Second Stage of Labor, repairs and Lactation Flashcards
Second Stage should conclude with:
“Easy vaginal delivery
OR
Easy C/section”
As quoted from Watson A. Bowes, MD
Two phases of Second Stage
Passive Second Stage:
From full dilatation to the commencement of involuntary expulsive effort by the woman
Active Second Stage:
From the commencement of expulsive efforts by the woman
PLUS (invol pushing can occur before 10 cms)
There are symptoms or signs of full dilatation
OR
The baby is visible
Second stage - definition
From “full dilation” until birth of infant
How long should 2nd stage take?
Wide disparity in “data”
Longer = ↑ assisted births, infection, exhaustion, lower Apgars
For nullipara:
2.5 hours without epidural
3 hours with epidural
For the parous patient:
60 minutes without epidural
120 minutes with epidural
NIHCE = NICE (UK) recommends:
OB consult for a Nullipara whose delivery is not imminent after 2 hours
And 1 hour in a previously parous patient
Reassess all patients with an epidural who do not push within 1 hour after fully dilated
What position? - pushing
Mostly “patient choice”
NEVER “supine”/lithotomy
Sitting, Semi-Fowler’s, lateral, squatting
Pushing
Women should be guided by their own urge to push – there is a place for “passive descent”
If their pushing is ineffectual then… Provide support & encouragement Change position Empty the bladder OK to take a “break” !!!!!!!!!
Perineal Massage/Compresses
Works better w/ epidural
May encourage “reflex pushing”
May “thin” the perineum, reducing tearing and/or need for episiotomy
Overzealous → lacerations!!
Warm compresses OK – not hot!!
Use sterile lube if necessary – not some magic oil or potion
Lidocaine spray – not helpful
Episiotomy? Routine? Restricted?
Meta analysis confirms that restricted episiotomy will result in:
- Less posterior trauma
- More anterior trauma
- Fewer 30 and 40 tears
Some studies also point to:
- Overall more intact perineums
- Less perineal pain
- Quicker return to coitus with restricted use of episiotomy and
- More anal sphincter damage with liberal episiotomy
But no difference in…
Sexual function at 3m & 3 yrs; or bladder function
Episiotomy – NICE Recommendations
Routine episiotomy is not recommended for spontaneous birth
Episiotomy should be performed when clinically indicated
e.g. fetal compromise suspected or instruments required
Mediolateral episiotomy is best – NOPE, SORRY – see next slide
i.e. start at the posterior fouchette and proceed at an angle of 45 - 60 degrees
Tested anaesthesia is required
Except in an extreme emergency
Which Episiotomy?
Median or Midline: Easier repair Less blood loss Less pain after (early) Virtually no infections Cosmetically better Less pain after (later)
Greater risk of 3rd or 4th degree extension
Mediolateral: Difficult repair More bleeding More infections Delayed healing Scarring, Cosmesis
Low risk of 3rd/4th
Low risk of fistula
DO if short perineum
Hx of 3rd or 4th or fistula?
Try to avoid episiotomy altogether!
Consider mediolateral
Consider C/S – esp if hx of fistula
Second stage – intervention?
A few patients should not push at all
Otherwise, there is no reason to interfere unless there is failure to progress
This usually means arrest after 60 minutes of active pushing
Not just full dilatation plus 1 – 2 hrs
When the patient (and others) are ready for intervention
Second stage – Hands off!
Monitor fetus, station
Expect steady, if slow, progress
OK for mom to take “breaks”
Assisted delivery - 2 options
forceps or vacuum
1 OR the other, never 1 then the other
Repairs - general
Use absorbable suture
Use a suture that does NOT cause tissue inflammation. Vicryl® = OK. Chromic gut = not.
Vicryl® = polyglactin = braided sugar polymer
Choose size of suture suitable to task
Usually, place first suture above apex of lac
Close “dead space” – except for sulcus
