I N F OCUS

JOGNN
A Practical Approach to Labor Support
Ellise D. Adams1 and Ann L. Bianchi2

Correspondence ABSTRACT
Ellise D. Adams, CNM, MSN,
CD (DONA), ICCE, College In the United States, intrapartum nurses are present at 99% of births. These nurses have a unique opportunity to
of Nursing, The University of positively affect a laboring woman’s comfort and labor progress through the use of labor support behaviors. These
Alabama in Huntsville, nonpharmacologic nursing strategies fall into four categories: physical, emotional, instructional/informational, and
337 Nursing Building, advocacy. Implementation of these strategies requires special knowledge and a commitment to the enhanced
Huntsville, AL 35899.
ellise.adams@uah.edu physical and emotional comfort of laboring women.
JOGNN, 37, 106-115; 2008. DOI: 10.1111/J.1552-6909.2007.00213.x
Keywords
Birth
Intrapartum care
Intrapartum nurse
Labor positions
Labor support Accepted May 2007

1CNM, MSN, CD (DONA),

ICCE, is a clinical assistant

professor in the College of
Nursing, The University of
Alabama in Huntsville
2RN, MSN, ICCE, ICD, is a
clinical assistant professor in
the College of Nursing, The
University of Alabama in
Huntsville
Q uality nursing care for laboring women combines a
variety of skills and behaviors to ensure a positive
birth experience. Labor support behaviors (LSB) by
nurses provide nonpharmacologic pain relief and support
to laboring women. Sauls (2004) defined labor support as
the “intentional human interaction between the intrapar-
tum nurse and the laboring woman that assists the client
to cope in a positive manner during the process of giving
birth” (p. 125). Association of Women’s Health, Obstetric
and Neonatal Nurses’ (AWHONN, 2000a) Clinical Position
Statement on this topic stated that “continuously available
labor support by a professional registered nurse is a criti-
cal component to achieve improved birth outcomes.” This
article offers instruction for many supportive behaviors
the intrapartum nurse can implement with laboring
women. Antepartum nurses and childbirth educators may
also utilize LSB in preparing clients for labor.
Types of Labor Support
Nurse researchers have categorized labor support in
a variety of ways. Bianchi and Adams (2004), Gagnon
and Waghorn (1996), McNiven, Hodnett, and O’Brien-
Pallas (1992), and Gale, Fothergill-Bourbonnais, and
Chamberlain (2001) grouped supportive care into four
areas: physical comfort, emotional support, instructional/
informational, and advocacy. Miltner (2002) identified the
first three categories of nursing support as including en-
couragement, positioning, application of heat and cold,
massage, instructions for relaxation and breathing, infor-
mation regarding labor progress, and negotiating with
the health care team. Hodnett (1996) identified five types:
emotional support, comfort measures, informational/
advice, advocacy, and supporting the husband/partner.
Sauls (2006) identified professional labor support as
having six dimensions: tangible support; advocacy;
emotional support—reassurance; emotional support—
creating control, security, and comfort; emotional sup-
port—nursing caring behaviors; and informational
support. Hottenstein (2005), based on Watson’s Theory
of Human Caring, named care modalities as auditory, vi-
sual, olfactory, tactile, kinesthetic, and caring conscious-
ness. For this review, the four categories on which several
research teams agreed were used: physical, emotional,
instructional/informational, and advocacy. Supportive
care to the laboring woman’s partner is also described
because partners may need assistance in order to sup-
port the laboring woman (Wood & Carr, 2003).
Choosing LSB
Intrapartum nurses use their assessment skills to choose
appropriate LSB for their patients’ varying needs.
Nurses may choose a combination of supportive behav-
iors. For example, when assisting women to change po-
sitions (physical LSB), the nurse conveys respect by
providing privacy and protecting modesty (advocacy
LSB). A single LSB may also fall into more than one cat-
egory. Bryanton, Fraser-Davey, and Sullivan (1994)
noted that praise and encouragement overlap both the
emotional and the informational categories.
Physical LSB
Physical support and comfort enhance labor progress
and increase satisfaction with the birth experience

