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

Managing the Second Stage of Labor

Denise M. Bourassa, RNC, MSN

Hartford Hospital


Second stage defined

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

Second-Stage Labor Management

  • Why are we managing it?

  • How are we managing it?

  • Should we manage it?


Epidural analgesia

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 analgesia1

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

Some of the ways we are managing

  • Coached or directed pushing

  • Closed glottis pushing

  • Early pushing or pushing without urge


Coached or directed pushing

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

Closed Glottis Pushing

  • Aka “purple pushing”

  • More like “red in the face” pushing

  • Usually the result of pushing without urge to push


Laboring down

Laboring Down

  • Many different names

    • Passive descent

    • Delayed pushing

    • Physiologic second stage


Open glottis pushing

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

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

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


Managing the second stage of labor

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

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 al outcomes

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 al conclusion

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 bulletin number 17 june 2000

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


Managing the second stage of labor

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

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)


Managing the second stage of labor

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 al outcomes

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

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

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

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


Managing the second stage of labor

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

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

Implications for practice?

  • Nature of labor is a mystery even today

  • No two are the same

  • Hold your breath, count, push, push!


Final conclusions

Final Conclusions

  • Google search

  • The debate continues

  • The past 30 years

  • The future


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