ICEA Study Guide 8 – Transition and Birth

OBJECTIVES At the completion of Part 8 the learner will:

■ describe the physical and emotional changes of the final phase of first stage – transition.

■ describe the physical changes marking the onset of second stage.

■ suggest positions for comfort in second stage labor.

■ compare and contrast directed and spontaneous pushing.

■ outline the AWHONN protocol for pushing.

■ construct the blood flow changes in the newborn circulatory system during transition from placental respiration to pulmonary respiration.

■ describe the APGAR score.

■ advocate for skin-to-skin care after birth.

 

OUTLINE

  1. Transition
  2. Physical and emotional changes of transition

Third Phase: Transition

From 1st to 2nd stage of labor. Cervix is reaching complete dilating and baby is beginning to descend into birth canal. Contractions are longer (90 sec – 2 min) and closer together (2-3 min apart). Labor still technically in 1st stage but showing signs of 2nd stage. Emotions and physical sensations intense. Feel tired, restless, irritable and consumed by efforts to cope. May lose ritual .Body begins secreting high levels of adrenaline, which may lead to a fight or flight response (temp fear, nausea, vomiting, agitation, hot flashes, chills, and trembling) but hormone is beneficial because you become more alert and have renewed strength and energy just when you need to push out baby.

Involuntary spasms (precursors of bearing down) may stimulate diaphragm, causing you to hiccup, grunt or belch. May find self-holding breath and straining or grunting during each contraction; this reaction is urge to push. Back or thighs may ache. Increased pressure may cause legs or even whole body to tremble and it may also cause heavy vaginal discharge of bloody mucus. Despite intensity and pain on contractions during transition, you may doze between contractions, as if body is conserving energy for managing them.

Lasts less than an hour (usually bw 5 and 20 contractions).

Getting Through Transition

Become focused only on labor; nothing else matters. Intensity of labor may frighten you. May feel it will last forever and you can’t cope much longer. Encouragement and support from partner, doula and caregivers essential.

Responses to transition (fear, nausea, trembling, despair, crying, dependence on others and difficulty maintaining ritual) are natural and unique to your labor. Goal at this time isn’t necessarily to remain calm, still and relaxed during contractions. Instead, aim to maintain a coping ritual, with the help of your partner or doula if necessary. You may rhythmically sway from side to side, tap your fingers or feet, stroke your belly, or rock back and forth. Or you may want your partner to stroke you or murmur rhythmically in your ear. You may find that moaning during contractions helps release tension. Or you may remain still and quiet during your contractions. Between contractions, try to relax and rest, if only for a few seconds.

Might like partner to hold you close or you might not want to be touched. May want partner to provide only eye contact and verbal encouragement. You may find hot, damp towels on lower abdomen soothing. If sweating, partner can fan you or wipe your face, neck and chest with a cool, damp cloth. If able to doze between contractions, partner can help you focus and begin breathing rhythmically as soon as the next contraction begins so the intensity doesn’t overwhelm you.

If you recognize you’re in transition, you can cope better with this phase. If you think cervix is only 5/6 cm dilated, you may become discouraged and worry that you have hours of demanding contractions to go. When you and partner recognize signs of transition, progress can hearten you. Can see that challenges of transition lead to 2nd stage of labor, when mental state will improve as the birth of baby draws closer.

Pain Medications during Transition

Can get through transition without pain medications, especially if you have the following: a desire for a non-medicated labor, knowledge of what to expect and how to cope in this phase, good support and a labor that’s progressing normally. Some women, however, find that transition is too much for them to handle; the pain is too great, they’re exhausted or they lose control or panic. If this happens to you, pain medications are usually an option.

While there’s no shame in wanting medical help during this phase, don’t take pain medications just because you fear that the intensity of labor is abnormal. Remember that strong emotional responses and challenging contractions are completely normal. Before deciding on pain medications, first find out how far your labor has progressed.   Since it lasts typically an hour , you may decide pain medications not necessary.

Urge to Push in Transition

May develop an urge to push, which may feel as though you need to have a bowel movement (because baby’s head is pressing against your rectum). May also start catching your breath and grunting (making pushing sounds). When you first feel an urge to push, let nurse or caregiver know. Try not to push until she can assist you. If your cervix isn’t completely dilated or is almost dilated except for one thickened area (a “lip” of cervix), you may be asked not to push.

While its okay to bear down in labor, doing so isn’t worthwhile before cervix is fully dilated. Pushing too early may cause cervix to swell and slow labor progress. May find it difficult and uncomfortable to keep from pushing when urge is strong. If asked not to push, try blowing or panting to keep from holding your breath. May be able to relieve a premature urge to push by changing positions, such as to hands and knees, side lying or other positions that neutralize effects of gravity.

Note to Partners

Transition is probably the most difficult challenge you’ll see your laboring partner experience. Her pain and discouragement may trouble you, but remember that her intense sensations and emotions are normal. She and your baby are all right. Nonetheless, you both need reassurance and encouragement from your doula, nurse or caregiver at this time.

Your job during this phase is simple: help her keep a rhythm. Don’t mistake rhythmic moans, groans or other intense sounds for cries of agony; if they rhythmic, she’s coping.

If she beings catching her breath and grunting, she may have an urge to push. Call caregiver – she may be ready to push.

Take Charge Routine for Partners

Use when laboring partner is in despair, weeping, crying out for help, or ready to give up. Also use when she’s overwhelmed with pain, cant relax and cant regain her coping rhythm/ritual

  • Keep composure. Touch should be firm and confident. Voice should be calm and reassuring. Give simple, concise directions. Don’t ask her questions.
  • Stay close to her. Remain by her side with your face near hers
  • Anchor her. Hold her hand or cradle her in your arms
  • Make eye contact. Tell her to open her eyes and look at your or at your hand. This helps her focus
  • Giver her rhythm to follow with her breathing; move your hand or head to set a pace for her to follow (1 breath per second or 2). If she loses rhythm, say “Breathe with me; follow my hand. That’s the way, just like that”; nod your head in time with her breathing to reinforce the rhythm
  • Encourage her. Acknowledge the labor is difficult, but not impossible. Remind her that she’s made a lot of progress and that her baby will be here soon. Tell her to look at you the moment she feels the next contraction so you can help her. Immediately set a rhythm for her to follow
  • Repeat yourself. She might not be able to do what you tell her for more than a few seconds, but repeating your instructions will continue to help her.

 

Emotions during labor – how partner can help you chart

  • Early labor – waiting and wondering. Excited, anxious, may overreact. Time contractions. Encourage her to relax, eat, drink and rest. Use distracting activities. Help her feel safe
  • Contractions 4-5 min apart – can no longer be distracted; cant walk/talk through contractions. Watch for her rhythm and reinforce it. Begin planned ritual; relax, breathe and focus
  • Active labor – quiet, withdrawn, discouraged as painful contractions require full attention. Feel need to be mobile and free to do whatever helps you cope. Follow her lead and move in close. Try bath or shower. Reinforce or adapt ritual.
  • Transition (peak of pain) – may be overwhelmed, panicky, angry and impatient. Remind her that intensity means labor will progress more quickly. Encourage her. Use “Take Charge” routine to help her regain rhythm. Develop new ritual.
  • “Lull” – renewed energy; mentally clear, optimistic. Reassure her that lull is normal. Match her mood. Discuss spontaneous pushing. Don’t rush
  • Descent – may be elated or alarmed by pressure in vagina. May hold back. Discouraged if progress is slow. Encourage release of pelvic floor. Assist with pushing positions
  • Crowning – excited, feel rim of fire. Desire to get it over with. Fear of tearing. Encourage her to listen to caregiver

 

First Stage of Labor: Transition

  • Physical Changes: cervix dilates from 8-10 cm; baby begins to descend toward vaginal opening; contractions are long and close together; pain and intensity of labor at its max; lasts less than 2 hours or less than 1 if given birth before; as cervix completes dilation, may have a lip that remains
  • How you may feel/respond: scared/lost; angry/frustrated; may want more help from others; may feel you’ve reached your limit; may lose rhythm and ritual; may cry out, tense, weep or protest; may feel hot, then cold; may tremble; may feel nauseated; may vomit
  • Ways To Cope: Keep a rhythm; follow partner/doula’s lead with Take Charge Routine; Hang in there! ; if want an epidural, can do it at this time as long as labor isn’t moving too fast
  • Ways Partner/Doula Can Help: maintain a confident, calm, optimistic manner; keep eye contact with you; Take Charge Routine; remind you that transition means you’re almost ready to push out baby; hold you tightly if that’s what you want; keep encouraging you and never give up; let you weep while acknowledging your pain

 

Second Stage of Labor: Resting Phase

  • Physical Changes: time from complete dilation to when begin to push; for up to 20 min, may have few noticeable contractions or have no urge to push; after baby’s head has slipped through cervix, uterus may need time to tighten around rest of baby’s body before you can begin to push
  • How you may feel/respond: feel relief, optimism, confidence and pain-free; have renewed energy, enthusiasm, hope even if you don’t experience a pause in contractions; no longer in the birth zone – your clearheaded, talkative and more aware of your surroundings
  • Ways To Cope: rest or doze, if you can; if want to push spontaneously, remind caregiver of preference, review positions, if resting phase lasts more than 20 min, change to upright positions to encourage an urge to push
  • Ways Partner/Doula Can Help: should match your enthusiasm, use the lull to renew energy (drink beverage, close eyes and rest for a moment, use restroom), help you change positions

 

Definition of 2nd stage – it is an esp brave midwife who will record 6 hr 2nd stage that included several hrs of latency; its far more comfortable to assign the start so that time comes in under whatever guideline locally requires.   Most have been there and adopted visualization of presenting part as reference marker for start of 2nd stage.

Midwifes known that women’s bodies don’t fit template of biomedical definition, because they have rest and be thankful phase after full dilation or they involuntarily push before. Both of these fall outside the normative physiology. Ascertaining the start of the 2nd stage even w a confirmatory vaginal examination was always problematic anyway. If there is no cervix palpable on examination, you are already too late – full dilation occurred some time before. Occasionally midwives, fed up with confines of biomedical model, may deliberately record full dilation at 9 or 11 cm because they argue the improbability that ever woman in world has a cervix that dilates to 10 cm exactly. They are facetiously commenting on the nonsense that birth anatomy and physiology is uniform across all women.

1st to stage transition: that mysterious phenomenon, virtually ignored by childbirth textbooks, yet transition is one of the earliest observed labor behaviors by students on birth suites. For women who experience transition, the notion that it is rather enigmatic and of little relevance would be laughable.

Spectrum of experiences/emotions (From inner calm to acute distress) in latter half of labor just prior to pushing. If time frames take on less significance, then midwives will be freer to work with the lived experience of transition and 2nd stage and arguably offer better individualized care. Women spoke of:

  • Paradox of being in control and letting go
  • Altered state of consciousness
  • Sense of timelessness
  • Wanting midwife to be a safe anchor, someone to put trust in, with a calm, quiet, unobtrusive presence
  • Unhelpful aspects of care were being treated as a naughty schoolgirl, being told off, intrusive interventions (fetal monitoring, requiring to be on bed, interruptions and being undermined)

One way out of this temporality bind is to adjust definition of start of 2nd stage. redefining this by changing criterion of full dilation of cervix to “when presenting part has passed through the cervix and is below the ischial spines. This alteration would allow for physiological variations observed in practice of latent episodes after reaching full dilation. Once presenting part has descended beyond ischial spines, then bearing down will occur as the fetus enters the perineal phase or women experience the fetal ejection reflex.

Acknowledgment of latent element and subsequent lengthening of the time frame has appeared in OB journals in recent years. Anesthetists and OBS became alarmed at assisted vaginal birth rates w epidurals and at fetal hypoxia associated with prolonged coached pushing. They began researching passive descent, in some studies up to 5 hours before active pushing was commenced. Now, its common practice to wait at least 2 hours in many consultant units. Blatant double standard exists where women without epidurals are allowed only 1 hr.

Concerns for baby when labor is exposed to oxytocin augmentation during 2nd stage have been raised; it’s a risk factor for fetal acidaemia.

  1. Coping skills for transition
  1. Urge to push in transition
  1. Take charge routine
  1. Second stage labor
  2. Physical changes of second stage

 

Stages and Phases of Labor

Prelabor may last for days/weeks; cervix moves forward, ripens (softens) and effaces (thins/shortens). Over course of labor, uterus contracts, cervix continues to ripen and efface and begins to dilate; baby moves down birth canal and you give birth to baby, placenta, umbilical cord and amniotic sac. Can take anywhere from a few hours to a day or longer.

Labor divided into 4 stages, each marks a sign of progress. 1st and 2nd further divided into phases, which represent more subtle changes.

  • 1st stage (dilation): begins w contractions that are becoming longer, stronger and more frequent (progressing) and ends when cervix is completely dilated. Has 3 phases: early labor, active labor, and transition.
  • 2nd stage (birth of baby) – begins when cervix is fully dilated and ends when baby is born
  • 3rd stage (delivery of placenta) – begins w birth of baby and ends with delivery of placenta
  • 4th stage (recovery) – begins after placenta is delivered and ends 1 to several hours later, when your condition has stabilized

 

Second Stage of Labor: Birth of Your Baby

As soon as cervix has dilated completely, you’re in 2nd stage. Baby gradually leaves uterus, rotates within pelvis, descends through vagina and is born. Typically lasts 15 min- more than 3 hours. First time mom average time is 90 min-2 hours. Second stage faster than previous birth for mom who has given birth before.

Signs of 2nd stage: Pain of contractions lessen and interval between them increases. Calm down and can think clear again. Experience renewed energy and become optimistic and aware of those around you.

Urge to Push: most significant sign of 2nd stage. Combination of forceful sensations and reflex (involuntary) actions caused by pressure of baby in vagina during contractions around the time your cervix is fully dilated. Occurs several times within a contraction and indicates that uterine muscles are pushing baby downward. When you have urge to push, you experience a compelling need to grunt or hold your breath and bear down. May feel like a strong urge to have a bowel movement.

When you have urge to push immediately or after a brief rest depends on degree and speed of baby’s descent, her station and position within your pelvis, your body position and other factors. Ask caregiver to check dilation of cervix. If its fully dilated, you can begin pushing when you feel urge. If its not, but is very ripe and effaced, you may be asked to bear down only enough to satisfy urge. If cervix isn’t completely dilated, may be asked not to push. Because urge is involuntary, resisting it may postpone pushing, but only temporarily.

Responding to urge is one of most satisfying aspects of birth experience for many women; some women even orgasm when giving birth. Others find pushing painful and exhausting, while many are simply relieved to start pushing.

Some women don’t feel a strong urge to push in this stage. Usually, time or changing to upright position can strengthen urge. If you receive pain medication, especially epidural, might not feel urge or it might be a vague sensation.

 

Summary of Normal Labor without Pain Medications (if plan to have epidural, use this until receive epidural)

Prelabor

  • Physical Changes: cervix begins to ripen, efface and move forward. Have nonprogressing contractions and may have restless back pain, soft bowel movements and menstrual like cramps; may last for days
  • How you may feel/respond: tired, discouraged, anxious. May be unable to sleep through contractions. May overestimate labor progress, start rituals and go to birthplace. May focus more than necessary on contractions.
  • Ways To Cope: engage in distracting activities and projects; alternate distracting activities with restful ones such as taking a bath, listening to music, lying down, having a massage etc; use labor-stimulating measures (only if you feel pressured to get into labor); eat if hungry (carbs), drink to thirst
  • Ways Partner/Doula Can Help: review route to birthplace; encourage you to eat/drink; pack vehicle and make sure there’s fuel; time contractions (5-6 at a time) every few hours or when labor seems to have changed; ensure you aren’t left alone; help make the time pleasant for you; alert your doula to be ready to come when you need her if she’s not already with you; enhance emotional security and reduce stress by creating a soothing, safe, private and loving atmosphere

 

First Stage of Labor: Early Labor

  • Physical Changes: denotes time from onset of labor until cervix is dilated 4-5 cm; contractions are progressing, usually mild at first, then becoming longer, stronger and closer together; cervix continues ripening, effacing and begins to dilate; may have bloody show; membranes may rupture (10% chance) but this usually happens later in labor; may have back pain with contractions
  • How you may feel/respond: same as in prelabor plus have mixed feelings – excitement, confidence, and optimism or anxiety and distress – often at same time; as contractions intensify, you can no longer be distracted by them
  • Ways To Cope: begin using planned rituals (relax, breathe, and focus through each contraction) when intensity of contractions stops you from doing distracting activities; use slow breathing, releasing tension with each exhalation; ask doula for help; contact caregiver or birthplace as instructed when contractions have reached 4-1-1 or 5-1-1 pattern; comfort measures for back pain
  • Ways Partner/Doula Can Help: continue timing contractions periodically; call caregiver or birthplace when contractions reach designated intensity, frequency and length or if membranes ruptured; focus on your contractions as soon as you begin doing a planned ritual; give you constructive feedback, not false praise; help you release tension in a selected area of your body with each exhalation; remind you of positions and comfort techniques

 

First Stage of Labor: Getting into Active Labor

  • Physical Changes: cervix dilated 4-5 cm; contractions intensify and occur every 3-4 min, lasting 1 min or longer; labor progress should begin to speed up at 5 cm
  • How you may feel/respond: head for birthplace or call midwife; may struggle to remain in control and worry that labor is too hard and long; may become serious, withdrawn, and focused on your labor; may recognize that labor isn’t within your control, leaving you feeling trapped – you may weep; you can no longer be distracted during contractions, you need partner or doula’s undivided attention during them; find unnecessary conversation annoying; may want pain meds; can release control and accept your labor if you can move freely, feel safe and uninhibited and have good support
  • Ways To Cope: try to release your need to be in control; let labor happen as you discover what helps you cope (finding your spontaneous ritual); maintain a rhythm with your breathing and movements, letting your partner or doula help as necessary; try to continue slow breathing if you find it restful; remember that labor progress should speed up soon; if planned for early epidural, can probably receive it during this phase
  • Ways Partner/Doula Can Help: drive to birthplace carefully!; use massage (hand or foot), double hip squeeze, counterpressure, slow dancing etc; rhythmically murmur soothing, encouraging words to you; guide you with visualizations, imagery, rhythmic talk or breath-counting – whatever helps you respond well; help you keep a rhythm in your breathing, moaning, swaying, tapping or whatever action you choose; refrain from asking questions during contractions and ask only simple yes or no questions between contractions; help with your ritual (stroking you, holding you, talking to you through contractions) or simply stay by you if that’s all you require; help you follow preferences on pain meds

 

First Stage of Labor: Active Labor

  • Physical Changes: cervix dilates from 5-8cm; lasts on average 3-5 hours; if baby is OP or her head is tilted to 1 side, dilation of cervix may pause as baby corrects position; may have back pain (30% chance)
  • How you may feel/respond: calmer than before, now that you’ve discovered how to get through contractions; may enter birth zone and become aware or little other than labor
  • Ways To Cope: same as for early labor and getting into active labor plus – take a bath for relaxation and pain relief; stay hydrated by taking frequent sips of water/juice
  • Ways Partner/Doula Can Help: same as for getting into active labor plus stay by you side, offer you liquids, remind you to empty your bladder

 

Friedman’s Legacy– in vast majority of hospital births, progress is assessed by vaginal examination. Normative mindset is so powerful that few midwives have had opportunity to observe laborious where no vaginal examinations occur. For millions of years, childbirth was not obsessed with labor duration. The word ‘pasmo’ described labor that stopped and everybody when home until lit started again.

Friedman’s legacy – Emanuel Friedman was first to graphically record cervical dilation over time. It became seminal in influencing our understanding of average length of labor for primigravid and multigravida women. Based on 2 samples of 200 primigravid women in 1954 and 500 primigravid a year later.

In early 1970s, Philpott and Castle added partogram to labor records and amplified cervicograph to give guidance for what to do if labors were slow. Using just active phase of 1st stage, they drew an alert line at 1 cm/hr rate, a transfer line at 2 hrs behind alert line and an action line 2 hrs behind that. Alert line was signal to monitor closely, transfer line to transfer physically to major hospital and action line to rupture membranes and administer oxytocin.

All 3 of these variations were adapted and added in O’Driscolls protocol of ‘active management of labor”; this interventionist approach had strict criteria for labor diagnosis and aggressive management of slow progress with early recourse to artificial rupture of membranes and IV oxytocin if labor didn’t progress at 1cm/ hr. it was much stricter than Philpott’s guideline of early 1970s. Some UK studies show that up to 57% of low risk primigravid women have labor augmented with oxytocin.

Organizational factors – Martin railed against assembly line childbirth in 1980s but it was not until Perkins critique of USA maternity policy that adopted essentially business/industrial model by maternity hospitals has been made so explicit. Perkins cited the Henry Ford’s car-assembly line as template.

One of best ways of reducing workload on very large labor wards is by opening up midwifery-led units or birth centers alongside these existing facilities.

An emergent critique – research that nulliparous labors were longer than Friedman had said. Some active phases 2x the length. (17.5 hrs vs 8.5 hrs for nulliparas and 13.8 hrs vs 7 hrs for multiparas) without any consequent morbidity. Primiparous women remained in first stage for up to 26 hrs and multiparous women for 23 hrs without adverse effects. The acceleratory phase occurred after 5 cm in multiparous women and after 6 cm in many nulliparous women. A parabolic curve of labor is much more realistic than linear versions of cervical dilation.

Oxytocin is the ‘benevolent queen” with an array of influences: directly on uterine contractions and in generating feelings of nurture, protection and altruism toward baby. Dynamic synergy of other hormonal interactions: of cortisol adrenaline (fight and flight) and noradrenaline (peace-maker) and endogenous endorphins. Adrenaline and noradrenaline prepare and empowers a woman for hard labor of birthing by mobilizing her strengths and inner resources. If woman, who towards an end of labor, has an epidural – there is complete removal of pain which stimulates noradrenaline, which wrongly interprets that labor is stopping so feeds back to stop the release of oxytocin so labor is becalmed again. Inner high of endogenous endorphins – secreted when body is in chronic pain. It synergizes with oxytocin to release at appropriate level to maintain marriage of 2 in progressing labor while calming soul.

 

Epidurals and 2nd stage – compared immediate coached pushing with delayed open-glottis pushing in nulliparous women with epidurals, demonstrating that latter group had better fetal outcomes and less perineal trauma. No difference in length of 2nd stage. Open-glottis pushing (pushing w out breath holding) demonstrated by women audibly grunting, shorter periods of breath-holding (6-8 sec) and no more than 3 pushes per contraction. Good practice to combine open-glottis pushing w upright posture, achievable now w low-dose epidurals.

Definition of 2nd stage – see pgs 107-108 above

 

Attitudes and philosophy – resist temptation after experience above to always do a confirmatory vaginal examination when signs of 2nd stage appear, takes experience and a supportive environment

Attitudinal change to enhance woman’s autonomy is imperative; a move from:

  • Loss of autonomy to being in control
  • Passive to active
  • Dependence to independence

For midwives, movement from:

  • Control to facilitation
  • Dominance to masterly inactivity
  • Surveillance and monitoring to watchful expectancy
  • More to less

Then the space is made for sensitive, intuitive support hat really does make a difference when needed in the 2nd stage

 

Definitions of the 2nd Stage of Labor – begins with complete dilation of cervix and ends with birth of baby. Being completely dilated is not believed to be sufficient reason to begin pushing; want complete dilation plus involuntary expulsive efforts (urge to push). Contractions sometimes decrease temporarily around time of full dilation.

Phases of the 2nd stage of labor – can be divided into phase (latent and active) just as first.

