CBL 3_Second Stage Management, Nuchal Cord

Question 1

What does a 2nd generally do at a home birth during the late first stage or second stage of labour:

Answer 1

• Provide assistance to the midwife
• Provide support to the client
• Check layout of supplies to ensure accessibility of drugs and instruments
• Auscultate, record and report the fetal heart rate to the midwife
• Check, record and report maternal blood pressure and pulse to the midwife
• Document in the health care record at the direction of the midwife.

Question 2

What does a 2nd generally do at a home birth during birth?(4)

Answer 2

• Provide assistance to the midwife
• Ensure warmth and safety of the newborn
• Check, record and report the condition of the newborn to the midwife
• Document in the medical record at the direction of the midwife.

Question 3

What do you include in your full report to the second?
3 big ones

8 fill in

Answer 3

– Client status
– Fetal status
– labour progress

– Gestational age
– Gravida/Para
– Rh neg/pos
– Risk factors
- If GBS + adaquete IAP?
- last void
- special requests of client
- hospital notified?

Question 4

Define active labour

Answer 4

regular intense contractions with evidence of cervical change over time

(monitoring progress in active labour from 6cms = evidence based so to avoid over diagnosis of labour dystocia)

Question 5

What is active first stage?

Answer 5

Textbook:

“regular, painful contractions and progressive cervical dilation”
Important to take the total clinical picture into account

(ctx strength, duration, frequency, Cervix change, fetal position & station change etc)

Question 6

What are the 2 stages of first stage?

Answer 6

Latent
Active

Question 7

Is Friedman curve still appropriate?

Answer 7

No – labour takes longer

Question 8

Why isn’t Friedman curve appropriate now?

Answer 8

(? Older birthers, increased use of epidurals, oxy, larger babies, increased BMI’s)

Question 9

What is the controversy around active first stage?

Answer 9

The Consortium on Safe Labour (and Zhangs work) suggest that both nulliparous and multiparous clients should not be considered to be in active labour until they reach 6cms dilated (hence; ‘6 is the new 4’)

But this isn’t reflected in SOGC guidelines.

Question 10

What is labour dystocia according to Zhang?

Answer 10

No dilation x 4 hrs w adequate contractions

Question 11

What is labour dystocia according to SOGC?

Answer 11

< 0.5cm/hr x 4 hrs
OR
no cx change x 2 hrs

Question 12

What was Friedman curve rate?

Answer 12

After 4 cm dilation averaging 3 cm (±2 cm) per hour until it reached 9 cm

Question 13

What should you consider around labour dystocia and 1st stage of labour?

Answer 13

Dystocia should NOT be dx prior to the onset of ACTIVE labor
AVOID going to the hospital in latent 1st stage if possible!

Question 14

What does ALARM suggest labour progression rate should be?

Answer 14

0.5 – 0.7cm/hr for nullips / 0.5 – 1.3 cm/hr for parous

Question 15

What are some proactive approaches to 1st stage of labour?

Answer 15

*Avoid & treat possible causes of prolonged latent/active labor early
*Attend to psychobiological factors that can promote or impede labor (P’s x 5)
*Trauma Informed Care for ALL clients
*Choice, Control & Continuity of care
*Labor Progress Handbook!

Question 16

Why is FHS done?

Answer 16

Fetal health surveillance is a screening test to detect fetal decompensation.
Done so to allow timely and effective intervention preventing fetal harm in the event of hypoxia

Question 17

Compare IA w/ EFM

Answer 17

-IA is a less sensitive tool but more specific than EFM.
-It is deemed sensitive enough when the likelihood of asphyxia is low.
-This has been shown to reduce false positives associated with EFM and thereby reduce unnecessary interventions & C/s’s

Question 18

Which is more sensitive IA or EFM?

Answer 18

EFM

Question 19

Which is more specific IA or EFM?

Answer 19

IA

Question 20

What are some of Simkin’s suggestions for supporting coping with pain and fear?

Answer 20

-Coping – acknowledge & reassure, support and encourage through difficult, intense, frequent ctx’s.
-The goal becomes getting her through by simplifying what needs to be done.
-‘Right now, all that matters is that you keep your rhythm through these contractions.
-Let me help you.
-Follow my moving hand with your breathing (or moaning) and keep that rhythm.
-We will get through this together’ - (maybe this one would be annoying?)

Question 21

What are some approaches to helping someone through fear in birth?(5)

Answer 21

• keep calm
• don’t rush
• encourage them to express her feelings
• validate their concerns
• give appropriate reassurance/ encouragement/ information/ suggestions.

Question 22

What should you do during latent 2nd stage if cx slow down and birthing person tired?