106 © 2008, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org
Adams, E. D., and Bianchi, A. L.
(Hodnett, Gates, Hofmeyr, & Sakala, 2003; Manogin,
Bechtel, & Rami, 2000). A variety of LSB are listed in
Table 1.
Environmental Control
Environmental control creates a comforting atmo-
sphere. Adjusting room temperature and lighting while
decreasing distracting noises contributes to physical
comfort. Therapeutic use of music can have a calming
effect. Music activates the right brain and can effec-
tively mediate pain (Chang & Chen, 2004; Phumdoung
& Good, 2003). Music selection is based on what the
woman finds relaxing and comforting. Phumdoung and
Good found that soft music without lyrics during the ac-
tive phase of labor significantly decreased the sensa-
tion and distress of pain. Antepartum nurses and
childbirth educators can encourage women to bring
music of their choice.
Positioning
Proper positioning in labor and birth can reduce pain,
analgesia use, and perineal trauma and enable more
effective uterine contractions (Mayberry et al., 2000).
The optimal position is determined by assessment of
the woman, her phase of labor, fetal position, and the
woman’s desires. Although only a few positions such as
Sim’s, sitting, and squatting have been supported by
research to show a positive effect on client outcomes,
the positions mentioned in this article have been re-
ported by laboring women and nurses to provide satis-
faction during labor and birth.
Sitting. Sitting positions during labor assist the natural
force of gravity to encourage fetal descent, improve the
quality and effectiveness of labor contractions, and de-
crease pain (Gilder, Mayberry, Gennaro, & Clemmens,
2002). Upright positions include sitting in a rocking
chair, on a birth ball, or on the toilet.
Towel Pull. The towel pull technique encourages
effective pushing when used in upright positions by
involving abdominal muscles in expulsive efforts. As
contraction begins, the woman leans forward and pulls
on one end of the towel, while the nurse or partner pro-
vides resistance. As the woman pulls the towel, abdomi-
nal muscles naturally contract, providing external
pressure on the uterus.
Sims’ Position for Comfort. The Sims’ position helps
avoid pressure on the sacrum, is gravity neutral, is rest-
ful, and provides comfort. If there are no complications
with fetal heart rate or maternal blood pressure, the la-
boring woman may choose the side that is most com-
fortable. Instruct the woman to lie on her hip and place
a pillow between the knees to decrease strain on the
back. Place a pillow against her back and one under
her upper arm for extra support.
JOGNN 2008; Vol. 37, Issue 1
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Proper positioning in labor and birth can reduce pain, analgesia use,
and perineal trauma and enable more effective uterine contractions.
Sims’ Position to Slow Fetal Descent or Facilitate
Rotation. Sims’ positions can help to slow down fetal
descent, allowing control over pushing efforts and pre-
venting perineal lacerations (Albers, 2003; Simkin &
Bolding, 2004). It can also facilitate anterior rotation of a
fetus (Ridley, 2007). This can be accomplished by in-
structing the woman to lie on the side of the fetal spine.
For example, if the fetus is in right occiput posterior po-
sition, the woman lies on her right side. Gravity pulls the
fetal occiput and trunk to the right occiput transverse
position and eventually to right occiput anterior. Wedge
a pillow between the woman’s back and bed, and place
a pillow under the abdomen for support (Adams &
Bianchi, 2006). Once the fetus is in proper alignment for
descent, encourage an upright sitting position.
Lunge. The lunge is used during labor to decrease
back pain and facilitate rotation of a fetus in the occiput
posterior position (Simkin, 2002). If the fetus is in the left
occiput posterior position, instruct the woman to place
her left foot on the chair while turning the left leg outward.
The femur acts as a lever at the hip joint, prying the is-
chium outward creating more space for rotation or cor-
rection of asynclitism. While supporting the woman,
instruct her to lean into the foot on the chair. Hold the
lunge for 3 seconds, then return to upright. Repeat this
motion three to five times during each contraction for sev-
eral successive contractions (Adams & Bianchi, 2005).
Dangle. The dangle position assists fetal descent by
reducing external pressure on the sacrum or hips
(Simkin & Ancheta, 2005). The nurse or partner stands
behind the woman, using a wide base of support, and
places the arms under the woman’s axillae. When con-
traction begins, the woman flexes her knees and drops
her weight to dangle. The nurse or partner supports the
weight of the woman during the contraction.
Squatting. Squatting increases the diameter of the pel-
vis, facilitating rotation and fetal descent (AWHONN,
2000). Women who squatted experienced less pain,
less genital tract trauma, and shorter second stage
(Albers, 2003; Mayberry, Gennaro, Strange, Williams, &
De, 1999; Soong & Barnes, 2005). A squatting bar can
be attached to the bed to help stabilize and provide bal-
ance. As contraction begins, instruct the laboring woman
to hold onto the bar for support. Feet should be hip dis-
tance apart and remain flat. If the woman is too fatigued
to support her weight, kneeling can be encouraged. The
towel pull can also be used to achieve the same benefit.
For the woman with epidural analgesia, a modified squat
may be achieved by having the woman sit on a birthing
bed with the foot of the bed in the lowest position.
107
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Table 1: Physical Labor Support

