Pattern and Management of long 2nd stage

My goal in this article is to change the view of "Prolonged 2nd stage" as a dysfuntion of labor to a view of long 2nd stage that is normal and manageable. This situation may be caused by such issues as prima-gravida, large baby or less then ideal fetal head position. From the perspective of the midwifery model of care, labor can cycle through several phases of activity and rest after a woman has reached, or nearly reached, full dilation. This may go on for many hours, some midwives report days. If there is any question as to the safety of “allowing” a woman at full dilation to labor, one only need look to the medical model for confirmation that there is no harm. In a hospital setting, resting a woman (on an epidural and often Pitocin) at full dilation with membranes intact is common. This is called “laboring down” and is employed in hospitals so that a woman can be “delivered” by her doctor at his or her convenience. There is a double standard for unmedicated labors, as more than two hours at full dilation with any pushing effort is considered abnormal.

Rhythm of Labor in a Long Second Stage

When the woman is unmedicated, her contractions will cycle through phases of activity and rest. During active phases, the contractions may come every three minutes and she may or may not feel the urge to push. During the resting phase, contractions may space out to every 20 minutes and last only 30 to 45 seconds. She needs as many cycles of rest and activity as she needs. These resting periods are not “inefficient contractions” as the medical model labels them. We must allow these periods of rest and reassure everyone that this is normal; the baby’s head can change shape and elongate during periods of rest. Some midwives report ten hours of labor (or more) at this pace with healthy outcomes, and a relatively short pushing period once the baby has passed most of the occiput, past the pubic bone and is visible at the introits.

Midwives’ ideal model of care is one of patient waiting. The baby needs time either to accomplish moulding and/or to navigate the pelvis with a less than ideal presentation. In a primip or primary VBAC labor, when we suspect a large baby or when we determine asynclitic, posterior, military or face presentation, management of the resting and active phases of a long second stage may be called for.

It’s very important to discern when the following intervention of aggressive second stage management is needed. Perineal pressure and assisted pushing can hasten birth when heart tones are less then reassuring (emergency use) or when ordinary pushing and position changes fail to bring progress. Informed choice and cooperation of the mother are extremely important. In my experience, a rhythm usually develops whereby the mother informs me when a contraction is coming and when she is ready for me to resume working with her in this way. Avoid the risk of transfer and/or emotional trauma by engaging a woman’s strength and determination. In the course of prenatal care I inquire or listen for the challenges a woman has faced in the course of her life. This is a good time to remind her of what a strong woman she is, by using specific examples from the successes in her past. For example; running a marathon, swimming with sharks or opening a business. By believing in her and in birth we can help her dig deep and find determination and reserves of strength.

At all costs avoid bullying and coercion when using these assisted pushing techniques. The need for management like this, is only about 1 in 20 births. Not long ago, Jenn Head CPM and I handled a birth with a multip who did not speak English. After an hour of non productive pushing effort we employed these techniques. The mother indicated the start of the contraction and her wish for and willingness to be assisted this way, by snapping her fingers and pointing at her vagina. The large baby soon emerged with a beautifully molded head after an hour of pushing.

Intervention in Second Stage

If you determine that intervention is appropriate and you have consent from the mother, position changes, assisted pushing and a positive attitude are the most effective tools.

The most effective positions are standing, the birth stool and, surprisingly, dorsal/lithotomy on the floor. Make a padded surface for the mother with a pillow or support person behind her. Alternating positions and resting between contractions is important. If contractions slow again, encourage her to rest on the bed, walk or eat. Remind her to stay hydrated and empty her bladder.

