Management of second stage of labor

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 MANAGEMENT OF SECOND STAGE OF LABOR



The transition from the first stage to the second stage is evidenced by the following features :
  • Increasing intensity of uterine contraction
  • Bearing down efforts 
  • Urges to push or defecate with descent of the presenting part
  • Complete dilatation of the cervix as evidence on vaginal examination 
Principles of management :
  1. To assist in the natural expulsion of the fetus slowly and steadily
  2. To prevent perineal injuries .
GENERAL MEASURES :
  • The patient should be in bed
  • Constant supervision is mandatory and the FHR is recorded at every 5 min 
  • To administered inhalation analgesics , if available in the form of gas N2O and O2 to relieve pain during contractions.
  • Vaginal examination is done at the beginning of the second stage not only to confirm its onset but to detect any accidental cord prolapse. The position and the station of the head are once more to be reviewed and the progressive descent of head is ensured.
PREPRATION FOR DELIVERY :
  1. Position : Position of the women during delivery may be lateral , squatting or partial sitting (45 degree). Dorsal position with 15 degree left lateral tilt is commonly favored as to avoids aortocaval compression and facilitates pushing efforts .
  2. The accoucheur scrub up : and puts on sterile gown , mask and gloves and stands on the right side of the table 
  3. To catheterize the bladder : if it is full
  4. Toileting the external genitalia : and inner side of the thighs is done with cotton swabs soaked in savlon or dettol solution 
Essential aseptic procedures are remembered 6C :
  1. Clean hand
  2. Clean surface
  3. Clean scissor 
  4. Clean cord
  5. Clean ligature of cord
  6. Clean water 
CONDUCTION OF DELIVERY : The assistance required in spontaneous delivery is divided into three phase :
  1. Delivery of the head 
  2. Delivery of the shoulders
  3. Delivery of the trunk
  • DELIVERY OF HEAD : The principles to be followed are to maintain flexion of the head, to prevent its early extension and to regulate its slow escape out of the vulval outlet.
Care following delivery of the head : 
  1. 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. Alternatively , mechanical or electrical sucker mat be used.
  2. The eyelids are then wipe with sterile dry cotton swabs using one for each eye starting from the medial to the lateral canthus to minimize contamination of the conjunctival sac
  3. The neck is then palpated to exclude the presence of any loop of cord (20-25% )
Prevention of perineal laceration : More attention should be paid not to the perineum but to the controlled delivery of head .
  1. Delivery by early extension is to be avoided 
  2. Spontaneous forcible delivery of head is to be avoided by assuring the patient not to bear down during contractions 
  3. To deliver the head in between contraction
  4. To perform timely episiotomy (when indicated )
  5. To take care during delivery of the shoulders as the wider bisacromial diameter emerge out the introitus
  • DELIVERY OF SHOULDER : 
  1. Not to be hasty in delivery of the shoulders 
  2. Wait for the uterine contraction to come and for the movement of restitution and external rotation of the head to occur
  3. 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.
  • DELIVERY OF THE TRUNK :
  1. After the delivery of the shoulders , the forefinger of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion
NURSING MANAGEMENT OF SECOND STAGE OF LABOR :
  1. Never leave the patient alone once she can be transferred to the delivery room
  2. Encourage the patient to rest between contractions and to push with contraction
  3. position the patient 
  4. monitor the patient blood pressure and the fetal heart beat 5 min and after each contraction
 

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