Specific Category Specific Behaviors

Environmental control Control room temperature; control noise; dim lights; control odors; arrange personal items
Positioning, first stage of labor Standing; ambulation; abdominal lift; slow dancing; leaning; knee-chest; hand and knees; pelvic rocking; lunge; sitting;
dangle; squatting; semi-Fowler’s; Sims’ position
Positioning, second stage of labor Knee-chest; hands and knees; squatting; Semi-Fowler’s; Sims’ position
Touch Massage; pressure
Application of cold and heat Use of ice packs; use of cool washcloths; use of hot packs; use of warm blankets
Hygiene Provide bath or shower prn; mouth care; perineal care; change bed linens; change gown
Hydrotherapy Use of shower; use of tub
Urinary elimination Promote frequent emptying of bladder; encourage ambulation to bathroom
Nourishment Provide ice chips; provide popsicles
Partner care Respite; nutrition; physical comfort; environmental control

Touch both knees with the hands. As contraction begins, the

Touch conveys an attitude of caring and encourages
comfort, but a pat on the hand or shoulder may be ac-
ceptable to some but not to others. Nurses must con-
sider the client’s personal space and cultural background
when determining appropriate touch during labor.
nurse uses entire body weight to lean in and apply pres-
sure against knees. The knee press can be used when
the woman is in a lateral position. The nurse presses the
upper knee toward her back, while the partner applies
pressure over sacrum (Simkin & Ancheta, 2005).

Massage, a form of touch, relaxes muscles and in-
creases blood flow (Brown, Douglas, & Flood, 2001)
and enhances the release of endorphins, promoting
comfort while decreasing pain (Simkin & Bolding, 2004).
Brown et al. found that clients who used pain medica-
tion also found the use of massage and acupressure to
be more effective than other nonpharmacologic meth-
ods of pain relief. Further investigation is needed to
determine whether massage alone directly decreases
pain during labor.
Ho-Ku Point Pressure. The Ho-Ku point is an acupres-
sure point which when stimulated can increase fre-
quency of contractions without increasing pain. The
point is located where the bones of the index finger and
thumb join (web of the hand). Apply pressure for 10 to
60 seconds and repeat six times (Simkin, 1997).
Double Hip Squeeze. The double hip squeeze changes
the shape of the pelvis and releases tension on the sac-
roiliac joints. Position the woman on her hands and
knees or have her lean over the bed. Standing behind
the woman, locate iliac crest and gluteal muscle. Place
hands on each side below iliac crest and over gluteal
muscle with fingers pointing toward midline. Apply pres-
sure by simultaneously pushing hands toward sacrum
throughout the contraction (Simkin & Ancheta, 2005).
Application of Cold and Heat
Pain perception is lowered and muscle spasms de-
crease when cold and heat are applied to different ar-
eas of the body. Temperature of the source should be
monitored to protect the woman’s skin from injury. Cold
compresses numb an area, slowing transmission of
pain and other impulses over sensory neurons, and last
longer than heat. If the woman is experiencing intense
pain in the lower back, an ice pack placed directly over
the sacral area can be helpful. Cold application to the
forehead and neck can also provide relief.
Heat application raises the pain threshold, increases
circulation, and relaxes muscles. A heat pack can be
placed over the lower back, groin, or thighs. Warm wa-
ter immersion increases relaxation (Benfield, Herman,
Katz, Wilson, & Davis, 2001) and promotes labor prog-
ress (Simkin & Bolding, 2004). Further investigation is
needed to determine whether other forms of cold and
heat application decrease pain during labor.
Partner Care
Physical labor support can be exhausting for the part-
ner. To maintain the partner’s energy, nurses can offer
respite time and encourage nutritional intake. Making
the environment comfortable by offering a pillow or
blanket is also helpful.

