Management In The Second Stage Of Labor 572

Front 1

Define what traditionally second stage has been described as, and also the social aspects of this stage

Back 1

-Traditionally: from complete dilatation to birth of the baby
-According to Joyce Roberts, CNM it is both a profound physiologic process and personal experience for the laboring woman
-Can be a very challenging part of labor for the health care team caring for the mother and the family
-There is a precedence that social definitions, circumstances, rituals, and processes supercede the maternal physiologic processes
-A socially accomplished phenomenon in which the laboring woman has little direct input

Front 2

What are the physiologic markers of second stage?

Back 2

-Digital, internal, vaginal examination to determine the complete dilitation of the cervix
-The laboring woman’s irresistible urge to push
-The fetal presenting part is at least at the +1 station

Front 3

What are the dangers of pushing too early?

Back 3

-Edema of the cervix
-Slowing down the labor process
-Injury to the cervix

Front 4

What is "pushing crisis"?

Back 4

-Problems arise when the laboring woman has the involuntary urge to push and the cervix is ‘not known’ to be fully dilated. The process appears to happen in this fashion:
1. The caregiver insists that the woman suppress the urge to push
2. Orientation to the future with certification of full dilatation
3. Recognizing the official transition to the 2nd stage of labor and considering the actions of the woman as appropriate and therefore actively encouraged
4. Following official recognition of complete dilatation the caregiver changes from active suppression to activities aimed to make the woman become effective in her efforts

Front 5

Why are there so many issue centering around the diagnosis of second stage?

Back 5

-Diagnosis - there is a great amount of variation based on when the clinician decides to evaluate the cervix
-Interventions - center around communications with the woman and her family regarding bearing down, methods to use, and positioning herself to prevent problems

Front 6

What are the aspects included in the "when to push, when not to push" ideas during second stage? And how do they end up affecting the mother/fetus?

Back 6

-When the woman has the involuntary urge to push and is told to ‘pant’, she begins to try to overcome the forces that are happening naturally. Then she finds it difficult to push with the urge once she is completely dilated
-The purpose of ‘holding off’ is to avoid a prolonged period of pushing, maternal fatigue, and possibly a swollen/torn cervix
-Pushing before the woman has the urge is also confusing for the woman
-She pushes only on direction and many times is out of phase with her own urges
-Creates a prolonged period of pushing, maternal exhaustion, potential for metabolic acidosis -> maternal then fetal, and great frustration
-Becomes disruptive

Front 7

What are strategies when deciding when to push?

Back 7

-Birth is a normal physiologic process and data is clear that outcomes are better when the normal processes are respected.
-Allowing the process to increase in intensity causing involuntary urge to push is supported in the literature rather than placing an arbitrary time span.

Front 8

What do the professional organizations say about the length of the second stage?

Back 8

-Arbitrary time limits are “not warranted” according to many reviews
-ACOG guidelines state, “the length of second stage is not in itself an absolute indication for operative termination of labor”
-Increasing evidence to support that it is the progression of the second stage that is important, not the length of time needed

Front 9

What are the phases of the second stage of labor?

Back 9

1. Initial phase - Period of time from complete cervical dilatation until the time that the mother begins to have involuntary bearing down efforts (European - pelvic phase)
2. Final phase - period of active maternal bearing down (European - perineal phase)
*It is during the final phase that there has been noted changes in fetal acid-base status

Front 10

What are adverse consequences that can occur with pushing?

Back 10

-Maternal fatigue
-Neuromuscular injury to the perineal structures
*Schaffer, et.al., found that
coached pushing in the 2nd stage
significantly affected urodynamic
indices and was associated with a
trend towards increased detrusor
overactivity.
-Increase in lactic acid build-up

Front 11

Describe coached pushing

Back 11

1. Head of bed up 30º
2. Position patient, as she desires, on back or side
3. Patient to pull back on both knees, tuck chin with pushing
4. Coach patient to take deep breath, hold for 10 count while bearing down and repeat at least 3 times with contraction

Front 12

Describe uncoached pushing

Back 12

1. Head of bed up 30º
2. Position patient, as she desires, on back or side
3. Patient allowed to “do what comes natural or whatever she feels the urge to do while having a contraction

Front 13

What did the PEOPLE study show us about pushing early vs. pushing late with an epidural?

Back 13

-Canadian randomized controlled trial of second stage pushing - 1,862 nullips
-Half began pushing upon diagnosis of complete dilatation, half delayed for two hours before beginning pushing (no information about the techniques used when pushing
-Delayed pushing reduced obstetric interventions
-Greater proportion of NN with cord pH <7.15 (v) and <7.1 (a)

Front 14

What are the negative effects of coached vagal pushing?

Back 14

-When bearing down efforts maintained longer than 5-6 seconds:
*results in alterations in maternal and fetal hemodynamics
*lower maternal blood pressure and placental blood flow
*lower fetal pH and PO2, higher PCO2
*more frequent occurrence of nonreassuring fetal heart rate (FHR) patterns, delayed recovery of FHR decelerations and subsequent newborn acidemia
*lower apgar scores
*Research is clear that conventional (hold breath for 10 seconds) pushing method increases hypoxic effects

Front 15

How do you avoid hypoxic affects when pushing?

