Labour

Original Editor - Esraa Mohamed Abdullzaher

Top Contributors - Victoria Geropoulos, Esraa Mohamed Abdullzaher, Regan Haley, Nicole Hills, Kim Jackson and Priya Gulla  

Definition of Labour[edit | edit source]

Labour is known as the process by which the products of conception are expelled from the uterine cavity after the 24th week of gestation or pregnancy.[1] Labour typically occurs between 37 and 42 weeks and can be classified into three stages.[2]

Stages of Labour[edit | edit source]

First stage[edit | edit source]

The first stage of labour begins with the onset of regular rhythmic contractions and culminates when the cervix is fully dilated to ~ 10 cm.[2] During early labour, contractions are fairly weak, occurring 15 - 20 minutes apart and lasting ~ 30 seconds in duration.[2]  Contractions begin in the fundus of the uterus and travel downwards and outwards towards the cervix.[2] This phenomenon is known as fundal dominance, whereby the contractions are strongest in the upper uterine segment and weakest in the lower uterine segment.[2]  Another phenomenon known as polarity also occurs during contractions whereby the upper uterine segment contracts while the lower uterine segment dilates to accommodate the fetus.[2] Following each contraction the uterine muscle fibres undergo retraction.[2] Instead of relaxing completely the muscle fibres remain shortened allowing for gradual progression of the fetus downward through the uterus.[2] At the same time contractions are occurring, the cervix will begin to dilate and will undergo effacement (or thinning of the uterus).[2] As the cervix dilates, the mucus plug formed during pregnancy is lost and the women might notice a bloody mucoid discharge.[2]

The first stage of labour can further be divided into 3 phases: the latent phase, the active phase and the transitional phase.

  1. Latent Phase: This phase lasts until cervical dilation is ~3-4 cm and can last upwards of 6-8 hours, if not longer.[2]
  2. Active Phase: In this phase cervical dilation occurs more rapidly, reaching a dilation of ~7 cm. In primigravida (or first time mothers) mothers dilation occurs at a rate of 1cm/hour  and in a multigravida (or a second time mother) dilation occurs at a rate of 1.5 cm/hour.[2]
  3. Transitional Phase: Cervical dilation slows down in this phase and the cervix reaches full dilation of 10 cm.[2]

Second stage[edit | edit source]

The second stage of labour begins when the cervix is fully dilated and ends when the baby is born.[2]  Stage two can be divided into two phases: the latent phase and the active phase. The average duration of stage 2 two is 50 minutes for primigravida mothers and 20 minutes for multigravida mothers.[3]

During the latent phase the mother will feel no urge to push.[2] In this phase the fetal head will continue to descend down through the uterus via the force of the uterine contractions until it is visible at the vaginal orifice.[2] During stage two contractions are longer and stronger, however are less frequent to allow the mother to recover between each contraction.[2] As the fetus is descending through the fetus it will change its position frequently to navigate the curvature of the birth canal.[2] As well, as the fetus continues to descend through the birth canal several pelvic tissues will be displaced; the bladder is pushed up into the abdominal cavity, the rectum flattens along the sacral nerve, the Levator Ani muscles are thinned out and the perineum is stretched.[2] 

Once the fetal head is visible at the vaginal orifice, the active phase of stage two begins. In this phase there is an increased pressure exerted on the rectum and pelvic floor from the fetal head.[2] This results in the initiation of the Ferguson Reflex, which provides the mother with the urge to push.[2] Women with epidurals might not feel this urge to push as strongly.[2] The women can adopt different birthing positions to increase the diameter of their pelvic outlet and allow for accommodation of the fetal head upon delivery.[2] However, this decision may be influenced by the delivery personnel and whichever position provides them with the greatest access to the baby. During pushing, women should be encouraged to avoid prolonged breath holding and excessive pushing as this can interfere with placental perfusion and compromise the fetus.[1]

The mother will typically push with her contractions. In between each contraction and push the uterus relaxes and the fetus recedes. At a certain point, the perineum will start to bulge and the baby’s head will become visible. This is termed crowning. Once the head is born, the shoulders and body follow with the next contraction.

