Physiology of Labor & Care of Women in Normal Labor (Part I, 2 & 3) PDF

Physiology of Labor & Care of Women in Normal Labor (Part I, 2 & 3) Bachelor of Science (Honours) in Nursing School of Nursing Dr Vivian Ngai 27 Sept 2024 Learning Outcomes By the end of this session, students will be able to: Describe signs of onset of labor Differentiate between true...

Physiology of Labor & Care of Women in Normal Labor (Part I, 2 & 3) Bachelor of Science (Honours) in Nursing School of Nursing Dr Vivian Ngai 27 Sept 2024 Learning Outcomes By the end of this session, students will be able to: Describe signs of onset of labor Differentiate between true & false labor Identify the five Ps of labor Describe physiological changes of four stages of labor Discuss the management & nursing care of women during each stage of labor Discuss fetal assessment & management of fetal distress during labor Discuss pharmacological & non-pharmacological methods of pain relief in labor Explain the indications, method, potential risks & nursing care of childbirth related procedures, e.g., induction of labor, artificial rupture of membranes & instrumental delivery  Labor Labor is a physiologic process by which the fetus, placenta & membranes are expelled from the uterus Signs of labor onset Show - Bloody cervical mucous is expelled T Regular uterine contractions Eydr ↑frequency, duration & intensity about every _____min 10 contraction, each last about _____ 10 second Cervical effacement & dilatation Cervical effacement – gradual thinning, shortening & taking up of cervix  Cervical dilatation – opening of cervix from 0 to 10cm ± Rupture of membrane (ROM) Copyright © Lippincott Williams & Wilkins  True Vs False Labor True Labor False Labor Contractions regular interval irregular & frequency, duration & intensity ___ no change M with walking ___ ↓ with rest, warm bath ____ ↓ with rest, warm bath not ____ Discomfort begins in back & radiate to abdomen in abdomen Cervical dilatation & progressive no change effacement  Possible Causes of Labor Onset Mechanical factors excaty Fetal pressure & tension  stretching of uterine muscles Hormonal factors Prostaglandin hypothesis Oxytocin stimulation Progesterone withdrawal hypothesis Corticotropin-releasing hormone Critical Factors in Labor 5Ps: 1. Passage (birth canal) 2. Passenger (fetus) 3. Powers (uterine contraction) 4. Psyche (psychological response) 5. Position (maternal postures & physical positions) 1. Passage Pelvis Size & type Caldwell-Moloy classification Gynecoid, Android, Anthropoid, Platypelloid Cervix Effacement & dilatation Effect of relaxin relax of pelvic ligament & softening of symphysis pubis Pelvis False pelvis area of pelvis above pelvic brim or linea terminalis (an imaginary line from sacral promontory to superior aspect of symphysis pubis) True pelvis fetus go through Pelvic inlet – bordered by pelvic brim & sacral promontory AP diameter of inlet Diagonal conjugate (DC) – distance from lower border of symphysis pubis to sacral promontory ~ 12 5 um. True conjugate (TC) – distance from upper border of symphysis pubis to sacral promontory /l um ~ Obstetric conjugate (OC) – distance from posterior border of symphysis pubis to sacral promontory ~5 (_________________cm 1. less than DC) Midpelvis – area between the inlet & outlet Pelvic outlet – bordered by ischial tuberosities & coccyx AP diameter – distance from lower border of symphysis pubis to tip of sacrum N 9 5. - 11 5 cm. Transverse diameter of outlet – distance between ischial tuberosity 8- 10cm Copyright © Lippincott Williams & Wilkins  Types of Pelvis Caldwell-Moloy classification Types Characteristics Effect on birth Gynecoid Inlet round, midpelvis & Favorable for 4 outlet adequate vaginal birth Android Inlet heart-shape, Not favorable P ↓midpelvis & outlet for vaginal birth Anthropoid Inlet oval shape, Favorable for midpelvis & outlet vaginal birth adequate Platypelloid Inlet oval shape, Not favorable ↓midpelvis & outlet for vaginal birth Copyright © Pearson 2. Passenger Fetal skull Diameter Copyright © Elsevier Copyright © Lippincott Williams & Wilkins Moulding Overlapping of skull bone along suture lines Degree of Moulding 0 No moulding Fetal attitude, presentation, position, lie, + No overlapping engagement, station ++ Overlapping +++ Overlapping & not reduceable Moulding (RCOG, 2021) 3. Power Primary force Uterine muscular