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
Lacerations – classified
Cervix – usually lateral
Vaginal sulcus or “lateral wall”
Periurethral
Perineal, including episiotomy
1st, 2nd, 3rd, 4th
Cervical laceration
Inspect with 4-finger retraction
2 ring forceps →
Begin repair above apex
Running suture of 0-Vicryl or 2-0-Vicryl
Vaginal sulcus or “sidewall” laceration
Inspect, as with cervix You’ll never see it unless you look Get help – right angle retractors Running suture of 0 or 2-0 Vicryl Avoid the dead space – approximate the vaginal mucosa only - Bleeding not usually an issue - Ureters are lurking!!!
Periurethral laceration
Inspect urethra + adjacent area
“Abrasion” or “skid mark” – leave alone if not bleeding
Re-approximate if not superficial
Interrupted 4-0 Vicryl w/ “GI” needle
No need to start above apex of lac
Stay away from urethra!
Warn patient about (external) dysuria after
First degree repair
Often not necessary
Running 3-0 Vicryl
Second degree repair
(perineal muscles torn)
“Continuous” repair 3-0 Vicryl Start above vaginal apex Vag mucosa = running interlocking “Pull-through”, then “crown” Perineal fascia = running, not locking Running subcuticular back up to hymen Use your non-dominant hand as a tripod
Third degree repair
(anal sphincter is torn)
Do rectal exam first. New glove. Identify anal sphincter – may need to reach for it. Hold R and L sides in Allis clamps It’s about the capsule, not the muscle! Use strong suture (0 Vicryl) 4 sutures, interrupted, in capsule Now, you have a “second degree” - repair Do rectal exam after finished
Fourth degree repair
Careful exam
Don’t do this one alone!
Irrigate
Vision is everything
Great lighting
Get an assistant
Have epidural re-injected
Rectal mucosa is repaired in two layers
Interrupted 4-0 Vicryl, “GI” needle. Start above apex. Submucosal. Avoid actual mucosa. At 5-7 mm intervals. Final suture is level with rectal sphincter.
Then, 4-0 Vicryl “running, imbricating” to reinforce rectum
Repair as 3rd degree, then as second degree
The “Buttonhole”
If deep 2nd, any 3rd, any 4th:
Do rectal exam before starting repair
Rectal buttonhole requires “opening” a “true 4th degree” and repairing from there
Care after the repair
Ice Hygiene – baby wipes Sitz, only to soak (shower for clean) NSAID’s, even opioids (3,4) No straining with BM’s (3, 4) Daily docusate sodium 100 mg BID x 2 weeks minimum No extra iron x 2-3 weeks
Lactation – a few pointers
Recognize inverted nipple(s). Coach patient on 4-way manual eversion Hydration is huge Baby sucks to start letdown, then drinks Break suction “Deep attachment” with latch-on “On demand” Rest Privacy HYDRATION !!!!!!!!! Limit visitors Continue prenatal vitamins
Hospital “Lactation Consultant”
ACA covers lactation assistance !!!!!!
Lactation– meds that are OK
NSAID’s – maybe not aspirin Certain antibiotics (not tetracycline) Opioids Tylenol Heparin/Lovenox – not warfarin
Lactation – the upside
Natural nutrition Immunity Bonding It’s FREE and instantly available No warming needed Baby has fewer allergies/asthma ETC!!
Lactation- cautions
Beware the “nursing Nazi’s”
Mom is not a “failure” if nursing doesn’t work out!
Don’t create a “maternal guilt trip”
Be ready to help the mom whose PP depression was actually caused by this very syndrome.
“Afterpains” PP
These are UC’s – uterus is involuting
NSAID’s
Heat
Soreness & discharge PP
“Lochia” for up to 6 weeks
Soreness abates after 7-10 days
Urinary issues PP
UTI’s and retention
Staff watches for voiding to return after delivery
Bladder scanner
Straight cath, even Foley x 2 weeks
Hemorrhoids PP
Most have these – varying degree
Stool softener – docusate sodium 100 mg daily or BID
Baby wipes
Thrombosis – get to CR surgeon
Hair loss PP
Due to abrupt ↓ in estrogen @ delivery
“Re-sets” follicles all into same phase
Time and reassurance – may take 6-12 months
Weight loss PP
Source of great concern – legitimize it Slow return to exercise, as tolerated Slow drop in weight is normal GOOD NEWS – baby is taking CALORIES with breast feeding! May take up to a year
PP Depression
Very common Some degree (“blues”) = normal Potentially very serious Recognize and treat (SSRI’s) Solicit reports from peds & family Hx of this is a WARNING SIGN Suicide = a leading cause of maternal death PP Psychosis
Coitus? PP
Avoid x 4 weeks minimum – better 6 weeks
Gentle
Have lube available
Lactation → lowers estrogen → vaginal effects
Either partner may be reluctant!!
BCM! – nursing offers little protection
Postpartum Appointment
Hx – nursing, menses, pain, dysfunctions Q&A What is plan for BCM? Lab – routine – Hct or Hgb Lab - special – e.g. FBS + HgbA1C if had GDM VS Breast exam – masses? Mastitis? Pelvic – check repair(s), consider Pap, bimanual (involution complete, adnexae clear)
