Physiology and Mangement of 2nd stage labour

1. Physiology and
MANAGEMENT OF 2ND STAGE
OF LABOUR
MRS.JAGADEESWARI.J
M.SC NURSING

2. NORMAL LABOUR
Series of events that takes place in
the genital organs in an effort to
expel the viable products of
conception out of the womb through
the vagina into the outer world is
called labour

3. SECOND STAGE OF LABOUR
DEFINITION
The second stage of labour begins with full dilatation of
cervix and ends with the expulsion of the fetus.
- DC .DUTTA
This stage is concerned with the descent and delivery of
the fetus through the birth canal.

4. Phases and duration of second stage of labour
Average duration is 2 hours in primigravidae
30 minutes in multiparae.
Second stage has two phases:
• Propulsive phase-from full dilatation until head touches the pelvic
floor.
• Expulsive phase-since the time mother has irresistible desire to
bear down and push until the baby is delivered.

5. Physiology of second stage of labour
The physiological changes result from a
continuation of the some forces which
have been at work desiring the first stage
of labour.
Descend
Uterine action
Rupture of membrane
Soft tissue displacement

6. descend
Descend of the fetal presenting part which
began during the first stage of labour and
reaches its maximum speed toward the end of
the first stage of labour,continues its rapid pace
through the second stage of labour until the
pelvic floor
The average maximum rate of descend is
1.6cm/hr in multiparae
5.4cm/hr in nullipara.

7. uterine action
• Contractions during the second stage are frequent ,strong
and slightly longer that is approximately every 2 minutes,
lasting for 60-90 seconds
• They are strong in intensity and become expulsive in
nature.
• In natural course of labour there is often a lull or quiet
period between first and second stage .
• The woman rests and may even nap
• The fetal head descends through the pelvis the contractions
become more forceful and the woman begins to voluntarily
bear down with expiratory, grunty short pushes.

8. Rupture of membrane
The membrane often rupture
spontaneously at the onset of the
second stage
The consequent drainage of liqour
allows the hard round fetal head to be
directly applied to the vaginal tissue
and aid distension

9. soft tissue displacement
As the hard fetal head descends the soft tissue of the pelvis
become displaced.
Anteriorly the bladder is pushed upwards into the abdomen
where it is at less risk of injury during fetal descent
Posteriorly the rectum becomes flattened into the sacral
curve and the pressure of the advancing head expels an
residual fecal matter.
The levator ani muscles dilates thin out and become
displaced laterally
The perineal body is flattened stretched and thinned
The fetal head become visible at the vulva advancing and
residing during resting phase until crowning.

10. Signs of second stage of labour
Expulsive contractions
Rupture of membrane
Dilatation and gaping of anus
and perineal bulging
Progressive visibility of fetal
head at the introitus
Congestion of the vulva

11. Mechanism of normal labour
definition
The series of movements
that occur on the head in the
process of adaptation during
its journey through the
pelvis is called mechanism
of labour.
DC.DUTTA

12. MECHANISM OF NORMAL LABOUR
Principles of mechanism of labour
• Descent takes place throughout labour.
• Whichever part leads and first meets the resistance of
the pelvic floor will rotate forward until it comes
under the symphysis pubis
• Whatever emerges from the pelvis will pivot around
the pubic bone.

13. description of normal labour
• The lie is longitudinal
• The attitude is flexion
• The presentation is cephalic
• The position is left or right occipito anterior
• The presenting part is posterior part of the anterior
parietal bone/vertex
• The denominator is occiput.

14. PRINCIPLE MOVEMENTS …..
• Engagement
• Descent
• Flexion
• Internal rotation of the head
• Crowning
• Extension
• Restitution
• Internal rotation of the shoulders
• External rotation of the head
• Lateral flexion of the trunk

15. Engagement
• In LOA of vertex, when the fetus head
enters pelvis brim the occiput lies in
relation to the left ileopectineal
eminence sinciput at right sacroiliac
joint and sagittal sutures lies on the
right oblique diameter of the maternal
pelvis
• The engaging antero -posterior
diameter of the head is either sub
occipito frontal 10cm
• The engaging transverse diameter is
biparietal diameter is 9.5cm