  • Latent phase – apparent lull in uterine activity around time of complete dilation is frequently observed and is sometime referred to as resting phase.
    • Hypothesis 1 (Simkin): During most of 1st stage, uterus is tightly wrapped around fetus. Uterine contractions in 1st stage not only dilate cervix but also shorten uterine muscle fibers and these actions gradually reduce intrauterine space and press fetus down. Last 2 cm of dilation are accompanied by cervical retraction around head (or presenting part) and beginnings of descent of head into vaginal canal. Fetal head represents 25-30% of entire body. When head (1/4th of contents of uterus) slips through, uterine muscle slackens because it is no longer tightly stretched around entire fetus and intrauterine space must now shrink to catch up with fetus. Catching up consists of shortening of uterine muscle fibers further reducing intrauterine space until once again the uterine muscle is tightly wrapped around fetal trunk. May take minutes or longer, during which woman’s contractions are weak or unnoticeable and woman may doze. Contractions resume and woman experiences an increasingly powerful urge to push, accompanied by a documented spurt in oxytocin release. Only some women experience a lull. Fetal position and station may be 2 of factors that determine whether, when and how long woman will experience resting phase.
    • Hypothesis 2 (Roberts): During latent phase, contractions continue and are measurable by electronic monitoring, although they may be below threshold of woman’s awareness. These cause fetal rotation, alignment and descent. Women exhibit less pain and distress than earlier in labor because of retraction of cervix around descending fetal head. Women begin to experience involuntary bearing-down efforts once fetal head is at +1 station and has rotated to OA and contractions have achieved and maintained an intensity of 30 mm Hg.
    • Asking woman to push during latent phase– with no interventions, powerful pushing contractions usually resume within 5-30 min. Woman gets rest, spirits rise and she begins to look forward to delivering her child. Caregivers trying to speed labor up may order Pitocin to augment uterine contractions – potential adverse effects such as tetanic contractions and fetal intolerance of labor, leading to increased reliance on cesareans. In unanesthetized woman with uncomplicated labor, her uncontrollable urge to push is best indicator of when she should begin bearing down spontaneously.
    • What if latent phase of 2nd stage persists? If lull persists for >30-20 min, caregiver may continue monitoring and waiting or may initiate measures to bring on contractions. Change in woman’s position to sitting up right (bed or toilet), squatting, walking, “Trial” expulsive efforts (breath holding and bearing down), acupressure and nipple stimulation. Many professionals await urge to push before checking cervix.
  • Active phase – characterized by involuntary urge to push and descent of fetus. Aka pelvic division of labor, press period or descent phase.
    • Directed expulsion efforts – some believe women should remain horizontal and when contractions begin, she draws legs up and curls body, takes a deep breath, holds it and bears down maximally for >10 sec; then release breath, quickly take another and repeat until contraction ends. Devised by natural childbirth advocates in 1950s as away to overcome antigravity effects of mandatory lithotomy position and to avoid forceps. Continues to be widespread.

 

Second Stage of Labor – when infant is born. Begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with baby’s birth. Force exerted by uterine contractions, gravity and maternal bearing-down efforts facilitates achievement of expected outcome of a spontaneous, uncomplicated vaginal birth. Median duration 50-60 minutes in nulliparous women and 20-30 min in multiparous women.   In addition to parity, maternal size and fetal weight, position, and descent influence the length of this stage. Use of epidural often increases length of stage because it blocks or reduces woman’s urge to bear down and limits her ability to attain an upright position to push.

Upper limits for duration of normal 2nd stage: nulliparous – 2 hrs w no regional anesthesia or 3 hours with anesthesia; multiparous women – 1 hr w no regional anesthesia, 2 hours with. Prolonged 2nd stage diagnosed after these time limits reached.

2nd stage composed of 2 phases: latent and active pushing phase. Maternal verbal and nonverbal behaviors, uterine activity, urge to bear down and fetal descent characterize these phases.

Latent (“laboring down”) phase – period of rest and relative calm. Fetus continues to descend passively through birth canal and rotate to an anterior position as a result of ongoing uterine contractions. Woman is quiet and often relaxes w her eyes closed between contractions. Urge to bear down is not strong, and some women do not experience it at all or only during acme (peak) of a contraction. Delayed pushing shown to result in significant decreases in pushing time, significant increase in during of 2nd stage, and a reduction in number of operative vaginal births. No differences in # of cesareans, perineal lacerations or episiotomies, or fetal complications linked to delayed pushing. Allowing a woman to rest during this phase and waiting until urge intensified significantly reduced time spent pushing but did not significantly increase total length of stage. Maternal fatigue scores, perineal injuries, and FHR decelerations were similar in immediate and delayed pushing groups. Another study found significant decrease in pushing time in nulliparous women with epidural who practice delayed pushing.

Careful monitoring with assurance of normal fetal status should be used during delayed pushing. If descent is slow and woman becomes anxious, she should be encouraged to change positions frequently or to stand by bedside to use advantage of gravity and movement to facilitate descent and progress to active pushing phase signaled by perception of need to bear down.

During active pushing (descent) phase the woman has strong urges to bear down as Ferguson reflex is activated when presenting part presses on stretch receptors of pelvic floor. Fetal station is usually +1 and position is anterior. Stimulation causes release of oxytocin from posterior pituitary gland, which provokes stronger expulsive uterine contractions. Woman becomes more focused on bearing down efforts, which become rhythmic. She changes positions frequently to find a more comfortable pushing position. Woman often announces onset of contractions and becomes more vocal as she bears down. Urge to bear down intensifies as descent progresses and presenting part reaches perineum. Woman may be more verbal about pain she is experiencing; she may scream or swear and may act out of control.

Validate woman’s experience of pressure, stretching and straining as normal and a signal that descent of fetus is progressing. Tell her to listen to her own body.

 

Nursing Care in 2nd Stage Labor

Assessment

Signs That Suggest Onset of 2nd Stage

  • Urge to push or feeling need to have a bowel movement
  • Sudden appearance of sweat on upper lip
  • Vomiting
  • Increased bloody show
  • Shaking of extremities
  • Increased restlessness; verbalization (I can’t go on)
  • Involuntary bearing-down efforts

Physical Assessment

  • Every 5-30 min: maternal bp, pulse and respirations
  • Every 5-15 min, depending on risk status: fetal heart rate and pattern
  • Every 10-15 min: vaginal show, signs of fetal descent and changes in maternal appearance, mood, affect, energy level and condition of partner/coach
  • Every contraction and bearing-down effort

Interventions

Latent (“Laboring Down”) Phase –

  • Help to rest in a position of comfort; encourage relaxation to conserve energy
  • Promote progress of fetal descent and onset or urge to bear down by encouraging position changes, pelvic rock, ambulation, showering

Active Pushing (Descent) Phase:

  • Help to change position and encourage spontaneous bearing down efforts
  • Help to relax and conserve energy between contractions
  • Provide comfort and pain relief measures as needed
  • Cleanse perineum promptly If fetal material is expelled
  • Coach to pant during contractions and to gently push between contractions when head is emerging
  • Provide emotional support, encouragement, and positive reinforcement of efforts
  • Keep woman informed regarding progress
  • Create a calm and quiet environment
  • Offer mirror to watch birth

Care Management – only certain objective sign that 2nd stage has begun is inability to feel cervix during vaginal examination, indicating that cervix is fully dilated and effaced. Don’t know exactly when it occurs because vaginal examination done at intervals; makes timing of actual duration of 2nd stage difficult. Other signs include urge to push or feeling need to have a bowel movement. Signs commonly appear at time cervix reaches full dilation. Can appear earlier in labor. Women with epidural may not exhibit such signs.

Women laboring without anesthesia can experience irresistible urge to bear down before full dilation. Can occur early as 5 cm; most often related to station of presenting part below level of ischial spines of maternal pelvis. Occurrence creates a conflict between woman, whose body is tell her to push, and health care providers, who may believe pushing fetal presenting part against incompletely dilated cervix will result in cervical edema and lacerations, as well as slow the labor progress. Evaluate urge as sign of labor progress, possibly indicating onset of 2nd stage. Base timing of when a woman pushes in relation to whether her cervix is fully dilated on research evidence rather than tradition or routine practice. Pushing w urge to bear down at acme of contraction may be safe and effective if cervix is soft, retracting and 8cm+ and if fetus is at 1+ station and rotating to an anterior position.

If mother is to be transferred to delivery room for birth, perform transfer early enough to avoid rushing her. Keep dry bedding and keep extraneous noise, conversation and other distractions to a minimum.

Preparing for Birth- Maternal Position – angles between baby and woman’s pelvis constantly change as infant turns and flexes down birth canal. She should be encouraged to change positions frequently and assisted in attaining and maintaining her position of choice. Supine, semi-recumbent or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor.

Birth attendants play a major role in influencing a woman’s choice of positions for birth. Upright position (walking, sitting, kneeling or squatting) offers a number of advantages. Gravity can promote descent of fetus. Uterine contractions are generally stronger and more efficient in effacing and dilating the cervix, resulting in shorter labor. Upright position is also beneficial to mother’s cardiac output, thereby increasing perfusion of uterus. Use of upright and lateral positions also associated with less pain and perineal damage, fewer episiotomies and abnormal FHR patterns, and fewer operative vaginal births.

Benefits upright positions may be related to:

  • Straightening of longitudinal axis of birth canal and improving alignment of fetus for passage through pelvis
  • Application of gravity to direct fetal head toward pelvic inlet, thereby facilitating descent
  • Enlargement of pelvic dimensions and restriction of encroachment of sacrum and coccyx into the pelvic outlet
  • Increased uteroplacental circulation, resulting in more intense, efficient uterine contractions
  • Enhancement of woman’s ability to bear down effectively, thereby minimizing maternal exhaustion.

Squatting is highly effective in facilitating descent and birth of fetus. It is one of the best and most natural positions for 2nd stage labor and has been associated with the same benefits as other upright and lateral positions. Women should assume a modified, supported squat until the fetal head is engaged, at which time a deep squat can be used. Firm surface is required for this position, and woman will need side support. In a birthing bed, a squat bar is available that she can use to help support herself. A birth ball can also help a woman maintain the squatting position. Fetus will be aligned with the birth canal, and pelvic and perineal relaxation is facilitated as she shits on the ball or holds it in front of her for support as she squats.

When a woman uses the supported squatting position for bearing down, her weight is borne on both femoral heads, allowing the pressure in the acetabulum to cause the transverse diameter of the pelvic outlet to increase by up to 1 cm. this can be helpful if descent of the head is delayed because occiput has not rotated from lateral (transverse diameter of pelvis) to anterior position. Birthing chairs or rocking chairs may be used to provide women with a good physiologic position to enhance bearing-down efforts during childbirth, although some women may feel restricted by a chair. The upright position also provides a potential psychological advantage in that it allows the mother to see the birth as it occurs and to maintain eye contact with the attendant.

Oversized beanbag chairs and large floor pillows can be used. They can mold around and support mother in whatever position she selects. These chairs are of particular value for mothers who wish to be actively involved in birth process. Birthing stools can be used to support woman in upright position similar to squatting. Some women may feel more comfortable sitting on toiled during pushing because they are concerned about stool incontinence. Encourage them to empty bladder to avoide effects of distended bladder. Must closely monitor these women, and ask them to move from toilet before birth becomes imminent. Sitting on chairs, stools, toilets or commodes can increase perineal edema and blood loss, assist woman to change position frequently (every 10-15 min).

Side-lying or lateral position, with upper part of woman’s leg held by nurse or coach or placed on pillow, is an effective position for 2nd stage. Some women prefer a semi-sitting (semi-recumbent) position instead. If semi-recumbent position is used, do not force woman’s legs against her abdomen as she bears down.   This position will increase perineal stretching and risk for perineal trauma as well as spinal and lower extremity neurologic injuries. Hands and knees position is yet another effective position for birth.

Birthing bed can be set for different positions according to woman’s need. Woman can squat, kneel, sit, recline or lie on her side, choosing position most comfortable for her without having to climb into bed for birth. Birthing bed provides excellent access and visualization for attendant to perform exams, place electrodes and assist woman giving birth. Can position bed for administration for anesthesia and its ideal to help woman receiving epidural to assume different positions to facilitate birth. Can also use bed to transport woman to operating room if cesarean is necessary. Woman can use squat bars, over the bed tables, birth balls and pillows for support.

 

Expected Maternal Progress in 2nd stage of labor

Latent Phase – Avg Duration 10-30 min

Contractions

  • Intensity – period of physiologic lull for all criteria; period of peace and rest
  • Descent, station- 0-+2
  • Show; color and amount
  • Spontaneous bearing-down efforts- slight to absent, except at peak of strongest contractions
  • Vocalization – quiet, concern over progress
  • Maternal behavior – experiences sense of relief that transition to 2nd stage is finished; feels fatigued and sleepy; feels a sense of accomplishment and optimism because worst is over; feels in control

Active Pushing Phase – Avg Duration Varies

Contractions

  • Intensity – significant increase becoming overwhelmingly strong and expulsive
  • Frequency – every 2-2.5 min progressing to every 1-2 min
  • Duration- 90 sec
  • Descent, station- +2-+4; rate of descent increases and Ferguson reflex is activated; fetal head becomes visible at introitus and birth occurs
  • Show; color and amount- significant increase in dark red blood show; bloody show accompanies emergence of head
  • Spontaneous bearing-down efforts- increased urge to bear down; becomes stronger as fetus descents to vaginal introitus and reaches perineum
  • Vocalization – grunting sounds or expiratory vocalizations; announces contractions; may scream or swear
  • Maternal behavior – senses increased urge to push and describes increasing pain; describes ring of fire; expresses feeling of powerlessness; shows decreased ability to listen to or concentrate on anything but giving birth; alters respiratory pattern; has short 4-5 sec breath holds w regular breaths in between, 5-7 per contraction; frequent repositioning; often shows excitement immediately after birth of head

*Duration of descent phase can vary, depending on maternal parity, effectiveness of bearing-down efforts, and presence of spinal anesthesia or epidural

*Pressure of presenting part on stretch receptors of pelvic floor stimulates release of oxytocin from posterior pituitary, resulting in more intense uterine contractions

 

Guidelines for Assistance at Emergency Birth of a Fetus in Vertex Presentation

  1. Lateral position often recommended to facilitate controlled birth of head, thereby minimizing risk for perineal trauma and neonatal head injury.
  2. Reassure its normal; use support person if available. Positive reinforcement.
  3. Wash hands; put on gloves
  4. Place clean material under woman’s buttocks
  5. Avoid touching vaginal area to decrease possibility of infection
  6. As head begins to crown:
    1. Tear amniotic membranes if still intact
    2. Instruct woman to pant or pant-blow, minimizing urge to push
    3. Place flat side of hand on exposed head and apply gentle pressure toward vagina to prevent head from popping out. Rapid birth of head must be prevented because rapid change of pressure within molded skull follows, which may result in dural or subdural tears. Rapid birth may also cause vaginal/perineal lacerations
  7. After birth of head, check to see if umbilical cord is around baby’s neck. If it is, gently slip it over baby’s head or pull gently to get some slack so you can slip it over shoulders.
  8. Support baby’s head as external rotation occurs. Exert gentle pressure downward so that anterior shoulder emerges under symphysis pubis and acts as a fulcrum; then, as gentle pressure is exerted upward, posterior shoulder, which has passed over sacrum and coccyx, emerges.
  9. Hold baby securely because rest of body may emerge quickly. Baby will be slippery!
  10. Cradle baby’s head and back in one hand and buttocks in other. Keep baby’s head down to drain away mucus. Use bulb syringe if needed to remove mucus from mouth and nose.
  11. Dry baby quickly to prevent rapid heat loss and immediately place on mom’s abdomen. Keep baby at same level as mom’s uterus until cord stops pulsating. Baby should be kept at same level as uterus to prevent baby’s blood from flowing to or from placenta and resulting in hypovolemia or hypervolemia. Do not milk cord.
  12. Cover baby with warmed blanked and have mom cuddle baby. Compliment on job well done.
  13. Wait for placenta to separate. Do not tug on cord. Inappropriate traction may tear cord, separate placenta, or invert uterus. Signs of placental separation include a slight gush of dark blood from introitus, lengthening of cord, and change in uterine contour from a discoid to globular shape.
  14. Instruct mom to push out placenta. Ease out placental membranes using up and down motion until membranes are removed. Do not cut cord without proper clamps and sterile cutting tool if outside hospital. Inspect placenta for intactness. Place baby on placenta and wrap two together for additional warmth.
  15. Check firmness of uterus. Gently massage fundus and demonstrate to mother how to massage properly.
  16. Clean mother’s perineal area and apply peripad if supplies available.
  17. To prevent/minimize hemorrhage:
    1. Put baby to mom’s breast ASAP. Sucking nipple stimulates release of oxytocin from posterior pituitary. If baby cannot nurse, manually stimulate nipples
    2. Do not allow mother’s bladder to become distended. Assess for fullness and encourage her to void.
    3. Expel any clots from mom’s uterus after ensuring fundus is firm.
  18. Comfort/reassure mom and family/friends. Give mom fluids.
  19. If more than one baby, identify in order of birth (A, B, C…)
  20. Make notations regarding:
    1. Fetal presentation and position
    2. Presence of cord around neck (nuchal cord) or other parts and # of times cord encircled part
    3. Color, character, and estimated amount of amniotic fluid, if rupture of membranes occurred immediately before birth
    4. Time of birth
    5. Estimated time of determination of Apgar score (1 and 5 min after birth), resuscitation efforts implemented, and ultimate condition of baby
    6. Gender of baby
    7. Time of placental expulsion, as well as appearance and completeness of placenta
    8. Maternal condition: affect, behavior, and demeanor, amount of bleeding, and status of uterine tonicity
    9. Any unusual occurrences during birth (maternal/paternal response, verbalizations, gestures in response to birth of baby)

 

Bearing-Down Efforts: as fetal head reaches pelvic floor, most women experience urge to bear down. Woman will begin to exert downward pressure reflexively by contracting ab muscles while relaxing pelvic floor. It is an involuntary response to Ferguson reflex. Strong expiratory grunt or groan (vocalization) often accompanies pushing when woman exhales as she pushes. Shouldn’t be discouraged.

Prolonged breath-holding, or directed bearing down still common practice, often beginning at 10 cm dilation and before urge to bear down is perceived. Woman is coached to hold breath, close glottis and push while nurse counts to 10; this is strongly discouraged because may trigger Valsalva maneuver, which occurs when woman closes her glottis and increases intrathoracic and cardiovascular pressure. This reduces cardiac output and decreases perfusion of uterus and placenta. Adverse effects include fetal hypoxia and subsequent acidosis, increased risk for pelvic floor damage, perineal trauma.

Benefits of spontaneous pushing efforts include less fatigue and enhanced comfort. Essential that nurses advocate for delayed and spontaneous bearing-down efforts with woman in upright or lateral position.

Phrases to use: You’re doing so well; do it again. You are moving baby down. Follow what your body is telling you. Rather than push, push, push.

Monitor woman’s breathing so she does not hold breath for more than 6-8 sec at a time followed by slight exhale. Remind her to ventilate lungs by taking deep, cleansing breaths before and after each contraction. Bearing down while exhaling and taking breaths between bearing-down efforts helps maintain adequate oxygen levels for mom and fetus. Active pushing phase considered to be most physiologically stressful part of labor. Use nondirected spontaneous pushing to conserve energy and maximize effect of each bearing-down effort. Woman’s bearing-down efforts naturally will become more forceful and frequent as 2nd stage progresses to birth.

Woman may reach 2nd stage then experience a lack of readiness to complete process. May have doubts about readiness or desire to wait for support person or OB. Fear, anxiety, unfamiliar or painful sensations and behaviors during pushing may be other inhibiting factors. Fear baby will be in danger may be present. Address woman’s concerns and coach effectively.

To ensure slow birth of head, encourage woman to control urge to bear down by coaching her to take panting breaths or exhale slowly through pursed lips as baby’s head crowns. Woman needs simple, clear directions from one person at this point. Amnesia between contractions often occurs in 2nd stage.

 

Fetal Heart Rate and Pattern – Check regularly. If baseline begins to slow, if absent or minimal variability occurs, or if deceleration patterns (late, variable, prolonged) develop, initiate interventions promptly. Turn woman onto side to reduce pressure of uterus against ascending vena cava and descending aorta. Oxygen can be administered by nonrebreather mask at 10L/min. These interventions are often all that’s needed to restore normal pattern. If FHR and pattern do not become normal immediately, notify OB because may need medical interventions to give birth.

Support of Partner – nurse should offer nourishment/fluids and encourage short breaks. Presence of partners maintains psychological closeness of family unit and partner can continue to provide supportive care during labor.

Supplies, Instruments and Equipment – birthing table set up during transition phase in nulliparous women and during active phase for multiparous women. Follow standard procedures for gloving, identifying and opening sterile packages, adding sterile supplies to instrument table, unwrapping sterile instruments, and handing them to OB. Ready crib or radiant warmer and equipment for support and stabilization of infant.

Nurse estimates time until birth. Even most experienced nurses may miscalculate time; therefore, every nurse who attends women in labor must be prepared to assist emergency birth.

Birth in Delivery Room or Birthing Room – stirrups not same height will strain ligaments in woman’s back as she bears down, leading to considerable discomfort in postpartum period.

Once woman is positioned, foot of bed is removed so OB can gain better perineal access for performing episiotomy, delivering large baby, using forceps or vacuum, or getting access to emerging head to facilitate suctioning.

Once woman is positioned, vulva and perineum are cleansed.

Prepare or obtain an oxytocic medication such as oxytocin (Pitocin) so that it is ready to be administered immediately after expulsion of placenta.

OB may put on a cap, mask w shield/protective eyewear and shoe covers. After washing hands, she puts on sterile gown with waterproof front and sleeves and sterile gloves. Nurses may also need to wear caps, protective eyewear, masks, gowns and gloves. Woman may be draped with sterile drapes.

Mechanism of Birth: Vertex Presentation – 3 phases: 1) birth of head 2) birth of shoulders 3) birth of body and extremities.

With voluntary bearing-down efforts, head appears at introitus. Crowning occurs when widest part of head distends vulva just before birth. Immediately before birth, perineal musculature become greatly distended. If episiotomy necessary, done at this time to minimize soft-tissue damage. Local anesthetic may be administered.

OB may use hands-on approach to control birth of head, believing that guarding perineum results in gradual birth that will prevent fetal intracranial injury, protect maternal tissues and reduce postpartum perineal pain. Approach involves 1) applying pressure against rectum, drawing it downward to aid in flexing head as back of neck catches under symphsysis pubis 2) applying upward pressure from coccygeal region (modified Ritgen maneuver) to extend head during actual birth, thereby protecting musculature of perineum and 3) assisting mother with voluntary control of bearing-down efforts by coaching her to pant while letting uterine forces expel fetus.

Some use hands-poised (hands-off) approach. Hands prepared to place light pressure on fetal head to prevent rapid expulsion. Provider does not place hands on perineum or use them to assist with birth of shoulders/body.

Hands on and hands-poised have similar results in terms of perineal and vaginal tears, but hands-on associated with higher incidence of 3rd degree tears and episiotomies. 1 study of hands-poised resulted in fewer 3rd degree tears. Hands on may result in less perineal pain.

Umbilical cord often encircles neck (nuchal cord) but rarely so tightly as to cause hypoxia. After head is born, gentle palpation used to feel for cord. Slip cord gently over head if possible. If loop is tight or if there is a 2nd loop, he/she will probably clamp cord 2x, cut between clamps, and unwind cord from around neck before birth is allowed to continue. Mucus, blood, or meconium in nasal/oral passages may prevent newborn from breathing. Moist gauze sponges used to wipe nose and mouth. Bulb syringe may be inserted first into mouth and oropharynx then into both nares to aspirate contents. S

Fundal Pressure – gentle, steady pressure against fundus of uterus to facilitate vaginal birth. No standard technique. Historically used when administration of analgesia and anesthesia decreased woman’s ability to push during birth, in cases of shoulder dystocia and when 2nd stage fetal bradycardia or other abnormal FHR patterns present. No legal, profession or regulatory standards exist for its use and no evidence related to effectiveness in facilitating safe vaginal birth available.

Immediate Assessments and Care of Newborn – time of birth is precise time when entire body is out of mother and must be recorded. If newborn’s condition not compromised, placed on mother’s abdomen and covered with warm, dry blanket. Cord may be clamped. May ask partner if want to cut cord. If so, given sterile pair of scissors, instruct to cut cord 1 inch above clamp.

Care given immediately after birth focuses on assessing and stabilizing newborn. AWONN recommends at least 2 nurses present for each birth – 1 for newborn and other for delivery of placenta/care of mom. Baby nurse watches infant for signs of distress and initiates appropriate interventions. In cases of multiple births, each baby has its own nurse.

Perform brief assessment of newborn immediately while mom is holding infant. Apgar scores at 1 and 5 minutes. Maintain patent airway, support respiratory effort and prevent cold stress by drying and preferably covering newborn with warmed blanked on mom or less optimally in radiant warmer. Can postpone further exams, ID procedures and care until later in 3rd stage or early in 4th stage.

Perineal Trauma Related to Childbirth – most acute injuries and lacerations of perineum, vagina, uterus and support tissues occur during childbirth. Alternative measures for perineal management, such as application of warm compresses and gentle perineal massage and stretching have been suggested to less degree of perineal lacerations and trauma. Perineal massage during last month of pregnancy has clear benefits of reducing perineal trauma during birth and pain afterward for women who had not given birth vaginally before. Cochrane review found that warm compresses may be beneficial in reducing incidence of 3rd and 4th degree lacerations.

