Management of second stage in labor.ppt.ppt
- 1. MANAGEMENT OF SECOND STAGE OF LABOUR PRESENTED BY: THOKOZIRE LIPATO THIRD YEAR 2020 10/01/2023
- 2. BROAD OBJECTIVE To equip student midwives with knowledge, skills and positive attitudes in managing women during second stage of labour.
- 3. SPECIFIC OBJECTIVES Define second stage of labour Define management of second stage of labour Describe the events that take place during the second stage of labour. Explain the diagnosis of second stage Explain instruments required during Second stage
- 4. SPECIFIC OBJECTIVES CONT…. Describe preparation of second stage of labour. Describe the care of the mother and observations required.
- 5. DEFINITION OF SECOND STAGE OF LABOUR The second stage of labour begins from full dilation of the cervix to the delivery of the baby. It lasts 15 -30 minutes for multipara and 40 minns to 1 hour for primigravida (Sellers, P.M(2011)
- 6. Management of second stage Encompasses midwifery care provided to the labouring woman from the time the cervix is fully dilated (10 cm) to expulsion of the baby. (Michele et.,al 2012)
- 7. Diagnosis of second stage of labour Could be done through: 1. Conclusive /diagnostic signs 2. Anticipatory signs
- 8. Conclusive sign of 2nd stage of labour 1. Full dilatation of cervix confirmed on vaginal examination
- 9. Anticipatory signs of 2nd stage of labour 1. Expulsive contractions 2. Spontaneous rupture of membranes 3. Behaviour signs 4. Foetal signs 5. Trickling of blood 6. Pouting and gaping of anus 7. Gaping of vulva 8. Appearance of presenting part 9. Bulging of the perineum
- 10. Anticipatory signs of 2nd stage of labour cont’d 1. expulsive contractions Contractions: - become very strong - Felt frequently - last longer and - are expulsive in nature
- 11. Anticipatory signs of 2nd stage of labour cont’d 2. Spontaneous rupture of membranes ◦May rupture when woman starts to bear down ◦It is unreliable sign unless taken with other signs
- 12. Anticipatory signs of 2nd stage of labour cont’d 3. Behaviour signs ◦The urge to bear down becomes compulsive and cannot control her actions e.g relaxing as before. ◦Flushed look; sweating or shivering during a contraction ◦May be flushed if dehydrated ◦May sweat especially if temperature is high
- 13. Behaviour signs cont… ◦ May shiver in between contractions if temp is low. ◦ Some women vomit at onset of 2nd stage due to Painful contractions
- 14. Anticipatory signs of 2nd stage of labour cont’d 4. Foetal signs • Foetal heart rate patterns changes • If recorded during a contraction, it may fade and take longer to return to normal after contraction hence need for more close observations
- 15. Anticipatory signs of 2nd stage of labour cont’d 5. Trickling of blood ◦May be noticed at the vaginal orifice due to some lacerations of the cervix and vaginal mucosa 6.Pouting and gaping of the anus ◦The anus will start to pout as it is pushed outwards. ◦As the head descends further, the anus will gape and the shiny anterior wall will be visible ◦This is a fairly reliable sign of 2nd stage
- 16. Anticipatory signs of 2nd stage of labour cont’d 7. Gaping of vulva ◦When the head reaches the perineum, it is directed forwards and upwards following the curve and the vulva starts to gape – indicates the presenting part is below the level of the ischial spines and the cervix is fully dilated.
- 17. Anticipatory signs of 2nd stage of labour cont’d 8. Appearance of presenting part ◦An almost positive sign of second stage, especially if the head is presenting and mature baby = conclusive. ◦Sometimes large caput and moulding could be visible.
- 18. Anticipatory signs of 2nd stage of labour cont’d 9. Bulging of the perineum • Caused by the hard head that is compressing the perineum as the woman is bearing down during a contraction.
