Atoosa Benji

October 31, 2016

Practice Guideline (MCU template Summer 2016)

Evaluation and Management of Continuous Lower-Back Pain During Labor

1. Key Clinical Information

Many women experience back pain during labor. For some women, the pain is
continuous and unyielding. Pain during labor can be expected, but anesthesia is not
the only method of pain management. Especially during an OOH birth, it is important
clients have reminders of frequent position changes, have a strong set of hands
available for physical comfort and be surrounded by supportive friends and/or family
members. It is important to remember that even though many of us have doula
backgrounds, we are not the doula when we are the midwife. Our priorities are safe
birth and good outcomes for mothers and babies. We can make suggestions to help
with pain management. We are not the primary support person. Some women have
support during labor, others do not have that luxury and have people present at the
birth who are ill-equipped to attend a birth.

2. Assessment

i. Risk Factors:
a. Mother is obese and does not exercise
b. Mother is sedentary for most of day. She sits at a desk all day.
c. She lacks a healthy, balanced diet and eats mostly processed sugar foods,
contributing to her obesity
d. She refuses to get off the bed during labor
e. She has low physical stamina and little flexibility in her joints
f. She has done nothing to prepare physically for the birth
g. She has very little support
h. Her first child was born OP after 42 hours of labor
i. GD- onset at 24 weeks

ii. Subjective Symptoms:

a. chronic sacral pain in late pregnancy and throughout labor both during and
in-between contractions
b. Reports feeling like my back is going to break in half
c. Reports that this is how her first birth felt
d. Reports that the contractions feel like they never go away

iii. Objective Signs:

a. Slow to progress labor. VE after 32 hours shows 80% effacement, 4cm
dilation, -2 station and ROP
b. Mother constantly digging into her back and asking partner to do the same
c. Pain reported as improving when counter pressure is applied with 2 tennis
balls to sacral area
 d. Intermittent emesis
e. BP 130/82 P=80 T=98.2degrees Fahrenheit

iv. Clinical Tests Considerations:

a. Palpation of mothers abdomen to assess babys position
b. Bimanual examination to assess position and station
c. VE to check progress of labor and locate sagittal sutures

3. Management Plan

i.Therapeutic measure to consider:

a. Tylenol
b. Glass of wine
c. Hot packs
d. IV (LR) for hydration
ii. Complementary measures to consider:
a. Labor tub
b. Shower with jets pointing to sacral region
c. Rolling pin/tennis balls to press into the back
d. Massage low back area
e. Stretching out hip-flexors
f. Position changes- all 4s, side-lying, lunging, climbing stairs, knee-press
position, leaning over birth-ball, slow-dancing with partner.
g. Infusion of lavender essential oils to promote relaxation
h. Music in the room to relax/distract
i. Epsom salt bath
j. Guided mediation and progressive relaxation exercises
k. Walking
iii. Considerations:
a. Must keep mother hydrated
b. Must remember that as much as possible, we are aiming for a positive
birth memory for the mother
c. Aiming to help the baby turn to reduce the risk of OP delivery, long 2 nd
stage and possible lacerations
d. Aiming for high Apgar scores for baby to assure immediate skin to skin
contact and early breastfeeding

iv. Client and family education:

a. Show client ad family poster of fetal positioning and the etiology of the
sacral pain.
b. Show passage of baby through the pelvis with a model pelvis and newborn
to help client understand the 3 Ps-passenger, power, passage
c. Teach partner how to do hip-squeeze and counter pressure
d. Explain why position change is important
e. Stay positive and complementary
 v. Follow-Up:
a. Head to toe examination, examine clients back and ask about any current
back pain she may be experiencing. Check Homans sign.
b. Examine perineum to check that laceration from 2nd degree tear healing
well.
c. Check BS (blood sugars) and vital signs
d. Ask how she is doing, discuss breastfeeding, the postpartum period, her
nutrition, and how she is doing in general
e. Recommend physical therapy twice a week to help with existing back pain
and stiffness
f. Recommend follow-up care with GP to monitor BS
g. Recommend nutritionist to help with nutrition counseling and education
h. Recommend a mommy group to seek support from other moms

4. Indications for Consult, Collaboration or Referral

Client to be referred to nutritionist for nutrition counseling to aid with weight

management and education on managing DM (diabetes mellitus). Client also
referred to PT to help to strengthen her back and to help with mobility. Client
referred to GP for collaborative care and possibly endocrinologist for management of
DM.
NOTE: The practice does not continue caring for the patients DM nor musko-skeletal
pain. Patient will be cared for with regards to management of the postpartum period.
This includes care of the perineum, checking vitals, answering questions,
breastfeeding education, and gynecological needs. Although many clients feel
comfortable speaking with their midwife about intimate issues, the midwives are NOT
therapists, psychologist or social workers and proper care must be taken to refer out
to other providers accordingly.

References

Simkin, P. (2013). The birth partner: A complete guide to childbirth for all dads and all other
labor companions.
Boston, MA: Harvard Common Press.
Simkin, P. , Whalley, J., & Keppler, A. (2001). Pregnancy, childbirth and the newborn- the
complete guide to childbirth. New York, NY: Simon & Schuster.