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The Second Stage of Labour

The Second Stage of Labour. Max Brinsmead PhD FRANZCOG March 2013. Subjects to be covered:. Definitions What is the evidence that interventions are useful in the 2 nd stage: Limitation on the length Position to adopt Coached pushing and or breath-holding What is recommended for:

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The Second Stage of Labour

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  1. The Second Stage of Labour Max Brinsmead PhD FRANZCOG March 2013

  2. Subjects to be covered: • Definitions • What is the evidence that interventions are useful in the 2nd stage: • Limitation on the length • Position to adopt • Coached pushing and or breath-holding • What is recommended for: • Observations in the 2nd stage • When to intervene • Maternal position for delivery • Advice to mothers about pushing • Reducing obstetric trauma • Care for patients with previous 30 and 40 trauma

  3. Resources: • Cochrane database • Pubmed • NICE (UK) Guidelines • My personal experience

  4. NICE recommends that the 2nd stage of labour be divided and defined as... • Passive Second Stage • From the time of 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 • There are symptoms or signs of full dilatation • OR • The baby is visible

  5. What is the evidence that the length of the second stage influences neonatal & maternal outcomes? • All studies are observational in nature • Only one large US study (15,759 women) is corrected for various confounders • This study found that 2nd stage >4 hrs is associated with: • Increased rate of CS (OR 5.65, CI 4.46 - 7.16) • Assisted birth (OR 2.83, CI 2.38 - 3.36) • Chorioamnionitis (OR 1.75, CI 1.44 - 2.22) • 3rd & 4th degree trauma (OR 1.33, CI 1.07 - 1.67) • 5 min Apgar <7 (OR 1.45, CI 1.25 - 1.84) • Other studies have found association with: • Low 1 min Apgar • Rate of PPH • Risk of puerperal fever • Some studies (6041 women in Canada & 1915 women in Taiwan) found no such associations

  6. So does a review of what is “normal” help? • The mean plus or minus 2 SD for “normal” women with a “normal” outcome is: • 54 ± 142 minutes for Nullips • 20 ± 60 minutes for Multips • Note the very wide SD • And the variable is not normally distributed • So the answer is “NO”

  7. NICE conclusions for the length of the second stage • For nullipara • 2.5 hours without an epidural • 3 hours with an epidural • For the parous patient • 60 minutes without an epidural • 120 minutes with an epidural • NICE recommends: • Consultation with the obstetrician 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

  8. Scalp pH in Labour

  9. My observations: • It is obvious that there is fetal deterioration with increasing length of the second stage • Because the ultimate outcome is fetal death • Few women can actively push in a normal second stage with 2-3:10 contractions for more than 60 minutes • So most will accept or even welcome intervention when they have become exhausted • Provided there is no suspicion of fetal compromise the second stage can continue for as long as there is evidence of progress • But convincing a patient of the need for intervention on the grounds of possible fetal compromise is our greatest challenge

  10. Observations in the 2nd stage of Labour • There are no studies that provide guidance for our practice in this area • NICE recommends: • Hourly observations of BP and PR • Continue 4th hourly temperature checks • Observe and record contractions 30 minutely • Listen to fetal heart every 5 minutes for not less than 60 sec and after a contraction • Offer hourly vaginal examinations (but always with abdominal palpation of position and descent) • Encourage frequent bladder emptying • Attend to the woman’s psychological needs • My comments: • These observations may not be frequent enough to plan appropriate intervention • Interpretation of CTG is, as always, difficult • Effectiveness of pushing and progress is sometimes best done by evaluation of maternal behaviour

  11. What is the evidence that there is an optimal maternal position for the second stage of labour? • A systematic review of 19 trials (but not all good RCT’s) involving 5764 women compared: • Sitting, semi recumbent , squatting and lateral positions • Compared to… • Supine or lithotomy positions • Findings: • Reduced length of 2nd stage (weighted mean reduction 4.5 minutes, CI 2.94 - 5.65 minutes) • Fewer assisted births (RR 0.84, CI 0.73 - 0.98) • Fewer episiotomies (RR 0.84, CI 0.79 - 0.91) • Reduced pain (RR 0.73, CI 0.60 - 0.90) • Fewer abnormal CTG’s (RR 0.31, CI 0.08 - 0.98) • *More frequent 20 tears (RR 1.23, CI 1.09 - 1.39) • *More PPH’s (RR 1.68, CI 1.32 - 2.15) *Seems to relate to the use of rigid birth stools rather than upright position • No difference in analgesia required, 30 & 40 tears, need for transfusion, patient satisfaction, NICU admission or any neonatal outcome