- 19. REQUIREMENTS Trolley with: Sterile delivery pack: 1 pair of scissors, gallipot with cotton wool and gauze swabs, 2 kidney dishes, perineal pads and 3 draping towels and 2 forceps and 2 cord clamps Episiotomy pack: Sterile Episiotomy Scissors; Needle holder, gallipot, cotton swabs, gauze and di-forceps.
- 20. REQUIREMENTS CONT…. Chromic 0, 2/0 Razor blade/surgical blade Pairs of sterile gloves Chlorohexidine 0.25% solution for cleansing the vulva Lignocaine 1% solution 10 cc syringe
- 21. REQUIREMENTS cont’d 6 Infection Prevention Buckets for: ◦Dry waste (with bin liners) ◦Contaminated waste (with bin liners) ◦Contaminated linen, Instruments, Soapy water ◦O.5% chlorine water for glove rinsing ◦Placenta and blood
- 22. REQUIREMENTS cont’d o1 sharp container o 1 cc syringe for oxytocin oTimer/wall clock
- 23. REQUIREMENTS cont’d Personal protective equipment ◦Heavy duty apron ◦Face mask ◦Eye goggles ◦Closed shoes/gumboots Resuscitation equipment for baby Receiving blanket or chitenje for baby
- 24. PREPARATION Prepare the necessary equipment Explain the findings to the woman and her support person, tell them what is going to be done, listen to her and respond to her questions and concerns to gain her consent and cooperation.
- 25. Preparation cont’d Review the bearing down technique (if mother is in Dorsal position) ◦ When a contraction is felt, the woman should flex her knees and pull the thighs ◦ Curve the back, with the chin on the sternum ◦ Keep knees wide apart ◦ Relax the pelvic floor while bearing down ◦ Hold the thighs, take a deep breath, close the lips and glottis then push ◦ A long sustainable push is more effective than numerous short ones
- 28. Preparation cont’d- the bearing down technique oTell the woman not to cry to hold the breath. oIf a contraction is still present but she needs to take another breath, instruct her to inhale deeply and bear down again. oDo not bear down in between contractions.
- 29. Preparation cont’d Ensure privacy Keep the delivery bed and surrounding area clean Bring the delivery trolley to the patients bed side Provide emotional support and re-assurance Put on personal protective barriers Ensure the bladder is empty Encourage woman to adopt position of choice (squatting, semi-fowlers, Dorsal)
- 30. OBSERVATIONS DURING DELIVERY ◦Foetal heart rate in between contractions ◦Strength and regularity of contraction ◦Advancement (descent) of presenting part ◦Condition of the mother Perineum for tear and make episiotomy if necessary
- 31. ACTUAL DELIVERY Put on apron, boots and goggles Wash hands thoroughly with soap and water then dry with sterile towel or air dry. Put on sterile surgical gloves on both hands. Double gloving is recommended Clean the woman’s vulva with chlorohexidine solution 0.25% using a 6 swab technique
- 32. ACTUAL DELIVERY CONT… Place one sterile drape from the delivery pack under woman’s buttocks, second one on the abdomen and third one to receive the baby. The midwife stands on the right side of the bed (if right handed) facing towards the woman if in supine position.
- 33. ACTUAL DELIVERY CONT… The woman should be encouraged to assume a position for pushing that is comfortable and aids in the descend of the foetus. Note time and the woman should push in response to her natural bearing down reflex
- 34. ACTUAL DELIVERY CONT… Help her rest between contractions Offer encouraging feedback after each push and praise her effort Place the second and third fingers of left hand on the occiput and maintain down ward flexion of the head until crowning occurs. Support the perineum to prevent extensive perineal tears.
- 35. ACTUAL DELIVERY CONT… When crowning has occurred instruct the mother to pant. Observe imminent signs of perineal tear and do episiotomy if present. Allow spontaneous birth of the head Discard the perineal pad Quickly check the cord around the neck.
- 37. CORD FELT ON THE NECK If the cord is around the neck but loose, slip over the head. If the cord is around the neck but can not reach over the neck, relax the cord so that it can slip backward over the shoulders as the shoulders are born. If the cord is tightly around the neck, clamp the cord with two artery forceps, placed in 3 cms apart and cut in between.
