Management of Second-Stage Second Stage Labor: Laboring Down

Maggie Shaw, CNM, PhD

This talk is limited to

Diagnosis and management of second stage of labor in women with epidurals using the technique known as laboring down . down. Discussion of the associated benefits and risks (Evidence based!) Recommendations for practice

Ideal Management g of Second Stage

The ideal management of the second stage should maximize the probability of vaginal delivery while minimizing the risks of maternal and neonatal morbidity and death. (Cheng, Hopkins, & Caughey, 2004)

A Midwifery Perspective

the midwife in the contemporary social context of birth care must learn not only how t interpret to i t t the th physical h i l and db behavioral h i l indicators of progress in labor, but s/he must also know how to transact the achievement of a good birth; that is, one accompanied by the healthiest possible newborn outcomes, and from the womans woman s perspective, perspective a positive birth experience, ideally one of joy and sense of accomplishment p ( (Roberts, 2002) )

Physiologic y g Process: Ferguson Reflex

Pelvic floor distended by descending fetal presenting part Stretch receptors activate and release endogenous oxytocin Leads to involuntary urge to push Increases effectiveness ff of f uterine pushing

What does the research indicate?

Brief literature search of OVID and CINHIL for the past 5 years. Overall concerns center around

Diagnosis of the second stage of labor Maternal and fetal outcomes related to prolonged second stage.

Are there benefits or risks to laboring g down? Do the benefits outweigh the perceived risks of prolonged second stage of labor?

Traditional Definition of the Second Stage of Labor

Complete dilatation of the cervix to the birth of the child

Definition of p prolonged g second stage of labor (ACOG)

Primipara More than two hours without regional anesthesia More than three hours with regional anesthesia th i Multipara More M than th one hour h without ith t regional i l anesthesia More than two hours with regional anesthesia

One phase or several?

Phase 1: Passive Fetal Descent Ph Phase 2: 2 Active A ti Pushing Efforts

Phase 1: The Lull Phase 2: Active bearing Down Phase 3: Perineal

The Lull or Passive Fetal Descent

From complete dilatation until: the urge to bear down rhythmic, bearing down efforts

Active Bearing g Down/Active Pushing Efforts

From the onset of rhythmic bearingdown efforts or the urge to push until the presenting part no longer retreats between bearing-down bearing down efforts

AKA Crowning

Perineal

From crowning of the presenting part until birth of the entire baby

Laboring Down

Maternally led During the Lull or Passive Fetal Descent Phase, women are allowed to rest rest, even if completely dilated When women identify a strong urge to push and/or experience rhythmic bearing-down contractions (A ti Pushing (Active P hi Phase), Ph ) then th encourage spontaneous, involuntary bearing-down efforts including grunting, groaning, exhaling during the push, h and db breath th h holding ldi l less th than 6 seconds d

Active Pushing Versus Passive Fetal Descent in Second Stage of Labor: A Randomized Controlled Trial
Hansen, Clark, & Foster (2002)

Comparison of perinatal outcomes between women who h pushed h d at t complete l t dil dilatation t ti and d those who had a period of rest before pushing

Randomized, controlled clinical trial N = 252 women who completed study (81% of total enrolled) Women with epidural (before complete dilatation), no know fetal anomaly, singleton, 37-42 weeks GA, vertex, otherwise uncomplicated pregnancy VBACs included in primipara groups

Methodology

Computerized fetal monitoring system at bedside that included FHTs, demographic and admission info, labor, delivery, and recovery info. Continuous fetal and uterine contraction monitoring S ft Software program that th t prompted t d nurses to t enter dependent and confounding variable information at appropriate times

Methodology (continued)

Same nurse reviewed all FHR tracings and determined number and type of fetal decelerations in second stage. Nurse or physician did VEs to determine complete dilatation Women were randomly assigned to Group 1 (pushing) or Group 2 (rest and descend before pushing)

Methodology (continued)

Women in immediate pushing group began as soon as completely dilated Women in delayed pushing group rested from complete dilatation until the head was seen at the introitus OR 120 minutes in primiparas or 60 minutes in multiparas

Methodology (continued)

Maternal fatigue assessed:

After epidural placed and mother comfortable Within 15 minutes of complete dilatation Within 60 minutes after delivery of placenta Uterine contractions Pt.s bladder Introitus for presenting part

Assessed every 30 minutes:

Results

No significant difference in rate of descent from onset of pushing to delivery Total pushing time less for Group 2 (delayed pushing group) than Group 1 (active pushing) in both primips and multips (not significant) Pi i i Primips in b both th groups h had d greater t f fatigue ti scores, but those in Group 2 had significantly less than those in Group 1 No difference in fatigue scores among multiparous women

Results (continued)

