Post on 03-Jan-2016
description
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