16. descent
• Descent is a continuous process which
ends with the expulsion of the fetus
• The head in primigravidae get engaged
priorly there is no descent in the first
stage while in multipara descent starts
with engagement
• Head reaches the pelvic floor when the
cervix is fully dilated

17. Flexion
•Flexion increases
throughout the
labour resulting in
smaller presenting
diameter ,which
will negotiate the
pelvic more easily

18. Internal rotation
• As the descent keeps on taking
place the leading part is pushed
downwards on to the pelvic
floor
• When the contraction fades the
pelvic floor rebounds causing
the occiput to glide forwards
• The occiput rotates through
1/8th of the circle to lie under
the pubic arch.

19. Crowning
• The internal rotation is followed by further
descent until the occiput passes beyond
symphysis pubis in flexed attitude of fetal
head.
• This causes a slight twist in the neck of the
fetus as the head is no longer in direct
alignment with the shoulders
• The anteroposterior diameter of the head
now lies in the widest diameter of the pelvis
outlet.
• The maximum diameter(biparietal) of the
head stretches the vulval outlet without any
recession of the head even after the
contraction is over is called crowning of the
head.

20. Extension of the head
•After crowning fetal head
can extend pivoting on the
sub -occipital region around
the public bone
•This releases the sinciput
,face and chin which sweeps
the perineum and head is
born by movement of
extension.

21. Restitution
•After the birth of the head
there is a visible passive
movement in the head to
undo the twist caused in
the neck of the fetus from
the internal rotation .
•During this untwisting
movement the occiput
moves 1/8th of the circle
towards the side from
which it is started

22. Internal rotation of the shoulders and
external rotation of head
• In the same way as head internal
rotation of the shoulders rotate .
• The shoulders now lie in the
widest diameter of the pelvic
outlet namely antero-posterior.
• The anterior shoulder reaches
first to the levator ani muscle and
rotates anteriorly to lie under the
symphysis pubis.
• The head turns 1/8th circle
externally in same direction as
restitution.

23. Lateral flexion
•With descent the
anterior shoulder
escapes below the
symphysis pubis.
•By the movement of
lateral flexion the
spine the posterior
shoulder sweeps the
perineum and the
trunk is born by lateral
flexion

24. MANAGEMENT of second stage of labour
AIMS
1) To achieve delivery of a normal
healthy child with minimal
physical and psychological
maternal effects
2) Early anticipation ,recognition
and management of any
abnormalities during labour
course.

25. MANAGEMENT of second stage of labour
Principles
To assist in the natural expulsion of the fetus
slowly and steadily
To prevent perineal injuries

26. General measures
• The patient should be in bed
• Constant supervision
• To administer analgesics
• Vaginal examination

27. Position during labour
Standing
supported squat
Semi sitting

28. cont…
sitting Sitting on toilet

29. cont…
Squatting Side

30. cont…
walking standing

31. Cont…
Leaning or kneeling
forward with
Knee chest

32. common position of labour
lithotomy

33. Preparation of the mother
•Change clothing's into hospital gown
•Monitor uterine contractions and per vaginal
findings for lie,attitude,presentation and
station.
•Provide perineal care
•Administer enema now contraindicated
•Provide preferable position

34. Preparation of the unit
•Place obstetric delivery pack on the table
•Maintain sterility
•Cover the table with sterile drape
•Ensure availability of oxygen and suction
source
•Maintain delivery record and newborn
admission record.

35. Preparation for delivery
• Positioning.
• Nurse and obstetrician scrubs up and puts on sterile
gown, mask and gloves
• Toileting the external genitalia and inner side of the
thighs
• One sterile sheet is placed beneath the buttocks of the
patient and one over the abdomen. Sterilized leggings are
to be used.
• Essential aseptic procedures are remembered as 3C’s:
clean hands, clean surfaces, clean cutting and ligaturing
of the cord.
• To catheterize the bladder, if it is full.

36. Conduction of delivery
3 phases:
• Delivery of the head
• Delivery of the shoulders
• Delivery of the trunk

37. Delivery of head
principles to be followed
1. To maintain flexion of the head .
2. To prevent its early extension and to regulate its slow
escape out of the vulval outlet.
Steps
 Encourage the client for the bearing down efforts
during uterine contractions to facilitate descent of the
head
 To maintain flexion of the head during contractions
when the scalp is visible foe about 5cm in diameter.

