The document provides information on the management of the second stage of labor by nurses. It discusses the normal physiology of the second stage, including cervical dilation, fetal descent and rotation, and maternal efforts. It describes the mechanism of labor, including engagement, descent, flexion, internal rotation, crowning, extension, and birth of the shoulders and trunk. Monitoring labor progress and managing the second stage with techniques like the partogram are also summarized.

1. 1
SEMINAR ON NURSING
MANAGEMENT OF 2ND STAGE
OF LABOUR
Submitted to Submitted by
Mrs.INDU BALAKRISHNAN Mrs. DRISYA.V.R.
Asst.professor 1st
year MSc Nursing
Govt.College of nursing Govt. College ofnursing
Alappuzha Alappuzha
INTRODUCTION

2. 2
The labor and birth process is an exciting, anxiety-provoking, but rewarding time
for the woman and her family. They are about to undergo one of the most meaningful
and stressful events in life. In the last 25 years there has been a steady increase in the
rate of cesarean births, from 5.5% in 1970, to approximately 25% in 1995. This
increase has occurred as a result of changes in the management of several factors,
including malpresentation, fetal distress, prior cesarean section, and dystocia. The
increase in the cesarean section rate has not been a major contributing factor in
decreasing the perinatal mortality rate, which has occurred during the same period of
time. The primary goal of nursing care is to ensure the bestpossible outcome for the
mother and the newborn. Nursing care focuses on establishing a meaningful, open
relationship; determining the fetal status; encouraging the woman’s self direction;
and supporting the woman and her family throughout the labor and birth process.
NORMAL LABOUR

3. 3
Series of events that takes place in the genital organs in an effort to expel the viable
products ofconception out of the womb through the vagina into the outer world is
called labour.
Labour is called normal if it fulfills the following criteria: (1) spontaneous in onset
and at term,(2) with vertex presentation (3) without undue prolongation, (4) natural
termination with minimal aids,(5) without having any complications affecting the
health of the mother and /or baby.
SECOND STAGE OF LABOUR
The second stage is that of expulsion of the fetus. It begins when the cervix is fully
dilated and the woman feels the urge to expel the baby. It is complete when the baby
is born. So this stage is concerned with the descentand delivery of the fetus through
the birth canal. Its average duration is 2 hours in primigravidae and 30 minutes
in multiparae.
EVENTS IN SECOND STAGE OF LABOUR
Second stage has two phases:
1. Propulsive –from full dilatation until head touches the pelvic floor.
2. Expulsive – since the time mother has irresistible desire to bear down and push
until the baby is delivered.
With the full dilatation of the cervix, the membranes usually rupture and there is
escapeof good amount of liquor amnii.The volume of the uterine cavity is thereby
reduced. Simultaneously, uterine contraction and retraction become stronger. The
uterus becomes elongated during contraction, while the antero-posterior and
transverse diameters are reduced. The elongation is partly due to the contractions of
the circular muscle fibers of the uterus to keep the fetal axis straight.
Delivery of the fetus is accomplished by the downward thrust offered by uterine
contractions supplemented by voluntary contraction of abdominal muscles against the
resistance offered by bony and soft tissues of the birth canal. There is always a
tendency to push the fetus back into the uterine cavity by the elastic recoil of the
tissue of the vagina and the pelvic floor. This is effectively counterbalanced by the
power of retraction. Thus, with increasing contraction and retraction, the upper

4. 4
segment becomes more and more thicker with corresponding thinning of lower
segment. Endowed with power of retraction, the fetus is gradually expelled from the
uterus against the resistance offered by the pelvic floor. After the expulsion of the
fetus, the uterine cavity is permanently reduced in size only to accommodatethe
after-births.
The expulsive force of the uterine contractions added by voluntary contraction of the
abdominal muscles called bearing down efforts.
CLINICAL COURSEOR PHYSIOLOGY OF SECOND STAGE OF LABOUR
Second stage begins with full dilatation of the cervix and ends with expulsion of the
fetus.
 Pain
The intensity of the pain increases. The pain comes at intervals of 2-3 minutes and
lasts for about 1- 11/2 minutes. It becomes successivewith increasing intensity in the
second stage.
 Bearing down efforts
It is the additional voluntary expulsive efforts that appear during the 2nd stage of
labour. It is initiated by nerve reflex (Ferguson Reflex) set up due to stretching of the
vagina by the presenting part .in majority, this expulsive effort start spontaneously
with full dilatation of the cervix. Along with uterine contraction, the woman is
instructed to exert downward pressure as done during straining at stool. Sustained
pushing beyond the uterine contraction is discouraged. Premature bearing down
efforts may suggest uterine dysfunction. There may be slowing of FHR during
pushing and it should come back to normal once the contraction is over.
 Membrane status
Membranes may rupture with a gush of liquor per vaginam. Rupture may
occasionally be delayed till the head bulges out through the introitus. Rarely,
spontaneous rupture may not take place at all, allowing the baby to be “born in a
caul”.
 Descent of the fetus
Features of descent of the fetus are evident from abdominal and vaginal
examinations. Abdominal findings are – progressive descentof the head, assessed in

5. 5
relation to the brim, rotation of the anterior shoulder to the midline and change in
position of the fetal heart rate shifted downwards and medially.
Internal examination reveals – descent of the head in relation to ischial spines and
gradual rotation of the head evidenced by position of the sagittal suture and the
occiput in relation to the quadrants of the pelvis.
Abdominal assessmentof progressive descent of the head (using fifth formula)
Progressive descent of the head can be usefully assessed abdominally by estimating
the number of ‘fifths’ of the head above the pelvic brim (Crichton) : the amount of
head felt suprapubically in finger breadth is assessed byplacing the radial margin of
the index finger above the symphysis pubis successively until the groove of the neck
is reached. When 1/5th above, only the sinciput can be felt abdominally and nought-
fifths represents a head entirely in the pelvis with no poles felt abdominally.
Advantages over “station of the head” in relation to ischial spines:
1. It excludes the variability due to caput and moulding or by a different depth of
the pelvis
2. The assessmentis quantitative and can be easily reproduced
3. Repeated vaginal examinations are avoided.
 Vaginal signs
As the head descents down, it distends the perineum, the vulval opening looks like a
slit through which the scalp hairs are visible. During each contraction, the perineum
is markedly distended with the overlying skin tense and glistening and the vulval
opening becomes circular (expulsive phase). The adjoining anal sphincter is stretched
and stoolcomes out during contraction. The head recedes after the contraction passes
off but is held up a little in advance because of retraction. Ultimately, the maximum
diameter of the head stretches the vulval outlet and there is no recession even after
the contraction passes off. This is called “crowning”of the head. The head is born by
extension. After a little pause, the mother experiences further pain and bearing down
efforts to expel the shoulders and the trunk. Immediately thereafter, a gush of liquor
follows, often tinged with blood.
 Maternal signs
There are features of exhaustion. Respiration is, however, slowed down with
increased perspiration. During the bearing down efforts, the face becomes congested
with neck veins prominent. Immediately following the expulsion of the fetus, the
mother heaves a sigh of relief.