Answer 22

Allow/support rest/sleep

Question 23

Explain the physiology of the latent 2nd stage?(5)

Answer 23

• Not experienced by everyone
• attributed to the station and position of the fetal head…still above ischial spines so not yet pressure on the pelvic floor to stimulate expulsive efforts.
• Rest may happen while the fetal head rotates into an OA position.
• Ctx’s may become shorter and less frequent at this time
• Simkin & Ancheta suggest when the head slips through the fully dilated cx, there is ‘slack’ in the uterus and the muscle must ‘catch up’

Question 24

What is complicated about latent 2nd stage and medical mgmt.?

Answer 24

Patience is antithetical to the medical paradigm
Physiological plateaus are reported across the entire continuum of healthy labor and birth and may reflect a healthy mechanism of self-regulation of the mother-infant dyad. Although the notion of physiological plateaus contradicts a prevalent paradigm of continuous and linear labor progress, existing evidence is compelling and warrants further investigation. Of particular concern is a risk that some physiological plateaus may be misinterpreted as dystocia. Research on physiological labor patterns, including plateaus, is a matter of some urgency as it is a necessary precursor to efforts aimed at reducing unnecessary and harmful interventions.”

Question 25

What is active 2nd stage?

Answer 25

full dilation plus spontaneous expulsive effort (Generally accepted definition).
Likely starts once the pp reaches +1 station, usually now rotated to OA, stimulating surge of oxytocin and renewed ctx strength

Question 26

How could/should the 2nd stage be re-defined?

Answer 26

Stating it should be at full dilation + when the pp has passed through the cx and is below ischial spines’
So at this point the fetal ejection reflex will follow.
This defines a physiological 2nd stage.

Question 27

What would Simkin say to support the physiology of 2nd stage? (6)

Answer 27

• freedom to move
• positions of choice
• non directed pushing
• fluid as desired
• empty bladder
• hot compresses

Question 28

What are some signs of active 2ns stage of labour?(6)

Answer 28

• involuntary urge to push
• show
• stool
• anal dilation, purple (or pink line to top of buttock cleft in people of colour)
• engorgement or distension of vulva
• presenting part visible at introitus

Question 29

Is a VE always indicated before a client starts pushing?

Answer 29

No – take the whole clinical picture into account. If progression obvious by other means then a VE is not necessary. Wait and see approach….

Question 30

What does BCCNM recommend around cervical lip mgmt.?

Answer 30

• If the client expresses a desire to push when there is reason to believe the cervix may not be fully dilated, dilation should be checked by vaginal examination
• If the client is less than 8 cm dilated and has an irresistible urge to bear down, assist the client to avoid pushing

Question 31

What does the research in BCCNM mgmt of second stage say about cervical lips?

Answer 31

It is commonly believed that pushing when cervical dilation is not complete can be both unproductive and damaging to the cervix, especially in nulliparas.

However, Enkin et al (2000) reassure that in the presence of a rim of cervix and a strong desire to push, little or no harm is likely if this instinctive urge is followed and there is progress. Full dilation can be confirmed by careful vaginal exam or be assumed when the presenting part is visible at the introitus.

Question 32

If you do a VE and there is a cervical lip what does BCCNM recommend?

Answer 32

ok to push on lip/9cm (see BCCNM/text p270) but if 8cm or less avoid pushing!

Question 33

How can you help a client NOT push? (4)

Answer 33

position changes
water immersion
breathing through ctx
(+/- Entonox) aka Nitrous oxide

Question 34

How often FHR in 2nd stage?

Answer 34

FHR every 5min (or after e contraction).

Question 35

How often birthing person vitals in 2nd stage?

Answer 35

• consider’ T/BP more frequently
• May take Temp/ BP every hour?
• Record maternal HR q 30 mins in 2nd stage (as per SOGC 2020 Intrapartum Surveillance Guideline)

Question 36

What other than vitals are your monitoring in 2nd stage?

Answer 36

ensure bladder emptied
encourage adequate food/fluid
position changes.

Question 37

Spontaneous pushing means…(8)

Answer 37

• Breathing & pushing efforts are self directed
• Time of initiating push is irregular often begins once ctx is well established
• May be accompanied by grunting, short, frequent bearing down efforts w ctx’s
• Open glottis pushing
• Follows cues from own body
• No verbal instruction
• No non-verbal instruction (eg; deep breath cues from attendants)
• Caregivers offer encouragement/ praise.. NOT instruction

Question 38

Directed pushing means….(9)

Answer 38

Birther follows instructions/cues of caregiver:
* When to start/ stop
* Length of push
* Position for pushing
* When to breathe/ how long to hold
* Strength of push
* How to push
* No noise with pushing efforts
* May include VE’s, manual manipulation or stretching perineum

Question 39

What does Cochrane review say about directed pushing?

Answer 39

We are unable to say whether spontaneous pushing or directed pushing coaching methods are best.

