1. The Second Stage of Labour Max Brinsmead MB BS PhD March 2013

2. Subjects to be covered: Definitions Definitions What is the evidence that interventions are useful in the 2 nd stage: What is the evidence that interventions are useful in the 2 nd stage: Limitation on the length Limitation on the length Position to adopt Position to adopt Coached pushing and or breath-holding Coached pushing and or breath-holding What is recommended for: What is recommended for: Observations in the 2 nd stage Observations in the 2 nd stage When to intervene When to intervene Maternal position for delivery Maternal position for delivery Advice to mothers about pushing Advice to mothers about pushing Reducing obstetric trauma Reducing obstetric trauma Care for patients with previous 3 0 and 4 0 trauma Care for patients with previous 3 0 and 4 0 trauma

3. Resources: Cochrane database Cochrane database Pubmed Pubmed NICE (UK) Guidelines NICE (UK) Guidelines My personal experience My personal experience

4. NICE recommends that the 2 nd stage of labour be divided and defined as... Passive Second Stage Passive Second Stage –From the time of full dilatation to the commencement of involuntary expulsive effort by the woman Active Second Stage Active Second Stage –From the commencement of expulsive efforts by the woman –PLUS –There are symptoms or signs of full dilatation –OR –The baby is visible

5. What is the evidence that the length of the second stage influences neonatal & maternal outcomes? All studies are observational in nature All studies are observational in nature Only one large US study (15,759 women) is corrected for various confounders Only one large US study (15,759 women) is corrected for various confounders This study found that 2 nd stage >4 hrs is associated with: This study found that 2 nd stage >4 hrs is associated with: Increased rate of CS (OR 5.65, CI 4.46 - 7.16) Increased rate of CS (OR 5.65, CI 4.46 - 7.16) Assisted birth (OR 2.83, CI 2.38 - 3.36) Assisted birth (OR 2.83, CI 2.38 - 3.36) Chorioamnionitis (OR 1.75, CI 1.44 - 2.22) Chorioamnionitis (OR 1.75, CI 1.44 - 2.22) 3 rd & 4 th degree trauma (OR 1.33, CI 1.07 - 1.67) 3 rd & 4 th degree trauma (OR 1.33, CI 1.07 - 1.67) 5 min Apgar <7 (OR 1.45, CI 1.25 - 1.84) 5 min Apgar <7 (OR 1.45, CI 1.25 - 1.84) Other studies have found association with: Other studies have found association with: Low 1 min Apgar Low 1 min Apgar Rate of PPH Rate of PPH Risk of puerperal fever Risk of puerperal fever Some studies (6041 women in Canada & 1915 women in Taiwan) found no such associations Some studies (6041 women in Canada & 1915 women in Taiwan) found no such associations

6. So does a review of what is “normal” help? The mean plus or minus 2 SD for “normal” women with a “normal” outcome is: The mean plus or minus 2 SD for “normal” women with a “normal” outcome is: 54 ± 142 minutes for Nullips 54 ± 142 minutes for Nullips 20 ± 60 minutes for Multips 20 ± 60 minutes for Multips Note the very wide SD Note the very wide SD And the variable is not normally distributed And the variable is not normally distributed So the answer is “NO” So the answer is “NO”

7. NICE conclusions for the length of the second stage For nullipara For nullipara –2.5 hours without an epidural –3 hours with an epidural For the parous patient For the parous patient – 60 minutes without an epidural –120 minutes with an epidural NICE recommends: NICE recommends: Consultation with the obstetrician for a Nullipara whose delivery is not imminent after 2 hours Consultation with the obstetrician for a Nullipara whose delivery is not imminent after 2 hours And 1 hour in a previously parous patient And 1 hour in a previously parous patient Reassess all patients with an epidural who do not push within 1 hour after fully dilated Reassess all patients with an epidural who do not push within 1 hour after fully dilated

8. Scalp pH in Labour

9. My observations: It is obvious that there is fetal deterioration with increasing length of the second stage It is obvious that there is fetal deterioration with increasing length of the second stage Because the ultimate outcome is fetal death Because the ultimate outcome is fetal death Few women can actively push in a normal second stage with 2-3:10 contractions for more than 60 minutes Few women can actively push in a normal second stage with 2-3:10 contractions for more than 60 minutes So most will accept or even welcome intervention when they have become exhausted So most will accept or even welcome intervention when they have become exhausted Provided there is no suspicion of fetal compromise the second stage can continue for as long as there is evidence of progress Provided there is no suspicion of fetal compromise the second stage can continue for as long as there is evidence of progress But convincing a patient of the need for intervention on the grounds of possible fetal compromise is our greatest challenge But convincing a patient of the need for intervention on the grounds of possible fetal compromise is our greatest challenge

