Case Study: Labor pain and second stage management

  1. 23 yr old G1 P0 at 39 wks by LMP c/w 19 week ultrasound arrives at triage and is having contractions, no loss of fluid, good fetal movement and a little bloody show. She was scheduled for induction on this same day for GDMA2- but is having contractions that are strong every 5 minutes.

What further history do you want?

What further exam do you want?

What do you want to do?

  1. So we wait for 2 hours and check her again. Now she is 5 cm/80%/-2 (same examiner) with BBOW. She is contracting every 5-6 minutes. FHTs reassuring. Pain is 2/10. What do you want to do now?
  1. You didn’t start pitocin before, although maybe you should have, and the re-check 2 hours later is unchanged. You discuss with her that her labor is slowed and we recommend starting pitocin to help her contractions. She agrees. She asks if the pain will get worse. What might you discuss with her at this point?
  1. Pitocin is started. Her pain over the next two hours becomes worse and worse. She rates it an 8/10. She has a cousin who is present who has had three children herself and is acting as her doula. She is using light massage and gentle efflurage and encouraging her through difficult contractions. Will this make any difference?
  1. You check her again and she is 8 cm/90% and -1 station. FHTs are re-assuring. She has a BBOW and contractions are every 3-5 minutes. What do you want to do now? Does she need an AROM? Does she need an IUPC?
  1. You don’t break her bag and you don’t place an IUPC and two hours later you check her cervix and she is complete and zero station. Her FHTs are re-assuring and she is tolerating pain well with the different positions you have suggested to her. She seems to be in “the zone” but when you ask if she feels like pushing she says, “not really, I have a lot of pressure but don’t really want to push yet.” What do you do now?
  1. So you hold the space for her success, take a deep breath, realize it is OK that it is taking as long as it is taking and let her labor down. She is tolerating her labor pain and really seems to be doing well. All of a sudden, about 45 minutes later you get called in to the room because she is throwing up and wants to “PUSH!!!”. What is going on?
  1. You go into the room and she is pushing and grunting with her legs closed and a lot of screaming. What do you do now?
  1. After a couple hours of pushing, progress has been made- she pushes down to almost plus two station and baby has very little molding. FHTs are fabulously reassuring. She really seems to have figured this pushing thing out- she is using a mirror and occasionally touches the baby’s head. She is uncomfortable and says she is feeling a lot of burning especially when we try to direct her pushing with fingers. How can you help? Should you take her to cesarean?- after all it has been two hours.
  1. She pushes out a vigorous baby boy 30 minutes later with no perineal tears! She is elated and baby is placed directly on her chest. They snuggle and bond and the every day miracle of birth has started the cycle of life again. How beautiful to be a witness of this.

“Attending births is like growing roses. You have to marvel at the ones that just open up and bloom at the first kiss of the sun but you wouldn't dream of pulling open the petals of the tightly closed buds and forcing them to blossom to your time line." ~ Gloria Lemay

“Labor is hard work, but women are strong and nature helps make the hard work possible. Working with pain, rather than avoiding it entirely, ensures high levels of endorphins and finding comfort in responding to what she feels—moving, rocking, walking, moaning. It also facilitates the progress of labor”

~Judith Lothian

Thanks!

Jen Phillips MD (creator of this here case study)

Leeman L, Fontaine P, King V, Klein M, Ratcliffe S. The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain Relief. Am Fam Physician. 2003 Sep 15; 68(6): 1109-1113.

Leeman L, Fontaine P, King V, Klein M, Ratcliffe S. The Nature and Management of Labor Pain: Part II. Pharmacologic Pain Relief. Am Fam Physician. 2003 Sep 15; 68(6): 1115-1120

Roberts J. (2007). Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning. Journal of midwifery and women’s health 52:238-245.

The Caesarean, Michel Odent 2004.

Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. AmericanJournal of Obstetrics and Gynecology, 194, 10-3. Downe S, Gerrett B, Renfrew M. (2004).

A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia. Midwifery, 20, 157-68.

Gupta JK, Hofmeyr GJ. Position in the second stage of labour for women without epidural anaesthesia. [Systematic Review]. The Cochrane Database of Systematic Reviews 2007 Issue