C

LINICAL

R

OUNDS

Management of the Second Stage of Labor in Women
with Epidural Analgesia

Peri Jacobson, CNM, WHNP, and Leslie Turner, CNM, WHNP

M.P., a healthy 21-year-old gravida 1 para 0 at 39 2/7 weeks’
gestation, was admitted to the hospital while in labor. Her history
and prenatal course were uncomplicated. Contractions had begun
9 hours earlier. The vaginal exam upon admission was 4/80/-1
with membranes intact. She was contracting every 4 minutes.
Two hours later, she was re-examined and her cervix was
unchanged. Her contractions were now occurring every 4 to 6
minutes. Her membranes were artificially ruptured in an attempt
to augment her labor. An hour later, her contractions had not
increased in frequency or duration, so the consulting midwife
recommended oxytocin augmentation. M.P. also requested and
received epidural analgesia at this time. Seven hours later, after
20 hours of labor, she was fully dilated and the head was at 0
station. Her epidural was discontinued, and 30 minutes later,
coached pushing began because she had no spontaneous urge to
push. She was instructed to use a closed glottis technique, in
several positions, including semi-Fowler’s, lateral, and on her
hands and knees. Her pain had returned, and despite encourage-
ment to push with her contractions, she clung to the bed’s
siderails and cried out through several of her contractions. She
was becoming exhausted, and her pushing efforts became in-
creasingly ineffective. Finally, 2 hours and 30 minutes later, she
spontaneously birthed a healthy baby boy weighing 3020 g, with
9/9 Apgars. Inspection revealed a second degree tear, which was
repaired under local anesthetic. Breastfeeding was not initiated in
the immediate postpartum period at M.P.’s request because of
self-reported exhaustion. When she was seen on her first day
postpartum, she expressed concern about the return of severe pain
during pushing and was angered that the epidural had been discon-
tinued without her understanding or consent. She stated that she was
“still exhausted” from labor and “just wanted to sleep,” so had not
attempted breastfeeding. She declined rooming-in the previous
night, and at the time of the visit, the baby remained in the nursery.
Later that day, following discussion with her husband, she requested
to speak to a patient advocate regarding the discontinuation of her
pain medicine.

MANAGEMENT OF SECOND STAGE IN WOMEN
WITH EPIDURALS

A midwife who practices in a hospital setting frequently
finds herself caring for a woman laboring with epidural
analgesia. According to a 2002 Maternity Care Associ-
ation survey, almost two-thirds of women choose to labor
with epidural anesthesia.

1

Care for these women during

the second stage can be challenging, because the urge to
push and overall sensation is limited by the medication.

In an effort to improve pushing effectiveness, many obstet-
ric practitioners routinely turn off epidurals during second
stage and/or coach the woman to practice closed glottis
pushing immediately upon full dilation. When deciding
upon appropriate management strategies for second stage, it
is advisable for practitioners to base their clinical decision
making on current evidence-based findings.

This article reviews the effectiveness of three common

second stage management decisions: 1) immediate ver-
sus delayed pushing, 2) closed versus open glottis push-
ing, and 3) epidural continuation versus discontinuation
at the beginning of second stage.

IMMEDIATE VERSUS DELAYED PUSHING

The current definition of second stage includes three
phases. Phase one is known as “the lull,” and it occurs
between full dilation and the urge to bear down, which is
caused by pressure of the presenting part on pelvic
musculature. The second phase signifies active pushing
efforts, and the third and final phase begins with crown-
ing and ends with birth of the entire body. Internal
rotation and descent begin to occur spontaneously during
the initial “lull” phase of second stage.

2

When active pushing efforts should begin in the patient

with an epidural is not agreed upon. Some clinicians
choose to begin directed pushing efforts immediately
following full dilatation, while others prefer to wait until
the head is seen at the introitus or an urge to push is felt.
The American College of Obstetricians and Gynecolo-
gists currently recommends that the time limit of second
stage for women with epidurals be 3 hours in primiparous
women and 2 hours in multiparous women.

3

Fraser et al.

4

conducted a large multicenter randomized control trial of
1862 women that compared the outcomes of primiparous
women with continuous epidural analgesia who were
encouraged to push at full dilation with those who were
permitted a period of rest and descent. In this study,
spontaneous delivery occurred more frequently when a
policy of delayed pushing was employed (57.5% vs
52.7%, respectively; relative risk [RR] 1.09; 95% confi-
dence interval [CI] 1.00 –1.18). The study also showed
that although the overall length of second stage was
slightly increased by delayed pushing, that time spent
pushing was actually reduced. Maternal and infant mor-
bidity were found to be similar in the two groups.

