Labour 130318024234-phpapp02

SECOND STAGE OF
LABOUR
Presented by Aiswarya s kumar

INTRODUCTION
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Mata Sahib Kaur College of Nursing, Mohali, Punjab
Normal labour and delivery is a physiologic
process in which the attendant closely monitor
the woman and fetus, with little medical
Intervention required.

DEFINITION
It is the process of expulsion of fetus, placenta
and its membranes through the birth canal.
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NORMAL LABOUR / EUTOCIA
Normal labor occurs
 at term,
 spontaneous in onset,
 fetus presenting by the vertex,
 it complete within 18 hours,
 no complication arise.
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STAGES OF LABOUR
 First stage (or) Dilating stage
 Second stage (or) Pushing stage (or) pelvic
stage
 Third stage (or) Placental stage
 Fourth stage (or) Recovery stage
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FIRST STAGE
OR
DILATING STAGE
8/25/20126 Mata Sahib Kaur College of Nursing, Mohali, Punjab

DEFINITION
It starts with regular and rhythmic uterine
contractions till completion of full cervical
dilatation (10cm).
DURATION :
 For primi gravida 16hrs to 18hrs.
 For multi gravida 6hsrs to 10hrs.
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SECOND STAGE OF LABOUR /
PUSHING STAGE / PELVIC STAGE
8/25/20128 Mata Sahib Kaur College of Nursing, Mohali, Punjab

DEFINITION
It begins with full cervical dilatation (10cm) till the
birth of the baby.
DURATION :
 Primi gravida - 2 hours.
 Multi gravida - 30 minutes.
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 In a woman of higher parity with a previously
dilated vagina and perineum, two or three
expulsive efforts after full cervical dilatation may
suffice to complete delivery.
 Conversely, in a woman with a contracted pelvis
or a large fetus or with impaired expulsive efforts
from conduction analgesia or sedation, the second
stage may become abnormally long.

RECOGNITION OF
COMMENCEMENT OF II STAGE
OF LABOUR
 Expulsive uterine contraction
 Rupture of the fore waters
 Dilatation and gaping of anus
 Appearance of present part
 Congestion of the vulva
 Show
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PHASES OF SECOND STAGE OF
LABOUR
Have 3 phases
* Latent phases / Propulsive phase
* Active phases / Expulsive phase
*Transition phases / Compulsive phase
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Cont. . .
 LATENT PHASES / PROPULSIVE PHASE :
Descend of the fetus 2 cm below from the os to the pelvic
floor .
 ACTIVE PHASES / EXPULSIVE PHASE :
Descend of the fetus from the os 2cm below to the vaginal
outlet ( Crowning )
Ferguson reflux : Pressure exerted by the presenting
part over the cervix causing involuntary
uterine contraction
 TRANSITION PHASES / COMPULSIVE PHASE :
Birth of the baby from the vaginal outlet till extension .
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Phases 2nd
stage:
1.Latent phase
-Is a period of rest and relative calm
-Fetus continues to decent passively through the
birth canal and rotate to anterior position as
result UT contraction

CONT.
- Woman is quiet and relax with her eyes closed
between contractions.
- The urge to bear down is not well
established and my not be experienced at
all or only during the peak of contraction

Phase 2nd
stage
2. Descent phase (active pushing)
- Strong urges to bear down as ferguson
reflex is activated when the presenting part
presses on the stretch receptor of the pelvic
floor, the fetal station 1+, position is
anterior.

Phase 2nd
stage
3. Transition phase
- The presenting part on the perineum
- Bearing down is more effective for promoting
birth
- woman more verbal about pain, she may
scream or swear and may act out of control

PHYSIOLOGY OF II STAGE OF
LABOUR
I Uterine action
 Contraction becomes stronger, longer but less frequent.
 Membranes rupture spontaneously.
 Consequent drainage of liquor allows the hard, round
fetal head to be directly applied to the vaginal tissues
and aid distension.
 Fetal axis pressure increasing the flexion of the head
which results in smaller presenting diameter ,more rapid
progress and less trauma to both mother and fetus.
 Expulsive contraction.
 Compulsive contraction
 Involuntary uterine contraction.
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Cont . . .
II Soft tissue displacement :
As the hard fetal head descend, the soft tissue of the
pelvis become displace.
Anteriorly the bladder is pushed upwards into the
abdomen which cause stretching and thinning of the
urethra.
Posterioly the rectum becomes flattened into the
sacral curve and the pressure of the advancing head
expels any residual faecal matter.
Laterly the Levator ani Muscles dilate and thins out
and perineal body is flattened ,displaced ,stretched
and thinned. 8/25/2012
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Duration of 2nd
The duration of 2nd
stage of labor is influenced by several
factors :
1. Effectiveness of the primary and secondary powers of
labor
2. Type and amount of analgesia used
3. Physical and emotional condition
4. Position, activity level, parity

