Module 6 (23-24) & Module 7:The Second Stage of Labor Flashcards
Compare the traditional and alternative definitions of the second stage.
Traditional: complete dilation/10 cm
Alternative: urge to push/involuntary bearing down efforts
What is the physiologic basis for the urge to push.
Ferguson reflex is caused by a surge of oxytocin, usually at a +1 station. The nerve plexus is stimulated and causes that urge to push.
Discuss the duration of second-stage
“In a nulliparous woman, the diagnosis of a prolonged second stage should be considered when the second stage exceeds 3 hours if regional anesthesia has been administered or 2 hours if no regional anesthesia is used. In multiparous women, the diagnosis can be made when the second stage exceeds 2 hours with regional anesthesia or 1 hour without. A prolonged second stage of labor warrants a clinical reassessment of the woman, fetus, and expulsive forces (p. 2, 2003).”
Further relaxation of time limits is noted in the 2014 publication by ACOG and the Society for Maternal and Fetal Medicine OB Care Consensus Document “Safe prevention of the primary cesarean delivery”:
“A specific absolute maximum length of time spent in the second stage of labor beyond which women should undergo operative delivery has not been identified.
Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following:
At least 2 hours of pushing in multiparous women
At least 3 hours of pushing in nulliparous women
Longer durations may be appropriate on an individual basis (eg, with the use of epidural analgesia or with fetal malposition) as long as progress is being documented.”
Discuss complications associated with the duration of second stage
A prolonged duration of the second stage is associated with increased maternal mortality, infection, PPH, 3rd/4th-degree lacerations, and shoulder dystocia. (Studies are inconsistent)
Prolonged second stage and neonatal complications are unclear. Some studies show no increased risk, and others find low APGAR, NICU admission, and sepsis. Most studies find no neonatal mortality risk.
Is there evidence that pushing before complete dilation causes complications?
It is believed that early pushing can cause cx edema and tearing, but the evidence is ONLY ANECDOTAL!! AKA there is NO evidence
Some birthing people reach complete dilation before an urge to push develops. What is the impact on outcomes of delaying pushing in this situation until an urge is present?
Evidence on delayed pushing is inconsistent. Some suggest a 1-2 delay or until the head is visible at the introitus. Most find longer second stages with less active pushing, fewer operative deliveries, and equal or superior outcomes for maternal and neonatal complications. ACOG supports immediate pushing.
Compare coached versus spontaneous pushing regarding fetal oxygenation, perineal trauma, and postpartum pelvic function.
Coached pushing without an urge can result in ineffective pushing, which may cause maternal exhaustion, fetal acidosis, and feelings of failure.
Spontaneous pushing causes less perineal trauma, better fetal oxygenation, and less pelvic floor injury
What position is the only one we have any evidence on this risks of?
Upright position can cause increased perineal tearing
Understand the possible risks of pushing in the supine or lithotomy positions.
increased risk of severe perineal trauma, comparatively longer labor, greater pain, and more fetal heart rate patterns.
Know the impact of the following on the occurrence of genital tract laceration: Antepartum perineal massage
nullips performings massage 1-2 times weekly reduces the risk of genital tract trauma. Benefit decreases when the frequency of massage is 3+ times a week.
Know the impact of the following on the occurrence of genital tract laceration: Perineal massage during birth
to much massages can cause edema and be uncomfortable. Some massage but not to much is important.
Summarize the evidence regarding the impact of routine episiotomy on: Risk of 3rd and 4th-degree lacerations
Mediolateral episiotomy is associated with a lower risk of third- and fourth-degree laceration than a median episiotomy. You cannot know if a patient will tear until it happens.
Summarize the evidence regarding the impact of routine episiotomy on: Postpartum pain
episiotomy is known to be more painful. It is easier to repair but more painful to heal.
Know the indications for episiotomy.
When the clinical circumstances place the baby at risk: i.e. fetal heart tracing is of concern and hastening vaginal delivery is warranted.
Understand the current evidence on birthing persons and neonatal outcomes associated with birth in water.
ACOG and AAP have published statements in which the safety of waterbirth for neonates is questioned. In fact, there is considerable evidence supporting the safety of waterbirth for neonates. There is also evidence of birthing person benefits such as high levels of birthing person satisfaction with pain relief and the experience of childbirth. The evidence on perineal outcomes varies.
