By: Janet Grabe, RN, BSN, ICCE, CD(DONA), CLD
Col Sylvia Wood, RN, MSN, CNM at Tripler Army Medical Center is a Co-Investigator and the Site Coordinator in a multi-site study on management of the second stage of labor. She was kind enough to share some of their knowledge with us by providing several excellent presentations on four concepts:
1. Use of upright positions throughout the 2nd stage ["pushing" stage]*.
2. Women may push when they feel the urge to push.
3. Women should non-valsalva (open-glottis) pushing [aka: "purple" pushing]*.
4. The length of the second stage of labor should not be arbitrarily limited to 2 hours.
The entire presentation was fascinating and very well supported by about 50 articles, one of which involved a study of 4,400 women that did not support the concept that the baby suffers ill effects when 2nd stage extends beyond 2 hours. Studies have shown that labor will be shorter when upright positions are used for labor, with one study finding a mean difference in length of over 2 hours (shorter) for those who labor in the upright position.
If given any choice of positions, 95% of women will choose to be upright during labor and second stage. Of these women, 75% report feeling less pain and 95% report feeling more comfort when they are upright. The upright position enhances the baby's ability to twist and turn down through the pelvis. It also allows the mother to breathe easier and causes the most optimum blood flow to the baby. Some studies actually show more positive interactions take place when a woman delivers in an upright position.
More and more articles are describing 2nd stage as having 3 phases just as 1st stage does: latent(complete dilation without an urge to push), active (bearing down efforts with each contraction) and transition (crowning and the actual birth).
Upright positioning was described by Col Wood as: standing, sitting, squatting, and kneeling. She noted that women in the U.S.A. generally do not squat in our daily lives. She stressed the need for prenatal education to include the importance of learning and practicing the squat to build up their ability to do so for prolonged periods of time. It has been shown that squatting increases the pelvic outlet by 28%.
Studies reveal that 66% of women birthing their first baby will have some type of perineal trauma: episiotomy or lacerations. However, approximately 1,000 studies reveal that episiotomy should not be practiced routinely, and possibly not at all. It is a commonly held belief that delivering a baby over an intact perineum causes delivery of the baby 5 minutes later than cutting an episiotomy. This is something even Col Wood has done when a baby has been in distress and every minute is important. However, one recent study refutes that commonly held belief and shows that the delivery time is exactly the same, whether an episiotomy is cut or
delivery takes place over an intact perineum.
Another study shows 85% of women will have ruptured their waterbag naturally by 9 cm. This evidence pleads strongly to lessen the routine practice of artificially rupturing the waterbag.
Important concepts [for mommas]* to remember:
1. Squatting needs to be practiced. All pregnant women should receive information prenatally on the benefits of upright positions for second stage prior to labor, which include a decrease in the duration and pain of labor as well as increase in the intensity of contractions. Prenatal education can prepare women to take an active role in their labor and encourage practice of pushing positions such as squatting.
2. Encourage the pregnant woman to try different positions throughout the second stage. No single position is appropriate for all labors. Varying positions can assist the fetus to maneuver down and out the pelvis.
3. Supine positions such as lithotomy should be discouraged. The lithotomy [flat on back, legs in the air]* position causes compression of the inferior vena cava, aorta, & iliac arteries by the uterus against the mother's spine. [This reduces the baby's oxygen supply.]*
4. Suggested positions should include: squatting, semi-recumbent, standing, and upright kneeling. Increased intraabdominal pressure can be generated in these positions due to increased efficiency of abdominal muscle contractions in addition to the force of visceral weight.
5. Squatting should be encouraged, especially for women with narrow pelvic outlets and/or large babies. During a squat, both the antereo-posterior and transverse diameters [the baby's head is not face down, but either sideways or partially face-up]* of the pelvic outlet increase 1-2cm. Also, the pressure of the mother's thighs against her abdomen helps keep the baby in proper alignment.
6. The mother should be encouraged to lean forward and maintain a pelvic tilt with contractions during the first phase of 2nd stage. Leaning forward will encourage the baby to keep from resting on the sacral vertebrae, which can malalign the baby's head and prevent it from entering the inlet. A pelvic tilt mobilizes the sacrum, enabling the baby to rotate during its descent.
7. Non-valsalva pushing should be taught and encouraged. [In other words, no "purple" pushing.]*
Expectations of staff supporting women during labor and birth are:
(Beginning May 1, 1993, these are policy and procedure at Tripler)
1. Review realistic expectations and sensations of early labor as well as the onset of 2nd stage. Learning about the range of emotions and effort involved in 2nd stage will assist the pregnant woman to prepare for the work and sensations of 2nd stage.
2. Encourage spontaneous bearing down. If baby's head has not descended low enough in the pelvis to stimulate Ferguson's reflex (stretch receptors in the pelvic floor) allow the mother to rest until she feels the urge to push. Refraining from instructing a mother to begin pushing prior
to the time she feels the urge to push minimizes maternal fatigue.
3. Consider fetal station and position in addition to dilation in determining a woman's readiness for pushing. Involuntary bearing down may be encouraged if fetal station is favorable (0-1+) as well as fetal position (OT to OA) regardless of a cervix which is dilated less than 10cm (8-9cm, soft and retracting). Tearing of the cervix is extremely rare. Col Wood has not seen one for approximately 15 years, although she routinely allows her clients to push when they feel the urge, regardless of their dilation. Studies have shown that once a woman feels the urge to push, she will be completely dilated within 10-16 minutes.
4. Discourage prolonged maternal breath-holding (greater than 6 seconds) during pushing. Breath holding involves the Valsalva maneuver: increased intrathoracic pressure due to a closed glottis causes a decrease in cardiac output and blood pressure. The fall in pressure causes a decrease in placental perfusion causing fetal hypoxia. (If allowed to push any way they want, all women who choose to hold their breath usually hold it 5-6 seconds or shorter. Many women will choose not to hold their breath at all.)
5. Support rather than direct the woman's involuntary pushing efforts. These efforts may include grunting, groaning, or exhaling during the push and/or breath holding less than 6 seconds. (This is sometimes referred to as the "Song of Labor" and is something medical professionals and support people will have to be accustomed to.) Spontaneous, involuntary bearing down efforts match the intensity of each contraction. An open glottis, as seen with grunting and exhale pushing, avoids the Valsalva maneuver and has physiological benefits for both the mother and baby.
6. Validate the normalcy of sensations and sounds the mother is voicing. Mothers and caregivers perceive low pitched groaning, sighing, and moaning to be sound of tension release which may assist her in coping with the pain of 2nd stage. (Caregivers must assist the mother to not feel self-conscious about the sounds she is making.)
7. If maternal and fetal status is satisfactory, duration of the 2nd stage should continue without time constraints. Fetal outcome may be affected more by the avoidance of sustained maternal breath holding and supine [back-lying]* position than by duration of the 2nd stage, as previously believed.
~~~~~~~~~~~~~~~~~~~~~~~This was written by Janet after attending a presentation by Sylvia Wood in 1993, reflecting on the results of new studies that were not yet published at the time. Even though the studies are pretty old, I can find no evidence of any change since that time. If you'd like to read more, here are a few links to get you started:
Blackwell-Synergy: Managing Second-Stage Labour, exploring the variables during the second stage.
Regrettably, to see the full article, this one requires a subscription...The Cochrane Collaboration: Position in the second stage of labour for women without epidural anaesthesiaPushing in Labor*Anything in []'s was added or changed by me for clarification.
