Obstetrics Clinical Guidelines Group December 2010

ROYAL HOSPITAL FOR WOMEN

LOCAL OPERATING PROCEDURES

Approved by Quality & Patient Safety Committee

CLINICAL POLICIES, PROCEDURES & GUIDELINES MANUAL

SECOND STAGE LABOUR CARE
1. OPTIMAL OUTCOMES Maximising the probability of safe vaginal birth for mother and baby 2. PATIENT Woman in the second stage of labour 3. STAFF Registered midwives Medical staff Student midwives

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4. EQUIPMENT Fetal monitoring equipment : hand-held Doppler, Cardiotocograph (CTG), fetal scalp electrode Delivery pack 5. CLINICAL PRACTICE Confirm the presentation, position and station of the fetus and assess the uterine contractions for strength, duration and frequency Confirm that the cervix is fully dilated by vaginal examination on all nulliparous women unless the head is on view and either by vaginal examination or by obvious external signs in multiparous women prior to active pushing Encourage the woman to empty her bladder regularly or consider changes of position that encourage progress. If unable to void and there is a palpable bladder, recommend urinary catheterisation Encourage the woman to choose a position that is most comfortable for her Auscultate and record the fetal heart rate every 5 minutes for 1 minute duration after a contraction, or if indicated monitor continuously Ensure adequate hydration Consult with the obstetric staff if the contractions become ineffective in the second stage Allow one hour for descent of presenting part if there is no urge to push Offer to turn the epidural down if the woman has no urge to push if one is present Reassess the woman one hour from the start of the active phase and inform the midwifery coordinator and obstetric staff on delivery suite if delivery is not imminent Inform the registrar on delivery suite prior to active pushing if after an hour of passive descent the fetal head remains above the spines Notify obstetric staff if there are concerns with the fetal heart rate Document evidence of descent of the presenting part, fetal heart rate or review by obstetric staff 6. HAZARDS / SUB-OPTIMAL OUTCOMES Perinatal morbidity and mortality Maternal morbidity including post partum haemorrhage, infection, severe perineal trauma and pelvic floor dysfunction, maternal exhaustion Increased assisted birth 7. DOCUMENTATION Partogram Integrated clinical notes ObstetriX Database ../2
Minor amendment by Obstetrics LOP Group June 2011 Reviewed December 2010 Previously titled Second Stage of Labour Guidelines Approved Quality Council 16/10/06

Obstetrics Clinical Guidelines Group December 2010

2.

ROYAL HOSPITAL FOR WOMEN

LOCAL OPERATING PROCEDURES

Approved by Quality & Patient Safety Committee

CLINICAL POLICIES, PROCEDURES & GUIDELINES MANUAL

SECOND STAGE LABOUR CARE contd

17/3/11

8. EDUCATIONAL NOTES The second stage of labour can be divided into two parts : o the passive, latent or descent phase when the cervix is found to be fully dilated prior to or in the absence of involuntary expulsive contraction. During this phase the fetal head descends through the pelvis and flexion and internal rotation occur o the active or pelvic floor phase is recognised when there is active maternal effort following confirmation of full dilatation or the babys presenting part is visible The urge to push is related to the level of the fetal head and pressure on the pelvic floor musculature not on the cervix being fully dilated. A significant number of women, both nulliparous and multiparous, have an urge to push before full dilatation. Premature pushing before full dilatation can lead to maternal exhaustion and cervical oedema and tears There is no indication for routine episiotomy A full bladder will delay descent of the fetus and pressure may result in bladder damage As the second stage progresses the probability of a spontaneous vaginal delivery remains but is reduced with time A prolonged phase of active pushing is associated with maternal neurological injury to the 2 perineal structures The maternal upright position in second stage provides benefits of shortening the second stage, reducing instrumental deliveries, reducing episiotomies, less abnormal fetal heart rate 3 patterns and reduced severe pain. However it may be associated with increased blood loss The lateral position has been shown to be beneficial during the passive or descent phase, reducing instrumental deliveries in nulliparous women with epidurals Postural changes may be a beneficial intervention to correct malposition or asynclitism and to prevent neurological injuries in the mother resulting from prolonged exaggerated flexion of the legs and sustained bearing down Current evidence supports allowing time for fetal descent prior to pushing with epidural analgesia. This has been shown to reduce instrumental deliveries and second stage caesarean sections. Overall, delayed pushing leads to an increase in the duration of the second stage which has shown to increase the risk for pelvic floor trauma. It does not increase the risk of postpartum haemorrhage. No evidence for adverse effects has been shown with infant Apgar scores, resuscitation, umbilical artery pH scores, fetal trauma or perinatal death when women have delayed pushing with epidural analgesia 9. RELATED POLICIES / PROCEDURES / CLINICAL PRACTICE GUIDELINES Care of a woman in normal labour Assisted vaginal birth Intrapartum fetal heart rate monitoring Care of woman in second stage with an epidural 10. REFERENCES 1 Rouse, DJ. Weiner, SJ. Bloom, SL. et al (2009) Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. American Journal of Obstetrics and Gynaecology 201 357.e1-7 2 Wong, Cynthia A. MD; Scavone, Barbara M. MD; Dugan, Sheila MD; Smith, Joanne C. MD; Prather, Heidi DO; Ganchiff, Jeanne N. MPH; McCarthy, Robert J. PharmD et al. Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstet Gynecol 2003;101:27988 3 Gupta JK, Hofmeyr GJ, Smyth RMD. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2

Minor amendment by Obstetrics LOP Group June 2011 Reviewed December 2010 Previously titled Second Stage of Labour Guidelines Approved Quality Council 16/10/06