1. Bernstein, Samantha L. PhD, RNC-OB, IBCLC

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The rate of cesarean birth in the United States rose to over 32% in 2021; even low-risk mothers experience a rate of over 26% (Hamilton et al., 2022). Although cesarean birth is sometimes necessary, there are labor support practices to prevent unnecessary cesarean birth. Nurses play a primary role in these bedside support labor practices and thus, the Association of Women's Health, Obstetric, and Neonatal Nurses developed an evidence-based clinical practice guideline on Labor Support for Intended Vaginal Birth (Association of Women's Health, Obstetric, and Neonatal Nurses [AWHONN], 2022a). This guideline is the result of an extensive literature review by a team of nurse scientists and clinical leaders.


Nurses are essential in creating a supportive environment during labor for the patient and their family. Nurses should integrate trauma-informed practices including creating a respectful environment that provides opportunities for them to freely express their wants and needs. These practices are important to minimize emotional trauma because a calm environment decreases stress hormones and facilitates improved uterine blood flow (AWHONN, 2022a). Nurses should provide continuous labor support, which is associated with shorter labors, fewer instrumented vaginal births, improved neonatal outcomes, and greater maternal satisfaction (Bohren et al., 2017). The ability of nurses to provide this support is based upon appropriate nurse staffing policies with nurse-to-patient ratios consistent with patient acuity, stage of labor, and individual patient needs (AWHONN, 2022b). Continuous labor support includes physical care (such as positioning, ambulation, and encouragement of adequate intake and output), emotional support, patient advocacy, and partner support.


Nonpharmacological pain management includes assessment of pain and anxiety, preferably using a standardized tool such as the Coping with Labor Algorithm (AWHONN, 2022a). Techniques to support coping may include hydrotherapy (either shower or immersion), freedom of movement, varied positions throughout labor, and labor support equipment such as birth balls and peanut balls (AWHONN, 2022a). Other complementary techniques may also be offered to patients in labor, including heat and cold therapy, aromatherapy, massage, and music therapy. These interventions should be guided by the preferences of the laboring person.


Nurses should be aware that medical interventions may create a cascade effect where each intervention leads to another, ultimately interfering with the physiologic birth process and leading to avoidable cesarean birth. The most common labor intervention is fetal heart monitoring. Although fetal heart monitoring is used to assess fetal status during labor, continuous electronic fetal monitoring (EFM) may be associated with an increase in interventions. Intermittent auscultation is appropriate for low-risk women but is a more labor-intensive technique than continuous EFM. Benefits of intermittent auscultation include allowing nurses more time to directly assess patients (Wisner & Holschuh, 2018). Availability and range of pharmacologic interventions vary by birth site. All those in labor require ongoing emotional support. Nurses should assess patients for both pain and comfort. Nursing presence is important to all patients, regardless of their choice of coping methods.


This evidence-based guideline for labor support from AWHONN (2022a) helps nurses create a supportive environment for all patients, incorporating principles of trauma-informed care, continuous labor support, and a range of coping techniques to meet their needs. Although not every birth environment will be able to incorporate all aspects of the guideline, it provides a vital starting point for nurses to evaluate the care they give during labor and how that care may decrease the risk of cesarean birth.




Association of Women's Health, Obstetric, and Neonatal Nurses. (2022a). Labor support for intended vaginal birth (Evidence-Based Clinical Practice Guideline). Nursing for Women's Health, 26(5), S1-S42.[Context Link]


Association of Women's Health, Obstetric, and Neonatal Nurses. (2022b). Standards for professional registered nurse staffing for perinatal units. Nursing for Women's Health, 26(4), e1-e94.[Context Link]


Bohren M. A., Hofmeyr G. J., Sakala C., Fukuzawa R. K., Cuthbert A. (2017). Continuous support for women during childbirth. The Cochrane Database of Systematic Reviews, 7(7), CD003766.[Context Link]


Hamilton B. E., Martin J. A., Osterman M. J. K. (2022, May). Births: Provisional data for 2021 (Vital Statistics Rapid Release No. 20). National Center for Health Statistics.[Context Link]


Wisner K., Holschuh C. (2018). Fetal heart rate auscultation, 3rd edition. Nursing for Women's Health, 22(6), e1-e32.[Context Link]