Second stage management of labour
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Lecture notes on second stage of labour( The images are adopted from global health media project
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Second stage management of labour
- 1. Heera KC MSc. Nursing(Maternal Health) MANAGEMENT OF 2nd STAGE OF LABOR
- 2. OBJECTIVES • Identify the clinical course of second stage of labor. • List the principles of management of second stage of labor. • Explain the management of second stage of labor. • Demonstrate the methods of conducting delivery.
- 3. CLINICAL COURSE OF SECOND STAGE OF LABOR • Second stage begins with full dilatation of the cervix and ends with expulsion of the fetus.
- 4. CLINICAL COURSE CONT… Pain • 2-3 min interval minutes. • For about 1–1½ minutes.
- 5. CLINICAL COURSE CONT… • Sustained pushing beyond the uterine contraction is discouraged. • Premature bearing-down efforts - uterine dysfunction. Along with uterine contraction, instructed to exert downward pressure as done during straining at stool. Bearing-down efforts
- 7. CLINICAL COURSE CONT… Descent of the fetus on abdominal examination
- 9. CLINICAL COURSE CONT… Descent of head on P/V examination
- 10. CLINICAL COURSE CONT… Descent of head on P/V examination
- 11. CLINICAL COURSE CONT… • With further descent, vulval opening looks like a slit through which the scalp hair is visible. • Perineum markedly distended with the overlying skin tense and glistening and the vulval opening becomes circular (expulsive phase). • Vaginal signs
- 12. CLINICAL COURSE CONT… • Triangular area of about 4 cm thickness perineum - a thinned out, membranous structure of less than 1 cm thickness. Vaginal and Anal signs
- 13. CLINICAL COURSE CONT… • Crowning” of the head. • The head is born by extension. • Expulsion of fetus
- 14. CLINICAL COURSE CONT… • Vital signs • . • Immediately following the expulsion of the fetus- a sigh of relief. MATERNAL SIGNS During the bearing-down efforts, the face becomes congested with neck veins prominent
- 15. CLINICAL COURSE CONT… • FETAL EFFECTS
- 16. MANAGEMENT OF THE SECOND STAGE
- 17. PRINCIPLES • To assist in the natural expulsion of the fetus slowly and steadily. • To prevent perineal injuries.
- 18. Factors to be considered • Monitoring maternal and fetal condition • Monitor Progress of labor • Preparation for bearing down • Comfort and support • Prevention of infection • Care of perineum • Preparation for delivery • Preparation of midwife, delivery room and equipment • Conduction of delivery
- 19. Monitoring maternal condition • Never leave the woman alone. • Bladder emptying. • Assisting in position of her choice. • Emotional and physical support. • Sponge the face with soaked towel. • Provide oral liquids including plane water. • Pulse every 15 minute and BP every hourly & record.
- 21. Monitoring fetal condition • FHR every 15 minutes and immediately after a contraction. • If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minutes), suspect fetal distress. • Observe for membrane rupture and its colour & detect accidental cord prolapse.
- 22. Monitor Progress of labour • Woman’s condition (mood and behaviour), (fetal heart rate) and • Progress of labour (frequency, intensity and duration of contractions; perineum thinning and bulging; visible descent of the fetal head during contractions.
- 23. Monitor Progress of labour • If, after 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of the cervix.
- 24. Satisfactory progress in 2nd stage of labor is indicated by • Steady descent of fetus through birth canal • Onset of expulsive phase with contraction
- 26. Preparation for bearing down • Support woman to push as she wishes with contractions. Do not urge her to push, particularly if the fetus remains at the pelvic midpoint. • Making noise while pushing is good because it keeps throat open. • Pushing for 5-10 seconds and then taking several breaths before pushing again helps ensure that the baby gets plenty of oxygen.
- 28. Preparation for bearing down • Keep curve chin on her chest and knees wide apart. • Relax pelvic floor while pushing. • When pushing, do not hold breath, close off throat or push hard for a long time.