4

Address correspondence to Peri Jacobson, CNM, WHNP, 181 Seventh
Avenue, 2B, New York, NY 10011. E-mail: [e-mail]

82

Volume 53, No. 1, January/February 2008

© 2008 by the American College of Nurse-Midwives

1526-9523/08/$34.00

• doi:10.1016/j.jmwh.2006.08.013

Issued by Elsevier Inc.

A prospective randomized trial of 252 women by

Hansen and Foster

5

compared pushing outcomes of

women with epidurals and found decreased pushing
times in both primiparous and multiparous women who
delayed pushing until descent had occurred (58.16 min vs
75.77 min, respectively; P

⫽ .021). The rest and descent

group also had fewer fetal heart rate decelerations (0.135
decelerations/min vs 0.227 decelerations/min, not statis-
tically significant) and the primiparous mothers reported
less fatigue. Both groups had similar rates of perineal
injury, overall instrumental delivery, and endometritis, as
well as comparable Apgar scores and cord pH values.

5

A meta-analysis done by Roberts et al.

6

reviewed nine

studies on the effects of immediate versus delayed
pushing with epidural analgesia, two of which have been
mentioned above. The only outcome measured by all of
these studies was the incidence of instrumental delivery.
This analysis showed a statistically significant 31%
reduction in midpelvic instrumental deliveries in women
who were in the delayed pushing groups. Seven of the
studies reviewed also revealed a significant lengthening
of second stage with delayed pushing, due to the increase
in the passive phase of second stage.

6

As evidenced by

the studies described above, a longer passive phase of
second stage does not mean poorer outcomes for mother
and baby. In fact, recent studies have suggested that an
increased length and intensity of the active pushing phase
of second stage may be responsible for greater maternal
and fetal compromise.

6

OPEN VERSUS CLOSED GLOTTIS PUSHING

Simpson and James

7

conducted a randomized controlled

trial of 45 nulliparous women with epidurals, randomized
during second stage into two groups with distinct push-
ing styles. One group was coached to perform closed
glottis pushing upon full dilation, and the other was
encouraged to perform open glottis pushing when the
urge to push was strongly felt. The length of the active
pushing stage in the immediate/closed glottis pushing
group was longer than in the delayed pushing group
(mean of 101 min vs 59 min, respectively; P

⫽ .002).

The women in the immediate pushing group had more
episodes of fetal oxygen desaturation (FSpO2

⬍ 30% ⱖ

2 min). This group also had more variable (22.4 vs 15.6,
respectively; P

⫽ .03) and prolonged fetal heart rate

decelerations (3.3 vs 1.9, respectively; P

⫽ .05), as well

as more perineal lacerations. There were no differences
in cord blood gas values or Apgar scores, but it is worth

stating that the participants in this study were healthy
women with reassuring fetal heart tracings at the onset of
labor.

7

This raises the question of what effects immedi-

ate/closed glottis pushing might have on a fetus who has
evidence of acidemia or fetal intolerance of labor. Be-
cause this was a small study, it would be helpful to see
more research done on this very important aspect of
second stage management.

Another randomized trial, done by Schaffer et al.

8

examined the effects of coached versus uncoached push-
ing on pelvic floor structure and function of 128 primip-
arous women without epidurals. The coached group was
instructed to perform closed glottis pushing with contrac-
tions at the onset of second stage. Each push was to last
10 seconds, and pushing was to be repeated until the
contraction was gone. The uncoached group was told to
“do what comes natural.” The coached group had signif-
icantly decreased bladder capacity and first urge to void
3 months postpartum. Urodynamic stress incontinence
was found in 16% for the coached group versus 12% in
the uncoached group (P

⫽ .17). Detrusor overactivity

also doubled in the coached group (P

⫽ .42).

8

Though

this study was conducted with women who did not use
epidural analgesia, the results suggest that the routine use
of immediate closed glottis pushing may have damaging
effects on the pelvic floor.

EPIDURAL: CONTINUATION VERSUS DISCONTINUATION

Epidurals are a highly effective method of pain control
for the laboring woman. However, epidural use is asso-
ciated with an increase in the incidence of vacuum and
forceps deliveries.

