Second Stage Labor Management
Evelyn M. Hickson, RN, MSN, CNS, WCC
Objectives
By the end of this presentation the learner will be
able to:
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Discuss traditional pushing and laboring down
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List nursing interventions to facilitate second
stage.
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Discuss the risk-benefit of operative vaginal
delivery.
Cardinal
Movements
Of
Birth
Pushing
When is it OK to begin pushing?
 When completely dilated
 When patient feels urge – as long as
completely dilated
Continue as long as fetal tolerates pushing
What Is Laboring Down?
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Done in the patient with an epidural
Passive action of second stage
Allowing the uterine activity to continue to
bring the baby down the birth canal without
active pushing.
What Patients Would I Use
Laboring Down On??????
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Patients who are exhausted
Cardiac Patients
Any patient that should not be pushing due
to medical or obstetrical issues
How Long Can You Do Laboring
Down?
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Maximum time is two hours.
Start from the time the patient is
determined to be complete
Contingent on a stable mom and a FHR
tracing that demonstrates fetal well-being
Positions For Pushing
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In the bed
HOB slightly up
Use of the bed
Safety measures for patients with epidurals
Positions that open the pelvis
Squat bars
Positions For Pushing
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Squatting
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On the toilet
Assisting The Patient
With Pushing
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Breathing
Bearing down
Support / Coaching
Focus
Episiotomy
Instrument Assisted Deliveries
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Vacuum
Nursing Responsibilities
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Chart Pressure amount
Chart Total Time / Duration of vacuum applied
Chart Number of pulls and pop-offs
Determine who needs to be present in room
Identify when to go up the chain of command
Assess the baby for outcome
Instrument Assisted Deliveries
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Forceps
Nursing Responsibilities
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Station of fetus when applied
Chart the number of pulls
Determine who needs to be present in the
room
Identify when to go up the chain of command
Assess the baby for outcome
Shoulder Dystocia

Definition:
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When neonatal shoulders cannot be delivered using
the “usual” delivery maneuvers
When extra delivery maneuvers are required to
deliver the baby
When the time from delivery of the head to the
delivery of the shoulders/body is >60 seconds
Incidence of 0.6 to 1.4 % of all births
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Shoulder Dystocia
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Obstetrical Emergency
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Time is of the essence
Risk Factors For Shoulder Dystocia
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History of prior delivery of a baby with a shoulder dystocia.
Suspected Macrosomia (>4,000 grams)
Diabetic mother (more often gestational or type II)
Excessive maternal weight gain during pregnancy (>35 pounds)
Slow slope - prolonged time to go from 8-10cm of dilatation
(primips=1.2cm/hr, multips= 1.5 cm/hr)
Delayed descent
Postdates
Pelvic Abnormalities
Abnormal pelvic shape or pelvic injury
Case Study
Oprah Winfrey arrives in labor at 41 3/7 wks. She is a G3P2 with a
previous Hx. of delivering two 9 LB+ babies within the last 6 years.
She remembers that the deliveries were “difficult” and she “tore” and
bled a lot. Oprah has a documented 50 lb weight gain during this
pregnancy. She was diagnosed as a gestational diabetic at 26 wks.
An ultrasound was done two weeks ago (at 39 wks.) because her
fundal height was 42 cm. EFW was shown at that time to be 4200
grams. The patient refused to be induced at 39 weeks stating that she
had to coordinate getting family to help and they were in the process
of moving to a bigger house.
The patient was admitted at 0830 in active labor at 5 cm/ 90%/-2.
She was 8cm/90%/-2 at 1330 and 10/100%/-2 at 1630.
Case Study
The patient pushed for 2 hours and doesn’t bring the baby down lower
than+1 station. The Physician applied forceps to assist with delivery
and descent. The head is delivered with the forceps after 3
contractions. The head advances slightly then retracted back up
“turtling” and the shoulders did not come out. The primary nurse
called for assistance The Physician requests supra-pubic pressure and
McRoberts maneuver.
The baby is delivered with a Rubin maneuver after 3 minutes of shoulder
dystocia with reduction techniques.
The baby is dark blue, floppy with eyes wide, no respiratory effort and a
HR rate of 80.
What Are The Risk Factors For
This Patient?
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History of Macrosomic babies with difficult deliveries
Increased fundal height
Slow slope / delayed rate of dilatation (abnormal labor
pattern for a multiparous patient
Postdate
Gestational Diabetes
Excessive maternal weight gain
Preparation For Shoulder Dystocia
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Have the proper equipment ready and available
 *Warmer that is functional – set up and warm
 *Bag and mask
 *O2
 *Suction
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May need stool in order to get up on the bed or
achieve better leverage with maternal
positioning
Preparation For Shoulder Dystocia
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Have the proper personnel at the delivery
 *NICU / SCN RN
 *Second pair of hands
 *Charge nurse /experienced RN
Nurse’s Role In Shoulder Dystocia
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Call for help/backup
Note time at the beginning of shoulder dystocia
Lower the head of the bed
Reposition the patient
Assist with shoulder dystocia reduction maneuvers
Prepare for newborn resuscitation
Remain calm
Reassure patient and help her to focus on pushing
Delegation of removal of unnecessary people /
family from the room
Implementing the chain of command if needed
DOCUMENT - re-creation of the events as they
occurred
Shoulder Dystocia Maneuvers
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1. McRoberts
2. Suprapubic Pressure
3. Woods Screw
4. Rubin
5. Delivery of the posterior arm
6. Maternal Reposition
7. Hibbard
8. Deliberate fracture of the clavicle
9. Deliberate breaking of the maternal coccyx
10. Zavenelli
11. Cleidotomy
12. Symphysiotomy (a large episiotomy may be cut at anytime)
McRoberts
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Hyperflexion of the maternal legs back towards
the chest and slightly rotated out.
