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Published byLoren Eustacia Wood Modified over 9 years ago
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Denise M. Bourassa, RNC, MSN Hartford Hospital
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Second stage of labor – what is it? Begins with full dilation (10 cm) and full effacement (100%) of the cervix Ends with birth of baby
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Why are we managing it? How are we managing it? Should we manage it?
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First epidural – 1898 1970’s – first widely used in obstetrics with problems 1975 – 20% chose epidural Current epidural in labor rate…75-85% ?
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Relaxation of the pelvic floor musculature Along came “Time – an important variable in normal delivery” (Wood et al, 1973) Leading to prolonged second stage and need for intervention (Maresh,Choong,Beard, 1983)
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Coached or directed pushing Closed glottis pushing Early pushing or pushing without urge
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Immediate pushing at 10 cm, regardless of urge to push Breath holding, counting for 10 seconds, repeat x 3 PUSH, PUSH, PUSH !!!!!
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Aka “purple pushing” More like “red in the face” pushing Usually the result of pushing without urge to push
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Many different names ◦ Passive descent ◦ Delayed pushing ◦ Physiologic second stage ◦
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When patient feels urge to push, will instinctively push, breathe when necessary, not when told.
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Authored by: Maresh, Choong and Beard Published in: British Journal of Obstetrics and Gynaecology, 1983 Design of Study 76 primigravidae with epidurals Delayed pushing group (n=40) Early pushing group (n=36)
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Authored by: Reynolds and Yukin Published in: Canadian Medical Association Journal, 1987
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Authored by: Vause, Congdon, Thronton Published in: British Journal of Obstetrics and Gynaecology, 1998 135 nulliparous with effective epidural
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Authors: Mayberry, Hammer, Kelly, True- Driver and De Journal of Perinatology – 1999 Pilot study designed to evaluate the use of delayed pushing in relation to five areas.
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Length of second stage Change in fetal station first hour after full dilation Apgar scores Arterial umbilical cord gases Perineal integrity
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Study suggests time limits could be more flexible because of improved fetal monitoring and better ability to identify fetus not tolerating labor Suggests redefinition of prolonged labor or failure to progress
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Clinical Management Guidelines for Obstetrician-Gynecologists Indications for operational Vaginal Delivery when fetal head is engaged and cervix fully dilated: Prolonged second stage: Redefinition
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Authored by: Fraser, Marcoux, Krauss, Douglas, Goulet, Boulvain, for the PEOPLE (pushing early or pushing late with epidural) study group Published in: American Journal of Obstetrics and Gynecology, 2000
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Multicenter, Randomized Controlled trial 1864 total participants Delayed pushing = waiting 2 hours (n=936) Early pushing = as soon as randomly assigned (n=926)
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Authored by: Hansen, Clark and Foster Published in: The American College of Obstetricians and Gynecologists, 2002
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Length of Second stage Length of time pushing Apgars Cord pH Episiotomies/lacerations Endometritis Rate of fetal descent Fatigue scores
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Authored by: Plunkett, Lin, Wong, Grobman, and Peaceman Published in: The American College of Obstetricians and Gynecologists, 2003 Randomized 202 total subjects ◦ Delayed pushing (n=117) ◦ Early pushing (n=85)
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Authored by: Simpson and James Published in: Nursing Research, 2005 45 nulliparous women in second stage ◦ Delayed pushing (n=23) ◦ Early pushing (n=21)
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Authored by: DiFranco, J.T, Romano, A.M., and Keen,R. Published in: Journal of Perinatal Education, 2007
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Authored by: Brancato, R.M., Church, S., and Stone, P.W. Published in: Journal of Obstetric, Gynecologic and Neonatal Nursing, 2008 Objective: to determine which method of pushing most benefits women with epidurals during second-stage
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Authored by: Kelly, M., Johnson, E., Lee, V., Massey, L., Purser, D., Ring, K., Sanderson, S., Styles, J., and Wood,D. Published in: Maternal Child Nursing, 2010 Randomized clinical trial Sample size 44 ◦ Delayed pushing (n=28) ◦ Early pushing (n=16)
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Nature of labor is a mystery even today No two are the same Hold your breath, count, push, push!
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Google search The debate continues The past 30 years The future
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