Some degree of trauma to soft tissues of birth canal and adjacent structures occurs during every birth. Damage is more pronounced in nulliparous woman because tissues are firmer and more resistant. Heredity also a factor. Reddish hair, light skinned women not as readily distensible as that of darker skinned woman and healing may be less efficient. Other risk factors include maternal nutritional status, birth position, pelvic anatomy, fetal malpresentation and position, large infants, use of forceps or vacuum, prolonged 2nd stage, and rapid labor where there in insufficient time for perineum to stretch.

Some injuries to supporting tissues, whether acute or nonacute and whether repaired or note may lead to genitourinary and sexual problems later in life, pelvic relaxation, uterine prolapse, cystocele, rectocele, dyspareunia, urinary and bowel dysfunction. Kegels in prenatal and postpartum periods improves and restores tone and strength of perineal muscles.

Perineal lacerations – usually occur as fetal head is being born. Defined in terms of its depth.

  • 1st degree: extends through skin and vaginal mucous membrane but not underlying fascia and muscle
  • 2nd degree – extends through fascia and muscles of perineal body, but not anal sphincter
  • 3rd degree – involves anal sphincter
  • 4th degree: extends completely through rectal mucosa, disrupting both external and internal anal sphincters

Perineal injury often accompanied by small laceration on medial surfaces of labia minora below pubic rami and to sides or urethra and clitoris. Lacerations in this highly vascular area often result in profuse bleeding. 3rd and 4th degree lacerations must be carefully repaired so woman retains fecal continence. Simple perineal injuries usually heal without permanent disability, regardless of whether they were repaired. Repairing a new perineal injury to prevent future complications is easier than correcting long term damage.

Vaginal and Urethral Lacerations – vaginal lacerations often occur in conjunction w perineal lacerations. Tend to extend up the lateral walls and if deep enough, involve levator ani muscle. Additional injury may occur high in vaginal vault near level of ischial spines. Vault lacerations often circular and may result from use of forceps, rapid fetal descent or precipitous birth.

Cervical injuries – occur when cervix retracts over advancing fetal head. Occur at lateral angles of external os. Most shallow and bleeding minimal. Larger lacerations may extend to vaginal vault or beyond it into lower uterine segment; serious bleeding may occur. Extensive lacerations may follow hasty attempts to enlarge cervical opening artificially or to deliver fetus before full cervical dilation achieved. Injuries to cervix can have adverse effects on future pregnancies and childbirth.

Episiotomy – incision in perineum used to enlarge vaginal outlet. Use has steadily decreased in recent years due to lack of sound, rigorous research to support its benefits.   Approx. 10% of births. Less common in Europe and Canada, probably because more routine use of side-lying position for birth; this puts less tension on perineum, making possible a gradual stretching of perineum. Giving birth over intact perineum provides best outcomes (less blood loss, less risk of infection, less postpartum pain).

Midline (median) episiotomy most commonly used in U.S. Effective, easily repaired, and generally least painful. Also associated with higher incidence of 3rd and 4th degree lacerations. Sphincter tone is usually restored after primary healing and a good repair.

Mediolateral used in operative births when need for posterior extension likely. 4th degree laceration may be prevented, but 3rd degree may occur. Blood loss greater and repair more difficult and painful than w midline episiotomies. More painful in postpartum period and pain lasts longer.

Increasingly common practice is to support perineum manually during birth rather than performing episiotomy with goal of minimizing trauma. If tears occur, they are often smaller than episiotomy are repaired easily or do not need to be repaired at all, and heal quickly w less pain. Episiotomies associated with more posterior perineal trauma, suturing and healing complications and later pain w intercourse. Should be avoided whenever possible.

  1. Three key concepts of second stage

The Three R’s: After several hours (or even a day or longer), you’ll be unable to ignore your contractions – can’t walk or talk without having to pause at its peak. Activities are no longer distracting or fun. This marks a shift in your coping strategy. Instead of using distracting activities, use the three R’s (p 206).

Partners: Prep hospital bag/gas in car or house (tidy up/enough food) if it’s a homebirth. If mama becomes quiet, become quiet with her. Don’t hover over her or stare. Touch tense areas ~ “Try to breathe away tension in shoulders.” Remind to sip water after every contraction or 2 and follow her rhythm. (Ch 11 relaxation techniques).

Prolonged Prelabor or Early Labor

Prolonged labor – takes a long time to get started. Can be difficult to distinguish between a long prelabor (in which contractions aren’t’ progressing and cervix isn’t dilating) and a slow early labor (contractions are cervical dilation progressing slower than usual).

Early labor prolonged if regular contractions continue for longer than 20 hours. Many caregivers believe if early labor is taking a physical or psychological toll on woman, it’s prolonged – regardless of time.

Don’t assume entire labor will be slow. Prolonged early labor is NOT a labor complication. In most cases, labor progresses normally as soon as it reaches active phase.

Important to figure out cause; most probably causes:

  • Contractions have begun before cervix has moved forward, ripened or effaced
  • Cervix is scarred from a previous surgery, cone biopsy or another cervical procedure (for cervix to dilate, may require frequent and intense contractions to overcome resistance by scar tissue)
  • Baby is malpositioned, such as occiput posterior or w a raised chin. May also have back pain. Contractions may seem irregular or may couple.
  • You’re tense, anxious or distressed, which increase stress hormones that can hinder labor progress. Previous unresolved emotional/physical trauma, previous difficult birth experience, grief from miscarriage/abortion, stressful relationship or fears about your/baby’s well being

What you can do:

  • When have vaginal exam, ask whether cervix has moved forward and is ripe; ask about effacement
  • Try not to become discouraged or depressed. Visualize contractions bringing cervix forward, then ripening and effacing it
  • Nurture yourself w food, drink and loving support
  • Alternate doing labor stimulating activities with restful, distracting activities
  • Don’t time every contraction. Time 6 in a row, then wait until pattern has changed
  • If have irregular or couple contractions or back pain, assume baby isn’t in ideal position. Once baby is in better position, back pain should dissipate
  • If worried or tense, talk with partner or support person. A good cry can help release any overwhelming sadness/anxiety

Medical care for prolonged labor

If become exhausted or have made little or no progress for more than 24 hrs, need to decide whether to turn to medical interventions. 2 major approaches to speeding up labor medically:

  • Using medications to stop contractions or help you rest, such as tranquilizers, sedatives, uterine relaxants, morphine or alcohol
  • Using medications or procedures to stimulate more effective contractions. Stripping membranes, mechanically ripening or dilating cervix, breaking bag of waters, ripening cervix with prostaglandins or inducing labor with Pitocin

If feel too exhausted or discouraged to continue on own, request medical help.

Rapid Labor – some women, esp those who’ve given birth before – have rapid labors. Start with contractions 3-4 min apart and become increasingly stronger, longer and more frequent than usual.

Second Phase: Active Labor

When cervix dilated 4-5 cm, contractions usually reach 4-1-1 or 5-1-1 pattern. At this point, shifting from early to active labor and dilation usually speeds up and contractions become more painful. Most expectant couples go to hospital at this phase.

Getting Through Active Phase – can manage this phase and cope better after if following true:

  • Allowed to labor in environment that fosters privacy, preserves modesty and minimizes disturbances. When undisturbed, can focus inward and find spontaneous rituals to help get you through contractions
  • Have support people who unconditionally accept your coping style and assist you whenever needed. In this phase, you become serious, quiet and preoccupied. During contractions, your require your partner and others to focus on you – they shouldn’t talk among themselves or to you
  • You have freedom to move and seek comfort in whatever ways you feel helpful

Traveling to birth site during active labor creates a major disturbance in your coping strategy. See Ch 11 for comfort techniques in noisy, busy environment before labor so you can find a coping technique for the ride and can return to ideal focused state once settle in room.

Partners: help her cope with slow dancing, walking with her, stroking her, moaning with her, matching her rhythm by swaying or by moving your hand or head, keeping eye contact with her, or counting her breaths. See Appendix B for suggestions on ways to help partner cope.

Arriving at Hospital/Birth Center: Report info in Early Labor Record (pg 175), make sure have bag, birth plan and any last min items (towel if you bags of water are leaking). Do not drive yourself, have partner drive. Ride to birthplace may be challenging and uncomfortable. Focus your breathing on something in vehicle to give you a rhythm to follow. Go to triage. If think bags of water has broken, nurse may give you sterile speculum exam to obtain a sample of amniotic fluid for diagnosis. If they decide you are in early labor, you may be asked to leave until labor pattern changes. Should follow this advice to keep busy at home. Labor is likely to progress min environment that feels safe, secure and familiar. If don’t want to return home, take a walk nearby or go to cafeteria. When admitted, will take medical history, get urine/blood samples, check baby’s heart rate and progress. Change into hospital gown or bring your own and get an ID bracelet. May have IV catheter inserted at this time. Nurse begins monitoring contractions and baby’s heart rate for 20-30 min, typically with external electronic fetal monitor or possible with hand-held Doppler.

IV Fluids in Normal Labor – in some hospitals, its routine to insert IV catheter in all laboring women shortly after they’re admitted. They carry a few mild risks. See PCNGuide. It can limit mobility in labor because you’re connected to a wheeled pole that holds bag of fluids. Ask if it’s routine at prenatal appointment. If routine, ask whether can have a Hep Lock (Heparin Lock) which involves inserting an IV catheter, but doesn’t require hooking it to an IV bag until IV fluids are needed.

Working with Your Labor – after labor nurse finishes assessing you make yourself as comfortable as possible. Continue/begin spontaneous ritual. Use comfort measures as appropriate, such as placing pressure and cold packs on back or hot compresses on lower abdomen and groin. Empty bladder every hour or so; a full bladder increases discomfort and can slow labor. Make sure to keep self-hydrated by sipping water after a few contractions or by sucking popsicle/ice chips.

Try not to lie in bed throughout labor – may increase pain and slow labor progress. Unless need to rest on contractions are coming so fast you can’t move, try to periodically move about in bed or take advantage of gravity by standing and walking in you room and in the hall.

Continue slow breathing for as long as it helps you relax. Switch to light breathing or one of adaptations if breathing begins to feel labored or If can’t keep breathing rate slow, or if can’t maintain your rhythm. Light breathing may be better suited for demanding contractions than slow breathing, just as short, quick breaths are better suited for demanding physical exercise than long, deep breaths are. By tuning into contractions, you can adapt your breathing rhythm as needed.

Monitoring You and Baby during Normal Labor – as long as labor is normal and baby is doing well, you don’t need medical procedures. PCNGuide has description of techniques if monitoring indicates a complication has developed in labor

  • Monitoring You – regularly checks blood pressure, temp, pulse, urine output, fluid intake, activity and emotional state. Vaginal exams periodically to determine effacement and dilation of cervix and station, presentation and position of baby. recorded on chart which shows labor progress. Observes frequency and intensity of contractions by hand or electronic monitor.
  • Monitoring baby with fetal heart rate monitoring – many things influence baby’s heart rate during labor: your contractions, baby’s activity (fetal movements), medications, body temp, position and other factors. Normal range is 120-160 bpm. Varies in response to changes in amount of oxygen that’s available. If baby is handling labor well, he has a reactive heart rate, which naturally slows down to compensate for temporary reductions in oxygen during a contraction and speeds up between contractions. Indicates he’s compensating well to normal variations in oxygen flow.
    • Depending on maturity/health of baby, ability to compensate varies. If lack of oxygen continues over time, his reserves may become exhausted. May not be able to compensate and might become distressed (also known as nonreassuring fetal heart rate or fetal intolerance of labor). Close observation and further testing help identify those who aren’t tolerating well and may need immediate medical intervention
    • Baby’s heart rate can be monitored by auscultation or by electronic fetal monitoring (EFM). Auscultation – listens during and between contractions with a Doppler, or hand held ultrasound stethoscope. May place a hand on abdomen to feel contractions, then count heartbeats, nothing whether speed up or slow down.
    • Two types of EFM – commonly used external EFM uses belts to place 2 sensor son abdomen and rarely used internal EFM uses 2 sensors placed inside uterus (only used if external isn’t picking up signals). 1 sensor picks up baby’s heartbeat, other picks up changes in uterine tone or pressure. Sensors connected to video screens in room or at nurses station. 2 graphs showing baby’s heart rate and intensity of contractions. All date stored electronically

Short, Fast Labor – 6 hours or less and leads to a precipitate birth. Contractions may have started only 3-4 min apart, lasted a min each and were so intense that a woman couldn’t cope. Rare among 1st time moms, but a few may have labors as short as 3 hours. Much more common for moms who’ve given birth before. Call caregiver if this happens.

Early labor may have passed so fast you have no time to prepare psychologically. First noticeable contractions may be long and painful. May quickly lose faith in ability to handle rest of labor.

What you can do – try not to tense up during contractions and use slow breathing. If slow breathing doesn’t help, use light breathing. Moan or bellow rhythmically. Consent to vaginal exam before making decision about pain medication; cervix may have already dilated to 8-10 cm. Anesthesia may be unnecessary or may take effect too late to provide relief before baby’s birth. Rely on partner, doula and staff to help you cope and to reassure you baby’s doing well.

May have urge to push before staff is ready. If so, like on side and pant or gently bear down. Doing so gives your birth canal and perineum more time to stretch, decreasing likelihood of vaginal tearing.

May need to discuss sequence of events with caregiver/partner after so you can process birth and come to terms with it

*Less than 1/1000 babies born on way to hospital/birth center.

 

Third Stage of Labor: Delivery of Placenta– lasting between 10 and 30 minutes, 3rd stage is shorter and less painful than earlier stages. Begins with birth of baby and ends when placenta is delivered.

What to Expect– after baby is born, contractions stop briefly, then resume with the purpose of separating the placenta from your uterine wall. Typically less intense than before birth, but may still need relaxation techniques and rhythmic breathing. May be so engrossed with baby that you don’t notice contractions. Caregiver may direct you to give a few small pushes to deliver placenta. May appreciate seeing placenta after delivery, as it’s an amazing organ that allowed your baby to thrive in your womb.

Newborn Assessment with Apgar Score– within 1 minute after birth and again at 5 min, caregiver evaluates baby’s well being. As soon as baby is breathing and dried off, caregiver considers 5 factors and gives a score of 0 to 2 points for each. Score of 7-10 indicates baby is in good condition. Score of 6 or less means baby needs additional medical attention and observation.

Can be done while you hold baby. Babies rarely receive a 1- on first score (most babies hands and feet are bluish for a while after birth). If score 6 or less, may have to go to baby warmer or oxygen. 2nd score is usually higher than 1st score, indicating improvement with time or medical assistance.

Helps determine if baby needs immediate medical attention, but can’t predict baby’s overall health or long-term well-being. More thorough exam will be done within 24 hours of birth to more accurately assess baby’s condition.

Apgar Score

  • HR – Absent (0); <100 BPM (1); >100 BPM (2)
  • Respiratory effort– Absent (0); Slow, irregular (1); Good, crying (2)
  • Muscle tone– Limp (0); Arms and legs flexed (1); Active movement (2)
  • Reflex irritability (reaction to something placed in nose) – No response (0); Grimace (2); Sneezing, coughing, pulling away (2)
  • Skin Color– Bluish-gray, pale all over (0); Normal skin color, except for bluish hands and feet (1); Normal color all over (2)

 

Clamping and Cutting Umbilical Cord– soon after birth, baby’s umbilical cord is clamped and cut with scissors; partner may cut cord

Timing of cord clamping and cutting affects baby’s blood volume. Before birth, baby’s blood circulates via the cord to and from the placenta, allowing the exchange of oxygen, nutrients and other substances. At birth, 1/3 or more of baby’s blood is in placenta, but over the first few minutes, it transfers to your baby. The blood vessels in the cord are gradually compressed by a substance called Wharton’s jelly, which expands when cord is exposed to air. If cord is clamped immediately (which is still common practice), baby doesn’t receive a large portion of the blood from the placenta. Delaying clamping until cord stops pulsating allows baby to receive as much blood as possible. Some blood remains in placenta after pulsation stops.

For years, OBs taught that placenta blood is “extra” and if it got to baby, it could cause jaundice. This belief has been disproved. Delayed clamping benefits baby by helping increase blood levels of iron and reduce anemia from 2-6 months. May also hasten separation and delivery of placenta by decreasing its size.

To achieve optimal blood volume, baby is placed on mother’s abdomen (level with the placenta) until cord stops pulsating. Then it is clamped and cut. Holding baby high above or low below the mother may alter the speed of transfer of blood that passes between placenta and baby, but placement on mother’s abdomen is the most physiologic and seems appropriate under most circumstances.

In challenging situations, baby may benefit even more from delayed cord clamping. Some hospital wait a few minutes to clamp and cut cord after a cesarean. For a baby who needs medical attention or resuscitation, these procedures can often be carried out with the cord intact so the baby, while remaining next to his mother, continues to benefit from oxygenated blood transferring to him. Discuss preference with caregiver and put in birth plan.

Collection and Storage of Umbilical Cord Blood– blood in umbilical cord is rich source of stem cells, which generate and continually renew supplies of red cells, platelets and white cells. Stem cells make it possible for a person to use oxygen, clot blood, and fight infection. Those found in umbilical cord are easier to match to another person’s tissue than mature stem cells found in bone marrow. They can be used to successfully treat people with disease such as immune deficiencies, severe inherited anemia and childhood leukemia and other cancers. They are also used in the search for cures of these diseases.

Some parents consider having babies’ cord blood collected and stored. It’s done after baby’s cord is cut and is accomplished most successfully within 10 minutes of birth, which means that baby still benefits from delayed cord cutting. After collection, stem cells are separated from blood in a lab and stored either in a blood bank for use by the public or in a private storage facility for later use, if needed, by the child or her family.

AAP encourages parents to donate cord blood to public and cautions against using private cord banks because more conditions that they may treat (such as precancerous changes and genetic abnormalities) already exist in baby’s cord blood, which means that her stored cord blood stem cells won’t treat the condition if she develops it later. Its also expensive. Public donated blood is tested for disease and genetic abnormalities before being approved for use. Do research before due date.

Fourth Stage of Labor: Recovery– begins just after placenta is delivered and lasts until your condition is stable, typically an hour or 2 after birth. This stage may last longer if you had anesthesia, if you labor was difficult or prolonged, or if you had a cesarean birth.

After delivering placenta, caregiver checks perineum and birth canal for bleeding. If had vaginal tear or episiotomy, tissues are stitched to speed healing (lasts <30 min). Unless given anesthesia in labor, will receive a local anesthetic by injection before perineum is stitched. Should be painless, but injection may sting and may need to use rhythmic breathing. If perineum is intact or have shallow tear, don’t need stitches, but area may become swollen or bruised. Whether have stitches or not, will appreciate an ice pack placed on perineum to reduce any swelling and relieve discomfort.

After birth, uterus begins process of involution (returning to nonpregnant size); it continues to contract, which close blood vessels where placenta was implanted in order to prevent excessive blood loss and to prompt the shedding of the uterine lining that build up during pregnancy. You pass lochia, the heavy red discharge made of the extra blood and fluid that supported your pregnancy and the uterine lining that sustained your baby. Maternity pad is necessary.

Once placenta is delivered, caregiver checks uterus frequently to make sure it remains firm. If uterus is relaxed, she massages it firmly, causing it to contract and preventing excessive blood loss. Uterine (or fundal) massage can be painful, and you may want to do it yourself to control the amount of pressure and perhaps reduce pain to a tolerable level.

How to Massage Uterus – Empty bladder. Lie on back and check uterus by pressing on area below navel. If uterus feels as firm as a grapefruit, you don’t need to massage it. If cant feel uterus, it has relaxed and softened. With one hand slightly cupped, massage lower abdomen firmly with small circular movements until you feel you uterus contract and become firm. This action may be painful. If can’t make uterus contract, tell caregiver. Because uterus can bleed excessively if it’s not firm, don’t skip this on the first couple days after birth. Afterward, you may periodically check to see if it needs massage.

Contractions during involution may be painful, especially if have given birth before. Although these afterpains are common and aren’t nearly as intense as labor contractions, you may need to use slow breathing to help manage.

After baby’s birth, legs may tremble, which is normal. Warm blanket may reduce trembling. May have missed meals during labor, so eat and drink to satisfy hunger and thirst.

This stage gives you a chance to get to know your baby without disturbances and to let him nuzzle at your breast. Most babies are ready to suckle within 20-60 minutes after birth.

Baby’s Hormones in 4th Stage– baby’s stress hormones (catecholamines) after birth stimulate her adaptation to life outside womb. They absorb fluid in her lungs so she can breathe easily, jump start her ability to regulate her temperature and make her alert and heighten her reflexes for the first few hours, during which time she begins feeding, exploring her world and seeing you for the first time.

During labor, baby produces beta-endorphins; after birth, she produces prolactin. She also begins producing oxytocin in synchrony with you. These 3 hormones help strengthen the bond between you, increase her interest in breastfeeding, and stimulate you to care for her. Other people can produce oxytocin too – to a lesser degree-by holding baby skin to skin, keeping eye contact and caring for her. By snuggling with baby after birth, skin-to-skin allows for mutual regulation of hormones as you adjust to new life together.

Entering Parenthood– this new role, along with other postpartum changes, may overwhelm you or bewilder you.

Enjoy baby’s first hours of awake time. He’s likely alert, calm and bright-eyed as he begins observing and sensing new sounds, smells, sights, touches and tastes. If light isn’t too bright, he’ll stare, particularly at your face (dim lights if too bright). These moments are time for falling in love with each other. Include partner.

Family-centered and baby-friendly hospitals encourage parents and babies to stay together as much as possible, unless problems develop. Caregiver performs routine observations or procedures while in mom’s arms. Check hospital – if caregivers routinely send healthy newborns to nursery, ask to issue an order to delay or bypass your baby’s admission.

A few hours after birth, baby will fall into a deep sleep. Someone who’s alert should periodically observe baby’s vital signs and yours, including skin color, pulse, respiration, blood pressure and temperature. In the hospital, nurse does this job. At home birth, midwife or birth assistant takes on job before passing on to rested friend or relative.

Processing Birth Experience– it isn’t over until you’ve had a chance to think about and understand it. Will become one of most vivid and poignant memories. Compare and contrast your feelings, thoughts and impressions with those who attended birth, getting answer to any question and look at photos. Write story or draw or paint a picture of it – each is a great way to preserve the special memory for you and your child.

Processing it may takes weeks, months or even years. If it was particularly difficult or disappointing, processing it may take longer. Dealing with a difficult birth may also bring up strong, disturbing feelings. If this is the case for you, talk with your caregiver, doula, childbirth educator or a counselor knowledgeable about childbirth.

 

3 Key Concepts for 2nd stage: don’t rush, push when you have urge, use different positions

  • Don’t Rush – bear down or push spontaneously as urge demands and allow time for vagina to stretch open gradually, which decreases likelihood of vaginal bruising or tearing. Don’t use prolonged pushing. Use your energy more efficiently if don’t rush. By holding breath and bearing down only when can’t resist urge, you’re working with uterus and not wasting effort.
  • Push When You Have Urge – different ways to push under certain circumstances
    • Expulsion Breathing and Spontaneous Bearing Down – use when you have urge to push. You naturally bear down or strain for 5-6 sec and take several breaths between efforts. Makes more oxygen available to baby than if you hold breath and bear down for as long as possible. Allows vagina to stretch gradually, reducing risk of tearing
    • Delayed Pushing (passive descent or laboring down with an epidural) – when have epidural, don’t usually have urge to push until baby is close to being born. Uterus continues pushing baby down and into a good position, but you don’t feel need to push in response. With delayed pushing, try to rest and refrain from pushing until baby’s head can be seen at vaginal opening (Crowning) or until you feel urge to push. This way, if baby is occiput posterior or his head is tilted (either a likely occurrence if you have an epidural), you avoid forcing him too deeply into your pelvis before he can reposition himself. Delayed pushing usually means a longer 2nd stage, but as long as baby is doing well, research shows waiting an hour or 2 before pushing with an epidural gives your baby time to gradually reposition until his head is visible. DP is much less tiring for you. It greatly improves chances of a spontaneous vaginal birth (one that doesn’t require vacuum or forceps) and greatly decreases chances of needing cesarean. Caregiver will prob tell you when and how long to push.
    • Directed Pushing – used if you can’t feel contractions and delayed pushing isn’t an option of if spontaneous pushing isn’t effective. Caregiver will tell you when, how long and how hard to push
    • Prolonged Pushing – differs from directed pushing in the length of time you’re expected to hold your breath and bear down (10 sec on more, instead of 5-7 sec). not long ago, standard care required women to push as long as hard as they could in order to push the baby out as quickly as possible. Research shows forceful pushing isn’t necessary and may sometimes cause problems that are less likely to occur with spontaneous bearing down, including exhaustion of the mother, overstretching of pelvic ligaments and muscles, possible perineal tears, later urinary incontinence, concerns with baby’s HR and failure of baby to rotate/descend.   Prolonged pushing, esp in supine position can also decrease oxygen to baby and may cause BP to drop, both of which can increase need for faster delivery w episiotomy. 2nd stage may last slightly longer with spontaneous or directed pushing but babies usually remain in good condition throughout process. Best reserved for women w inadequate progress in 2nd stage, even after trying different positions, or for women whose babies are already in distress and may require interventions (such as forceps, vacuum or cesarean) unless they’re pushed out quickly. Discuss with caregiver before due date and include preferences regarding the practice in your birth plan and discuss with staff when you arrive at hospital.
  • Use Different Positions – as long as labor is progressing well in 2nd stage and baby is fine, use whatever positions seem most comfortable to you. If caregiver concerned about progress of baby’s well being, they might suggest a different position. Even if its uncomfortable, it may correct the problem and avoid the need for further interventions. If 2nd stage is rapid, try a position that neutralizes effects of gravity, such as side-lying to help slow labor. If progress is prolonged, try positions that take advantage of gravity. Change positions every 20-30 min. some caregivers comfortable with woman birthing in any position, but most prefer a position they are used to (usually semi-sitting on back). If they only deliver in 1 position, plan to use several other positions during 2nd stage to aid labor progress. If pushing is prolonged, ask whether a change in position might help. If received pain medications, mobility and choice of positions may be limited.
    1. Don’t rush
    2. Push with the urge
    3. Use different positions
  1. Phases of second stage

Phases of the 2nd Stage:

3 phases: resting, descent and crowning and birth phase. They share characteristics with the 3 phases of the 1st stage. High spirits, little pain, and slow progress characterize the first phases of both stages. Intense contractions, total mental absorption and steady progress characterize 2nd phases. Lastly, intense sensations and confusion characterize 3rd phases.