During crowning there is intense stretching of the perineal tissue, increasing the risk of perineal trauma. Perineal tears can be classified into four degrees:[2]

  • First Degree Tear: involves the skin of the fourchette is torn only[2]
  • Second Degree Tear: involves the skin of the fourchette, the perineum and the perineal body[2]
  • Third Degree Tear: involves the skin of the fourchette, the perineum, the perineal body and the anal sphincter[2]
    • 3A: less than 50% of the external anal sphincter is torn
    • 3B: greater than 50% of the external anal sphincter is torn
    • 3C: internal anal sphincter is torn
  • Forth Degree Tear: involves the skin of the fourchette, the perineum, the perineal body, the external and internal anal sphichters and the anal epithelium.[2]

Alternatively, an episiotomy can be performed. This is a surgical incision made to the perineum to increase the diameter of the pelvic outlet. It would be the equivalence of a second degree tear.[2]

Third stage[edit | edit source]

The third stage of labour involves the delivery of the placenta and the control of bleeding to prevent a hemorrhage.[2] This stage normally lasts from 5 to 30 minutes in duration, however can sometimes take up to an hour. Separation and delivery of the placenta occurs spontaneously via contractions, however these contractions are much less painful than what is experienced in stage two.[2] Once the placenta is delivered, the goal is to control bleeding so that a haemorrhage can be prevented.[2]  Control of bleeding can occur through ligatures which involves the contraction of the oblique muscles to constrict the uterine blood vessels; through the application of pressure from the uterus to the placental site; and through blood clotting whereby the uterus will be covered with a fibrin mesh.[2] Alternatively, control of bleeding can occur through pharmacological intervention.[1] Placement of the baby onto the breast can also help to achieve placental separation and assist with control of bleeding via release of oxytocin. Following delivery the placenta is examined for completeness.[2]

Physiotherapy Management[edit | edit source]

Transcutaneous Electrical Stimulation (TENS)[edit | edit source]

TENS provides a non-pharmacological method for pain relief.[4] It has been used in clinical practice to relieve both acute and chronic pains as well as treat various conditions including dysmenorrhea and back pain.[5][6]

During labour, electrodes are typically positioned over the areas of the skin that overlie the thoracic (T10), lumbar (L1) and sacral nerve endings (S2-S4).[2][4][5][7] Accurate placement of electrodes is vital in maximizing pain relief.[2] Once turned on the TENS unit will emit low-voltage impulses.[4]The woman may operate the unit herself to control frequency and intensity of the impulses during labour.[2][4]  Typically, the application of TENS is most effective when commenced during the early stages of labour.[2][8] However, it is important to not that it may not provide sufficient pain relief for some women on its own.[2] When using the TENS unit it is important to screen the mother for any contraindications (i.e. cardiac pacemaker).

The mechanism by which TENs relieves pain is unknown, however two theories have been proposed:

  1. The Gate Control Theory:[9] Transmission of pain is inhibited by stimulation of afferent nerve fibres that carry impulses towards the CNS.[4][9]As afferent nerve fibres are stimulated, the pathway for painful stimuli is closed by the “gate” in the spinal cord that controls transmission to the brain.[4][9] TENS stimulates afferent nerve fibres which can consequently inhibit the transmission of painful stimuli from the uterus, vagina and perineum during labour.[10]
  2. Endorphin Release: TENS increases the release of endogenous opiates in the cerebrospinal fluid (endorphins and encephalins) that increase pain threshold and increase the feeling of well-being.[11][12]

