Laboring Down

7/30/2019 Laboring Down

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Labor: Laboring Down

Maggie Shaw, CNM, PhD


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This talk is limited to

Diagnosis and management of second

using the technique known as laboring

wn.

Discussion of the associated benefits

Recommendations for practice


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Ideal Mana ement of SecondStage

The ideal management of the second

vaginal delivery while minimizing the

ri k f m t rn l n n n t l m r i itand death. (Cheng, Hopkins, &Cau he 2004


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A Midwifery Perspective

the midwife in the contemporary socialcontext of birth care must learn not only howo n erpre e p ys ca an e avoraindicators of progress in labor, but s/he mustalso know how to transact the achievement ofa good birth; that is, one accompanied bythe healthiest possible newborn outcomes,

,birth experience, ideally one of joy and senseof accom lishment (Roberts, 2002)


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Ph siolo ic Process:Ferguson Reflex

Pelvic floor distended by descending

Stretch receptors activate and release

Leads to involuntary urge to push

Increases e ectiveness o uterinepushing


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What does the researchindicate?

Brief literature search of OVID and CINHIL forthe past 5 years.

Overall concerns center around

Diagnosis of the second stage of labor

prolonged second stage.

Are there benefits or risks to laboring down?

Do the benefits outweigh the perceived risksof prolonged second stage of labor?


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Traditional Definition of theSecond Stage of Labor

Complete dilatation of the cervix to the


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Definition of rolon ed secondstage of labor (ACOG)

Primipara More than two hours without regional

anesthesia

More than three hours with regionalanes es a

Multipara

ore an one our w ou regonaanesthesia


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One phase or several?

Phase 1: Passive

Fetal Descent

Phase 1: The Lull

ase : ctvePushing Efforts

bearing Down

Phase 3: Perineal


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The Lull or Passive FetalDescent

From complete dilatation until:

rhythmic, bearing down efforts


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Active Bearin Down/ActivePushing Efforts

From the onset of rhythmic bearing-

the presenting part no longer retreats

tw n rin - wn ff rt AKA Crowning


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Perineal

From crowning of the presenting part


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Laboring Down

Maternally led During the Lull or Passive Fetal Descent Phase,

,

When women identify a strong urge to push and/or

experience rhythmic bearing-down contractionsc ve us ng ase , en encourage

spontaneous, involuntary bearing-down effortsincluding grunting, groaning, exhaling during the

pus , an reat o ng ess t an secon s


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Active Pushing VersusPassive Fetal Descent in

Randomized Controlled Trial

Hansen, Clark, & Foster (2002)


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Comparison of perinatal outcomes between

women w o pus e a compe e a a on anthose who had a period of rest before pushing

Randomized, controlled clinical trial =

(81% of total enrolled)

W m n with i r l f r m l tdilatation), no know fetal anomaly,singleton, 37-42 weeks GA, vertex,

otherwise uncomplicated pregnancy VBACs included in primipara groups


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Methodology

Computerized fetal monitoring system atbedside that included FHTs, demographicand admission info, labor, delivery, and

recovery info. Continuous fetal and uterine contraction

monitoring

o tware program t at prompte nurses toenter dependent and confounding variable


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Methodology (continued)

Same nurse reviewed all FHR tracingsand determined number and type offetal decelerations in second stage.

Nurse or physician did VEs todetermine complete dilatation

Women were randomly assigned to

Group 1 (pushing) or Group 2 (rest anddescend before pushing)


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Women in immediate pushing group

Women in delayed pushing group

head was seen at the introitus OR

in multiparas


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Maternal fatigue assessed: After epidural placed and mother comfortable

Within 15 minutes of complete dilatation

Within 60 minutes after delivery of placenta Assessed every 30 minutes:

Uterine contractions

Pt.s bladder Introitus for presenting part


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Results

No significant difference in rate of descent from onsetof pushing to delivery

group) than Group 1 (active pushing) in both primips

and multips (not significant) rmps n o groups a grea er a gue scores,

but those in Group 2 had significantly less than thosein Group 1

No difference in fatigue scores among multiparouswomen


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Results (continued)