Duration of second stage
5. Pelvic adequacy of the laboring woman (size,
presentation, position of the fetus)
6. Nature of support the woman receives

CONT.
If the woman has been given epidural analgesia
pushing can last more than 2hrs, anaglesia
reduce the urge bear down and limits the
woman’s ability to attain an upright position to
push

CONT.
-Commonly 2nd
stage of more than 2hrs may be
consider prolonged in woman without analgesia
and is reported to the primary of health care
provider using assessment to FTR and pattern,
decent of the presenting part, quality of UT
contraction and the status of the woman.
- premature interventions with episiotomy or
forceps or vacuum assisted birth can be avoided.

MECHANISM OF NORMAL
LABOUR / CARDINAL MOVEMENTS
OF LABOUR
DEFINITION
As the fetus descends, soft tissue and bony structures exert pressures which
force the fetus to negotiate the birth canal by a series of passive movements
collectively known as Mechanism of labor.
PRINCIPLES
 Descent takes place throughout the labor.
 Whichever part leads and first meets resistance of the pelvic floor
will rotate forwards until it comes under the symphysis pubis.
 Whatever emerges from the pelvis will pivot around the public
bone.
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CHARECTERISTICS
 Lie is longitudinal
 Attitude is one of good flexion
 Presentation is cephalic presentation
 Position is right or left occipito anterior
 Denominator is the occiput
 Presenting part is the posterior part of the anterior
parietal bone
 Occiput pointing left / right ileo pectinal eminence
 Sagital sutures lies on right / left oblique diameter
 Presenting diameter is suboccipito frontal 10cm
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CARDINAL MOVEMENTS
1) Descend
2) Flexion
3) Internal rotation of the head
4) Extension of the head
5) Restitution
6) Internal rotation of the shoulder
7) External rotation of the head
8)Lateral flexion of the body
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Cont . . .
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1) Descend:
 In primi gravida it occurs during latter weeks of pregnancy
 It will be aided by
 Forces of uterine contraction and retraction
 Rupture of fore waters
 Full cervical dilatation
 Maternal efforts speeds progress
 Slope of the pelvic floor muscle
2) Flexion:
 This increases throughout the labor
 Because of uterine contraction, fetal axis pressure will be exerted more on
the occiput than the sinciput causing good flexion
 Because of flexion the suboccipito frontal 10cm is reduced into suboccipito
bregmatic 9.5cm
 The occiput is the leading part

 1- DESCENT. Descent is brought about by the force
of the uterine contractions, maternal bearing-
down (Valsalva) efforts, and, if the patient is
upright, gravity.
 2- FLEXION. Partial flexion exists before labor as a
result of the natural muscle tone of the fetus.
During descent, resistance from the cervix, walls
of the pelvis, and pelvic floor cause further flexion
of the cervical spine, with the baby's chin
approaching its chest.

 In the occipitoanterior position, the effect of
flexion is to change the presenting diameter
from the occipitofrontal to the smaller
suboccipitobregmatic.
 In the occipitoposterior position, complete
flexion may not occur, resulting in a larger
presenting diameter, which may contribute to a
longer labor.

 3- INTERNAL ROTATION. In the occipitoanterior
positions, the fetal head, which enters the pelvis in
a transverse or oblique diameter, rotates so that
the occiput turns anteriorly toward the symphysis
pubis. Internal rotation probably occurs as the
fetal head meets the muscular sling of the pelvic
floor.
 It is often not accomplished until the presenting
part has reached the level of the ischial spines
(zero station) and therefore is engaged.


 In the occipitoposterior positions, the fetal head
may rotate posteriorly so the occiput turns
toward the hollow of the sacrum. Alternatively,
the fetal head may rotate more than 90 degrees,
positioning the occiput under the pubic
symphysis and thus converting to an
occipitoanterior position

Crowning
 Occurs when the largest diameter of the fetal
head is encircled by the vulvar ring.
 At this time, the vertex has reached station +5.
When necessary, an incision in the perineum
(episiotomy) may aid in reducing perineal
resistance, although current management is to
allow the fetus to deliver without an episiotomy.


Cont . . .
33
3) Internal rotation of the head:
 Because of gutter – shaped and slope of pelvic floor gives resistance
 The slope of the pelvic floor determines the direction of rotation
 The second principle applied. The occiput is the leading part and meets
the pelvic floor resistance and it will rotate 1/8 of the circle forward until
it comes under the symphysis pubis.
 Because of internal rotation there is a twist at the neck.
 The sagital suture move from right or left oblique to Antero – posterior
diameter
4) Crowning:
 The occiput slips beneath the sub-pubic arch and crowning take place
 The presenting part engages the vaginal outlet and it will not recede
backward.
 The sub-occipito bregmatic diameter 9.5cm distends the vaginal outlet.