38. 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.
• Spontaneous forcible delivery of the head is to be avoided.
• To infiltrate the perineum with 2% 10ml inj.lidocaine
• To perform timely episiotomy.
• To take care during delivery of the shoulders as the wider
bisacromial diameter emerges out of the introitus

39. episiotomy
• A surgical planned incision on the
perineum and posterior vaginal wall
during the second stage of labour is
called episiotomy
INDICATIONS
Rigid perineum
Anticipating perineal tear in case of
big baby, shoulder dystocia
Operative delivery like forceps or
vacuum delivery
Previous perineal surgery

40. Median Medio-lateral
Merits - The muscles are not cut
- Blood loss is least
- Repair is easy
- Post operative comfort is
maximum
- Healing is superior
- Wound disruption is rare
- Relative safety from
rectal involvement from
extension
Demerits - Extension , if occurs,
may involve the rectum
- Not suitable for
manipulative delivery or
in abnormal presentation
or position
- Apposition of the tissues is
not so good
- Blood loss is little more
- Post operative discomfort
is more
- Relative increased
incidence of wound
disruption
- Dyspareunia is
comparatively more

41. Cont..steps to delivery the head
• Encourage the client to bear down
during uterine contractions to facilitate
descent of the head
• A firm perineal support is given with a
pad or gauze
• The fore head ,nose, mouth and chin are
born by extension
• Immediately the following delivery of
the head the mucus and blood in mouth
and pharynx are wiped with a sterile
gauze or a bulb sucker
• The neck is palpated for any loop of the
cord .if found loose enough it can be
removed. If tight it is clamped and
ligated and the baby is shoulders are
delivered.

42. Delivery of shoulders
• Do not be panic in delivery of the shoulders
• Wait for contractions and watch for restitution
and external rotation of head.
• Thus indirectly signifies that bisacromial
diameter is place din antero posterior of the
pelvis
• During next contractions the anterior shoulder
is born behind the symphysis pubis
• Place on each side of the head and deliver the
anterior shoulder
• By drawing upward traction of the head the
posterior shoulder is released from the
perineum.

43. Delivery of the trunk
•After the delivery of
the shoulders the trunk
is delivered by lateral
flexion .

44. IMMEDIATE CARE OF THE NEWBORN
• Baby should be placed on a tray covered with clean dry
linen with the head slightly downwards soon after
delivery.
• Maintaining thermoregulation
• Suctioning to clear the air passages
• Maintaining cardio respiratory
function
• Oxygen may be given as needed
until the infant cries vigorously
• APGAR score

45. Apgar score
Category 0 1 2
Heart rate absent <100 >100
Respiratory
efforts
absent Slow irregular Good crying
Muscle tone flaccid some flexion of
extremities
Active motion
Reflex
irritability
No response grimace Vigorous cry
colour Blue,pale Body
pink,extremities
blue
Completely pink

46. Cont…
• Clamping and ligature of the cord ie 2-5cm from abdomen
• Documenting urination/passage of meconium
• Administering vitamin K
• Prophylactic eye care
• Promoting parent-newborn bonding
• Quick check is made to detect any gross abnormality

47. NURSING CARE OF PATIENT IN SECOND STAGE OF
LABOUR
• Never leave the patient alone once she has been
transferred to the delivery room
• Encourage the patient to rest between contractions and to
push with contractions
• Position the patient’s legs in the stirrups for the lithotomy
position
• Prepare the patient’s perineum
• Monitor the patient’s blood pressure and the fetal heart
beat every 5 minutes and after each contraction

48. Evaluations in second stage of labour
•To evaluate the progress of second
stage of labour check..
1. Uterine contractions
2. FHR for every 5minutes-
15minutes
3. Descend and station of fetal head
4. Progress through the mechanism
of labor

49. Records to be maintained
• Exact date and time of delivery
• Sex of the fetus
• Condition of the baby by APGAR after birth
• Type of delivery-spontaneous ,forceps, vacuum
• Type of episiotomy if performed
• Number of vessels in umbilical cord
• Condition of mother and baby through out
labour .