contractions  complete effacement & dilatation of cervix Secondary force Use of abdominal muscles to push during 2nd stage of labor Uterine contractions Three phases blood How back to placenter/fetus Increment – ↑intensity of contraction & Acme – peak of contraction Decrement – ↓intensity of contraction Frequency, duration, intensity Copyright © Lippincott Williams & Wilkins 4. Psyche Self-esteem Expectations Preparation of childbirth Feeling of apprehension, anxiety Coping mechanisms in response to stressful life events Support Trust in healthcare professionals Cultural influences Copyright © Pearson 5. Position 1st stage – upright position e.g. walking, sitting, kneeling or squatting ↓compression of aorta/vena cava, more effective contraction, ↑decent 2nd stage – upright position ↑pelvic outlet, better align fetus with inlet Stages of Labor First stage Second stage Third stage Fourth stage  First Stage of Labor Begins with regular uterine contractions & ends with complete cervical dilatation at 10cm Stage of labor Cervical dilatation Contraction Nullipara Multipara First Latent phase 0-3 cm Every 5-30 mins to 5-7 mins 8 6 _____________. hrs _____________ 53. hrs stage Duration 30-40 seconds Intensity 25-40 mmHg Active phase 4-7 cm Every 2-3 mins _____________ 46. hrs _____________ 2 4. hrs Duration 40-60 seconds Intensity 50-70 mmHg Transition 8-10 cm Every 1.5-2 mins ____________ 3 6 hrs. Variable phase Duration 60-90 seconds Intensity 70-90 mmHg Second Begins with complete cervical Every 1.2-2 mins ≤ 2 hrs (no use of ≤ 1 hr (no use of stage dilatation & ends when the baby Duration 60-90 seconds regional anesthesia) regional anesthesia) is delivered Intensity 70-100 mmHg 3 ≤ _____ hrs (use of z ≤ _____ hrs (use of regional anesthesia) regional anesthesia) : pushing most effective Second Stage of Labor Begins with complete cervical dilatation & D ⑪ ends when the baby is delivered Mechanism of normal labor Cardinal movements Descent D Flexion ⑪ Internal rotation of head ↑ Extension of head Restitution External rotation Da Expulsion Copyright © Lippincott Williams & Wilkins Third Stage of Labor Period after birth of baby to expulsion of placenta & membranes Signs of placental separation Lengthening of umbilical cord Sudden gush of blood from vagina Uterus rise upward, contract & feel firm Placenta is visible at vaginal opening > 30min may indicate retained placenta Fourth Stage of Labor ______________ 1- 4 hours after the expulsion of placenta Physiological adjustment hemodynamic changes due to blood loss (________________________ml) N200 - 500 sudden reduction in intra-abdominal pressure moderate tachycardia uterus contract (involution) vessel constriction at placental site fundus firm at umbilicus or ____________cm - 12 lower, in midline bladder is often hypotonic ______________________ urinary retention Nursing Management of Labor Normal birth Spontaneous in onset Low-risk at start of labor & remaining so throughout labor & delivery Infant is born spontaneously in vertex position between 37 & 42 weeks of pregnancy After birth mother & infant are in good condition Major concepts in promoting normal birth Labor begins on its own, not be artificially induced Freedom of movement throughout labor, not be confined to bed Continuous labor support from a caring support person during labor No routine interventions Spontaneous pushing in non-supine positions No separation of mother & baby, unlimited opportunity for breastfeeding (WHO, 2018) First Stage of Labor Nursing Care during Admission S/S of labor onset time of labor onset frequency, duration, intensity of uterine contraction bloody show ROM, leaking of liquor & characteristics Review antenatal record General condition Vital signs BW, oedema Urine for sugar & albumin First Stage of Labor Nursing Care during Admission Abdominal examination Check if uterus is corresponding to date Measure symphysis-fundal height Confirm fetal lie, presentation & engagement Feel for characteristic of uterine contractions Detect if fetus is viable & normality of FHR  AY Am I First Stage of Labor Nursing Care during Admission ± Vaginal examination Determine degree of cervical effacement & dilatation 3/5 head : Fetal position engage Cm Fetal station level of presenting part in relation to pelvic ischial spines Station is “0” when presenting part is at ischial spine or engaged in pelvis