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PubMed1997

Nursing management of second stage labor.

Despite considerable research into nursing management of second stage labor, traditional approaches continue to predominate. Women are still encouraged to deliver in a recumbent position using sustained, closed-glottis pushing. Current research suggests that utilizing an upright position with pushing that is open glottis and complementary with the involuntary bearing-down reflex produces good maternal/fetal outcomes. Issues such as position, second stage phases, and bearing-down techniques are discussed in view of recent research findings. Gaps in knowledge are identified and practice implications are clearly defined. Now is the time to apply research-based knowledge to nursing management of second stage labor.

Journal Article↗
PubMed1991

A randomized trial of birthing stool or conventional semirecumbent position for second-stage labor.

Two hundred ninety-four women were randomly allocated to a group in which the use of a birthing stool (experimental group) or a conventional semirecumbent position (control group) was encouraged. The birthing stool was 32 cm high and allowed the parturient to sit upright and to squat. The husband could sit close behind his wife and support her back. No differences were observed between the two groups regarding mode of delivery, length of the second stage of labor, oxytocin augmentation, perineal trauma, labial lacerations, or vulvar edema. Infant outcome measured by Apgar scores at 1 and 5 minutes postpartum and numbers of neonatal intensive care unit transfers was the same in both groups. Mean estimated blood loss and the number of mothers with a postpartum hemorrhage 600 ml or more were greater in the experimental group than in the control group. Women in the experimental group reported less pain during the second stage of labor, and they and their spouses were more satisfied with the birth position than were parents in the control group. Midwives were less satisfied with their working posture in the experimental group.

Adult↗
PubMed1989

Management of the second stage of labor: a review (Part I).

The second stage of labor is defined as that time from the completion of dilitation of the cervix to the delivery of the infant. Considerable controversy exists in the current obstetric and midwifery literature concerning the appropriate management of this stage of labor. With increased use of regional anesthesia, electronic fetal monitoring and the shift in favor of active management of labor, the second stage is often accompanied by forceful bearing-down efforts, repeated Valsalva maneuvers and an increase in the use of forceps, vacuum extraction and episiotomies. Probably the single strongest point resulting in active intervention in the second stage of labor is the rigid use of the Friedman Curve. This approach tends to insist upon a predetermined time interval and promotes early intervention. The opinions on both sides of this controversy are the topic of this review.

Female↗
PubMed1989

Management of the second stage of labor: a review (Part II). Maternal positioning as it relates to the management of the second stage of labor is reviewed.

In the previous article, the rigid use of the Friedman Curve, breathing techniques, and other management options for the second stage of labor were examined. This article concentrates on the affect of maternal positioning, on the length of the second stage of labor, and summarizes the contents of that former article and this one.

Female↗
PubMed2000

Intrathecal narcotics are associated with prolonged second-stage labor and increased oxytocin use.

BACKGROUND: Safe and effective labor analgesia is an important part of obstetric care. Intrathecally injected narcotics (ITN) are an effective alternative to epidural anesthesia, and are perceived less likely to interfere with the course and outcome of labor. Data on their effects, however, are sparse and contradictory. METHODS: Our retrospective study compared labor length, oxytocin use, delivery type, maternal side effects, and neonatal outcomes among women who received ITN (n=100) and a group who received intravenous narcotics or no analgesia during labor (n=100). We randomly sampled medical records with stratification for parity and collected data through systematic chart review. RESULTS: Women receiving ITN were more likely to be white. They experienced longer second-stage labors (73 minutes vs 40 minutes, P=.000) and used oxytocin twice as often. These differences remained significant after controlling for potential confounding factors. ITN use was also associated with a trend toward more cesarean sections (7% vs 1%, P=.06). More of the women receiving ITN required urinary catheterization (25% vs 5%, P=.000) and experienced significant pruritus (10% vs 0%, P=.001). Neonatal outcomes were similar for both groups. CONCLUSIONS: In our retrospective study, ITN use was associated with a significant prolongation of second-stage labor, which may be clinically relevant for women having their first child. ITN were also associated with increased oxytocin use and a trend toward more cesarean births. Whether these relationships are causal or a proxy for more difficult labors is a question for future prospective studies.

Adult↗
PubMed1990

Perinatal outcome after a prolonged second stage of labor.

