Chapter 8. The second stage of labour
Introduction
The second stage of labour starts when the cervix is fully dilated, and ends when the baby is born. For some women (especially for multigravidae), this stage is relatively short; for others, it is prolonged and seems to last forever. The student midwife needs to learn how to recognize when labour is progressing effectively. This chapter describes issues regarding the care the midwife provides during the second stage. Some women need assistance to give birth to their baby, and the indications and procedure for episiotomy, forceps and ventouse will be described. Issues surrounding the third stage of labour and perineal repair will be discussed in Chapter 9 and Chapter 11 respectively.
Recognizing the second stage
As each labour progresses at its own unique pace – depending on the position of the baby, parity, length, strength and frequency of contraction – recognizing when the transition from first stage to second stage has been reached is an essential midwifery skill. Being able to identify that a woman is in second stage when you greet her at the labour ward doors will dictate your next actions, and make a difference to her overall experience.
The signs that second stage is being approached or has been reached include: presenting part becomes visible, anus dilates, woman wishes to push with contractions and may do so involuntarily, and/or the vulva becomes congested. With experience, the student midwife will also recognize changes in the woman’s behaviour, her voice and posture. Uterine contractions become less frequent but last longer. Hobbs (1998) describes how cervical dilatation can be estimated by observing the progression of a thin purple line up the natal cleft towards the sacral dimple at full dilatation. It may not be necessary to confirm full dilatation of the cervix by vaginal examination (VE) if the woman has been making good progress, continues to have regular strong contractions, does not have an epidural and the presenting part is visible at the introitus. However, if there has been delay during first stage of labour, and there was any evidence of caput succedaneum at previous VEs, then full dilatation should be confirmed. It is important to feel gently all the way around the presenting part as, occasionally, a rim or lip or cervix can be reluctant to dilate.
If the woman has an epidural in situ, and external signs suggest that full dilatation may have been reached, assessment will depend on how the epidural is being managed and on current local policy. If the epidural is not continuous but is being managed by top-ups, then full dilatation should be confirmed via VE prior to administration of the next top-up. If full dilatation has been reached, and there is no evidence of fetal compromise, a further top-up may be administered to enable further descent of the fetal head. Alternatively, it may have been agreed with the woman that the epidural should be allowed to wear off to enable her to feel her contractions and respond to them. However, suddenly to experience second-stage contractions after being pain-free can be difficult to cope with, and the woman will need a lot of support to adjust to the pain.
Care during the second stage
Immediate vs delayed pushing
The evidence on immediate pushing versus delayed pushing is contradictory. A randomized controlled trial (RCT) of primigravidae with continuous epidural analgesia (Fitzpatrick et al 2002) did not find any difference regarding mode of birth between those who began pushing as soon as second stage was confirmed and those who waited an hour. Another study of primigravidae with continuous epidurals (Plunkett et al 2003) compared duration of pushing in second stage in those who pushed immediately and those who waited for an urge to push. They found no difference between the groups for duration of pushing or rates of spontaneous vaginal birth. However, a multi-centre RCT of delayed pushing for primigravidae with continuous epidural found that spontaneous birth was more frequent among women in the delayed pushing group (delay of 2 hours or more) (Fraser et al 2000).
Passive second stage of labour
Passive second stage of labour is defined as:
‘the finding of full dilatation of the cervix prior to or in the absence of involuntary expulsive contractions’
(NICE 2007:29).
Although it may be confirmed that the cervix is fully dilated, while the presenting part remains high the woman may not have an urge to push. Subsequent contractions will cause the fetus to advance and stretch the soft tissues of the vagina. Further advancement will lead to stretching of the pelvic floor fascia, and exert pressure on the rectum combined with an associated urge to bear down. Although most women without an epidural experience an overwhelming urge to push, some do not (McKay et al 1990). A meta-analysis of the research comparing immediate versus passive descent in women with an epidural concluded that when passive descent is practised the risk of birth complications is reduced (Brancato et al 2008). The student midwife will gain valuable experience observing the range of women’s responses to second stage of labour. S/he will learn to judge when to provide guidance and when to follow the woman’s lead.
Active second stage of labour
Active second stage of labour is defined as:
■ The presenting part is visible
■ Expulsive contractions with a finding of full dilatation of the cervix or other sign of full dilatation of the cervix
■ Active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
During the active phase of the second stage of labour, the woman is pushing with contractions. This requires a lot of effort on her part, especially for the primigravida. She may become very hot from her exertions and will be grateful for sips of iced water and a gentle face wash with a familiar facecloth. These tasks can be undertaken by her partner, helping him/her to feel a valuable part of the birthing team. The woman may become frustrated at times, feeling that her efforts are not achieving any progress. She may behave out of character, perhaps by swearing or lashing out. However, joking with her partner about her behaviour should be avoided as this can undermine the trust she has placed in your loyalty and respect. It would be more appropriate to update her on her progress, reassure her that the baby is fine and praise her stamina.
