Second Stage of Labor

Stage of Expulsion

Stage II of Labor, the stage of expulsion, begins with full cervical dilation (10 cm) and ends with the birth of the newborn. Maternal efforts to bear down occur involuntarily during contractions that are 1.5–2 min apart, lasting 60–90 sec. The average rate of fetal descent is 1 cm/hr for nulliparas, 2 cm or more per hr for multiparas.

• Activity/Rest-Reports of fatigue-May report inability to self-initiate

pushing/relaxation techniques-Lethargic-Dark circles under eyes

• Circulation-BP may rise 5–10 mm Hg in between contractions.

• Ego Integrity-Emotional responses may range from feelings of

fear/irritation to relief/joy.-May feel a loss of control or the reverse as she is

now actively involved in bearing down.• Elimination-Involuntary urge to defecate/push with contractions,

combining intraabdominal pressure with uterine pressure.

-May have fecal discharge while bearing down.-Bladder distension may be present, with urine

expressed during pushing efforts.

• Pain/Discomfort-May moan/groan during contractions.-Amnesia between contractions may be

noted.-Reports of burning/stretching sensation of

the perineum.-Legs may tremble during pushing efforts.-Uterine contractions strong, occurring 1.5–2

min apart and lasting 60–90 sec.-May fight contractions, especially if she did

not participate in childbirth preparation classes.

• Respiratory-Respiratory rate increases.

• Safety-Diaphoresis often present-Fetal bradycardia appearing as early

decelerations on electric monitor during contractions (head compression) or variables (cord compression)

• Sexuality-Cervix fully dilated (10 cm) and 100% effaced.-Increased vaginal bloody show.-Rectal/perineal bulging with fetal descent.-Membranes may rupture at this point if still intact.-Increased expulsion of amniotic fluid during

contractions.-Crowning occurs; caput is visible just before birth

in vertex presentation.

Assessment• Signs of imminent delivery

• Progress of descent

• Maternal/fetal vital signs

• Maternal pushing efforts

• Vaginal distension

• Bulging of perineum

• Crowning

• Birth of baby

Nursing diagnosis • Pain [acute]• Skin/Tissue Integrity, risk for impaired• Injury, risk for fetal

Planning• Facilitate normal progression of labor

and fetal descent.• Promote maternal and fetal well-

being.• Support client’s/couple’s wishes

regarding delivery experience, maintaining safety as a priority.

• NURSING DIAGNOSIS: Pain [acute]• May Be Related To: Mechanical pressure of

presenting part, tissue dilation/stretching, nerve compression, muscle hypoxia, intensified contractile pattern

• Possibly Evidenced By: Verbalizations, distraction behavior (e.g., restlessness), facial mask of pain, narrowed focus, autonomic responses

• DESIRED OUTCOMES/EVALUATION Verbalize reduction of pain.

• CRITERIA—CLIENT WILL: Use appropriate techniques to maintain control. Rest between contractions.

INTERVENTIONS1. Identify degree of

discomfort and its sources.

2. Provide comfort measures, such as mouth care; perineal care/massage; clean, dry linen and underpads; cool environment (68°F–72°F [20°C–22.1°C]), cool, moist cloths to face and neck; or hot compresses to perineum, abdomen, or back, as desired.

3. Monitor and record uterine activity with each contraction.

RATIONALE1. Clarifies needs; allows for

appropriate intervention.

2. Promotes psychological and physical comfort, allowing client to focus on labor, and may reduce the need for analgesia or anesthesia.

3. Provides information/legal documentation about continued progress; helps identify abnormal contractile pattern, allowing prompt assessment and intervention.

INTERVENTIONS

4. Assist client in assuming optimal position for bearing down; (e.g., squatting or lateral recumbent, semi-Fowler’s position (elevated 30–60 degrees). Assess effectiveness of efforts to bear down.

5. Encourage client to relax all muscles and rest between contractions.

RATIONALE

4. Proper positioning with relaxation of perineal tissue optimizes bearing-down efforts, facilitates labor progress, reduces discomfort, and reduces need for forceps application.

5. Complete relaxation between contractions promotes rest and helps limit muscle strain/fatigue.

• NURSING DIAGNOSIS: Skin/Tissue Integrity, risk for impaired

• Risk Factors May Include: Precipitous labor, hypertonic contractile pattern, adolescence, large fetus, forceps application

• DESIRED OUTCOMES/EVALUATION Relax perineal musculature during bearing-down efforts.

• CRITERIA—CLIENT WILL: Be free of preventable lacerations.

INTERVENTIONS

• Assist client/couple with proper positioning, breathing, and efforts to relax. Ensure that client relaxes the perineal floor while using abdominal muscles in pushing.

• Offer use of birthing bed in upright position. Encourage squatting, Fowler’s position, or standing while pushing, if these positions are not contraindicated.