Although TENS has been involved in childbirth since the 1970s,[10] its use during labour still remains inconclusive in the literature. Several systematic reviews assessing the role of TENS for pain relief during labour have stated that there is not strong evidence to support the analgesic effect of TENS during labour.[4][13][14] Some evidence states that women using TENS are less likely to rate their pain as severe, however the results among these studies are not consistent.[4] Furthermore, evidence has found that TENS has no effect on labour outcomes, including: mode of delivery, length of labour, or well-being of mothers and babies.[4] 

Despite the discrepancies in the literature, TENS is still perceived well by many women, some of which would be willing to use TENS again in a future labour.[4] Due to this debate has arisen regarding whether this satisfaction is due to the analgesic effect of the TENS itself or the sense of control it provides a woman with.[4]  Green and Baston (2003) have stated that a woman's satisfaction with the childbirth experience is affected by their sense of control during labour, specifically, control during their contractions.[15] The ability for women to operate the TENS unit by themselves during labour could therefore explain its popularity.[4]  For this reason, women should be given the choice of using TENS during labour if they think it will be helpful.[4]

Massage Therapy[edit | edit source]

Massage Therapy, which involves manipulation of the body’s soft tissue, can be performed by a physiotherapist, a midwife, or parturient’s partner. Massage therapy may be used to relax tense muscles, potentially providing pain relief during labour.[16] Additionally, given that it involves physical contact with the women, some evidence has stated that it can have a role in relaxation and emotional stress.[5][17][18]

Massage can encompass a wide variety of techniques including deep tissue massage, trigger point massage,neuromuscular massage, etc. [19][16] Different techniques may be preferred by different women. For example, massage over the lumbosacral area may be more preferred by a woman who is experiencing back pains during labour.[16] Alternatively, effleurage over the abdominal region may provide women with stress relief as soft touch and light stroking have been associated with the release of oxytocin.[16][20] No adverse effects have been noted in the literature regarding massage therapy.[16]

The proposed theories behind the mechanism by which massage therapy provides pain relief includes: improving blood flow and oxygenation of tissues, reduction of cortisol and norepinephrine levels, an increase in serotonin levels, endorphin release or via the pain gating theory.[9][16][21][22]

While a few trial studies have identified massage therapy as an effective technique to reduce the amount of pain and anxiety that is experienced during the first stage of labour,[17][21][23]more high quality evidence regarding massage therapy's role in labour is still required. This is supported by a cochrane review published by Smith and Colleagues (2018) who found very low-quality evidence regarding the analgesic effect of massage therapy during the first stage of labour and low quality evidence during the second and third stage of labour.[16]Furthermore, there was no clear effect of massage therapy over routine care during a vaginal birth or cesarean section, on the length of labour or on pharmacological pain.[16]

Thermotherapy and/or Cryotherapy[edit | edit source]

Warm compresses are used during labor with the intention to reduce perineal pain and increase comfort during labor.[24][25][26][27][28][29]Heat promotes dilation of blood vessels, increases blood flow, and interrupts the transmission of pain.[30][31][32] Dahlen and colleagues (2009) reported that women who received a warm compress during the second stage of labor were less significantly less likely to report the pain they experienced as “bad” or as the “worst pain in my life” and had a statistically significant lower mean pain score than women who received standard care.[33]  Other studies with smaller sample sizes have supported the use of warm packs.[24][25][26][34][35][36][37] Similarly, immersion in warm water has been supported in the literature to reduce labor pains (Cluett, Geissbuhler, Grodzka). When considering the use of warm compresses during the first stage of labor a review by Smith and colleagues (2018) reported that very low quality evidence exists.During the third phase of labor heat could increase a mother’s comfort, increase endorphin and oxytocin release, and potentially allow for earlier delivery of the placenta (Gangi 2013). 

Gangi and Colleagues (2013) examined the effects of simultaneous heat and cold on managing labor pains and reported that local warming with intermittent cold packs to the low back, lower abdomen and perineum can reduce labour pains during the first and second phases of labor (Gangi 2013). No adverse effects on maternal and fetal outcomes were reported (Gangi 2013). The use of ice or cold packs during labor has been supported by the works of Waters and Raisler who found a reduction in reported labor pain when ice massage was applied to the Hugo point (Waters and Raisler, Gangi 2013).

