Oxford Handbook of Midwifery (64 page)

proper consent!

CHAPTER 13
Pain relief: pharmacological

262

Complications

• Impaired descent and rotation of the presenting part. This can sometimes be countered by use of IV oxytocin during the second stage. This is the main cause of the increase in instrumental delivery associated with epidural analgesia.
  
• Sudden profound hypotension can be prevented by adequate loading of the maternal circulation throughout. Emergency resuscitation drugs should be available in the room at all times.
  
• Dural tap: the spinal needle or cannula pierces the dura mater, allowing cerebrospinal fluid (CSF) to escape and causing severe headache. Pushing efforts may need to be restricted. Following delivery, the mother must be nursed flat for 24h. A blood patch may be performed to seal the dura mater.
  
• Infection at the site of introduction.
  
• Fetal hyperthermia due to the increased warming effect in the woman’s lower body. This increases as the length of labour increases. Continuous electronic monitoring of the fetal heart is required throughout. This can be offset by delaying the commencement of epidural analgesia by using other methods, such as an opiate or inhalational analgesia, during early labour; and then by using the lowest doses possible to achieve maternal comfort.
  
• Neurological problems: injury/trauma to the spinal cord caused by drug or operator errors.
  

  Care of the woman during epidural analgesia
  

  How is the lumbar epidural commenced?
  

• Before inserting the epidural, 500mL of IV normal saline (or equivalent) is used to pre-load the maternal circulation, to offset the hypotensive effects of the epidural. This infusion must be maintained throughout labour until the epidural analgesic is no longer required (approximately 1h following delivery).
  
• A senior anaesthetist, appropriately trained nurse, or operating department assistant (ODA) sites the epidural cannula, and the first dose is administered at this time.
  
• The cannula is inserted through a spinal needle, which is used to locate the epidural space. The woman’s position during insertion is critical: she must sit up with her legs over the edge of the bed, feet supported, or lie flat, on her left side with her spine curved outwards and legs flexed, and lie completely still until the cannula is in place.
  
• This position is very difficult to achieve and maintain during frequent
  painful contractions. The midwife must assist the woman and remain
  

  with her until the procedure is completed.
  

• If the anaesthetist needs assistance, a second midwife should be present.
  
• During insertion it is very important to have a clear record of the fetal heart, and the midwife may need to use a hand-held ultrasound transducer to achieve this.
  
• The cannula is secured firmly with adhesive dressings and the filter on the distal end is left easily accessible.
  

  LUMBAR EPIDURAL ANALGESIA
  

  263
  

Care as labour progresses

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Normal labour: second stage
‌‌

Chapter 14

265

Recognition of the second stage
266

Mechanism of labour
270

Principles of care in the second stage of labour
274

Care of the perineum
276
Performing an episiotomy
280
Female genital mutilation
282

Conduct of normal vaginal delivery
284

CHAPTER 14
Normal labour: second stage

266‌‌

Recognition of the second stage

The sometimes difficult transition between the first and second stages of labour is usually an indicator of the changes and readjustments that are made physically and emotionally, in order for labour to continue success- fully. Changes in the woman’s behaviour and physical demeanour provide the midwife with visual and auditory clues, which are characteristic of the end of the first stage of labour and the onset of the second stage. During this time the stress hormones associated with labour are at their peak, suggesting a favourable physiological response to labour.

Visual, auditory, and physical signs

Women may:

• Experience contractions that come very close together, feeling more intense and painful (due to the action of stretch receptors and the effect of oxytocin).
  
• Feel a sensation of wanting to bear down, although the cervix is not quite fully dilated—there is no rationale for preventing women from bearing down if they so desire.
  
• Rest or sleep for periods, sometimes women enter a sleepy phase, where contractions are weaker and less frequent.
  
• Appear to be in trance-like state; distant and withdrawn from carers and difficulty in concentrating, the focus is mainly on giving birth.
  

  This is thought to be the result of the maternal release of B-endorphins during labour, which peak at birth. In a drug-free and non-interventionist labour the woman (and the baby) will be impregnated with opiates which also contribute to the early dependency (attachment) of mother and baby following birth. Women may:
  

• Lose control or feel unable to cope
  
• Strongly vocalize their needs by:
  
  • Distressed statements such as ‘Get me an epidural, I am going home. Get this baby out!’
    
  • Swearing or using language that is uncharacteristic
    
  • Shouting and groaning
    
• Feel strange, shaky, trembling
  
• Feel nauseated or vomit
  
• Experience extremes of hot and cold
  
• Express body language of restlessness and irritability; often women curl their toes during contractions.
  

  Latent phase: physiology
  

  The anatomical recognition of the second stage is full dilatation of the
  cervix, but this does not necessarily coincide with expulsive contractions.
  

• The contractions may subside for a period of 10–12min, or up to 2h, women often take this opportunity to sleep or doze. Often referred to as the ‘rest and be thankful’ phase.
  
• Contractions and the urge to push may be absent or weak.
  
• Once the presenting part has passed through the cervical walls, some adjustment due to decreased volume may be needed. This requires the muscle fibres of the upper segment of the uterus to shorten and
  

  RECOGNITION OF THE SECOND STAGE
  

  267
  

  thicken further; only when the slack has been taken up can progress be made to expulsive contractions and descent down the birth canal.