- 29. Preparation for bearing down • Between contraction, legs should be flat and relax • Not be permitted to push between contraction. • Encouragement should be given praising her that she is doing well.
- 30. Comfort and support • Sponge face and neck with a cool flannel or sponge. • Mouth and lips may become very dry, sips of iced water are refreshing and moisturizing cream can be applied to her lips. • Partner may help with these tasks as a positive contribution to ease her discomfort.
- 32. Comfort and support • Leg cramp can be relieved by massaging the calf muscle, extending the leg and dorsiflexion of the foot. • Give assurance, advice and instruction to patient as to keep up the morale and to avail maximum co-operation during voluntary expulsion of the fetus. • Privacy.
- 34. Care of perineum • Toileting the external genitalia and inner side of the thighs with cotton swabs soaked in betadin solution. • One sterile sheet is placed beneath the buttocks of the patient and one over the abdomen.
- 35. Preparation of midwife, delivery room and equipment • Room preparation/Labor room management
- 36. Preparation for delivery • Collect necessary information from woman and her chart. • Recheck the delivery set, episiotomy set, essential drugs, light, warmth and ventilation. • Prepare baby’s identification tag, O2 and room warmer. • Warm aseptic solution. • Cotton wool and pads • Cord scissors and clamp.
- 38. Delivery set contains • Sponge holder forcep 1 - For cleaning purpose • Plain long artery forcep 2- For cord clamping • Cord scissor 1 For cord cutting • Galipot 1- For antiseptic lotion • Bowl 1- For placenta
- 40. Delivery set contains • Gauze pieces & cotton balls sterile for swabbing • Perineal pads 3-4Pieces (Sterile) • Sterile clothes 4 For baby & to prevent contamination Draper 2 Baby wrapper 2 • Sterile gloves and gown, eye glasses and gumboot • Antiseptic lotion or boiled water
- 41. CONDUCTION OF DELIVERY The assistance required in spontaneous delivery is divided into three phases : • Delivery of the head • Delivery of the shoulders • Delivery of the trunk
- 42. Delivery of the head • to maintain flexion of the head • to prevent its early extension and • to regulate its slow escape out of the vulval outlet. The principles to be followed are
- 43. Procedure for delivery of the head • Patient is encouraged for the bearing down efforts during uterine contractions. This facilitates descent of the head. • When the scalp is visible for about 5 cm in diameter, flexion of the head is maintained during contractions. • This is achieved by pushing the occiput downwards and backwards by using thumb and index fingers of the left hand while pressing the perineum by the right palm with a sterile vulval pad.
- 46. Procedure for delivery of the head Cont… • If patient passes stool, it should be cleaned and the region is washed with warm water solution. • Repeated during subsequent contractions until the subocciput is placed under the symphysis pubis. • “crowning of the head”
- 47. Procedure for delivery of the head • Purpose of increasing the flexion of the head ✔ to ensure that the small suboccipitofrontal diameter 10 cm (4") distends the vulval outlet instead of larger occipitofrontal diameter 11.5 cm (4 1/2")
- 48. Procedure for delivery of the head Cont… • Perineum if fully stretched and threatens to tear- episiotomy Bulging thinned out perineum is a better criterion than the visibility of 4–5 cm of scalp to decide the time of performing episiotomy.
- 49. Procedure for delivery of the head Cont… • Slow delivery of the head in between the contractions. • Done when suboccipitofrontal diameter emerges out. • Pushing the chin with a sterile towel covered fingers of the right hand placed over the anococcygeal region while the left hand exerts pressure on the occiput (Ritgen’s maneuver). Delivery of the head by extension
- 50. The forehead, nose, mouth and the chin are thus born successively over the stretched perineum by extension.
- 51. Care following delivery of the head • Immediately following delivery of the head, the mucus and blood in mouth and pharynx are to be wiped with sterile gauze piece on a little finger. • Note: Routine intrapartum nasal or oral suction should not be done, even in babies born through liquor with meconium.