Copyright © Lippincott Williams & Wilkins Copyright © Pearson Copyright © Pearson First Stage of Labor Nursing Care during Admission ± Speculum exam to confirm ROM Pool of liquor seen in posterior fornix / leaking onto lower genital tract Test fluid to confirm ROM Ferning pattern Nitrazine test Actim PROM test – Insulin like growth factor binding protein 1 (IGFBP1) Nursing Care during First Stage of Labor General care Hygiene, elimination, diet & hydration, activity & rest, comfort measures Review childbirth plan Support & family involvement Psychological care & education Empower the women & family to make informed decisions Nursing Care during First Stage of Labor Monitoring of labor 1) Maternal condition Vital signs S/S maternal distress e.g. __________________________________________________________ dehydration ketoria fewer hot dry vagina , , , & Fluid balance Elimination urine~ within 24 hours ensure encourage empty bladder, ± catheterization, urine test Vaginal bleeding / bloody show Response to pain relief  Nursing Care during First Stage of Labor Monitoring of labor 2) Fetal condition Fetal heart rate (FHR) by intermittent auscultation / continuous fetal heart monitoring (CFHM) using cardiotocography (CTG) S/S fetal distress Tachycardia (FHR > __________ 160 beats/min), bradycardia (FHR < _________beats/min), 110 irregular rhythm thick = dan green > + feral hypoxemia Abnormal CTG normal clear = thin = greenish/yellowish Meconium-stained liquor (MSL) To Fetal blood sampling - blood pH < _________________  Fetal acidosis Nursing Care during First Stage of Labor Monitoring of labor 3) Labor progress Abdominal exam position uterine contractions descent of presenting part Vaginal exam cervical dilatation & descent status of membranes Rom ? / not - access liquer amniotic fluid – color, amount, consistent & odor Documentation - Partogram Partogram FHR "mother pelvic fetal head & / of meconium = mod conu Darker colour -> ↑ Conv Copyright © Churchill Livingstone  Antenatal CTG Fetal Heart Rate Monitoring – Cardiotocography (CTG) What is CTG? D change to resp toy s Measures response of fetal heart rate (FHR) to fetal movement (Non-stress Test, NST) or maternal ⑪ uterine contractions (Continuous Fetal Heart Monitoring, CFHM) CTG monitor has 2 transducers, one records FHR & the 2nd records maternal uterine contractions cardio to c Why is CTG Important? Purpose assess fetal well-being identify fetal hypoxia prevent fetal death Indications Previous history of stillbirth Pregnancy at-risk ↓Fetal movement Induction of labor (IOL), Trial of labor (TOL) following previous C/S Preterm labor MSL CTG Normal CTG / FHR tracing Baseline heart rate: _________________________beats/min 110-160 (bpm) Baseline variability: _________________________ - 5 35 bpm Accelerations with fetal movement Accelerations ≥ __________________bpm 15 15 for ≥ _________________seconds Absence of late or variable decelerations Early deceleration may be present Abnormal CTG Baseline heart rate: tachycardia or bradycardia Loss of variability < ______________ j bpm Recurrent late or variable decelerations CTG Early decelerations Onset of deceleration begin with onset of contraction, lowest point of deceleration coincide with peak of contraction, return to baseline by end of contraction Cause – ____________________ need compression Late decelerations Onset of deceleration is after onset of contraction, lowest point of deceleration is after peak of contraction, time lag between peak of contraction & nadir of deceleration : Supine hypotensive syn Cause – ______________________ uteroplacental insufficiency Variable decelerations Deceleration unrelated to uterine contraction, variable in shape & timing umbilical Lord compression : Lord colapse Cause – _______________________  Xpattern Red at. > tell mother i - X pushing Copyright © Pearson  FHR Tracing Uterine contraction: Yes /D No Baseline heart rate: _______ 130bpm - Baseline variability: _______ 10bpm FHR Accelerations: D +15 Yes / No Decelerations: OYes / No Which types?  Early decelerations  Late decelerations -Variable decelerations  O / Abnormal CTG  Normal CTG paper speed at 1cm/1min (1 small square = 30 second) Copyright © Wikipedia  FHR Tracing D Uterine contraction: Yes / No 3m@1 Frequency: ______ CominTAS Duration: ________ Im Baseline heart rate: _______ 150 Baseline variability: _______ 20 Accelerations: Yes / DNo Decelerations: Yes /D No Which types?  