Second Stage Labor Management

Evelyn M. Hickson, RN, MSN, CNS, WCC

ObjectivesBy the end of this presentation the learner will be

able to:

Discuss traditional pushing and laboring down  

List nursing interventions to facilitate second stage.

Discuss the risk-benefit of operative vaginal delivery.

Cardinal MovementsOf Birth

Pushing

When is it OK to begin pushing? When completely dilated When patient feels urge – as long as

completely dilated

Continue as long as fetal tolerates pushing

What Is Laboring Down?

Done in the patient with an epidural Passive action of second stage Allowing the uterine activity to continue to

bring the baby down the birth canal without active pushing.

What Patients Would I Use Laboring Down On??????

Patients who are exhausted Cardiac Patients Any patient that should not be pushing due

to medical or obstetrical issues

How Long Can You Do Laboring Down? Maximum time is two hours. Start from the time the patient is

determined to be complete Contingent on a stable mom and a FHR

tracing that demonstrates fetal well-being

Positions For Pushing In the bed HOB slightly up Use of the bed Safety measures for patients with epidurals Positions that open the pelvis Squat bars

Positions For Pushing

Squatting

On the toilet

Assisting The Patient With Pushing

Breathing Bearing down Support / Coaching Focus

Episiotomy

Instrument Assisted Deliveries

Vacuum Nursing Responsibilities

Chart Pressure amount Chart Total Time / Duration of vacuum applied Chart Number of pulls and pop-offs Determine who needs to be present in room Identify when to go up the chain of command Assess the baby for outcome

Instrument Assisted Deliveries Forceps Nursing Responsibilities

Station of fetus when applied Chart the number of pulls Determine who needs to be present in the

room Identify when to go up the chain of command Assess the baby for outcome

Shoulder Dystocia

Definition: When neonatal shoulders cannot be delivered using

the “usual” delivery maneuvers When extra delivery maneuvers are required to

deliver the baby When the time from delivery of the head to the

delivery of the shoulders/body is >60 seconds Incidence of 0.6 to 1.4 % of all births

Shoulder Dystocia

Obstetrical Emergency

Time is of the essence

Risk Factors For Shoulder Dystocia History of prior delivery of a baby with a shoulder dystocia. Suspected Macrosomia (>4,000 grams) Diabetic mother (more often gestational or type II) Excessive maternal weight gain during pregnancy (>35 pounds) Slow slope - prolonged time to go from 8-10cm of dilatation

(primips=1.2cm/hr, multips= 1.5 cm/hr) Delayed descent Postdates Pelvic Abnormalities Abnormal pelvic shape or pelvic injury

Case StudyOprah Winfrey arrives in labor at 41 3/7 wks. She is a G3P2 with a previous Hx. of delivering two 9 LB+ babies within the last 6 years. She remembers that the deliveries were “difficult” and she “tore” and bled a lot. Oprah has a documented 50 lb weight gain during this pregnancy. She was diagnosed as a gestational diabetic at 26 wks. An ultrasound was done two weeks ago (at 39 wks.) because her fundal height was 42 cm. EFW was shown at that time to be 4200 grams. The patient refused to be induced at 39 weeks stating that she had to coordinate getting family to help and they were in the process of moving to a bigger house.

The patient was admitted at 0830 in active labor at 5 cm/ 90%/-2. She was 8cm/90%/-2 at 1330 and 10/100%/-2 at 1630.

Case StudyThe patient pushed for 2 hours and doesn’t bring the baby down lower

than+1 station. The Physician applied forceps to assist with delivery and descent. The head is delivered with the forceps after 3 contractions. The head advances slightly then retracted back up “turtling” and the shoulders did not come out. The primary nurse called for assistance The Physician requests supra-pubic pressure and McRoberts maneuver.

The baby is delivered with a Rubin maneuver after 3 minutes of shoulderdystocia with reduction techniques.

The baby is dark blue, floppy with eyes wide, no respiratory effort and a HR rate of 80.

What Are The Risk Factors For This Patient?

History of Macrosomic babies with difficult deliveries Increased fundal height Slow slope / delayed rate of dilatation (abnormal labor

pattern for a multiparous patient Postdate Gestational Diabetes Excessive maternal weight gain

Preparation For Shoulder Dystocia Have the proper equipment ready and available

*Warmer that is functional – set up and warm *Bag and mask *O2 *Suction

May need stool in order to get up on the bed or achieve better leverage with maternal positioning

Preparation For Shoulder Dystocia

Have the proper personnel at the delivery *NICU / SCN RN *Second pair of hands *Charge nurse /experienced RN

Nurse’s Role In Shoulder Dystocia Call for help/backup Note time at the beginning of shoulder dystocia Lower the head of the bed Reposition the patient Assist with shoulder dystocia reduction

maneuvers Prepare for newborn resuscitation Remain calm Reassure patient and help her to focus on pushing Delegation of removal of unnecessary people /

family from the room Implementing the chain of command if needed DOCUMENT - re-creation of the events as they

occurred

Shoulder Dystocia Maneuvers 1. McRoberts 2. Suprapubic Pressure 3. Woods Screw 4. Rubin 5. Delivery of the posterior arm 6. Maternal Reposition 7. Hibbard 8. Deliberate fracture of the clavicle 9. Deliberate breaking of the maternal coccyx 10. Zavenelli 11. Cleidotomy 12. Symphysiotomy (a large episiotomy may be cut at anytime)

