Care during labour and delivery

SEMINAR ON SECOND STAGE OF LABOUR
SUBMITED TO SUBMITTED BY
JYOTHI K DIVAKARAN AISWARYA S KUMAR
ASST PROFESSOR 1ST
YEAR MSC.NURSING
GCON GCON

INTRODUCTION
Normal labour and delivery is a physiologic process in which the attendant closely monitor
the woman and fetus, with little medical Intervention required.
SECOND STAGE OF LABOUR / PUSHING STAGE / PELVIC STAGE
It begins with full cervical dilatation (10cm) till the birth of the baby.
DURATION :
 Primi gravida - 2 hours.
 Multi gravida - 30 minutes.
 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
PHASES OF SECOND STAGE OF LABOUR
Have 3 phases
* Latent phases / Propulsive phase
* Active phases / Expulsive phase
*Transition phases / Compulsive phase

 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 .
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 Uterine contraction
- 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
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.
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.
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.
Duration
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
5. Pelvic adequacy of the laboring woman (size, presentation, position of the fetus)
6. Nature of support the woman receives
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

-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.
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
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
1) Descend:
Descent is brought about by the force of the uterine contractions, maternal bearing-down
(Valsalva) efforts, and, if the patient is upright, gravity.
 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:
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.
 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
2) 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
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.
 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.
5) 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
6) 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.
 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
7) 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
8) 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
9) EXTERNAL ROTATION OF THE HEAD:
 The head rotate in same direction as restitution and the occiput of the fetal head now lies
laterally
10) 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
.
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.
Research evidence
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.
 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.
Research implications
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
-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
-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.
* 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
Transitional phase (8-10cm)
* Encourage slow, gentle pushing
* Explains that “blowing away the contraction” facilitates a slower birth of the head
* 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
- 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.
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.
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-war techniques.
 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.
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.
- 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.

-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.
-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.
- 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.
- A brief assessment of the newborn can be performed includes checking the airway and Apgar
Score.
PERINEAL TRAUMA RELATED TO 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).
- Immediate repair:
* Promotes healing
* Limits residual damage
* Decreases the possibility of infection
- 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
3. Third degree: Laceration continues through the anal sphincter muscle.
4. Fourth degree: Laceration involves the anterior rectal wall.
- 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.
- 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.
- 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.
- 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.
- This laceration occur at the angles of the external os, most are shallow, bleeding is minimal.
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.
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.

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
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
IMPORTANT NURSING DIAGNOSIS IN 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
 Risk for deficient fluid volume related to lack of intake or excessive vascular loss
 Risk for fetal injury related to descent / pressure changes / compromised circulation /
environmental exposure

 Impaired urinary elimination related to decreased fluid intake ,mechanical compression
of the bladder as evidenced by urine retention,slowed progression of labour
 Fatigue related to discomfort,pain,overwhelming psychologic demands,increased energy
demands
 High risk for maternal infection related to repeated invasive procedures,traumatized
tissue,exposure to pathogens,rupture of membranes
 Anxiety related to labour pain,outcome as evidenced by verbalization,facial expression
Reference
Adelele Pilleteri,Maternal And Child Health Nursing,6th
Edition Wilkins Publishers,Pg
No 740-750
D.C.Dutta Textbook Of Obstetrics 6th
Edition New Central Publications Pg No 115-140
Indian Academy Of Pediatrics Training Manual Of Newborn Resuscitation
Guidelines For Antenatal Care And Skilled Birth Attenders By The Ministry Of Health
And Family Welfare.Govt Of India April 2010.

Care during labour and delivery

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