1. Denise M. Bourassa, RNC, MSN Hartford Hospital

2. 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

3.  Why are we managing it?  How are we managing it?  Should we manage it?

4.  First epidural – 1898  1970’s – first widely used in obstetrics with problems  1975 – 20% chose epidural  Current epidural in labor rate…75-85% ?

5.  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)

6.  Coached or directed pushing  Closed glottis pushing  Early pushing or pushing without urge

7.  Immediate pushing at 10 cm, regardless of urge to push  Breath holding, counting for 10 seconds, repeat x 3  PUSH, PUSH, PUSH !!!!!

8.  Aka “purple pushing”  More like “red in the face” pushing  Usually the result of pushing without urge to push

9.  Many different names ◦ Passive descent ◦ Delayed pushing ◦ Physiologic second stage ◦

10.  When patient feels urge to push, will instinctively push, breathe when necessary, not when told.

11.  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)

12.  Authored by: Reynolds and Yukin  Published in: Canadian Medical Association Journal, 1987

13. Authored by: Vause, Congdon, Thronton  Published in: British Journal of Obstetrics and Gynaecology, 1998  135 nulliparous with effective epidural

14.  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.

15.  Length of second stage  Change in fetal station first hour after full dilation  Apgar scores  Arterial umbilical cord gases  Perineal integrity

16.  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

17.  Clinical Management Guidelines for Obstetrician-Gynecologists  Indications for operational Vaginal Delivery when fetal head is engaged and cervix fully dilated:  Prolonged second stage: Redefinition

18.  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

19.  Multicenter, Randomized Controlled trial  1864 total participants  Delayed pushing = waiting 2 hours (n=936)  Early pushing = as soon as randomly assigned (n=926)

20.  Authored by: Hansen, Clark and Foster  Published in: The American College of Obstetricians and Gynecologists, 2002

21.  Length of Second stage  Length of time pushing  Apgars  Cord pH  Episiotomies/lacerations  Endometritis  Rate of fetal descent  Fatigue scores 

22.  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)

23.  Authored by: Simpson and James  Published in: Nursing Research, 2005  45 nulliparous women in second stage ◦ Delayed pushing (n=23) ◦ Early pushing (n=21)

24.  Authored by: DiFranco, J.T, Romano, A.M., and Keen,R.  Published in: Journal of Perinatal Education, 2007

25.  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

26.  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)

27.  Nature of labor is a mystery even today  No two are the same  Hold your breath, count, push, push!

28.  Google search  The debate continues  The past 30 years  The future