appears to be particularly suited to female complaints. It is a powerful emmenagogue, and promotes delivery, the menstrual flux, and dropsical discharges.“8 There are many references to herbs and their use in the case of prolonged labor. It is difficult to find dosages and possible side effects, but it certainly is interesting to explore
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the possibility of these herbs being helpful in promoting labor. Prolonged latent phase always presents the question of stimulation versus rest. The use of wine is an alternative to the use of drugs for sedation. It may or may not slow or stop contractions. Alcohol may cause nausea, but “Ethanol may have a direct depressant action on the myometrium.“g Sedation with morphine or Seconal has been used with reported success. The idea is to give the mother some much needed rest with the hope that when she wakes up she will be in strong, effective labor. There does come a point when the use of Pitocin becomes the indicated measure. The decision of when it is necessary will depend on the physical and emotional condition of the mother.
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The wisdom and sensitivity of the midwife will help her make decisions that are right for the individual situation and for the individual patient. Patricia Deibel, CNM JNM Assistant Editor, Region 2 Practicing midwifery at Family Maternity Service Rochester, NY
3. Mendez-Bauer C, Arroyo J, GarciaRamos C, et al: Effects of the standing position on spontaneous uterine contractility and other aspects of labor. J Perinat Med 3:89,1975. 4. Roberts JE, Mendez-Bauer C, et al: Effects of lateral recumbency and sitting on the first stage of labor. J Reprod Med 7:477,1984. 5. Dumoulin JC: Ketonuria during labor. Br J Obstet Gynaecol 91:1,1984, p. 97. 6. Elliott JP, Flaherty JF: Breast stimulation to ripen the cervix. Am J Obstet Gynecol 1949:583,1984.
REFERENCES 1. Friedman EA: Labor: Clinical eualuation and management, 2nd ed. New York: Appleton, 1978. 2. Okun A: Characteristics and significance of the latent phase in the outcome of labor among Nigerian parturients. J Natl Med Assoc 76(6):609,1984.
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7. Brown C: Therapeutic effects of bathing during labor. J Nurs-Midwif 27:13,1982. 8. Hylton W (ed): The Rodale herb book, 1st ed. Pennsylvania. Rodale Press, 1974, p. 397. 9. Pritchard JA, Macdonald PC (eds): Williams obstetrics, 16th ed. New York: Appleton-Century-Crofts, 1980, p. 933.
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