laboring down
TRANSCRIPT
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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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Methodology (continued)
Women in immediate pushing group
Women in delayed pushing group
head was seen at the introitus OR
in multiparas
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Methodology (continued)
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.