Running head: SUPPORTING WOMEN IN LABOR 1

Supporting Women in Labor

Katlyn Carter

Midwives College of Utah

PHYT 2050 Advanced Comfort Measures

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Physical and Emotional Reasons for Providing Support During Labor

As our society has developed, the hospital has replaced the home as the primary location

for childbirth. The general improvement in living conditions and technology available for

hospital births has improved both maternal and neonatal outcomes in the last century. However,

those statistics have begun to show a different trend. There has been concern that these new

technological advances (electronic fetal monitoring, ultrasound, etc.) have emotionally

distanced obstetricians and midwives from their patients (Zhang et al., 1996, p. 739). This gap

in emotional support for women in labor can be filled by a labor attendant whether that be a

doula (providing emotional support), monitrice (providing emotional support and basic medical

care), or supportive family member.

There can be detrimental physical and emotional risks for women who have extreme

anxiety about giving birth, a fear of losing control, low self-esteem, or unhappy experiences of

labor or previous births (Leap & Hunter, 2016). Extreme anxiety and fear can create these

problems, or exacerbate them and may include pre-eclampsia, fatigue and sleeplessness, more

pain and anxiety in labor, an increase in interventions, including epidural use and emergency and

elective cesarean sections, an overall unhappy experience, postnatal depression and difficulties

with mother-baby attachment, and long-term risks associated with post-traumatic stress disorder

(Leap & Hunter, 2016). By addressing that fear and anxiety, women can have better experiences

and outcomes.

In 1996, a group of researchers, Zhang, Bernasko, Leybovich, Fahs, and Hatch, set out to

evaluate the available literature (including several randomized clinical trials) examining the

effectiveness of continuous labor support by labor attendants. Some of the studies they looked at

showed significant beneficial effects on labor outcome, but others did not (Zhang et al., 2016).
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Their meta-analysis concluded that among young, low-income, primiparous women who gave

birth on a busy labor floor in the absence of a companion suggested that continuous labor support

by a labor attendant

Shortens the duration of labor by 2.8 hours

Doubles spontaneous vaginal birth
Halves the frequency of oxytocin use
Halves the cesarean delivery rate
The women with labor support also reported higher satisfaction and a better postpartum course

(Zhang et al., 1996).

A more recent meta-analysis done by Conniff & Dresang that involved 15,288 women

compared the effect of continuous, one-to-one intrapartum support to the usual care. (Conniff &

Dresang, 2016). They were specifically looking at the rates of spontaneous vaginal delivery,

assisted vaginal birth, and cesarean birth (Conniff & Dresang, 2016). Overall, the women who

received continuous labor support were more likely to have an SVD (spontaneous vaginal

delivery) and less likely to have a cesarean birth or instrumented vaginal birth (Conniff &

Dresang, 2016). Also, interesting to note, that the rates were better when the support provider

was a third party rather than a hospital staff member or part of the womans social network

(Conniff & Dresang, 2016).

In 2014, Chaillet et al. conducted another interesting meta-analysis looking at

nonpharmacological approaches for pain management during labor compared with usual care.

This analysis broke down nonpharmacologic approaches into three subgroups: Gate Control

(water immersion, massage, ambulation, positions), Diffuse Noxious Inhibitory Control (DNIC)

(acupressure, acupuncture, electrical stimulation, water injections), and Central Nervous System

Control (education, attention deviation, support) (Chaillet et al., 2014). The researchers
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concluded that Gate Control and DNIC are associated with reduction in epidural analgesia and a

higher maternal satisfaction with childbirth (Chaillet et al., 2014, p. 122). When comparing the

nonpharmacological approaches based on Central Nervous System techniques, the usual care is

associated with

Increased odds of epidural

Cesarean delivery
Instrumental delivery
Use of oxytocin
Labor duration
Lesser satisfaction with childbirth (Chaillet et al., 2014, p. 122).
The researchers concluded that the nonpharmacological approaches provide significant benefits

to women and their infants (Chaillet et al., 2014).

Five Comfort Measure Techniques

Direct contact between provider and laboring mother, in the form of support and comfort,

may be provided in simple, non-invasive ways:

Heat & Cold Heat increases local skin temperature and circulation, reduces muscle spasm, and

raises the pain threshold which can help in labor (Simkin & Ancheta, 2017). This may be applied

as a hot, moist towel or heating pad (or any other kind of hot pack) applied to the lower

abdomen, groin, thighs, lower back, shoulders, or perineum (Simkin & Ancheta, 2017). Cold can

be applied with cold compresses on the lower back, perineum, or anus (for painful hemorrhoids)

using an ice pack, gel pack, latex glove filled with ice, wet wash cloth, etc. (Simkin, 2013). Cold

is useful for musculoskeletal and joint pain, decreases muscle spasm, creates a numbing effect,

reduces swelling, and is cooling to the skin (Simkin & Ancheta, 2017).

Hydrotherapy Hydrotherapy reduces muscle tension, pain, and anxiety for many women.

Immersion in water provides buoyancy which reduces the effect of gravity on the woman
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(Simkin & Ancheta, 2017). Women may stand or sit on a stool in the shower or submerge in a

bath. The even distribution of hydrostatic pressure over the immersed portions of the womans

body bring pain relief and more rapid active labor progress (Simkin & Ancheta, 2017).

