Management of the second stage of labor

1. Management of the second stage of labor Mrs. Mahdia Samaha

2. Begins with complete dilation of the cervix and ends with delivery of fetus • Duration of Second Stage - • Primigravida: 50 minutes • Multiparous: 20 minutes or less • Contractions • Interval: 2 to 3 minutes • Duration: 50 to 100 seconds

3. Signs of the second stage of labor: • Increase in apprehension and irritability. • S.R.O.M. • Sudden appearance of sweat on upper lip • Bloody show • Low grunting sounds from the woman • Rectal and perineal pressure • Involuntary bearing down

4. Signs of progress of second stage of labor: • Bulging of the perineum • Labial separation • Advancing and retreating of the fetal head during and between maternal pushing effort. • Crowning: fetal head is visible at the perineum.

5. Nursing Interventions: • Position the client: • Lithotomy position • Semi sitting position • Lateral/ side lying • Sitting on birthing stool • Squatting position • kneeling with hands on bed and knees comfortably apart.

6. Nursing Interventions: • Provide continuous comfort measures • Instruct the woman on the organized pushing technique • Monitor FHR • Explanation to the client • Psychological support • Upright position • Observe V/S • Pain management

7. Nursing Interventions: • Continuous nursing presence • Appraise maternal efforts • Prepare for and assist with delivery by: 1- preparing the delivery bed 2- prepare perineal area 3- Offer a mirror 4- explain all procedures 5- Delivery instrument 6- Receive new born , cover with blanket on the womans abdomen 7- Provide initial care and assessment of the newborn

8. Episiotomy Indications • Perform to avoid unecessary tearing when head is crowning • Controlled delivery avoids need for episiotomy in most cases. • Anesthetize with pudendal block • Put two fingers into the vagina along the posterior wall • Place one blade of scissors between fingers inside vagina, other blade outside vagina toward anus • Cut to approximately 1 inch away from anus during a contraction

9. Indications of episiotomy • to facilitate delivery when the fetal status is non-reassuring: • epidural anesthesia • onset of persisting moderate to severe variable fetal heart rate decelerations while still some minutes from spontaneous delivery. • To allow spontaneous delivery and avoid the need for operative vaginal intervention. 2. shoulder dystocia 3. breech delivery 4. operative vaginal delivery 5. occiput posterior presentation

10. Benefits of episiotomy • decrease the incidence of first- and second-degree periurethral and vaginal lacerations. • Although an episiotomy may be simpler to repair than a spontaneous laceration, it is associated with a higher incidence of third- and fourth-degree lacerations

11. Complications of episiotomy • Pain and edema are the most frequent postepisiotomy findings. Treatement: regimen of sitz baths several times a day is encouraged in the immediate postpartum period. • Dyspareunia may be a complaint of some women for up to 3 months postpartum. • Infection can be one of the most serious complications of episiotomy

12. Birth • Delivery of head - CONTROL head to prevent explosive delivery and subsequent tearing • Check for presence of cord around neck • Aspirate oral and nasal cavities with bulb syringe • Deliver anterior shoulder with downward pressure • Complete delivery and HANG ON TO BABY!

13. Birth • Clear airway, Assess respirations, Resuscitate if necessary • Clamp cord when pulsations cease • Leave 3 - 6 inches of cord on baby • Obtain blood for fetal labs from the placental stub of cord

15. Immediate care of the newborn • Reassess Airway and Respirations • Keep warm and dry • Allow for maternal bonding • Stimulation of nipples during attempts at breastfeeding will aid in release of oxytocin by posterior pituitary gland resulting in uterine contraction and hemorrhage control

16. APGAR SCORE • Taken at 1 minute and 5 minutes after delivery • Score of zero to two is given for each category • The higher the score, the more vigorous and “healthy” the child is considered to be

17. APGAR SCORE • APPEARANCE: • 2: Completely Pink • 1: Hands and Feet are blue • 0: Paleness and blue color over entire body • PULSE: (most important sign) • 2: Greater than 100 BPM • 1: Detectable rate below 100 BPM • 0: No heart rate detected

18. APGAR SCORE • Muscle tone: (flexing and muscle tone of limbs and resistance to straightening) • 2: Normal muscle tone • 1: Limp to normal muscle tone • 0: No resistance to straightening • ACTIVITY: (response to irritation) • 2: Infant cries in response to flick • 1: Weak cry or head movement in response • 0: No response

19. APGAR SCORE • RESPIRATORY: (Second most important) • 2: Regular respirations and vigorous cry • 1: Weak cry • 0: No respiratory response • Scoring: • 7 to 10 provide supportive care • 4 to 6 indicates moderate depression • < 4 requires aggressive resuscitation

20. Delivery of the placenta • Delivery of the placenta can be accomplished by either expectant or active management of the third stage of labor. • Normally, the placenta separates spontaneously from the uterine wall within approximately 5 minutes of delivery, but may take as long as 20 to 30 minutes. No attempt should be made to extract the placenta before its separation.

21. Signs of separation • Uterus rises to become globular • Increase (gush) of blood from vagina • Lengthening of cord • The fundus changing to a firm consistency

22. Expectant management of third stage of labor: • Do not PULL cord. Apply gentle traction • Check Placenta for completeness • Check the cord for 3-vessels, 2 small arteries and one larger vein • Recover missing pieces of placenta as necessary • Massage uterus to aid in hemostasis • IV Oxytocin can be given if available to aid uterine contractions and aid in hemostasis

24. Assess any perineal trauma: • Firm fundus with bright- red blood trickling: laceration • Boggy fundus with red blood flowing: uterine atony • Boggy fundus with dark blood clots: retained placenta.

25. Active Management • After delivery of the anterior shoulder, or immediately after birth of the infant, give the patient an oxytocic drug to stimulate uterine contraction. • Clamp and cut the cord. • Wait for a strong uterine contraction and then apply controlled cord traction while applying counter traction above the pubic bone. • If the placenta is not delivered, wait until the next contraction.

26. Advantages of active management of the third stage • Decrease the length of third stage • Decrease maternal blood loss • lower risk for postpartum hemorrhage and postpartum anemia, and decreased need for transfusion.

27. Disadvantages • Increased incidence of nausea, vomiting, and headache. • Hypertension is also increased if an ergometrine is used

29. Manual Extraction • Indications: If the placenta has not delivered after 30 minutes if separation has occurred without delivery of the placenta Purpose: to reduce excessive blood loss. Alternative: Injection of oxytocin into the umbilical vein. Complication: Intrauterine bacterial contamination, but is not a common complication.

33. Active Prophylaxis against Postpartum Atony • Gentle but firm external fundal message should always be part of postpartum management. • oxytocin agent either IM with the delivery of the anterior shoulder (10 U oxytocin) or in IV drip after the delivery of the placenta (20 U in 1,000 ml of 5% dextrose in water at 100 drops per minute). • Side effect: marked hypotension if administered as an intravenous bolus.

34. Active Prophylaxis against Postpartum Atony • Methylergonovine maleate (Methergine), 0.2 mg intramuscularly, often produces sufficient uterine contractility to correct atony. • contraindicated in patients who are hypertensive (hypertension may be aggravated), and should be avoided as well in patients who are hypotensive • Side effect: peripheral vasoconstriction in a patient in hypovolemic shock may result in digit loss secondary to vascular insufficiency.

35. Management of the fourth stage of labor: • Assess V/S Q 15 min. • Assess fundal height, position, and firmness Q15min. • Assess the perenium and episiotomy • Assess the woman comfort • Assess lochia

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