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CLINICAL ISSUES
plish delivery challenges women physically and psychologically. The second stage of labor is also a challenge for the nurse. This article reviews these challenges for the nurse and identifies principles to help
guide this care.
The challenges for the nurse begin with assessment of labor progress based on cervical dilation,
fetal rotation, and descent; decision making about
the timing of instructions or direction to the expectant mother to push; and consideration of how to
most effectively help her with bearing-down, what
positions might be helpful, and which companion at
her birth may be most able to help. The nurse also
must identify any factorsemotional or physical
that may be interfering with progress; she will need
to assess how the woman is coping with the pain,
pressure sensations, or concerns about her progress,
her safety, and her ability to achieve this feat of
childbirth. Other challenges the nurse must incorporate into care of the woman are assessment of the
ongoing features of uterine contractions, fetal heart
rate (FHR) patterns, bladder status, and maternal
vital signs; ongoing documentation of maternal and
fetal status, labor progress, and accompanying
events; and maintenance of appropriate and timely
communication with the birth attendant, nursery
staff, or other caregivers. The nurse also needs to
ensure that the necessary equipment and supplies are
available and, when needed, ready for the birth. This
is, indeed, a period of intensive care that in the contemporary perinatal unit is accompanied by much of
the technology of a specialized care unit.
The equipment that may accompany the care of a
woman in advanced labor has increased in number
and complexity (Kozak & Weeks, 2002). Despite the
lack of scientific evidence for continuous electronic
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Duration of Phases
It is not clear from the available research how long the
duration of active pushing should extend. Arbitrary limits on the duration of second stage, such as the 2-hour
rule, have been refuted (American College of Obstetricians and Gynecologists [ACOG], 1994). European investigators who have addressed the duration of rest in the
early phase of second stage when epidural analgesia is
used recommend that this phase be no longer than 1 hour
(Gleeson, & Griffith, 1991; Manyonda, Shaw, & Drife,
1990). However, evidence of the development of fetal acidosis and maternal perineal denervation injury to pelvic
muscles and nerves suggests that forceful pushing for
more than 1 hour is detrimental (Allen, Hosker, Smith, &
Warrell, 1990; Handa et al., 1996). The duration of active
pushing is more relevant to fetal and maternal condition
than the total duration of the second stage.
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Directed Pushing
The adverse effect of directing a woman to push in a
manner that seems effective to the care provider, or based
on the appearance of a contraction on the uterine monitor, is establishment of a pattern of BDEs not in synchrony with the womans own bearing-down urge. This
involuntary urge is evoked when a uterine contraction
achieves an amplitude of at least 30 mm Hg, and as the
fetal head stretches the muscles of the pelvic floor and
evokes Fergusons reflex, which is accompanied by oxytocin release (Roberts, 2002; Roberts, Goldstein, Gruener, Maggio, & Mendez-Bauer, 1987). The additional oxytocin augments the quality of uterine contractions and
facilitates expulsive effort when mothers bear down with
the more forceful contractions.
Therefore, the obstetric conditions optimal for fetal
descent include cervical dilation, fetal station of at least
+1, fetal position approaching OA, an involuntary urge to
push (in the absence of an epidural), and uterine contractions of adequate intensity. When these conditions exist,
the nurse should offer encouragement in accordance with
the womans involuntary urge, relying on the coordination of the contraction with maternal effort, not on the
nurses external assessment of the contraction from the
uterine monitor.
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TABLE 1
Delay in Descent
The feature of second-stage progress important to
assess in deciding how to assist a woman with BDEs in
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FHR (bradycardia < 110 beats per minute [bpm] or tachycardia > 160 bpm); minimal or absent baseline variability; variable decelerations with progressive loss of variability; late decelerations; or prolonged decelerations
(King & Simpson, 2001). It is reassuring when there are
FHR accelerations, particularly in response to acoustic,
abdominal, or scalp stimulation. The absence of FHR
accelerations (of 15 bpm amplitude lasting 15 seconds)
requires further assessment and continued observation in
conjunction with assessment by the physician. The
appearance of meconium during second stage also
requires further assessment of fetal status along with notification of qualified persons to assist in ensuring adequate
respiration at birth.
Intolerance of labor by the mother is reflected in
fatigue and inability to continue to push. This is most
likely to develop when the woman is encouraged in bearing down before the obstetric conditions are optimal. It
can be minimized by avoiding the arbitrary practice of
directing a woman to push upon complete cervical dilation. When the woman experiences an urge to push
prior to adequate fetal rotation and descent, maternal
fatigue can be minimized by continuing to coach her in
relaxation and slow breathing techniques as a contraction
starts, which results in pushing only at the peak of the
contraction when the urge is irresistible. It is important
that she also remain well hydrated with oral or intravenous fluid, and that her bladder not become overly distended.
These basic features of care in labor are ongoing, along
with offering encouragement and information that minimize her anxiety or concern about progress. It is anxietyproducing for the woman if the nurse or physician performs a vaginal examination during the second stage and
does not share the findings with her (Bergstrom, Roberts,
Seidel, & Skillman, 1992). Discouraging findings on a
vaginal examination can be used as motivation to try
another position for effective pushing or for some other
strategy that will promote rotation, descent, and comfort.
In conclusion, nursing care during the second stage of
labor should be characterized by support to women in
making active decisions about their care and labor management; by strategies to prolong the early passive phase
of fetal descent; support in involuntary bearing-down
efforts; the provision of instruction or assistance, as needed, when the woman enters the later phase of active pushing; and the use of maternal positions that can enhance
descent and are accompanied by less pain. Nurses should
assess all of the obstetric conditions that are related to
progress in the second stage along with maternal and fetal
well-being. Further research is needed to establish parameters for duration of the phases of second stage and the
effectiveness of these supportive strategies to achieve optimal birth outcomes.
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