  12. What about hands and knees? • One RCT in USA (147 women) of all fours for POP found: • No effect on the rate of head rotation • But less back pain • No effect on maternal or neonatal outcomes • Confirmed by a Swedish RCT of 271 women • Also found less perineal pain in the puerperium • But no effect on the length of the second stage • My observation: • Once you get used to the back to front mechanism of birth, then all fours, kneeling or standing with the accoucheur posterior has much to recommend it • And I still put a woman on her side with the back uppermost when there is malposition and slow progress in the second stage of labour

  13. NICE recommendations for maternal position in the second stage of labour • Women should be discouraged from lying supine or semi supine • But otherwise encouraged to adopt the position that is most comfortable for them

  14. Closed glottis or breath-holding in the 2nd stage labour? • Breath-holding → ↓maternal pO2 & oxygen saturation • Does this have adverse fetal effects? • A study by Simpson & James Nurs. Res. 2005 • Randomised 45 nullipara at 10 cm to either immediate pushing or delayed until the mother had the urge to push • Monitored fetal O2 saturation continuously, fetal & maternal outcomes • The early pushing group experienced: • Lower mean fetal O2 (12.5 vs 4.6, p<0.001) • More frequent O2 <30% for >2 min • More variable heart rate decels • More perineal lacerations • No difference in length 2nd stage, Apgars or cord pH

  15. What is the evidence that women should refrain from breath-holding pushing in 2nd stage labour? • Two RCT’s in the US (total of 450 women) compared coached (closed glottis) pushing with “doing what comes naturally” and found: • No difference in any neonatal or maternal outcome • Shorter second stage for coached patients in one study • (supported by a UK RCT with 32 women) • No adverse fetal or maternal effects from breath-holding pushing was confirmed in a Danish RCT of 306 nullipara but… • There was no effect on the length of the second stage • HOWEVER • Recruitment to the study was difficult and • Compliance with the allocated method was poor • Similar concerns about the earlier studies

  16. NICE recommendations about pushing in the second stage of labour • Women should be guided by their own urge to push • If their pushing is ineffectual then… • Provide support & encouragement • Change position • Empty the bladder • My observation: • I find this advice to be unhelpful • Some women obviously require advice about how to push • But the physiological evidence suggests that they should avoid really prolonged breath-holding

  17. Perineal Massage • One large RCT in Australia (1340 women in 3 sites) of midwife massage between contractions in the second stage: • No effect on any measure of obstetric trauma, pain, return to coitus or urinary and bowel function • There was no apparent measure of compliance • But the study is confirmed by a US RCT of 1211 women in which compliance was high • I am impressed by the RCT’s of the Epi-No device (a self-performed progressive dilation of the perineum from 36 weeks)

  18. Hot Compresses for the Perineum? • One large US observational study (2595 women) found that: • Warm compresses reduced the need for episiotomy in nulliparas and was borderline for multiparas • Also reduced the rate of spontaneous 20 tears in both • But this was not confirmed by another US RCT of 1211 women

  19. “Hands on” or “Hands poised” during delivery of the fetal head? • One large UK RCT of 5316 ♀ found: • A small reduction in perineal pain at 10 days from “hands on” • No difference in any measure of obstetric trauma • Inexplicably fewer manual removals in the “hands poised” group (2.6% vs 1.5%) • Broadly similar findings in an Austrian study of 1076 women • But episiotomy was more common in the “hands on” group • NICE concludes that either technique is appropriate • And noted evidence that there is less trauma when the head delivers between contractions

  20. Lignocaine spray for the perineum? • One RCT of 185 women found that: • No effect on perineal pain • But less dyspareunia when coitus was resumed • And fewer second degree tears in the treated group (RR 0.63, CI 0.42 – 0.93) • But NICE concludes that Lignocaine spray should not be used

  21. Routine or restricted use of episiotomy? • Seven RCT’s with 5001 women and 8 cohort studies with 6463 women. Meta analysis confirms that restricted episiotomy will result in: • Less posterior trauma (RR 0.87, CI 0.83 - 0.91) • More anterior trauma (RR 1.75, CI 1.52 - 2.01) • Fewer 30 and 40 tears (RR 0.74, CI 0.42 - 1.28) • 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

  22. NICE recommendations for the use of episiotomy • 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 • 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

  23. Birth after Previous 30 and 40 Trauma • There are no prospective trials and only a few retrospective studies • The risk of repeat 30 and 40 trauma is similar to the original incidence • There is some evidence that if the woman is asymptomatic then vaginal birth does not further increase the risk of those symptoms • There is some evidence that for symptomatic women then vaginal birth does increase the severity of those symptoms

  24. NICE recommendations for the care of patients with previous 30 and 40 trauma • Routine episiotomy is not recommended • Discussion about intrapartum care should cover… • Current symptoms of dysfunction of the anal sphincter • The previous trauma • The risk of recurrence • Success of previous repair • Psychological aspects of the trauma • Then a combined decision concerning subsequent mode of birth and intrapartum care can be made

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