 4- Extension: The head is born by rapid extension as the
occiput, sinciput, nose, mouth, and chin pass over the
perineum.
 In the occipitoposterior position, the head is born by a
combination of flexion and extension.
 At the time of crowning, the posterior bony pelvis and the
muscular sling encourage further flexion.
 The forehead, sinciput, and occiput are born as the fetal
chin approaches the chest.
 Subsequently, the occiput falls back as the head extends,
and the nose, mouth, and chin are born.

Cont . . .
35
5) Extension of the head:
 Once crowning occur fetal head can extend
 Third principle applied
 The fetal head pivot around the the pubic bone
 This releases sinciput, face and chin sweeps the perineum and born by a
movement of extension.
 The suboccipito frontal diameter 10cm distends the vaginal outlet
6) Restitution:
 The occiput moves one-eighth of a circle towards the side from it started
 Because of this the twist in the neck of the fetus which resulted from
internal rotation is now corrected by a slight un twisted movement

36
7) Internal rotation of the shoulder:
 Now the shoulder is the leading part which meets the pelvic floor
resistance
 Again second principle applied
 So from oblique diameter it will turn to Antero – posterior diameter
8) External rotation of the head:
 The head rotate in same direction as restitution and the occiput of the
fetal head now lies laterally
9) Lateral flexion:
 Anterior shoulder deliver by downwards and backward movement
and posterior shoulder deliver by upward and forward movement
 Body will be delivered by lateral flexion

 5- EXTERNAL ROTATION.
In both the occipitoanterior and occipitoposterior
positions, the delivered head now returns to its
original position at the time of engagement to
align itself with the fetal back and shoulders.
Further head rotation may occur as the shoulders
undergo an internal rotation to align themselves
anteroposteriorly within the pelvis.

 6- EXPULSION. Following external rotation of
the head, the anterior shoulder delivers under
the symphysis pubis, followed by the posterior
shoulder over the perineal body and the body of
the child. Clinical management of the second
stage. As in the first stage, certain steps should
be taken in the clinical management of the
second stage of labor.

Management of the Second Stage of Labor
 With full dilatation of the cervix, which signifies
the onset of the second stage of labor, a woman
typically begins to bear down, and with descent
of the presenting part she develops the urge to
defecate.

 Uterine contractions and the accompanying
expulsive forces may last 1 /2 minutes and recur
at an interval no longer than 1 minute.

Maternal Expulsive Efforts
 In most cases, bearing down is reflexive and spontaneous
during second-stage labor, but occasionally a woman may
not employ her expulsive forces to good advantage and
coaching is desirable.
 Her legs should be half-flexed so that she can push with
them against the mattress. Instructions should be to take a
deep breath as soon as the next uterine contraction begins,
and with her breath held, to exert downward pressure
exactly as though she were straining at stool.

 She should not be encouraged to "push" beyond the time
of completion of each uterine contraction.
 Instead, she and her fetus should be allowed to rest and
recover.
 During this period of active bearing down, the fetal heart
rate auscultated immediately after the contraction is likely
to be slow, but should recover to normal range before the
next expulsive effort.
 Gardosi and associates (1989) have recommended a
squatting or semisquatting position using a specialized
pillow.

 They claim that this shortens second-stage labor
by increasing expulsive forces and by increasing
the diameter of the pelvic outlet.
 Eason and colleagues (2000) performed an
extensive review of positions and their effect on
the incidence of perineal trauma.
 They found that the supported upright position
had no advantages over the recumbent one.

 As the head descends through the pelvis, feces
frequently are expelled by the woman.
 With further descent, the perineum begins to
bulge and the overlying skin becomes stretched.
Now the scalp of the fetus may be visible
through the vulvar opening.
 At this time, the woman and her fetus are
prepared for delivery.

Preparation for Delivery
 Delivery can be accomplished with the mother in
a variety of positions.
 The most widely used and often the most
satisfactory one is the dorsal lithotomy position.
 At Parkland Hospital the lithotomy position is not
mandated for normal deliveries.
 In many birthing rooms delivery is accomplished
with the woman lying flat on the bed.

 For better exposure, leg holders or stirrups are
used.
 In placing the legs in leg holders, care should be
taken not to separate the legs too widely or place
one leg higher than the other, as this will exert
pulling forces on the perineum that might easily
result in the extension of a spontaneous tear or an
episiotomy into a fourth-degree laceration.
 The popliteal region should rest comfortably in
the proximal portion and the heel in the distal
portion of the leg holder.