Knee Press. Pressure on the knees pushes the femurs

toward the hips to relieve strain on sacroiliac joints. Po-
sition the woman in a chair with knees a few inches
apart and feet flat on the floor. The nurse faces the
woman and locks elbows into his or her sides, cupping
Emotional LSB
Emotional LSB provide the client with a sense of emo-
tional comfort (see Table 2). Lazarus and Folkman

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Adams, E. D., and Bianchi, A. L. I N F OCUS

(1984) defined emotional support as contributing to the

feeling of being loved or cared about and includes at-
tachment, reassurance, and the ability to rely on and
confide in a person. These LSB assist to occupy the cli-
ent’s mind with positive thoughts and diminish or block
feelings of fear, dread, and anxiety. Sauls (2004) defined
emotional support in labor as the ability to subjectively
participate and share in the laboring client’s feelings.
Nursing Presence
Jackson (2004) defined nursing presence as being with
the client rather than performing tasks on the client and as
complete physical, emotional, psychological, and spiri-
tual engagement between nurse and client. MacKinnon,
McIntyre, and Quance (2005) identified physical pres-
ence, developing a trusting relationship and emotional
presence as essential components of nursing presence.
Nursing presence includes portraying a high level of
nursing skill; being open, honest, and nonjudgmental with
the client; listening intently to her needs and concerns;
understanding the privilege of being part of the client’s
life; and the client’s perception of the meaningfulness of
the relationship with the nurse (Hunter, 2002; Jackson).
The optimum staffing for labor and delivery units is one
nurse to one client. Although most unit staffing matrices
will not allow for continuous presence, choosing when
to be at the bedside, demonstrating a caring, effective
attitude, and being fully present when in the room are
important. Nursing tasks can be clustered to provide
longer periods of physical and emotional presence.
Distraction includes providing laboring women with specific activities
so that conscious thoughts and anxieties are reduced.
maternal satisfaction with the birth process was not re-
lated to relief of pain but more closely related to the atti-
tudes and behaviors of caregivers. Communicating
caring, competence, and advocacy early in the nurse-
client relationship fosters the development of a trusting
relationship through which emotional and physical
needs can be met.
Distraction
Focal Point. Distraction includes providing laboring
women with specific activities so that conscious thoughts
and anxieties are reduced. During the contraction, the
focal point assists the laboring woman to tune out painful
stimuli by focusing on visual stimuli. When using an in-
ternal focal point such as a thought or visual image, the
woman closes her eyes and uses mental images to pro-
vide distraction from the pain of labor.
Guided Imagery. The effectiveness of guided imagery
has not been reported within the nursing literature; how-
ever, the usefulness in clinical practice has been fre-
quently reported (Jacobson, 2006). This technique uses
the mind to create a pleasant image and enhance relax-
ation in early labor. It is important to keep the environ-
ment free of distractions and the client comfortable. Use
a script meaningful to the client. Make a suggestion to
picture a scene and engage each of her senses to ex-
perience the scene. See Table 3.

Effective Caring Attitude Spirituality

Nurse theorist Leininger (2001) called caring the es-
sence of nursing. In Bowers’ (2002) review of 17 studies
of perceived labor support, clients described a caring
nurse as calm, warm, and open. Supportive nurses
bestowed praise and encouragement upon the client,
were concerned, respectful, and competent, and pro-
vided a constant presence. Hodnett (2002) found that
The laboring woman’s spirituality or faith may serve as a
source of inner strength and comfort during labor (Breen,
Price, & Lake, 2006). To provide effective spiritual care,
the nurse must attend to the client’s spiritual well-being
and detect and address spiritual distress (Jackson,
2004). Questions such as “Tell me about your sources of
inner strength” or “In what ways can I assist you to rely on

Table 2: Emotional Labor Support

Specific Category Type of Behavior Specific Behaviors

Distraction Visual focal point; guided imagery; visualization; hypnosis; encourage client rituals; engage in social
conversation
Effective caring attitude Verbal expression Affirming words or phrases; soft tone; calm voice; confident voice; encouraging words; reassuring praise
Nonverbal expression Undivided attention; eye contact; flexible, noninterfering, unobtrusive care; pleasant facial expression
Nursing presence Physical presence; emotional presence; cluster tasks; establish trusting relationship early; convey
expertise
Therapeutic use of humor Assist client to focus on the comic elements of labor; ensure humor is used appropriately
Refocusing Simkin’s (2002) take charge routine; reframe negative thoughts into positive
Spirituality Acknowledge spirituality; prayer; meditation; chanting; quoting scripture
Partner care Encouragement; praise; reassurance; presence

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Table 3: Supportive Distraction Through Guided Imagery: Beach Scene