6. 6
 Fetal effects
Slowing of FHR during contractions is observed which comes back to normal before
the next contraction.
MECHANISM OF NORMAL LABOUR
The series of movements teat occuron the head in the process ofadaptation, during
its journey through the pelvis, is called mechanism of labour.
Principles of mechanism of labour
1. Descent takes place throughout labour.
2. Whichever part leads and first meets the resistance of the pelvic floor will
rotate forward until it comes under the symphysis pubis
3. Whatever emerges from the pelvis will pivot around the pubic bone.
MECHANISM
The series of movements that occuron the head in the process ofadaptation, during
its journey through the pelvis, is called mechanism of labour.
Presentation- cephalic
Lie- longitudinal
Attitude- flexion
Presenting part- vertex
Position- ROA or LOA
In normal labour, the head enters the brim more commonly through the available
transverse diameter (70%) and to a lesser extend through one of the oblique
diameters. Left occipito –anterior is little commoner than right occipito –anterior as
the left oblique diameter is encroached by the rectum .the engaging antero-posterior
diameter of the head is either subocciopito bregmatic 9.5 cm or in slight deflexion-
the suboccipito frontal 10 cm.The engaging transverse diameter is biparietal 9.5 cm.
As the occipito-lateral position is the commonest, the mechanism of labor in such
position will be described. The principal movements are:

7. 7
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Crowning
6. Extension
7. Restitution
8. External rotation and
9. Expulsion of the trunk.
Engagement
The term 'Engagement' is used when the largest diameter of the fetal head is at the
level of the smallest diameter of the mother's pelvis. Head brim relation prior to the
engagement as revealed by imaging studies show that due to lateral inclination of the
head, the sagittal suture does not strictly correspond with the available transverse
diameter of the inlet. Instead, it is either deflected anteriorly towards the symphysis
pubis or posteriorly towards the sacral promontory. Such deflection of the head in
relation to the pelvis is called asynclitism. When the sagittal suture lies anteriorly,
the posterior parietal bone becomes the leading presenting part and is called
posteriorasynclitism or posterior parietal presentation. In others, the sagittal
suture lies more posteriorly with the result that the anterior parietal bone becomes the
leading presenting part and is then called anterior asynclitism or anterior parietal
presentation. Mild degrees of asynclitism are common but severe degrees indicate
CPD.
In primigravidae, engagement occurs in a significant number of cases before the
onset of labour while in multiparae, the same may occurin late first stage with
rupture of the membrane.
Descent
Descent is a continuous process when there is no undue bony or soft tissue
obstruction. It is slow or insignificant in 1st stage but pronounced in 2nd stage. It is
completed with the expulsion of the fetus. In primigravidae, with prior engagement of
the head, there is practically no descent in the first stage, while in multiparae, descent

8. 8
starts with engagement. Head is expected to reach the pelvic floor by the time the
cervix is fully dilated. Factors facilitating descentare:
 Uterine contraction and retraction
 Bearing down efforts and
 Straightening of the fetal ovoid especially after rupture of membrane.
Flexion
As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft
tissues of the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is
brought into contact with the fetal thorax and the presenting diameter changes from
occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage
through the pelvis.
Internal rotation
As the head descends, the presenting part, usually in the transverse position, is rotated
about 45° to anteroposterior (AP) position under the symphysis. Internal rotation
brings the AP diameter of the head in line with the AP diameter of the pelvic outlet.
The theories which explain the anterior rotation of the occiput are:
1. Slope of pelvic floor – two halves of levator ani form a gutter and viewed from
above, the direction of the fibres is backwards and towards the midline. Thus,
during each contraction, the head, occiputin particular, in well flexed position,
stretches the levator ani , particularly that half which is in relation to the
occiput. After the contraction passes off, elastic recoil of the levator ani occurs
bringing the occiput forward towards the midline. The process is repeated until
the occiput is placed anteriorly. This is called rotation by law of pelvic floor
(Hart’s rule).
2. Pelvic shape – forward inclination of the side walls of the cavity, narrow
bispinous diameter and long antero-posterior diameter of the outlet result in
putting the long axis of the head to accommodatein the maximum available
diameter i.e., antero-posterior diameter of the outlet leaving behind the
smallest bispinous diameter
3. Law of unequal flexibility (Selheim and Moir) - the internal rotation is
primarily due to inequalities in the flexibility of the component parts of the
fetus.
Crowning

9. 9
After the internal rotation of the head, further descentoccurs until the subocciputlies
underneath the pubic arch. At this stage, the maximum diameter of the head
(biparietal diameter) stretches the vulval outlet without any recession of the head
even after the contraction is over called crowning.
Extension
Delivery of the head takes place by extension through “couple of force” theory. The
driving force pushes the head in a downward direction while the pelvic floor offers a
resistance in the upward and forward direction. The downward and upward forces
neutralize head to be born through the stretched vulval outlet are vertex, brow and
face. Immediately following the release of the chin through the anterior margin of the
stretched perineum, the head drops down, bringing the chin in close proximity to the
maternal anal opening.
Restitution
It is the visible passive movement of the head due to untwisting of the neck sustained
during internal rotation. Movement of restitution occurs rotating the head through
1/8th of a circle in the direction oppositeto that of internal rotation. The occiputthus
points to the maternal thigh of the correspondingside to which it originally lay.
External rotation
It is the movement of rotation of the head visible externally due to internal rotation of
the shoulders. As the anterior shoulder rotates towards the symphysis pubis from the
oblique diameter, it carries the head in a movement of external rotation through 1/8th
of a circle in the same direction as restitution. The shoulders now lie in the antero-
posterior diameter. The occiput points directly towards the maternal thigh
corresponding to the side to which it originally directed at the time of engagement.
Birth of shoulders and trunk
After the shoulders are positioned in antero-posterior diameter of the outlet, further
descent takes place until the anterior shoulder escapes below the symphysis pubis
first. By a movement of lateral flexion of the spine, the posterior shoulder sweeps
over the perineum. Rest of the trunk is then expelled out by lateral flexion.
Signsof Impending Birth
Specific behaviors may suggest that birth is imminent, such as:
• Sitting on one buttock
• Making grunting sounds
• Involuntarily bearing down with contractions
• Stating “the baby is coming”

10. 10
• Bulging of the perineum
If birth appears imminent, the nurse should not leave the woman alone, should
prepare for precipitate birth, and summon help with the call bell.
Flowchart
Engagement
Increasing flexion
Internal rotation of occiput anteriorly to 2/8th of circle,
Simultaneous rotation of the shoulders to 1/8th of circle
Crowning
Delivery of the head by extension
Restitution
External rotation
Delivery of the shoulders and trunk by lateral flexion
D
E
S
C
E
N
T

11. 11
EVALUATION OF PROGRESSOF LABOUR
Monitoring the progress of labour requires more than the assessment of cervical
changes and fetal descent. Vaginal examinations are only one method of measuring
progress in labour.
When vaginal examinations are used, there are six ways to determine progress in
labour: -
 the cervix moves from a posterior to an anterior position;
 the cervix ripens or softens;
 the cervix effaces; - the cervix dilates;
 the fetal head rotates, flexes and moulds;
 the fetus descends.
The toolused to measure labour in hospital settings is the partogram.