- 53. Care following delivery of the head • Neck palpated to exclude the presence of any loop of cord (20–25%).
- 54. Prevention of perineal laceration • More attention should be paid not to the perineum but to the controlled delivery of the head. • Delivery by early extension is to be avoided. • Flexion of the subocciput comes under the symphysis pubis so that lesser suboccipitofrontal 10 cm (4") diameter emerges out of the introitus.
- 55. Prevention of perineal laceration • Spontaneous forcible delivery of the head is to be avoided. • To deliver the head in between contractions. • To perform timely episiotomy (when indicated). • To take care during delivery of the shoulders as the wider bisacromial diameter (12 cm) emerges out of the introitus.
- 56. Delivery of the shoulders • Not to be hasty in delivery of the shoulders. • Wait for uterine contractions, restitution and external rotation of the head to occur. • Indirectly signifies that the bisacromial diameter is placed in the anteroposterior diameter of the pelvic outlet. • During next contraction, the anterior shoulder is born behind the symphysis. •
- 57. Delivery of the shoulders • If there is delay, head is grasped by both hands and is gently drawn posteriorly until the anterior shoulder is released from under the pubis. • By drawing the head in upward direction, the posterior shoulder is delivered out of the perineum.
- 58. Delivery of the shoulders • Traction on the head should be gentle to avoid excessive stretching of the neck causing injury to the brachial plexus, hematoma of the neck or fracture of the clavicle.
- 59. Delivery of the trunk • After the delivery of the shoulders, the fore finger of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion. • Note: If there is difficulty delivering the shoulders, or if the infant’s head retracts against the perineum as it is born, suspect shoulder dystocia
- 60. Immediate care of the newborn 1. Dry stimulate and wrap the baby. 2. Assess breathing and color 3. Decide if baby needs resuscitation 4. Tie and cut the cord 5. Give identification tag 6. Skin to skin contact 7. Initiate breast feeding 8. Eye care
- 61. Immediate care of the newborn • Soon after the delivery of the baby, place the baby on the mother’s abdomen. • Dry the baby and wipe the eyes. Remove the wet cloth. • Note the time of birth. • • Keep the baby warm; position skin-to-skin with the mother and cover the baby’s head and body. • Assess the baby’s breathing.
- 62. Clamping and ligature of the cord • If the baby is breathing normally, clamp and cut the umbilical cord two to three minutes after the birth of the baby, while initiating simultaneous essential newborn care. • Note: Only clamp the cord early (within one minute) if the newborn needs to be moved immediately for resuscitation.
- 63. Procedure for cord clamp • Clamped by two Kocher’s forceps, the near one is placed 5 cm away from the umbilicus and is cut in between. • Two separate cord ligatures are applied with sterile cotton threads 1 cm apart using reef-knot, the proximal one being placed 2.5 cm away from the navel. • Presence of any abnormality in cord vessels (single umbilical artery) is to be noted.
- 64. • The purpose of clamping the cord on the maternal end is to prevent soiling of the bed with blood and to prevent fetal blood loss of the second baby in undiagnosed monozygotic twin. • Delay in clamping for 2–3 minutes or till cessation of the cord pulsation facilitates transfer of 80–100 mL blood from the compressed placenta to a baby. • Ensure that the baby is kept warm and in skin-to-skin contact on the mother’s chest. Keep the baby covered with a soft, dry cloth or blanket, and ensure that the baby’s head is covered to prevent heat loss. •
- 65. • If the mother is not well, request the support of an assistant so that both mother and baby can be appropriately monitored and cared for. • • • Palpate the woman’s abdomen to rule out the presence of an additional baby(s), and proceed with active management of the third stage of labour.
- 66. • NOTE: Anticipate the need for resuscitation and have a plan to get assistance for every baby, but especially if the mother has a history of eclampsia, bleeding, prolonged or obstructed labour, preterm birth, or infection. • Apgar rating at 1 minute and at 5 minutes is to be recorded.
- 68. SUMMARY