Total number of fetal decelerations (all types) insecond stage significantly less with laboring down

Mild variable decelerations (among primips and

multips), moderate and severe variable decelerations,(among multips) were all significantly less in Group 2(delayed pushing) compared with Group 1

ere were no ate eceeratons on t e montorstrips n this study


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Results (continued)

No statistical difference in:

Umbilical arterial cord pH

Perineal injuries

but not significant)


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Potentiall ConfoundinVariables

Bladder status Position changes (Group 1 primips changed

positions more frequently)

Uterine contraction pattern (Group 2 [delayed

contraction pattern)

pushing began (Group 2 primips and multipshad increased pushing frequency)


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Myles and Santolaya (2003)

Compared women with second stage of labor< 2 hours and > 2 hours to determine riskac ors or pro onge secon s age anevaluate maternal and neonatal outcomes

6791 patients Group 1 (n=6259) < 120 minutes

Group 2A (n=384) 121-240 minutes Group 2B (n=148) >240 minutes


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M les and Santola a 2003Results

Prolonged second stage associated with a high rate ofvaginal delivery, a high rate of maternal morbidity but not

Group 2 had higher rates of perineal trauma, episiotomy

usage, chorioamnionitis, post partum hemorrhage, andopera ve vagna e very .

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.


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Factors Associated withProlonged Second Stage

Diabetes

Macrosomia

Nulliparity

Chorioamnionitis

Oxytocin usage


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Plunket, et al (2003)

N=202 (randomly assigned to immediately pushing ordelayed pushing)

All had continuous low-concentration epidurals

Women in delayed pushing group had:

stronger urge to push

lon er second sta e from com lete to deliver

No difference in:

time spent actively pushing,

Median level of atient satisfaction

Cesarean or vaginal delivery Neonatal or maternal morbidity


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Fitzpatrick, et al (2002)

Prospective, randomized, controlled trial N = 178

Assessed effects of delayed versus

immediate ushin in second sta e withepidural analgesia on

delivery outcome

Postpartum fecal continence Postpartum anal sphincter and pudendal nerve


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Fitz atrick, et al 2002Results

High overall rates of pudendal nerve damage, analsphincter 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


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OConnell, et al (2003)

Retrospective, case controlled study identifyingfactors associated with a prolonged second stage

N=364 (182 women with second stage < 2 hours

and 182 women with second stage > 2 hours) pon aneous vag na e very

< 1 hour 86.3%

1-2 hours 83%

2-3 hours 64% 3-4 hours 50%

> 5 hours 0%


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O'Connell, et al (continued)

Assisted vaginal delivery rate doubled if secondstage > 4 hours

< 2 hours 4.7 %

2-3 hours 6.7% - ours .

No difference in neonatal outcomes

Women with lon er second sta es were older, had

bigger babies, more likely to have an epidural andoxytocin augmentation


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Myles and Santolaya (2003)

Retrospective study (N=6791) to

second stage of labor and evaluate

m t rn l n n n t l t m Group 1 (n=6259) < 120 minutes

= - Group 2B (n=148) >240 minutes


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M les and Santola a 2003Results

Prolonged second stage associated with a high rateof vaginal delivery, a high rate of maternal morbidity,

Group 2 had higher rates of perineal trauma,

episiotomy usage, chorioamnionitis, post partum,.001)

Group 2B had higher rates of episiotomy usage,

operatve vagna e veres, an pernea trauma t anGroup 2A (P < .001)

Neonatal morbidit was the same for both rou s


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Factors Associated withProlonged Second Stage

Diabetes

Macrosomia

Nulliparity

Chorioamnionitis

Oxytocin usage


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What are the questions?

How long is too long for second stage of

What are the benefits of delayed

What are the risks?

Is there a way to make an evidencedbased decision?


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Optimal Obstetrical Conditions

To diagnose the second stage of labor, the practitionermust assess all three factors Cervical dilatation

Fetal position

Station

If woman is instructed to push too soon, may result in out-of-sync pushing, longer active pushing phase, andmaternal exhaustion.

Laboring Down

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