Management of the Second Stage of Labor in Women with Epidural Analgesia

Abstract

CNM, WHNP M.P., a healthy 21-year-old gravida 1 para 0 at 39 2/7 weeks' gestation, was admitted to the hospital while in labor. Her history and prenatal course were uncomplicated. Contractions had begun 9 hours earlier. The vaginal exam upon admission was 4/80/-1 with membranes intact. She was contracting every 4 minutes. Two hours later, she was re-examined and her cervix was unchanged. Her contractions were now occurring every 4 to 6 minutes. Her membranes were artificially ruptured in an attempt to augment her labor. An hour later, her contractions had not increased in frequency or duration, so the consulting midwife recommended oxytocin augmentation. M.P. also requested and received epidural analgesia at this time. Seven hours later, after 20 hours of labor, she was fully dilated and the head was at 0 station. Her epidural was discontinued, and 30 minutes later, coached pushing began because she had no spontaneous urge to push. She was instructed to use a closed glottis technique, in several positions, including semi-Fowler's, lateral, and on her hands and knees. Her pain had returned, and despite encouragement to push with her contractions, she clung to the bed's siderails and cried out through several of her contractions. She was becoming exhausted, and her pushing efforts became increasingly ineffective. Finally, 2 hours and 30 minutes later, she spontaneously birthed a healthy baby boy weighing 3020 g, with 9/9 Apgars. Inspection revealed a second degree tear, which was repaired under local anesthetic. Breastfeeding was not initiated in the immediate postpartum period at M.P.'s request because of self-reported exhaustion. When she was seen on her first day postpartum, she expressed concern about the return of severe pain during pushing and was angered that the epidural had been discontinued without her understanding or consent. She stated that she was "still exhausted" from labor and "just wanted to sleep," so had not attempted breastfeeding. She declined rooming-in the previous night, and at the time of the visit, the baby remained in the nursery. Later that day, following discussion with her husband, she requested to speak to a patient advocate regarding the discontinuation of her pain medicine. MANAGEMENT OF SECOND STAGE IN WOMEN WITH EPIDURALSA midwife who practices in a hospital setting frequently finds herself caring for a woman laboring with epidural analgesia. According to a 2002 Maternity Care Association survey, almost two-thirds of women choose to labor with epidural anesthesia. 1 Care for these women during the second stage can be challenging, because the urge to push and overall sensation is limited by the medication.In an effort to improve pushing effectiveness, many obstetric practitioners routinely turn off epidurals during second stage and/or coach the woman to practice closed glottis pushing immediately upon full dilation. When deciding upon appropriate management strategies for second stage, it is advisable for practitioners to base their clinical decision making on current evidence-bas...