Early decelerations  Late decelerations  Variable decelerations O  Normal / Abnormal CTG duration -- Copyright © Pearson ⑭ Management of Fetal Distress Inform obstetrician Change position to left lateral Administer O2, IVF Slow down or stop syntocinon infusion Vaginal exam to exclude cord prolapse Closely monitor fetal condition CFHM, characteristics of liquor, fetal blood sampling Expedite delivery 1st stage 2nd stage Paediatrician standby for resuscitation Labor Pain 1st Stage T10-21 Pain is transmitted via spinal nerves _____________ can be referred to abdominal wall, lumbosacral region, iliac crests, gluteal areas & thighs 2nd Stage Pain is transmitted via pudendal nerves, entering spinal cord via nerve roots ________________ So S4 - characterised by a combination of visceral pain from uterine contractions & cervical stretching, & somatic pain from distension of vaginal & perineal tissues  Factors Influencing Pain Response Physiological factors Weig Nulliparous women experience greater sensory pain than multiparous women during early labour Positions adopted by women & the extent of their mobility during labour affect perception of pain Cochrane systematic review found a reduction in reporting of severe pain during 2nd stage of labour for women using any upright/lateral position as compared with women lying on their back during labour (Gupta et al., 2017) Women experience induced labour as being more painful than spontaneous labour M Psychosocial factors Prior experience of labour & childbirth Anxiety, woman’s ability to cope Physical & cultural birth environment Degree of emotional support provided by HCP & woman’s birth companions Pain Relief in Labor Non-pharmacological methods can be combines Breathing & relaxation exercise, massage, positioning, birth ball, aromatherapy, music therapy, hydrotherapy Transcutaneous electrical nerve stimulation (TENS) Psychological support Pharmacological methods Entonox Pethidine Epidural analgesia  Pain Relief in Labor Entonox F 50 ~ Inhalational analgesia (___________% nitrous oxide & __________% 30 oxygen) Peak action about _____________ 30 seconds after administration Excrete rapidly via lung  no residual effect on fetus Instructions to mother apply mask closely & firmly to nose & mouth take steady & deep breaths, inhale _________ 10 seconds before contraction starts remove mask & rest in between contractions Allow residue gas to exhale  Pain Relief in Labor ↓ baseline variability sleeping Pethidine or baby Opioid analgesic Dosage: ______________________mg 50-100 IMI 10 Onset ______________min, 30-50 peak ____________min, 2 y duration ___________hrs - S/E on mothers confusion, respiratory depression, nausea & vomiting, hypotension Adverse neonatal effect – respiratory depression Avoid given _______________________hrs 2 4 - before delivery Opiate antagonist – Naloxone (Narcan) + DEEE/E : give pethiding Epidural Analgesia Injection of local anesthetic solution into epidural space to achieve full pain relief Common injection site: between lumbar vertebrae ____________ C-1 13-14 or Nursing care Pre-hydrate with Hartman’s solution IVI Position – lateral with back well-arched Monitor vital signs (BP&P), FHR, uterine contractions, pain level Potential complications Hypotension Neurological deficit Infection Extradural haematoma/haemorrhage Copyright © Wikipedia Nursing Care during Second Stage of Labor Monitoring Fetal condition – FHR, characteristics of liquor Maternal condition – Vital signs Uterine contractions Descent of presenting part Crowning – Fetal head are distending vulva & no longer recedes between contractions Position, bearing down effort with uterine contraction Bladder care, pain relief, support Inform obstetrician if: fetal distress, maternal fever, ↑BP, slow progress Nursing Care during Second Stage of Labor Delivery of baby Ferguson’s reflex blood flow : Physiological response of woman with an urge to bear down ↑ Support spontaneous pushing efforts close : hold breath - push e.g. Open glottis pushing (American College of Nurse-Midwives, 2012) ± Episiotomy if necessary now open = X hold breath Surgical incision of perineal tissues to enlarge vulva Midline or medio-lateral episiotomy Xe damage anal sphincter ~ put finger 2 inside Q medio-lateral Copyright © American College of Nurse-Midwives Copyright © American