Back 15

-Delay pushing until the urge to push is present
-Pay attention to the perineal phase rather than just the pelvic phase
-Focus on the manner in which the woman is pushing - minimize the sustained breath holding

Front 16

What is specific to pain during the second stage of labor?

Back 16

-Pain is a dominant feature of second stage of labor, uterine contractions and the stretching as the fetus descends
-Catecholamines secondary to pain along with lactic acid accumulation from muscular efforts reduces quality of uterine contractions

Front 17

What does the use of an epidural contribute to in the second stage of labor?

Back 17

-Significant influence on the progression of second stage
-Associated with increased length of 1st and 2nd stages, increased incidence of fetal malposition, and increased use of oxytocin and operative vaginal delivery
-Contributes to horizontal positioning and conventional pushing method (Valsalva)

Front 18

Should you withdrawl an epidural once the second stage begins?

Back 18

-Withdrawal of epidural has not been found to change outcome in randomized study and in fact found an increased use of instrumentation at delivery in group with withdrawal of epidural
-Return of pain places woman in the vicious cycle of increasing catecholamine release and increasing lactic acid accumulation from breath holding = inhumane practice

Front 19

What is the opinion currently on epidurals and "laboring down"?

Back 19

-Mixed results in the studies
-May be due to the varied length of time used before pushing began
-Additional research is needed but results are promising

Front 20

What is the purpose of positioning for pushing, and what are the common positions and possible added risk to those positions?

Back 20

-Purpose of positioning is to prevent or correct misalignment, promote descent and/or relieve pain
1. Hands and knees - ‘all fours’
2. Upright - pain relief is greater, blood loss is greater
3. Squatting

-AWHONN continues to express concern that the horizontal position has prevailed despite evidence of physiologic harm

Front 21

Regarding fatigue in the second stage:
1. what can contribute to it
2. what muscle is particularly susceptible to it
3. what are the two common characteristics of second stage that increase fatigue
4. what positions are known to be less fatiguing for pushing?

Back 21

-Central fatigue may be present prior to the onset of active labor
-Muscle fatigue results from labor in general, some greater than others
-The diaphragm may be particularly susceptible in second stage
-Pain increases metabolism and therefore fatigue
-Valsalva pushing increases all types of fatigue
-Upright and squatting positions have been shown to be less fatiguing

Front 22

When may fundal pressure be indicated and when is it not indicated?

Back 22

Indicated:
-with AROM
-application of FSE
Not Indicated:
-Labor has not progressed in a normal or average fashion
-Estimated fetal weight is large
-Previous history of shoulder dystocia

Front 23

What are the risks of fundal pressure to the fetus?

Back 23

-shoulder dystocia
-increased fetal intracranial pressure with significant decrease in cerebral blood flow and non-reassuring FHR patterns
-umbilical cord compression
-increasing placental insufficiency
-subgaleal hemorrhage
-spinal cord injuries

Front 24

What are the risks of fundal pressure to the mother?

Back 24

-perineal injuries (3rd and 4th degree lacerations)
-uterine rupture
-uterine inversion
-hypotension
-respiratory distress
-abdominal bruising
-fractured ribs
-liver rupture
-pain

Front 25

What are alternatives to fundal pressure?

Back 25

-Patience, patience, patience
-Avoidance of arbitrary time frame
-Analgesic v. anesthetic level for epidural
-Laboring down
-Appropriate physiologic pushing
-Careful analysis of potential risks and benefits

Front 26

Read the next slide for a summary of the evidence in second stage pushing

Back 26

-It is the duration of active pushing that is related to maternal and fetal outcomes not the total duration of the second stage.
-There are at least two phases of the second stage - it is time for reconceptualization.
-Awaiting the urge to push prevents problems
-Maternal positioning for success.
-Coached pushing is a potentially modifiable obstetric practice and is without benefits.
-There is no place for fundal pressure in the second stage.
-Placing women at the center of second-stage management is congruent with the evidence and the hallmarks of midwifery practice.

Front 27

What is the evidence on perineal massage before labor and how it may affect preventing genital tract trauma during birth?

Back 27

AP perineal massage:
-Shipman (kegel exercises vs perineal massage for 4 minutes during last 6 weeks) found 6% reduction in trauma

-Labrecque (perineal massage for 10 minutes last 6 weeks) found 9% reduction in sutured trauma in nulliparas, none in multips

Front 28

What does the evidence say about what does NOT offer genital tract trauma prevention and what DOES ?

Back 28

-Evidence does not support lowering overall rates of genital tract trauma with birth when using:
*Warm compresses
*Massage with lubricant
*Hands on or hands off techniques
-What does appear important in reducing genital tract trauma is:
*A reasonably comfortable mother
*Slow, controlled expulsion of the
infant
*Shared responsibility for the
outcome