The Role of Passive Descent and Epidural Analgesia in Outcomes Associated With Prolonged Pushing Among Nulliparous Individuals in Midwifery Care

INTRODUCTION

Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery-led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital-based midwifery care. Epidural analgesia and the role of passive descent in midwifery-led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications.

METHODS

Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent.

RESULTS

Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours.

DISCUSSION

Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities.

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.

Clinical evaluation of labor: an evidence- and experience-based approach

During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful physical diagnosis and the ability to translate the acquired information into meaningful prognostic decision-making. We describe a coordinated approach to the assessment of labor. Graphing of serial measurements of cervical dilatation and fetal station creates "labor curves," which provide diagnostic and prognostic information. Based on these curves we recognize nine discrete labor abnormalities. Many may be related to insufficient or disordered contractile mechanisms. Several factors are strongly associated with development of labor disorders, including cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity. Clinical cephalopelvimetry involves assessing pelvic traits and predicting their effects on labor. These observations must be integrated with information derived from the labor curves. Exogenous oxytocin is widely used. It has a high therapeutic index, but is easily misused. Oxytocin treatment should be restricted to situations in which its potential benefits clearly outweigh its risks. This requires there be a documented labor dysfunction or a legitimate medical reason to shorten the labor. Normal labor and delivery pose little risk to a healthy fetus; but dysfunctional labors, especially if stimulated excessively by oxytocin or terminated by complex operative vaginal delivery, have the potential for considerable harm. Conscientiously implemented, the approach to the evaluation of labor outlined in this review will result in a reasonable cesarean rate and minimize risks that may accrue from the labor and delivery process.

The impact of epidural analgesia on the mode of delivery in nulliparous women that attain the second stage of labor

Objective: We aimed to evaluate the impact of epidural analgesia on the mode of delivery of nulliparous women with a term single fetus in vertex presentation (NTSV) that attained the second stage of labor.Study design: A single-center retrospective study provided a strict and constant department protocol for epidural analgesia practice and obstetric interventions, between 2005 and 2014. Epidural users were compared to nonusers. The primary outcome was the mode of delivery. Secondary outcomes were diagnosis of prolonged second stage of labor and maternal and neonatal morbidities. The outcomes were evaluated by adjusted multivariate analyses (Adjusted Odds Ratios (aOR), 95% CI).Results: During the study period, 25,643 NTSV attained the second stage of labor; 18 676 (73%) epidural users and 6967 (27%) nonusers. Epidural users had an increased risk of instrumental delivery 2.48, [2.22-2.76], along with a lower risk of cesarean delivery 0.38, [0.29-0.50]. Notably, the diagnosis of prolonged second stage of labor was comparable among the study groups 0.99, [0.89-1.12]. The epidural users had a significantly higher risk of early postpartum hemorrhage 1.15, [1.04-1.27]. The risk for neonatal morbidity was comparable among the study groups 1.21 [0.90-1.63].Conclusion: Epidural analgesia in a population of NTSV that attains the second stage of labor is associated with a higher risk of instrumental delivery, nonetheless with a reduced risk of cesarean delivery; independent of the length of the second stage of labor is and safe for the neonate.

Attempted operative vaginal delivery vs repeat cesarean in the second stage among women undergoing a trial of labor after cesarean delivery

BACKGROUND

It is not well-characterized whether attempting operative vaginal delivery is a safe and effective alternative among women who undergo a trial of labor after cesarean delivery who are unable to complete second-stage labor with a spontaneous vaginal delivery.

OBJECTIVE

The purpose of this study was to compare maternal and neonatal outcomes that are associated with attempted operative vaginal delivery with those that are associated with second-stage repeat cesarean delivery without an operative vaginal delivery attempt among women who undergo a trial of labor after cesarean delivery.

STUDY DESIGN

This is a retrospective secondary analysis of data from Cesarean Registry of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Women who underwent a trial of labor after cesarean delivery who were at least 36 weeks gestation were eligible for analysis if they had a live, singleton, nonanomalous gestation in cephalic presentation and reached second-stage labor (defined as complete cervical dilation) with a fetal station of at least +2. The data for women who had an attempted operative vaginal delivery with either forceps or vacuum were compared with those of women who underwent second stage repeat cesarean delivery without operative vaginal delivery attempt. Outcomes of maternal and neonatal complications were compared between groups with bivariable and multivariable analyses.

RESULTS

Of 1230 women whose cases were eligible for analysis, 945 women (76.8%) had an attempted operative vaginal delivery. Of those who underwent attempted operative vaginal delivery, 914 women (96.7%) achieved a vaginal delivery. Women who attempted operative vaginal delivery had a lower mean body mass index (30.4±6.0 vs 31.8±5.9 kg/m²; P=.001) and gestational age (39.5±1.3 vs 39.8±1.2 weeks; P=.012) at delivery and were more likely to be of non-Hispanic black race (30.0% vs 22.1%; P=.002), to have had a previous vaginal delivery (34.9% vs 20.4%; P<.001), and to have fetal descent greater than +2 station at complete dilation (55.6% vs 16.8%; P<.001) and were less likely to have chorioamnionitis (6.8% vs 19.3%; P<.001). The frequency of endometritis was significantly lower among women who had an attempted operative vaginal delivery compared with those who had repeat cesarean delivery (2.5% vs 9.1%; P<.001). However, other serious maternal or neonatal adverse outcomes were not statistically different between the groups. These findings persisted after adjustment for potential confounders.

CONCLUSION

In the setting of a trial of labor after cesarean delivery in the second stage with a fetal station of at least +2, attempted operative vaginal delivery resulted in a vaginal birth after cesarean delivery in most women and was not associated with increased adverse maternal and neonatal outcomes but was associated with a reduced frequency of endometritis compared with repeat cesarean delivery without operative vaginal delivery attempt.

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.

Midwives' verbal support of nulliparous women in second-stage labor

OBJECTIVE

To describe how nurse-midwives verbally support nulliparous women during second-stage labor and document specific details of each second stage.

DESIGN

Descriptive qualitative study.

SETTING

A university hospital labor and delivery unit in the southwestern United States.

PARTICIPANTS

Nulliparous women (n = 14) older than age 18 and their attendant midwives (n = 9).

METHODS

A single research midwife observed the entire second stage of each woman and used a standardized data collection form to record spontaneous or directed pushing, position changes, open and closed glottis pushing. A digital audio recorder was employed to capture verbal communication between the midwife and laboring woman. The research midwife and two qualitative experts employed content analysis to analyze the audio transcripts and identify categories of verbal support.

RESULTS

Analysis revealed four categories of verbal support: affirmation, information sharing, direction, and baby talk. The vast majority of verbal communication by nurse-midwives consisted of affirmation and information sharing. Nurse-midwives gave direction for specific reasons. Women pushed spontaneously the majority of the time, regardless of epidural use.

CONCLUSION

Nurse-midwives use a range of verbal support strategies to guide the second stage. Directive support was relatively uncommon. Most verbal support instead affirmed a woman's ability to follow her own body's lead in second-stage labor, with or without epidural.