  • Resting – After intensity of transition, uterus may stop contracting for 10-20 min, allowing you to rest, clear your head, recoup your energy and grow excited for your baby’s arrival. This is normal and may occur because baby’s head has slipped into birth canal, causing uterus, which had been stretched tightly around baby, to slacken. Your uterus needs a few min to adjust to the change, but once it begins to tighten around the rest of your baby’s body, strong contractions resume and your urge to push becomes powerful. This phase doesn’t occur in all labors. If baby is low in pelvis when 2nd stage begins, or if she’s descending rapidly, your body may skip it or make it brief. Even if this phase doesn’t offer much rest, your probably still become clearheaded and emotionally recharged as you move into 2nd If lasts longer than 15-20 min, caregiver may ask you to try a position that enhances effects of gravity to encourage an urge to push. Or he may direct your pushing, asking you to hold your breath and bear down even if you don’t have an urge to push. Directed pushing may frustrate both you and caregiver, as labor rarely progresses without urge to push. However, directed pushing may be worth trying before medical intervention such as Pitocin.
  • Descent – Baby descends into birth canal and likely completes rotation to the occiput anterior position. At this time, powerful contractions make your urge to push irrestible. May find bearing down thrilling and rewarding because you can feel progress. Or you may feel alarmed by the full, bulging, stretching feeling in your perineum. May tense pelvic floor and “hold back” afraid to let baby descend. When pushing, its important to relax pelvic floor and bulge your perineum. Prenatal perineal massage is excellent prep for 2nd stage because it teaches you to relax perineum while its being stretched. Your partner can help you during this phase by reminding you to relax, open up, bulge your bottom, or ease your baby out. This type of encouragement is usually more helpful than hearing “push, push, push”. May need several contractions before you can push effectively. If have trouble trying to figure out where to direct pushing, ask caregiver to perform perineal massage or to use warm compress to give you a location. Using a mirror to watch when push may also help you figure out how to push more effectively. Clenching your jaw and clamping lips together are signs that you’re tensing muscles in the vagina. By relaxing face/mouth, you may be able to relax vagina. If you let yourself release tension and push despite the pain, you’ll find that pushing feels better than holding back. As this phase progresses, the joy and anticipation you feel give you renewed strength. Perineum begins to bulge, labia part and vagina opens as baby’s head descends each time you bear down. Between pushes, your vagina partially closes and baby’s head retreats. With another contraction, your baby moves farther down, his head becomes clearly visible, and you may be able to see it in a mirror. You may want to reach down and touch his soft, wrinkled head. The normal squeezing of baby’s head by vagina causes scalp to wrinkle until his head moves further down birth canal.
  • Crowning and Birth Phase – Begins when baby’s head no longer retreats from vaginal opening between pushes and ends when body completely exits yours. During this phase, vaginal opening stretches to its max, which likely causes a stinging, burning sensation called rim of fire. To reduce risk of vaginal tear or rapid birth, you may need to stop pushing to let vagina and perineum gradually stretch around baby’s head as it emerges. Depending on speed of birth, caregiver may direct you to push only moderately or to push only between contractions. He may ask you not to push at all. Caregiver may support perineum with warm compresses to prevent baby’s head from coming too rapidly and to help your perineum stretch gradually. Research finds clear problems with routine episiotomy to enlarge vaginal opening; nonetheless, some caregivers commonly perform.
    • Protecting Perineum from Large Tear or Episiotomy – many women wear about damaging vaginal tissues or fear that episiotomy will be needed. Research actions to take during pregnancy and labor to protect perineum:
      • Choose caregiver who prefers to avoid episiotomies and has low rate (less than 20%)
      • Good nutrition promotes healthy tissues, so eat well during pregnancy
      • Perform perineal massage regularly for a few weeks before birth
      • When push, use spontaneous bearing down or bear down for only 5-7 sec each time
      • During birth, use positions that put minimal strain on perineum, such as side-lying, kneeling or hands and knees
      • During birth, pant lightly and listen to caregivers directions to avoid pushing while baby’s head and shoulders are born

 

Second Stage – (pgs 42, 44-45 in workbook):

Current research and recommendations

  • “Laboring Down” – encouraging her to listen to signals her body is giving her and to bear down as she desires works beautifully for woman who doesn’t have epidural. With epidural, she may not be able to feel signals her body is giving her. Research indicates its most often safe for her to rest without actively pushing, until uterus alone pushes baby down to a +1 station. After this period of laboring down, an urge to push spontaneously. Some caregivers may use directed pushing if baby’s descent is too slow.
  • Coached vs physiologic pushing
    • Researchers found that at 3 months postpartum, women who were coached during 2nd stage had impaired pelvic floor and bladder function as compared to women who were instructed to do what comes naturally
    • Kathleen Simpson found that babies whose mothers were instructed to begin pushing upon full dilation and to push while holding their breath to a count of 10 had less oxygen in their blood than women who were allowed to wait until they felt the urge to push and to push without holding their breath. The women in the breath-holding group had more perineal lacerations.
  • ACOG/SMFM Recommendations: in their 2014 joint consensus statement, ACOG and Society for Maternal-Fetal Medicine recommend that health care providers give women more time in 2nd stage before recommending cesarean surgery for failure to progress than under the old guidelines established by the Friedman Curve. They say “A specific absolute maximum length of time spent in the 2nd stage of labor beyond which all women should undergo operative delivery has not been identified. “ They go on to recommend that nulliparous women be allowed to push for at least 3 hours and multiparous women, 2 hours. However, they also say that “longer durations may be appropriate on an individualized bases (epidural/fetal malposition) as long as progress is being documented”
    1. Resting (latent)
    2. Descent (active)
    3. Crowning and birth (transition)

III. Positions for comfort during second stage

 

Positions and Movements for 1st/2nd stage of labor

  • Sitting Upright: is a good resting position, uses gravity to a degree, can be used w epidural
  • Sitting on toilet: same as sitting upright, plus helps with effective pushing and prevents holding back
  • Semi-sitting: same as sitting upright, plus is an easy position to get into and is a common birthing position, epidural ok. Disadvantage: man increase back pain and doesn’t allow expansion of pelvis
  • Hands and Knees: helps relieve back pain; helps baby rotate if she’s OP, allows for pelvic rocking, takes pressure off hemorrhoids, may reduce premature urge to push, may slow a rapid 2nd stage because position neutralizes effects of gravity, epidural ok
  • Side-lying: is an excellent resting position, may reduce back pain, helps lower blood pressure, is a safe position if you’ve received pain medications, neutralizes effects of gravity, making position useful for slowing a rapid labor, takes pressure off hemorrhoids, in 2nd stage, allows your sacrum to shift to create a wider opening for your baby’s descent, epidural ok

Positions and Movements for 2nd stage of labor

  • Squatting – may relieve back pain, takes advantage of gravity, widens pelvic outlet (but may diminish pelvic inlet, which is why it’s best to do in 2nd stage and not first), may enable baby to rotate and descend in a difficult birth, is helpful if you don’t feel an urge to push, allows you freedom to shift weight for comfort
  • Lap Squatting – same as squatting, plus reduces strain on knees and ankles, allows more support and requires less effort, enhances sense of well-being since have contact from loved one. Disadvantage: if heavier than partner, may not be possible
  • Supported Squat – allows greater mobility of pelvic joints than any other position and eliminates external pressure (from bed, chair), takes advantage of gravity, lengthens trunk – allowing baby more room to maneuver into position, allows baby’s head movements to change the shape of your pelvis. Disadvantage: requires your partner to have strength enough to support you for long periods
  • Dangle – same as supported squat except partner sits so his or her legs are braced and well supported, making this position easier to maintain

 

Resources:

DVDs: 2nd Stage: showing powerful images of women giving birth spontaneously will help to increase the confidence of women in your classes. The births in Celebrate Birth! Are excellent. The Timeless Way shows how women have used upright positions and benefited from labor support throughout the ages. Your students will be amazed by how easy birth appears in the stunning video, Birth in the Squatting Position. Spontaneous pushing, the natural pause at the beginning of 2nd stage, vocalization and superb support from the nurse-midwife are all featured in Jasmine’s birth in the VIDA video, Open Minds to Birth. The powerful video, Kangaroo Mother Care, illustrates the benefits of immediate skin-to-skin contact for both full-term and preterm babies.

Handouts: Health Children Project: The first hour after birth: A baby’s 9 instinctive stages www.healthed.cc

DVDs:

  • Breastfeeding: Baby’s Choice
  • The magical hour: holding your baby skin to skin for the first hour after birth
  • Skin to skin in the first hour after birth: practical advice for staff after vaginal and cesarean birth

http://commonhealth.wbur.org/2014/06/birth-canal-bacteria-c-section

http://academicobgyn.com/2009/12/03/delayed-cord-clamping-should-be-standard-practice-in-obstetrics

Penny Simkin on Delayed Cord Clamping (4:53)

Why not clamp and cut baby’s umbilical cord immediately after birth?

Common procedure to cut w/in 30 sec of birth. Good reason to wait 2 min if not until cord stops pulsating. When baby is born, placenta still inside. There is baby’s blood in baby body but also in placenta. Over the course of a few min, placenta will drain to baby (will be some back and forth). All this blood belongs to baby.

Volume of blood shared between baby and placenta at birth -450 ml.

Amt of blood in baby’s body – 300ml

Amt of blood remaining in placenta after birth, which will transfer over 2-5 min: 150 ml

Baby is shy 1/3 of total blood volume if cut right away.

Over time, blood in placenta will transfer to baby. Studies show us at 2 min, about 70% of blood will have be transferred. If wait until blood stops pulsating, all blood will be transferred.

Even when babies need to be resuscitated or have meconium, normal practice is to cut cord. Resuscitation can take place w placenta attached and next to mother.

Believed before that if 1/3 of blood was added to body; red blood cells would break down and cause more bilirubin. Recent studies show they do not reach clinical jaundice levels if left intact. If cord is intact, more time for resuscitation because getting oxygenated blood from placenta.

So wait 2 min or ideally until cord stops pulsating.

Effects of timing of umbilical cord clamping:

  • Immediate clamping & cutting – enables removal of baby from mom’s arms to a warmer, which is rarely good for either of them.   Doesn’t prevent jaundice, as commonly believed
  • Delayed clamping for 2 min or more – encourages close mother-infant contact. allows baby to receive most or all of its blood that was in placenta at birth. Improves infant hematologic status (reduces infant anemia) at 2 and 6 months.

Possible Challenges of Labor (pg 44 workbook): after presenting a textbook labor to class, don’t fail to integrate the many challenges that a woman might face into scenarios of possible labors. Not much is certain in labor. Rarely utter the words always or never when speaking of the birth experience! Nausea, chills, shakes, leg cramps, and back pain are all challenges that may or may not occur in a woman’s labor, but she needs to be advised what to do in case it happens to her.

Research update: term “back pain” replaces “back labor”- researchers found that babies change position often during labor and that final position for birth is not established until very late in labor. According to periodic ultrasounds, more than 1/3 (36%) of babies were in OP at some point during labor. Women who had babies in OP early in labor did not complain of more back pain than mothers with babies in OA position and were not more likely to request epidural. Women who chose epidural were more likely to have a baby in OP at birth, establishing a strong association between OP and epidural.

Models – pelvis and doll are used to show OA and OP positions and how an all-fours position during labor could possible help (gravity will pull heavier backside of baby toward floor and away from mom’s back. This relieves back pain and facilitates rotation to OA).

Some use funnels of varying shapes and sizes to create visual images of different types of labors women may experience. Some compare opening of funnel with 1st stage and neck with 2nd stage; can also compare neck to pre-labor and early phase and opening of funnel to rest of labor. The funnel with both a long neck and large opening represents a slow long hard labor – the type of labor, which often accompanies labor induction, especially if the cervix is not ripe.

Practice:

  • Pelvic rock in all fours
  • Passive pelvic tuck on side
  • Lunge (standing and kneeling)
  • Counterpressure to relieve backache
  • Panic routine

DVDs: Comfort Measures, 3Rs, Understanding Birth (Injoy)

 

Verbal support of spontaneous bearing down efforts – offer words of approval and encouragement, along with reminders to relax legs and perineum.

  • “Let yourself push naturally. Your body knows what to do”
  • “That’s they way; just like that. There is plenty of room for this baby”
  • “Your perineum is starting to stretch. That’s a very good sign”
  • “Good job”
  • “I can see the head”
  • “You are moving your baby with every push”
  • “Let yourself rest between contractions. Good”
  • “That burning you feel is normal. Its your body telling you that the stretching is happening. Feel free to ease off a bit on the push until it starts to go away. “

Maternal birth positions – laboring women benefit from autonomy is selecting positions that work best for them. Women laboring in upright positions also experience fewer episiotomies, fewer fetal heart rate abnormalities, slight reductions in both duration of 2nd stage of labor and need for operative deliveries, less discomfort, improved satisfaction, and improved ability to participate actively in birth. When woman’s legs are separated widely, as in lithotomy position, there is more tension on delicate tissue of perineum, which may result in more tearing with and without episiotomy. Positions in which woman’s legs are relaxed promote better perineal outcomes. Women who gave birth in hands and knees required significantly less suturing than those with legs spread. Periodic position changes during 2nd stage are a good way to protect perineum from damage, as well as to change pelvic shape and alter gravity effects to aid descent.

Side-lying position in which only 1 of woman’s legs is flexed on to her abdomen serves to avoid tension on perineum and prevents vena cava” compression, thereby increasing blood flow to fetus and maximizing mobility of pelvis. Physiologic alternative to continued overuse of exaggerated lithotomy position.

Guiding women through crowning of the fetal head– may use warm compress or topical anesthetic to help relieve pain. Important not to hear variety of voices giving conflicting instructions.   If woman appears distracted, doula can say quietly in woman’s ear “listen to your midwife/dr. She will guide you through this part”.

Slow delivery of fetal head over perineum allows perineal tissues to stretch more gradually. Many midwives encourage women to breathe head out as it crowns. Others prefer to deliver fetal head between contractions – requires birth attendant to give woman specific directions to avoid pushing during contractions when head is crowning. Majority actively direct maternal pushing to prevent perineal damage.

Hand skills to protect the perineum– if fetal head is emerging rapidly, gentle counterpressure can be used to slow birth and protect perineum. Pressure w 3 fingers on vertex can offer both support and control. Some midwives gently squeeze perineum to avoid sudden overstretching of delicate tissues. Use of towel can offer mild traction on moist tissues of perineum while allowing visualization of crowning.

If fetus in in OA position, midwife may give downward pressure to keep fetal head flexed. If fetus in OP, upward pressure is used to maintain flexion. Use of manual flexion technique criticized because it counters extension mechanism of labor that is essential for fetus to negotiate curve of birth canal.

Hands on care – midwife maintains flexion during crowning, while simultaneously supporting perineum and then uses lateral flexion to deliberately and gently deliver fetal shoulders. Hand-poised care – keep hands near perineum (in case of rapid birth) but otherwise not touch head/perineum, allowing shoulders to deliver spontaneously. Women in hands on group had significantly less postpartum pain than women in hands-poised group.

3 techniques to reduce perineal damage:

  • Warm compresses continuously to perineum
  • Massage perineum with lubricated fingers in vagina using side to side motions and downward pressure
  • Hands off approach

Differentiating perineal massage from other interventions– sometimes used to describe other more forceful techniques that have not been found to reduce perineal damage. Includes pressing vigorously against posterior vaginal wall (to show woman where to push) and done in an attempt to hasten birth. Used along with directed closed glottis (Valsalva) pushing, this may have a detrimental impact on perineal outcomes.

When Progress in 2nd Stage Labor Remains Inadequate:

  • Duration of 2nd stage labor – support of spontaneous bearing-down efforts does not lead to clinically significant increase in 2nd stage duration. Reconceptualized approach to 2nd stage is it starts with urge to push rather than complete dilation. Potential benefits for fetus because active bearing down is more associated with potentially problematic alterations of fetal hemodynamics
    • Women experience urge to bear down at 9 +/- 1 cm with a range of 5-10 cm. when both mom and baby are healthy as indicated by assessment date, birth attendant can continue to support spontaneous bearing down while progress in descent continues to occur
    • If woman is full dilated but has no spontaneous urge to bear down (aka latent stage), she may be supported to rest and breathe through contractions until there is at least a minimal urge to bear down. Use of more upright positions w sacrum free of compression (Squatting/standing) may stimulate fetal rotation/descent as well as fetal ejection (Ferguson) reflex, which can lead to spontaneous urge to bear down
    • If mother is becoming fatigued, encouraging her to breathe through contractions may lead to recovery of her energy. Focus less on time and more on condition of mother/baby.
    • If fetal HR nonreassuring, may be corrected by encouraging woman to breathe through a few contractions or to bear down with every other contraction. During fetal bradycardia episode, breathing instead of pushing w contractions leads to more rapid resolution to normal HR baseline
  • Supportive directions for bearing-down efforts– provide more direction when fetal HR is nonreassuring or progress in 2nd stage has been less than adequate. Can do supportive direction instead of count to 10. Instruct woman to hold bearing down effort for slightly longer duration. Closed glottis bearing down efforts of up to 6 sec will not lead to adverse maternal or fetal hemodynamics. Position changes can help accomplish progress when urgently needed. When fetal compromise suspected, use of calm, firm statements can elicit energy and focus of mother. “Your baby is in trouble and needs to be born. I need you to give birth to the baby” signals to woman she has power to make birth happen sooner rather than later

 

Posture in the 2nd stage of labor – number of advantages for upright posture:

  • Shorter 2nd stage
  • Fewer episiotomies
  • Fewer assisted births
  • Less severe pain
  • Bearing down easier
  • Fewer fetal heart abnormalities

Only outcome that favored supine was a reduced blood loss (<500 ml), though this may have been related to the fact that measurements of blood loss is more accurate in upright posture. Blood loss and vulval oedema were less in upright posture. Comparing sitting and kneeling positions, women preferred kneeling and experienced less pain that way.

Avoidance of supine hyptotension syndrome has clear physiological benefit for fetus, which is reflected in fewer fetal heart abnormalities. In upright postures, the flexion and abduction of hips, combined w freedom for coccyx to articulate backwards, provide greater room at pelvic outlet, both in the anterior/posterior and transverse dimensions. When pelvis is not resting on anything and occupies free space, the diameters of the outlet will be maximized.

Women are to be encouraged to adopt an upright posture, esp in 2nd stage and for birth. Disadvantages of semi-recumbent bed births:

  • Decreased fetal oxygenation, lower pH
  • Increased abnormal fetal heart patterns
  • Longer 2nd stage
  • More likely to have other interventions (epidural, syntocinon, episiotomy, instrumental births)
  • Less desire to bear down
  • Smaller outlet diameters
  • More severe pain

Pics: upright sitting on bed, kneeling on bed, lateral on bed, kneeling on floor, lateral on floor, on all fours, standing, birth stool, one leg up, standing deep squat, standing squat

Posture and perineal outcomes – upright births result in less perineal trauma. Lateral posture associated with most intact perineums and fewest episiotomies. All-fours, standing, kneeling and semi-recumbent were all similar in relation to intact perineum. Squatting position, esp for nulliparous women, have worst outcomes of all positions, but had small sample size. All fours resulted in less suturing.

Also impacts perineal trauma: increasing birth weight, increasing maternal age, first births and length of 2nd stage (linked to more episiotomies). More recent research links epidural use and instructed pushing in 2nd stage w more trauma.

Amount of room at pelvic outlet should theoretically have some impact, with upright posture allowing for easier birth of head and shoulders. Studies of Waterbirth show more intact perineums; women tend to adopt upright postures in this setting and move more frequently.

Trial of women with epidurals concluded more normal vaginal births if women gave birth in lateral postures. Anesthetists looking at ways of harnessing value of upright postures to reduce incidence of assisted vaginal births in women with epidurals.

Occiput-posterior positions and labor posture – incidence of posterior position 10-15% at onset of labor and 6% at birth. Number of posterior positions at onset of labor is increasing arguing that Western lifestyles are contributing to this. More sedentary lifestyles, preponderance of reclining postures that tilt baby back in uterus contribute to increase. Solution more controversial: encourage forward-tilting postures, sitting upright and side-lying in later pregnancy.

Aquanatal exercises facilitate anterior position at beginning of labor. Extremely low incidence of posterior position at birth, esp in nulliparous women. Rates of persistent posterior position in this group increased by epidural use.

Address persistent posterior position during labor lunge (Creating disequilibrium between hips and use of steps) and hip squeeze. Birth ball. Technique of creating a false pelvic floor during vaginal examinations to help rotate fetal head.

Upright posture and assisted vaginal birth – very low incidence of forceps in upright posture

Birth position and educational initiative s- 30% increase in upright posture for birth and 50% reduction in epidurals after childbirth education classes. Exposing women to posture possibilities in late pregnancy in environment they are likely to be laboring in.

Practice recommendations:

  • Women need to be informed of advantages of upright postures and disadvantages of recumbent postures
  • Positions need practice antenatally

 

Rhythms in 2nd stage of labor – origins of medicalization of 2nd stage date back to 1600s – one obvious concern w coached pushing is tendency to reinforce professional hegemony while undermining women’s confidence in own physiology. Widespread collapse in current generation of women to instinctively do 2nd stage w out professional instruction.

Research evidence (Ch 8) – prolonged breath-holding in 2nd stage decreased placental perfusion resulting in fetal hypoxia. Coached pushing involving prolonged breath-holding decreased fetal cerebral oxygenation. If coached pushing in 2nd stage lasted longer than an hour, babies had lower pH at birth. Coached pushing results in a longer 2nd stage than spontaneous pushing with no differences in type of birth, fetal outcome and perineal outcome.. # of other concerns:

  • Maternal exhaustion
  • More assisted vaginal births
  • More episiotomies and perineal tears
  • Deleterious impact on pelvic floor, in particular urinary stress incontinence

When spontaneous pushing combined with upright posture, 2nd stage shorted by 45 min compared with coaching and semi-recumbent position in low risk primiparous women. Women also said they experienced less pain, less fatigue and were more satisfied

Spontaneous pushing:

  • Breathing pattern during contraction and pushing is self-directed
  • Tie of initiating push is irregular (women initiates push independently and pushing often begins once contraction is well established)
  • Pushing may be characterized by grunting with pushing, short and more frequent bearing-down efforts with each contraction or both
  • Open-glottis pushing (Grunting noise while pushing)
  • Patient follows cues from body
  • No verbal instruction as to how to push
  • No non-verbal instruction is given (deep breaths)
  • Caregivers offer encouragement and praise only, not instruction

Directed pushing – following verbal direction, demonstration or instruction from caregivers regarding:

  • Time of pushing (when to start/stop)
  • Length of pushing (how long to push)
  • Position for pushing
  • Breathing during pushing
  • Strength of push
  • Specific direction on how to push
  • Instruction to make no noise with pushing efforts
  • Actively positioning woman in a certain way for pushing or verbally directing her to position herself in a certain way
  • Vaginal examination w concurrent direction such as push my finger out
  • Vaginal examination actively stimulating Ferguson’s reflex or manipulating or stretching cervix or perineum
  • Following any non-verbal instructions on how to push

Concluded from examination of 10 studies of Valsalva’s maneuver (pushing while breath-holding) that practice should be discontinues because of negative effects on fetal heart and perineum. All forms unlikely to beneficial included routine directed pushing, pushing by sustained bearing down and breath-holding.