 The legs are not strapped into the stirrups,
thereby allowing quick flexion of the thighs
backward onto the abdomen should shoulder
dystocia develop.
 The legs may cramp during the second stage, in
part, because of pressure by the fetal head on
nerves in the pelvis.
 Such cramps may be relieved by changing the
position of the leg or by brief massage, but leg
cramps should never be ignored.

 Preparation for delivery should include vulvar
and perineal cleansing.
 If desired, sterile drapes may be placed in such a
way that only the immediate area about the
vulva is exposed.
 In the past, the major reason for care in
scrubbing, gowning, and gloving was to protect
the laboring woman from the introduction of
infectious agents.

Spontaneous Delivery
 Delivery of the Head
 With each contraction, the perineum bulges
increasingly, and the vulvovaginal opening
becomes more dilated by the fetal head,
gradually forming an ovoid and finally an almost
circular opening.
This encirclement of the largest head diameter by
the vulvar ring is known as crowning.

 Unless an episiotomy has been made, the
perineum thins and, especially in nulliparous
women, may undergo spontaneous laceration.
 The anus becomes greatly stretched and
protuberant, and the anterior wall of the rectum
may be easily seen through it.
 Considerable controversy exists concerning
whether an episiotomy should be cut.

 Individualization and NO routine cut of an
episiotomy is advocated.
 An episiotomy will increase the risk of a tear
into the external anal sphincter or the rectum,
or both.
 Conversely, anterior tears involving the urethra
and labia are much more common in women in
whom an episiotomy is not cut.

Ritgen Maneuver
 When the head distends the vulva and perineum
enough to open the vaginal introitus to a
diameter of 5 cm or more, a towel-draped,
gloved hand may be used to exert forward
pressure on the chin of the fetus through the
perineum just in front of the coccyx.
 Concurrently, the other hand exerts pressure
superiorly against the occiput.

 it is customarily designated the Ritgen maneuver,
or the modifiedRitgen maneuver.
 This maneuver allows controlled delivery of the
head.
 It also favors extension, so that the head is
delivered with its smallest diameters passing
through the introitus and over the perineum.
 Mayerhofer and colleagues (2002) have
challenged the use of the Ritgen maneuver on the
grounds that this procedure was associated with
more third-degree perineal lacerations and more
frequent use of episiotomy.

 They preferred the "hands-poised" method, in
which the attendant did not touch the perineum
during delivery of the head.
 This method had similar associated laceration
rates and neonatal outcomes as the modified
Ritgen maneuver, but with a lower incidence of
third-degree tears.

Delivery of the Shoulders
 After its delivery, the fetal head falls posteriorly,
bringing the face almost into contact with the
maternal anus.
 The occiput promptly turns toward one of the
maternal thighs and the head assumes a
transverse position.

 This movement of restitution (external rotation)
indicates that the bisacromial diameter
(transverse diameter of the thorax) has rotated
into the anteroposterior diameter of the pelvis.
 Most often, the shoulders appear at the vulva just
after external rotation and are born
spontaneously.
 If delayed, immediate extraction may appear
advisable.

 The sides of the head are grasped with two hands,
and gentle downward traction is applied until the
anterior shoulder appears under the pubic arch.
 Some practitioners prefer to deliver the anterior
shoulder prior to suctioning the nasopharynx or
checking for a nuchal cord to avoid shoulder
dystocia.
 Next, by an upward movement, the posterior
shoulder is delivered.

 The rest of the body almost always follows the
shoulders without difficulty; but with prolonged
delay, its birth may be hastened by moderate
traction on the head and moderate pressure on
the uterine fundus.
 Hooking the fingers in the axillae should be
avoided because this may injure the nerves of the
upper extremity, producing a transient or possibly
a permanent paralysis.

 Traction, furthermore, should be exerted only in
the direction of the long axis of the neonate, for
if applied obliquely it causes bending of the neck
and excessive stretching of the brachial plexus.
 Immediately after delivery of the newborn,
there is usually a gush of amnionic fluid, often
tinged with blood but not grossly bloody.

Clearing the Nasopharynx
 To minimize aspiration of amnionic fluid,
particulate matter, and blood once the thorax is
delivered and the newborn can inspire, the face
is quickly wiped and the nares and mouth are
aspirated.