The use of heat or cold therapy provides a safe and inexpensive method for pain relief and provides mothers with an increased satisfaction with their labor experience (Dahlen 2009, Gangi 2013). As previously mentioned, the greater satisfaction could be a result of the perceived sense of empowerment and control during birth while using these modalities (Gangi 2013, Green 2003).

Accupuncture and/or Accupressure:[edit | edit source]

Acupuncture is a technique that involves the insertion of needs into different points of the body, where as acupressure involves applying pressure to different points of the body using one’s thumb or fingers (AA for induction).

The role of acupuncture for labor induction has been documented by three different studies. (Tsuei 1974; Tsuei 1977; Yip 1976) Furthermore, two other studies documented the ability for acupuncture to initiate contractions in women at term (Theobald 1973, Kubista 1975). The speculated mechanism behind acupuncture's role in labor induction is through the release of oxytocin and a increased in the parasympathetic stimulation of the uterus (Tempfeer 1998). However, a more recent systematic review conducted by Smith and Colleagues (2017) found no evidence for acupressure or acupuncture to induce labor and reduce the need for cesarean section (Smith and colleagues 2017).

When considering pain relief, Smith and Colleagues (2020) stated that acupuncture may increase a woman's satisfaction with pain relief during labor. Additionally, acupressure may also help to reduce pain during labour but not by a large amount. The use of acupressure and acupuncture may have little to no effect on assisted vaginal deliveries. This is evidence however is low in quality. More higher quality evidence is still needed when considering the use of acupuncture or acupressure during labor. 

Relaxation Techniques[edit | edit source]

Relaxation techniques aim to help women come with their labour pains by slowing down breathing, lowering blood pressure and providing a sense of wellbeing (Smith, Levett 2018). Relaxation techniques encompass guided imagery and progressive relaxation and breathing techniques (Smith, Levett 2018).

Guided Imagery involves using one’s imagination as a therapeutic tool (McCaffery 1979). During guided imagery the individual can substitute an unpleasurable or painful sensation with a pleasurable and relaxing experience to decrease intensity of the painful stimulus (Smith, Levett 2018). For example, the individual can imagine replacing pain with a comforting sensation such as heat or cold (Smith, Levett 2018).  

Progressive muscle relaxation, developed by Edmund Jacobson, involves consecutive tensing and relaxation of the different muscle groups in a toe to head direction until relaxation of the entire body is achieved (Jacobson 1938, Smith Levet 2018). Both guided imagery and progressive muscle relaxation provide an easy to learn and teach technique that is safe to the soon to be mother.

Relaxation techniques are associated with lower pain intensity during the latent phases of labour (Smith Levet 2018). However, their effect is not clear during the active phases of labour  (Smith Levet 2018). Although very low quality evidence exists, education on relaxation techniques have increased a woman's satisfaction with pain relief during labour in the literature( Smith Levet 2018).

Breathing Techniques[edit | edit source]

Breathing techniques can interrupt the transmission of pain from the uterus to the brain by decreasing sympathetic activity and emotional regulation (Busch 2012, Smith Levet 2018). Slow and deep breathing has been encouraged during labour to increase relaxation and decrease pain (Boaviagem et al., 2017, Bonn et al., 1984, Brown et al., 2013)

Examples of breathing techniques that have been assessed in the literature include soft sleep breaths performed in between contractions  (Levett 2016), blissful belly breaths performed during contractions for pain relief (Levet 2016), cleansing calming breaths to be used following contractions during the transition period of labour (Levett 2016) and gentle birth breaths to be used during the second stage of labour to encourage descent of the baby and avoid active pushing and promote protection of the pelvic floor  (Levet 2016). 