Epidurals and 2nd stage – compared immediate coached pushing with delayed open-glottis pushing in nulliparous women with epidurals, demonstrating that latter group had better fetal outcomes and less perineal trauma. No difference in length of 2nd stage. Open-glottis pushing (pushing w out breath holding) demonstrated by women audibly grunting, shorter periods of breath-holding (6-8 sec) and no more than 3 pushes per contraction. Good practice to combine open-glottis pushing w upright posture, achievable now w low-dose epidurals.

Definition of 2nd stage – it is an esp brave midwife who will record 6 hr 2nd stage that included several hrs of latency; its far more comfortable to assign the start so that time comes in under whatever guideline locally requires.   Most have been there and adopted visualization of presenting part as reference marker for start of 2nd stage.

Midwifes known that women’s bodies don’t fit template of biomedical definition, because they have rest and be thankful phase after full dilation or they involuntarily push before. Both of these fall outside the normative physiology. Ascertaining the start of the 2nd stage even w a confirmatory vaginal examination was always problematic anyway. If there is no cervix palpable on examination, you are already too late – full dilation occurred some time before. Occasionally midwives, fed up with confines of biomedical model, may deliberately record full dilation at 9 or 11 cm because they argue the improbability that ever woman in world has a cervix that dilates to 10 cm exactly. They are facetiously commenting on the nonsense that birth anatomy and physiology is uniform across all women.

1st to stage transition: that mysterious phenomenon, virtually ignored by childbirth textbooks, yet transition is one of the earliest observed labor behaviors by students on birth suites. For women who experience transition, the notion that it is rather enigmatic and of little relevance would be laughable.

Spectrum of experiences/emotions (From inner calm to acute distress) in latter half of labor just prior to pushing. If time frames take on less significance, then midwives will be freer to work with the lived experience of transition and 2nd stage and arguably offer better individualized care. Women spoke of:

  • Paradox of being in control and letting go
  • Altered state of consciousness
  • Sense of timelessness
  • Wanting midwife to be a safe anchor, someone to put trust in, with a calm, quiet, unobtrusive presence
  • Unhelpful aspects of care were being treated as a naughty schoolgirl, being told off, intrusive interventions (fetal monitoring, requiring to be on bed, interruptions and being undermined)

One way out of this temporality bind is to adjust definition of start of 2nd stage. redefining this by changing criterion of full dilation of cervix to “when presenting part has passed through the cervix and is below the ischial spines. This alteration would allow for physiological variations observed in practice of latent episodes after reaching full dilation. Once presenting part has descended beyond ischial spines, then bearing down will occur as the fetus enters the perineal phase or women experience the fetal ejection reflex.

Acknowledgment of latent element and subsequent lengthening of the time frame has appeared in OB journals in recent years. Anesthetists and OBS became alarmed at assisted vaginal birth rates w epidurals and at fetal hypoxia associated with prolonged coached pushing. They began researching passive descent, in some studies up to 5 hours before active pushing was commenced. Now, its common practice to wait at least 2 hours in many consultant units. Blatant double standard exists where women without epidurals are allowed only 1 hr.

Concerns for baby when labor is exposed to oxytocin augmentation during 2nd stage have been raised; it’s a risk factor for fetal acidaemia.

  1. Time and fetal health – many OBs believe direct link between length of 2nd stage and fetal health and this primarily drives time restrictions on 2nd stage

Examined 25k women and found length of 2nd stage not associated with low Apgar scores or neonatal unit admissions. 6000 nulliparous women – some who had 2nd stages lasting longer than 5 hours and concluded non increase in low 5 min Apgar scores, neonatal seizures or neonatal unit admission. No association between length of 2nd stage and neonatal morbidity. Some found links to maternal morbidity such as infection and bleeding, but these were explained by labor practices or 1st stage factors.

2 papers that suggest neonates might be at more risk form long 2nd stages. Those whose 2nd stages were longer than 3 hours, babies at greater risk. Babies exposed to long 2nd stages had lower 5 min Apgars and more admission to neonatal units. Both confounded by high rates of epidural in samples. Maternal outcomes, principally postpartum hemorrhage, assisted vaginal birth, infection and perineal trauma were worse in this group. Some of maternal outcomes can be explained by compounded effects of more forcep births.

In summary, long 2nd stage has links with some maternal morbidities but link w fetal compromise more speculative. Some evidence when presenting part is on pelvic floor, fetal lactic acid begins to accumulate and this may be reflected in deterioration in fetal heart patterns.

2nd stage of labor does not need to be terminated for duration alone but on individual assessment of mom/baby in each case. Encourage upright posture and spontaneous pushing, both of which will optimize fetal/maternal health.

  1. Early pushing – unlikely to be beneficial. Student midwives have been told it will lead an oadematous lip of cervix which, if left untreated, will slough off leading to hemorrhage. Focuses mind of midwife – to get woman lying on side breathing on entonox or, if that fails, sitting an epidural.
  2. Posterior Position in 2nd stage – link between persistent posterior position and range of maternal outcomes including prolonged 1st and 2nd stage labor, oxytocin augmentation, epidural, assisted vag birth, sphincter tears, cesareans and postpartum hemorrhage.
  3. Evidence base of 9 prevailing concepts that guide current labor management for posterior position concluded that only 2 proven: ultrasound diagnosis to identify fetal position and digital or manual rotation in 2nd stage to correct malposition. In terms of birth outcome, it is the position of the baby at commencement of 2nd stage that is best predictor of outcome. Back pain is unreliable marker of OP position as it can occur in OA labors and not occur in OP ones. A delay in labor without back pain could still be related to an OP position. Vaginal examinations were found to be unreliable in diagnosing OP. Some evidence that changes of position may help OP position to rotate and certainly many midwives advocate lunge maneuver (creating disequilibrium in hips by stepping up and down) as well as pelvic squeeze (pressing inwards on iliac crests). Trent towards OA rotation in OP labors as well asa successful treatment of backache with h ands/knees position. Good section on OP in Holistic Midwifery Volume II.
  4. Tips for delay in 2nd stage: these are experiential, based on general good practice principles, anecdotal or sometimes counter-intuitive; little research on physiological interventions for this scenario:
  • Variety of upright postures
  • Psychological barriers
  • Empty bowel/bladder
  • Offer water immersion
  • Suggest nipple/clitoral stimulation
  • Change of voice tone or carer, if possible
  • Recumbent postures, including McRoberts
  • Coached pushing but for short time frames
  • Agree a time frame before initiating an assisted vaginal birth or transfer out of home or birth centers – sometimes mentioning the end point of forceps or transfer to labor ward seems to bring a reward

Attitudes and philosophy – resist temptation after experience above to always do a confirmatory vaginal examination when signs of 2nd stage appear, takes experience and a supportive environment

Attitudinal change to enhance woman’s autonomy is imperative; a move from:

  • Loss of autonomy to being in control
  • Passive to active
  • Dependence to independence

For midwives, movement from:

  • Control to facilitation
  • Dominance to masterly inactivity
  • Surveillance and monitoring to watchful expectancy
  • More to less

Attitudes and philosophy – resist temptation after experience above to always do a confirmatory vaginal examination when signs of 2nd stage appear, takes experience and a supportive environment

Attitudinal change to enhance woman’s autonomy is imperative; a move from:

  • Loss of autonomy to being in control
  • Passive to active
  • Dependence to independence

For midwives, movement from:

  • Control to facilitation
  • Dominance to masterly inactivity
  • Surveillance and monitoring to watchful expectancy
  • More to less

Then the space is made for sensitive, intuitive support hat really does make a difference when needed in the 2nd stage

Practice recommendations – care should be based on:

  • Rehabilitating women’s confidence in their own ability to do the 2nd stage
  • Fetal and maternal condition
  • Evidence of descent of presenting part in the presence of expulsive contractions and spontaneous pushing
  • Time restrictions for duration of a physiological 2nd stage should be as flexible as they are for women w epidurals in 2nd stage
  • Women should be encouraged to follow their instincts
  • Midwives’ role is to affirm physiology, not control it or deny it
  • Routine coached pushing should be abandoned
  • Coaching for women w epidurals should mimic physiological behaviors regarding shorter periods of breath-holding, open-glottis pushing and vocalizing
  • Combine deregulated approach w upright postures
  • Transition and early bearing down are part of a spectrum of physiological labor behaviors
  • In content of delay, counter-intuitive measures may have a place

 

Bowel Elimination – most women do not have bowel movements during labor because of decreased intestinal motility. Stool that has formed in the large intestine often moves downward toward anorectal area as a result of pressure exerted by the fetal presenting part as it descents. Tis often expelled during 2nd stage pushing and birth; however passage with bearing-down efforts increases risk of infection and may embarrass woman. Immediately cleanse perineal area to remove any stool and assure it’s normal.

Routine use of edemas on admission shown only modest benefits. Trend toward lower infection rates and newborns have fewer lower respiratory tract infections and less need for antibiotics. Cause discomfort and increase costs so benefits don’t outweigh disadvantages.

When presenting part is deep in pelvis, even in absence of stool in anorectal area, woman may feel rectal pressure and think she needs to defecate. Woman should perform a vaginal examination to assess cervical dilation and station. When a multiparous woman experiences the urge to defecate, this often means birth will follow quickly.

Ambulation and Positioning – upright positions and mobility during labor may be more pleasant for laboring women; associated with improved uterine contraction intensity and shorter labors, less need for pain medications, reduced rate of operative birth, increased maternal autonomy and control, distraction from discomforts of labor and opportunity for closer interaction with woman’s partner and care provider.

Confinement to bed is norm for laboring women in U.S.; increased use of epidurals and multiple medical interventions, reduced motor control contribute to this practice, interfering with woman’s freedom of movement and often slowing labor progress.

Encourage ambulation if membranes are intact, after ROM If fetal presenting part is engaged, and if woman hasn’t received pain medication.

When woman lies in bed, she usually changes position spontaneously as labor progresses. If she doesn’t change every 30-60 min, assist her to do so. The side-lying lateral position is preferred because it promotes optimal uteroplacental and renal blood flow and increases fetal oxygen saturation. If woman wants to lie supine, nurse should place a pillow under 1 hip as a wedge to prevent uterus from compressing the aorta and vena cava. If fetus is in OP, encourage woman to squat during contractions because this increases pelvic diameter, allowing head to rotate to a more anterior position. Hands and knees during contractions or lateral position on same side as fetal spine also recommended for rotation of fetal occiput from posterior to anterior, as gravity pulls fetal back forward; these also provide access to back for counterpressure by partner. Women with epidurals may not be able to squat or assume a hands and knees position.

Birth ball – leaning over bed, lean over ball to support upper body and reduce stress on arms/hands w hands/knees position. Encourages pelvic mobility and pelvic and perineal relaxation. Warm compresses to perineum and lower back can maximize relaxation. Birth ball should be large enough that when woman sits, her knees are bent at a 90 degree angle and her feet are flat on floor approx. 2 feet apart.

Supporting Care During Labor and Birth – women w continuous support beginning in early labor less likely to use pain medication or epidurals, more likely to have spontaneous vaginal birth and less likely to report dissatisfaction with birth experience.

Labor rooms should be airy, clean and homelike. Turn off bright overhead lights when not needed, keep noise and intrusions to minimum. Control temp of labor room to woman’s comfort. Room should be large enough to accommodate a comfortable chair for woman’s support person, monitoring equipment and hospital personnel. Encourage women to bring own pillows.

Labor Support by Nurse

  • Help her maintain control and participate to extent she wishes
  • Continuity of care that is nonjudgmental
  • Listening to her concerns and encouraging her to express her feelings
  • Acting as her advocate, relating her wishes as needed to other health care providers
  • Helping her conserve her energy and cope effectively w pain
  • Helping control her discomfort
  • Providing positive reinforcement and acknowledging efforts
  • Protecting her privacy, modesty and dignity.

 

Common Maternal Positions During Labor and Birth:

Semi-recumbent Position – woman sits w upper body elevated to at least a 30 degree angle; place wedge or small pillow under her hip to prevent vena cava compression and reduce likelihood of supine hypotension

  • Greater the angle of elevation, the more gravity/pressure exerted that promotes fetal descent, the progress of contractions and the widening of pelvic dimensions
  • Convenient for providing care measures and for EFM

Lateral Position – have woman alternate between left and right side-lying and provide abdominal and back support as needed

  • Removes pressure from vena cava and back, enhances uteroplacenta perfusion and relieves backache
  • Facilitates internal rotation of fetus in posterior position to anterior position (woman should lie on same side as fetal spine)
  • Makes it easier to perform back massage or counterpressure
  • Associated with less frequent, but more intense, contractions
  • May be more difficult to obtain good EFM tracings
  • May be used as a birthing position
  • Takes pressure off perineum, allowing it to stretch gradually
  • Reduces risk for perineal trauma

Upright Position – gravity effect enhances contraction cycle and fetal descent: the weight of fetus places increasing pressure on cervix; cervix is pulled upward, facilitating effacement and dilation; impulses from cervix to pituitary gland increase, causing more oxytocin to be secreted; and contractions are intensified, thereby applying more forceful downward pressure on fetus, but they are less painful

  • Fetus is aligned with pelvis, and pelvic diameters are widened slightly
  • Effective upright positions include:
    • Ambulation
    • Standing and leaning forward w support provided by coach, end of bed, back of chair, or birth ball; relieves backache and facilitates application of counterpressure or back massage
    • Sitting up in bed, in chair, in birthing chair, on toilet or on bedside commode
    • Squatting

Hands and Knees Position – Position for Posterior Positions of Presenting Parts – assume all fours position or lean over and object (birth ball) while on knees in bed or on covered floor; this allows for pelvic rocking

  • Relieves backache characteristic of back labor
  • Facilitates internal rotation of fetus by increasing mobility of coccyx, increasing pelvic diameters, and using gravity to turn fetal back and rotate head (side-lying position, double hip squeezes or knee squeeze also can facilitate internal rotation)
  1. Comfort techniques for second stage
  2. Spontaneous bearing down

 

Comfort Techniques for 2nd Stage of Labor (Pushing)

Many of comfort techniques during first stage also helpful during 2nd stage.

Working with urge to push in labor – around time cervix becomes completely dilated, your breathing rhythm will change and you’ll feel pressure on your pelvic floor as your baby moves deep into your pelvis. These developments will cause you to have an irresistible urge to push. At first, you may mistake this urge for the need to have a bowel movement. (If have epidural, will feel urge to push much less clearly or might not feel it at all)

Spontaneous Bearing Down – your responses to contractions during the 2nd stage will depend on the sensations you feel. Will probably feel several strong surges (irresistible urges to push) during each contraction. Each surge will last a few seconds. During a surge, you’ll use expulsion breathing. Breathe using whatever technique suits you until you have an urge to push and body begins bearing down. Bear down for as long as you feel the urge. Then breathe lightly until you feel another urge or contraction ends. Expect to bear down 3-5x per contraction, with each effort lasting ~5-7 seconds. Between contractions, rest and relax.

How hard you bear down in response to an urge is similar to how hard you sneeze in response to an irritant in your nose. Both sneezing and spontaneous bearing down are involuntary reflexes. Sometime you need 1 tiny sneeze to clear an irritant; other times, you need several explosive sneezes. Sometimes you need to gently bear down; other times you feel compelled to push with all your strength.

Spontaneous bearing down is recommended if labor is progressing normally and you haven’t had anesthesia. If you have, you’ll use delayed or directed pushing since it diminishes the pushing sensations and the effectiveness of your ability to bear down.

 

  1. Directed pushing

Using spontaneous bearing down in labor –

  • As contraction begins, start slow or light breathing
  • Focus on a positive image, such as baby moving down and out of uterus
  • Breathe rhythmically as contraction intensifies. When you can no longer resist urge to push, bear down or strain while holding your breath or while slowly releasing air by grunting or vocalizing, whichever feels best. Relax your pelvic floor! Partner may need to remind you to relax perineum
  • Exhale when urge passes (usually after 5-7 seconds) and breathe rhythmically for several seconds until you feel another urge to push. Then, bear down again. The urge to push will come in waves during the contraction, giving you time to “breathe for your baby” (that is, to oxygenate your blood to provide enough oxygen for your baby between urges)
  • When contraction ends, slowly lie or sit back (or stand up if squatting) and take 102 relaxing breaths.

Rehearsing Spontaneous Bearing Down for Labor– when practicing comfort techniques for 2nd stage of labor, bear down just enough to feel your pelvic floor bulge. Don’t bear down forcefully. To practice more effectively, use different positions and imagine what will be happening when you’re pushing in labor. Visualize your baby descending and rotating into your birth canal. Remind yourself that contractions are proof that your baby is working to be born and it’s important to relax and bulge your pelvic floor.

Directed Pushing – unlike with spontaneous bearing down, when you push in response to an urge, directed pushing is bearing down when someone tells you to do so. You’ll use this if:

  • You’ve had an epidural and don’t feel contractions
  • You don’t have an urge to push or you’re not pushing effective when spontaneously bearing down, even after trying gravity-enhancing positions such as squatting, sitting, dangling, lap squatting, or standing upright
  • Directed pushing is routine for your hospital or caregiver

Directed pushing is typically more forceful than spontaneous bearing down, which means it may be more stressful for both you and your baby. for this reason, many caregivers reserve this type of pushing for births that may require forceps delivery or vacuum extraction. Before the birth, check whether directed pushing is routine for your caregiver or birthplace. If it is, find out when and under what circumstances it’s used.

Using Directed Pushing in Labor – caregiver, nurse or partner will tell you when, how long and how hard to push. Can use various positions

  • At beginning of contraction, take 2 or 3 breaths. When told to push, inhale and hold your breath. Curl forward, tucking your chin on your chest, and bear down, tightening your abdominal muscles
  • Relax your pelvic floor muscles. Bear down for 5-7 seconds. Quickly exhale as directed, then take another few breaths
  • Repeat steps 1 and 2 until contraction subsides
  • When contraction ends, slowly lie or sit back (or stand up if squatting), rest and breathe normally

Directed pushing will continue for each contraction until your baby’s head is almost out. At that point, your caregiver may tell you to stop pushing to allow your baby’s head to pass slowly through your vaginal opening. Relax and exhale completely to decrease your risk of developing a vaginal tear.

Rehearsing Directed Pushing for Labor – since told when and how hard to push, practice only enough to coordinate holding breath with bearing down and bulging pelvis, as partner coaches you through the contractions as described above. May find it helpful to occasionally hold breath and bulge your perineum during perineal massage.

Prolonged Directed Pushing – requires you to hold your breath and push hard for 10 seconds. Caregivers generally don’t recommend, but some circumstances require it. Because you’d only use under guidance, no need to practice it.

 

Bearing-Down Techniques for the 2nd Stage

  • Spontaneous bearing down (pushing)
    • She bears down when she has the reflexive urge, usually 5-7 seconds. May hold her breath, moan, release air or bellow. Breathe quickly and lightly for several seconds in between.
  • Self-Directed pushing
    • When bearing down is unfocused, ineffective and diffuse, without progress for 30 minutes. Eyes clenched shut. Encourage woman to try new position. Gravity enhancing positions. Have her open eyes and gaze at vaginal outlet.
  • Directed Pushing
    • Directed how, when and how long to push. Usually holds breath for 10 seconds with 1 short breath in between. Aka purple pushing. Use when anxious and asks for help or if has epidural but should be delayed until fetal head visible or woman feels urge to push.

 

Focused Breathing – focusing attention on breathing and on other comfort techniques, rather than on pain, is a positive strategy for many women in labor. Respiratory physiologists refer to breathing at a rate and depth which is voluntarily controlled as “paced breathing.” Besides helping to maintain the blood oxygen and carbon dioxide at appropriate levels, the mental concentration required to maintain the pace can help divert the breather’s attention from intruding thoughts or painful contractions, and can prevent hyperventilation, as well as other stress responses such as increased heart rate and muscle tension. Encourage women to pace their own breathing during labor to the depth and rate that is most comfortable for them.

Slow breathing increases the ability to relax, conserves energy, fully oxygenates the body and provides a positive focus. When fully relaxed, most people breath at about ½ their normal resting breathing rate.

During labor if slow breathing ceases to be comfortable, a woman will often increase her breathing rate as the contraction increases in intensity. Breathing faster over the peak may help her to cope, but theoretically her pace should not exceed 2x her normal breathing rate to keep her from hyperventilating or becoming more fatigued. Breathing patterns can help her to get into a ritual that is rhythmic and relaxing. Additional attention-focusing is attained by adding words, phrases, or images to her rhythmic breathing. Using a strategy of counting to 4 or 5 with each inhalation and exhalation may be effective for her. If she practices yoga, she will likely turn to the pranayama she uses in her practice.

Any breathing pattern or pace may be used at any time during labor. For many women, changing breathing strategies (pg 43 of handbook) will offer diversion of focus and decreased pain perception, while maintaining adequate oxygenation and encouraging the relaxation response.

DVDs: Penny Simkin’s comfort measures for childbirth and Relaxation, rhythm & ritual: The 3 Rs of childbirth.

  1. Positions

 

Positions for 2nd stage of labor – just as moving around/changing positions helps in first stage, can help during 2nd stage. Until in labor and ready to push baby out, you won’t know which positions will feel right. Try to practice spontaneous bearing down in all positions so you’re prepared to effectively bear down while in any of them.

If baby descends rapidly, you might not have the time or desire to change positions, however, if 2nd stage progresses slowly, you’ll have a chance to try many positions.

Other factors may influence the positions you can try, such as caregiver’s preferences or your willingness and freedom to change positions. Some procedures/equipment may impair your mobility, including electronic fetal monitors, catheters, anesthetics, IV equipment and narrow beds. With help and encouragement, you can work around these.

Discuss birthing positions when preparing birth plan. Although some are comfortable with any, most are confident only with supine or semi-sitting position for delivery. Ask whether you can use other positions that allow the pelvic outlet to open fully during beginning of pushing until baby is close to being born.

 

Modifiable Labor Influences: Freely Move About, or “Gravity Works”: Ancient works or art and sculpture show birthing women in upright positions. Changed when Dr. James Young Simpson used ether amnesia for birth in 1847, assisting a woman with a deformed pelvis. He then was appointed to Queen Victoria, who used diethyl ether (chloroform) to give birth. When anesthesia is used, mother cannot move around freely or remain upright for birth. Dr. Joseph DeLee formally introduced the lithotomy (on back, legs in stirrups) position to U.S obstetrics in his 1913 textbook.

1979 study from Dr. Caldeyro-Balcia in Uruguay showed vertical mothers had 36% shorter first stages, less pain and infants were less likely to have marked molding on head after delivery.

Study in 2006: “risks of both maternal and perinatal adverse outcomes rise with increased duration of second stage, particularly for duration longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women. Found upright positions associated with shorter, less painful 2nd stages, small reductions in instrumental deliveries and reduction in episiotomy but increase in 2nd degree lacerations.

Squatting women had faster 2nd stages, required less labor stimulation with oxytocin, fewer assisted deliveries than semi-recumbent mothers. Squatting group also had fewer episiotomies and severe lacerations.

Fetal oxygenation is compromised by horizontal, especially supine, maternal positions during labor. Longer labor puts more stress on the infant and mother, which increases drug consequences to the mother and infant, which affect breastfeeding. Longer labor also causes poorer oxygenation of the infant, which reduces the infant’s readiness for birth and feeding.

Electronic Fetal Monitoring: instrumental delivery and cesarean surgery raters higher in EFM groups

Survey: 71% of mothers did not walk around once they were admitted to the hospital in labor. 4 years later, 76% did not walk…

Odent began researching squat and other positions in 1980s.

Summary Points:

  • No evidence that directly links maternal position in labor with breastfeeding outcomes
  • No evidence shows safety or restricting mother’s movement or position in labor, except to correct specific complications
  • Restriction of movement strongly associated with longer labors; more instruments which can injure mom or baby, more pain for mom and poorer oxygenation for baby
  • 2006 BFHI Mother Friendly Childbirth supports moving around in labor
  1. Perineal massage

PCN Pgs 235-236 Prenatal Perineal Massage – stretches inner tissue of lower vagina. Teaches you to respond to pressure in vagina by relaxing pelvic floor muscles; a rehearsal for responding to sensations of vaginal stretching during birth.