Positions for second stage
Women should be encouraged to adopt the most comfortable position for them. The position adopted for a labour that is progressing normally should be to the advantage of the woman rather than of her attendant. Although it can be challenging to a midwife for a woman to give birth in a position other than semi-recumbent on the bed, the benefits to the woman of being active during the birth are significant. In a systematic review of the evidence relating to alternative positions during second stage, Gupta & Hofmeyr (2004) concluded that pushing is more effective when an upright posture is adopted, and is associated with shorter duration of second stage, fewer episiotomies and assisted births. Upright positions can reduce the likelihood of vena-caval compression impeding fetal oxygenation. If progress has slowed down, a change in position can help fetal descent.
Directed or undirected pushing
Traditionally, women have been encouraged to take a deep breath, put their chin on their chest and push for up to 30 seconds (Valsalva manoeuvre). However, this technique leads to reduced blood flow to the uterus and lower cord blood pH (Enkin et al 2000). Women who are left to find their own pattern of pushing usually employ a combination of techniques, including pushing accompanied by the release of air. In the absence of fetal compromise, women should be encouraged to push as they feel the need (NICE 2007). In a randomized study comparing spontaneous pushing and the Valsalva technique, the babies in the spontaneous group had higher Apgar scores and umbilical cord pH and P02 levels and the women felt that they pushed more effectively than women in the Valsalva group (Yildirim & Beji 2008). However, women who have an epidural in situ may need some assistance in developing an effective pushing technique. Much encouragement is necessary; sometimes the use of a mirror, so that the woman can see the presenting part advancing, provides useful feedback.
Monitoring maternal and fetal wellbeing
At the onset of the active phase of the second stage, baseline observations of maternal temperature, pulse and blood pressure should be recorded on the partogram. The woman should be encouraged to pass urine to avoid trauma to an over-distended bladder. The time at which active pushing starts should be noted, along with the length, strength and frequency of contractions. Details of progress should be documented half-hourly on the partogram, and include an assessment of how the women is coping with this strenuous activity. Maternal pulse and blood pressure should be repeated hourly, temperature continued 4-hourly (NICE 2007).
The colour of the liquor is noted as it drains onto a frequently replaced sanitary towel. When women are low risk and making good progress, the fetal heart should be auscultated after a contraction (for at least 60 seconds) at least every 5 minutes during the active phase of labour (NICE 2007) using a pinnard or fetal Doppler. If the fetal heart appears to deviate from the normal 110−160 beats per minute, the maternal pulse should be checked to differetiate the two (NICE 2007). Ideally, all documentation should be completed at the woman’s side; this should not prevent supportive interaction.
Preparing for the birth
Confirmation of the second stage of labour does not mean ‘panic’. It requires the midwife to prepare calmly and quietly for the imminent birth, while continuing to care for the woman and her partner. Generally, the midwife has more time to prepare when caring for a primigravida. However, the unique nature of childbirth means that slow progress cannot be assumed. The woman should not be left alone during the second stage. It is important that the midwife who is coordinating the labour suite is aware that the woman has progressed to this stage. The woman should be introduced to an identified second midwife (where this practice is unit policy). This midwife will focus her care on the newborn baby while the first midwife continues to care for the woman. In some units, only one midwife is present for the birth, with practical assistance from another healthcare worker. However, another midwife should always be available, hence the need for two midwives at a home birth.
The midwife must ensure that all equipment that might be needed is in working order and available for use. The room should be warm, with no overpowering lights or other distractions. Interruptions should be kept to a minimum; the woman should feel that her room is private and secure. She may wish to play some music during the birth. Her wishes should be accommodated wherever possible.
As the presenting part advances with contractions, it will initially recede in between. This is normal as the perineal muscles are stretched and thinned. Progressively, a little more of the fetal head will become visible, and the partner can provide feedback to the woman about the amount of hair that can be seen. The midwife can now begin to prepare for the baby’s arrival by making ready her equipment and creating a sterile field. This sterile field can be created anywhere – for example, on a tray on the floor – to suit the woman’s chosen position and place of birth. However, the general concept of knowing where equipment can quickly be brought to hand, while not increasing the woman’s risk of acquiring infection, should be maintained yet flexibly practised. The vulva and perineum should be swabbed with warm water, and a sterile pad placed over the anus. Cord clamps should be placed in the foreground of the field, with the scissors for cord-cutting and episiotomy at arm’s length. Care should be taken not to contaminate your sterile gloves.
A rapidly advancing fetal head may mean that the delivery pack is being opened while you quickly put on sterile gloves, but the woman must remain your focus rather than a beautifully arranged sterile field. She should not be prevented from pushing, but you will need to gain eye contact with her and gently encourage her to listen to your voice. Before the next contraction you can coach her in what you will be asking her to do during the birth of the head. Ask her to blow out gently as the head crowns. This slow birth of the head will minimize the trauma to the perineum.
Minimizing perineal trauma
Woman-focused care
Probably one of the most important factors in helping the woman to minimize trauma to her perineum is through the development of a trusting relationship. It is crucial to develop a dialogue with her so that she knows that you are involving her in decisions about her care. She will develop confidence in your skills, and value the suggestions you make. Expecting her to respond to shouting, ‘Don’t push!’, when you have hardly spent any time with her is a tall order. She is much more likely to respond to your voice at the crucial moment of crowning if she has heard your encouraging words throughout her labour.