Other breathing exercises in the literature include deep diaphragmatic breathing (Yurksell et al., 2018), slowed inhalation (~ 5 sec in duration) during the first stage of labour (Boavigaem et al., 2017, Yildirim and Sahin 2004), shallow breathing during the active phases of labour ((Yildirim and Sahin 2004), pursed lip breathing during contractions (Boavigaem et al., 2017), and the “pant-blow” technique during pushing in the second stage of labour (Yildirim and Sahin 2004).

Boaviagem and colleagues (2017) demonstrated that the use of various breathing techniques (i.e. slow deep breathing, pursed lip breathing, post-exhalation pause) in isolation had no effect on anxiety, pain, fatigue and maternal satisfaction compared to routine care (Boaviagem 2017) . However, several studies have reported that breathing exercises in combination with other techniques (i.e. massage, relaxation techniques) are effective in reducing the perception of pain by women during labour (Yildrim and Sahin, 2010, Bahadoran 2010, Levett et al., 2016). This literature stresses the importance of a multifactorial approach in labor pain management. Breathing may provide an effective strategy for pain relief in combination with other techniques (i.e guided imagery, massage, relaxation) (Boaviagem 2017)

Perineal Massage[edit | edit source]

Perineal massage provides a method to gently stretch the pelvic floor in preparation for birth. A cochrane review written by Aasheim and colleagues (2017) states that there is moderate quality evidence in favor of perineal massage to reduce the incidence of third and fourth degree perineal tears while performed during the second stage of labour (Aasheim 2017). Additionally there is also some evidence to support the idea that perineal massage is associated with an increased number of women with an intact perineum (Aasheim 2017). Aasheim and colleagues (2017) has also reported that the use of warm compresses over the perineum can reduce the incidence of third and fourth degree perineal tears during labour (Aasheim and Colleagues).

Other studies have assessed the use of perineal massage during pregnancy as a protective measure against perineal trauma.  Specifically perineal massage during the last month of pregnancy can enable the perineal tissue to expand more easily during birth (Beckmann and Garett). Through appropriate education from a pelvic floor physiotherapist, perineal massage can be performed by the woman or her partner for 10 minutes, as little as once or twice a week starting from 35 weeks (Beckmann and Garrett). A review by Beckmann and Garrett (2006) reported that antenatal perineal massage was associated with an overall reduction in the incidence of perineal trauma requiring suturing, as well as incidence of episiotomies (Beckmann and Garret 2006). However, no benefits have reported regarding the incidence of first/second and third/fourth degree tears (Beckmann and Garrett 2006). Antenatal perineal massage is generally well-received by most women (Labrecque 2001, Beckmann and Garrett), however some women may find that the massage can be uncomfortable during the first few weeks and may even produce a burning sensation. Additionally, newer techniques of perineal massage involve the use of a massaging device, however more research is still needed regarding its effectiveness.

Positioning[edit | edit source]

The position a woman adopts during labor varies depending on which stage of birth they are in, whether they have received epidural anaesthesia, and the risks and benefits that are associated with each position.

Birthing positions can be divided into two different categories: vertical or upright positions and horizontal or recumbent/semi-recumbent positions (Huang 2019):

Vertical/ Upright positions:

  • Squatting: supported by partner or prop; squatting
  • Kneeling: mother is kneeling with their trunk upright or palms resting on the ground/cushion
  • Sitting: the mother can sit on a bed or chair with their trunk leaning forward at a 45 degree angle

Horizontal/ Recumbent and semi-recumbent positions:

  • Supine position: Lying on back or with her trunk slightly raised (< 45 degrees from horizontal)
  • Lithotomy Position: lying flat on back with legs raised in stirrups
  • Lateral Position: lying on side with upper leg close to the chest

The use of upright postures during the second stage of labour has been debated in the literature. Being in an upright posture during labour allows for the effects of gravity, promotes better alignment of the fetus through the birth canal, increases strength of the uterine contractions, reduces incidence of aortocaval compression (or compression of the inferior vena cava by the uterus when a pregnant women in lying in supine position) and increase the diameter of the pelvic outlet in the squatting and kneeling positions (Rosser 2003 and the Gupta Cochrane review). Despite these benefits, a semi-recumbent position is commonly used as it provides caregivers with increased access to the baby during birth, as well, most caregivers are trained to deliver babies using this position (Gupta 2017).