Enhances hormonal changes that soften connective tissue during late pregnancy, which can reduce chances of needing an episiotomy or developing a serious tear during birth. Massage your perineum 5-7x a week during the last 5-6 weeks.

Some caregivers aren’t familiar or don’t recommend. Some women find it distasteful. Others feel it is worthwhile. Some may even find it enjoyable after they’ve learned to relax while it’s done.

If you have vaginitis, genital herpes sore or other vaginal problem, perineal massage may worsen condition. Wait until problem is completely gone before beginning.

How to Do Perineal Massage – you or partner can do with clean hands and short fingernails. If either has rough skin, use disposable vinyl or latex gloves. If doing yourself, may want to use mirror to help guide.

  • Get into a semi-sitting position (partner can be behind you) or stand with 1 foot on side of tub or chair
  • Use a squeeze bottle to squirt vegetable oil on thumb (dipping fingers can contaminate). Wheat herm oil has high vitamin E content, which may be soothing on skin. Can also use another vegetable oil or water-based lubricant such as K-Y. Don’t use baby oil, mineral oil, petroleum jelly or hand lotion because skin may not tolerate well.
  • Place thumb, or have partner place index finger( 1 at first, 2 when more comfortable) well inside your vagina (up to 2nd knuckle). Do a few Kegel exercises so you can feel pelvic floor muscles tense. Relax the muscles. Curl your thumb and gently pull outward and downward toward anus, then rhythmically move it within your vagina in a U motion. Focus on relaxing your pelvic floor muscles. 3 minutes. At first, vaginal wall will feel tight. After a few days, it will relax and stretch more easily
  • Concentrate on relaxing muscles as you feel pressure and stretching. As you become comfortable, increase pressure just enough to make tissue begin to sting or burn slightly. (The same sensation will occur as baby’s head is being born)
  • If you have questions after trying, ask caregiver, childbirth educator or someone familiar with technique

 

Prenatal Perineal Massage – will help you prepare for the stretching and pressure you will feel as the birth canal opens and your baby’s head crowns. Learning to relax as you feel the stretching will help you to release when you feel that burning sensation during the birth. Prenatal massage may help the tissues to stretch during birth so that an episiotomy won’t be needed.   The purpose is not to enlarge the opening.

According to current research, 1st time mothers who do prenatal perineal massage are less likely to need episiotomies during childbirth and are less likely to experience tears which need repair (stitches).

Begin perineal massage about 6 weeks before due date. 1x/day for ~5 min. do not massage if you have active genital herpes or any other genital infection. Always use clean hands with short fingernails and avoid touching opening of urinary tract.

To learn the process, it may be helpful first to prop a mirror so you can see your vagina and perineum. You can see and feel the perineum move as you do the Kegel exercise. Practice relaxing the muscles with a warm washcloth held on the perineum. (Some women prefer to take a warm bath to help them relax before massage). A lubricant may help to soften massaging fingers or thumbs, and to increase elasticity of perineum. You may use cocoa butter, K-Y jelly, wheat germ oil or even vegetable or olive oil from your pantry.

Place either your thumbs or index fingers an inch or 2 inside your vagina and press downward toward the rectum. As you press, you will feel a slight burning, stretching sensation. At that point, hold the pressure for 1-2 min until the stinging subsides. Slowly move your fingers or thumbs up along the lower sides of the vagina with the same steady pressure. Massage back to center and up the sides, pulling slightly forward, for 3-4 min. this will work the lubricant into the tissues. Practice releasing the perineum to the sensation of the stretch, as you will do at your baby’s birth. In a week you should notice that the tissue stretches much easier as you massage. Do Kegels to help increase muscle tone of the pelvic floor.

Directions for prenatal perineal massage:

  • Wash hands
  • Lean back in a comfortable semi-sitting position, with pillows supporting your back and knees
  • Put a lubricant on fingers and perineum
  • Massage, firmly but gently, relaxing your muscles as you feel the pressure or stinging
  • Tell you partner how much pressure to apply if they do the massage for you.

 

Fostering Normality in Birth

Perineal Management

Prenatal perineal massage – beginning at 35 weeks; associated with decrease in perineal damage requiring repair with suture. Use good-quality water-soluble lubricant, coconut oil or any vegetable oil for 3-10 min each day (avoid mineral oil and petroleum based products because vagina cannot clear these oils effectively and they may alter normal flora and result in an infection from overgrowth of other organisms).

  • Recline in semi sitting position with knees bent, use pillow for support. Partner applies oil/lubricant to index fingers and perineal tissues. Place finger(s) 1-1.5 inches into vagina, while keeping them inserted and slightly flexed, rub toward sides, using sweeping U-shaped movement and press downward (Toward rectum) in center. Once experience a slight burning sensation, maintain position for 1-2 min while woman uses relaxation and breathing techniques. Within a week or less, woman will notice more elasticity along w reduction in burning sensation. Primigravidas experienced significantly reduced intrapartum perineal damage that required suturing; multigravidas didn’t experience same benefits.

Perineal management during 2nd stage – spontaneous bearing down rather than prolonged forceful pushing, improved perineal and fetal outcomes.

Verbal support of spontaneous bearing down efforts– offer words of approval/encouragement along w reminders to relax legs/perineum.

  • “Let yourself push naturally. Your body knows what to do”
  • “That’s the way; just like that. There is plenty of room for this baby”
  • “Your perineum is starting to stretch. That’s a very good sign.”
  • “Good job”
  • “I can see the head”
  • “You are moving your baby with every push”
  • “Let yourself rest between contractions. Good”
  • “That burning you feel is normal. It’s your body telling you that the stretching is happening. Feel free to ease off a bit on the push until it starts to go away”
  1. AWHONN protocol for pushing

AWHONN Recommendations (AWHONN is professional organization that includes labor and delivery nurses) – since ’00, has recommended that nurses encourage physiologic pushing during 2nd stage.   Their evidence-based recommendations include the following:

  • The information that pregnant women receive before labor about 2nd stage should include realistic expectation about the length of 2nd stage; sensations women may experience; the benefits of spontaneous (non-directed) pushing over directed pushing; the benefits of upright positions and the risks of the supine position; and the benefits of labor support, including doulas
  • A woman should be allowed to rest until she feels the urge to push
  • A woman should be encouraged to try a variety of upright positions during 2nd stage
  • Spontaneous bearing down, rather than directed pushing, should be encouraged
  • Breath-holding for longer than 6-8 sec should be discouraged
  • Noises such as grunting, groaning and exhaling should be supported
  • Nurses should validate the normalcy of the sensations and sounds the laboring woman is making

Lecture/Discussion Points

3 phases of 2nd stage

  • Lull or resting phase – when baby’s head leaves uterus, that muscle is no longer stretched as much as it was when baby was totally inside. There may be a welcome lull in the contractions as the uterus now works to take up the slack which before was tight around the baby. the muscle fibers shorter, but the mother may not be aware of contractions. Sheila Kitzinger refers to this as “rest and be thankful” time which may last up to 20-30 min. Once uterus is again hugging the baby tightly, the urge-to push generally begins. If not, a squatting position, as long as baby has descended to 1 station, may help bring it on
  • Active or descent phase – the contractions resume and intensify, with the urge-to-push occurring at the peak of each wave during the contraction. If allowed to push spontaneously, a mother will generally bear down intermittently with lighter breaths between her urges. She may wish to change positions to facilitate the baby’s descent during this phase.
  • Crowning or perineal phase – the last few contractions from crowning to birth are intense, both physically and emotionally. Emotionally the woman is ready to give birth, but physically she experiences an intense burning and stretching sensation which signals her to stop pushing hard and to allow the birth to happen gently. If being directed by the care provider, she may be instructed to blow to counteract the urge-to-push. Her reluctance to push to vigorously at this time often allows the perineum to stretch so that an episiotomy is unnecessary. The labor woman’s bod knows what to do to birth this baby!
  1. Women should receive information on benefits of upright positions
  2. Variety of positions should be tried
  3. Supine discouraged; squatting encouraged
  4. Semi-recumbent/side-lying positions recommended for epidurals C. Breath-holding discouraged
  5. Caregivers should support rather than direct involuntary pushing efforts E. Caregivers should validate normalcy of sounds
  6. Holding back in second stage

 

Holding back during descent phase – may tense pelvic floor in response to stretching sensations you feel when baby’s head is in birth canal. This is normal and usually passes quickly once you feel baby descending. To stop self form holding back, try telling yourself to let go. If successful, pain decreases and you wont have a desire to hold back again. However, you may have trouble letting go for 1 or more of the following reasons

  • Pressure of baby’s head within vagina alarms you and you find it difficult to give in to that pressure – remind self that holding back tends to increase pain and slow progress. You’ll feel much better after letting go. Listen to partner, doula and caregiver when they encourage you to let go. Try sitting on toilet for a few contraction. May help perineal muscles release naturally because its associated with letting go. Warm compresses on perineum can help because moist heat promotes relaxation and relieves stretching sensation. Can also alleviate perineal pain and reduces risks of tearing and urinary incontinence. Also helps reassure you that they will help guide baby out. Discuss with caregiver before due date and include in birth plan. Some caregivers use fingers to stretch woman’s perineum; research finds that this is very painful and no more effective for enlarging vaginal outlet and preventing a tear than use of warm compresses or no treatment.
  • You’re uncomfortable with having people stare at your perineum – they are watching progress of baby, but ask to be covered as much as possible. Warm compresses can conceal perineum
  • You fear you’ll have a bowel movement while pushing – because baby presses on rectum while descending. Caregiver interprets this as progress. May not even be aware of it because caregiver wipes away and removes stool discreetly (perhaps with a warm compress). Sitting on toilet for a few contractions may help you dispel this fear and relax.
  • If you’ve been sexually abused, you fear that the sensation of your baby in your vagina will remind you of your abuse – tell yourself that you’re pushing your pain out of your body as you push out your baby. its important to separate your abuse from the birth of your child. Pg 59

 

Triggers of emotional distress unique to 2nd stage

Triggers of emotional distress unique to 2nd stage:

  • Fatigue or exhaustion, which can lead to hopelessness or anxiety
  • The intense sensations of 2nd stage or of manual stretching of vagina. These sensations may be esp. frightening if woman has been sexually abused or otherwise traumatized in genital region in past, as may trigger flashbacks
  • Fear of behaving inappropriately or offensively (making noise, passing stool while pushing)
  • The immediacy of the birth and the responsibility of parenting the child, esp fi her own parents were dysfunctional or she has relinquished a child for adoption or had a child removed from her care
  • Fear for baby’s well-being esp if a sibling or previous child died around birth or had another adverse outcome
  • Loss of privacy, sense of modesty when surrounded by strangers watching her perineum
  • Previous cesarean during 2nd stage
  • Thoughtless or unkind treatment by loved ones or caregiver during labor

Common response to fears in 2nd stage is extreme tension in pelvic floor as to deter fetus’s descent, while pushing. Woman may be pushing hard but not effectively. Sometimes she unintentionally and unconsciously contracts her pelvic floor muscles and buttocks as she pushes with her diaphragm and ab muscles. Tension in perineum and constriction of anus while pushing indicate woman is holding back.

(Don’t confuse excessive and prolonged pelvic tension with normal confusion many woman have when they first begin to push; esp true for those without strong urge to push – may be best for them to rest and await a stronger urge).

If woman exhibits “diffuse pushing” and does not benefit from measures to improve her bearing down efforts, consider possibility of emotional dystocia.

Whatever fears/anxieties cause woman to hold back, she prob cannot simply “snap out of it”

  • Encourage woman to express feelings. Ask “What was going through mind during last contraction??” listen to her, acknowledge and validate her concerns and try to give appropriate reassurance, encouragement or info and suggestions. Often, all woman needs is a chance to express her concerns. She needs to know she is being heard, fears are normal, and she will get through this event. Even normal evens can be very troublesome to anxious women
  • Sometimes, when its clear to everyone including woman, that there is a delay, asking her why she thinks labor has slowed down reveals useful info. “I cant push right” or “Baby doesn’t want to come out” might indicate emotional dystocia
  • Provide appropriate info. If woman is afraid of having bowel movement – she can be reassured passing stool indicates she is pushing effectively, its common and any fecal material will be quickly wipe away and disposed of. One of many good reasons to apply warm compresses to perineum at this time
  • If she’s afraid she will rip or split apart, reassure her by relaxing perineum or letting baby come, her perineum will actually stretch better and tear is less likely. Unless there’s a good reason not do to so, let her try a few contractions without pushing. Lets try breathing through this next one, so she feels she has options
  • Give woman time to adjust to intense sensations/emotions of 2nd Avoid creating a sense of rushing. No need for a caregiver to raise voice
  • Encourage woman to relax perineum between contractions and let it bulge during contractions. Application of hot compresses (washcloths soaked in warm water, wrung out) to perineum often feels good and promotes relaxation. Encourage woman to push as if blowing imaginary balloon, or if she were trying to urinate rapidly. Give her positive reinforcement whenever she bears down effectively. Pushing in this manner sometimes causes pelvic floor to bulge. If she seems reluctant to sustain bearing-down effort and she’s not making progress, advise her to “push to the pain, and right through it. It will feel better when you push through it”
  • Have woman try pushing while sitting on toilet. If she’s worried about passing stool, toilet is a reassuring place to be. Toilet sitting also elicits conditioned response or releasing pelvic floor. If woman feels baby is coming, she will need to move to more appropriate delivery site

VII. Breathing to avoid pushing

 

Rehearsing Breathing Adaptations for Labor

Relax for only 30 sec or so between practice contractions to prepare for brief rest youll experience between contractions during late 1st stage of labor. In this stage, contractions may last 2 min or may occur in pairs with little break between the 1st and 2nd contractions (coupling). During labor, need to be prepared to use light breathing or its adaptations for up to 3 min without losing breath.

Using Breathing Techniques to Avoid Pushing

May have an early urge to push at peak of a contraction. Urge is considered premature if it occurs before cervix is completely dilated. Lift chin and either breathe deeply, pant, or blow lightly until urge subsides. May be helpful to say/sing “puh, puh, puh” or “hoo, hoo, hoo” with each exhalation. When urge passes, resume rhythmic breathing for rest of contraction. Changing positions can also help reduce premature urge to push *hands and knees, side lying an open knee chest. These breathing techniques wont take away body’s urge to push but will keep you from holding breath and bearing down with urge.

Rehearsing Breathing Techniques to Avoid Pushing – hold breath or grunt as you breathe to signal to partner you have urge. Partner can remind you to resist urge until it passes.

 

Physiologic effects of prolonged breath-holding and straining

  • On woman– lead to closed pressure in her chest, which leads to following chain of events:
    • Decreases in venous return, cardiac output
    • Lowering of maternal arterial bp
    • Increase in peripheral stasis of blood in her head, face, arms and legs. Her face reddens and if an IV line is in place, blood often backs up in IV catheter
    • Decrease in maternal blood oxygen levels and blood flow to placenta
    • An increase in maternal carbon dioxide levels until she gasps for air
    • Sudden increase in bp as she gasps for air, causing bursting of tiny blood vessels in whites of her eyes, face, neck and eyes (petechial hemorrhages)
    • Rapid distention of vaginal canal and pelvic musculature, along w stretching of supportive ligaments, leading to perineal trauma and possible urinary stress incontinence
    • Maternal exhaustion
    • Lactic acidosis
    • Longer pushing time
    • These effects are well tolerated by young healthy women but may present risks for older or high risk woman and those w residual pelvic floor weakness, esp if such efforts are required for several hours. Perineal damage is increased (denervation, muscle damage, later incontinence) when women bear down forcefully in unfavorable positions.
  • On baby – nonreassuring fetal heart rate patterns sometimes occur when woman holds her breath for prolonged periods and her straining may increase fetal head compression. If bearing down efforts are combined with a dorsal position, supine hypotension may exacerbate nonreassuring heart rate patterns. Decreases in maternal bp, blood oxygen content and placental blood flow cause decrease in oxygen available to fetus (fetal hypoxia and acidosis)
    • These effects are well tolerated by a healthy, well nourished term fetus but may distress the fetus who is preterm, small for gestational age or already compromised earlier in labor or is experiencing cord compressing
    • Not associated with better neonatal outcomes

 

VIII. Birth

Your Baby’s Birth – 2nd stage of labor ends with baby’s birth. If baby’s position is head down (occiput anterior or posterior), first the crown of his head emerges, followed by his brow and face. His head appears bluish-gray and is soaking wet. After head is out, it rotates to the side to allow shoulders to slip more easily through pelvis. 1 shoulder emerges, followed by rest of body, perhaps rather quickly. You or partner may want to help catch baby.

Baby’s body may appear bluish at first and may be streaked with blood, mucus, and vernix caseosa.   With baby’s first breath, skin color quickly becomes normal.

Birthplace policy may require baby to have nose and mouth suctioned after birth. Studies find that healthy vigorous newborns don’t benefit from this procedure. Discuss policy with caregiver and include in birth plan.

While you await delivery of placenta, baby may be dried and immediately placed on abdomen or in arms. Umbilical cord is typically clamped and cut around this time; however, there are long-term advantages for baby if cord clamping is delayed. Custom in some hospitals is to assess newborns well being while in baby warmer in birthing room. Research shows newborns are warmer and begin breastfeeding earlier when kept skin to skin with mothers. Most women report greater satisfaction when they have their babies immediately with them after birth. Before birth, find hospitals custom on use of baby warmers, in birth plan, express preferences to hold baby immediately after birth (if he’s doing well). Nurse or caregiver can assess baby while in your arms or at a later time, after he’s at least had 30 min of skin to skin with you.

Your Reactions After the Birth – first response may be “its over – no more contractions” and may feel grateful and relieved baby is out of body. These may overtake interest in baby especially if you’ve had long, tiring labor.

May temporarily forget about labor and birth the moment you hear/see newborn. May be surprised/awed by baby’s appearance. May hold breath in suspense until you hear her breathe, smiling with relief and joy when you hear first hearty cry. If caregiver needs to inspect perineum and check for separation of placenta, may find procedures painful and distracting and may be unable to focus completely on baby. After caregiver ahs finished, can return total attention to baby.

Note to Partners: requires great physical effort by partner, even if she had an epidural. To assist her, help her change positions and physically support her as needed. Encourage her to relax her pelvic floor as she pushes. Cheer her on as she pushes, but don’t override caregiver’s directions.

When baby is born, you may experience happiness, exhaustion, relief, wonder, joy and love for partner and baby – all at the same time.. Baby becomes focus of your attention..

If baby can’t remain in partners arms immediately after birth (because of concerns for baby’s wellbeing or because staff want to check him in baby warmer), stay with baby so you can report what you see being done to partner. Talk to baby since baby knows your voice and hearing it calms them.

 

Third Stage Management: Care of the Baby

  • Oral and nasopharynx suctioning – fetal chest compressed tightly as it passes through vagina, providing pressure that helps to clear amniotic fluid and mucus from respiratory passage. No evidence that routine suctioning the oral cavity and nasopharynx of neonate prior to delivery of shoulders is necessary or improves neonatal outcomes. Routine intrapartum suctioning may lead to instability in neonatal breathing, heart rate and oxygen saturation. Routine suctioning immediately following birth has no known benefits, since healthy newborns can usually clear their own airways. Potential hazards of bulb suctioning include laryngospasm and pulmonary artery vasospasm. A policy of no bulb suctioning unless indicated will ensure an airway free of amniotic fluid. Routine suctioning of babies who have meconium-stained amniotic fluid is also not supported by scientific evidence. Babies born with thick meconium-stained amniotic fluid who are vigorous at birth require only routine care and observation. Infants not vigorous are immediately placed in radiant warmer and endotracheal intubation is performed by a trained professional to asses for presence of meconium below vocal cords.
  • Delayed clamping and cutting of the umbilical cord– both term and preterm neonates benefit significantly from delayed cord clamping. When cord clamping is delayed, the newborn gains 30% – 60% more red blood cells (RBCs) as cord pulses, delivering placental blood to baby. These additional RBCs transfused associated with reduced neonatal anemia and improved heart and lung transitioning to extrauterine environment. Delayed cord clamping has no been associated with adverse outcomes such as jaundice or polycythemia. While delayed cord clamping may slightly elongate the 3rd stage of labor, it is not associated with an increased risk of postpartum hemorrhage. When healthy neonate is placed on mother’s abdomen immediately following birth and cord clamping is delayed for 3+ min, an increase in blood volume can be expected. When newborn is pale or slightly cyanotic following tight nuchal cord, baby can be held at a level lower than placenta for 30 sec – 1 min (in order to maximize blood that is transfused) then placed on mother’s abdomen while cord clamping is delayed for at least a total of 3 min. can improve color and tone of neonates who are otherwise healthy at birth. In situation of tight nuchal cord, it’s possible to avoid cutting it by using “somersault maneuver” to deliver baby. by holding baby’s head against woman’s thigh while baby’s trunk is born, cord is not overstretched and remains intact.

 

Research evidence – Prolonged breath-holding in 2nd stage decreased placental perfusion resulting in fetal hypoxia. Coached pushing involving prolonged breath-holding decreased fetal cerebral oxygenation. If coached pushing in 2nd stage lasted longer than an hour, babies had lower pH at birth. Coached pushing results in a longer 2nd stage than spontaneous pushing with no differences in type of birth, fetal outcome and perineal outcome. Number of other concerns:

  • Maternal exhaustion
  • More assisted vaginal births
  • More episiotomies and perineal tears
  • Deleterious impact on pelvic floor, in particular urinary stress incontinence

When spontaneous pushing combined with upright posture, 2nd stage shorted by 45 min compared with coaching and semi-recumbent position in low risk primiparous women. Women also said they experienced less pain, less fatigue and were more satisfied

Spontaneous pushing:

  • Breathing pattern during contraction and pushing is self-directed
  • Tie of initiating push is irregular (women initiates push independently and pushing often begins once contraction is well established)
  • Pushing may be characterized by grunting with pushing, short and more frequent bearing-down efforts with each contraction or both
  • Open-glottis pushing (Grunting noise while pushing)
  • Patient follows cues from body
  • No verbal instruction as to how to push
  • No non-verbal instruction is given (deep breaths)
  • Caregivers offer encouragement and praise only, not instruction

Directed pushing– following verbal direction, demonstration or instruction from caregivers regarding:

  • Time of pushing (when to start/stop)
  • Length of pushing (how long to push)
  • Position for pushing
  • Breathing during pushing
  • Strength of push
  • Specific direction on how to push
  • Instruction to make no noise with pushing efforts
  • Actively positioning woman in a certain way for pushing or verbally directing her to position herself in a certain way
  • Vaginal examination w concurrent direction such as push my finger out
  • Vaginal examination actively stimulating Ferguson’s reflex or manipulating or stretching cervix or perineum
  • Following any non-verbal instructions on how to push

Concluded from examination of 10 studies of Valsalva’s maneuver (pushing while breath-holding) that practice should be discontinues because of negative effects on fetal heart and perineum. All forms unlikely to beneficial included routine directed pushing, pushing by sustained bearing down and breath-holding.

  1. Third stage of labor: expulsion of the placenta

 

Third Stage of Labor: Delivery of the Placenta

Typically lasts 1-30 min; its shorter and less painful than earlier stages. Begins with birth of baby and ends when placenta is delivered.

After baby is born, contractions stop briefly, then resume with purpose of separating placenta from uterine wall. They are typically less intense than those before baby’s birth, may still need to use relaxation techniques and rhythmic breathing. May be so engrossed in baby that don’t feel contractions. Caregiver will probably direct you to give a few small pushes to deliver placenta. May appreciate seeing placenta afterwards as its an amazing organ that allowed your baby to thrive in the womb.

 

Third Stage Management: The Placenta – 3rd stage begins following birth of baby and ends w delivery of placenta. Placental separation follows a predictable pattern. Initially strong contractions lead to thickening of uterus, which results in shearing off, eventual separation and then finally expulsion of placenta.

Signs of placenta separation include: uterus rising in maternal abdomen, uterus changing shape from discoid to globular, umbilical cord lengthening and small gush of blood flowing from mother’s vagina.

Average duration 3rd stage: 5-10 min w risk of postpartum hemorrhage increasing beyond 30 min.

 

3rd stage of labor lasts from birth of baby until placenta is expelled.

Goal is prompt separation and expulsion of placenta, achieved in easiest, safest manner. Shortest stage of labor. Placenta is usually expelled within 10-15 min after birth of baby. if hasn’t been completed w in 30 min, placenta is considered to be retained and interventions to hasten its separation and expulsion are usually instituted.

