2. Second Stage Labor Management Evelyn M. Hickson, RN, MSN, CNS, WCC

3. Objectives By the end of this presentation the learner will be able to: Discuss traditional pushing and laboring down List nursing interventions to facilitate second stage. Discuss the risk-benefit of operative vaginal delivery.

4. Cardinal Movements Of Birth

8. Pushing When is it OK to begin pushing?  When completely dilated  When patient feels urge – as long as completely dilated Continue as long as fetal tolerates pushing

9. What Is Laboring Down? Done in the patient with an epidural Passive action of second stage Allowing the uterine activity to continue to bring the baby down the birth canal without active pushing.

10. What Patients Would I Use Laboring Down On?????? Patients who are exhausted Cardiac Patients Any patient that should not be pushing due to medical or obstetrical issues

11. How Long Can You Do Laboring Down? Maximum time is two hours. Start from the time the patient is determined to be complete Contingent on a stable mom and a FHR tracing that demonstrates fetal well-being

12. Positions For Pushing In the bed HOB slightly up Use of the bed Safety measures for patients with epidurals Positions that open the pelvis Squat bars

14. Positions For Pushing Squatting On the toilet

15. Assisting The Patient With Pushing Breathing Bearing down Support / Coaching Focus

19. Episiotomy

20. Instrument Assisted Deliveries Vacuum Nursing Responsibilities Chart Pressure amount Chart Total Time / Duration of vacuum applied Chart Number of pulls and pop-offs Determine who needs to be present in room Identify when to go up the chain of command Assess the baby for outcome

22. Instrument Assisted Deliveries Forceps Nursing Responsibilities  Station of fetus when applied  Chart the number of pulls  Determine who needs to be present in the room  Identify when to go up the chain of command  Assess the baby for outcome

24. Shoulder Dystocia Definition: When neonatal shoulders cannot be delivered using the “usual” delivery maneuvers When extra delivery maneuvers are required to deliver the baby When the time from delivery of the head to the delivery of the shoulders/body is >60 seconds Incidence of 0.6 to 1.4 % of all births

25. Shoulder Dystocia Obstetrical Emergency Time is of the essence

26. Risk Factors For Shoulder Dystocia History of prior delivery of a baby with a shoulder dystocia. Suspected Macrosomia (>4,000 grams) Diabetic mother (more often gestational or type II) Excessive maternal weight gain during pregnancy (>35 pounds) Slow slope - prolonged time to go from 8-10cm of dilatation (primips=1.2cm/hr, multips= 1.5 cm/hr) Delayed descent Postdates Pelvic Abnormalities Abnormal pelvic shape or pelvic injury

27. Case Study Oprah Winfrey arrives in labor at 41 3/7 wks. She is a G3P2 with a previous Hx. of delivering two 9 LB+ babies within the last 6 years. She remembers that the deliveries were “difficult” and she “tore” and bled a lot. Oprah has a documented 50 lb weight gain during this pregnancy. She was diagnosed as a gestational diabetic at 26 wks. An ultrasound was done two weeks ago (at 39 wks.) because her fundal height was 42 cm. EFW was shown at that time to be 4200 grams. The patient refused to be induced at 39 weeks stating that she had to coordinate getting family to help and they were in the process of moving to a bigger house. The patient was admitted at 0830 in active labor at 5 cm/ 90%/-2. She was 8cm/90%/-2 at 1330 and 10/100%/-2 at 1630.

28. Case Study The patient pushed for 2 hours and doesn’t bring the baby down lower than+1 station. The Physician applied forceps to assist with delivery and descent. The head is delivered with the forceps after 3 contractions. The head advances slightly then retracted back up “turtling” and the shoulders did not come out. The primary nurse called for assistance The Physician requests supra-pubic pressure and McRoberts maneuver. The baby is delivered with a Rubin maneuver after 3 minutes of shoulder dystocia with reduction techniques. The baby is dark blue, floppy with eyes wide, no respiratory effort and a HR rate of 80.

29. What Are The Risk Factors For This Patient? History of Macrosomic babies with difficult deliveries Increased fundal height Slow slope / delayed rate of dilatation (abnormal labor pattern for a multiparous patient Postdate Gestational Diabetes Excessive maternal weight gain

30. Preparation For Shoulder Dystocia Have the proper equipment ready and available *Warmer that is functional – set up and warm *Bag and mask *O2 *Suction May need stool in order to get up on the bed or achieve better leverage with maternal positioning

31. Preparation For Shoulder Dystocia Have the proper personnel at the delivery *NICU / SCN RN *Second pair of hands *Charge nurse /experienced RN

32. Nurse’s Role In Shoulder Dystocia Call for help/backup Note time at the beginning of shoulder dystocia Lower the head of the bed Reposition the patient Assist with shoulder dystocia reduction maneuvers Prepare for newborn resuscitation Remain calm Reassure patient and help her to focus on pushing Delegation of removal of unnecessary people / family from the room Implementing the chain of command if needed DOCUMENT - re-creation of the events as they occurred

33. Shoulder Dystocia Maneuvers 1. McRoberts 2. Suprapubic Pressure 3. Woods Screw 4. Rubin 5. Delivery of the posterior arm 6. Maternal Reposition 7. Hibbard 8. Deliberate fracture of the clavicle 9. Deliberate breaking of the maternal coccyx 10. Zavenelli 11. Cleidotomy 12. Symphysiotomy (a large episiotomy may be cut at anytime)