Preparation Assist the client to a comfortable position; remove distractions from the room; ask the client to close her eyes and practice
abdominal breathing.
Read this script in a calm, “You have arrived at the beach. It is early in the day and there are no people in sight. You are alone. With your eyes closed,
quiet voice raise your head toward the sun. Feel how warm the sun feels against your skin.
You slowly move toward the edge of the sand. With bare feet you feel the sand and it is soft and warm against your toes.
You stand for a moment, to experience your surroundings. The day is fair and bright. There is a light, warm breeze that moves
in little swirls around your body. It moves your hair and you feel free.
You can smell the seashore and you hear the seagulls a short distance away.
Listen to the gentle waves as they move along the edge of the sand. You can see them roll in and out. There is a rhythm to the
waves and it matches your breathing.
You move closer and feel the coolness of the water around your legs. As you float in the coolness of the water, match your
breathing with the waves and let it relax you.
You are totally relaxed. The sun rays feel warm upon your face. The water is refreshing and you feel peaceful.”

your faith?” are useful in assessing the client’s reliance
upon this source of strength. Nurses also must critically
assess their own comfort with providing spiritual care. If
a spiritual need is identified that the assigned nurse is
unable to meet, a reassignment may be necessary.
Labor support behaviors that incorporate spirituality in-
clude prayer, meditation, chanting, reading or reciting
from scriptures, and the use of rituals or sacraments.
Prayer or meditation can be facilitated by a quiet and
respectful environment. Nurses can read scripture or
prayers on request of the client. Spiritual rituals or sac-
raments are typically administered by clergy.
Partner Care
Nurses must be aware of the emotional status of the la-
boring woman’s partner and provide the partner with
encouragement, praise, reassurance, and nursing pres-
ence. Relieving the emotional stress of the partner can
in turn alleviate maternal stress.
birth experience for all (see Table 4). Effective verbal
and nonverbal communication is vital when delivering
instructional and informational support to clients. Verbal
and nonverbal communication is delivered simultane-
ously, and the message is stronger when these are con-
gruent (Adams & Bianchi, 2005). Verbal communication
must be culturally sensitive, taking into consideration
how instruction or information is understood by the
woman. When an interpreter is used, the nurse should
face the woman and direct questions to her instead of
the interpreter (Trivasse, 2006).
Instruction for Relaxation
The ideal time to provide instruction for relaxation is
prior to labor. At the time of labor admission, the intra-
partum nurse should assess knowledge and comfort
with relaxation techniques. When instructions are
provided during labor, a demonstration may be neces-
sary. Instruction presented to the laboring woman
should also be directed to the partner. The nurse can
encourage relaxation by offering instructions on pro-

Instructional/Informational LSB gressive relaxation and touch relaxation (see Table 5).

Instruction and information on all aspects of labor and Instruction for Breathing
birth provide clients with an opportunity to be a part of Breathing patterns are a learned technique of controlling
the decision-making process, which fosters a positive the depth and rate of respiration to match the intensity

Table 4: Instructional/Informational Labor Support

Specific Category Type of Behavior Specific Behaviors

Effective communication Verbal Reflecting; reframing; choosing appropriate words and phrases; choosing culturally sensitive words;
techniques using interpreter
Nonverbal Gestures; body language; eye contact; culturally sensitive behaviors
Instructional Breathing patterns Cleansing breath; abdominal breathing; patterned breathing; breathing levels
Relaxation techniques Progressive; physiological; passive; touch; selective relaxation
Pushing techniques Open glottis; closed glottis
Informational Routines Familiarize with surroundings; plan of care; interpret medical jargon; labor and birth process
Procedures Nonpharmacologic pain relief; pharmacologic pain relief; routine hospital procedures; electronic fetal
monitoring
Partner care Explain procedures; update on client progress; role model support behaviors

