A Menu of Change
Transitioning into the Birth Setting
Admission Processes to Support Physiologic Labor
In the United States, the vast majority of women move from their home environments to other sites for care at some point during labor. This shift from one environment to another affects the rhythm of the labor and the woman’s perception of pain.1,2 If institutional requirements are at the forefront during admission, this transition can significantly disrupt the process of physiologic labor.
The timing of the admission is a critical first step in promoting physiologic birth.3 Early admission before active labor can lead to interventions aimed at increasing labor progress.3-6 Researchers have demonstrated that admission to the hospital during earlier phases of labor is associated with nearly twice the risk for increased use of interventions, such as augmentation with oxytocin, as compared to admission during active labor.3-6 Allowing more time for labor to progress may be the more judicious and evidence-based approached however the culture on many hospital units is to anticipate a set pace of labor once admission occurs.3,7 To reduce the risk of increased interventions in normal labor, women with healthy pregnancies should be encouraged to stay home or return home instead of being admitted until she is in active labor.4,5
Creating an Environment to Promote Physiological Birth
Labor admission process
Specific strategies to individualize care and promote physiologic labor include the following:
Minimize the number of personnel engaging the woman in labor.
Provide the woman with uninterrupted time to get acquainted with the birth room before others enter the space.
Keep environmental stimuli to a minimum.
Give the woman options upon entering the birth room. For example, allow her to choose the quantity and quality of light and sound in the space, and follow her lead on turning back bed covers.
These simple practices alone challenge the usual hospital admission practices by encouraging the woman to be up and around instead of sitting or lying down in the bed.
Adjust routines used during the admission process for labor
Routine procedures, such as obtaining a woman’s vital signs and ongoing intermittent assessment of fetal well-being, can be redesigned to cause less disruption to the process of labor:
Obtain vital signs quietly between several contractions, not during a contraction.
Ask assessment questions between contractions while maintaining eye contact with the woman; allow her to make labor her primary focus.
Avoid overly focusing on the paper or computer health record while recording information.
These measures convey a message of the woman’s importance and help to establish a relationship between the woman and her maternity care providers, particularly the nurse who will be with her during labor.
Assessment of fetal well-being on admission
Some settings require continuous electronic fetal monitoring when a woman presents to the triage area for assessment of her labor status. Researchers have provided evidence indicating that this process of performing fetal assessment with continuous electronic fetal monitoring can disrupt the labor process and lead to increased rates of interventions.8 In these settings, fetal assessment using telemetry is preferable to maintain freedom of movement for the woman. a portable and silent telemetry unit can be used.8 After fetal well-being has been established, continuous monitoring should be discontinued in favor of intermittent auscultation for all eligible women (Refer to the Assessment of Fetal Well-Being section for more information).9 It is possible to obtain the initial history and conduct the physical, including pelvic examination, based on the woman’s preference: quickly at a moment of her choosing or over a period of time. When a woman is in advanced, active labor with limited time between contractions, the midwife, physician, or nurse should prioritize actions critical to providing safe, immediate care to the woman and fetus. Establishing the fetal position and presentation, confirming fetal well-being, and obtaining maternal vital signs may take priority, and other assessments can be completed as time allows.
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Leap N, Dodwell M, Newburn M. . Working with pain in labour: an overview of the evidence. New Digest. 2010;49:22-26.
Maher J. The painful truth about birth?: Contemporary discourses of caesareans, risk and the realities of pain. Presented at: The 2007 Australian Sociological Association Conference; December 4-7, 2007; Auckland, New Zealand. https://tasa.org.au/wp-content/uploads/2008/12/19.pdf. Accessed April 14, 2014.Neal, JL, Lamp, JM, Buck, JS, Lowe, NK,
Gillespie, SL, Ryan, SL. . Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. J Midwifery Womens Health. 2014; 59 (1):28-34.
Bailit JL, Dierker L, Blanchard MH, Mercer BM. Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstet Gynecol. 2005;105(1):77-79.
Holmes P, Oppenheimer LW, Wen SW. The relationship between cervical dilatation at initial presentation in labour and subsequent intervention. BJOG. 2001;108(11):1120–1124.
Rahnama, P., Ziaei, S., Faghihzadeh, S. Impact of early admission in labor on method of delivery. Int J Gynaecol Obstet. 2006; 92(3): 217-20.
American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus: safe prevention of the primary cesarean delivery. http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery. Published March, 2014. Retrieved March 2, 2014.
Gourounti K, Sandall J. Admission cardiotocography versus intermittent auscultation of fetal heart rate: effects on neonatal Apgar score on the rate of caesarean sections and on the rate of instrumental delivery--a systematic review. Int J Nurs Stud. 2007;44(6):1029-1035.
American College of Nurse-Midwives. Intermittent auscultation for intrapartum fetal heart rate surveillance. ACNM clinical bulletin, no. 11. J Midwifery Womens Health. 2010; 55(4):397–403.
Association of Women’s Health, Obstetric and Neonatal Nurses. Fetal Heart Monitoring Principles & Practices. 4th ed. Philadelphia. PA: Lippincott; 2009.