Managing the second stage of labor
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Managing the Second Stage of Labor. Denise M. Bourassa, RNC, MSN Hartford Hospital. Second stage - Defined. Second stage of labor – what is it? Begins with full dilation (10 cm) and full effacement (100%) of the cervix Ends with birth of baby. Second-Stage Labor Management.

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Managing the Second Stage of Labor

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Managing the Second Stage of Labor

Denise M. Bourassa, RNC, MSN

Hartford Hospital


Second stage - Defined

Second stage of labor – what is it?

Begins with full dilation (10 cm) and full effacement (100%) of the cervix

Ends with birth of baby


Second-Stage Labor Management

  • Why are we managing it?

  • How are we managing it?

  • Should we manage it?


Epidural Analgesia

  • First epidural – 1898

  • 1970’s – first widely used in obstetrics with problems

  • 1975 – 20% chose epidural

  • Current epidural in labor rate…75-85% ?


Epidural Analgesia

  • Relaxation of the pelvic floor musculature

  • Along came “Time – an important variable in normal delivery” (Wood et al, 1973)

  • Leading to prolonged second stage and need for intervention (Maresh,Choong,Beard, 1983)


Some of the ways we are managing

  • Coached or directed pushing

  • Closed glottis pushing

  • Early pushing or pushing without urge


Coached or directed pushing

  • Immediate pushing at 10 cm, regardless of urge to push

  • Breath holding, counting for 10 seconds, repeat x 3

  • PUSH, PUSH, PUSH !!!!!


Closed Glottis Pushing

  • Aka “purple pushing”

  • More like “red in the face” pushing

  • Usually the result of pushing without urge to push


Laboring Down

  • Many different names

    • Passive descent

    • Delayed pushing

    • Physiologic second stage


Open glottis pushing

  • When patient feels urge to push, will instinctively push, breathe when necessary, not when told.


Delayed pushing with lumbar epidural analgesia in labor

  • Authored by: Maresh, Choong and Beard

    Published in: British Journal of Obstetrics and Gynaecology, 1983

    Design of Study

    76 primigravidae with epidurals

    Delayed pushing group (n=40)

    Early pushing group (n=36)


Changes in the management of labour: length and management of the second state.

  • Authored by: Reynolds and Yukin

  • Published in: Canadian Medical Association Journal, 1987


Immediate and delayed pushing in the second stage of labour for nulliparous women with epidural analgesia; a randomised controlled trial

Authored by: Vause, Congdon, Thronton

  • Published in: British Journal of Obstetrics and Gynaecology, 1998

  • 135 nulliparous with effective epidural


Use of delayed pushing with epidural anesthesia; findings from a randomized, controlled trial

  • Authors: Mayberry, Hammer, Kelly, True-Driver and De

  • Journal of Perinatology – 1999

  • Pilot study designed to evaluate the use of delayed pushing in relation to five areas.


Mayberry et alOutcomes

  • Length of second stage

  • Change in fetal station first hour after full dilation

  • Apgar scores

  • Arterial umbilical cord gases

  • Perineal integrity


Mayberry et alConclusion

  • Study suggests time limits could be more flexible because of improved fetal monitoring and better ability to identify fetus not tolerating labor

  • Suggests redefinition of prolonged labor or failure to progress


ACOG Practice BulletinNumber 17, June 2000

  • Clinical Management Guidelines for Obstetrician-Gynecologists

  • Indications for operational Vaginal Delivery

    when fetal head is engaged and cervix fully dilated:

  • Prolonged second stage: Redefinition


Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia

  • Authored by: Fraser, Marcoux, Krauss, Douglas, Goulet, Boulvain, for the PEOPLE (pushing early or pushing late with epidural) study group

  • Published in: American Journal of Obstetrics and Gynecology, 2000


Fraser, et al. Design

  • Multicenter, Randomized Controlled trial

  • 1864 total participants

  • Delayed pushing = waiting 2 hours (n=936)

  • Early pushing = as soon as randomly assigned (n=926)


Active pushing versus passive fetal descent in the second stage of labor: A randomized Controlled Trial

  • Authored by: Hansen, Clark and Foster

  • Published in: The American College of Obstetricians and Gynecologists, 2002


Hansen et alOutcomes

  • Length of Second stage

  • Length of time pushing

  • Apgars

  • Cord pH

  • Episiotomies/lacerations

  • Endometritis

  • Rate of fetal descent

  • Fatigue scores


Management of the second stage of labor in nulliparas with continuous epidural analgesia

  • Authored by: Plunkett, Lin, Wong, Grobman, and Peaceman

  • Published in: The American College of Obstetricians and Gynecologists, 2003

  • Randomized 202 total subjects

    • Delayed pushing (n=117)

    • Early pushing (n=85)


Effects of immediate versus delayed pushing during second-stage labor on fetal well-being

  • Authored by: Simpson and James

  • Published in: Nursing Research, 2005

  • 45 nulliparous women in second stage

    • Delayed pushing (n=23)

    • Early pushing (n=21)


Care Practice #5: Spontaneous pushing in upright or gravity-neutral positions

  • Authored by: DiFranco, J.T, Romano, A.M., and Keen,R.

  • Published in: Journal of Perinatal Education, 2007


A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor

  • Authored by: Brancato, R.M., Church, S., and Stone, P.W.

  • Published in: Journal of Obstetric, Gynecologic and Neonatal Nursing, 2008

  • Objective: to determine which method of pushing most benefits women with epidurals during second-stage


Delayed versus immediate pushing in second stage of labor

  • Authored by: Kelly, M., Johnson, E., Lee, V., Massey, L., Purser, D., Ring, K., Sanderson, S., Styles, J., and Wood,D.

  • Published in: Maternal Child Nursing, 2010

  • Randomized clinical trial

  • Sample size 44

    • Delayed pushing (n=28)

    • Early pushing (n=16)


Implications for practice?

  • Nature of labor is a mystery even today

  • No two are the same

  • Hold your breath, count, push, push!


Final Conclusions

  • Google search

  • The debate continues

  • The past 30 years

  • The future


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