When comparing the risks and benefits of each position, Huang and colleagues (2019) concluded that upright and lateral positions provide more benefits to mother and her baby during labour. Lateral positions are associated with fewer perineal tears. Upright positions are  associated with less labor pain, shorter durations of the second stage of labour and fewer episiotomies. However, whenever using the squatting and sitting position caregivers should be aware of the increased risk of perineal trauma. Huang and colleagues (2019) suggested that supine and lithotomy positions should be avoided, unless preferred by the mother, as they increase the risk for severe perineal trauma, longer labor, and greater labor pain (Huang 2019).

During the first stage of labour women are encouraged to adopt a forward leaning posture. A forward lean posture can facilitate the fetal head into a more favorable position for passage through the birth canal. Furthermore, the forces of gravity associated with this position can help lead to the ferguson reflex which provides mother’s with the urge to push in the second stage of labour (Cite Txtbook)

A review by Gupta and Colleagues (2017) stated upright positions were associated with a reduced duration of the second stage of labour, a reduction in assisted deliveries, a reduction in episiotomies and lower risk for abnormal fetal heart rate in women who did not receive epidural (Gupta 2017). However, there was a noted increase in blood loss greater than 500 ml and second degree perineal tears (Gupta 2017). These findings were supported by Deliktas and Kuulu who reported a decrease in forcep-assisted births, a decrease in the incidence in episiotomies and increased risk of postpartum blood loss (Deliktas and kukulu).

A review by Walker and Colleagues (2018) reported little to no difference between upright and supine positions on rates of cesarean sections, assisted birth or length of the second stage of labour in women who had received epidural during labor. There was also no difference in the number of perineal tears and the amount of excessive bleeding following labour. This review also stated that women were slightly more satisfied with lying down positions.

Despite these findings, more research is still needed to confidently recommend which birthing position is most favorable. Women should be encouraged to give birth in whichever position feels most comfortable (Gupta 2017). 

For more detail on the the different positions, visit the review by huang and colleagues (2016).

Education:[edit | edit source]

Approximately 90% of the stress and anxiety women experience during pregnancy is related to the process of childbirth and the lack of knowledge of childbirth and it’s risks (Hosseininasab 2010, Firouzbakht 2015). Furthermore, anxieties and expectations can be moulded by the mother’s personal experiences, her culture and societal views (Neuhaus 1994, Chalmers 1995, Ringler 1986, Short 1997). Fear and anxiety can increase muscle tension, further increasing the perception of pain during labor (Dick-read 2004). Furthermore, fear and anxiety can have consequences on the baby, potentially leading to preterm birth, low fetal birth rate and fetal hypoxia (Mehdizadeh 2005). Physiotherapists, along with other health care professionals can play a vital role in educating new mothers prenatally, antenatally (during pregnancy) and postnatally about what they can expect to avoid these fears and anxieties.

The goal of antenatal education is to provide support and reassurance during pregnancy and to assess and treat any problems that arise during pregnancy (Atteeq 2015). Education should include information about postpartum care, newborn care, breastfeeding, intercourse during pregnancy,  signs of complications and appropriate steps to take  (Atteeq 2015).. Education during pregnancy provides an opportunity for pregnant women to discuss any concerns they have with a healthcare professional (Atteeq 2015).Furthermore education allows healthcare professionals to empower women during their pregnancy to develop their own unique set of coping strategies (Escott 2009). It is important to provide women with this opportunity as satisfaction with childbirth is linked to a women’s sense of self-agency and their participation in the decision making of their pregnancy (Hodnett 2002; Hollins Martin 2013; Hotelling 2013; Howarth 2010 and green 2003)).