10. Observations in the 2 nd stage of Labour There are no studies that provide guidance for our practice in this area There are no studies that provide guidance for our practice in this area NICE recommends: NICE recommends: Hourly observations of BP and PR Hourly observations of BP and PR Continue 4 th hourly temperature checks Continue 4 th hourly temperature checks Observe and record contractions 30 minutely Observe and record contractions 30 minutely Listen to fetal heart every 5 minutes for not less than 60 sec and after a contraction Listen to fetal heart every 5 minutes for not less than 60 sec and after a contraction Offer hourly vaginal examinations (but always with abdominal palpation of position and descent) Offer hourly vaginal examinations (but always with abdominal palpation of position and descent) Encourage frequent bladder emptying Encourage frequent bladder emptying Attend to the woman’s psychological needs Attend to the woman’s psychological needs My comments: My comments: These observations may not be frequent enough to plan appropriate intervention These observations may not be frequent enough to plan appropriate intervention Interpretation of CTG is, as always, difficult Interpretation of CTG is, as always, difficult Effectiveness of pushing and progress is sometimes best done by evaluation of maternal behaviour Effectiveness of pushing and progress is sometimes best done by evaluation of maternal behaviour

11. What is the evidence that there is an optimal maternal position for the second stage of labour? A systematic review of 19 trials (but not all good RCT’s) involving 5764 women compared: A systematic review of 19 trials (but not all good RCT’s) involving 5764 women compared: Sitting, semi recumbent, squatting and lateral positions Sitting, semi recumbent, squatting and lateral positions Compared to… Compared to… Supine or lithotomy positions Supine or lithotomy positions Findings: Findings: Reduced length of 2 nd stage (weighted mean reduction 4.5 minutes, CI 2.94 - 5.65 minutes) Reduced length of 2 nd stage (weighted mean reduction 4.5 minutes, CI 2.94 - 5.65 minutes) Fewer assisted births (RR 0.84, CI 0.73 - 0.98) Fewer assisted births (RR 0.84, CI 0.73 - 0.98) Fewer episiotomies (RR 0.84, CI 0.79 - 0.91) Fewer episiotomies (RR 0.84, CI 0.79 - 0.91) Reduced pain (RR 0.73, CI 0.60 - 0.90) Reduced pain (RR 0.73, CI 0.60 - 0.90) Fewer abnormal CTG’s (RR 0.31, CI 0.08 - 0.98) Fewer abnormal CTG’s (RR 0.31, CI 0.08 - 0.98) *More frequent 2 0 tears (RR 1.23, CI 1.09 - 1.39) *More frequent 2 0 tears (RR 1.23, CI 1.09 - 1.39) *More PPH’s (RR 1.68, CI 1.32 - 2.15) *More PPH’s (RR 1.68, CI 1.32 - 2.15) *Seems to relate to the use of rigid birth stools rather than upright position No difference in analgesia required, 3 0 & 4 0 tears, need for transfusion, patient satisfaction, NICU admission or any neonatal outcome No difference in analgesia required, 3 0 & 4 0 tears, need for transfusion, patient satisfaction, NICU admission or any neonatal outcome

12. What about hands and knees? One RCT in USA (147 women) of all fours for POP found: One RCT in USA (147 women) of all fours for POP found: No effect on the rate of head rotation No effect on the rate of head rotation But less back pain But less back pain No effect on maternal or neonatal outcomes No effect on maternal or neonatal outcomes Confirmed by a Swedish RCT of 271 women Confirmed by a Swedish RCT of 271 women Also found less perineal pain in the puerperium Also found less perineal pain in the puerperium But no effect on the length of the second stage But no effect on the length of the second stage My observation: My observation: Once you get used to the back to front mechanism of birth, then all fours, kneeling or standing with the accoucheur posterior has much to recommend it Once you get used to the back to front mechanism of birth, then all fours, kneeling or standing with the accoucheur posterior has much to recommend it And I still put a woman on her side with the back uppermost when there is malposition and slow progress in the second stage of labour And I still put a woman on her side with the back uppermost when there is malposition and slow progress in the second stage of labour