Placenta is attached to decidual layer of basal plate’s thin endometrium by numerous fibrous anchor villi. After birth of fetus, strong uterine contractions and sudden decrease in uterine size cause placenta site to shrink. This causes anchor villi to break and placenta to separate from its attachments. Normally, first few strong contractions that occur after baby’s birth cause placenta to shear away from basal plate. A placenta cannot detach itself from a flaccid (relaxed) uterus because placental site is not reduced in size.

Placental Separation and Expulsion – depending on preference, midwife will use passive or active approach. Passive management involved patiently watching for signs that placenta has separate from uterine wall spontaneously and monitoring for spontaneous expulsion. This is commonly practiced in U.S. Active management practiced in many countries; includes administering oxytocic (Pitocin) when anterior shoulder is birthed or immediately following birth of fetus, clamping and cutting cord within 3 min after birth, and gently controlling cord traction following uterine contraction and separation of placenta. WHO and evidence based literature now recommends active management because it decreases rate of postpartum hemorrhage caused by uterine atony.

Woman is instructed to push when signs of separation have occurred. Woman should expel placenta during uterine contraction. Alternate compression and elevation of the fundus along with minimal, controlled traction on umbilical cord may also be used to facilitate delivery of placenta and amniotic membranes. Oxytocics usually administered after placenta is removed when active management of 3rd stage is not implemented because they stimulate uterus to contract, thereby helping to prevent hemorrhage.

Whether placenta first appears by its shiny fetal surface (Schultze mechanism) or turns to show its dark roughened maternal surface first (Duncan mechanism) is of no clinical importance.

After placenta and amniotic membranes emerge, OB examines them for intactness to ensure no portion remains in uterine cavity. Nurse will obtain sample of blood from umbilical cord to be used for determining baby’s blood type and Rh status.

Physician examines woman for any perineal, vaginal or cervical lacerations requiring repair. Nurse may need to assist by providing adequate lighting. If an episiotomy was performed, it will be sutured. Immediate repair promotes healing, limits residual damage and decreases possibility of infection. Woman usually feels some discomfort while OB carries out postbirth vaginal examination. Baby nurse performs quick assessment of newborn’s physical condition and places matching ID bands on mom and baby. weighing baby, eye prophylaxis, vitamin K injection can be delayed until after initial bonding time.

After any necessary repairs, cleanse vulvar area with warm water or normal saline, and apply perineal pad or ice pack to perineum. Reposition birthing bed and lower woman’s legs simultaneously from stirrups. Removed any drapes and place dry linen under woman’s buttocks. Provide her w clean gown and blanket, warmed if needed.

Some women have cultural beliefs about placenta, viewing care and disposal as way of protecting newborn from bad luck and illness. In Spanish its referred to as el companero. Request to take home sometimes conflicts with health care agency policies, esp those related to infection control and disposal of biologic wastes. Many cultures follow specific rules regarding disposal (burning, drying, burying, eating), site for disposal (in/near home) and timing of disposal (immediately after birth, time of day, astrologic signs). Disposal rituals may vary according to gender of child and length of time before another child is desired. Some cultures believe eating it is a way or restoring moms health after birth or ensuring high quality breast milk.

 

Nursing Care in 3rd Stage

Assessment

Signs That Suggest Onset of 3rd Stage

  • Firmly contracting fundus
  • Change in uterus from discoid to globular ovoid shape as placenta moves into lower uterine segment
  • Sudden gush of dark blood from introitus
  • Apparent lengthening of umbilical cord as placenta descents to introitus
  • Finding of vaginal fullness (placenta) on vaginal or rectal examination or of fetal membranes at introitus

Physical Assessment

  • Every 15 min: maternal bp, pulse and respirations
  • Signs of placenta separation and amount of bleeding
  • Assist w determination of Apgar score at 1 and 5 min after birth
  • Maternal and paternal response to completion of childbirth process and reaction to newborn

Interventions

  • Assist to bear down to facilitate expulsion of the separated placenta
  • Administer an oxytocic medication as ordered to ensure adequate contraction of uterus, thereby preventing hemorrhage
  • Provide nonpharmacologic and pharmacologic comfort and pain relief measures
  • Perform hygienic cleansing measures
  • Keep mother/partner informed of progress of placenta separation and expulsion and perineal repair if appropriate
  • Explain purpose of medications administered
  • Introduce parents to baby and facilitate attachment process by delaying eye prophylaxis; wrap mom and baby together for skin to skin
  • Provide private time for parents to bond w new baby; help create memories
  • Encourage breastfeeding if desired

 

4th stage of labor – first 1-2 hrs after birth; crucial time for mom and newborn. Maternal organs undergo initial readjustment to nonpregnant state and functions of body systems begin to stabilize

in most hospitals mother remains in labor and birth area. In traditional settings, women taken from delivery room to separate recovery rom. In many settings, baby remains with mother. In other institutions the baby is taken to nursery for several hrs of observation after initial bonding w parents, siblings and other family members.

Assessment – if recovery nurse has not previously cared for new mother, gets oral report from nurse who did and review of parental, labor and birth records. Of primary importance are conditions that could predispose mom to hemorrhage, such as precipitous labor, a large baby, grand multiparity (5+ previous births), induced labor. For healthy women, hemorrhage is most dangerous potential complication during this stage. ACOG recommends bp and pulse be assessed every 15 min for first 2 hrs after birth. Temperature assessed every 4 hrs for first 8 hrs and then every 8 hrs.

Post anesthesia Recovery – cesareans or regional anesthesia require special attention. PAR score determined for each women on arrival and update as part of every 15 min assessment. components include activity, respirations, bp, level of consciousness and color.

She should be awake and alert and oriented to time, place and person. Respiratory rate should be within normal limits and her oxygen saturation at least 95%. Should be able to raise, legs, extended at knees, off bed, or flex her knees, place feet flat on bed, and raise her buttocks well off bed. Numb or tingling, prickly sensation should be entirely gone from legs. Length of time required to recover varies; often it takes several hrs to disappear completely.

 

Physiological 3rd stage and neonatal transition – cord issues dominate recent thinking on neonatal transition physiology. Delaying cord clamping up to 2 min in preterm infants associated w less need for transfusion and less intraventricular hemorrhage. These babies may also be less prone to respiratory distress syndrome. Delaying in term infants can provide an additional 30% extra blood and up to 60% more red blood cells; this allows baby to start extra uterine life w peak hematocrit, hemoglobin and ferritin levels, less anemia, better perfusion of vital organs, better cardio pulmonary adaptation and increased duration of breastfeeding.

Successful neonatal transition dependent upon newborn having an adequate blood volume to recruit the lung for respiratory function through capillary erection and an adequate red cell volume to provide enough oxygen delivery to stimulate and maintain respiration. Usually complete within 3 minutes of birth. Immediate crying efforts are not effective at gaseous exchange within the lungs because blood flow has not had time to initiate capillary erection.

Mammalian birth always includes a rest period after the birth when the cord is left alone. One min Apgar score is not useful for assessing respirations because this may take up to 3 min to be established. No-touch technique combines with warm water medium combine to make babies often peaceful and quiet at birth.

Cutting cord early is effectively starving baby of oxygen seems an unnecessarily aggressive and harsh method of facilitating neonatal transition and of welcoming a new baby.

Cutting cord on ‘flat’ baby so that resuscitation can take place on a resucitaire should be challenged. It makes no sense at all to cut this lifeline when the baby is already compromised. The placenta is a resuscitative organ and it should be harnessed for this purpose.

Stress importance of not disturbing the immediate post-birth period when optimum hormonal conditions exist for bonding. Endorphins are at high levels in both mother and baby, contributing to the baby’s alertness and the mother’s attentiveness. In the mother, an oxytocin surge is triggered to contract the uterus and help separate the placenta. This surge is augmented by skin to skin contact and breast-suckling. The drop in circulating catecholamines at birth facilitates oxytocin secretion which is more likely to be inhibited if the immediate post-birth period is disturbed and hurried. Time pressures on birthing rooms. Post-birth tasks of checking, weighing, administering drugs and dressing baby all have to be completed, along with readying mother for transfer out. The ‘luxury’ of allowing an undisturbed 30-60 min post-birth bonding time would be difficult to achieve.

Language games – there is a chance of hemorrhage if we leave 3rd stage happen naturally. With injection, it will be quicker and cleaner. Or if the rest of the labor is normal, it is worth considering a normal 3rd stage. There may be a little more bleeding but you can have uninterrupted time with your baby and no drugs.

Some found shorter and less bleeding with natural 3rd stage rather than active management.

Practice Recommendations:

  • A physiological approach is the appropriate care when labor is normal
  • If an active approach is chosen, then syntocinon ten units is the uterotonic of choice
  • There may be advantages in delaying administration of uterotonic until after birth of placenta, but this requires more research.

Key Points:

  • Rhythmic nature of 2nd stage – change body positions, bear down spontaneously and vocalize when perceives urge to push.
  • Bear down several times during contraction using open-glottis pushing method; avoid closed-glottis pushing because inhibits oxygen to fetus
  • Nurses roles is advocate to prevent routine episiotomy
  • Objective signs placenta separated and ready to be expelled; excessive traction on cord can result in maternal injury
  • 4th stage – woman’s fundal tone, lochial flow and vital signs assessed frequently
  1. Newborn transition
  2. Physical transitions of the newborn

 

Overview of the Normal 3rd and 4th Stages of Labor for Unmedicated Mother and Baby – 3rd stage encompasses both delivery of placenta and baby’s enormous physiologic shift from complete in utero dependence on placenta to dependence on herself. She takes over task of taking in and using oxygen and food, adapting to new surroundings and regulating own temp and all life functions. First breath and cry due to stimulation and stress caused by labor contractions.

During first minutes after birth, she inflates her lungs and they will never deflate for the rest of her life. Now that lungs have taken over as her organs of respiration, her circulation is rerouted and her heart is restructured so that soon all her blood will circulate through her lungs to pick up the oxygen needed throughout her body. Skind tones become ruddy due to increased oxygenation of blood. Soaking wet and streaked with blood, mucus, amniotic fluid and vernix. Body – at first very warm to touch, begins to lose heat, which challenges her underdeveloped temp-regulating system and with help from person who wipes her dry and warmth from mother’s body, she stays warm.

After 15-30 min, she becomes active, crawling in a rudimentary way, brings hands to mouth, bobs head up and down and side to side and shows interest in finding breast. Guided by scent and other mysterious knowledge, she works toward 1 berast. She knows when she reaches destination and opens mouth.

As uterus contracts to expel placenta, cocktail of hormones floods body to give her what she needs to make shift. 4th stage – beginning after birth of placenta, and lasting 1-2 hours referred to as recovery or stabilization stage for mother.

Oxytocin is at high levels, endorphins are flowing which give mother high spirits and feelings of love and gratefulness. They also help override fatigue, pain and discouragement she may have felt earlier.

Baby’s squirming on abdomen stimulates uterus to contract and expel placenta. Once baby begins nuzzling and suckling at breast, oxytocin flows and helps her uterus contract and stimulates pituitary gland to secrete prolactin, the key to production of breastmilk.

If delicate hormonal interaction and mutual regulation between baby and mother are postponed, rushed, disturbed, altered with medications or interrupted by surgery, they may not resume as smoothly later, when delay is over. Chances increase for emotional stress for mom/baby, more crying by baby, temp drops in baby, poorer uterine muscle tone, challenges in initiation of breastfeeding and increased need for medical interventions.

Third Stage Management: Care of the Baby (see above)

  1. Transition from placental respiration to pulmonary respiration

YouTube: Baby Circulation Right After Birth (13:24 KhanAcademyMedicine)

2 Huge Changes after birth:

  • Placenta removed
    1. Clamp cord (umbilical cord does not have nerves so does not hurt mom/baby; Wharton’s jelly starts squeezing around vessels as soon as temp falls (a natural clamp vs manmade clamp).
    2. Low resistance to high resistance
  • Lungs take in air (pushes fluid out into capillaries)
    1. High resistance to low resistance

Adaptations:

  • Umbilical vein- first few days
  • Ductus venosus – first few days
  • Foramen ovale closes– first few minutes
  • Ductus arteriosus- (when prostaglandins decrease or oxygen levels increase, ductus arteriosus closes) closes first few hours
  • Umbilical artery – first few hours

 

  1. Physiologic cord clamping

YouTube Penny Simkin On Delayed Cord Clamping – good reason to wait for 2 min if not until cord stops pulsating. Volume of blood shared (450 mL; about a water bottle full). Amount of blood in baby’s body – ½ water bottle or 300 mL). amount of blood remaining in placenta.

If cut immediately after birth, baby shy 1/3 of total blood volume. In 2 min, 70% of placenta blood will transfer. If wait until cord stops pulsating, all blood will be transferred. Even in cases where baby has to be resuscitated or baby has meconium, many suggest cord remains intact and resuscitation takes place with baby attached to mother.

Some believe added RBCS (extra blood) causes jaundice, but studies show not true.

 

Clamping and Cutting Baby’s Umbilical Cord

Soon after birth, baby’s umbilical cord is clamped, then cut with scissors. Partner may cut cord.

Timing of cord clamping and cutting affects baby’s blood volume. Before birth, baby’s blood circulates via cord to and from placenta. At birth, 1/3 or more of baby’s blood is in placenta, but over first few minutes, it transfers to baby. Blood vessels in cord gradually compress by a substance called Wharton’s jelly, which expands when cord is exposed to air. If cord is clamped immediately, baby doesn’t receive a large portion of his blood from placenta. Delayed clamping until cord stops pulsating allows baby to receive as much blood as possible. Some blood remains in placenta after pulsation stops.

For ears, OBs taught placental blood is extra and if it go to baby, could lead to jaundice. Belief has been disproved. Delayed clamping benefits baby by helping increase blood levels of iron and reduce anemia at ages 2 months and 6 months. May also hasten separation and delivery of placenta by decreasing its size.

Baby is placed on mothers abdomen until cord stops pulsating. Holding baby high above or low below mother may alter speed of transfer of blood, but mother’s abdomen is most appropriate.

For a baby who needs medical attention or resuscitation, these procedures can often be carried out with cord intact so baby continues to benefit from oxygenated blood transferring to him.

Discuss delayed cord clamping and cutting with caregiver and put in birth plan.

Collection and storage of umbilical cord blood – blood in umbilical cord is a rich source of stem cells, which generate and continually renew supplies of red cells, platelets and white cells. Stem cells make it possible for a person to use oxygen, clot blood and fight infection. Those found in umbilical cord blood are easier to match to another person tissue that the more mature stem cells found in bone marrow. Can help treat people with immune deficiencies, severe inherited anemia and childhood leukemia and other cancers. Also used in search fro cures of these diseases. Accomplished within 10 min after birth. Its separated from blood in lab and stored in blood bank for use by public or in private storage facility for later use, if needed, by child/family.

AAP encourages parents to donate cord blood to public and cautions against using private cord blood banks since most conditions the cells may help treated (such as precancerous changes and genetic abnormalities) already exist in baby’s cord blood, which means her store cord blood stem cells wont help treat condition if she develops it later. Private storage also expensive. Publicly donated blood tested for disease and genetic abnormalities.

 

“Microbial seeding” – increasing scientific evidence supports the critical importance to the healthy development of the immune system of the “microbial” seeding” that takes place as the baby passes through the birth canal during vaginal birth. This process is further enhanced by skin-to-skin contact and breastfeeding. Research is underway looking at ways of providing babies born by cesarean with “microbial seeding”. The 2014 film MicroBirth powerfully describes it.

Delayed Cord Clamping – in their book Optimal Care in Childbirth, Henci Goer and Amy Romano describe the important role of delayed cord clamping in aiding the transformation from fetal circulation to air breathing in the newborn. For a newborn who does not require emergency resuscitation, research now indicates that delaying cord clamping for 2-3 min (or more) aids this transition, poses no harms, and may improve iron stores for up to 6 months of age. According to a 2013 Cochrane Review, “a more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early hemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.” A 2014 study published in Lancet reassures health care providers that the benefits of delayed cord clamping still hold true when the baby is placed immediately on the mother’s chest after birth. Penny Simkin effectively demonstrates the benefits of delayed cord clamping in a YouTube video clip.

Models:

  • Baby Blockhead – you can use this to show students why the baby must rotate for the birth to occur. The wider diameter of the pelvic inlet, then outlet, matches the wider diameter of the baby’s head, then shoulders, as the baby rotates through the pelvis. It becomes evident that this process will require time, even after the cervix has fully dilated (these models are no longer for sale).
  • Pelvic model and fetal model– demonstrate the cardinal movements as the baby descends, flexes, rotates internally, extends and finally rotates externally (2 pelvic models that allow the bones to give as demonstrate cardinal movements are available from ICEA or Childbirth Graphics).

Practice – because the emphasis today is on encouraging the laboring woman to tune into her body’s signals and to bear down spontaneously, there is not a lot of pushing practice that needs to be done in childbirth classes. However, a variety of positions with discussion of the benefits of each should be practiced, so that the laboring woman will feel comfortable using them during 2nd stage.

 

c. Meconium

Assessing the Fetus – most of time, term fetus of otherwise healthy woman tolerates prolonged or dysfunctional labor well. When signs of fetal compromise are present, resolving distress becomes paramount. Fetal Heart Rate, gestational age and presence/absence of meconium in amniotic fluid are elements of fetal assessment.

Fetal Heart Rate – primary source of info about fetal well-being during labor is FHR and fetus’ response to contractions.

 

Gestational Age – both preterm and post-term fetuses more vulnerable to stress of labor.

With premature fetuses:

  • Decelerations of FHR more ominous
  • Additional risk to fetus may be related to etiology of preterm labor (infection or placental abruption)

With post-term fetuses:

  • There are increased risks of oligohydramnios, meconium passage, meconium aspiration syndrome and cord compression. Increased likelihood of macrosomia, with its attendant labor risks (cephalopelvic disproportion and malposition)
  • Some studies have also found a positive association between postdates and shoulder dystocia. Other studies have not confirmed this associated, except when there is macrosomia
  • There is increased risk for placenta insufficiency, resulting in growth restriction and higher rates of stillbirth

Meconium: fetus may pass meconium in utero when there is a brief episode of hypoxia that causes relaxation of anal sphincter. May indicate a compromise in fetal oxygenation. However, it is more often a normal maturational event, occurring more frequently as gestational age reaches and exceeds 40 weeks; and in 35%-50% of all post-term pregnancies

Should be considered a sign of fetal compromise if it is:

  • Associated with a nonreassuring FHR pattern
  • Associated with maternal fever or other signs of infection
  • Thick, dark colored, or particulate (containing discrete pieces or chunks)

Consultation: midwives who attend out of hospital settings consider following fetal conditions to be indications for intrapartum consultation and/or transfer to hospital:

  • Nonreassuring FHR assessment
  • Gestational age less than 37 weeks
  • Gestational age > 42 weeks
  • Significant (dark, thick or particulate) meconium in amniotic fluid

 

When Progress in Prelabor or Latent Phase Remains Inadequate –

  • Therapeutic rest – either augment labor or address exhaustion. Assuming all else is normal and latent labor is not progressing, may use medications to give “Therapeutic rest”. Goal is sleep rather than analgesia
  • Nipple stimulation– can be used to augment labor when contractions are inadequate. When cervix was favorable and breast stimulation was compared to no intervention, # of women not in labor by 72 hors was significantly reduced. Also significantly lower rate of postpartum hemorrhage. No significant differences in rates of cesarean birth, meconium-stained amniotic fluid or hyperstimulation of uterus. When breast stimulation was compared with oxytocin, no significant differences were found on outcomes of labor initiation by 72 hours, cesarean rate or meconium-stained fluid. Should not be used in high risk women until further research verifies safety.
    • While it appears to be beneficial in initiating labor, protocols vary. 1 says use electric breast pump unilaterally for 15 min on each breast. Alternatively, women can use manual stimulation or electric breast pump unilaterally (on lowest setting) for 10 min, followed by 5 min of rest. Repeated up to 4x or until contractions are less than 3 min apart. Stop nipple stimulation if a contraction occurs or to simulate nipples only between contractions. No evidence for efficacy of one protocol over another

 

2nd Trimester Changes for You and Baby – “development” period – baby’s organs and structures begin to enlarge and mature.

15th-27th Week

  • Changes in Baby: baby starts to grow hair, eyelashes and eyebrows. Lanugo develops on arms, legs and back. Fingernails and toenails appear. 18 weeks, baby can do all movements you’ll see her do as a newborn. Forming in baby’s intestines is meconium, collection of digestive enzymes and residue from swallowed amniotic fluid; won’t expel til after birth. Skin is wrinkled and covered in vernix caseosa. Feel baby move for first time (quickening). Light tapping/fluttering sensation that reminds you of gas bubbles. Some babies born at end of this trimester (25 weeks) survive. 23 weeks – heartbeat audible via regular stethoscope. 27 weeks eyes are open, begins to hear.
  • Changes in Placenta/Uterus – uterus expands into abdominal cavity to accommodate growing baby. length of pregnancy in weeks approximates distance in centimeters between pubic bone and top of uterus (fundus).   Uterus normally contracts periodically, although wont notice. Braxton hicks contractions make uterus hard for ~1 minute but aren’t painful; don’t cause changes in cervix.
  • Changes in You – milk glands in breasts begin making small amounts of colostrum by mid-pregnancy. Linea nigra may appear between pubic bone and navel. Skin around eyes may darken, especially after sun exposure; mask of pregnancy called chloasma usually disappears within a few weeks after baby’s birth.   Groin pain from round ligament contractions. Leg cramps.
  • Emotions – more sensitivity to kind word, beautiful sunset or touching photo. May affect sleep, recall more of dreams and may become introspective, distracted by need to examine thoughts and feelings. Swelling belly becomes more obvious; feel baby kick or wiggle. Being able to see evidence gets partner more involved.

Evaluating Your Amniotic Fluid – When membranes rupture, appearance of amniotic fluid can indicate baby’s condition. Normal fluid is clear and has slightly fleshy odor. If has strong odor of old fish, may have infection. If green/dark, baby has expelled meconium from bowels, which may indicate she’s stresses; occurs in 20% of labors. Caregiver will observe baby’s heart rate frequently to assess well being.

When researching caregiver and birthplace, ask about protocol for treating a newborn who has expelled meconium during labor. Many suction baby’s nose, mouth and trachea when head is born and before first breath. Belief is that suctioning prevents baby from inhaling meconium thereby preventing breathing problems or a rare type of pneumonia called meconium aspiration syndrome. Research hasn’t found that aggressive suctioning prevents meconium aspiration syndrome. Instead, suctioning seems to cause abrasions in membranes of baby’s nose and mouth.

 

Concerns About Baby’s Well Being – Most healthy full term babies get a better start in life if undergo labor. Contractions jump start many processes that improve a baby’s transition to life outside womb, such as breathing, temperature regulation, alertness and suckling.

During a contraction, amount of oxygen that’s available to baby varies. Most babies compensate for this variation well, but a few cant and instead show signs of distress. EFM of heart rate patterns indicates they’re not getting optimal amount of oxygen during contractions. Can be described as nonreassuring fetal heart rate, fetal intolerance of labor or fetal distress.

Presence of meconium in amniotic fluid may indicate a baby that isn’t compensating well for the varying amount of available oxygen during contractions. When a baby’s oxygen supply is low, her intestines cramp to send oxygen rich blood to other areas that need oxygen most (brain). Cramping causes meconium to pass from intestines, giving fluids normal clear color a brownish or greenish tint (if a lot of meconium, can be dark brown or black). When a woman’s bag of water breaks, caregiver notes presence of meconium and assesses baby health.

EFM and presence of meconium don’t always identify oxygen-deprived babies, some caregivers wont hesitate to take measures if assessment indicates distress.

What you can do if baby has nonreassuring heart rate pattern – need professional help to resolve. Follow caregivers requests to change positions, and breathe deeply; these measures are often enough to restore baby’s heart rate to normal.

Medical care for babies in distress during labor – sometimes problem resolves itself without intervention. If baby is pressing on umbilical cord and constricting flow of oxygen rich blood, he may shift position so he moves off the cord, thereby restoring normal blood flow.

If intervention is necessary, there are several options to restore a baby’s heart rate to normal. May breathe oxygen by mask and change your position to increase baby’s heart rate. If Pitocin causing too intense contractions, dose can be reduced.

 

How Your Body Makes Breast Milk – Prolactin and oxytocin are 2 hormones that play a significant role in milk production and milk ejection (flow). When baby suckles at breast, action stimulates anterior pituitary gland in brain to release prolactin into bloodstream. Prolactin causes cells in alveoli to draw water and nutrients from blood to make milk. Baby’s suckling (or crying) also prompts posterior pituitary gland to release oxytocin. Oxytocin makes the muscle around milk-producing cells contract and expel milk. Makes ducts widen and shorten, helping with milk flow. Process is called let down reflex.