Although further research regarding antenatal education is still needed, studies have reported benefits of education to reduce fear and anxiety during pregnancy (Hosseininasab 2010, Firouzbakht 2015, Ferguson 2012 ), increase a mother's self-confidence (Hosseininasab 2010,Firouzbakht 2015), increased satisfaction with pregnancy (Miquelutti 2013), less false labour admissions (Ferguson 2012) and more partner involvement (Ferguson 2012)

For physiotherapists, this might include education about:

  • Physical changes that will occur to a women’s body during their pregnancy
  • Information on how women can remain active during pregnancy
  • Education on appropriate body mechanics for lifting and bed mobility during pregnancy and postpartum
  • Physical changes that occur during the postpartum period.
  • Pain education and prevention of pain catastrophization
  • Pelvic floor education
  • Relaxation strategies
  • pelvic floor education 

For more specific regarding the antenatal education that can be provided, consult physiopedia pages Cesarean Section, DRA, Physical changes during pregnancy, physical activity during pregnancy.

See also[edit | edit source]

Physical Activity and Pregnancy

Transcutaneous Electrical Nerve Stimulation (TENS)

Preconceptual care

Rebound Therapy

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Stuart PO. Tidy’s physiotherapy. Elseivier Limited, London. 2008.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 2.38 Stables D, Rankin J. Physiology in childbearing: With anatomy and related biosciences. Elsevier Health Sciences; 2010 Apr 19.
  3. ↑ Stephenson RG, O'Connor LJ. Obstetric and gynecologic care in physical therapy. Slack Incorporated; 2000.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour.
  5. ↑ 5.0 5.1 5.2 Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. Journal of Midwifery & Women’s Health. 2004;49(6):489–504.
  6. ↑ Samanta A, Beardsley J. Low back pain: which is the best way forward?. Bmj. 1999 Apr 24;318(7191):1122-3.
  7. ↑ Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. Journal of Midwifery & Women’s Health. 2004;49(6):489–504
  8. ↑ Santana LS, Gallo RB, Ferreira CH, Duarte G, Quintana SM, Marcolin AC. Transcutaneous electrical nerve stimulation (TENS) reduces pain and postpones the need for pharmacological analgesia during labour: a randomised trial. Journal of physiotherapy. 2016 Jan 1;62(1):29-34.
  9. ↑ 9.0 9.1 9.2 9.3 Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov 19;150(3699):971-9.
  10. ↑ 10.0 10.1 Augustinsson LE, Bohlin P, Bundsen P, Carlsson CA, Forssman L, Sjöberg P, Tyreman NO. Pain relief during delivery by transcutaneous electrical nerve stimulation. Pain. 1977 Oct 1;4:59-65.
  11. ↑ Bortoluzzi GA. Transcutaneous electrical nerve stimulation in labour: practicality and effectiveness in a public hospital labour ward. Australian Journal of Physiotherapy. 1989 Jan 1;35(2):81-7.
  12. ↑ Salar G, Job I, Mingrino S, Bosio A, Trabucchi M. Effect of transcutaneous electrotherapy on CSF beta-endorphin content in patients without pain problems. Pain. 1981 Apr;10(2):169-72.
  13. ↑ Carroll D, Tramèr M, McQuay H, Nye B, Moore A. Transcutaneous electrical nerve stimulation in labour pain: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 1997 Feb;104(2):169-75.
  14. ↑ Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane database of systematic reviews. 2012(3).