Perineal massage
Antenatal perineal massage has been shown to reduce the incidence of second- and third-degree tears and episiotomies (Beckmann & Garrett 2006), particularly in women aged 30 or above (Shipman et al 1997). In an observational study of the acceptability of perineal massage (Labrecque et al 2001), women from 34–35 weeks’ gestation were advised to undertake 5 to 10 minutes’ daily massaging of the perineum. The study concluded that this practice was seen positively by women, and that most said they would do it in a subsequent pregnancy and recommend it to other pregnant women. There is no evidence to support the use of perineal massage by health professionals during the second stage of labour (NICE 2007).
Guarding the perineum
Women experience a range of practices during the second stage of labour, with the aim of protecting the perineum from undue damage and assisting the birth of the shoulders. The HOOP trial (Hands On Or Poised) was designed to compare two methods of perineal management during the second stage of labour (McCandlish et al 1998). ‘Hands on’ required the midwife to use one hand to flex the fetal head and the other to support or ‘guard’ the perineum – birth of the shoulders was assisted by lateral flexion. ‘Hands poised’ required the midwife to allow spontaneous birth of the head and shoulders, without touching the perineum.
The primary outcome for the trial was postpartum pain. There were significant differences between the two groups regarding perineal pain reported by women at 10 days postpartum, with more women in the ‘hands poised’ group reporting pain in the previous 24 hours. However, women in this group were less likely to have an episiotomy but more likely to require a manual removal of the placenta. The results of this trial provide valuable information for midwives when discussing second-stage management with women.
Episiotomy
An episiotomy is a surgical incision made in the perineum to facilitate birth of the presenting part of the fetus. Although once routine, systematic review of the evidence confirms that this practice should be restricted to clinical need (Renfrew et al 1998) and should not form part of routine care during spontaneous birth (NICE 2007).
Indications for episiotomy include fetal heart rate anomolies and maternal exhaustion or distress, and when the perineum is preventing adequate progress. When the midwife considers that episiotomy is required, she must inform the woman of her rationale in language that she can easily comprehend; verbal consent must be gained prior to the procedure (see Box 8.1) and following administration of local anaesthetic (Fig. 8.1). It should be performed only when the presenting part has descended onto the perineum, to allow the levator ani muscle to have been laterally displaced. The technique of preference is a mediolateral incision starting at the fourchette and directed to the right side (NICE 2007) (Fig. 8.2).
Box 8.1
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Procedure for episiotomy
• Inform the woman of the situation that you feel warrants the need for an episiotomy
Rationale So that the woman can make a judgment about the situation and be fully involved in her care
• Gain verbal consent from the woman to perform an episiotomy
Rationale This is a surgical procedure and requires informed consent
• Ask assistant to open 10ml syringe and needle onto sterile field
Rationale In preparation for administration of local anaesthetic
• Apply needle to the syringe, and withdraw plunger (if using local anaesthetic supplied in vial with rubber stopper)
Rationale In preparation for extracting local anaesthetic from glass vial
• Ask assistant to show you and check (drug, dosage, clear liquid and expiry date) local anaesthetic
Rationale To ensure correct drug has been selected and is in condition for safe administration
• While assistant holds vial upside down, position needle into centre of rubber bung and insert some air
Rationale To facilitate withdrawal of drug from a vacuumed vessel
• Withdraw 10ml of 0.5% (or 5 ml of 1%) lignocaine, and check amount with assistant
Rationale To check that correct amount of drug has been prepared
• If right-handed, insert index and middle fingers of left hand in between the presenting part and the perineum, pointing downwards, and make perineal skin accessible
Rationale To protect the presenting part from the local anaesthetic
• In between contractions, insert needle into perineum along the line of the intended episiotomy site. Withdraw the plunger and, if no blood returns into the syringe, inject 2–3ml. Repeat either side of the intended site (Fig. 8.1).
Rationale To anaesthetize the skin around the intended episiotomy avoiding a maternal vein
• Dispose of needle and syringe in appropriate sharps bin
Rationale To avoid needle stick injury to midwife, woman, baby or assistants
• If fetal and maternal conditions allow, wait for two contractions
Rationale To allow local anaesthetic to take effect
• If right-handed, insert index and middle fingers of left hand in between the presenting part and the perineum, pointing downwards
Rationale To protect the presenting part from the episiotomy scissors and make perineal skin accessible
• With right hand, take the open scissors and position in between presenting part and perineum, over area of intended episiotomy
Rationale To find optimum position in readiness for next uterine contraction
• At height of next contraction, and with maternal effort applying the presenting part on to the perineum, turn scissor blades at right angles to the skin and make single cut
Rationale To aid thinning of perineum prior to incision, aiding performance of episiotomy and reducing blood loss
• Apply even pressure to the advancing presenting part with left hand. inform woman of her progress