12. 12
MANAGEMENT OF SECONDSTAGE OF LABOUR
The transition from the first stage is evidenced by the following features:
 Increasing intensity of uterine contractions
 Appearance of bearing down efforts
 Urge to defecate with descent of the presenting part
 Complete dilatation of the cervix as evidenced on vaginal examination.

13. 13
Aims
a. To achieve delivery of a normal healthy child with minimal physical and
psychological maternal effects.
b. Early anticipation, recognition and management of any abnormalities during labour
course.
Principles
1. To assist in the natural expulsion of the fetus slowly and steadily
2. To prevent perineal injuries.
Generalmeasures
 The patient should be in bed
 Constant supervision is mandatory and the FHR is recorded at every 5 minutes
 To administer 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 prolapsed. The position and
station of the head are oncemore to be reviewed and the progressive descent of
the head is ensured.
Preparationfor delivery
 Position – position of the woman during delivery may be lateral or partial sitting.
Dorsal position with 15o left lateral tilt is commonly favoured as it avoids
aortocaval compression and facilitates pushing effort.
Positioning during labour
 STANDING SUPPORTEDSQUAT
Allows patient to be supported byher standing or sitting partner, the wall or a
squat bar. Takes advantage of gravity. Makes contractions feel less painful and
more productive. Lengthens your trunk and helps your baby line up with the angle
of your pelvis. Movement causes changes in your pelvic joints, helping baby
through the birth canal. May increase urge to push in the second stage of labor.
 SEMI-SITTING
Comfortable.
Good use of gravity.
Good resting position.
Works well in hospital beds.
Good visibility at birth for the supportteam.

14. 14
Easy access to fetal heart tones for health-care provider.
 SITTING
Good for resting.
Uses gravity.
Can be used with continuous electronic fetal monitoring.
May not be possible for patient having high blood pressure
 SITTING ON TOILET
Helps relax perineum.
Mother gets used to an open-leg position and pelvic pressure.
Uses gravity
 SQUATTING
Encourages rapid descent.
Uses gravity.
May increase rotation of baby.
Allows freedom to shift weight for comfort.
Allows excellent perineal access.
Excellent for fetal circulation.
May increase pelvis diameter by as much as 2 centimeters.
Requires less bearing-down effort.
Descent is encouraged by the position.
Your thighs keep baby well aligned.
 SIDE-LYING
Helps get oxygen to the baby.
Good resting position.
Helpful if mother is having elevated blood pressure.
Fine with epidural.
Can make contractions more effective.
Easier for you to relax between contractions during the second stage.
Can slow a birth that’s moving too fast.
Partner can assist in the birth by supporting her legs.
Lowers chances of tearing or the need for episiotomy.
Good access to perineum.
 WALKING
Uses gravity.
Contractions are often less painful.
Baby is well aligned in your pelvis.
May speed labor.
Reduces backache.

15. 15
Encourages descent.
Not recommended for patients having high blood pressure.
Cannot be used with continuous electronic fetal monitoring
 STANDING
Uses gravity.
Helps get oxygen to the baby.
Contractions are more effective and less painful.
May speed labor.
Helps create a pushing urge.
Poorcontrol at birth.
Hard for health-care provider to see the baby.
 LEANING OR KNEELING FORWARDWITH SUPPORT
Can help shift the baby if needed.
Uses gravity.
Birth ball can be used.
Contractions are often less painful and more productive.
Baby is well aligned in the pelvis.
Relieves backache.
Easier for the partner to help relieve her back pain.
May be more restful than standing.
Good for pelvic rocking.
Less strain on the wrists and arms.
Hard for health-care provider to help with birth.
 KNEE-CHEST
Good for back labor.
Assists with rotation of baby, if needed.
Takes pressure off hemorrhoids.
Good position to avoid tearing or episiotomy.
Good delivery position for large baby.
Helpful if fetal heart tones are low.
Hard for the supportteam to maintain eye contact with patient.
Hard for mother to see what’s going on.
 LITHOTOMY
Works against gravity.
Compresses all major vessels.
Tearing or need for an episiotomy is more likely.
No use of gravity to aid in birth.
 The accoucheurscrubs up and puts on sterile gown, mask and gloves and stands on
right side of the table.

16. 16
 Toileting the external genitalia and inner side of the thighs is done with cotton
swabs soaked in Savlon or Dettol solution. 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: claen hands, clean
surfaces, clean cutting and ligaturing of the cord.
 To catheterize the bladder, if it is full.
Conduction of delivery
The assistance required in spontaneous delivery is divided into 3 phases:
o Delivery of the head
o Delivery of the shoulders
o Delivery of the trunk
Delivery of the 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.
 The patient is encouraged for the bearing down efforts during uterine
contractions. This facilitates descentof the head.
 When the scalp is visible for about 5 cm in diameter, flexion of the head is
maintained during contractions. This is achieved by pushing the occiput
downwards and backwards by using thumb and index fingers of the left hand
while pressing the perineum by the right palm with a sterile vulval pad. If the
patient passes stool, it should be cleaned and the region is washed with
antiseptic lotion
 The process is repeated during subsequent contractions until the subocciputis
placed under the symphysis pubis. At this stage, the maximum diameter of the
head stretches the vulval outlet without any recession of the head even after the
contraction is over and it is called crowning of the head. The proposeof
increasing the flexion of the head is to ensure that the small suboccipito-frontal
diameter 10cm distends the vulval outlet instead of larger occipito – frontal
diameter 11.5cm.
 When the perineum is fully stretched and threatens to tear specially in
primigravidae, episiotomy is done at this stage after prior infiltration with 10ml
of 2% lignocaine. Bulging thinned out perineum is a better criterion than the
visibility of 4-5cm of scalp to decide the time of performing episiotomy
 Slow delivery of the heads in between the contractions is to be regulated. This
is done when the suboccipito frontal diameter emerges out. This is
accomplished by pushing the chin with a sterile towel covered fingers of the
right hand placed over the anococccygealregion while the left hand exerts