110 JOGNN, 37, 106-115; 2008. DOI: 10.1111/j.1552-6909.2007.00213.x http://jognn.awhonn.org

Adams, E. D., and Bianchi, A. L. I N F OCUS

Table 5: Instructions for Relaxation

Type Purpose Instructions

Progressive relaxation Allows the woman to differentiate between
tense muscles and relaxed muscles.
Once this distinction is made, the
woman will be more aware of tension
and able to consciously relax muscles.
Touch relaxation Touch brings awareness of tense muscles
and signals the woman to release
tension. Touch can be applied to the
forehead, back of neck, shoulders,
arms, hands, back, legs, or feet.
Instruct laboring woman
1. Progressively contract each of the following sets of muscle groups beginning with
face and neck; shoulders, arms, and hands; chest, back, and buttocks; ending
with the legs, feet, and toes.
2. Become aware of how it feels when all muscle groups are contracted.
3. Progressively release tension in each muscle group in reverse order: toes, feet,
and legs; buttocks, back, and chest; hands, arms, and shoulders; neck and face.
4. Pay attention to how it feels when all muscle groups are relaxed.
Nursing actions
1. Determine whether woman prefers a light touch or a firm touch.
2. Place hand flat over the muscle group or if possible, wrap hand around the
muscle.
3. Apply a light touch or firm touch over muscle.
4. Instruct the woman to release tension into the touch.
5. Continue to apply touch until the muscle is relaxed.

of the contraction. Breathing awareness and use of dif-
ferent breathing levels can increase a laboring woman’s
confidence and ability to cope with contractions and re-
duce discomfort. Breathing patterns are most effective
when learned and practiced before labor begins (Ad-
ams & Bianchi, 2005). Antepartum nurses have an op-
portunity to increase the confidence of pregnant women
and their ability to learn breathing and relaxation skills
before labor begins, and they can encourage clients to
attend childbirth classes that incorporate breathing and
relaxation.
Breathing awareness and breathing patterns enable a
woman to better control her response to labor. When the
woman becomes aware of her breathing rhythm and
depth as she inhales and exhales, she is better able to
adjust her breathing levels as labor progresses. (See
Table 6.) As labor becomes more difficult, a woman may
state that she feels overwhelmed by the contractions.
When the laboring woman is unable to maintain her
concentration, the intrapartum nurse can suggest
switching to the next breathing level, one that has a
faster pace and requires more concentration (Adams &
Bianchi, 2005).
Instruction During Pushing
During the second stage, the nurse can support the
woman to use open-glottis pushing and follow her own

Table 6: Instructions for Breathing

Breathing Technique Purpose Instructions to Laboring Woman

Breathing awareness Allows client to identify normal 1. Sit up, place one hand palm down over abdomen, and the other hand on top of
breathing pattern the first hand.
2. Breathe in and out normally, paying attention to how the abdomen rises and falls,
like having a balloon in your abdomen. Each time a breath is taken in, the
abdomen expands. Each time a breath is let out, the abdomen collapses.
Cleansing breath at start and Serves as a signal to begin the 1. Take an exaggerated inhalation of air through the nose and exhale through the
end of contraction contraction, initiate breathing mouth.
patterns, and end the contraction
Level 1 breathing Promotes relaxation 1. Place hands over lower abdomen and inhale until lower abdomen expands.
2. Breathe in and out slowly at a rate that is half your normal respiratory rate.
Level 2 breathing Promotes relaxation 1. Place hands on waist and inhale until waist expands.
2. Breathe in and out at a rate slightly faster than normal.
Level 3 breathing Promotes concentration 1. Place hands above the breast area at the level of shoulder blades and inhale until
that area expands.
2. Breathe in and out at a rate that is double your normal rate.
Level 4 breathing Promotes maximum concentration 1. Place hands at the level of the clavicle and inhale to that level.
during transition 2. Breathe in and out in a shallow fashion, as in a pant.
3. Alternation: Take three short breaths in and out, then blow out quickly, and inhale
quickly again, in a three-inhale to one-exhale pattern.

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Table 7: Advocacy Labor Support

Specific Category Type of Behavior Specific Behaviors

Conveying respect Ensure privacy; protect modesty; provide complete information; provide
nonjudgmental care; protect patient rights; respect existing relationships
Ensuring security Support client to express both positive and negative emotions; provide physical
safety/security; provide emotional safety/security
Acknowledging mother’s Listening to her wishes Encourage woman to verbalize her needs, fears, anxiety; convey that she has the
expectations for labor right to choose; give her time to consider choices
and birth Assisting with making informed choices Explain risks and benefits; periodically offer reevaluation and reflection
Birth planning Support her wishes with words and actions; negotiate with health care team on
her behalf; communicate birth plan to others
Conflict resolution Encourage problem-solving behavior; intervenes if others interfere
Partner care Determine partner’s expectations; convey respect; encourage partner to be an
advocate for the client

