Lecture notes on second stage of labour( The images are adopted from global health media project

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

6. CLINICAL COURSE CONT…

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.

33. Prevention of
infection
• Universal
precaution-

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