Nuchal Cord
 Following delivery of the anterior shoulder, a
finger should be passed to the fetal neck to
determine whether it is encircled by one or more
coils of the umbilical cord.
 Nuchal cords are found in about 25 percent of
deliveries and ordinarily do no harm.
 If a coil of umbilical cord is felt, it should be
slipped over the head if loose enough.
 If applied too tightly, the loop should be cut
between two clamps and the neonate promptly
delivered

Clamping the Cord
 The umbilical cord is cut between two clamps
placed 4 to 5 cm from the fetal abdomen, and
later an umbilical cord clamp is applied 2 to 3
cm from the fetal abdomen.
 A plastic clamp (Double Grip Umbilical Clamp)
that is safe, efficient, and fairly inexpensive is
used.

Timing of Cord Clamping
 If after delivery, the newborn is placed at or below
the level of the vaginal introitus for 3 minutes and
the fetoplacental circulation is not immediately
occluded by clamping the cord, an average of 80
mL of blood may be shifted from the placenta to
the neonate.
 This provides about 50 mg of iron, which reduces
the frequency of iron deficiency anemia later in
infancy.

 Some policies use to clamp the cord after first
thoroughly clearing the airway, all of which
usually requires about 30 seconds.
 The newborn is not elevated above the introitus
at vaginal delivery or much above the maternal
abdominal wall at the time of cesarean delivery.

 Accelerated destruction of erythrocytes, as
found with maternal alloimmunization, forms
additional bilirubin from the added erythrocytes
and contributes further to the danger of
hyperbilirubinemia.

MIDWIFERY CARE DURING SECOND STAGE OF
LABOR

Care and intervention in 2nd
-Latent phase
* Encourages woman to listen to her body
* Continues support measures allowing woman to
rest
* Suggest an upright position to encourage
progression of decent

CONT.
-Decent phase
* Encourage respiratory of short breath holds and
open glottis pushing.
* Stresses normality and benefits of grunting
sounds and expiratory vocalizations.
* Encourage bearing down effort with urge to
push.

CONT.
* Encourage maternal movement and position
changes upright , if decent is not occurring
* Discourage long breath hold (no longer than
5 to 7sec)
* Place the woman in lateral recumbent position to
slow decent

CONT.
- Transitional phase (8-10cm)
* Encourage slow, gentle pushing
* Explains that “blowing away the contraction”
facilitates a slower birth of the head
*

CONT.
* Coaches woman to relax mouth, throat and neck
to promote relaxation of pelvic floor
* Apply warm compress to perineum to promote
relaxation

Preparing For Birth
1.Maternal position
2.Bearing-down efforts
3.Fetal heart rate and pattern
4.Support of the father or partner
5.Supplies, instruments, and equipment

Maternal Position
-The woman my want to assume various
position for childbirth, and she should be
encourage and assisted in attaining and
maintaining her position of choice
-Hason(1998) found that sitting and side Lying are
the most common position assumed by women
for their bearing down effort and birth

Upright position:
- Facilitate birth and fetal decent
- Reduce the duration of the 2nd
stage
of labor
- Reduce the need for episiotomy, forceps, or
vacuum extractor

Mechanism Of Upright position
1. Straighten the longitudinal axis of the birth canal
2. Use gravity to direct the fetal head toward
the pelvic inlet
3. Enlarge pelvic dimensions and restrict the
encroach of the sacrum and coccyx into the
pelvic outlet
4. Increase uteroplacental circulation
5. Enhance the woman’s ability to bearing down
effectively

Upright position
- Provides potential psychologic advantage it
allows the mother to see the birth as occur, and
maintain eye contact with attendant.
-Upright position slightly increase the
risk for 2nd
degree laceration and blood loss greater
than 500ml
(Donsante & shorten,2002)

Evidence
-Use of supine position is associated with negative
maternal, fetal and neonatal hemodynamic out
comes.
-Upright positions were associated with a slight
reduction in second stage duration, reduction in
assisted deliveries, reduction in epsiotomies
increase in second degree tear, and fewer
abnormal fetal heart rate.
Robert J. Best practices in second stage of labor care.2007

Squatting position
-Is highly effective to facilitating the
decent and birth of the fetus, and is
one of the best positions for the 2nd
stage of labor.
- Firm surface is required.
- Woman need side support.

Standing position
-Uses the standing position for bearing down, her
weight is born on both femoral heads, allowing
the pressure in the acetabulum to cause the
transverse diameter of the pelvic outlet to
increase by up to 1cm (if the occiput has not
rotated from the lateral to the anterior position.

