Interventions in Second Stage Labor

When are these used? 1) Anytime there is a concern about the baby that means it would be safer for the baby to be delivered ASAP, rather than 15 or more minutes away. 2) Prolonged Second Stage Labor: Normal second stage lasts anywhere from a few minutes to 3 hours. After 3 hours (or two hours, by some caregiver’s definition), it’s considered prolonged, and close medical observation is necessary. 3) Maternal exhaustion, medications that inhibit mom’s ability to push.

Alternatives to Intervention: Patience and persistence. If the baby is tolerating contractions well, and if you are still able to push effectively, your caregiver may encourage you to continue your efforts. Changing positions or moving around may help, reducing pain medication may help.

Episiotomy

What is it? A surgical incision of the perineum, done during delivery, to enlarge the vaginal opening. The perineum may also tear during second stage, with or without an episiotomy.

How common is it? Rates vary significantly between hospitals and caregivers. Between 1980 and 1998, rates in the U.S. dropped by 39%. This decline is due in part to some survey results which questioned the benefits of episiotomy (see below.) In 1996 survey of Seattle hospitals, rates for first time moms ranged between 10% and 80%. The rate has likely declined since this time. However, episiotomy rates range radically from caregiver to caregiver. For nurse-midwives, the average is 5 – 15%. Some obstetricians are this low, others perform episiotomy as a routine in virtually all births they attend.

Benefits? Shortens the time till delivery by 5-15 minutes, which may be important in cases of significant fetal distress. Episiotomy is necessary with forceps delivery.

Disputed benefits?

• Theoretical benefit: Reduce risk of spontaneous lacerations. (Tears.)
• Researchers have found that when health care providers actively attempt to help women avoid episiotomy and tears, 34.2 – 69.6% of women are able to give birth with an intact perineum.
• Theoretical benefit: Reduce risk of severe lacerations. Research results:
• Most women who have spontaneous tears have only mild first- or second-degree lacerations. In one study, only .7% had third- or fourth-degree tears.
• Episiotomies create a laceration that is at least second-degree, thus more severe than the majority of women would have without an episiotomy.
• There are at least 12 studies that show there’s actually a greater risk of severe lacerations after an episiotomy than with spontaneous lacerations. The surgical cut may tear further, extending the incision.
• Shiono (1990) found that women who had midline episiotomies (straight down from vaginal opening toward anus) were 50 times more likely, and women with mediolateral incisions (from vaginal opening, down toward the right or the left) were 8 times more likely to have severe lacerations than women with no episiotomy.
• Theoretical benefit: Prevents relaxation of the pelvic floor, which can lead to incontinence and backache.
• Recent studies show no correlation between poor perineal function and episiotomy. Exercise is probably the key ingredient in restoring pelvic floor strength. Kegel exercises are the primary example.
• Pelvic floor relaxation may be related to prolonged breath-holding and maximal straining and pushing during second stage.
• Theoretical benefit: A surgical cut is easier to repair and heals better than a jagged tear. This theory does not appear to be supported by research data. Also, since most lacerations are shallower and shorter than the typical episiotomy, they tend to require fewer stitches, and tend to heal better. Episiotomies tend to cause more post-partum pain than tears.
• Theoretical benefit: Medical necessity. Clearly, there are cases in which episiotomy is appropriate, and would be recommended by any caregiver. In studies where care providers attempted to reduce episiotomy rates, they still used this intervention in 1.4 – 17% of births. Note, however, that this is lower than the episiotomy rate at most hospitals, which may indicate an overuse of the intervention.

Summary of Risks? The surgical incision may be larger than a spontaneous tear would have been. Incision can tear further, creating a higher risk of severe lacerations, involving anal sphincter and rectum. With any surgery, there is a risk of infection or excessive blood loss.

What can you do before labor to help prevent an episiotomy (or a tear)? Eat nutritious foods, as this will promote healthy tissue. Perform perineal massage (www.childbirth.org/articles/massage.html)for a few weeks before the birth (Note, perineal massage is recommended for preparation prior to labor. Perineal massage during second stage delivery has been found to increase risk of tears.) Kegel exercises throughout pregnancy. Consciously bulging and relaxing pelvic floor. (See “Practice for Pushing” under the description of second stage labor.) Select a caregiver who attempts to avoid episiotomies.

What can you do during labor to help prevent an episiotomy (or a tear)? During second stage, push for only five to seven seconds at a time, bearing down gently (i.e. try to avoid pushing hard for ten seconds while holding breath). If you experience the “ring of fire” sensation, try to rest through a couple of contractions without pushing, by raising chin and panting during contraction rather than bearing down. Positions: kneeling or on hands-and-knees have been shown to reduce tears. (If the baby is coming down quickly, lying on your side may slow the birth down enough for perineum to stretch.) Caregiver can provide manual support of perineum during delivery.

Forceps Delivery

What is it? Steel tongs / spoon-like instruments, are inserted into the vagina, and placed on either side of the baby’s head. During each contraction, the doctor turns and/or pulls gently on the handles to aid the baby’s rotation and descent.

How common is it? .1% of births in Washington state in 1999. (Many doctors do not feel skilled at forceps delivery, and may choose to use cesarean section instead.)

Benefits? Helps baby rotate to anterior position; helps bring baby down when bearing-down efforts are insufficient. Speeds delivery in cases of fetal distress. May help avoid c-section.

Risks? Usually requires episiotomy, usually requires anesthesia. May bruise baby’s head or face. May bruise or tear vaginal tissues. Other complications are possible but rare.

Alternatives? Gravity-enhancing positions; pelvis-opening positions, patience, and time.

Vacuum Extractor

What is it? A silicone suction cup is placed on baby’s head. A hand-held vacuum pump creates a light suction. During contractions, the caregiver pulls on the cup’s handle to aid baby’s descent.

How common is it? Approximately 30% of births. Far more common for women with epidurals.

Benefits? Helps descent. Advantages over forceps: requires less space in vagina thus may not require episiotomy, little need for anesthesia, fewer injuries to mother’s vagina, bladder, uterus.

Risks? Bruising or swelling of baby’s scalp (fades in a few days to a few weeks); bruising or swelling of mother’s perineum.

Alternatives? See above.

 If none of these interventions are successful, often a cesarean birth is recommended.

Compiled by Janelle Durham, 2002. Sources: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (2001 edition). Family-Centered Maternity and Newborn Care by Celeste R. Phillips (Fourth edition, 1996). “Perineal outcomes in a home birth setting” by Aikins, et al. Birth 1998. “Routine Episiotomy: Medical Dogma versus Medical Wisdom” by Campen, Childbirth Instructor, 1:1. Lecture notes from childbirth educator class, Birth Education Northwest and Seattle Midwifery School. Washington state statistics from Department of Health website.

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