  15. ↑ Green JM, Baston HA. Feeling in control during labor: concepts, correlates, and consequences. Birth. 2003 Dec;30(4):235-47.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 16.7 Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database of Systematic Reviews. 2018(3).
  17. ↑ 17.0 17.1 Kimber L, McNabb M, Mc Court C, Haines A, Brocklehurst P. Massage or music for pain relief in labour: A pilot randomised placebo controlled trial. European Journal of pain. 2008 Nov;12(8):961-9.
  18. ↑ Field T. Pregnancy and labor massage. Expert Review of Obstetrics & Gynecology 2010;5(2):177‐81. [DOI: 10.1586/eog.10.12]
  19. ↑ Rich GJ. Massage Therapy: The Evidence for Practice. 1st Edition. Philidelphia: Elsevier, 2002.
  20. ↑ Uvnäs-Moberg K, Handlin L, Petersson M. Self-soothing behaviors with particular reference to oxytocin release induced by non-noxious sensory stimulation. Frontiers in psychology. 2015 Jan 12;5:1529.
  21. ↑ 21.0 21.1 Field T, Hemandez-Reif M, Taylor S, Quintino O, Burman I. Labor pain is reduced by massage therapy. Journal of Psychosomatic Obstetrics & Gynecology. 1997 Jan 1;18(4):286-91.
  22. ↑ Mc Nabb MT, Kimber L, Haines A, McCourt C. Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth?—A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth. Complementary Therapies in Clinical Practice. 2006 Aug 1;12(3):222-31.
  23. ↑ Chang MY, Wang SY, Chen CH. Effects of massage on pain and anxiety during labour: a randomized controlled trial in Taiwan. Journal of advanced nursing. 2002 Apr;38(1):68-73.
  24. ↑ 24.0 24.1 Schrag K. Maintenance of pelvic floor integrity during childbirth. Journal of nurse-midwifery. 1979 Nov 1;24(6):26-31.
  25. ↑ 25.0 25.1 Balaskas J. Active Birth. Unwin Hyman, London.1983.
  26. ↑ 26.0 26.1 Kitzinger S, Simkin P. Episiotomy and Second Stage of Labour. Penny Press, Seattle. 1984. 
  27. ↑ Albers LL, Anderson D, Cragin L, Daniels SM, Hunter C, Sedler KD, Teaf D. Factors related to perineal trauma in childbirth. Journal of nurse-midwifery. 1996 Jul 1;41(4):269-76.
  28. ↑ Hobbs L. The best labour possible?. Books for Midwives Pr; 2001 Apr 17.
  29. ↑ Sanders J, Peters TJ, Campbell R. Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice. Midwifery. 2005 Jun 1;21(2):154-60.
  30. ↑ Porth C. Pathophysiology: Concepts of altered health states. Lippincott Williams & Wilkins; 2005.
  31. ↑ Hayes KW. Manual of Physical Agents. Prentice-Hall, Upper Saddle River. 2000.
  32. ↑ Fritz S. Mosby's Fundamentals of Therapeutic Massage. Mosby Lifeline, St. Louis. 1995.
  33. ↑ Dahlen HG, Homer CS, Cooke M, Upton AM, Nunn RA, Brodrick BS. ‘Soothing the ring of fire’: Australian women's and midwives’ experiences of using perineal warm packs in the second stage of labour. Midwifery. 2009 Apr 1;25(2):e39-48.
  34. ↑ Sanders J, Peters TJ, Campbell R. Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice. Midwifery. 2005 Jun 1;21(2):154-60.
  35. ↑ Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial. Journal of midwifery & women's health. 2005 Sep 10;50(5):365-72.
  36. ↑ Albers LL, Anderson D, Cragin L, Daniels SM, Hunter C, Sedler KD, Teaf D. Factors related to perineal trauma in childbirth. Journal of nurse-midwifery. 1996 Jul 1;41(4):269-76.
  37. ↑ Musgrove H. Perineal preservation and heat application during the second stage of labor. Midwifery Today E-News. 1999;1(33).
Retrieved from "https://www.physio-pedia.com/index.php?title=Labour&oldid=241257"