College of Nurse-Midwives Third Stage of Labor Methods of delivering placenta Maternal effort Controlled cord traction need to see the Fundal pressure ↑ signs of 3rd stage Placental separation Schultze mechanism X separate from inside to outer margins expelled with fetal surface presenting Duncan mechanism Ex more common separate from outer margins inward expelled with maternal surface first Nursing Care during Third Stage of Labor nurse intervention Active management Give oxytocic drug at the delivery of anterior shoulder of the baby e.g. Syntocinon or Syntometrine IMI enterine cone (biopsy) Double clamp & cut umbilical cord Cord blood sample for TSH, T4, G6PD Deliver placenta by controlled cord traction, when signs of placental separation are noted Check uterus is firmly contracted Assess amount of blood loss make Sure X remaining tissue - bleeding Inspect placenta & membranes for completeness Examine perineum & lower vagina for laceration ± Repair of episiotomy / laceration if indicated  Oxytocic Drug in Third Stage of Labor Syntocinon Ergometrine Syntometrine Dosage 5 or 10 units IMI 0.5 mg IMI 1 ml IMI (5 units syntocinon + 0.5 mg ergometrine) Onset _____ dorts 2-3 mins last for _____mins 27 ______ 23 mins last for _______ hrs Action Stimulate rhythmic uterine Produce sustained uterine stimulate rapid, stronger & contractions contractions sustained contraction lasting several hours hasten separation of placenta diminish blood loss Safe to be used in women with S/E: Vasoconstriction  transient S/E: Same as Ergometrine PET & cardiac disease HT, tachycardia, headache, pulmonary oedema C/I: Hypertension, cardiac disease C/I: Same as Ergometrine (WHO, 2014) Examination of Placenta Size _____________cm 15-20 in diameter, _____________cm 2 thick Weight ______________kg [ w 0. (__________________of 116 baby’s birth weight) Cord Cut end – 2 arteries, 1 vein ⑳ > arteries Tvein : blood screen Length __________________cm 50 too long : wrap neck/lord collapse ± True knot, false knot, jelly cord Short : disect Examination of Placenta Fetal surface Cord insertion Control cord fracture Central, Eccentri, Battledore (marginal), Velamentous (attached to membranes) Blood vessels - should not radiate beyond placental edge Succenturiate placenta – one/more accessory lobes Membranes 2 membranes Shiny inner Chorion – thick, opaque, friable outer Amnion – smooth, tough, translucent form a complete bag Maternal surface complete lobes (cotyledons), edge forming a uniform circle ± infarctions, calcifications Placenta Functions Descriptions I Respiration naemoglobin Oxygen from mother’s _____________________ pass into fetal blood by diffusion Nutrition gluse amino acids Nutrients e.g. ________________________are , transferred from maternal blood to fetal blood Storage Metabolize glucose, store ______________________________________ iron & fat-soluble vitamins (A , P K) , E , Excretion Carbon dioxide, bilirubin, waste products Protection Transmit maternal ______________________________ antibodies & some drugs Endocrine e.g. HCG , 0.  Laceration Classification First-degree laceration involves perineal skin & vaginal mucous membrane Second-degree laceration Involves skin, mucous membrane, fascia of perineal body Third-degree laceration Involves skin, mucous membrane & muscle of perineal body & extends to _____________________ and sphincter Fourth-degree laceration Extend to rectal mucosa & exposes lumen of rectum Copyright © MedicoApps Nursing Care during Fourth Stage of Labor Monitor Vital signs Uterus – size, consistency, fundal height, position Lochia – amount & characteristics Perineal wound – well-union without active oozing Pain level Bladder care, comfort & hygiene Emotional state, bonding, skin-to-skin contact, early breastfeeding Induction of Labor (IOL) Induction of labor stimulation of uterine contractions before spontaneous onset of labor Augmentation of labor stimulate uterine contraction that has started spontaneously but is not effective Indications for IOL post-term pregnancy PROM premature rupture of membrane chorioamnionitis complicated pregnancy e.g. PET, GDM IUGR intrauterine growth restrictionA IUD intra ultra depth Contra-indications A Placenta previa, vasa previa Floating fetal presenting part high head Cord prolapse CPD Prior uterine incision that preclude TOL Active genital herpes infection Induction of Labor