Childbirth is a termed as a complex phenomenon of inter-related physiological, hormonal and psychological changes, which is different for different women. Midwives play a pivotal role in supporting and caring for women during the childbirth process and normally have an autonomous practitioner position in the care women going through normal birth. The decisions made by midwives while caring and supporting from women during these moments are extremely substantial and determine various sorts of childbirth outcomes.
The process of childbirth is grouped into stages;
First stage or the labouring stage: the cervix is dilated and the foetus is positioned for the birth due to the uterine contractions.
Second stage or the birthing stage: the baby descends and is born.
Third stage: Here, the placenta and membranes are discharged.
The current essay gives a detailed review about the practice of imposing time limitations on the second stage of childbirth and gives appropriate recommendations on the issue. The paper also identifies the midwifery care given whilst applying time restrictions on second stage of labour.
The time restrictions and statistical model for the duration of childbirth stages were introduced by Emanuel A Freidman in 1954 in the ‘Freidman’s curve of Labour’. Cesario (2004) illustrates how Freidman’s study findings were derived from a relatively small sample of only 100 nulliparous women in their early 20’s. This happened at a time well before the advent of electronic foetal monitoring (EFM) and foetal scalp blood gas analysis, when results could only be estimated purely on duration instead of the costlier assessment of maternal and foetal wellbeing adopted nowadays. There is lack of evidence to propose that enforcing an arbitrary restriction on the duration of second stage is necessary, when it is progressing and there is satisfactory condition of both mother and baby. Decisions on limiting the second stage of labour must be made on the basis of the sample rules of studying the wellbeing of baby and mother which apply throughout the first labour stage. When conditions of the mother and baby are satisfactory and the descent of the baby’s head can be witnessed, operative treatments can be avoided. Whenever the head is presenting, the midwife needs to monitor it’s positioning with respect to the brim of the pelvis by both abdominal palpation and vaginal exams. Abdominal palpation can decrease the number of vaginal exams that are essential. The moulding of the foetus should also be assessed along with examining the descent and position during vaginal exam, particularly during slow progress and possibility of cephalopelvic disproportion. However, if the baby’s head is engaged, the descent becomes slow and the membranes remain intact. On consultation, the midwife must then conduct a controlled rupture of the membranes so as to facilitate delivery. Although studies indicate that there is no justification to the arbitrary time limit on second stage of childbirth, time is still an element that must be looked at. Hillan (1999) cites that the total duration of completing the second stage will differ substantially between individual mothers; clearly it must not be allowed to continue for several hours. Nevertheless, when regular contractions and progressive descent are evident, and maternal and foetal conditions are good, flexibility in duration must be allowed.
In case the second stage is getting prolonged, or other issues like the presence of meconium are observed, then immediate operative intervention may or may not be necessary. In such events, closer monitoring of foetal wellbeing by EFM is required, and consultation must be taken. When non-reassuring foetal heart rate patterns are noted and the childbirth is not immanent, a shift to continuous EFM is advocated, with physician consultation.
According to Gupta et al. (2004), “in women without epidural anaesthesia, use of any upright or lateral position, compared with supine or lithotomy positions, is associated with reduced duration of second stage of labour”
Recommendations on why midwives are encouraged to place time limits on second stage of labour:
Janni et al. (2002), Cheng et al. (2004) and Altman & Lydon-Rochelle (2006) state that the time duration of second stage is not related to neonatal morbidity
Janni et al. (2002) suggest that greater maternal morbidity in women with lengthy second stage can be partly subjected to the higher rate of surgical interventions and must not be exclusively based on the elapsed time post full dilatation.
Further investigation is needed on the impact of prolonged second stage of childbirth on pelvic support, and faecal and urinary continence.
According to Cheng et al. (2004), women with exceedingly lengthy second stage, over 4 hours, is subject to higher risks of postpartum haemorrhage and undergoing caesarean section.
A compared to earlier national guidelines, the NICE (2007) guidelines are more flexible, even though some make exceptions on any second-stage time restriction if progress is noted and no foetal or maternal concern is present, claiming that time per se and weak neonatal result are not linked to each other (Sleep et al., 2000; Walsh, 2000b)
References:
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