17. 17
pressure on the occiput(Ritzen maneuver). The forehead, nose, mouth and the
chin are thus born successively over the stretched perineum by extension.
Care Following the Delivery Of The Head
Immediately following delivery of the head, the mucus and blood in the
mouth and pharynx are to be wiped with sterile gauze piece on a little finger.
Alternatively, mechanical or electrical sucker may be used. This simple
procedureprevents the serious consequenceof mucus blocking the air
passage during vigorous inspiratory efforts.
The eyelids are then wiped with sterile dry cottonswabs using one for each
eye starting from the medial to the lateral canthus to minimize contamination
of the conjunctival sac.
The neck is then palpated to exclude the presence of any loop of cord. If it I
found and if loose enough, it should over the shoulders as the baby is being
born. But if it is sufficiently tight enough, it is cut in between 2 pairs of
Kocher’s forceps placed 1 inch apart.
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. Flexion of the sub-occiputcomes
under the symphysis pubis so that lesser sub-occipito-frontal 10cm diameter
emerges out of the introitus.
- Spontaneous forcible delivery of the head is to be avoided by assuring the
patient not to bear down during contractions.
- To deliver the head in between contractions.
- To perform timely episiotomy.
- To take care during delivery of the shoulders as the wider bisacromial diameter
emerges out of the introitus.
EPISIOTOMY- Defined as a surgically planned incision on the perineum
and the posterior vaginal wall during the second stage of labour. Also called
perineotomy.
Objectives
1. To enlarge the vaginal introitus
2. To minimize the overstretching and rupture of the perineal muscles and
fascia
Indications

18. 18
 Inelastic (rigid) perineum :causing arrest or delay in descent of the presenting part
as in elderly primigravidae
 Anticipating perineal tear : big baby, face to pubis delivery, breech delivery,
shoulder dystocia
 Operative delivery: forceps and ventouse delivery
 Previous perineal surgeries: pelvic floor repair, perineal reconstructive surgeries
Timing: it requires judgment. If done early, the blood loss will be more. If done
late, it fails to protect the pelvic floor. Bulging thinned perineum during
contraction just prior to crowning 9when 3-4 cm of head is visible) is the ideal
time.
Advantages
 Maternal :
a) a clear and controlled incision is easy to repair and heals better than a lacerated
wound that might occur otherwise
b) Reduction in the duration of second stage
c) Reduction of trauma to the pelvic floor muscles
 Fetal: it minimizes intracranial injuries specially in premature babies or after
coming head of breech.
Types
o Mediolateral - the incision is made downwards and outwards from the
midpoint of the fourchette either to the right or left. It is directed diagonally
in a straight line which runs about 2.5 cm away from the anus.
o Median – the incision commences from the centre of the fourchette and
extends posteriorly along the midline for about 2.5 cm.
o Lateral – the incision stats from about 1 cm away from the centre of the
fourchette and extends laterally.
o J shaped – the incision begins in the centre of the fourchette and is directed
posteriorly along the midline for about 1.5 cm and then directed downwards
and outwards along 5 or 7O’ clock position to avoid the anal sphincter.
Merits
Median Medio-lateral
- The muscles are not cut
- Blood loss is least
- Repair is easy
- Postoperative comfort is
maximum
- Healing is superior
- Wound disruption is rare
- Relative safety from rectal
involvement from extension
- If necessary, the incision can be
extended

19. 19
Postoperative care
- Dressing: the wound is to be dressed each time following urination and defecation
to keep the area clean and dry. The dressing is done by swabbing with cotton
swabs soaked in antiseptic solution followed by application of antiseptic powderor
ointment.
- Comfort: to relieve pain in the area, MgSO4 compress orapplication of infra red
heat may be used. Ice packs reduces swelling and pain also. Analgesic drugs
(ibuprofen) may be given when required.
- Ambulance: the patient is allowed to move out of the bed after 24 hours. Prior to
that, she is allowed to roll over on to her side or even to sit but only with thighs
apposed.
- Removal of stitches: when the wound is sutured by catgut or Dexon which will be
absorbed, the sutures need not be removed. But if non-absorbable material like silk
or nylon is used, the stitches are to be cut on 6th day. The no-of stitches removed
should be checked with the record of the stitches given.
Complications
Immediate
1. Extension of incision
2. Vulval hematoma
3. Infection
4. Wound dehiscence
5. Injury to anal sphincter
Remote
1. Dyspareunia
2. Chance of perineal lacerations
3. Scar endometriosis (rare)
- Dyspareunia is rare
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
- Postoperative discomfort is more
- Relative increased incidence of
wound disruption
- Dyspareunia is comparatively more

20. 20
Delivery of the shoulders
Not to be hasty in delivery of the shoulders. Wait for the uterine contractions to
come and for the movements of restitution and external rotation of the head to occur.
This indirectly signifies that the bisacromial diameter is placed in the antero-posterior
diameter of the pelvis. During the next contraction, the anterior shoulder is born
behind the symphysis.If there is delay, the head is grasped by both hands and is
gently drawn posteriorly until the anterior shoulder is released from under the pubis.
By drawing the head in upward direction, the posterior shoulder is delivered out of
the perineum. 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
After the delivery of the shoulders, the forefinger of each hand is inserted under the
axillae and the trunk is delivered gently by lateral flexion.
IMMEDIATE CARE OF THE NEWBORN
The goals of care of the newborn in the delivery room include the following:
oSoonafter the delivery of the baby, it should be placed on a tray covered with
clean dry linen with the head slightly downwards. It facilitates drainage of the
mucus accumulated in the trachea-bronchial tree by gravity. The tray is placed
between the legs of the mother and should be at a lower level than the uterus to
facilitate gravitation of blood from the placenta to the infant.
o Maintaining thermoregulation
Maintaining warmth of the newborn is important because hypothermia (low body
temperature) forces the newborn to use glucose to warm his or her body, thereby
causing hypoglycemia (low blood sugar). Hypoglycemia is associated with the
development of neurologic problems. Cold stress also causes an increase in the
newborn’s baseline metabolic rate (BMR) in an effort to warm the body. An
increase in the BMR results in increased oxygen consumption, which can lead to
hypoxia (low blood oxygen level). Therefore once the baby is born, he or she is
immediately dried with a soft towel and placed on the back or side in a heated
crib or radiant warmer, with the neck slightly extended. A hat may be placed on
the head after it is dried to prevent heat loss from this large body surface area.
When the infant is removed from the radiant warmer, a warm blanket wrap
should be applied
o Air passage(oropharyngeal) should be cleared of mucus and liquor by gentle
suction
o Maintaining cardio respiratory function