13. NICE recommendations for maternal position in the second stage of labour Women should be discouraged from lying supine or semi supine Women should be discouraged from lying supine or semi supine But otherwise encouraged to adopt the position that is most comfortable for them But otherwise encouraged to adopt the position that is most comfortable for them

14. Closed glottis or breath-holding in the 2 nd stage labour? Breath-holding → ↓maternal pO 2 & oxygen saturation Breath-holding → ↓maternal pO 2 & oxygen saturation Does this have adverse fetal effects? Does this have adverse fetal effects? A study by Simpson & James Nurs. Res. 2005 A study by Simpson & James Nurs. Res. 2005 Randomised 45 nullipara at 10 cm to either immediate pushing or delayed until the mother had the urge to push Randomised 45 nullipara at 10 cm to either immediate pushing or delayed until the mother had the urge to push Monitored fetal O 2 saturation continuously, fetal & maternal outcomes Monitored fetal O 2 saturation continuously, fetal & maternal outcomes The early pushing group experienced: The early pushing group experienced: Lower mean fetal O 2 (12.5 vs 4.6, p<0.001) Lower mean fetal O 2 (12.5 vs 4.6, p<0.001) More frequent O 2 2 min More frequent O 2 2 min More variable heart rate decels More variable heart rate decels More perineal lacerations More perineal lacerations No difference in length 2 nd stage, Apgars or cord pH No difference in length 2 nd stage, Apgars or cord pH

15. What is the evidence that women should refrain from breath-holding pushing in 2 nd stage labour? Two RCT’s in the US (total of 450 women) compared coached (closed glottis) pushing with “doing what comes naturally” and found: Two RCT’s in the US (total of 450 women) compared coached (closed glottis) pushing with “doing what comes naturally” and found: No difference in any neonatal or maternal outcome No difference in any neonatal or maternal outcome Shorter second stage for coached patients in one study Shorter second stage for coached patients in one study (supported by a UK RCT with 32 women) (supported by a UK RCT with 32 women) No adverse fetal or maternal effects from breath-holding pushing was confirmed in a Danish RCT of 306 nullipara but… No adverse fetal or maternal effects from breath-holding pushing was confirmed in a Danish RCT of 306 nullipara but… There was no effect on the length of the second stage There was no effect on the length of the second stage HOWEVER HOWEVER Recruitment to the study was difficult and Recruitment to the study was difficult and Compliance with the allocated method was poor Compliance with the allocated method was poor Similar concerns about the earlier studies Similar concerns about the earlier studies

16. NICE recommendations about pushing in the second stage of labour Women should be guided by their own urge to push Women should be guided by their own urge to push If their pushing is ineffectual then… If their pushing is ineffectual then… Provide support & encouragement Provide support & encouragement Change position Change position Empty the bladder Empty the bladder My observation: My observation: I find this advice to be unhelpful I find this advice to be unhelpful Some women obviously require advice about how to push Some women obviously require advice about how to push But the physiological evidence suggests that they should avoid really prolonged breath-holding But the physiological evidence suggests that they should avoid really prolonged breath-holding

17. Perineal Massage One large RCT in Australia (1340 women in 3 sites) of midwife massage between contractions in the second stage: One large RCT in Australia (1340 women in 3 sites) of midwife massage between contractions in the second stage: No effect on any measure of obstetric trauma, pain, return to coitus or urinary and bowel function No effect on any measure of obstetric trauma, pain, return to coitus or urinary and bowel function There was no apparent measure of compliance There was no apparent measure of compliance But the study is confirmed by a US RCT of 1211 women in which compliance was high But the study is confirmed by a US RCT of 1211 women in which compliance was high I am impressed by the RCT’s of the Epi-No device (a self-performed progressive dilation of the perineum from 36 weeks) I am impressed by the RCT’s of the Epi-No device (a self-performed progressive dilation of the perineum from 36 weeks)

18. Hot Compresses for the Perineum? One large US observational study (2595 women) found that: One large US observational study (2595 women) found that: Warm compresses reduced the need for episiotomy in nulliparas and was borderline for multiparas Warm compresses reduced the need for episiotomy in nulliparas and was borderline for multiparas Also reduced the rate of spontaneous 2 0 tears in both Also reduced the rate of spontaneous 2 0 tears in both But this was not confirmed by another US RCT of 1211 women But this was not confirmed by another US RCT of 1211 women