34. McRoberts Hyperflexion of the maternal legs back towards the chest and slightly rotated out. Straightens out the sacrum Straightens out the incline (angle) of the symphysis pubis Rotates the pubic bones Increases the area of the posterior outlet and decreases the stretching of the baby’s brachial plexus

35. McRobert’s Least amount of potential injury if mother does herself If patient has epidural, legs must be hyperextend or patient can receive sacral and leg nerve damage Reduces the likelihood of neonatal clavicular fracture and brachial plexus injury 90% success rate without additional maneuvers

37. Suprapubic Pressure Second maneuver used in conjuction with McRoberts May increase the incidence of clavicular fracture Procedure *Communicate with the delivering MD which direction to exert pressure *Using flat surface of the fist, exert a firm downward and oblique pressure, just above the maternal symphysis pubic on the anterior fetal shoulder in the direction the MD is rotating

38. Supra-pubic Pressure

39. Woods Screw Maneuver Procedure *Continual rotation in a circular motion of the shoulders either in a clockwise or counter- clockwise motion in an effort to “unscrew” the neonate from the pelvis

40. Rubin “Rotational” Maneuver Or “Reverse Woods Screw” Identified in 1943 Posterior shoulder is rotated 180 degrees then the delivering provider reaches in to access the shoulder and push the anterior shoulder and scapula towards the surface of the chest. “Shoving scapulas saves shoulders” Coordination with the delivering provider *Rocking the baby’s shoulders from side to side, using the flat surface of the fists or heels of the hands, just above the maternal symphysis pubis.

41. Delivery Of The Posterior Arm Delivering provider slips in behind anterior shoulder and reaches in to grasp neonate’s arm and rotate it out. Reduces the diameter of the shoulder to shoulder width. Increased risk of fracture to the humerus

42. Maternal Reposition Hands and knees - all fours Squatting Rotational maneuvers then tried again Purpose is to open the pelvis and provide more room

43. Hibbard Identified in 1982 Pressure is placed on the baby’s jaw and neck downward in the direction of the maternal rectum while strong fundal pressure is given This allows delivery of the anterior shoulder

44. Deliberate Fracture Of The Clavicle Pressure is put on the baby’s clavicle to intentionally fracture or “break” the clavicle and reduce the shoulder

45. Deliberate Breaking Of The Maternal Coccyx Strong downward pressure is placed on the coccyx with intention to break it and increase the pelvic outlet diameter and allow more room for delivery of the shoulders.

46. Zavenelli Also known as “Cephalic replacement” Identified in 1985 The presenting part if returned or pushed back into the maternal pelvis and an emergency cesarean section is performed Is considered as a last resort to get out a live baby.

47. Symphysiotomy Identified in 1986 The maternal symphysis pubis is cut or split in order to allow delivery of a dead baby.

48. Cleidotomy Identified in 1983 The clavicle(s) of a dead baby is cut in order to allow delivery

49. Nursing Implications For Fundal Pressure Should never be used to expedite second stage Should never be used in shoulder dystocia except during Hibbard procedure Will further impact the anterior shoulder against the symphysis pubis

50. Nursing Implications For Fundal Pressure May cause maternal injury *Lacerate the liver *Damage the diaphragm *Cause uterine rupture *Cause uterine inversion and prolapse *Cause cervical lacerations and tears *Cause vaginal wall tares **Has a 77% complication rate

51. Documentation Time head delivered and shoulder dystocia diagnosed Duration of the shoulder dystocia Procedures and maneuvers performed and in what order Presence of personnel in the delivery room Neonatal resuscitation Neonate condition and complications Maternal condition and complications Interventions taken to support mother and family

52. Maternal Implications Of Instrument Deliveries And Shoulder Dystocia Higher risk for injury to mother (and nurse) Higher risk for postpartum hemorrhage Higher risk for c-section Potential injury to baby and possibly death

53. Birth What are your responsibilities? Fetal monitoring Time of delivery Delivery of placenta Labs – cord blood / gases Repair Feeding/Bonding

54. Safety Eye protection Blood and body fluids Physical safety Body mechanics

57. References Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2011), Fetal Heart Monitoring Principles & Practices. (4th ed.). Dubuque, Iowa: Author. ACOG Practice Bulletin: Shoulder Dystocia. Number 40, November 2002 American Academy of Pediatrics and The American College of Obstetricians and Gynecologists (2005). Guidelines for Perinatal Care (6 th ed). Authors. Simpson, K.R., & Creehan, P.A. (2010). AWHONN Perinatal Nursing (4 th ed). Philadelphia: Lippincott. Martin, E. J., et. al. (2010). Intrapartum Management Modules: A Perinatal Education Program (4th ed). Philadelphia : Lippincott. Cunnighanm, F.G., Gant, N.F., Leveno, K.J., Gilstrap, L.C,, Hauth, J. C and Wenstrom, K.D. (2001). Williams Obstetrics (21 st ed). New York: McGraw-Hill. Oxorn, H. (2001) Oxorn-Foote: Human Labor and Birth (5 th ed). Connecticut: Appleton- Century-Crofts