21. 21
The face is gently wiped to remove excess mucus and amniotic fluid. The
newborn is an obligate nose breather and will not breathe through the mouth
voluntarily if the nose is obstructed. Therefore nasal suction with a bulb syringe
contributes to a clear airway. Bulb suctioning of the mouth prevents aspiration of
mucus and amniotic fluid. As soonas the baby is placed in the radiant warmer, a
heart monitor is applied becausethe heart rate is the most reliable indicator of
need for resuscitation. A newborn with a heart rate greater than 100 beats/min
will generally need only suctioning. If cyanotic, supplemental blow-by oxygen
can be given. A cyanotic newborn with a heart rate less than 100 beats/min
requires stimulation by rubbing the back with a towel while being given blow-by
oxygen. If rapid responseto suction, oxygen, and tactile stimulation does not
occur, bag and mask resuscitation may need to be initiated by the registered nurse
or health care provider.
o Oxygen may be given as needed until the infant cries vigorously.
Acrocyanosis (a blue color to the hands and feet of the newborn) is normal
because of sluggish peripheral circulation for the first few hours after birth.
o An APGAR score is assigned at 1 and 5 minutes after birth. A scoreof 7 to 10
indicates a baby who has good cardio respiratory function with minimal bulb
suctioning assistance.
o Clamping and ligature of the cord –The cord is clamped by 2 Kocher’s forceps,
the near one is placed 5cm away from the umbilicus and is cut in between. 2
separate cord ligatures are applied with sterile cottonthreads1cm apart using
reef-knot, the proximal one being placed 2.5 cm away from the navel. Squeezing
the cord with fingers prior to applying ligatures or plastic cord clamps, prevents
accidental inclusion of embryonic remnants. Leaving behind a length of the cord
attached to the navel not only prevents inclusion of the embryonic structure, if
present, but also facilitates controlof primary hemorrhage due to a slipped
ligature. The cord is divided with scissors about1 cm beyond the ligatures taking
aseptic precautions so as to prevent cord sepsis. Presenceof any abnormality in
cord vessels (single umbilical artery) is to be noted. The cut end is then covered
with sterile gauze piece after making sure that there is no bleeding. The purpose
of clamping the cord on the maternal end is to prevent soiling of the bed with
blood and to prevent fetal blood loss of the second baby in undiagnosed
monozygotic twin
Delay in clamping for 2-3 minutes or till cessation of the cord pulsation
facilitates transfer of 80-100 ml blood from the compressed placenta to a baby
when placed below the level of uterus. This is beneficial to a mature baby but may
be deleterious to a preterm or a low birth weight baby due to hypervolaemia. But
early clamping should be done in cases of Rh-incompatibility (to prevent antibody

22. 22
transfer from the mother to the baby) or babies born asphyxiated or one of a
diabetic mother.
UMBILICAL CORD BLOOD BANKING Blood from the placenta and umbilical
cord has traditionally been treated as a waste product and discarded. It is now known
that cord blood contains the same type of blood stem cells as bone marrow. Stem
cells give rise to all cells found in the blood, including immune bodies. Stem cell
transplants can be an invaluable aid in the treatment of many malignant and genetic
diseases of children and adults. Malignancies such as leukemia and lymphoma, blood
disorders such as sickle cell anemia, immunodeficiencies such as Wiskott-Aldrich
syndrome, inborn errors of metabolism such as Hurler’s syndrome, and autoimmune
disorders such as rheumatoid arthritis and systemic lupus erythematosus have been
successfully reversed with cord blood stem cell transplants. Cord blood can be
collected at birth for storage and possible future use if needed. The collection process
requires informed consent and involves using special collection kits that contain
vacutainers, screening for infectious diseases, and packaging materials required for
sending the blood to the storage facility.
The Human Genome Project and development of gene therapy may result in the
increased value of cord blood banking. Seventy to 80 ml of cord blood is usually
collected by the health care provider after delivery of the newborn and clamping of
the cord but before the placenta is expelled. The stump of the cord is wiped with
alcohol and povidone-iodine before collection to prevent contamination of the blood
sample. Cord blood must be transported to the cord blood bank storage facility within
48 hours of collection. It is then processed and cryopreserved at a –196o C with liquid
nitrogen. No expiration date is required for undisturbed samples. All pregnant women
and their partners should be counseled concerning cord blood banking. The costs of
cord blood collection and banking are not usually covered by health insurance, and
only a few public banks currently exist because of a lack of funding.
o Documenting urination/passage ofmeconium: The newborn cannot be
discharged to the home before patency of the gastrointestinal and genitourinary
tracts are established. If the newborn urinates or passes meconium in the delivery
room, it must be recorded in the medical record.
o Administering vitamin K: Vitamin K is needed for blood clotting and is naturally
produced by the intestinal flora. However, the newborn has not yet established
intestinal flora and therefore is given an intramuscular doseof vitamin K
(phytomenadione) by 1 hour of age before leaving the delivery room.
o Prophylactic eye care: All newborns are given eye medication to protectagainst
ophthalmia neonatorum, which is caused by Neisseria gonorrhea and Chlamydia
trachomatis. Erythromycin eye ointment is recommended by the American

23. 23
Academy of Pediatrics. It is administered after the newborn has an opportunity to
bond with the parents but before leaving the delivery room.
o Promoting parent-newborn bonding: As soonas the newborn is dry, warm, and
stable, he or she should be wrapped in a clean blanket and placed in the mother’s
arms. Breastfeeding should be started if the mother desires. The alert period of the
newborn in this first period of reactivity lasts only 1 hour; the infant will then sleep
for approximately 4 hours. Therefore every effort should be made to promote
bonding as soonas possible.
o Quick check is made to detect any gross abnormality and the baby is wrapped with
a dry warm towel. The respiratory and heart rate are monitored and recorded. The
identification tape is tied both on the wrist of the baby and the mother. Once the
management of third stage is over (usually 10-20 minutes), baby is given to the
mother or to the nurse.
NURSING CARE OF PATIENT IN SECOND STAGE OF LABOUR
The woman most often delivers in the same room where she has labored. The
maternal position for birth varies from a lithotomy position, to one in which her feet
rest on a footrest while she holds a bar, to a side-lying position with the woman’s
upper leg held by the coach. Once the woman is positioned for birth, her vulva and
perineum are cleansed. The nurse prepares the delivery table for use. The nurse
(usually the same nurse as the labor nurse) continues to monitor the FHR every 5 to
15 minutes. To protect all the care providers in the delivery room, each wears splash-
resistant gowns, gloves, and face masks that incorporate eye shields or goggles. The
physician or nurse midwife will have carried out appropriate hand washing (surgical
scrub)before putting on the sterile barrier attire. The health care provider and partner
coachthe woman through the second stage of labor.
If the physician or nurse-midwife elects to perform an episiotomy (an incision into
the perineum, performed during the second stage to enlarge the perineal opening to
prevent tearing as the head of the fetus is born), the circulating nurse opens the
appropriate instruments and sutures for repair once the placenta has been delivered.
a. Neverleave the patient alone once she has been transferred to the delivery
room.
In addition, never turn your backon the perineum becausethe baby could push
through the vaginal opening while your back is turned.
b. Encourage the patient to rest betweencontractions and to push with
contractions.
Only one personshould coach. Verbal encouragement and physical contact help
reassure and encourage the patient.