- 38. ACTUAL DELIVERY CONT… Clean secretions with clean gauze or cotton swabs from mouth, nostrils then eyes to ensure clear airway and prevent infection. Wait for the restitution, external rotation of the head which is accompanied by internal rotation of the shoulders, so that the smallest diameter is presented thereby preventing tears to birth canal.
- 39. DELIVERY OF THE SHOULDERS Place hands on each side of the baby’s head (biparietal) Ask the woman to bear down until anterior shoulder escapes from under the pubic arch. The midwife continues hold the baby’s head between the hands. The mother is then asked to stop bearing down and to pant again.
- 40. DELIVERY OF THE SHOULDERS The head is lifted up gently towards the mother’s symphysis pubis and abdomen, allowing posterior shoulder to slip free of the perineum.
- 41. DELIVERY OF THE SHOULDERS
- 42. DELIVERY OF THE BODY When the body emerges from the vaginal orifice, Move the top most hand from the head to support the rest of the baby’s body Grasp around the thorax at the same time support back of the head and carry it over the symphysis pubis up to the abdomen.
- 43. DELIVERY OF THE BODY Note the time and sex of the baby. Quickly wipe the baby (starting with mouth, nose then eyes) while assessing the breathing if there will be need for further resuscitation.
- 44. APGAR SCORING AT 5&10 MINUTES
- 45. ACTUAL DELIVERY CONT… Mechanisms of Labour During the Second Stage MECHANISM DEFINITION Engagement The widest diameter of the presenting part crosses the maternal pelvic brim Descent Downward movement of the leading bony edge of the presenting part inside the birth passage Flexion Maximum movement of the fetal chin towards the fetal chest wall when the sinciput presses against the film pelvic floor muscles due to ongoing uterine contractions, leading to the flexion of the fetal neck Internal rotation Rotation of the fetal occiput due to contractions from a transverse or oblique diameter to an anteroposterior Extension Upward movement of the sinciput as the fetal head emerges from the resistance offered by symphysis pubis
- 46. ACTUAL DELIVERY CONT… Mechanism of Labour Restitution Restoration of anatomy as the fetus attempts to correct the twisting of the neck during internal rotation External Rotation Rotation of the occiput outside the mothers birth passage as the fetal shoulders undergo internal rotation Delivery of the Shoulders Once the delivery of the fetal head has occurred and following the internal rotation of the shoulders, the second stage of labour is completed when the fetal shoulders, trunk, buttocks and legs are delivered
- 47. ASSIGNMENT 1 Read on: ◦Different positions adopted in labour ◦Advantages and disadvantages ◦Why certain positions are preferred compared to others in a Malawian context
- 48. ASSIGNMENT 2 Formulate a care plan Include the following: 1. 3 priority midwifery diagnosis: 2. Midwifery goal on each midwifery diagnosis 3. 2 priority interventions in respective to the midwifery diagnosis 4. Indicate clear rationale for each Midwifery intervention 5. Include evaluation under each midwifery intervention
- 49. SUMMARY Management of second stage of labour comprises of midwifery care provided to the labouring woman from the time the cervix is fully dilated (10 cm) to expulsion of the baby. (Michele et.,al 2012) Fully cervical dilatation(10cms) is considered as conclusive sign of the second stage of labour. During preparation of delivery make sure that the woman has been told the bearing down techniques.
- 50. REFERENCES Fraser, D.M., Cooper, M.A & Nolte, A.G.W(2006) Myles text book for midwives(African edition). Edinburgh, Churchill Livingston Sellers, P.M(2004) Midwifery (volume1)Lansdowne, Juta and Co, Ltd. Michele R. Davidson, Marcia L. London, Patricia A. Wieland Ladewig. Olds' maternal-newborn nursing & women's health across the lifespan (2012) 9th ed, Upper Saddle River