Movement Movement in labor may help resolve fetal malposition, enhance fetal descent by

changing the shape and size of the womens pelvic basin, reduce labor pain, and increase the

womans active participation and decrease her emotional distress, also contributing to fetal well-

being (Simkin & Ancheta, 2017). Movement can include walking or stair climbing, pelvic

rocking, lunging, slow dancing, etc. (Simkin & Ancheta, 2017).

Touch & Simple Massage Touch conveys a kind, caring, and comforting message to the

laboring mother (Simkin, 2013, p. 151). Laboring mothers can like gentle, comforting, or

reassuring touch such as a pat on her back or shoulder, rubbing a painful spot, holding her hand,

stroking her hair, scratching her back, etc. (Simkin, 2013). The mother will often let you know

whether she wants lighter touch or more pressure, during a contraction or in between, or where

she wants it (Simkin, 2013). Massage can be short (1-3 minutes) and simple including shoulder

massage, crisscross over the lower back, hand massage, foot massage, etc. (Simkin, 2013).

Attention Focusing Attention focusing diverts the mothers pain by focusing on something else.

This could be looking at a certain picture or object, listening to a particular sound (voice, music,

etc.), feeling a touch (touch, massage, caress etc.), or concentrating on a mantra or ritual (Simkin,

2013).

Comfort Measures in My Future Midwifery Practice & Changes to My Doula Practice

I believe understanding comfort measures to support clients in labor is essential. As I

have begun my journey down the path to midwifery, Im so glad I started out as a doula. I have
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loved starting with what knowledge came from my doula training class, then learning from other

doulas, and seeing things done (or not done) in different practices with different care providers. I

have been encouraged with more and more people wanting support in labor, but I have also been

surprised and little saddened that many midwives dont want to give support during labor. In my

area, the local birth center began requiring their primiparous clients hire a doula after their first

year in business saw a 60% transfer rate in primiparous women. Those women needed support

before they were in strong, active labor (which is when the birth center would accept them into

labor and delivery care). Their requirement of doulas was great for business (and Im grateful for

the experiences that provided me), but it saddened me that that was the expectation for that

practice. However, theyre not the only ones. I recently had a couple contact me seeking doula

services. They were 36 weeks along, and their homebirth midwife strongly suggested they get a

doula because she hoped to get there just in time to catch the baby (she came, checked mom, left,

came back a few hours later when mom was pushing). I was, again, grateful to have been a part

of that birth, but was disheartened that the midwife wasnt there offering support to her laboring

client. That birth really gave me the opportunity to learn so much about comfort measures

(positions, touch, energy flow, heat therapy, hydrotherapy, and others, Im sure); Im truly

grateful and humbled to have been there.

I have also had the privilege to support women alongside amazing midwives, elder

students, nurses, and even a funny, older obstetrician. Bringing comfort to a woman in labor is

truly an art-knowing what to do or try next, and finding just the right thing. There is much to be

learned.

In my future practice, I want to offer the comfort and support that is so needed. I dont

want it to have to be an additional out-of-pocket expense. I believe that comfort measures,

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support, and time should be part of the package deal. I was blessed to have had an older,

experienced midwife come into our life when I was pregnant with our second baby. We were

planning our first homebirth and interviewing midwives and doulas. This amazing woman said

that we were welcome to hire a doula, but that she would be there with us regardless. She didnt

require a doula, only snacks because she planned to be there awhile! She was such a great

example of what a midwife can be. I want to be that kind of midwife. It is not only representative

of so much of the midwives model of care, it is truly evidence-based practice.

I understand everyone has their reasons and preferences for how they practice.

Regardless of setting, care provider, race, socioeconomic status, insurance, or anything else,

women should have support in labor.

I was so excited to take this class. Ive been a doula for about a year and a half. Starting

out, I was unsure of my skills and what difference I might make for a laboring mother (or the

new family). I have made sure that I am constantly learning and growing... consulting books,

other doulas, a midwife friend (bless her heart, she keeps taking my calls and answering my

questions), and learning all I can about comfort measures. Im thrilled to utilize the things we

learned in this class and incorporate them into my practice. I think learning to be with women

and fine-tuning ones comforting/encouraging skills and knowledge-base should be mandatory

for anyone wanting to enter the field of womanly care-midwifery, nursing, obstetrics, or

otherwise!
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References

Chaillet, N., Belaid, L., Crochetire, C., Roy, L., Gagn, G. P., Moutquin, J. M., ... & Bonapace,

J. (2014). Nonpharmacologic approaches for pain management during labor compared

with usual care: a metaanalysis. Birth, 41(2), 122-137.

Conniff, J., & Dresang, L. (2016). Does continuous labor support decrease rates of cesarean and

assisted vaginal delivery?.

Simkin, P. (2013). The birth partner: A complete guide to childbirth for dads, doulas, and all

other labor companions. Houghton Mifflin Harcourt.

Simkin, P., Hanson, L., & Ancheta, R. (2017). The labor progress handbook: early interventions

to prevent and treat dystocia. John Wiley & Sons.

Zhang, J., Bernasko, J. W., Leybovich, E., Fahs, M., & Hatch, M. C. (1996). Continuous labor

support from labor attendant for primiparous women: a meta-analysis. Obstetrics &

Gynecology, 88(4), 739-744.