24. 24
c. Positionthe patient’s legs in the stirrups for the lithotomy position.
This is the most common position for delivery. Facilities using birthing beds have the
patient in an upright position. Positioning also depends upon the type of anesthesia to
be used and C-section delivery. Each casemay be different.
d. Prepare the patient’s perineum.
A Betadine scrub and water are used. Clean the perineum by washing the pubic area,
down each thigh, down each side of the labia, down the perineum, and down the
rectal area. Discard used sponges after each wipe. Rinse area with the remaining
solution.
e. Monitor the patient’s blood pressure and the fetal heart beat every 5
minutes and after eachcontraction.
f. Breathing exercises
Rhythmic breathing during labour will maximise the amount of oxygen available to
mother and baby. Breathing techniques can also help to handle contractions and be
more satisfied with how mother coped with her labour.
Using relaxation techniques, including breathing, has also been linked to a reduced
risk of assisted birth
Expulsion Breathing
Used once the cervix is fully dilated and the second stage of labor has begun.
1. Take an organizing breath—a big sigh as soonas the contraction begins.
Release all tension (go limp all over—head to toe) as you breathe out.
2. Focus on the baby moving down and out, or on another positive image.
3. Breathe slowly, letting the contraction guide you in accelerating or lightening
your breathing as necessary for comfort. When you cannot resist the urge to
push (when it “demands” that you join in), take a big breath, tuck chin to chest,
curl your bodyand lean forward. Then bear down, while holding your breath
or slowly releasing air by grunting, moaning or other verbalizing. Most
important of all, relax the pelvic floor. Help the baby come down by releasing
any tension in the perineum.
4. After 5-6 seconds,release your breath and breathe in and out. When the urge
to push takes over join in by bearing down. How hard you push is dictated by
your sensation. You will continue in this way until the contraction subsides.
The urge to push comes and goes in waves during the contraction. Use these

25. 25
breaks to breathe deeply providing oxygen to your blood & sufficient oxygen
for the baby.
5. When the contraction ends, relax your bodyand take one or two calming
breaths.
INFORMATION TO BE RECORDED ABOUT THE DELIVERY
Record the following information:
a. Exactdate and time of delivery.
b. Sexof the infant.
c. Condition of the infant (APGAR) after birth.
APGAR is the most widely used method of evaluating the condition of a newborn
baby. A value of 0 to 2 is given for each observation (i.e., heart rate, respiratory
effort, muscle tone, reflex irritability, and color). The values are added giving a total
APGAR score. A baby in excellent condition would score9 to 10 and a dead baby
would score0. Most babies score7 or better. The condition of the infant will be taken
at one (1) minute, at five (5) minutes, and at thirty (30) minutes.
APGAR Score
Category 0 Points 1 Point 2 Points
Heart Rate Absent <100 >100
Respiratory
Effort Absent Slow, Irregular Good, crying
Muscle Tone Flaccid
Some flexion of
extremities Active motion
Reflex Irritability No Response Grimace Vigorous cry
Color Blue, pale
Body pink,
extremities blue Completely pink
d. Positionof the infant at delivery.

26. 26
e. Type of episiotomy, lacerations.
f. Spontaneous orforceps delivery.
g. Use of oxygenand suction on the infant.
h. Number of vessels in the cord.
i. Mother’s name.
j. Any other pertinent facts about the delivery.
NURSING DIAGNOSES
1. Acute pain related to effects of labour and delivery process
2. Ineffective coping regarding fear, anxiety, and feelings of powerlessness
3. Ineffective tissue perfusion (fetal) relating to impaired gas exchange during
labor and delivery process
4. Risk for infection related to contamination
COMPLICATIONS DURING SECOND STAGE OF LABOUR
Even if you’re healthy and well prepared for labour and giving birth, there’s always a
chance of unexpected difficulties
 Slow progress oflabour
The labour is said to be progressing if
This could happen with a big baby, a baby that does not present normally or with a
uterus that does not contract appropriately. If the cervix is opening slowly, or the
contractions have slowed down or stopped doctormay say that you labour isn’t
progressing. It’s good if patient can relax and stay calm – anxiety can slow things
down more. Give adequate psychological and emotional supportto patient.
The midwife or doctormay suggest some of the following:
 change to a position the patient is comfortable in
 walk around – movement can help the baby to move further down, and
encourage contractions
 a warm shower or bath
 a back rub
 have a nap to regain her energy
 have something to eat or drink.

27. 27
If progress continues to be slow doctormay suggest inserting an intravenous drip
with Syntocinon or Oxytocin to make contractions more effective. If the patient is
tired or uncomfortable, she can be given measures for pain relief.
 When the baby is in an unusual position
Most babies are born head first, but some are in positions that may complicate labour
and the birth.
Posterior position
This means the baby’s head enters the pelvis facing the front instead of back. This
can mean a longer labour with more backache. Most babies will turn around during
labour, but some don’t. If a baby doesn’tturn, she may be able to push it out herself
or the doctormay need to turn the baby’s head and/or help it out with either forceps
or a vacuum pump. She can help by getting down on her hands and knees and
rotating or rocking her pelvis - this may also help ease the backache.
Breech birth
This is when a baby presents bottom or feet first. In Australia about 2% of babies are
in the breech position by the time labour starts. Sometimes ‘external cephalic
version’ can be done – this is where a doctorgently turns the baby in late pregnancy
by placing their hands on patient’s abdomen and gently coaxing the baby around so it
can be born head first. This turning is done at around 36 weeks, using ultrasound to
help see the baby, cord and placenta. The baby and the mother are monitored during
the procedure to make sure everything is ok. There’s a small risk that turning the
baby may tangle the cord or separate the placenta from the uterus.
Multiplepregnancy
When there is more than one baby, labour may be preterm. When the last baby has
been born, the placenta (or placentas) is expelled in the usual way. If the babies
are premature, they are likely to need extra care at birth and for a few days or weeks
afterwards. At term, induction may be done if the babies are in the correct position.
Often the obstetrician will suggest that patient needs an epidural. This is because after
the first twin is born the second twin can get in an unusual position and the
obstetrician may need to manoeuvre the second twin into position for birth.
 Concernabout the baby’s condition
Sometimes there may be concerns that the baby is distressed during labour. Signs
include:

28. 28
 a faster, slower or unusual pattern to the baby’s heartbeat
 a bowel movement by the baby ( ‘meconium’ in the fluid around the baby).
If a baby is not coping well, its heart rate will usually be monitored. If necessary, the
baby will be delivered as soonas possiblewith vacuum or forceps (or perhaps by
caesarean).
 Perinealtear
A perineal tear is a spontaneous (unintended) laceration of the skin and other soft
tissue structures which, in women, separate the vagina from the anus. The majority is
superficial and requires no treatment, but severe tears can cause significant bleeding,
long-term pain or dysfunction
Classification
Tears are classified into four categories:
 First-degree tear: injury to perineal skin only.
 Second-degree tear: injury to perineum involving perineal bodybut not involving
the anal sphincter
 Third-degree tear: injury to perineum involving the anal sphincter complex (both
internal and external)
Third-degree tears may be further subdivided into three subcategories
3a: partial tear of the external anal sphincter involving less than 50% thickness
3b: greater than 50% tear of the external anal sphincter
3c: internal sphincter is torn
 Fourth-degree tear: injury to perineum involving the anal sphincter complex and
anal epithelium
Management
Recent tear should be repaired immediately following the delivery of the placenta. In
case of delay beyond 24 hours, the repair is to be withheld .antibiotics should be
started to prevent infection. The complete tear, should be repaired after 3 months, if
delayed beyond 24 hours
Aftercare
o A low residual diet consisting of milk, bread , egg, biscuits, fish, sweets etc is
given from 3rd day onwards