Until further high-quality studies are available, women should be encouraged to push and bear down according to their comfort and preference

Question 40

What ways can we support physiology of pushing?(3)

Answer 40

• Support birthers innate ability to do it
• Not routinely offering directed pushing
• Supporting spon pushing WITH routinely facilitating mobility and upright positions

Question 41

Labouring down with an epidural yes or no?

Answer 41

Study suggests there may be some benefits for immediate pushing, but it’s just one study

-Study suggests immediate pushing could reduce chorio – but less VEs is the strongest link and labouring down has benefits

Question 42

Possible benefits of immediate pushing w epidural? (3)

Answer 42

• Shorter overall second stage
• Lower risk of PPH
• Lower risk of chorio

Question 43

Possible benefits of labouring down with an epidural?(4)

Answer 43

• Shorter overall pushing time
• Fewer variable decels
• Lower risk of neg effect on fetal oxygen
• Less maternal fatigue
• Less risk of 3 & 4th degree tears

Question 44

What is the rhombus of michaeleas? (4)

Answer 44

-Kite-shaped area that includes the three lower lumber vertebrae, the sacrum and that long ligament which reaches down from the base of the scull to the sacrum.
-Moves backwards during the second stage of labour and as it moves back it pushes the wings of the ilea out, increasing the diameters of the pelvis.
-Birhter’s hands reach upwards to find something to hold onto for stability, her head goes back and her back arches.
-Important to support it happening for phsyiological birth

Question 45

What is the fetal ejection reflex?

Answer 45

As our baby moves through the pelvis, they will stimulate the nerve endings and initiate powerful, involuntary, expulsive contractions that enable us to birth our babies.

Question 46

What is a reason we want to support a quiet undisturbed birth?

Answer 46

To support fetal ejection reflex

(among other reasons)

Question 47

What does BCCNM say about timeframe for second stage?

Answer 47

Three hours or so…

before the risk of maternal and/or fetal compromise begins to increase

Question 48

How does BCCNM define second stage dystosia?

Answer 48

1 hour of active pushing with no fetal descent

Question 49

What does the literature say about arbitrary time limits for 2nd stage? (4)

Answer 49

• There is no good evidence about the absolute time limits of physiological labour -
• Most researchers who have examined this area have shown that, the second stage of labour can last for up to three hours
• Second-stage dystocia is defined as greater than one hour of active pushing with no descent of the presenting part.
• Descent of** less than 1 cm per hour in the second stage **is associated with increased rate of operative delivery, maternal stress and anxiety, maternal infection and postpartum hemorrhage.

Question 50

What does Denis Walsh say about fetal outcomes related to length of second stage?

Answer 50

Questions the evidence on poorer fetal outcomes attributed to length of 2nd stage alone – several studies have supported this.

Perhaps poor outcomes are more related to labour practices around second stage than the prolonges second stage itself. - these practices get in the way of upright birthing positions and supporting physiological processes

Question 51

Key points of supporting physiological second stage? (6)

Answer 51

Care should be based on;
* Fetal and maternal condition
* Building client confidence and empowerment to birth
* Evidence of progress/ descent of pp
* Routine time restrictions & directed pushing not evidence based
* Clients encouraged to follow own instincts
* Midwife role to support and affirm physiology

Question 52

Management of nuchal cord? (4)

Answer 52

Managing the nuchal cord:
- Cord reduction: if cord is loose, provider can slip over head before shoulders are born
- Birthing through the cord: if cord is too tight for reduction, but has some ability to move slip it over the shoulders as newborn is born so babe is born through the cord
- Somersault maneuver: if cord too tight but still has some mobility, use a hand to flex baby’s head to one side of the birther’s thigh and the other hand somersaults the baby’s body over the perineum to reduce tension on cord; shoulders should be supported to emerge slowly without manipulating the cord; once baby is fully born, cord is unwrapped, regular cord management can occur
- Clamp and cut: if cord is too tight for any of the above maneuvers, clamp and cut cord at baby’s neck before birth of body
- Cutting cord before birth is associated with number of risks: hypovolemia, anemia, shock, hypoxic ischemic encephalopathy, rarely cerebral palsy; additional risk if cord cut before shoulders are born due to shoulder dystocia

Question 53

What is the preferred method of mgmt of nuchal cord?

Answer 53

Not to cut

• Cutting cord before birth is associated with number of risks: hypovolemia, anemia, shock, hypoxic ischemic encephalopathy, rarely cerebral palsy; additional risk if cord cut before shoulders are born due to shoulder dystocia

Question 54

Nuchal cord?

Answer 54

1- Checking for presence of nuchal cord - no strong evidence
2- Risks of nuchal cord - 20-30% of all births; most are not emergencies