19. “Hands on” or “Hands poised” during delivery of the fetal head? One large UK RCT of 5316 ♀ found: One large UK RCT of 5316 ♀ found: A small reduction in perineal pain at 10 days from “hands on” A small reduction in perineal pain at 10 days from “hands on” No difference in any measure of obstetric trauma No difference in any measure of obstetric trauma Inexplicably fewer manual removals in the “hands poised” group (2.6% vs 1.5%) Inexplicably fewer manual removals in the “hands poised” group (2.6% vs 1.5%) Broadly similar findings in an Austrian study of 1076 women Broadly similar findings in an Austrian study of 1076 women But episiotomy was more common in the “hands on” group But episiotomy was more common in the “hands on” group NICE concludes that either technique is appropriate NICE concludes that either technique is appropriate And noted evidence that there is less trauma when the head delivers between contractions And noted evidence that there is less trauma when the head delivers between contractions

20. Lignocaine spray for the perineum? One RCT of 185 women found that: One RCT of 185 women found that: No effect on perineal pain No effect on perineal pain But less dyspareunia when coitus was resumed But less dyspareunia when coitus was resumed And fewer second degree tears in the treated group (RR 0.63, CI 0.42 – 0.93) And fewer second degree tears in the treated group (RR 0.63, CI 0.42 – 0.93) But NICE concludes that Lignocaine spray should not be used But NICE concludes that Lignocaine spray should not be used

21. Routine or restricted use of episiotomy? Seven RCT’s with 5001 women and 8 cohort studies with 6463 women. Meta analysis confirms that restricted episiotomy will result in: Seven RCT’s with 5001 women and 8 cohort studies with 6463 women. Meta analysis confirms that restricted episiotomy will result in: Less posterior trauma (RR 0.87, CI 0.83 - 0.91) Less posterior trauma (RR 0.87, CI 0.83 - 0.91) More anterior trauma (RR 1.75, CI 1.52 - 2.01) More anterior trauma (RR 1.75, CI 1.52 - 2.01) Fewer 3 0 and 4 0 tears (RR 0.74, CI 0.42 - 1.28) Fewer 3 0 and 4 0 tears (RR 0.74, CI 0.42 - 1.28) Some studies also point to: Some studies also point to: Overall more intact perineums Overall more intact perineums Less perineal pain Less perineal pain Quicker return to coitus with restricted use of episiotomy and Quicker return to coitus with restricted use of episiotomy and More anal sphincter damage with liberal episiotomy More anal sphincter damage with liberal episiotomy But no difference in… But no difference in… Sexual function at 3m & 3 yrs or bladder function Sexual function at 3m & 3 yrs or bladder function

22. NICE recommendations for the use of episiotomy Routine episiotomy is not recommended for spontaneous birth Routine episiotomy is not recommended for spontaneous birth Episiotomy should be performed when clinically indicated Episiotomy should be performed when clinically indicated –e.g. fetal compromise suspected or instruments required Mediolateral episiotomy is best Mediolateral episiotomy is best –i.e. start at the posterior fouchette and proceed at an angle of 45 - 60 degrees Tested anaesthesia is required Tested anaesthesia is required –Except in an extreme emergency

23. Birth after Previous 3 0 and 4 0 Trauma There are no prospective trials and only a few retrospective studies There are no prospective trials and only a few retrospective studies The risk of repeat 3 0 and 4 0 trauma is similar to the original incidence The risk of repeat 3 0 and 4 0 trauma is similar to the original incidence There is some evidence that if the woman is asymptomatic then vaginal birth does not further increase the risk of those symptoms There is some evidence that if the woman is asymptomatic then vaginal birth does not further increase the risk of those symptoms There is some evidence that for symptomatic women then vaginal birth does increase the severity of those symptoms There is some evidence that for symptomatic women then vaginal birth does increase the severity of those symptoms

24. NICE recommendations for the care of patients with previous 3 0 and 4 0 trauma Routine episiotomy is not recommended Routine episiotomy is not recommended Discussion about intrapartum care should cover… Discussion about intrapartum care should cover… Current symptoms of dysfunction of the anal sphincter Current symptoms of dysfunction of the anal sphincter The previous trauma The previous trauma The risk of recurrence The risk of recurrence Success of previous repair Success of previous repair Psychological aspects of the trauma Psychological aspects of the trauma Then a combined decision concerning subsequent mode of birth and intrapartum care can be made Then a combined decision concerning subsequent mode of birth and intrapartum care can be made

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