29. 29
o Lactulose 8 ml twice daily beginning on the 2nd day and increasing the doseto
15 ml on the 3rd day is a satisfactory regime to soften the stool
o Any one of the broad spectrum antibiotics (IV Cefuroxime 1.5 g) is used
during the intraoperative and the postoperative period. Metronidazole 400 mg
thrice daily is to be continued for 5-7 days to cover the anaerobic
contamination of fecal matter.
 Postpartum haemorrhage
It’s normal to bleed a little after the birth. Heavier than normal bleeding after birth is
called ‘postpartumhaemorrhage’. This is when loss of 500ml of blood or more. The
most common cause is the muscles of the uterus relaxing instead of contracting to
prevent bleeding. An oxytocin injection given after the birth of the baby helps the
uterus push the placenta out and reduces the risk of heavy bleeding. Nurse has to
check uterus involution regularly after the birth to make sure that it is firm and
contracting. Postpartum haemorrhage can cause a number of complications and may
mean a longer stay in hospital. Some complications are severe but they rarely result
in death.
 Retainedplacenta
Occasionally the placenta doesn’tcomeaway after the baby is born, so the doctor
needs to remove it promptly. This is usually done with an epidural or a general
anaesthesia in theatre
 Umbilical Cord Prolapse
The umbilical cord is the connection between the fetus and placenta. Oxygen and
other nutrients are passed from mother to baby through the placenta and the umbilical
cord. Sometimes before or during labor, the umbilical cord can slip through the
cervix, preceding the baby into the birth canal. It may even protrude from the vagina.
This is dangerous because the umbilical cord can get blocked and stop blood flow
through the cord. This is an emergency situation. So adequate management should be
done like emergency cesarean.
 Umbilical Cord Compression
Because the fetus moves a lot inside the uterus, the umbilical cord can get wrapped
and unwrapped around the baby many times throughout the pregnancy. While there
are "cord accidents" in which the cord gets twisted around and harms the baby, this is
extremely rare and usually can't be prevented.

30. 30
Sometimes the umbilical cord gets stretched and compressed during labor, leading to
a brief decrease in the flow of blood within it. This can cause sudden, short drops in
the fetal heart rate, called variable decelerations, which are usually picked up by
monitors during labor. Cord compressionhappens in about one in 10 deliveries. In
most cases, these changes are of no major concern and most babies quickly pass
through this stage and the birth proceeds normally. But a cesarean section may be
necessary if the heart rate worsens or the fetus shows other signs of distress, such as
decrease of fetal blood pH or passing of the baby's first stool(meconium).
RELATED RESEARCHES
1. Care of the perineum in the second stage of labour: a study of
views and practices of Australian midwives.
Stamp GE1.
1North Western Adelaide Health Service, Faculty of Nursing, University of South
Australia.
Abstract
OBJECTIVES:
To seek the views of midwives on the practices related to the perineum in the second
stage of labour; to identify predictors of their practices and to identify their actual
practices in the second stage of labour, prior to a randomised trial of second stage
perineal massage.
PARTICIPANTS AND SETTING:
Independent midwives in South Australia and 194 midwives working in the delivery
suites and birth centres of seven public hospitals in four states of Australia.
DESIGN:
Midwives were surveyed using a questionnaire which sought their views on and
practices relating to, second stage perineal massage, delivery of the head and reasons
for cutting an episiotomy.
FINDINGS:
One third of the respondents 'never' practised perineal massage in the second stage of
labour, 43% were 'undecided' as to its value and 19% disagreed with the practice.
Over half agreed that its use should be decided by the woman and her partner. When
invited to select the five statements they most agreed with, and the five they most
disagreed with, out of a possible 24, equal numbers (26%) were for and against the
statement referring to such massage as helping to stretch the perineum and prevent
tearing. More than half (55%) disagreed with the statement which predicted they

31. 31
would find the practice distasteful, while only 1.6% agreed with this statement.
During delivery of the head, 71% of respondents attempted some form of flexion.
There was 100% agreement that fetal distress almost always or frequently was an
indication for cutting an episiotomy.
CONCLUSIONS:
There is little evidence from randomised trials to supportmany of the second stage
practices, and further research will clarify those which are most effective. This
sample of midwives demonstrated considerable variation in their views on, and
practices in, the second stage of labour. Although one-fifth disagreed with the
practice of second stage perineal massage, and 40% agreed that the midwife should
decide, more than half (57%) believed it was a matter of choice for the woman and
her partner. All were supportive of episiotomy use for fetal distress.
2. Fundal pressure during the second stage of labour
Cochrane review
Citation: Verheijen EC, Raven JH, Hofmeyr GJ. Fundal pressure during the second
stage of labour. Cochrane Databaseof Systematic Review 2009, Issue 4. Art. No.:
CD006067. DOI: 10.1002/14651858.CD006067.pub2
Findings of the review: Fundal pressure is a widely used practice which involves
the use of manual or instrumental pressure on maternal abdomen in the direction of
the birth canal with the purposeof accelerating the second stage of labour. While it
is used routinely in many settings, it is also considered obsolete in many countries
and there is some concern about its effectiveness as well as its potential adverse
consequences. The aim of this review was to determine the benefits and adverse
effects (for both the mother and her baby) of fundal pressure in the second stage of
labour. Only one trial, judged by the authors to be of good methodological quality,
was included in this review. That trial involved 500 nulliparous women (who had
received epidural analgesia) compared fundal pressure by insufflatable belt with no
fundal pressure. No significant differences were found in the duration of the
second stage of labour, mode of delivery, five-minute APGAR scores, neonatal
arterial cord pH and admission to neonatal intensive care unit. In the intervention
group there was an increase in intact perineum but also an increase in anal
sphincter tears. The lack of blinding may have influenced these two opposite
results, although a possible association with the intervention cannot be ruled out.
MAIN RESULTS
We excluded two of three identified trials from the analyses for methodological
reasons. This left no studies on manual fundal pressure. We included one study
(500 women) of fundal pressure by means of an inflatable belt versus no fundal