urges to push, reminding the woman and her partner
that her body will respond appropriately. The closed-
glottis method of pushing has been linked to negative
effects on the fetus, such as fetal heart decelerations
associated with prolonged second stage (Thomson,
1993). Despite this evidence, rising rates of epidural
anesthesia have contributed to the continuation of the
closed-glottis method (Simpson & James, 2005).
Information Regarding Patient Care
Informing women of the plan of care and interpreting
medical jargon can ease anxiety. As labor progresses,
the woman must be updated on fetal status and cervical
change. Allow time for information to be assimilated.
The laboring woman and her partner may want time
alone to discuss health care decisions. The nurse
should follow up to make sure they understand the infor-
mation that has been provided.
Partner Care
Nurses can ease the partner’s anxiety and provide sup-
port by offering information concerning the woman’s la-
bor progress. Taking time to demonstrate and explain
supportive measures allows the partner to effectively
participate in labor support.
care, and protecting client rights. Nurses ensure privacy
and protect modesty by keeping unnecessary people
from the room, securing the door during procedures,
providing gowns that adequately cover her while ambu-
lating, and covering her with drapes when appropriate.
Lothian (2004) noted that feeling respected allows women
to “tap into inner wisdom and dig deep to find the strength
needed to give birth” (p. 6). Nonjudgmental care in-
cludes putting self aside and providing competent care
in all situations. Being an advocate means providing the
same quality of care to the client at 28 weeks in preterm
labor who refuses tocolytic therapy as to the previously
infertile couple pregnant with their first child.
Acknowledgment of Mothers’ Expectations
Simkin (2002) suggested that when laboring women are
distressed, nurses can ask, “What’s going through your
mind?” (p. 729). Wuitchik, Bakal, and Lipshitz (1989)
found that distressing thoughts in latent labor increased
the likelihood of prolonged labor, fetal distress, and
medical intervention. Nurses can help relieve distress
by determining the woman’s concerns and giving accu-
rate information.
Birth Planning. A motto promoted by the American Col-
lege of Nurse-Midwives is “listen to women” (Kathryn,

Advocacy LSB
Advocacy includes protecting the client, attending to
needs, and assisting in making choices related to health
care; this requires the establishment of a therapeutic re-
lationship (Foley, Minick, & Kee, 2002). Advocacy may
require being the client’s voice when she is vulnerable
or unable to speak for herself. In being an advocate for
the client, the nurse empowers the client to give birth
with dignity (see Table 7).
Conveying Respect
Conveying respect to the laboring woman means ensur-
ing privacy, protecting modesty, providing nonjudgmental
1993). Listening enables the nurse to hear the woman’s
intuitive wisdom on her needs and desires for labor,
birth, and the postpartum period. Constructing a care-
fully executed birth plan requires a thorough assessment
of the client’s needs and desires. Clients’ needs and de-
sires may require the nurse to negotiate with members of
the health care team or her family, or both. Negotiation
requires clear delineation of the client’s desires, appro-
priate timing, and respectful communication skills.
Development of a standard birth plan form can diminish
duplication of effort and promote continuity among
health care providers. The birth plan form should be de-
veloped by an interdisciplinary team. Consent forms