Methods Cervical ripening Oxytocin Amniotomy - Artificial Rupture of Membranes (AROM)  Induction of Labor Cervical Ripening a change in cervical consistency from firm to soft Bishop Scoring S Score < _________  Unfavorable cervix Stripping / sweeping of membrane separating membranes from lower uterine segment manually  release of prostaglandin Administration of Prostaglandins e.g. Prostaglandin E2 (PGE2) per vaginal assist woman in side-lying position after insertion monitor fetal & maternal condition, onset of labor Copyright © Lippincott Williams & Wilkins Induction of Labor Oxytocin Action – stimulate rhythmic uterine contraction Administration by titration method till regular contractions occurring every _______________min, 2 3 - lasting ________________second, 40-60s strong intensity S/E Hypertonic uterine contraction, abruption placenta, uterine rupture, fetal hypoxia C/I Grand multiparity, CPD, malpresentation, scarred uterus, fetal distress, preterm infant Close monitor FHR, maternal vital signs, contractions, infusion rate Amniotomy Artificial rupturing of membranes (AROM) during labor to induce or augment labor An amnihook is inserted into vagina to puncture amniotic membrane & allow amniotic fluid to drain slowly Performed when fetal head is well-engaged Assess fetal presentation, position & station before amniotomy Monitor FHR before & immediate after amniotomy Amniotic fluid – amount, color & odor Maternal temperature Progress of labor Amniotomy Advantages Monitor FHR internally by placing a scalp electrode against fetal head Obtain fetal scalp blood sampling for pH Evaluate color & composition of amniotic fluid Disadvantages Risk for infection, ↑ if labor proceeds beyond ________________hrs 24 Risk of cord prolapse Fetal injury e.g. __________________ laceration of presenting part Variable decelerations  Instrumental Delivery Forceps-assisted Birth Vacuum-assisted Birth/Vacuum Extraction Definition Instrument with 2 curved blades to assist birth Assist the birth of fetus by applying a of fetal head vacuum cup to fetal head Indications Prolonged 2nd stage of labor, Prolonged 2nd stage of labor, fetal/maternal distress fetal/maternal distress Criteria Cervix fully dilated, presenting part engaged, Criteria similar to forceps delivery membrane ruptured, position known, no CPD, C/I: nonvertex presentation, bladder empty maternal/fetal coagulation defect Maternal Risks Perineal lacerations, genital tract injury/ Perineal lacerations & edema, infection, incontinence genital tract infection Newborn Ecchymosis/edema on face, facial laceration, Caput succedaneum, cephalohematoma, Complications caput succedaneum/cephalhemaoma, scalp lacerations, intracranial haemorrhage transient facial paralysis, cerebral haemorrhage Copyright © Lippincott Williams & Wilkins  References American College of Nurse-Midwives (2012). Second stage of labor: Pushing your baby out. Journal of Midwifery & Women’s Health, 57(1): 107-108. Ayres-de-campos, D., Spong, C. Y., Chandraharan, E., & FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. (2015). FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. International Journal of Gynecology & Obstetrics, 131(1), 13-24. Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews(7). Durham, R. F., & Chapman, L. (2023). Maternal-newborn nursing: The critical components of nursing care (4th ed.). Philadelphia: F. A. Davis Company. Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews(5). doi:10.1002/14651858.CD002006.pub4  References Ivars, J., Garabedian, C., Devos, P., Therby, D., Carlier, S., Deruelle, P., & Subtil, D. (2016). Simplified Bishop score including parity predicts successful induction of labor. European Journal of Obstetrics & Gynecology and Reproductive Biology, 203, 309-314. Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F. (2024). Maternity Women’s Health Care (13th ed.). St. Louis, MO: Elsevier Inc. Silbert-Flagg, J., & Kennedy, C. E. (2023). Maternal & child health nursing: Care of the childbearing & childrearing family (9th ed.). Philadelphia: Wolters Kluwer. Smith, C. A., Levett, K. M., Collins, C. T., Armour, M., Dahlen, H. G., & Suganuma, M. (2018). Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews(3). doi:10.1002/14651858.CD009514.pub2 World Health Organization (2018). WHO Recommendations: Intrapartum care for a positive childbirth experience. Geneva: WHO.