The “Push” for Evidence: Management of the Second Stage

Abstract

Recognition that the available evidence does not support arbitrary time limits for the second stage of labor has led to reconsideration of the influence of maternal bearing down efforts on fetal/newborn status as well as on maternal pelvic structural integrity. The evidence that the duration of 'active' pushing is associated with fetal acidosis and denervation injury to maternal perineal musculature has contributed to the delineation of at least two phases during second stage, an early phase of continued fetal descent, and a phase of "active" pushing. The basis for the recommendation that the early phase of passive descent be prolonged and the phase of active pushing shortened by strategies to achieve effective, but non-detrimental pushing efforts is reviewed. The rational includes an emphasis on the obstetric factors that are optimal for birth and conducive to efficient maternal bearing down. Explicit assessment of these obstetric factors and observation of maternal behavior, particularly evidence of an involuntary urge to push, should be coupled with the use of maternal positions that will promote fetal descent as well as reduce maternal pain. The use of epidural analgesia for pain relief can also be accompanied by these same principles, although further research is needed to verify the strategies of "delayed pushing" and maintenance of pain relief along with a reconceptualization of the second stage of labor.

Influence on birthing positions affects women's sense of control in second stage of labour

“…The model includes general factors that are related to sense of control, such as education, parity, information, feelings towards birth, place of birth, pain, influence on what is happening during birth (Green and Baston, 2003;Borquez and Wiegers, 2006;Ford et al, 2009;Janssen et al, 2009). Factors related to use and choice in birthing positions are age, education, place of birth, duration of second stage, antenatal information, preference in birthing position, influence of environment (Roberts, 2002;De Jonge et al, 2007;Seefat-van Teeffelen et al, 2011;Nieuwenhuijze et al, 2012).…”

“…Moreover, circumstances may necessitate the use of other positions (De Jonge et al, 2008). The possibility to change positions during labour might be more important than using one single chosen position (Roberts, 2002). In addition, being able to rely on the support of the care providers also contributes to women's experience of birth and is linked to feeling in control (Walker et al, 1995;Halldorsdottir and Karlsdottir, 1996).…”

“…The questionnaire for the women included questions on sociodemographic and childbirth factors known from literature to be related to choice of birthing positions, such as age, education, place of birth, duration of second stage, antenatal information, women's preferences in birthing positions during pregnancy, influence of care provider (Roberts, 2002;De Jonge et al, 2007;Nieuwenhuijze et al, 2012). Information was collected about women's sense of control, their experience of pain during birth, and women were asked for the feelings they had towards birth during their pregnancy.…”

Coordination of Breathing with Nonrespiratory Activities

“…Panting is often recommended to avoid exhaustion during the first stage of labor (effacement and dilation of the cervix). Despite conventional coaching to perform strong Valsalva maneuvers throughout each contraction in the second stage of labor (actual delivery of the infant), there is some evidence (28,270) and strong advocacy (119,230) for the superiority for both mother and infant of spontaneous, uncoached pushing, which usually consists of several brief efforts during each contraction, without closure of the glottis.…”

Early pushing urge in labour and midwifery practice: A prospective observational study at an Italian maternity hospital

“…The nature of the physiology of the second stage labour has been subject of debate for many years (Buxton & Redman, 1990;Cohen, 1977;Downe, 2003;Maresh, 1987;McCandlish et al, 1998;Petersen & Besuner, 1997;Roberts et al, 1987;Roberts & Woolley, 1996;Roberts, 2002;Roberts et al, 2004;Roberts & Hanson, 2007;Sampselle et al, 2005;Simkin, 1986;Yeates & Roberts, 1984).…”