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Straightens out the sacrum
Straightens out the incline (angle) of the symphysis
pubis
Rotates the pubic bones
Increases the area of the posterior outlet and
decreases the stretching of the baby’s brachial
plexus
McRobert’s
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Least amount of potential injury if mother does herself
If patient has epidural, legs must be hyperextend or
patient can receive sacral and leg nerve damage
Reduces the likelihood of neonatal clavicular fracture
and brachial plexus injury
90% success rate without additional maneuvers
Suprapubic Pressure
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Second maneuver used in conjuction with McRoberts
May increase the incidence of clavicular fracture
Procedure
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*Communicate with the delivering MD which direction to
exert pressure
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*Using flat surface of the fist, exert a firm downward and
oblique pressure, just above the maternal symphysis pubic
on the anterior fetal shoulder in the direction the MD is
rotating
Supra-pubic Pressure
Woods Screw Maneuver
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Procedure
 *Continual rotation in a circular motion of the
shoulders either in a clockwise or counterclockwise motion in an effort to “unscrew” the
neonate from the pelvis
Rubin “Rotational” Maneuver Or
“Reverse Woods Screw”
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Identified in 1943
Posterior shoulder is rotated 180 degrees then the delivering
provider reaches in to access the shoulder and push the anterior
shoulder and scapula towards the surface of the chest.
“Shoving scapulas saves shoulders”
Coordination with the delivering provider
*Rocking the baby’s shoulders from side to side, using the flat
surface of the fists or heels of the hands, just above the maternal
symphysis pubis.
Delivery Of The Posterior Arm
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Delivering provider slips in behind anterior shoulder
and reaches in to grasp neonate’s arm and rotate it
out.
Reduces the diameter of the shoulder to shoulder
width.
Increased risk of fracture to the humerus
Maternal Reposition
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Hands and knees - all fours
Squatting
Rotational maneuvers then tried again
Purpose is to open the pelvis and provide more room
Hibbard
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Identified in 1982
Pressure is placed on the baby’s jaw and neck downward in the
direction of the maternal rectum while strong fundal pressure is
given
This allows delivery of the anterior shoulder
Deliberate Fracture Of The Clavicle
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Pressure is put on the baby’s clavicle to
intentionally fracture or “break” the clavicle
and reduce the shoulder
Deliberate Breaking Of The
Maternal Coccyx
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Strong downward pressure is placed on the
coccyx with intention to break it and
increase the pelvic outlet diameter and
allow more room for delivery of the
shoulders.
Zavenelli
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Also known as “Cephalic replacement”
Identified in 1985
The presenting part if returned or pushed back into
the maternal pelvis and an emergency cesarean section
is performed
Is considered as a last resort to get out a live baby.
Symphysiotomy
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Identified in 1986
The maternal symphysis pubis is cut or
split in order to allow delivery of a dead
baby.
Cleidotomy
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Identified in 1983
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The clavicle(s) of a dead baby is cut in
order to allow delivery
Nursing Implications
For Fundal Pressure
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Should never be used to expedite second stage
Should never be used in shoulder dystocia
except during Hibbard procedure
Will further impact the anterior shoulder
against the symphysis pubis
Nursing Implications
For Fundal Pressure
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May cause maternal injury
 *Lacerate the liver
 *Damage the diaphragm
 *Cause uterine rupture
 *Cause uterine inversion and prolapse
 *Cause cervical lacerations and tears
 *Cause vaginal wall tares
 **Has a 77% complication rate
Documentation
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Time head delivered and shoulder dystocia
diagnosed
Duration of the shoulder dystocia
Procedures and maneuvers performed and in
what order
Presence of personnel in the delivery room
Neonatal resuscitation
Neonate condition and complications
Maternal condition and complications
Interventions taken to support mother and
family
Maternal Implications Of Instrument
Deliveries And Shoulder Dystocia
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Higher risk for injury to mother (and nurse)
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Higher risk for postpartum hemorrhage
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Higher risk for c-section
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Potential injury to baby and possibly death
Birth
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What are your responsibilities?
Fetal monitoring
Time of delivery
Delivery of placenta
Labs – cord blood / gases
Repair
Feeding/Bonding
Safety
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Eye protection
Blood and body fluids
Physical safety
Body mechanics
References
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2011), Fetal
Heart Monitoring Principles & Practices. (4th ed.). Dubuque, Iowa: Author.
ACOG Practice Bulletin: Shoulder Dystocia. Number 40, November 2002
American Academy of Pediatrics and The American College of Obstetricians and Gynecologists
(2005). Guidelines for Perinatal Care (6th ed). Authors.
Simpson, K.R., & Creehan, P.A. (2010). AWHONN Perinatal Nursing (4th ed).
Philadelphia: Lippincott.
Martin, E. J., et. al. (2010). Intrapartum Management Modules: A Perinatal Education
Program (4th ed). Philadelphia : Lippincott.
Cunnighanm, F.G., Gant, N.F., Leveno, K.J., Gilstrap, L.C,, Hauth, J. C and Wenstrom, K.D.
(2001). Williams Obstetrics (21st ed). New York: McGraw-Hill.
Oxorn, H. (2001) Oxorn-Foote: Human Labor and Birth (5th ed). Connecticut: AppletonCentury-Crofts