Managing the Second Stage of Labor

1. Managing the Second Stage of Labor Denise M. Bourassa, RNC, MSN Hartford Hospital

2. 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

3. Second-Stage Labor Management • Why are we managing it? • How are we managing it? • Should we manage it?

4. 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% ?

5. 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)

6. Some of the ways we are managing • Coached or directed pushing • Closed glottis pushing • Early pushing or pushing without urge

7. 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 !!!!!

8. Closed Glottis Pushing • Aka “purple pushing” • More like “red in the face” pushing • Usually the result of pushing without urge to push

9. Laboring Down • Many different names • Passive descent • Delayed pushing • Physiologic second stage

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

11. 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)

12. 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

13. 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

14. 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.

15. Mayberry et alOutcomes • Length of second stage • Change in fetal station first hour after full dilation • Apgar scores • Arterial umbilical cord gases • Perineal integrity

16. 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

17. 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

18. 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

19. 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)

20. 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

21. Hansen et alOutcomes • Length of Second stage • Length of time pushing • Apgars • Cord pH • Episiotomies/lacerations • Endometritis • Rate of fetal descent • Fatigue scores

22. 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)

23. 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)

24. 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

25. 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

26. 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)

27. Implications for practice? • Nature of labor is a mystery even today • No two are the same • Hold your breath, count, push, push!

28. Final Conclusions • Google search • The debate continues • The past 30 years • The future