2nd stage of labor

7/31/2019 2nd Stage of Labor

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KANMANI.S

12TH BATCH MSc (N)


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NORMAL LABOUR Series of events that takes place in

the genital organs in an effort toexpel the viable products ofconception out of the womb

through the vagina into the outerworld Is called labor.


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Cont-----Labor is called normal (eutocia) if itfulfils the following criteria. 1.

Spontaneous in onset and at term, 2.With vertex presentation, 3. Withoutundue prolongation, 4. Natural

termination with minimal aids, 5.Without having any complicationsaffecting the health of the mother or

the baby.


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Events in the second stage of labor

The second stage begins with the complete dilatation of thecervix and ends with the expulsion of the fetus.

This stage is concerned with the descent and delivery of the

fetus through the birth canal. With the full dilatation of the cervix , the membraneusually rupture and there is escape of good amount ofliquor amnii.

uterine contraction and retraction become stronger. The

uterus becomes elongated during contraction. The elongation is partly due to straightening , of the fetusand partly due to stretching of the lower uterine segment.


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Contin----Delivery of the fetus is accomplished by the

downward thrust offered by uterinecontractions supplemented by voluntary

contraction of abdominal muscles against theresistance offered by bony and soft tissues ofthe birth canal. There is always a tendency topush the fetus back into the uterine cavity by

the elastic recoil of the tissue of the vaginaand the pelvic floor. This is effectivelycounterbalanced by the power of retraction.


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Contin----Thus, with increasing contraction and

retraction, the upper segment becomes

more and more thicker with correspondingthinning of lower segment.

The expulsive force of uterine contractions is

added by voluntary contraction of theabdominal muscles called bearing downefforts.


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CLINICAL COURSE OF SECOND

STAGE OF LABORThree phases: the latent

the descent

the transition phases.

Each phase is characterized by

maternal verbal and nonverbalbehaviors, uterine activity, the urge tobearing down, and fetal descent.


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The latent phase is a period of rest and relative calm. Theurge to bearing down is not well established and isexperienced primarily during the time of contraction.

The descent phase is characterized by strong urges tobearing down as Fergusons reflex is activated when thepresenting part presses on the stretch receptors of thepelvic floor.

In the transition phase, the presenting part is on theperineum and bearing down efforts are most effective forpromoting birth. The woman may be more verbal about thepain she is experiencing; and may act out of control.


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Pain and bearing down efforts Pains: The intensity of the pain increases. The pains come

at intervals of 2-3 minutes and lasts for about 1-1.5 minutes.

BEARING DOWN EFFORTS(Fergusons reflux)

It is the additional voluntary expulsive effortsthat appear in the late second stage (expulsive phase). It isinitiated by nerve reflexes set up due to stretching of the

vagina by the presenting part. This stimulation causes therelease of oxytocin from the posterior pituitary glands,

which provokes stronger expulsive uterine contractions.


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Contin---- MEMBRANES STA TUS Membranes may rupture with a gush of liquor per

vaginam. Rarely, spontaneous rupture may not takes placeat all, allowing the baby to be born in a caul

DESCENT OF THE FETUSAbdominal findings are- progressive descent of

the head, assessed in relation to the brim, rotation of theanterior shoulder to the midline and change in position ofthe fetal heart rate shifted downwards and medially.

Internal examination reveals descent of the head inrelation to the Ischial spines and gradual rotation of thehead evidenced by position of the sagittal suture and theocciput in relation to the quadrants of the pelvis.


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VAGINAL SIGNS

As the head descends down, it distends theperineum, the vulval opening looks like a slit through which the

scalp hairs are visible. During each contraction, the perineum is markedly distended

with the overlying skin tense and glistening and the vulvalopening becomes circular.

The maximum diameter of the head stretches the vulval outlet

and there is no recession even after the contraction passes off.This is called crowning of the head.The head is born by theextension.

Immediately after the delivery of shoulders and trunk, a gush ofliquor(hind waters) follows, often tingled with blood.


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Crowning of head


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MATERNAL SIGNS

There are features of exhaustion.Respiration is, slowed down with increased

perspiration. During the bearing down efforts, the facebecomes congested with neck veins prominent.Immediately following the expulsion of the fetus, themother heaves a sigh of relief.

FETAL EFFECTS Bradycardia during contractions is very

much prominent which often continues because ofquick successive contractions.


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MANAGEMENT OF SECOND STAGE

OF LABOUR PRINCIPLES

To assist in the natural expulsion of the fetus slowlyand steadily.

To prevent perineal injuries.


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GENERAL MEASURES

The patient should lie down in bed

Constant supervision_ (a) to note FHR at 5 minutes interval, (b)

to note the maternal pulse and blood pressure at 15minutesinterval,(c) to give assurance, advice and instruction to patient soas to keep up the morale and to avail maximum co-operationduring voluntary expulsion of the fetus.

To administer inhalation analgesics

Vaginal examination is done at the beginning of the second stagenot only to confirm its onset but to detect accidently cordprolapse, if any. Position and station of the head and progressivedescent of the head can be ensured.

Nothing is given by mouth, except sips of water or ice.


