Management of the Second stage of Labour

Hello! Class 2010

The SECOND STAGE OF LABOUR (The Pushing Stage)

Objectives
At the end of the session, students are able to; (i) Define the second stage of labour (ii) Describe events taking place . (iii) Explain the care of the woman in the second stage of labour (v) Discuss the preparation of a delivery room

Cont. objectives
Briefly describe the concepts in conducting a normal delivery Discuss the techniques in promotion of aseptic technique Define episiotomy and describe how it is done Estimate Apgar scoring

Definition of the second stage

It is the stage of labor which begins from complete dilatation of the cervix(10cm) to the delivery of the baby(Novak & Broom,1999). Time range: 1 hour NB: There is continuation of the same forces which have been at work during the 1st stage of labour but the activity is accelerated once the cervix is fully dilated

Cont.
The cervix is fully dilated and no longer in front of the baby s head. A smooth passageway now exists through which she can push her baby from her uterus through the birth canal to delivery. The length of the stage varies with the position and the size of the baby and the ability of the mother to push with the contractions

What happens in second stage

Uterine action/contraction Becomes stronger and longer Contraction lasts for about 50-60 secs at 2-3 mins interval Can be less frequent The membranes often rupture spontaneously

Cont.
The consequent drainage of liquor allows the hard, round fetal head to be directly applied to the vaginal tissues and aid distension

Cont.
Contraction becomes more expulsive as pressure is exerted on the rectum and the pelvic floor The mother feels a compelling urge to push This reflex may initially be controlled to a limited extent but becomes increasingly compulsive, overwhelming and involuntary during each contraction

Cont.
The mothers response is to employ her secondary powers of expulsion by contracting her abdominal muscles and diaphram Soft tissue Displacement; As the hard fetal head descends, the soft tissues of the pelvis become displaced. Anteriorly, the bladder is pushed upwards into the abdomen where it is at less risk of injury

Cont.
during fetal descent. This results in the stretching and thinning of the urethra so that its lumen is reduced. Posteriorly, the rectum becomes flattened in to the sacral curve and the pressure of the advancing head expels any residual faecal matter. The lavato- ani muscles dilate, thin out and are displaced laterally and the perineal body is flattened, stretched and thinned.

Cont.
The fetal head becomes visible at the vulva,advancing with each contraction and receding during the resting phase until crowning takes place and the head is born. The shoulders and the body follow the next contraction, accompanied by a gush of amniotic fluid. The 2nd stage culminates in the birth of the baby.

Mechanism of Labour
Engagement Descend Flexion of the Head Crowning Extension of the Head Restitution Internal Rotation of the shoulder Lateral flexion Expulsion

Determinant Factor in a normal labour/delivery

The 4 Ps; Passage - Bony Pelvis Passenger - Baby Powers Contractions Psyche - maternal emotional state

Passage

Passenger

Powers

Psyche

NB/
At 2nd stage, sometimes the membrane may or may not be ruptured The station of the presenting part may still be high(ie -3,-2 or -1)

Recognition of the 2nd stage of Labour

Mother have a strong urge to push with each contraction Heavy show is noted at perineum Bulging of the perineum Gaping of the anus Appearance of the presenting part .

Confirmatory evidence
Only with a vaginal examination can confirm the onset of the 2nd stage

When to transfer the woman to the delivery suit

In primips when the head is on view In multips when the cervix is fully dilated In other cases where an uncooperative client continues to push, before the cervix is fully dilated(transfer-at 8/9cm)

Observations during the second stage of labour

(i)Uterine contraction (ii)Descent of the presenting part (iii)Fetal condition (iv)Maternal condition

(i)Uterine contractions; The strength, length and frequency of contractions should be assessed continuously It s usually stronger and longer with a longer resting phase

Cont.
(ii)Progress of the descent Is observed by noting the descent of the fetal head as it advances during contractions and recedes afterwards It is not necessary to make a further vaginal examination if the descent has been progressive If there's a delay in progress of > 1/2 hr, a VE should be performed This will confirm whether or not the internal rotation of the head has taken place the station or whether a caput succedaneum has formed

 (iii)Fetal condition; The colour of the liquor draining is noted As the fetus descend, fetal oxygenation may be less efficient due to either cord or to reduced perfusion at the placental site Check fetal heart rate every 15mins and chart in the partograph.Recognize the changes in fetal heart rate patterns so that assistance may be sought at the earliest as possible.