You have 2 or more let downs from each breast during each feeding. In first weeks after birth, let down might not occur until several minutes after baby has begun suckling. After good breastfeeding relationship, let down occurs within seconds.

Let down sensations vary widely. During first few days, might not feel milk let down. Afterward, still might not feel it or might feel tingling, itching, or flowing sensation. If don’t feel it, you’ll know it occurred when hear baby swallow, see milk in his mouth or feel uterine cramping.

Frequency and duration of feedings strongly affect milk supply. More your baby suckles and drains breast, more milk you produce.

Make less milk if delay/limit feedings, use pacifier or offer supplements (formula, water or other liquids) or schedule baby’s feedings to every 3-4 hours. A protein in breast milk called feedback inhibitor of lactation (FIL). When breast is full, FIL slows milk production. When baby frequently drains breast, there is less FIL and milk production increases.

Feed baby frequently for as long as he wants.

  1. APGAR Score

 

Newborn Assessment with Apgar Score – within 1 min after birth and again at 5 min, caregiver evaluates well being of baby. as soon as baby is dried off and breathing, considers 5 factors and gives score of 0-2 points for each one. 7-10 score indicates baby is in good condition. 6 or less means baby needs additional medical attention and observation.

Apgar score can be done while you hold baby. Babies seldom receive a 10 on first score (most babies hands and feet are bluish for a while). If score less than 6, baby may be taken to baby warmer in birthing room for stimulation or oxygen. 2nd score usually higher than first. Score cant predict baby’s overall health or long term well being. Newborn exam will be given within 24 hours of birth to more accurately assess baby’s condition.

Sign: 0 points/1 point/2 points

HR: Absent/Fewer than 100 bpm/ more than 100 bpm

Respiratory Effect: Absent/ slow, irregular/ good crying

Muscle Tone: Limp/ Arms and Legs flexed/ Active movement

Reflex irritability (baby’s reaction to something placed in her nose): No response/ Grimace/ Sneezing, coughing, pulling away

Skin Color: bluish-gray, pale all over/ normal skin color, except bluish hands and feet/ normal skin color all over

General appearance of newborn – neonate’s maturity level can be gauged by assessing general appearance. Posture, activity, any overt signs of anomalies that can cause initial distress, presence of bruising or other birth trauma and state of alertness. Normal resting position is one of general flexion.

 

Apgar Score (Score 0/1/2)

  • HR – absent/ slow (<100/min)/ >100 min
  • Respiratory effort– absent/ slow, weak cry/ good cry
  • Muscle tone – flaccid/ some flexion of extremities/ well flexed
  • Reflex irritability – no response/ grimace/ cry
  • Color– blue, pale/ body pink, extremities blue/ completely pink

Vital Signs – temp, HR and respiratory rate always obtained. BP not routinely assessed unless cardiac problems suspected. Irregular, very slow or very fast HR can indicate need for further evaluation of circulatory status.

Axillary temp is safe, accurate measurement. Temporal artery, tympanic and oral routes not considered accurate. Taking temp can cause infant to cry. Normal axillary temp averages 98.6F with range from 97.7 -99.5. Rectal temps should not be done because of risk of perforation

Respiratory rate varies w state of alertness and activity after birth. Respirations are abdominal in nature and can be counted by observing or lightly feeling rise and fall of abdomen. Neonatal respirations are shallow and irregular. Should be counted for a full minute to obtain accurate count because there are periods when respirations can cease for seconds (<20) and resume again. Avg respiratory rate 40 BPM but will vary 30-60; can exceed 60 if newborn very active or crying.

Apical pulse rate should be obtained on all newborns. Auscultation should be for a full min, preferably when infant asleep or in quiet alert state. Normal HR 110-160 BPM when infant awake. Common to detect brief irregularities in hear rate. Varies with behavior state. Bradycardia is HR less than 100 BPM. Infant in deep sleep can have HR In 80s or 90s; rate should increase when infant awakens. Tachycardia is HR exceeding 160 BPM. Not unusual for crying infant to have HR greater than 160 but should decrease when crying ceases.

If BP is measured, osciollometric monitor calibrated fro neonatal pressures preferred. BP highest immediately after birth and falls to min by 3 hrs after birth. Then begins to rise steadily and reaches plateau between 4-6 days after birth. Usually equal to that immediately after birth.  Varies with activity; accurate measurement best when infant at rest. Varies w gestation and chronologic age. Systolic pressure avg 60-80 MmHg; diastolic avg 40-50; mean arterial pressure should approx. weeks of gestation. Upper extremity >15 than lower, infant may have cardiac defect such as coarctation of aorta.

 

Initial Physical Assessment of Newborn

  • General Appearance: color ink, acrocyanosis present; flexed posture; alert; active
  • Respiratory system: airway patent; no upper airway congestion; no retraction sor nasal flaring; resp rate 30-60 BPM; lungs clear to auscultation bilaterally; chest expansion symmetric
  • Cardiovascular system: HR >100 BPM; strong and regular; no murmurs heard; pulses strong and equal bilaterally
  • Neurologic system: moves extremities, normotonic, symmetric features, movement; reflexes present: sucking, rooting, moro, grasp; anterior fontanel soft and flat
  • Gastrointestinal system: abdomen soft, no distention; cord attached and clamped; anus appears patent
  • Eyes, nose, mouth: eyes clear, palate intact, nares patent
  • Skin: no signs of birth trauma, no lesions/abrasions
  • Genitourinary system: normal
  • Other: no obvious anomalies

Significance of Apgar – designed to be used for limited time frame. Affected by factors such as gestational age, maternal medications, trauma, congenital anomalies, hypovolemia and hypoxia

Term gestation/breathing/crying/good tone -> Yes; stay with mother for routine care: provide warmth, clear airway if necessary, dry, ongoing evaluation

If not -> warm, clear airway if necessary, dry, stimulate, HR below 100, gasping or apnea -> PPV, SPO2 monitoring -> take ventilation corrective steps; if HR below 60 -> consider intubation, chest compressions, coordinate w PPV -> IV epinephrine (consider hypovolemia, pneumothorax)

Targeted Preductal SPO2 after birth

  • 1 min: 60-65%
  • 2 min: 65-70%
  • 3 min 70-75%
  • 4 min 75- 80%
  • 5 min 80-85%
  • 10 min 85-95%

 

Current evidence base of electronic fetal monitoring (EFM) – compared to intermittent auscultation, continuous CTG showed now significant difference in perinatal death but was associated with a halving of neonatal seizures. There was a significant increase in cesareans and assisted vaginal births in continuous group. There were no differences in Apgar scores, neonatal admissions or hypoxic ischemic encephalopathy.

Using #s needed to treat method, one neonatal seizure might be prevented in every 660 cases if all women were continuously monitored. This has to be balanced against the much greater risk of emergency cesarean (1/58 women).

The results have shaped national and local guidelines, which pretty universally recommend continuous CTG for high-risk groups. Does not show any difference in perinatal death and cerebral palsy even in high-risk group. One trial in preterm labors found higher rates of cerebral palsy in latter group and only other study that examined the 2 methods in high-risk women showed no differences in outcome.

Some maternity unites allow intermittent auscultation in particular groups such as induction of labors that don’t require syntocinon. Those who had previous cesareans found a higher vaginal birth rate in intermittent group and higher rates of cesarean for non-reassuring CTG in continuously monitored group without any impact on perinatal outcome.

Makes no sense to install very expensive central bank monitoring system where individual women’s traces can be viewed centrally. Yet many labor wards across the world have invested in this technology.

ESNLB 110 Time and fetal health – many OBs believe direct link between length of 2nd stage and fetal health and this primarily drives time restrictions on 2nd stage

Examined 25k women and found length of 2nd stage not associated with low Apgar scores or neonatal unit admissions. 6000 nulliparous women – some who had 2nd stages lasting longer than 5 hours and concluded non increase in low 5 min Apgar scores, neonatal seizures or neonatal unit admission. No association between length of 2nd stage and neonatal morbidity. Some found links to maternal morbidity such as infection and bleeding, but these were explained by labor practices or 1st stage factors.

2 papers that suggest neonates might be at more risk form long 2nd stages. Those whose 2nd stages were longer than 3 hours, babies at greater risk. Babies exposed to long 2nd stages had lower 5 min Apgars and more admission to neonatal units. Both confounded by high rates of epidural in samples. Maternal outcomes, principally postpartum hemorrhage, assisted vaginal birth, infection and perineal trauma were worse in this group. Some of maternal outcomes can be explained by compounded effects of more forcep births.

In summary, long 2nd stage has links with some maternal morbidities but link w fetal compromise more speculative. Some evidence when presenting part is on pelvic floor, fetal lactic acid begins to accumulate and this may be reflected in deterioration in fetal heart patterns.

2nd stage of labor does not need to be terminated for duration alone but on individual assessment of mom/baby in each case. Encourage upright posture and spontaneous pushing, both of which will optimize fetal/maternal health.

 

Psychosocial benefits – In UK, water immersion guidelines require continuous presence of midwife, although rationale unclear. No particular risks with water immersion. . some guidelines state that water immersion is not recommended before 5 cm dilated but study challenged notion that labor might slow if woman entered pool before 5 cm. trial involving nulliparae who had primary dystocia found that water immersion resulted in less use of augmentation and a shorter labor. No rational for differentiating between a bath and birthing pool for water immersion.

  1. Skin to skin advantages

 

The new baby and the importance of immediate skin-to-skin contact – celebrate the birth of the baby! if the new parents have chosen not to find out the sex of the baby ahead of time, encourage them to ask their caregiver to allow them to announce the sex of their new son or daughter.   Describe the appearance of the baby at birth; explain the Apgar score. Emphasize that immediate skin-to-skin contact with the mother helps to stabilize the baby’s temperature, heartbeat, and respiration. Because of catecholamines secreted by the mother during 2nd stage, most babies are born wide awake and eager to look into their parents’ eyes. Many babies will search for the familiar deep voice of their fathers in the birthing room. Skin-to-contact also increases the flow of birth hormones that aid breastfeeding and attachment. It is especially important for women who have cesarean delivers or births with many interventions.

Swedish breastfeeding researcher Ann Marie Widstrom has identified 9 instinctive stages that a baby moves through when placed skin-to-skin on his mother’s belly immediately after birth. Left undisturbed, the baby will gradually make his way to the breast to self-attach. This can take as long as 90 min. Dr. Widstrom believes that if a baby is allowed to move through these 9 phases without being “helped,” he is very likely to be successful at breastfeeding. Students who have learned about the 9 instinctive stages in their childbirth classes are fascinated to watch their own babies move through these phases. As long as the baby is healthy, even cesarean mothers can experience the same uninterrupted skin-to-skin contact immediately after birth. If the hospital(S) where your students will be giving birth do not offer this option, bring the research and DVDs to the attention of the nursing staff.

 

Restoration and Recovery – for breastfeeding to succeed, the newborn must have access to mom many hours a day; be able to cue for feeds; and suck, swallow and breathe in a coordinated pattern. Mom’s body must heal and recover; her breasts must make milk and she must be supported in her close, frequent-contact relationships with her baby. BFHI’s (Baby Friendly Hospital Initiative) supports evidence based care of exclusive breastfeeding for 6 months followed by breastfeeding with appropriate complementary foods for 2 years or beyond.

The 3 most important and urgent post-birth strategies to support breastfeeding are 1) skin-to-skin 2) skin-to-skin and 3) more skin-to-skin. Separating the mother-baby dyad for any reason except resuscitation is unjustified and harmful to both.

AAP says baby should be placed immediately after delivery on mom’s chest until first feeding is accomplished. The alert, healthy newborn is capable of latching on to a breast without specific assistance within the first hour of birth…dry the infant, assign APGAR scores and perform initial physical assessment while infant is in skin-to-skin contact with mother. Mother is optimal heat source for baby. delay weighing, measurement, bathing, needle sticks and eye prophylaxis until after first feeding is complete.

Original Step 4 of 10 Steps to Successful Breastfeeding is “help mothers initiate breastfeeding within a half hour of birth”. Says to put baby for at least an hour and encourage moms to help baby if needed. Immediately is interpreted as within 1 min after birth, without placing the infant anywhere else first.

Newborns born with behavioral capability to breastfeed, regulated by limbic system of the brain. However, this capability is fragile, and requires uninterrupted presence of mother, with specific stimuli at early critical periods working to reinforce the inborn ability.

The simple action forms the foundation of neurodevelopment of the infant and mother. The mother’s body forms the baby’s habitat – the place where inborn behaviors can unfold normally. The mother’s body provides rich sensory input: auditory, gustatory, olfactory, proprioceptive, tactile and visual. Senses of smell and touch are esp powerful triggers of infant and maternal behavior, because the nerve fibers lead directly to the amygdala, the seat of emotional memory and fear conditioning. The newborn’s sense of smell is esp acute in the first hours, triggering breast-seeking behavior and movements. Washing or bathing mother or baby removes olfactory cues that support breastfeeding and attachment, and thus should be avoided. Bathing newborns shortly after birth increases risk of hypothermia, despite use of warm water and STS care for thermal protection of newborn.  Hypoglycemia increases risk of baby beging given unnecessary prelacteal feeds, which compromises initiation of breastfeeding.

Time immediately after birth – infant’s catecholamine levels are high, pupils are dilated, reflexes are keen, and newborn is in wide-awake, alert state. Newborns in skin-to-skin (STS) contact exhibit specific coordinated patterns of newborn hand and sucking movements and massage of mother’s breasts, crawl or scoot toward breast, and begin feeding effectively.

Skin-to-skin, ventral-to-ventral contact between mom and baby triggers a flood of hormonal changes, esp releasing oxytocin, which builds trust, fosters caregiving behaviors and memory, and releases milk to the newborn. Tactile contact increases gastrin secretion in mom and baby, promoting gastrointestinal motility and digestion.   Mom’s body and breasts will increase or decrease in temp to keep newborn appropriately warm. Thermal instability is a common reason for separating mom and baby and may cause or exacerbate hypoglycemia and result in inappropriate supplementation.

Mother’s position immediately after birth also matters. She should be assisted into a position of her choice to hold and examine baby. Primitive neonatal reflexes that stimulate breast-seeking and breastfeeding behaviors are highest when mother is in semi reclining (not supine) posture. 24 hr rooming in w safe bed sharing strongly supports breastfeeding. Newly delivered mothers can and should eat and drink a wide range of nutritious foods. Postpartum mothers can and should be offered pain-relieving medications for any surgeries or injuries sustained during birth, because most of theses compounds transfer poorly to human milk.

 

Make notation regarding parents reaction to newborn in recover record – how to parents look/what they say/do. Esp important if you notice warning signs (passive or hostile reactions to newborn, disappointment w gender or appearance of newborn, absence of eye contact, limited interaction of parents with each other.

Many parents need reassurance of dusky appearance of baby’s hands and feet immediately after birth; normal until circulation well established. Explain molding of head. Korean mothers believe head should not be touched because its most sacred part of person body. Hispanic moms believe too much praise or evil eye will cause illness, restlessness or excessive crying.

Key Points

  • Onset of labor may be difficult to determine for both nulliparous and multiparous women
  • Familiar environment of home most ideal place during latent phase of 1st stage
  • Nurse assumes much of responsibility for assessing progress of labor and keeping OB informed
  • Fetal HR and pattern reveal fetal response to stress of labor
  • Assessing laboring woman’s urinary output and bladder critical to ensure progress and prevent bladder injury
  • Couples perception of birth experience most likely to be positive if consistent w expectation, esp in terms of maintaining control and adequacy of pain relief
  • Woman’s level of anxiety may increase when she doesn’t understand what’s being said because of medical terminology or language barrier
  • Comfort measures encourage her to use energy constructively in relaxing and working w contractions
  • Progress of labor enhanced when changes positions frequently in 1st stage
  • Doulas provide continuous support that have positive effect on process of childbirth
  • Cultural beliefs can have significant influence
  • Siblings need preparation and support for labor and birth
  • Women with history of sexual abuse often experience profound stress and anxiety during childbirth
  • Inability to palpate cervix during vaginal examination indicates complete effacement and full dilation have occurred and is only certain, objective sign that 2nd stage has begun
  • Women may have an urge to bear down at various times during labor; for some it may be before cervix is fully dilated and for others it may not occur until active phase of 2nd stage of labor

 

Physical Care of High Risk Newborn – environmental support measures for preterm infant typically consists of following equipment and procedures:

  • Incubator or radiant warmer to control body temp
  • Oxygen administration, depending on infant’s cardiopulmonary and circulatory status
  • Electronic monitors as needed for ongoing assessment of respiratory and cardiac functions
  • Assistive devices for positioning infant in neutral flexion and w boundaries
  • Clustering of care and minimization of stimulation according to infant cues

Various metabolic support measures that can be instituted consist of following:

  • Parenteral fluids to help support nutrition and maintain normal arterial blood gas (ABG) levels and acid-base balance
  • IV access to facilitate administration of antibiotic therapy if sepsis is a concern
  • Blood work to monitor ABG levels, pH, blood glucose levels, electrolytes and status of blood cultures

Maintaining Body Temperature – high risk infant susceptible to heat loss and its complications. LBW infants can be unable to increase metabolic rate because of impaired gas exchange, caloric intake restrictions, or poor thermoregulation. Transepidermal water loss is greater because of skin immaturity in very preterm infants (<28 weeks) and can contribute to temp instability

Preterm infant should be transferred from birthing room in prewarmed incubator; ELBW infants can be placed in polyethylene bag to decrease heat and water loss. Skin to skin between stable preterm infant and parent viable option because of maintenance of appropriate body temp by infant

High-risk infants cared for in thermoneutral environment created by use of external heat source. Probe to an external heat source supplied by a radiant warmer or a servo-controlled incubator is attached to infant. Infant acts as thermostat to regulate amount of heat supplied by external source. Idealized environment maintains infants normal body temp between 97.9 and 99F. maintaining thermoneutral condition in youngest, most immature infants decreases need for them to generate additional heat, increasing physiologic stability and decreasing oxygen consumption.

 

Care of Hypothermic Infant – can appear pale and mottled; skin is cool to touch, esp extremities. Acrocyanosis and respiratory distress can occur as oxygen consumption increases in an effort to generate heat. As hypothermia worsens , infant can have apnea, bradycardia and central cyanosis.

When infant becomes hypothermic, rewarming should begin immediately by providing external heat. Rapid changes in body temp can cause apnea and acidosis. For infant w mild hypothermia, slow rewarming is recommended.   External heat sources should be slightly warmer than skin temp and increased gradually until infants temp is within range of NTE. For severely hypotermic infant (body temp less than 95F), more rapid rewarming needed. Use of radiant heaters or heated water mattresses helps prevent prolonged metabolic acidosis and hypoglycemia and reduces mortality.

 

Care of Premature Baby

If baby born prematurely, expect staff to take following measures:

  • If baby is born before corticosteroids have had enough time to mature her lungs, treatment for RDS becomes necessary, which includes administering oxygen and mechanical assistance with breathing. Baby may need to have surfactant instilled into her lungs, which allows lungs to expand during an inhalation and remain partially inflated during an exhalation
  • If baby is very premature, may need to transfer to a hospital with a NICU. High risk babies may require continuous HR monitoring
  • Might not be allowed to hold baby right away. May be taken to special care nursery or neonatal intensive unit (NICU) where they stay until can breathe on their own, stay warm at room temp and breastfeed/take a bottle
  • Premature baby may require prolonged hospitalization. Parents participation in baby’s care benefits both child and adults

Kangaroo Care – newborns kept skin to skin with one of parents as much as possible. Some believe its the most effective way to promote baby’s well being especially for premature or sick baby. as soon as newborns condition is stable, placed nude on mothers bare chest or abdomen. Blanket covers them both. Done for extended periods several times a day.

Studies show baby’s growth and development improved with Kangaroo care. He spends more time in deep sleep, more time in quiet alert state and less time crying. He has fewer episodes of Apnea and fewer episodes of bradycardia. Temperature stabilizes and gains weight more rapidly leading to shorter hospital stay if he’s ill or was born prematurely. Premature baby’s health particularly improves when allowed to smell parents familiar scent, heart their heartbeats and absorb their body heat. Skin to skin helps easy anxiety he may have from being connected to various monitors, IV lines, and tubes for oxygen and food.

If at risk for preterm labor and premature birth, contact newborn nursery to learn about policies on Kangaroo care and how to arrange for it.

 

ICEA YouTube Channel Members Minute: Skin to Skin (Donna Walls) 3:13

  • Baby stays warmer
  • Helps stabilize blood sugars
  • Increases breastfeeding success
  • Healthy gut – general health, immunity
  • Babies feed more often (smell milk)
  • Frequent feedings reduce risk of engorgement for mom and reduce risk of jaundice for newborn; ensures better milk supply

XII. Other Part 8 References

  1. YouTube:

Penny Simkin on Delayed Cord Clamping (see above)

  1. ICEA Position Paper on Skin to Skin Contact

Infant bare on mom’s chest with no diaper, hat or hospital gown hindering total skin contact.

Benefits:

  • Thermoregulation and temp maintenance
  • Temp synchrony bw mother and newborn
  • Cardio-respiratory stability
  • Self-attachment for breastfeeding
  • Higher blood glucose levels
  • Infants hands and feet warmed within 90 min

Postpartum for Mom:

  • Infant cries 10x less and for shorter periods than infants in cribs
  • Increased maternal affectionate/nurturing behaviors
  • Enhances effective breastfeeding
  • Less maternal requested time in nursery; sleep synchronized w newborn

Postpartum for Newborn:

  • Apnea reduction
  • Less initial weight loss
  • Positively influences state organization (sleep to awake and back) and motor system modulation (smoothness of movement)
  • More restful natural sleep cycles and more quiet sleep
  • Reduced stress reaction to painful procedures

Kangaroo care for premature newborns, also beneficial for healthy full term infants

  1. ICEA Position Paper on Water Birth

May reduce perception of pain, shorten phases of labor and may reduce need for medical intervention such as analgesia and anesthesia.

Women should be deeply immersed to cover belly and up to breast. Full immersion promotes optimum physiologic responses, primarily stimulation of oxytocin and vasopressin. Entering pool between 3-5 cm dilation and staying approx. 2 hours allows for optimum relaxation and labor progression. Some who step out for 30 min and return, often experience enhanced dilation. Recommended temp 98-101 degrees. F some recommend 95-97 degrees. Baby with hyperthermia may show signs of distress.

Benefits:

  • Increased satisfaction with birth
  • Reduction in perception of pain
  • Increased endorphin release and increased relaxation
  • Reduction in need for pharmacologic pain relief
  • More ease for assuming various labor/birth positions (due to buoyancy) that leads to increased functional diameter of true pelvis
  • Shorter 1st and 2nd stage due to reduction in stress hormones and catecholamines, which inhibit oxytocin and labor progress
  • Less perineal trauma
  • Less postpartum hemorrhage

No difference in Apgar scores

When baby is born and prostaglandin level is still high, baby’s muscles for breathing simply don’t work. Babies are born experiencing acute hypoxia or lack of oxygen. Hypoxia causes apnea and swallowing, not breathing or gasping. If baby experienced extreme severe lack of oxygen, may gasp as soon as born, possibly inhaling water into lungs. If baby were in trouble during labor (FHR), caregiver would ask mom to leave bath. Reflex to begin breathing only initiated after trigeminal nerves in face, nose and mouth are stimulated with combination of room air and complete removal from water. Once activated, pulmonary circulation begins for first time with oxygen rich blood flowing into lungs and carbon dioxide removed.

During water birth, there is a strong instinct to bring baby above level of water immediately, may cause rapid cord traction (rare). Clues include sudden change in water to deep red ( gush of blood), sudden release of cord tension, visual confirmation, snapping sound and signs of neonatal hemorrhagic shock.

Reduced group b strep – 1/4432 for Waterbirths vs 1/1450 for land births

Contraindications: VBAC, Pitocin augmentation/induction where telemetry not available. Analgesia/anesthesia, multi fetal gestation and gestational age less than 37 weeks

  1. ICEA Position Paper on Delayed Cord Clamping

Optimal time to clamp for all infants regardless of gestational age or fetal weigh is when circulation of cord has ceased and cord is pulseless.

30 sec – 180 sec; some say insufficient data beyond 60 sec

Benefits:

  • Improved hematocrit
  • Improved iron as measured by ferritin
  • Reduction in risk of newborn anemia and need for transfusion

No significant different in postpartum hemorrhage rates when early and late cord clamping compared.

  1. ICEA Postpartum Doula Certification Program

About The Author

Jessica