Denise M. Bourassa, RNC, MSNHartford Hospital

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

Why are we managing it?

How are we managing it?

Should we manage it?

First epidural – 1898

1970’s – first widely used in obstetrics with problems

1975 – 20% chose epidural Current epidural in labor rate…75-85% ?

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)

Coached or directed pushing

Closed glottis pushing Early pushing or pushing without urge

Immediate pushing at 10 cm, regardless of urge to push

Breath holding, counting for 10 seconds, repeat x 3

PUSH, PUSH, PUSH !!!!!

Aka “purple pushing”

More like “red in the face” pushing

Usually the result of pushing without urge to push

Many different names

◦ Passive descent

◦ Delayed pushing

◦ Physiologic second stage

◦

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

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)

Authored by: Reynolds and Yukin

Published in: Canadian Medical Association Journal, 1987

Authored by: Vause, Congdon, Thronton

Published in: British Journal of Obstetrics and Gynaecology, 1998

135 nulliparous with effective epidural

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.

Length of second stage

Change in fetal station first hour after full dilation

Apgar scores

Arterial umbilical cord gases

Perineal integrity

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

Clinical Management Guidelines for Obstetrician-Gynecologists

Indications for operational Vaginal Delivery when fetal head is engaged and cervix fully

dilated:

Prolonged second stage: Redefinition

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

Multicenter, Randomized Controlled trial

1864 total participants

Delayed pushing = waiting 2 hours (n=936)

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

Authored by: Hansen, Clark and Foster

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

Length of Second stage

Length of time pushing

Apgars Cord pH Episiotomies/lacerations Endometritis Rate of fetal descent

Fatigue scores

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)

Authored by: Simpson and James

Published in: Nursing Research, 2005

45 nulliparous women in second stage◦ Delayed pushing (n=23)◦ Early pushing (n=21)

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

Published in: Journal of Perinatal Education, 2007

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

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)

Nature of labor is a mystery even today

No two are the same

Hold your breath, count, push, push!

Google search

The debate continues

The past 30 years

The future