9 –11

This has been a subject of contro-

versy within the anesthesia and obstetric communities, as
some authors claim that there is no increase in the
incidence of instrumental delivery between women la-
boring with or without epidural analgesia.

12–14

Instru-

mental deliveries are more likely to cause negative
maternal and neonatal sequelae than normal spontaneous
vaginal birth.

We have observed practitioners in the obstetric and

midwifery communities regularly discontinue epidural
administration once full dilatation is achieved, based on
the speculation that this will improve pushing efforts,
shorten second stage, decrease instrumental deliveries,
and improve perineal outcomes. While the decision to
discontinue epidural anesthesia once fully dilated is
widespread, there is a surprising lack of research exam-
ining its effectiveness.

15

A 2004 Cochrane Systematic Review of five random-

ized control trials provides the most comprehensive
examination of this practice to date. The review specif-
ically compared maternal and neonatal outcomes follow-
ing second stage epidural discontinuation versus contin-
uation. This analysis, which included data from 462
women, found that stopping epidural administration did

Peri Jacobson, CNM, WHNP, was enrolled in her final semester at
Columbia University, completing a CNM/WHNP dual certification at the
time the article was written.

Leslie Turner, CNM, WHNP, was enrolled in her final semester at
Columbia University, completing a CNM/WHNP dual certification at the
time the article was written.

Journal of Midwifery & Women’s Health

• www.jmwh.org

83

not significantly decrease the incidence of instrumental
delivery. The only statistically significant difference
found was an increase in the rate of inadequate pain
relief.

16

There are several flaws in this review, as it is based on

only 5 studies; 2 of which were considered to be substan-
dard. The epidural protocols (difference in medications
used, dosage rates, and methods/time of administration)
varied in each of the studies as well, further confounding
the conclusions. Furthermore, 28% of women with con-
tinuous epidural infusion had instrumental deliveries
versus 23% of those with epidurals discontinued at full
dilatation. While this difference may not be statistically
significant, it is clinically significant.

13

We must qualify

that there is a paucity of research on this issue.

DISCUSSION

Based on the current evidence, management of second
stage for women with epidural anesthesia should include
the following: 1) time allowance for fetal descent prior to
pushing, coupled with the encouragement of open glottis
or uncoached pushing, and 2) continuation of epidural
infusion through second stage. In the case presented here,
the patient’s epidural was discontinued and coached
pushing started upon full dilation. This patient was not
given time for rest and to allow passive fetal descent, nor
was she consulted about the discontinuation of her pain
medication. These management decisions may have led
to M.P.’s poor coping, maternal exhaustion secondary to
prolonged pushing, and dissatisfaction with pain control.
In addition, without the benefit of endogenous endor-
phins, which are produced in women who labor without
anesthesia, the sudden, unexpected return of pain, often
at an intensity much greater than experienced preanes-
thesia, can be overwhelming.

17

As we know, the psyche of

a laboring woman is a critical component of a successful
birth; therefore, her emotional response to the return of
painful contractions should not be minimized. The pa-
tient’s fear and anxiety resulting from the unexpected
return of painful contractions may, in fact, have a negative
impact on labor outcomes.

As the Cochrane Systematic Review has shown, the

only statistically significant outcome of discontinuing
epidural anesthesia in second stage is a marked increase
in pain. This patient reported an unmanageable level of
pain, and as a result, was unable to focus her attention on
her pushing efforts. When questioned postpartum about
her birthing experience, she reported dissatisfaction be-
cause of inadequate pain control and exhaustion. This
exhaustion was possibly caused by the long active phase
of second stage, which may have been prevented if she’d
had a period of rest once full dilation was diagnosed. Her
dissatisfaction and exhaustion appeared to negatively
impact the important mother– child bonding that occurs
in the first days of life.

Practitioners need to examine the ethics of discontinu-

ing pain medication that a patient has requested and for
which she has given informed consent. Pain relief is a
patient’s right, and the removal of pain medication
without informed consent, especially in light of research
demonstrating its ineffectiveness in improving birth out-
comes, is both ethically and clinically questionable.
Practitioners should also strive to provide individualized
care to their clients, discarding the notion that every
mother will push effectively utilizing standardized tech-
niques. Lastly, midwives need to contribute to the knowl-
edge base by exploring the psychological and emotional
aspects of labor.

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