It is commonly held that the second stage of labor should last no more than two hours because of an apparently increased risk of morbidity. The purpose of this investigation was to determine whether this commonly held notion is true in this era of close fetal monitoring and umbilical blood gas determination. Between May 1987 and October 1988, 50 (3.5%) of 1,432 uncomplicated term pregnancies ended in delivery after a second stage of labor lasting greater than 120 minutes. A prolonged second stage was associated more commonly with nulliparity, occiput posterior positioning, epidural anesthesia and a need for operative delivery but not birth weight greater than 4,000 g or a short umbilical cord. Infants born after a prolonged second stage did not have an increased incidence of umbilical artery pH less than 7.20 or of five-minute Apgar scores less than 7, nor did they need intensive care nursery admission. A prolonged second stage of labor appears not to impose an increased hazard on the fetus but does require close fetal monitoring and increases the possibility of operative delivery.

Apgar Score↗
PubMed2003

Myometrial thickness during human labor and immediately post partum.

OBJECTIVE: Morphologic studies suggest dramatic, asymmetric uterine growth during pregnancy that is caused by muscle cell hypertrophy. This growth is most marked at the fundus. Our objective was to evaluate sonographically the in vivo changes in myometrial thickness during active labor, second-stage labor, and after delivery. STUDY DESIGN: Abdominal ultrasound scans were performed on 52 term pregnant women to investigate the dynamic changes in myometrial thickness during the active and second stages of labor and immediately after delivery. Twenty-six women (mean +/- SEM gestational age, 39.09 +/- 0.3 weeks) were in active labor (cervical dilatation >4 cm with regular uterine contractions). An additional 26 nonlaboring women (gestational age, 39.8 +/- 0.2 weeks) provided control measurements. The myometrium was defined sonographically as the echo homogeneous layer between the serosa and the decidua. Myometrial thickness was measured at the low segment and mid anterior, fundal, and posterior uterine walls by the same observer. Myometrial thickness was also measured during uterine contractions and after artificial rupture of the amniotic membranes. All laboring women had uncomplicated labor patterns when studied and were delivered spontaneously. RESULTS: The myometrium was significantly thinner during active labor compared with nonlabor at each site studied: midanterior (mean [+/-SEM] myometrial thickness, 5.8 +/- 0.27 vs 8.83 +/- 0.51 mm; t test, P <.001), fundus (mean myometrial thickness, 6.78 +/- 0.32 vs 8.49 +/- 0.35 mm; P =.0015), and posterior (mean myometrial thickness, 6.22 +/- 0.34 vs 8.12 +/- 0.30 mm; P <.001). However, myometrial thickness did not differ among sites within the two groups. The thickness of the low segment was not affected by labor status (nonlabor, 4.68 +/- 0.48 vs labor, 4.66 +/- 0.37 mm; P =.97). Similarly, the myometrial thickness of the anterior uterine wall was unaffected by contractions (no contractions, 5.56 +/- 0.2 vs contractions, 5.68 +/- 0.22 mm; t test, P =.654). There was no change in myometrial thickness measured immediately before and after rupture of the amniotic membranes, despite a significant decrease of the amniotic fluid index. There was significant thickening of the anterior and fundal myometrium during the second stage of labor after the fetal head descended to +3 station by digital examination (anterior, 12.99 +/- 0.60 vs 5.8 +/- 0.27 mm; t test, P <.001; fundus, 10.61 +/- 1.63 vs 6.78 +/- 0.32 mm; t test, P =.04). Valsalva maneuver (pushing) during contractions did not affect myometrial thickness at the fundus (between contractions, 10.61 +/- 1.63 vs pushing, 10.76 +/- 1.95 mm; t test, P =.99). Immediately after delivery, the myometrial thickness at the placental insertion site was the thinnest. After completion of the third stage of labor, the uterine fundus remained significantly thinner than the anterior and posterior walls (fundus, 27.37 +/- 3.5 mm vs anterior, 40.94 +/- 3.5 vs posterior, 42.34 +/- 2.44; one-way analysis of variance, P =.02). CONCLUSION: There is significant and widespread thinning of the myometrium during active labor. Descent of the fetal head during the second stage of labor is associated with a significant relative thickening of the anterior and fundal myometrium. After delivery, the relationship reverses. These findings suggest the directionality of the expulsive force vectors (fundal dominance) is not determined by asymmetric myometrial growth but, rather, may be a function of increased "myometrial mass" that results from increased surface area at the fundus.

Adult↗
PubMed1981

Intrapartum fetal heart rate monitoring. V. Fetal heart rate patterns in the second stage of labor.