Total number of fetal decelerations (all types) in second stage significantly less with laboring down patients Mild variable decelerations (among primips and multips), moderate and severe variable decelerations (among primips), primips) and severe variable decelerations (among multips) were all significantly less in Group 2 (delayed pushing) compared with Group 1 Th There were no late l t decelerations d l ti on the th monitor it strips n this study

Results (continued)

No statistical difference in:

Apgar scores Umbilical arterial cord pH Post partum endometritis Perineal injuries Operative delivery (slightly less in Group 2 but not significant)

Potentially y Confounding g Variables

Bladder status Position changes (Group 1 primips changed positions more frequently) Uterine contraction pattern (Group 2 [delayed pushing] primips had increased uterine contraction pattern) Frequency and duration of pushing once pushing began (Group 2 primips and multips had increased pushing frequency)

Myles and Santolaya (2003)

Compared women with second stage of labor < 2 hours and > 2 hours to determine risk f t factors for f prolonged l d second d stage t and d evaluate maternal and neonatal outcomes Retrospectively looked at the second stage of 6791 patients

Group 1 (n=6259) < 120 minutes Group 2A (n=384) 121-240 minutes Group 2B (n=148) >240 minutes

Myles y and Santolaya y ( (2003) ) Results

Prolonged second stage associated with a high rate of vaginal delivery, a high rate of maternal morbidity but not neonatal morbidity Group 2 had higher rates of perineal trauma, episiotomy usage, chorioamnionitis, post partum hemorrhage, and operative ti vaginal i ld delivery li (P < .001) 001) Group 2B had higher rates of episiotomy usage, operative vaginal deliveries, and perineal trauma than Group 2A (P < .001) Neonatal morbidity was the same for both groups.

Factors Associated with Prolonged Second Stage

Diabetes Pre-eclampsia Macrosomia Nulliparity Chorioamnionitis Oxytocin usage Labor induction

Plunket, et al (2003)

N=202 (randomly assigned to immediately pushing or delayed pushing) All had continuous low-concentration epidurals p Women in delayed pushing group had: stronger urge to push longer g second stage g (from ( complete p to delivery) y) No difference in: time spent actively pushing, Median level of patient satisfaction Cesarean or vaginal delivery Neonatal or maternal morbidity

Fitzpatrick, et al (2002)

Prospective, randomized, controlled trial N = 178 Assessed effects of delayed versus immediate p pushing g in second stage g with epidural analgesia on

delivery outcome Postpartum fecal continence Postpartum anal sphincter and pudendal nerve function

Fitzpatrick, p , et al (2002) ( ) Results

High overall rates of pudendal nerve damage, anal sphincter injury and altered fecal continence in both groups (not significantly different) No statistical differences between two groups for: Oxytocin use Spontaneous vaginal, instrumental, or Cesarean births Perineal outcomes Anal manometry results Endosonographic results Neurophysiological results

OConnell, et al (2003)

Retrospective, case controlled study identifying factors associated with a prolonged second stage of labor N=364 (182 women with second stage < 2 hours and 182 women with second stage > 2 hours) S Spontaneous t vaginal i l delivery d li

< 1 hour 86.3% 1-2 hours 83% 2-3 hours 64% 3-4 hours 50% > 5 hours 0%

O'Connell, et al (continued)

Assisted vaginal delivery rate doubled if second stage > 4 hours Cesarean birth rate

< 2 hours 4.7 % 2-3 hours 6.7% 34h 3-4 hours 14 14.6% 6%

No difference in neonatal outcomes Women with longer g second stages g were older, , had bigger babies, more likely to have an epidural and oxytocin augmentation

Myles and Santolaya (2003)

Retrospective study (N=6791) to determine risk factors for prolonged second stage of labor and evaluate maternal and neonatal outcomes Group 1 (n=6259) < 120 minutes Group 2A (n=384) 121 121-240 240 minutes Group 2B (n=148) >240 minutes

Myles y and Santolaya y ( (2003) ) Results

Prolonged second stage associated with a high rate of vaginal delivery, a high rate of maternal morbidity, but not neonatal morbidity Group 2 had higher rates of perineal trauma, episiotomy usage, chorioamnionitis, post partum hemorrhage and operative vaginal delivery (P < hemorrhage, .001) Group 2B had higher rates of episiotomy usage, operative ti vaginal i ld deliveries, li i and d perineal i lt trauma th than Group 2A (P < .001) Neonatal morbidity y was the same for both g groups p

Factors Associated with Prolonged Second Stage

Diabetes Pre-eclampsia Macrosomia Nulliparity Chorioamnionitis Oxytocin usage Labor induction

What are the questions?

How long is too long for second stage of labor? What are the benefits of delayed pushing? What are the risks? Is there a way to make an evidenced based decision?

Optimal Obstetrical Conditions

To diagnose the second stage of labor, the practitioner must assess all three factors

Cervical dilatation Fetal position Station

If woman is instructed to push too soon, may result in outof-sync pushing, longer active pushing phase, and maternal exhaustion.