presentation on second stage of labor
- 1. PRESENTATION ON SECOND STAGE OF LABOR Ms. Shailvi (BSc.(H) Nursing student)
- 2. INTRODUCTION During the second stage of labor the whole tempo and nature of activities surrounding labor tend to change. Labor remain as a continuum ,at this time woman often become more vulnerable and dependent on the influence of those who assist them,
- 3. . Discussion about alternative and choices is not easy at this time and this leaves the care giver with even more than usual responsibilities to safe guard the interest of the mother and baby.
- 4. DEFINITION The second stage of labor begins with complete dilatation of the cervix and ends with the birth of the baby . It is known as the stage of expulsion.
- 5. PHYSIOLOGICAL PROCESSES яВз Descend яВз Uterine action яВз Rupture of membranes яВз Soft tissue displacement
- 6. DESCEND яГШThe average maximum rate of descend is 1.6cm/hr in nulliparas and 5.4cm/hr in multiparas.
- 7. UTERINE ACTION яГШContractions during the second stage are frequent ,strong & slightly longer that is approximately every 2 minutes lasting 60-90 seconds.
- 8. RUPTURE OF MEMBRANES The membranes often rupture spontaneously at the onset of second stage .
- 9. SOFT TISSUE DISPLACEMENT яГШAs the hard fetal head descends ,the soft tissues of the pelvis become displaced . яГШAnteriorly the bladder is pushed upwards into the abdomen where it is at less risk of injury during fetal descent .
- 10. PRESUMPTIVE SIGNS OF SECOND STAGE AND DIFFERENTIAL DIAGNOSIS
- 13. MECHANISM OF NORMAL LABOR When the fetus present in left or right occipitoanterior position the way the fetus is normally situated can be described as follows:-
- 18. Positional movements ENGAGEMENT :- яВвEngagement takes place when the biparietal diameter of the fetal head has passed through the pelvic inlet.
- 19. DESCEND яВвDescend occur throughout the mechanism of labor and is therefore both the requisite to and simultaneously with the other mechanism.
- 20. FLEXION яВвFlexion is essential to further descend. Pressure exerted down the fetal axis will be transmitted to the occiput. яВвThe effect is to increase flexion which result in the substitution of smaller suboccipitobregmatic diameter of 9.5cm for the larger suboccipitofrontal diameter of 10cm.
- 21. . .
- 22. INTERNAL ROTATION OF HEAD яВвIn a well flexed vertex presentation the occiput leads and meets the pelvic floor first and rotates anteriorly through 1/8th of circle. яВвThis causes a slight twist in the neck of the fetus as the head is no longer in direct allignment with the shoulders.
- 23. CROWNING яВвAt this stage, the maximum diameter of the head stretches the vulval outfit without any recession of the head even after the contraction is over. This is called crowning of head.
- 24. BIRTH OF THE HEAD яВвBy further pressure from the contracting uterus and maternal pushing serves to further extend the head & the head is born by extension as the sinciput face & chin sequentially sweep over perineum.
- 25. RESTITUTION яВвRestitution untwist the neck so that the head is again at right angle with the shoulders . The occiput moves1/8th of circle towards the side from which it started .
- 26. INTERNAL ROTATION OF SHOULDER яВвThe anterior shoulder reaches the pelvic floor and rotates anteriorly1/8th of a circle . яВвThe shoulder come to lie in the anteriorposterior diameter of the pelvic outlet.
- 27. EXTERNAL ROTATION OF THE HEAD яВвIt occurs as the shoulders rotate 45 degree internally causing the head to rotate another 45 degree. яВвExternal rotation occurs in the same direction as restitution and the occiput of the fetal head now lies laterally.
- 28. BIRTH OF THE SHOULDER AND BODY BY LATERAL FLEXION яВвThe anterior shoulder comes into view at the vaginal orifice where it impinges under the symphysis pubis while the posterior shoulder distends the perineum. яВвAfter the shoulder are delivered the remainder of the body is born by lateral flexion.
- 30. MANAGEMENT OF SECOND STAGE OF LABOR PRINCIPLES яВвTo assist in natural expulsion of the fetus slowly and steadily. яВвTo prevent perineal injuries.
- 31. GENERAL MEASURES яВвThe patient should be in bed. яВвConstant supervision is mandatory and FHR is recorded at every 5 minutes. яВвTo administer inhalation analgesics if available in the form of gas N2O and O2 to relieve pain during contractions.