A total of 1,755 fetal heart rate (FHR) tracings of the second stage of labor was analyzed. The FHR patterns were classified according to the behavior of the baseline FHR and are listed in decreasing order of benignity: normocardia, transitory bradycardia, tachycardia, persistent bradycardia, and progressive bradycardia. Each category was further subdivided into four groups on the basis of association or nonassociation with early, variable, or late decelerations. Cord compression pattern were noted in over 50% of the FHR tracings and account for the majority of low Apgar scores and fetal acidosis. FHR abnormalities occurred in 91% of second-stage labor patterns, and were mild in most cases or of too short duration to influence fetal outcome. An effort was made to establish therapeutic guidelines based on the morphologic features, prognostic grading, and the etiology of the FHR patterns in the second stage of labor.

Bradycardia↗
PubMed1990

Continuous epidural infusion of 0.0625% bupivacaine-0.0002% fentanyl during the second stage of labor.

A randomized, double-blind, placebo-controlled study was performed to evaluate the analgesic efficacy and influence of continuing an epidural infusion of 0.0625% bupivacaine-0.0002% fentanyl during the second stage of labor in nulliparous women. When the cervix was fully dilated, coded study solution was substituted for the known bupivacaine-fentanyl solution. The study solution for 29 patients was 0.0625% bupivacaine-0.0002% fentanyl; 34 patients received saline placebo. The two groups had similar pain scores during the first stage of labor. During the second stage, pain scores were significantly higher in the saline-placebo group at each 30-min interval between 60 and 150 min after the diagnosis of full cervical dilation. Similarly, there was a significant difference between the two groups in global assessment of analgesia quality during the second stage, but the difference occurred in those patients with a second-stage duration of greater than or equal to 60 min. Among the women who delivered vaginally, eleven of 28 (39%) women in the bupivacaine-fentanyl group, versus five of 34 (15%) in the saline-placebo group, had surgical perineal anesthesia for vaginal delivery (P less than .05). Six of 28 (21%) women in the bupivacaine-fentanyl group, and five of 34 (15%) in the saline-placebo group, underwent instrumental vaginal delivery (P = NS). The median duration of the second stage of labor was 53 min (range = 5-283) in the bupivacaine-fentanyl group, and 63 min (range = 16-181) in the saline-placebo group (P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, Epidural↗
PubMed1983

Maternal half-sitting position in the second stage of labor.

The maternal half-sitting and supine position during the second stage of fullterm labor was compared in 100 women who, after identical opening phases in supine position, randomly delivered in half-sitting (50 degrees, n = 50) or supine position (n = 50). The whole duration of the second stage of labor or the time spent in active pushing did not differ between the groups. Vacuum extraction was needed twice (4%) in the group delivering in half-sitting and six times (12%) in the group delivering in supine position. Vaginal tear occurred in one mother in both groups. Early decelerations in fetal cardiotocography were seen 22 times in half-sitting and 14 times in supine group (p less than 0.05). However, late decelerations were seen in only one mother with half-sitting, as compared to five mothers with supine position. Four infants of mothers giving birth in supine position had 1 minute APGAR scores 7 or less, whereas all infants of mothers delivering in half-sitting position had APGAR scores higher than 7. Subjectively the mothers liked more the half-sitting position. We conclude that a women can deliver in half-sitting position without maternal or fetal risks.

Adult↗
PubMed1987

Continuous infusion epidural analgesia with lidocaine: efficacy and influence during the second stage of labor.

A randomized double-blind study evaluated the analgesic efficacy and influence of maintaining a continuous epidural infusion of 0.75% lidocaine during the second stage of labor in nulliparous women. When the cervix was 8 cm or more dilated, unidentified study solution was substituted for the known 0.75% lidocaine solution and continued until delivery. The study solution for 26 patients was 0.75% lidocaine; 27 subjects received saline. During the first stage of labor, 88% of women in the lidocaine group and 81% of women in the saline group had analgesia of excellent or good quality, a nonsignificant difference. During the second stage, there was a tendency (not statistically significant) toward improved analgesia quality in the lidocaine patients, but there was no significant difference in the frequency of perineal anesthesia (23% lidocaine, 7% saline). There was no difference between the groups in the duration of the second stage of labor (73 +/- 63 versus 76 +/- 48 minutes). Operative delivery frequency was similar (31 and 37%), as were umbilical cord blood acid-base values. It is concluded that maintenance of the continuous epidural infusion of 0.75% lidocaine did not prolong the second stage of labor, but it also did not significantly differ from saline in quality of second stage analgesia or frequency of perineal anesthesia.

Anesthesia, Epidural↗