Birthing chair
-Used to provide women with a good
physiologic position to enhance her bearing
down effort during childbirth, although some
women feel restricted by a chair
- Most birthing chair are designed if emergency
occurs, the chair can be adjusted to horizontal or
trendelenburg position

Side-Lying position
-With the upper part of the woman’s leg held by
the midwife or placed on a pillow low, is an
effective for the 2nd
stage of labor

Semi-sitting position
-Use to maintain good uteroplacental circulation
and to enhance the woman’s bearing down
effort
- The episiotomy rate for nulliparas highest in
this position
- (Shorten, Donsante, &shorten,2002)

Hands –and knees position
- Is an effective position for birth because it
enhances placental perfusion.
- Help rotate the fetus from posterior to an
anterior position.
-Facilitate the birth of the shoulders if the fetus is
large.
- Reduce perineal trauma.

Birthing Bed
-The Birthing bed used according to the
woman’s needs.
- At the same time is excellent exposure for
examinations, electrode placement and birth.
- The bed can be positioned for
administration of anesthesia.
- The bed can be used to transport the woman to
the operating room if C/S necessary.

Bearing down efforts
-Is an involuntary response to the Ferguson reflex
the midwife should encourage women to push as they feel
like pushing (spontaneous pushing).
-The midwife should monitor the woman’s breathing , so that
the woman does not hold her breath for more than 5 to 7
seconds at time and should remind her to ventilate her
lung fully by taking deep breaths before and after each
contraction, this help maintain adequate O2 For the
mother and fetus.

Pushing Techniques
 Pushing techniques can be either
 (1) delayed or
 (2) nondirected.

 Delayed pushing waiting for fetal descent or
initiation of Ferguson's reflex before pushing
begins (ie, not pushing until the urge is felt even
with complete cervical dilatation).
 The Ferguson's reflex is a physiologic response
that is activated when the presenting part of the
fetus is at least at a +1 station and is usually
accompanied by spontaneous bearing-down
efforts.

 Delayed pushing can be used with epidural
anesthesia/analgesia as women cannot feel the
urge to push.
 Clinical practice recommends assessing women's
knowledge of pushing techniques to include
presence of Ferguson's reflex.
 Also referred to as laboring down

 Nondirected pushing use of nontraditional pushing
techniques such as open glottis or tug-of-wartechniques.
 Open glottis pushing for 4 to 6 seconds followed by slight
exhaling (essentially pushing while exhaling/grunting)
and repeating this pattern for 5 or 6 pushes/uterine
contraction. There is minimal change in maternal blood
pressure, thus minimal, if any, change in the FHR pattern.
This method also relaxes the perineum, allowing the
gentle delivery of the fetal head. Closed glottis pushing
(holding breath for the count of 10) is not recommended.

 Tug-of-war uses the natural bearing down effort of the
abdominal muscles. A gown or short sheet can be tied in a
knot at both ends. When the mother has the urge to push,
she grabs one end of the gown or sheet and pulls as much
as she can while the coach or nurse provides resistance by
holding the other end. (Alternative way is to tie knot in
one end and tie other end to squat bar of labor bed.) This
method also causes minimal change in the maternal blood
pressure, relaxes the perineum, and has been found to
decrease the second stage of labor as much as 20 minutes.
 Use of birthing aids such as birthing balls, squat bars,
birthing stools, and cushions to support the woman and
her fetus.
98

Fetal Heart Rate and Pattern
- FHR must be checked if there is loss of variability,
or if deceleration pattern developed.
-The woman can be turned on her side.
- O2 can be administer by mask at 8 to 10 L/m to
mother.
-If FHR does not become reassuring immediately
the primary health care provider should be
notified.

Support of the Father
- During 2nd
stage, woman needs continuous
support and coaching.
-The support person who attends the birth in a
delivery room is instructed to put on a cover
gown, mask, hat, and shoes cover as agency
policy.

CONT.
- Partners are encourage to be present at the birth
of their babies as cultural and personal
expectation and beliefs.
- In this way the psychologic closeness of the family
unit is maintained, and the partner can continue
to provide the supportive care given during labor.

CONT.
-The woman and her partner need to
have an equal opportunity to initiate
attachment process with the baby.

Supplies, Instruments, and
Equipment
-The birthing table should be prepared during the
transition phase for nulliparous, and during the
active phase for multiparous woman.
- Standard procedures for gloves,sterile packages,
unwrapped sterile instruments and handling them
to the primary health care provider.

CONT.
-Radiant warmer and equipment are
readied for the support and
stabilization of the baby.

Birthing Room
-Prepare the woman for delivery
-The circulating nurse continues to support the
woman.
- The nurse auscultates FHR or evaluates the
monitor every 5 to 15 minutes.
- Oxytocin may be prepared to be
administered after delivery of the placenta.

CONT.
- midwife attending the birth my need to wear cap,
protective eyewear, masks gown and gloves.
- The woman draped with sterile drapes
- midwife contact with the parents is
maintained by touching, verbal
comforting, explaining the reasons for care and
sharing in the parents’ joy at birth of their baby.