Anne Frye describes assisted pushing and management of a cervical lip quite well in her book Holistic Midwifery Vol ll. The attitude of the midwife is crucial in preventing a situation where the mother feels violated by this active management. Honor her strength and determination, and do everything with her, not to her. I have found that in cases of a managed second stage, you can never stop checking for a cervical lip until the head is visible or prevents your fingers from reaching that high. I have also found in such circumstances that mothers often need assisted pushing. These things are done in a continual rotation, with a positive attitude, until you feel the descent of the head. Keep sweeping up for the lip and evaluating. Additionally, downward vaginal pressure can give mom direction for pushing effort. Finger forceps, which offer lateral vaginal pressure and ischial spine opening, is also useful. The attitude to hold in mind, body, tone and words, as well as fingers, has to be positive and intentional when doing this invasive and aggressive intervention. You have to know, feel and communicate compassion: it hurts but is needed. The intention is to make room for the baby and you have to believe it is going to work. The position for finger forceps is wrists crossed and the index and middle fingers all the way up to the ishial spines. Here again, you alternate between sweeping upwards with the fingers of one hand to feel for and manage the lip and downwards to palpate for the coccyx, stool, muscular tension on the pelvic floor and any other surprises ahead of the baby.

Pressure is steady and firm, the wrists are crossed, preventing excessive pressure, and the pressure is evenly distributed along the length of the fingers to the hand, preventing a “poking” sensation. You can try this in any position but lithotomy is most often used. Managing the lip and/or helping the baby shift head position while mother is in an open, knee/chest position is also very useful. Any position can be assumed after the baby clears the pubic bone and is descending, but the birth stool is often most useful to maintain progress. The use of a mirror at this point can encourage a woman and help her direct her pushing efforts as she watches the head emerge.

Shoulders, or at least slow emergence of the body from soft tissue dystocia due to swelling and size of baby, can be expected in such a case and calculations for space and assistance must be made in your head beforehand for getting the mother into (Gaskin) hands and knees, if needed. Be ready for resuscitation, especially if fetal heart tones are questionable. In an ideal world we would always have good fetal heart tones and a mother who stays focused and positive with only small expressions of doubt. These are very big considerations, but even with a flustered mother or slow recovery, a birth with a long pushing phase (4 to 10 hours) is very possible. Prevent maternal exhaustion by encouraging mom to eat, stay hydrated and empty her bladder.

Clean up as you go. Constantly evaluate the environment for the way it is organized and think (fluidly, not rigidly) about how to best use the space for different scenarios. Keep track of your supplies and promptly throw out glove wrappers, gauze, etc. Debris builds up quickly, especially during a long labor, if not attended to promptly. Fold and stack towels, remove soiled linen, shift and move your bags as needed, and, in general, scan the situation to make sure your actions and supplies are not impediments or hazards. At a long birth, these things can be important in keeping spirits and energy high. This also helps in the postpartum period when you feel tired and are packing up to go.

Minimize sudden movements and excessive talking. Graceful, slow movements and low, calm voices are always appropriate. Doing so conserves energy for the long haul, keeps mom calm and reassures normalcy. Cheerleading is tiresome, especially after many hours. It’s also important to be mindful of self-care. Take naps during the mother's resting phases and encourage doulas, husbands and less experienced midwives or assistants to also rest. Take the time to refresh yourself with nourishment and fresh air; take a walk and take long deep breaths. Make contact with people who recharge your battery. I call this last one the Ben Adam Maneuver, after my boyfriend, who made sure I ate and kept my own oxytocin levels high during a recent long primary HBAC of a 9 lb 8oz baby that inspired this article.

At this birth I thought I was using every midwifery trick in the book, only to find no book containing a description of such management. I had witnessed a few births managed this way during my training as a homebirth midwife and I had managed a few as well. Many experienced midwives I talked to agreed this was a labor pattern and management practice they were aware of but some were not. My intention was to gather or create teaching materials to support the normalization of such management and prevent unwanted transfers and unnecessary surgical births.

These techniques can and have been used in ways that traumatize or re-traumatize birthing woman. Also some midwifery students have been traumatized by being forced by preceptors to preform these techniques regardless of the need or efficacy . I hope I have been able to contribute useful parameters and guidelines for use. As well as a helpful description and how-to.