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ASSESSMENT

In 1st stage Dilatation and effacement of cervix

Sudden appearance of bloody showAn episode of vomiting

Increased bloody show

Shaking of extremities

Increased restlessness

Involuntary bearing down efforts


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Assessment in the second stage of

labor The frequency, strength, and duration of uterine contractions;

the duration of uterine relaxation; and the fetal response. Monitor fetal heart rate-including variability, acceleration and

deceleration pattern; low risk birth-FHR in every 15mins;highrisk birth-FHR in every 5 mins

Maternal pulse and blood pressure Status of bladder( especially in case of epidural block) Status of show and character of amniotic fluid Maternal energy level Emotional response of woman and partner towards 2nd stage of

labor Fetal descent


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Duration of 2nd

stageA second stage of more than 2 hours in a1st pregnancy

and of 1.5 hours in subsequent pregnancies may beconsidered prolonged in women without regional

analgesia .

n e case o pro onge secon


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n e case o pro onge seconstage

Nursing diagnosis Risk for injury to mother and fetus related to

persistent use of Valsalvas maneuver

Situational low self esteem related to knowledgedeficit regarding normal beneficial effects ofvocalization during bearing down efforts, / inability tocarry out birth plan for birth without medication

Ineffective individual coping related to coaching thatcontradicts womans physiologic urge to push

Pain related tobearing down efforts and distentionof the perineum

n e case o pro onge secon


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n e case o pro onge seconstage

Nursing diagnosis Anxiety related to inability to control defecation when

bearing down / knowledge deficit regarding and

inexperience with perineal sensations associated with theurge to bear down.

Risk for injury to mother related to inappropriatepositioning of mothers legs in stirrups

Risk for infections related to prolonged rupture ofmembranes/ perineal incision(episiotomy) / perineallacerations

Situational low self esteem, partner or father, related toinability to support mother during second stage of labor.


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CONDUCTION OF DELIVERY Delivery is divided into three phases-

Delivery of the head

Delivery of the shoulder Delivery of the trunk

Delivery of the head: The principles to be followedare to maintain flexion of the head, to prevent its

early extension and to regulate its slow escape outof the vulval outlet.


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BEARING DOWN EFFORTS


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Care following delivery of the head

The mucus and blood in the mouth and pharynx are to bewiped with sterile gauze piece on little finger. Or by using

bulb syringe The eye lids are then wiped with sterile cotton swabs.(from

medial to the lateral canthus)

The neck is then palpated to exclude the presence of any

loop of cord(20-25%)


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Contin--- Delivery of the shoulders

Wait for the uterine contractions tocome and for the movements of restitution and

external rotation of the head to occur. Traction on thehead should be gentle to avoid excessive stretching ofthe neck causing injury to the brachial plexus,hematoma of the neck or fracture of the clavicle

Delivery of the trunk After the delivery of the shoulders, the fore

finger of each hand are inserted under the axillae andthe trunk is delivered gently by lateral flexion.


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Immediate care of new born Soon after the delivery of the baby, it should be

placed in a tray covered with sterile linen. The trayis placed between the legs of the mother andshould be at a lower level than the uterus tofacilitate gravitation of blood from the placenta to

the fetus.Air passage should be cleared of mucus by sucker.

Apgar rating at 1 to 5 minutes is to be recorded


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Contin--- Clamping and ligature of the cord--- cord is to be clamped and

divided as soon as convenient following birth of the baby. Butearly clamping should be done in cases of Rh incompatibility (toprevent antibody transfer), neonatal asphyxia, preterm babies,

IUGR babies. The cord is clamped by two Kochers forceps, thenear one is placed 5cm away from the umbilicus and is cut inbetween.

Quick check method is made to detect any gross abnormalityand the baby is wrapped in cotton or warm material. The

identification tape is tied both on the wrist of the baby and themother in hospital confinement and after showing the baby tothe mother, the baby is transferred to the nursery for furthermanagement and care.


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EPISIOTOMY

A surgically planned incision onthe perineum and the posterior

vaginal wall during the secondstage of labor is called episiotomy.


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Objectives

To enlarge the vaginal introitus

To prevent perineal tearsA neat surgical incision is easier to

repair than a ragged tear

May prevent pelvic relaxation andvaginal wall prolapsed


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IndicationsoAnticipating perineal

Inelastic perineum

Manipulative delivery

To cut short second

Fetal interest fetal distress, premature baby, breech presentation


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Timing of episiotomy

Bulging thinned perineum duringcontraction just prior to crowningis the ideal time


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Types

Medio-lateral episiotomy

Midline episiotomy

Lateral episiotomy

J shaped episiotomy


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Contin---Medio-lateral: the incision is made

downwards and outwards from the

midpoint of the fourchette either to theright or left.

Midline: the incision commences fromthe centre of the fourchette andextends posteriorly along the midlinefor about 2.5cm


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Contin---Lateral: the incision starts from about 1cm

away from the centre of the fourchette and

extends laterally. J shaped: the incision begins in the centre

of the fourchette and is directed posteriorly

along the midline for about 1.5cm and thendirected downwards and outwards along 5or7 o clock position to avoid the analsphincter.


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Post operative care

Dressing :

Comfort:Ambulance:

Removal of stitche


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Complications

Immediate

Extension of the incision

Vulval haematoma

InfectionWound dehiscence


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contin---Remote

Dyspareunia:

Chance of perineal lacerations


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Advantages of episiotomy

Maternal: -- Easy to repair and healsproperly.

--Preserves the strength of pelvic floor

-- Lacerations of rectum can be avoided

--Shortening of second stage


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Fetal: -- It minimizes intracranial injuries

-- Reduces fetal asphyxia and acidosis.


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EQUIPMENTS NEEDED FOR

NORMAL VAGINAL DELIVERY


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sponge holding forceps


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Long straight scissors or

perineorraphy scissors


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Kochers haemostatic forceps


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Cord clamp


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Needle holder


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Suture needle with holder


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Catgut suture


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suture needle with holder


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THANKSTHANKS

2nd stage of labor

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