Immediate Assessment and Care of
the Newborn
- The care given after the birth focuses on
assessing and stabilizing the newborn.
- The midwife must watch the infant for any
signs of distress and initiate appropriate
interventions.

CONT.
- A brief assessment of the newborn
can be performed includes checking
the airway and Apgar Score.

Perineal Trauma R/t child birth
- Lacerations:
-Most acute injuries or laceration of the perineum,
vagina, uterus and their supportive tissues occur
during child birth.
- Laceration if not repair lead to genitourinary and
sexual problem (pelvic relaxation, uterine
prolapse, cystocele, rectocele, dyspareunia,
urinary and anaL bowel dysfunction).

CONT.
- Immediate repair:
* Promotes healing
* Limits residual damage
* Decreases the possibility of infection

CONT.
- Primary health care provider
continue to inspect the perineum
carefully and evaluate lochia to
identify any missed damage during
the early postpartum period.

Perineal Lacerations
Degree of laceration:
1. First degree: laceration extends through
the skin and structures superficial to muscle.
2. Second degree: Laceration extends through
muscles of the perineal body

CONT.
3. Third degree: Laceration continues through
the anal sphincter muscle.
4. Fourth degree: Laceration involves the
anterior rectal wall.

CONT.
- Special attention must be paid to third and
fourth stage laceration so that woman retains
fecal continence.
- Measures are taken to promote soft stools (e.g.
roughage, fluid, activity, and stool softeners) to
increase comfort and healing.

CONT.
- Antimicrobial therapy may be used
- Enemas and suppositories are
contraindication

Vaginal & Urethral laceration
- Vaginal laceration occur in
conjunction with perineal laceration
- Vaginal laceration tend to extend
up the lateral walls and if deep enough involve the
levator ani muscle.

CONT.
- Vaginal vault laceration may be
circular and result from forceps
rotation especially in the
cephalopelvic disproportion, rapid
fetal decent.

Cervical Injuries
- Occur when the cervix retracts over the
advancing fetal head.
- This laceration occur at the angles of the external
os, most are shallow, bleeding is minimal.

CONT.
- Cervical injuries when extend to vaginal vault or
beyond it into the lower uterine segment
serious bleeding may occur.
- Cervix laceration can have adverse effect on
future pregnancies and child birth.

Evidence
-The highest rate of trauma have consistently been
observed in first births or operative vaginal
deliveries (forceps or vacuum extraction).
-Rate of trauma appear to increase with infant birth
weight, maternal weight gain in pregnancy,
and fetal malposition.
- Use of episiotomy increases serious trauma to
genital tract, especially third and fourth degree
laceration.
Leah L .Reduction Genital Tract Trauma at Birth. 2003.

Episiotomy
- Is an incision in the perineum to
enlarge the vaginal outlet.

Episiotomy
- Indication:
1. Facilitates vacuum or forceps assisted
birth
2. Fetal distress
3. Facilitates the birth of large baby
4. Premature baby

Type of episiotomy
1. Median: -Is most commonly used
- It is effective
-Easily repaired
-Least painful
- Midline episiotomy are associated with a higher
incidence of third and fourth degree of laceration.

Type of episiotomy
2. Mediolateral: Is used in operative births when
need for posterior extension.
- Fourth degree laceration may be prevented, third
degree may occur.
- Blood loss is greater, painful, difficult repair than
midline.

Risk Factor associated with
perineal trauma
1.Nulliparity
2. Maternal position
3. Pelvic inadequacy
3. Fetal malpresentation and position 4. Large
baby
5. Use of instruments to facilitate birth

CONT.
6. Prolong second stage of labor
7. Fetal distress
8. Rapid labor

Evidence
- Episiotomy should not be used unless indicated .
Measures should be taken to avoid perineal
trauma during labor to establish bonding early
between mother and infant & to minimize
perineal discomfort after birth.
Karacam Z. Effects of episiotomy on bonding and mothers health. 2003

Perineal management
- Warm compress
- Massage
- Kegel’s exercises in the prenatal and
postpartum periods
- Good nutrition, hygienic measures
- As advocates, encourage women to use
alternative birthing positions and use
spontaneous bearing down effort.

