Midwifery Management of the Second Stage of Labor PDF

Midwifery Management of the Second Stage of Labor  The Family-Centered Birth Environment The decision of who to include in the birth room is an important one. Most hospitals allow any number of support persons in the labor room, though restrictions are likely to be placed on the number o...

Midwifery Management of the Second Stage of Labor  The Family-Centered Birth Environment The decision of who to include in the birth room is an important one. Most hospitals allow any number of support persons in the labor room, though restrictions are likely to be placed on the number of persons able to be in the operating room if a cesarean birth is necessary. Hospitals today also often allow siblings to be present during labor and birth; if children will be present, however, the institution usually requires the presence of an adult whose primary responsibility will be care of the child.  Maternal Pushing Efforts oSeveral management options may be initiated for helping women push during the second stage of labor, including: passive descent open versus closed glottis technique spontaneous versus directed pushing. oAn initial consideration is whether a period of passive descent would be beneficial for the woman who has an epidural or who does not have an urge to push. oOnce active pushing begins, pushing efforts can be open glottis versus closed glottis (Valsalva).  Delayed Pushing: Passive Descent Versus Immediate Maternal Pushing Efforts Passive descent as a management strategy was initially introduced for the purpose of reducing the incidence of instrumental birth in women using epidural analgesia. Most of studies defined passive descent as no active pushing for 1 to 2 hours unless an uncontrollable urge to push developed or the fetal head was visible at the introitus. The theory behind its use is as follows: During the process of passive descent (also referred to as laboring down), the fetus descends in response to the force generated from contractions alone and begins to internally rotate once the presenting part reaches the pelvic floor. Encouraging a period of maternal rest prior to engaging in active pushing efforts allows for conservation of the woman’s energy until there is a physical stimulus to actively push. Once the woman does engage in active pushing, her efforts will be more effective and efficient in the presence of physical cues from pressure of the presenting part on the pelvic floor.  Open-Glottis Versus Closed-Glottis (Valsalva) Pushing Traditionally, women have been counseled to take a deep breath, hold their breath, and push forcefully throughout the duration of a uterine contraction. The use of breath holding combined with prolonged bearing down results in a Valsalva maneuver that can decrease cardiac output and subsequent blood flow to the uterus. Conversely, open-glottis pushing is similar to the semi-voluntary grunting and pushing associated with defecation. Because the glottis is not closed, this form of maternal pushing effort does not greatly increase intrathoracic pressure and, therefore, does not affect cardiac output.  Open-Glottis Versus Closed-Glottis (Valsalva) Pushing Studies that have compared Valsalva-type closed-glottis pushing to open-glottis pushing have found that Valsalva-type pushing is associated with: more FHR decelerations higher incidence of perineal trauma (lacerations, episiotomy) maternal exhaustion Increased risk for cystocele and urinary stress incontinence. closed-glottis pushing is not recommended in practice today!  Spontaneous Versus Directed Pushing Spontaneous pushing occurs when a woman in labor responds to the strong sensations of rectal pressure and an urge to push with bearing-down efforts and open-glottis pushing. In contrast, directed or coached pushing occurs when the healthcare provider instructs the woman to push in a specific manner, including direction for the woman to take a deep breath and hold it for a sustained period, typically “to the count of 10.” Directed pushing also includes providing direction for a woman to push before she feels an urge to do so and asking her to hold the push beyond what she would do spontaneously. While there are gaps in the literature regarding the benefits of spontaneous pushing, its use has not been shown to cause harm to either the woman or her newborn. Maternal Position During the Second Stage of Labor  Preparing for the Birth The midwife should be aware of institutional criteria for use of a specific location. For example, in some settings the presence of meconium-stained fluid may require added personnel to be in attendance and the location of the birth to change. Two healthcare providers should always be present. The presence of additional personnel also depends on any risk factors that may be present. It is the responsibility of the midwife to consider the unique risk factors of the woman and newborn, to request the necessary resources and to know how to activate the call for emergency support if an unexpected complication occur. In general, if labor is progressing normally, it is best to begin preparations for birth before complete dilation if the woman is multiparous and at the beginning of second-stage labor if the woman is nulliparous.  Management of the Birth Management of the birth includes: using standard hand maneuvers to support the birth immediate assessment of the newborn immediate assessment of maternal status after the birth. In managing the birth, the midwife may need to make quick sequential decisions about the following: (1) How to provide supportive direction to the woman in labor through the final perineal phase of the second stage of labor (2) whether to use warm compresses, perineal massage, or a “handsoff” versus “hands-on” approach (3) the best approach to maintaining perineal integrity while supporting birth of the head (4) whether to cut an episiotomy (5) where to place the newborn immediately after birth (skin-to-skin contact) (6) when to clamp and cut the umbilical cord.  Perineal Integrity As the birth begins, the first focus is on promoting perineal integrity and preventing perineal lacerations. Birth positions known to decrease the incidence of genital tract trauma include lateral and semi-upright positions. Squatting is associated with more second-degree lacerations, perhaps because it is a position in which the midwife may have difficulty controlling extension of the fetal head. The position associated with the highest incidence of genital tract trauma is lithotomy because marked abduction of the thighs stretches the perineum transversely so that it becomes a tight band without significant ability to flex around the emerging head.  Perineal Integrity Perineal support techniques that are purported to decrease the incidence of genital tract trauma include: warm compresses perineal massage “hands-off” versus “hands-on” perineal support. Most women who give birth vaginally sustain some degree of perineal trauma. Severe perineal lacerations that extend through the anal sphincter are termed “obstetric anal sphincter injuries” (OASIS). Perineal lacerations can result in both short-term and long-term morbidity and pain.  Episiotomy Routine episiotomy was part of standard obstetric management until the 1990s, as it was historically believed that an episiotomy would decrease the incidence of perineal lacerations and brain damage in the fetus/newborn. The change from routine episiotomy to the rare use of episiotomy occurred over the course of a decade in the 1990s. In 1989 a seminal study that found episiotomies are more likely to result in third- or fourth degree lacerations than are spontaneous perineal tears. Today routine episiotomy is not recommended.  Episiotomy The primary indication for an episiotomy is an FHR pattern that indicates a rapidly increasing risk that the fetus is developing acidemia. An additional argument can be made that an episiotomy is beneficial in anticipation of use of forceps or vacuum extractor, or in the presence of risk factors for shoulder dystocia. However, there is no evidence that an episiotomy is beneficial prophylactically in these situations, and this procedure clearly increases the risk for an extension to or through the anal sphincter. If an episiotomy is determined to be indicated, local anesthesia or a pudendal block can be instituted  Types of episiotomy A mediolateral episiotomy is less likely to result in a third- or fourth-degree laceration than is a midline episiotomy. If the distance between the posterior fourchette and the rectal sphincter is unusually short, a mediolateral episiotomy may be preferable to prevent laceration through the rectal sphincter, especially if the woman has any condition that impairs healing ability, which would increase the chance that the episiotomy repair would break down. A midline episiotomy is less painful than a mediolateral episiotomy during the healing process because there are fewer nerve branches in the locale of a midline episiotomy and its repair, but the risk of a fourth-degree laceration is higher when a midline episiotomy is used.