Cont.
Maternal condition; (i)Psychological support A clear explanation of her progress and the steps she has to take mostly enables the mother s co-operation - Ensure privacy (ii)Promotion of Maternal comfort (a) She usually feels very hot and sticky it s always soothing to have her face and neck sponged with a cool flannel (b) - sips of water are refreshing to a dry mouth and lips or a moisturizing cream.

Cont.
(c)The presence of her partner can be a positive contribution to her comfort (d) position Adopt a position that the mother is comfortable in. The position the mother may choose is influenced by several factors (i) the mother s personal preferences (ii) the environment for reasons of safety

Cont.
(iii)Maternal and fetal condition; the concern of the wellbeing of either the woman or her baby (iv) The midwives/ birth attendants preferences; in her own skills to supervise the delivery when the mother prefers to adopt a posture. The real understanding of the mechanism of labour should enable the midwife to adopt to any position

Cont.
(e) Bladder care The bladder base may become compressed between the pelvic brim and the fetal head. The woman be encouraged to pass urine during her first stage. Small amount of urine may dribble with contractions When a full bladder is noted to slow the descend, catheterization can be done.

Cont.
(e)Pushing; Assist the woman in her pushing effort. - Encourage her to push with her contractions and praise her of her efforts Mother be helped to avoid active pushing when the head is visible.

 Once the head becomes visible each mother should be encouraged to follow her own inclinations in relation to own expulsive effort Pushing effort will be regulated in response to the varying intensity of her contractions Therefore she is the best judge of when and how to push Some mothers may become frightened by the overwhelming urge and cry out-she should feel free to express herself in this way

Cont.
However, these sounds are an embarrassment to the other woman or cause distress to other couples . The nurse s reassurance and praise boost confidence enabling the mother to assert her control over events The atmosphere should be calm and the pace unhurried

Cont.
(g) Vital signs; Maternal pulse be recorded quarter hrly and BP hrly,

Preparation of the delivery room

Responsibility of the registered nurse or midwife Have a clear concept of the principles of sterile technique Know where the supplies are kept Know the clients special need and the attending physician or the nurse/midwife s desire

Cont. preparation
The room should be set up to accomplish the following goals; Provide an aseptic field for the anticipated birth and subsequent newborn and maternal care Ensure the convenient placement and operation of all necessary articles and equipment for safe efficient care of the mother and the newborn

Cont.
Aid in necessary legal and statistical recording of the event. 4 SIMPLE RULES FOR AN ASEPTIC TECHNIQUE Know what is sterile Know what is not sterile Keep the two apart Remedy contamination immediately

What to prepare
A clean room with good spotlight. Clean delivery bed with pillow A sterile delivery pack& delivery bundle with the nurses gown-set up a delivery trolley
Cord clamps, gloves, syringes,needles,oxytocin Neonatal resuscitation equipment. Wrist label ,MCH card NB/- A drip stand , drip set, angio-cath & oxygen apparatus should always be ready in a delivery room in case of an emergency

Conducting the delivery

The birth attendants skill and judgment are crucial factors in minimizing maternal trauma and ensuring a safe delivery of the baby These qualities are important; (i)observation of the progress (ii)prevention of infection (iii)emotional & physical comfort of the mother

Cont.
(iv) anticipation of normal events (v)recognition of abnormal developments ASEPSIS The mother and the baby are particularly vulnerable to infection Aseptic technique must be observed in preparing sterile equipment Sterile surgical gloves & gown are worn to protect both the mother and the midwife

Delivery of the head

As soon as the fetal head becomes visible; The birth attendant, scrub up, put on her gown , gloves, face mask with eye shield A delivery assistant present is always be an advantage The perineum is swabbed with an antiseptic solution, the delivery area is draped with sterile linen . With these preparations the accoucher must not be distracted from monitoring the descent of the fetus

Cont.
With each contraction the head descend. She places her fingers at the advancing head to monitor descent and prevent expulsive crowninglaceration Light pressure is applied on the head and another hand with a dressing pad supporting the perineum so that the birth is controlled The decision of whether or not to do an episiotomy is done

Cont.
It may take 2 or 3 contractions to deliver the head, but delicate control will avoid unnecessary trauma The head is born by extension as the head appears at the perineum During the resting phase, before the next contraction, check that the cord is not around baby's neck

Cont.
If found, it should be slackened which the shoulder may pass through If it s very tightly wound around the neck, 2 artery forceps are applied 3 cm apart and the cord is cut between them. Hold a swab over when cutting so as not to be sprayed with blood during the procedure. Once cord is cut, un-wound it from around the neck