112 JOGNN, 37, 106-115; 2008. DOI: 10.1111/j.1552-6909.2007.00213.x http://jognn.awhonn.org

Adams, E. D., and Bianchi, A. L.
and waivers are necessary when families make requests
that are outside the usual care provided at the facility.
Many facilities require the birth plan form to be signed
by each physician or certified nurse-midwife in the
practice. This formality may assist in ensuring that the
laboring woman’s needs are met.
In a Swedish study (Lundgren, Berg, & Lindmark,
2003), midwives assisted one group of women in de-
velopment of a birth plan, while the control group did
not use a birth plan. There was no improvement in the
birth plan mothers’ relationship to caregivers, fear and
pain related to childbirth, perceived control over child-
birth, or concerns for the unborn child, and their rela-
tionship with the caregivers was less satisfying. Lothian
(2006) suggested that birth plans may increase tension
when clients and providers hold conflicting views of
birth: as a normal natural process that could occur
safely without intervention or as full of risk, requiring in-
terventions to avoid negative outcomes. For clients or
providers who hold the second view, birth plans repre-
sent a request to remove the safeguards put in place to
avoid risk.
The intrapartum nurse must be aware of personal views
in order to set them aside to support a client’s decisions.
Once a woman makes an informed health care deci-
sion, the nurse has a responsibility to support the deci-
sion rather than adhering only to the nurse’s personal
belief structure. For example, a nurse’s approach to al-
leviating pain in labor may be a reflection of a personal
philosophy of pain in labor. If the nurse believes that
pain in labor is pathologic, a pharmacologic approach
to pain relief may be the first line of defense. However,
nurses who believe that pain in labor is normal or physi-
ological may offer a variety of nonpharmacologic LSB
(Lowe, 2002).
Conflict Resolution
Labor rooms are not conflict-free zones. The stress of
labor can promote conflict that may have negative ef-
fects on labor progress. The intrapartum nurse must
step in quickly when the client’s needs, desires, or
safety is compromised and promote problem-solving
behaviors. Steps of problem solving include defining
the problem, looking for potential causes, identifying al-
ternative solutions, choosing the best approach, and
carefully implementing that approach.
For instance, if the client’s father voices concern that his
daughter’s pain is not managed appropriately, the nurse
can step in quickly and address this issue, sparing the
client the distress of trying to manage her father’s anxi-
ety. The nurse can ask for a clearer understanding of
the father’s concern, provide an explanation of comfort
measures that have been implemented, describe the
stages and phases of labor, and with the client’s permis-
JOGNN 2008; Vol. 37, Issue 1
I N F OCUS
The intrapartum nurse must step in quickly when the client’s
needs, desires, or safety is compromised and promote
problem-solving behaviors.
sion, outline the client’s plan of action regarding pain
management.
Partner Care
While the laboring woman’s wishes and needs must
have priority, it is appropriate for the intrapartum nurse
to determine the partner’s expectations related to la-
bor and birth. If these are not in conflict with the client’s
wishes, every attempt should be made to honor them.
Implementing LSB in Practice
As obstetric nursing content in nursing school curricula
decreases (AWHONN, 2006a), there is less emphasis
on LSB and less value placed on this type of hands-on
nursing care. Therefore, in addition to training in elec-
tronic fetal monitoring, neonatal resuscitation, and sur-
gical scrub techniques, extensive hands-on training in
LSB should be a required element of labor and delivery
orientation. When intrapartum nurses have knowledge
and confidence in their LSB skill, they more effectively
provide this care (Kardong-Edgren, 2001).
Mentoring is an effective means to pass on the skill of
labor support. One way to implement this is to desig-
nate a day of the month as Labor Support Day. The LSB
expert is not assigned a client but rotates between labor
rooms and provides hands-on instruction and support
in LSB to the labor and delivery staff.
Intrapartum nurses need time to develop into expert
caregivers. It takes time, most likely more than 5 years,
in a consistent setting to develop expertise (Benner,
2001). Experts should be studied closely. What charac-
teristics or traits does this nurse exhibit? If these traits
could be identified, nurse managers could more easily
identify prospective staff members.
All nurses must have access to current nursing literature
to develop evidence-based practice (Romano &
Lothian, 2004). Hanson (1998) found that nurse-mid-
wives who spent time reading professional journals
used the most effective positions for second stage la-
bor. Maintaining subscriptions to professional journals
and attending regular continuing education activities on
current research will assist the intrapartum nurse to
maintain practice that is supported by science.
Labor support behaviors must be faithfully documented,
even if a narrative note is required. Consistent terminology
for LSB will increase their value and better define the prac-
tice of intrapartum nursing. Specific LSB can be added
113
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to the preprogrammed list of annotations of electronic
monitoring systems. This may make charting easier and
assist in data collection for future research related to LSB.
Improving LSB Definition and
Developing Certification
While many researchers have studied labor support,
there is no “acceptable or agreed upon definition (that)
exists for professional labor support and its underlying
components and attributes” (Sauls, 2006, p. 38). Con-
cepts, definitions, components, and attributes need to be
developed by a consortium of nursing leaders who have
proven to be knowledgeable in the field of labor support.
This work can produce standards, policies and proce-
dures, competencies, and plans for a comprehensive
certification program. Credentialing lends authority to any
discipline. Designing and implementing a certification
program in labor support would lend importance and
credibility to this discipline. Kardong-Edgren (2001)
stated that this type of certification should be required just
as certification in electronic fetal monitoring is required.
For the program to be comprehensive, it should include a
workshop with opportunities for hands-on practice of
each LSB, a training manual, and an exit examination.
Conclusion
Intrapartum nurses can use a multitude of nonpharma-
cologic pain relief methods to assist laboring women.
Labor support behaviors can be enhanced when the in-
trapartum nurse taps into more than one labor support
category at a time. The nurse who is committed to labor
support will positively affect birth experiences (Adams
et al., 2006). Every effort should be made to position a
nurse who is skilled and committed to labor support at
the bedside of all laboring women.
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