McRoberts

Hyperflexion of the maternal legs back towards the chest and slightly rotated out. Straightens out the sacrum Straightens out the incline (angle) of the symphysis

pubis Rotates the pubic bones Increases the area of the posterior outlet and

decreases the stretching of the baby’s brachial plexus

McRobert’s Least amount of potential injury if mother does

herself If patient has epidural, legs must be hyperextend or

patient can receive sacral and leg nerve damage Reduces the likelihood of neonatal clavicular fracture

and brachial plexus injury 90% success rate without additional maneuvers

Suprapubic Pressure Second maneuver used in conjuction with McRoberts May increase the incidence of clavicular fracture Procedure

*Communicate with the delivering MD which direction to exert pressure

*Using flat surface of the fist, exert a firm downward and oblique pressure, just above the maternal symphysis pubic on the anterior fetal shoulder in the direction the MD is rotating

Supra-pubic Pressure

Woods Screw Maneuver

Procedure *Continual rotation in a circular motion of the

shoulders either in a clockwise or counter-clockwise motion in an effort to “unscrew” the neonate from the pelvis

Rubin “Rotational” Maneuver Or “Reverse Woods Screw”

Identified in 1943 Posterior shoulder is rotated 180 degrees then the delivering

provider reaches in to access the shoulder and push the anterior shoulder and scapula towards the surface of the chest.

“Shoving scapulas saves shoulders” Coordination with the delivering provider *Rocking the baby’s shoulders from side to side, using the flat

surface of the fists or heels of the hands, just above the maternal symphysis pubis.

Delivery Of The Posterior Arm

Delivering provider slips in behind anterior shoulder and reaches in to grasp neonate’s arm and rotate it out.

Reduces the diameter of the shoulder to shoulder width.

Increased risk of fracture to the humerus

Maternal Reposition Hands and knees - all fours Squatting Rotational maneuvers then tried again Purpose is to open the pelvis and provide more room

Hibbard Identified in 1982 Pressure is placed on the baby’s jaw and neck downward in the

direction of the maternal rectum while strong fundal pressure is given

This allows delivery of the anterior shoulder

Deliberate Fracture Of The Clavicle

Pressure is put on the baby’s clavicle to intentionally fracture or “break” the clavicle and reduce the shoulder

Deliberate Breaking Of The Maternal Coccyx

Strong downward pressure is placed on the coccyx with intention to break it and increase the pelvic outlet diameter and allow more room for delivery of the shoulders.

Zavenelli

Also known as “Cephalic replacement” Identified in 1985 The presenting part if returned or pushed back into

the maternal pelvis and an emergency cesarean section is performed

Is considered as a last resort to get out a live baby.

Symphysiotomy

Identified in 1986 The maternal symphysis pubis is cut or

split in order to allow delivery of a dead baby.

Cleidotomy

Identified in 1983

The clavicle(s) of a dead baby is cut in order to allow delivery

Nursing Implications For Fundal Pressure

Should never be used to expedite second stage Should never be used in shoulder dystocia

except during Hibbard procedure Will further impact the anterior shoulder

against the symphysis pubis

Nursing Implications For Fundal Pressure May cause maternal injury

*Lacerate the liver *Damage the diaphragm *Cause uterine rupture *Cause uterine inversion and prolapse *Cause cervical lacerations and tears *Cause vaginal wall tares **Has a 77% complication rate

Documentation Time head delivered and shoulder dystocia

diagnosed Duration of the shoulder dystocia Procedures and maneuvers performed and in

what order Presence of personnel in the delivery room Neonatal resuscitation Neonate condition and complications Maternal condition and complications Interventions taken to support mother and

family

Maternal Implications Of Instrument Deliveries And Shoulder Dystocia

Higher risk for injury to mother (and nurse)

Higher risk for postpartum hemorrhage

Higher risk for c-section

Potential injury to baby and possibly death

Birth

What are your responsibilities? Fetal monitoring Time of delivery Delivery of placenta Labs – cord blood / gases Repair Feeding/Bonding

Safety Eye protection Blood and body fluids Physical safety Body mechanics

ReferencesAssociation of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2011), Fetal Heart Monitoring Principles & Practices. (4th ed.). Dubuque, Iowa: Author.

ACOG Practice Bulletin: Shoulder Dystocia. Number 40, November 2002

American Academy of Pediatrics and The American College of Obstetricians and Gynecologists (2005). Guidelines for Perinatal Care (6th ed). Authors. Simpson, K.R., & Creehan, P.A. (2010). AWHONN Perinatal Nursing (4th ed). Philadelphia: Lippincott. Martin, E. J., et. al. (2010). Intrapartum Management Modules: A Perinatal Education Program (4th ed). Philadelphia : Lippincott.

Cunnighanm, F.G., Gant, N.F., Leveno, K.J., Gilstrap, L.C,, Hauth, J. C and Wenstrom, K.D. (2001). Williams Obstetrics (21st ed). New York: McGraw-Hill.

Oxorn, H. (2001) Oxorn-Foote: Human Labor and Birth (5th ed). Connecticut: Appleton-Century-Crofts