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 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 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 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 > 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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