Management of the Second Stage of Labour and Trial of Instrumental delivery
Clare Willocks
The Issues women may face in the second stage
Pain AND Exhaustion….
…Epidural …..Intervention and it’s consequences
Additional “issues” that we may impose
1 Defying gravity
…Defying gravity - Use of lithotomy and epidural Additional “issues” that we may impose
2 Shift change
3 Clock watching
Additional “issues” that we may impose
4 Training issues a) CTG interpretation b) Choice of instrument c) Second stage CS and consequences
4 a) CTG Interpretation - Understanding what is happening 4 b) Choice of Instrument ? Vacuum assisted delivery ? Or Kiellands Rotation ? 4 c) Morbidity of second stage CS Back to basics
3 P’s (1) POWER
relates to the forces propelling the baby through the birth canal; passage coupled to the dimensions of the pelvis, and passenger associated with the size and presentation of the baby.
Issues involving POWER
Clock watching
Epidural rates – do we give 2 hours passive second stage with epidural or malposition What is use of syntocinon in second stage?
Defying gravity – reasons for being supine Prolonged ineffective pushing – maternal exhaustion Use of lithotomy and OASIS
Keeping Upright and Active
Keeping Upright and Active
Supporting normal physiological process ‘Active labour’ is positively encouraged by the WHO and the RCM : women with an active first stage of labour ‘off the bed’ cope better and are more likely to adopt a birthing position of their choice.
Maternal Positioning Needs Better Understanding
Power
Needs to be expanded to include female empowerment in psychosomatic sense and include ..
..The power of language
Is it all the womens fault ? The language we use
“Ineffective UA Failure to progress Wrong way round Square peg in a round hole
Fetal distress”
What is their experience of this ? Listening to women
Shared decision making Consent Respectful care , decision making Continuity of care Pain relief
FREDA
2 ) Passage
The ‘passage’, not only includes the bony pelvis but also the soft tissues, which we know are affected by psychobiological factors
Making space ...... For the 3) Passenger
Maternal Positioning Needs Better Understanding
“Turning a posterior baby is not universally successful simply by hands and knees positions. When you use gravity, remember contractions and opening the part of the pelvis that baby needs to pass is important to let gravity work
Awareness of birthing muscles helps pushing in 2nd stage”
Training Issues for Operative delivery Malposition
Rapid progress to 8 or even 10 cm can indicate asynclitism or malposition
Use of manual rotation before descent
Directed pushing or breathing the baby out requires awareness
Trial of instrumental delivery
In room or theatre ?
Competence and training
Competence with instrument for rotational deliveries – hand , kiwi , kiellands
Choice of instrument- vacuum or forceps?
Vacuum assisted vaginal delivery is all about‘ ‘RESTARTING’’the (stalled) mechanism of labour
Correct placement is KEY to success and safety Kiwi
Prerequisties
As with for forceps 0- 1 /5 palpable , bladder empty , at / below spines Efficient uterine activity “Know estimated fetal weight “ Effective pushing Descent with each traction Prepare for shoulder dystocia and PPH Kiwi 5 step technique
1 Locate flexion point , calculate cup insertion distance 2 Hold and insert the cup 3 Manouevre cup toward and over flexion point 4 Create vacuum and exclude maternal tissue 5 Use Finger tip traction and finger/thumb technique, pull along axis of the pelvis The flexion point Correct cup application Axis of traction Kiwi continued….
Traction with each contraction Descent and perineal phase
Restoring the cardinal movements of labour
When to stop
Vacuum assisted delivery should be abandoned If descent does not occur with EACH traction If delivery is not achieved or imminent after 3 tractions unless complete distension of perineum 15--20 minute total time limit If the vacuum cup detaches (““pops--ff””) >2x AVOID attempting forceps after failed VAVD Intracranial haemorrhage rates increase 3 times
Vacuum extraction in the Netherlands Barbara Nolens, OB/GYN Lotte Hamel, Resident Canisius-Wilhelmina hospital, the Netherlands Births > 22 wk in the Netherlands 2015 Population Hospital CWZ CWZ based 2015 based 2015 2015 2010-2015
n 166.733 118.599 1583 11.512 Midwifery led 28.9%
Vacuum extraction 8.1% 12.1% 13.1% 11.3% Homebirth 13.1% Forceps delivery 0.03% 0.04% 0.0% 0.1%
(50) (50) (0) (9) Epidural 21.8% All CS 16.6% 23.4% 20.3% 19.2% Elective CS 8.2% 11.6% 10.1% 8.7% Secondary CS 8.4% 11.8% 10.2% 10.5%
”Rule”: Fully and station 0 or more = trial of vacuum extraction
Failed vacuum: 58/1358= 4.3%
56 x CS and 2x forceps
Second stage intervention 2011-2015
Deliveries: 9593 Second stage intervention: 1237 (12.9%) CS: 154 (12.4%, 8.6% no trial, 3.8% failed) vacuum: 1083 (87.6%)
Second stage CS without trial of vacuum: 107 (1.1% of all deliveries)
Kiellands
Spinal anaesthetic Dense epidural No descent
EXPERTISE with instrument Long Term effects Physical Trauma- OASIS PTSD Impact on future reproductive performance – accreta , adhesions, stillbirth “Obstetric Violence “ Intrapartum stillbirth / Neonatal Mortality and Morbidity- HIE
How can we strike the balance between too little too late and too much too soon ?
Consent
Effective birth preparation
Readiness for intervention vs aiming for normality
Experience of care
How do we measure this ?
Antenatal education
What is effective Birth Preparation ?
How do we prepare women for the second stage ? Summary
Back to basics- 3 P’s Pain relief, empowerment , allowing gravity to assist Respecting physiology vs promoting normality Power of language Listening to women Education for mothers and partners Education for staff – maternal and fetal physiology ( rather than normality) , risk assessment , CTG interpretation and simulation
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