The smart way to learn. The smart way to teach.


Course PAID
Do you realy want to delete this discussion?
Forum >>

prolonged second stage

prolonged second stage Posted by Aroosha B.
This woman needs assisted delivery most likely instrumental vaginal .(ventouse / forceps )and less likely abdominal delivery, the need of which may arise in case of contraindication , failure or woman refusal for instrumental delivery .
Decision of above intervention will depend upon assessment of foetal and maternal well being ,ruling out any fetopelvic disproportion ,Skill and experience and facilities for instrumental delivery and informed consent of patient .
So first step in management would be to assess fetal well being by CTG by which we can decide whether to have non interventional approach or urgent delivery .As regards to maternal wellbeing ,it is assessed by ruling out medical conditionS Which contraindicate prolonged pushing and urine Ketone assessment is also indicated for urgent delivery.
Next Step is to rule out feto pelvic disproportion which although is very unlikely in this case but is prerequisite for any intervention It is done by ruling out any H/O diabetes ,fetal macrosmia shown by recent. USG and by per abdomens and pervaginum is also important to assess effectiveness of uterine contraction.

After assessment different option of delivery are discussed with the patient and informed consent is taken. Option of non interventional delivery for another half an hour with or without Syntocinon dependindg upon uterine activity is valid , if there?s no Contraindication and the women gives Consent for it as it is l as associated with less maternal and fetal risk But this option may not be acceptable in this woman as she is exhausted.Anyhow if she accepts, she is given psychological Support and asked to bear down only when the head is on the perineum without her being exhausted
Other option are instrumental vaginal delivery . Risk and benefits are to be explained to patient .Ventouse is recommended as instrument of choice by RCOG as it is associated with less maternal risk but has risk of failure which can be decreased by use of Bird cup .Its associated fetal Complication LIKE subgaleal hematoma and retinal hemorrhage is to be explained .
Other options?are of forceps delivery either by manual rotation followed by direct application of it or by low out let forceps or rotational forceps delivery but it need more skill and experience and associated with more maternal complication (like cervical ,Vaginal, perineal tear , hemorrhage and fistula) Its fetal complication include injury to nerve ,soft tissue and skull.
If woman opts for instrumental delivery prerequisite of it is to be ensured that is it is preferably done in OR with all preparation for LSCS, experienced operator,neonatal facilities, backup plan in case of failure is to be ensured. Any OPERATIVE vaginal delivery is to be abandoned if there is no imminent delivery following three pulls of correctly applied instrument by experience operates If this fails option of Sequential instrument like application of forceps after VENTOUSE is there as it is associated with less maternal mortality and morbidity than LSCS in second Stage .
Incase of woman refusal or failed instrumental delivery Lscs is an option which Should be done by an experienced person .
Post-Natal care ?..Pts is advised to Keep good hygiene.,analgesic like paracetamol or dicloferac is given ,Antibiotics are prescribed. women Should be assessed for Risk of VTE and thrombo prophylaxis is accordingly considered. It is also important to Keep fluid balance Chart for first 24 hour to detect urinary retention. As this patient is with epidural,choice of indwelling Catheter is given for12 hours to avoid urinary retention. Pt is also advised physiotherapy to avoid incontinence which is common after instrumental delivery .Psychological support is also necessary.
Pt is reviewed by Obstetricians before discharge to discuss indication ,and Complication of procedure and mode of delivery in future Which is likely vaginal in more than 80%, of cases. If there is associated with third or fourth degree perineal tear, patient is given antibiotic analgesic and Stool Softener and advised to followed by anal USG and manometry which will help in detection of degree of defect on which future mode of delivery will depend..