- 32. .яВв Vaginal examination is done at the beginning of 2nd stage not only to confirm its onset but to detect any accidental cord prolapse. яВвThe position and the station of the head are once more to be reviewed and the progressive descent of the head is ensured.
- 33. PREPARATION FOR DELIVERY яВв Position. яВв The accoucheur scrubs up. яВв Toileting the external genitalia and inner side of thighs with betadine. яВв Essential aseptic procedures are remembered as three Cs. яВв Clean hands. яВв Clean surface. яВв Clean cutting and ligaturing of the cord. яВв To catheterize the bladder if it is full.
- 34. CONDUCTION OF DELIVERY яВвDelivery of the head. яВвThe patient is encouraged for the bearing down efforts during contractions . This fascilitates descent of the head.
- 35. . яВвWhen the scalp is visible for about 5cm in diameter, flexion of head is maintained during contractions. яВвThis is achieved by pushing the occiput downward and backward by using thumb and index finger of left hand while processing the perineum by the right palm with a sterile vulval pad.
- 36. . яВвIf the patient passes stool it should be cleaned. яВвWhen the perineum is fully stretched and threatens to tear especially in primigravidae episiotomy is done at this stage.
- 37. . яВвSlow delivery of the head in between the contractions is to be regulated. яВвThe forehead , nose ,mouth and the chin are thus born successively over the stretched perineum by extension.
- 38. CARE FOLLOWING THE DELIVERY OF HEAD яВвMucus and blood in mouth and pharynx to be wiped. яВвEyelids are wiped with sterile dry swabs. яВвThe neck is palpated to exclude the presence of any loop of cord.
- 39. PREVENTION OF PERINEAL LACERATION яВвDelivery by early extension is to be avoided. яВвSpontaneous forcible delivery of the head is to be avoided by assuring the patient not to bear down during contractions.
- 40. . яВвTo deliver the head in between contractions. яВвTo perform timely episiotomy. яВвTo take care during delivery of the shoulder as the wider bisacromial diameter emerges out of the introitus.
- 41. DELIVERY OF SHOULDER яБ▒The head is to be grasped both the hands and is gently drawn posteriorly until the anterior shoulder is released under the pubis. яБ▒By drawing the head in upward direction the posterior shoulder is delivered out of perineum.
- 42. . яБ▒Traction of the head should be gentle to avoid excessive stretching of neck causing injury to the brachial plexus , hematoma of the neck or fracture of clavicle.
- 43. DELIVERY OF THE TRUNK яВвAfter the delivery of shoulder the forefinger of each hand are inserted under the axillae & the trunk is delivered gently by lateral flexion.
- 44. IMMEDIATE CARE OF THE NEW BORN яВвSoon after the delivery of the baby it should be placed on a tray covered with clean dry linen. яВвAir passage should be cleared by gentle suction яВвAPGAR rating at 1 min and 5 min.
- 46. . яВвClamping and ligature of the cord. яВвThe cord is divided with scissors about 1cm beyond the ligatures taking aseptic precautions яВвNote presence of any abnormality яВвThe purpose of clamping the cord on maternal end is to prevent soiling of the bed and to prevent fetal blood loss.
- 47. . яВвDelay in clamping for 2-3 min or till cessation of the cord pulsation fascilitates transfer of 80 -100 ml of blood. яВвThis is beneficial to mature baby but maybe deleterious to a preterm or low birth weight due to hypervolemia and hyperbilirubinemia.
- 48. яВвEarly clamping is done in cases of Rh incompatibility. яВвCord is usually clamped after cleaning the airway after about 1-2 mints of birth early clamping reduces the need of phototherapy due to hyperbilirubinemia. яВвQuick check is made to detect any gross abnormality .
- 49. SUMMARY
- 50. CONCLUSION 1)Over the course of second stage of labor upright and lateral positions may have more potential benefits improving maternal and neonatal outcomes and dealing with certain obstetric complications .
- 51. . 2) However when woman gives birth in upright position especially in squatting and sitting position midwives should pay close attention to the perineum to prevent perineal trauma. 3) Midwives play a roll in child birth so she should master the skills and techniques.
- 52. BIBLIOGRAPHY яВвDutta DC. Textbook of obstetrics. 9th edition. New delhi:jaypee brothers publication; 2018.page no. 128-130. яВвJacob anamma. Textbook of obstetrics and midwifery. 3rd edition;new delhi: jaypee brothers publication 2012. Page no. 166- 182.
- 53. EVALUATION
- 54. THANK YOU