NURSING DIAGNOSES IN THE SECOND
STAGE OF LABOUR
 Acute pain related to contraction – related hypoxia,
dilatation of tissues and pressure on adjacent
structures as evidenced by verbal reports,
restlessness, muscle tension and narrowed focus
 Risk for impaired fetal gas exchange related to
mechanical compression of head or cord / maternal
position / prolonged labour affecting placental
perfusion / effects of maternal anaesthesia /
hyperventilation
 Risk for impaired skin / tissue integrity related to
untoward stretching / laceration
8/25/2012
130

Cont . . .
131
 Risk for fatigue related to anxiety / environmental
humidity
 Risk for deficient fluid volume related to lack of intake
or excessive vascular loss
 Risk for infection related to broken or traumatized
tissue / increased environmental exposure / rupture
of amniotic membrane
 Risk for fetal injury related to descent / pressure
changes / compromised circulation / environmental
exposure

NURSING MANAGEMENT OF II
STAGE OF LABOR
 Assess FHR
 Assess uterine contraction
 Assess the progress of labor
 Arrange the delivery room
 Follow a sterile technique
 Clean vulva and perineal region using downward strokes
 Support woman
 Provide necessary materials and equipment
 Provide equipment for episiotomy
 Provide perineal support
 Give immediate care
 Assess the APGAR score for 1st
, 5th
, 15th
minutes
 Assess for haemorrhage
132

Nursing Interventions
 Minimizing Fear and Anxiety
 Monitor maternal vital signs as follows:
 Blood pressure ât every 5 to 15 minutes
depending on the woman's status.
 Pulse and respirations ât every 15 to 30
minutes.
 Temperature ât every 1 hour when membranes
have ruptured.
 Monitor FHR and uterine contractions every 15
minutes in low-risk women and every 5 minutes
in high-risk women.


 Early decelerations and some fetal bradycardia may
occur due to head compression.
 There is normally no loss of variability during pushing.
 Contractions may become less frequent, but intensity
does not decrease.
 Explain procedures and equipment during pushing and
delivery.
 Keep the woman or couple informed of their status.
 Provide frequent, positive encouragement.
 Use of a mirror usually allows the woman to see her
progress.
 Assist with positioning and pushing as outlined above.
134

 Promoting Comfort
 Assist the woman to a comfortable position.
 Left or right lateral, squatting, hand and knees, or
semisitting positions may be used.
 Assist the woman with pulling her legs back so her
knees are flexed.
 Teach the woman to put her chin to her chest so her
body forms a â€œCâ€ shape while pushing.
 Evaluate bladder fullness, and encourage voiding
or catheterize as needed.
 Evaluate effectiveness of anesthesia as indicated.

 Preventing Infection and Promoting Safety
 Prepare the birthing room or delivery room
using aseptic technique, allowing ample
time for setup before delivery.
 Prepare the infant resuscitation area for
delivery.
 Prepare necessary items for neonatal care.
 Notify necessary personnel to prepare for
delivery.

137
 If delivery room is to be used, transfer the primigravida
to the delivery room when the fetal head is crowning.
The multigravida is taken earlier depending on fetal size
and speed of fetal descent.
 Place all side rails up before moving. Instruct the
woman to keep her hands off the rails, and move from
the bed to the delivery table between contractions.
 If delivering in LDR (Labor, Delivery, Recovery) or LDRP
(Labor, Delivery, Recovery, Postpartum) room, prepare
labor bed for delivery in accordance with
manufacturer's instructions. Prepare infant warmer and
remainder of room for delivery.
 Position the woman for delivery using a large cushion
for her head, back, and shoulders. Elevate the head of
the bed. Stirrups or footrests may be used for foot
support. Pad the stirrups. Place both legs in the stirrups
at the same time to avoid ligament strain, backache, or
injury.

 Clean the vulva and perineal areas when the woman is
positioned for delivery.
 Cleanse from the lower abdomen to the mons.
 Then clean the groin to the inner thigh on each side.
 Then clean each labia.
 Finally, clean the introitus.
 Guide the woman step by step during the delivery
process.
 When the fetal head is encircled by the vulvovaginal
ring, an episiotomy may be performed to prevent
tearing.

139
When the head is delivered, mother is instructed to stop
pushing. Mucus is wiped from the infant's face, and the
mouth and nose are aspirated with a bulb syringe. If thick
or particulate meconium amniotic fluid is present, the
mouth and nose are suctioned on the perineum with deep
suction before the delivery of the body.
If loops of umbilical cord are found around the neonate's
neck, they are loosened and slipped from around the neck.
If the cord cannot be slipped over the head, it is clamped
with two clamps and cut between the two clamps.
After this step, the woman is instructed to give a gentle
push so the neonate's body may be quickly delivered.
After delivery of the neonate's body and cutting of the
cord, the neonate is shown to the parents and then placed
on the maternal abdomen or taken to the radiant warmer
for inspection and identification procedures.
Practice standard precautions during labor and delivery.

 Evaluation: Expected Outcomes
 Verbalizes positive statements about delivery
outcome
 Reports decreased pain from proper positioning
 No infection results

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