Managing second-stage labor

Effect of supported sitting position during second stage of labor on its outcome in primigravidae: A quasi-experimental study

Background

The childbirth position has a significant influence on labor, maternal comfort, and neonatal outcome. In sitting position, there is a faster fetal descent with the effect of gravity. The information on this subject is relatively scant. Therefore, this study aimed to examine the effect of a supported sitting position during second stage of labor on its outcome in primigravidae.

Materials and Methods

A quasi-experimental study with a post-test only control group design was used. 60 primigravidae were selected using total enumerative sampling. The labor outcome was assessed by self-structured maternal neonatal outcome checklist and socio-demographic proforma.

Results

Statistically significant difference was observed on the mean duration of second stage of labor among primigravidae in control and experimental group (t = 5.87, P < 0.001) and also in the APGAR score of newborns (t = -3.98, P < 0.001). A statistical significant association of duration of second stage of labor with height and intensity of maternal work was also observed.

Conclusions

A supported sitting position during labor was found to be effective in reducing duration of the second stage of labor. This can be used as a nursing intervention while providing care during labor especially at primary healthcare centers that can help in reducing the duration of second stage of labor.

Use of the peanut ball during labour: A systematic review and meta-analysis

AIM

This study aimed to determine effectiveness of peanut ball on the duration of the stages of labour and frequency of caesarean section.

DESIGN

A systematic review and meta-analysis.

METHOD

A comprehensive electronic search was carried out with no time limit until December 2020. Collected data were analysed using software RevMan- version 5.3. Heterogeneity was assessed using I2 , T2 , and 2 . GRADE approach was used to assess the certainty of evidence.

RESULTS

The meta-analysis on six clinical trials with 645 participants showed no statistically significant difference between the two groups in caesarean surgery rate (RR = 0.82) and length of the first (MD = -15.64).

CONCLUSIONS

Therefore, further clinical trials with stronger evidence should be carried out to assess the effectiveness of peanut ball on caesarean surgery rate and length of first and second stages of labour.

Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural

One strategy for reducing the primary cesarean surgery rate and length of labor is using a peanut-shaped exercise ball for women laboring under epidural analgesia. A randomized, controlled study was conducted to determine whether use of a "peanut ball" decreased length of labor and increased the rate of vaginal birth. Women who used the peanut ball (n = 107) versus those who did not (n = 91) demonstrated shorter first stage labor by 29 min (p = .053) and second stage labor by 11 min (p < .001). The intervention was associated with a significantly lower incidence of cesarean surgery (OR = 0.41, p = .04). The peanut ball is potentially a successful nursing intervention to help progress labor and support vaginal birth for women laboring under epidural analgesia.

A practical approach to labor support

In the United States, intrapartum nurses are present at 99% of births. These nurses have a unique opportunity to positively affect a laboring woman's comfort and labor progress through the use of labor support behaviors. These nonpharmacologic nursing strategies fall into four categories: physical, emotional, instructional/informational, and advocacy. Implementation of these strategies requires special knowledge and a commitment to the enhanced physical and emotional comfort of laboring women.

Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia

BACKGROUND

Although epidural analgesia provides the most effective labour analgesia, it is associated with some adverse obstetric consequences, including an increased risk of instrumental delivery. Many centres discontinue epidural analgesia late in labour to improve a woman's ability to push and reduce the rate of instrumental delivery.

OBJECTIVES

To assess the impact of discontinuing epidural analgesia late in labour on: i) rates of instrumental deliveries and other delivery outcomes; and ii) analgesia and satisfaction with labour care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (1 September 2003).

SELECTION CRITERIA

Randomised controlled trials of epidurals discontinued late in labour compared with continuation of the same epidural protocol until birth, in women who receive an epidural for analgesia in the first stage of labour.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study eligibility and quality and extracted the data. We analysed categorical data using relative risk (RR), and continuous data using weighted mean difference.

MAIN RESULTS

We identified six studies, of which five were included (462 participants). Three of these were high quality studies whilst the other two were judged to be of lower quality because placebo was not used and the method of randomisation not described. All studies used different epidural analgesia protocols (type of drug, dosage or method of administration). Overall, the reduction in instrumental delivery rate was not statistically significant (23% versus 28%, RR 0.84, 95% confidence interval (CI) 0.61 to 1.15) nor was there any statistically significant difference in rates of other delivery outcomes. The only statistically significant result was an increase in inadequate pain relief when the epidural was stopped (22% versus 6%, RR 3.68, 95% CI 1.99 to 6.80).

REVIEWERS' CONCLUSIONS

There is insufficient evidence to support the hypothesis that discontinuing epidural analgesia late in labour reduces the rate of instrumental delivery. There is evidence that it increases the rate of inadequate pain relief in the second stage of labour. The practice of discontinuing epidurals is widespread and the size of the reduction in instrumental delivery rate could be clinically important; therefore, we recommend a larger study than those included in this review be undertaken to determine whether this effect is real or has occurred by chance, and to provide stronger evidence about the safety aspects.

The "push" for evidence: management of the second stage

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.