RATIONALE

1. Helps promote gradual stretching of perineal and vaginal tissue. If maternal tissue within the birth canal or perineum resists gradual stretching as the presenting part of the fetus descends, trauma or lacerations of the cervix, vagina, perineum, uretha, and clitoris are possible.

2. Upright positions reduce duration of labor, enhance forces of gravity, reduce need for episiotomy, and maximize uterine contractility.

INTERVENTIONSCollaborative

3. Assess for bladder fullness; catheterize prior to delivery, as appropriate.

4. Assist with midline, or mediolateral episiotomy, if necessary.

5. Maintain accurate delivery records of location of episiotomy and/or lacerations. Record type and timing of forceps if used.

RATIONALE

3. Reduces bladder trauma from presenting part.

4. Although controversial, episiotomy may prevent tearing of perineum in cases of a large infant, rapid labor, and insufficient perineal relaxation. It may shorten stage I of labor, especially when forceps are used.

5. Ensures proper documentation of events occurring during delivery process; identifies specific problems affecting postpartal recovery; e.g., maternal tissue

trauma is increased with forceps application, which

may result in possible lacerations or extension of

episiotomy, increased level of postpartal discomfort.

NURSING DIAGNOSIS: Injury, risk for fetal

Risk Factors May Include:Malpresentations/positions, precipitous delivery, or cephalopelvic disproportion (CPD)

DESIRED OUTCOMES/EVALUATION: Be free of preventable trauma or other complications.

INTERVENTIONS1. Assess fetal position, station,

and presentation.

2. Monitor labor progress and rate of fetal descent.

RATIONALE1. Malpresentations such as face,

mentum (chin), or brow may prolong labor and increase the likelihood that cesarean delivery will be necessary, because lack of neck flexion increases the diameter of the fetal head as it passes through the pelvic outlet. Breech presentation usually necessitates surgical intervention, owing to the high risk of spinal cord injuries resulting from hyperextension of the fetal head during vaginal delivery.

2. Precipitous labor increases the risk of fetal head

trauma because skull bones do not have adequate

time to adjust to dimensions of the birth canal.

INTERVENTIONS3. Note color of amniotic fluid.

4. Transfer to delivery room, as appropriate, when vertex is visible at introitus in nullipara, or when multipara is 8 cm dilated.

5. Remain with client and monitor pushing efforts as head emerges. Instruct client to pant during process.

RATIONALE3. Meconium-stained amniotic fluid,

greenish in color, may indicate fetal distress caused by hypoxia in a vertex presentation or to compression of fetal intestinal tract in breech presentation.

4. If delivery is to occur in area separate from the labor setting, transfer at this time ensures that infant is born where emergency medications and equipment are available, if needed.

5. Ensures that trained personnel are present and reduces possibility of trauma to fetal vertex; allows gradual accommodation of skull bones to birth canal and overriding of sutures.

Mechanisms of Labor

There are eight classical steps in the normal mechanism of labor as following here:

Engagement• This is also called lightening or dropping• The fetus nestles into the pelvis• This is when the presenting part is at the level of the

ischial spines or at a zero (0) station. Before this time, it is referred as "floating."

Descent• This process starts from the time of engagement until

birth and is assessed by the station.• The fetal head undergoes as it begins its journey through

the pelvis.• As the fetal head engages and descends, it assumes an

occiput transverse position because that is the widest pelvic diameter available for the widest part of the fetal head.

Flexion

While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis. When flexion occurs, the occipital (posterior) fontanel slides into the center of the birth canal and the anterior fontanel becomes more remote and difficult to feel. The fetal position remains occiput transverse.

Internal RotationWith further descent, the occiput rotates anteriorly and

the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position.

ExtensionAs the previously flexed head slips out from under the pubic bone, the fetus is

forced to extend his head so that the head is born pushing upward out of the vaginal canal. The natural curve of the lower pelvis and the baby's head being pushed outward forces distention of the perineum and vagina. As it moves through the vaginal canal, the chin lifts up (extends) and the head is delivered. During this maneuver, the fetal spine is no longer flexed, but extends to accommodate the body to the contour of the birth canal.

RestitutionAfter the head emerges, the fetal head becomes in a realignment.

External RotationThe shoulder of fetus externally rotates after head emerging and

restitution The shoulder is in the anteroposterior diameter of the pelvis.

Expulsion• This is the birth of entire body.(a)The top of the anterior shoulder is seen next just under the

pubis. (b) Gentle downward pressure by the physician delivers the

anterior shoulder. (c) The head is gently raised to deliver the posterior shoulder. (d) The rest of the body follows the head, which then completes

expulsion. (e) The fetus remains completely passive as it moves through

the birth canal.

The first four movements (descent, flexion, engagement, and internal rotation) do not have to occur in any specific order.

A general understanding of how the fetus may present itself during labor will help you to understand why some labors are so long and difficult. In addition, this will help you in understanding what the fetus must go through during the process of presenting himself out of the patient's womb.