Standardization of the 2 nd Stage of Labor Phillip N. Rauk, MD Associate Professor Maternal-Fetal Medicine Division Department of Obstetrics, Gynecology, And Women’s Health University of Minnesota Samantha Sommerness, RN, MSN, CNM Advanced Practice Nurse Leader, Fairview Southdale and Ridges Hospital

1.Lack of standardization on management of the length of second stage 2.Inconsistent use of operative vaginal delivery bundle 3. Fetal heart rate patterns are managed differently in second stage than in first stage 4. Inadequate fetal monitoring in second stage 5. Failure to rescue 6. Lack of documentation during second stage IHI Assessment of 2 nd Stage Labor Management – 2010 Deep Dive Project

Institute for Healthcare Improvement 2010 In 2010 IHI recognized there were significant Opportunities for Improvement in the Management of the 2 nd Stage of Labor 1.Standardization a.Laboring down b.Positioning and pushing methods c.Epidural use and management d.Assessment and documentation e.Use of the operative vaginal delivery bundle 2.Fetal assessment and management of Category II patterns in second stage 3.Culture of safety in second stage

Phases of the 2 nd stage of labor There are two phases –Phase I: “the lull” or Latent phase: From complete dilatation until the urge to bear down –Phase II: Active phase or pushing phase: From the onset of pushing efforts to crowning of the presenting part In most cases, the woman is encouraged to push upon complete dilatation without the urge to push, despite high fetal station

A Better Approach… Based on current evidence, a better approach is to delay pushing until the woman feels the urge to push (Simpson, 2006) WHY? –The duration of pushing is shorter (up to 51%) without extending the total time –Maternal fatigue was decreased –Decrease in OVD’s and Cesarean Sections –By shortening the active pushing phase you decrease the amount of fetal distress With the use of epidural anesthesia, pushing can be delayed up to 2 hours for nulliparous women, and 1 hour for a multiparous woman (Fraser et al., 2000; Hansen et al., 2002, Simpson & James, 2005 ).

Positional Movements (Cardinal Movements) through the Curve of Carus Lower uterine relaxed in labor, even more so with epidural Pushing too early without the urge to push, not only leads to exhaustion, but works against the natural curve of the maternal spine Of the eight positional movements, we will focus on steps: 2, 3, and 4.

Positional Movements (Cardinal Movements) through the Curve of Carus We will focus steps 2-4: 1. Head Floating, before engagement 2: Engagement, descent, flexion 3: Further descent, internal rotation 4: Complete rotation, beginning extension 5: Complete extension, 6: Restitution (external rotation) 7. Delivery of anterior shoulder 8. Delivery of posterior shoulder

AOI Categories potentially influenced by Second Stage Management Strategies Third and fourth degree laceration Birth trauma Term admission to NICU Low Apgar Score

Effects of Delayed Pushing During the Second Stage on Postpartum Fatigue and Birth Outcomes in Nulliparous Women Lai, et JNR 2009 Experimental group pushed with maternal urge, station at +1 and OA, and adequate contractions Control group pushed at full dilation, OA, and adequate contractions Outcomes: Less fatigue at 1 and 24 hour postpartum Shorter pushing – 70 min versus 130 min Higher SVD rate – 89% versus 69% No change in Apgar, perineal tear, or neonatal outcomes despite a overall increase duration of the second stage

Delayed Versus Immediate Pushing in Second Stage of labor Kelly M, et al. MCN 2010 Delayed pushing of up to 90 minutes in nulliparous women with a continuous epidural resulted in: A decrease in pushing time of 51% No change in overall second stage time – 117 versus 87 minutes No change in Apgar Score BUT fewer decelerations No change in 3 rd of 4 th degree perineal lacerations

Active Pushing Versus Passive Fetal Descent in the Second Stage of Labor: A randomized Controlled Trial Hansen, SL, et al. Obstet Gynecol 2002 A delay in pushing of up to 120 minutes in nulliparous and 60 minutes in multiparous patients resulted in: –Longer overall second stage –Decreased pushing time –Fewer fetal heart rate decelerations –Less fatigue –No change in Apgar Score, lacerations, cesarean section or operative vaginal delivery –A second stage of up to 4.9 hours in the delayed pushing group resulted in no adverse perinatal outcome and significant benefit

Proposal for Second Stage Labor Management Determine providers’ and nurses’ current understanding of second stage management including laboring down and position change and provide evidence-based education. Standardize the approach to second stage labor management including guidelines for laboring down, position change, and attention to FHR patterns. Develop common language and communications around the management of the second stage Adopt a protocol for second stage management and track outcomes related to AOI.