Delivery of the shoulders

Always wait for the external rotation of the head so that the shoulders can be delivered safely avoiding perineal laceration A hand is placed on each side of the baby s head, over the ears, and downward traction is applied This allow the anterior shoulder to slip beneath the symphysis pubis while the posterior one remains in the vagina

Cont.
When the axillary crease is seen, the head and the trunk are guided in an upward curve so that the posterior shoulder to escape over the perineum Then she grasp the baby around the chest to aid the birth of the trunk and lift the baby towards the mother s abdomen The newborn usually cries soon after birth Put the baby on the delivery table, clamp the umbilical cord with 2 artery forceps and make a cut in between them

Cont.
A plastic cord clamp can then be applied about 2-3cm from the abdomen Aspiration/ suction of mucous is only done when it is necessary Swab the eyes and face and the whole body Wrap baby properly in a pre warmed baby wrapper Baby is put on the mothers abdomen to promote early attachment between the mother and baby(skin to skin) An identification wrist band is attached on baby s wrist with the mother s name ,date of birth,sex and the mother s hospital no.

Administer oxytocic
The assistant feel the mothers abdomen to exclude a second twin then an oxytocic is given It is either syntometrine or syntocinon and is given IMI at the antero- lateral thigh In case of PPH risk, sytocinon is given IV( in the decision of the midwife)

Apgar Scoring
This is a method of evaluating the newborn infant:- Designed by Dr Virginia Apgar in 1953 Its purpose is to ascertain the physical condition of the newborn and the need for resuscitation. This is done at 1min, 5 mins and 10 minutes using the following criteria; Heart rate, Respiratory effort, Muscle tone, Reflex irritability, and Colour

TABLE 11-4 Modified Apgar Scoring Chart to Evaluate Newborn Status 1 and 10 Minutes After Birth New Name A Appearance P Pulse G Grimace Traditional Sign Color Heart Rate Reflex response (e.g., to catheter in nostril) Muscle tone 0 Blue, pale absent No response 1 Body pink Extremities blue Slow (below 100) Grimace 2 Completely pink

Over 100 Cry, cough, or sneeze

A activity R Respiratory effort Total score:

Flaccid

Some flexion of extremities Slow, irregular Severely depressed Moderately depressed Vigorous

Actual motion

Respiratory effort

Absent

Good, crying 0 to 3 4 to 6 7 to 10

1 min ________________ 10 min ________________

Episiotomy
It is a planned incision of the perineum done to enlarge the vaginal opening so as to expedite delivery Justifiable indications; In case of fetal distress Prior to assisted deliveries such as forceps or ventouse extraction To minimize the risk of intracranial damage during preterm and breech delivery

Types of incision
Mediolateral; This begins at the mid-point of the forchette and is directed at 45 degrees angle to the midline towards a point of midway between the Ischia tuberosity to the anus.This line avoids the danger to the anal sphincter and the bartholin s glands. It is more difficult to repair

Cont.
Median; This is a midline incision which follows the natural line of insertion of the perineal muscles . It is associated with reduced blood loss. A higher incidence of damage to the anal sphincter. It is easier to repair and results in less pain.

EPISIOTOMY

54

Infiltration of the perineum

Lignoccaine is commonly used to anaesthetize the perineum prior the incision. 10mls of 0.5% or 5ml of 1% lignoccaine It takes 3-4mins to take effect. Method of infiltration; Explain the procedure to the mother The perineum is cleansed with an antiseptic solution, Two fingers are inserted into the vagina along the line of the proposed incision

Cont.
In order to protect the fetal head The needle is inserted beneath the skin for 45cm The piston of the syringe should be withdrawn prior to injection- to check whether the needle is in the blood vessel Lignoccaine is continuously injected as the needle is slowly withdrawn

Cont.
The Mayo-scissors is used. Two fingers are in are inserted into the vagina as before the open blades are positioned The incision is best made during a contraction when the tissues are stretched and there s a clear view of the area. Bleeding is less likely to be severe. A single cut,4-5cm made at the correct angle

Cont.
Pressure should be applied to the episiotomy site to minimize bleeding(i.e if there is delay in the delivery of the head) Perineal Repair; Trauma is best repaired as soon as possible after delivery Lithotomy position is the usual position chosen- clear view of the area.

Cont.
The full extent of the trauma is assessed and explained to the mother. Suturing is done & usually begins from the apex of the vagina incision or tears and downward