32. 32
pressure to reduce operative delivery rates. The methodological quality of the
included study was good.
Use of the inflatable belt did not change the rate of operative deliveries (RR 0.94,
95% CI 0.80 to 1.11). Fetal outcomes in terms of five-minute APGAR scores
below seven (RR 4.62, 95% CI 0.22 to 95.68), low arterial cord pH (RR 0.47, 95%
CI 0.09 to 2.55) and admission to the neonatal unit (RR 1.48, 95% CI 0.49 to 4.45)
were also not different between the groups. There was no severe neonatal or
maternal mortality or morbidity. There was an increase in intact perineum (RR
1.73, 95% CI 1.07 to 2.77), as well as anal sphincter tears (RR 15.69, 95% CI 2.10
to 117.02) in the belt group. There were no data on long-term outcomes.
AUTHORS'CONCLUSIONS
There is no evidence available to conclude on beneficial or harmful effects of
manual fundal pressure. Good quality randomised controlled trials are needed to
study the effect of manual fundal pressure. Fundal pressure by an insufflatable belt
during the second stage of labour does not appear to increase the rate of
spontaneous vaginal births in women with epidural analgesia. There is insufficient
evidence regarding safety for the baby. The effects on the maternal perineum are
inconclusive.
3. Position in the second stage of labour for women without
epidural anaesthesia.
Gupta JK1
, Hofmeyr GJ, Shehmar M.
Abstract
BACKGROUND:
For centuries, there has been controversy around whether being upright (sitting,
birthing stools, chairs, squatting, kneeling) or lying down have advantages for women
delivering their babies.
OBJECTIVES:
To assess the benefits and risks of the use of different positions during the second
stage of labour (i.e. from full dilatation of the uterine cervix).
SEARCH METHODS:
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28
February 2012).
SELECTIONCRITERIA:
Randomised or quasi-randomised controlled trials of any upright or lateral position
assumed by pregnant women during the second stage of labour compared with supine
or lithotomy positions. Secondary comparisons include comparisonof different
upright positions and the lateral position.

33. 33
DATA COLLECTIONAND ANALYSIS:
Two review authors independently assessed trials for inclusion and assessed trial
quality. At least two review authors extracted the data. Data were checked for
accuracy.
MAIN RESULTS:
Results should be interpreted with caution as the methodological quality of the 22
included trials (7280 women) was variable. In all women studied (primigravid and
multigravid) there was a non-significant reduction in duration of second stage in the
upright group (mean difference (MD) -3.71 minutes; 95% confidence interval (CI) -
8.78 to 1.37 minutes; 10 trials, 3485 women; random-effects, I(2) = 94%), a
significant reduction in assisted deliveries (risk ratio (RR) 0.78; 95% CI 0.68 to 0.90;
19 trials, 6024 women, I(2)= 27%), a reduction in episiotomies (average RR 0.79,
95% CI 0.70 to 0.90, 12 trials, 4541 women; random-effects, I(2) = 7%), an increase
in second degree perineal tears (RR 1.35; 95% CI 1.20 to 1.51, 14 trials, 5367
women), increased estimated blood loss greater than 500 ml (RR 1.65; 95% CI 1.32
to 2.60; 13 trials, 5158 women, asymmetric funnel plot indicating publication bias),
fewer abnormal fetal heart rate patterns (RR 0.46; 95% CI 0.22 to 0.93; two trials,
617 women). In primigravid women the use of any upright compared with supine
positions was associated with: non-significant reduction in duration of second stage
of labour (nine trials: mean 3.24 minutes, 95% CI 1.53 to 4.95 minutes) - this
reduction was largely due to women allocated to the use of the birth cushion.
AUTHORS'CONCLUSIONS:
The findings of this review suggest several possible benefits for upright posture in
women without epidural, but with the possibility of increased risk of blood loss
greater than 500 mL. Until such time as the benefits and risks of various delivery
positions are estimated with greater certainty, when methodologically stringent data
from trials are available, women should be allowed to make choices about the birth
positions in which they might wish to assume for birth of their babies.
4. Hands-poised technique: The future technique for perineal
management of second stage of labour? A modified systematic
literature review
Petra Petrocnik, RM, MSc (UK) (Midwifery teaching assistant), Jayne E. Marshall,
PhD, MA, PGCEA, ADM, RM, RGN (Head of Schoolof Midwifery and Child
Health/Lead midwife for education)

34. 34
Abstract
Background
Vaginal birth is often accompanied with perineal trauma that affects postpartum
morbidity. There are many techniques for protecting the perineum from injury during
childbirth. The Hands-On or Hands Poised (HOOP) study (McCandlish et al., 1998)
was the first trial that compared different techniques of perineal protection during the
second stage of labour with very little research subsequently being undertaken.
Objectives
To systematically review all available literature that compares the hands-on and
hands-poised techniques of perineal management during the second stage of labour.
Methods
Using the principles of a modified systematic literature review, quantitative,
comparative and primary research studies were selected. These were assessed for
quality using the Critical Appraisal Skills Programme (CASP) framework including a
data extraction form. The results were reported narratively.
Main results
Five studies were included and outlined the importance of both techniques. The
hands-poised technique appeared to cause less perineal trauma and reduced rates of
episiotomy. The hands-on technique resulted in increased perineal pain after birth and
higher rates of postpartumhaemorrhage.
Conclusion
As the five studies selected for this review have widely differing variables,
comparisons that have been drawn must be viewed with caution. Evidence would
suggest that the hands-poised technique is a safe and recommended technique for
perineal management and discussions of sucha technique should be included in all
midwifery education and training programmes.
The challenge for midwives is how to supportwomen in making informed choices
about perineal management during childbirth. Until there is conclusive evidence, the
choice of the hands-on or hands-poised technique will ultimately be determined by
the clinical judgment of the individual midwife at the time of birth.

35. 35
5. Vacuum Delivery in a Tertiary Institution, in Northern Nigeria: A
5-Year Review
I. A. Yakasai*, I. S. Abubakar, E. M. Yunus
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano
Teaching Hospital, Kano,Nigeria
Abstract
Background:
There is a progressive shift away from the use of forceps in favour of the vacuum
extractor as the instrument of choice for operative vaginal deliveries. The overall
objective of this is to improve safe motherhood by reducing the contribution of
second stage of labour complications to maternal mortality and morbidity.
Objective:
This study was carried out to determine the incidence, indications, outcome and
complications of Ventouse delivery in Aminu Kano Teaching Hospital,
Kano, Nigeria. Materials and Methods: This was a retrospective study carried out at
the Aminu Kano Teaching Hospital. The casenotes of all parturients who had
vacuum deliveries in the hospital within January 2008 to December 2012 were
retrieved from the statistics unit of the hospital and analysed using SPSS. Results:
22,680 patients delivered in the hospital over this 5-year period. Ventouse was used
on 210 occasions giving an incidence rate of 0.9%. One hundred and eighty (85.7%)
had successfulvacuum delivery. The failed extractions (14.3%) were delivered by
caesarean sections. The mean age of the patients was 29.4 years. The mean parity
was 2.2. Ninety (42.9%) were primipara while 120 (57.1%) were multipara. The
commonest indication for the vacuum delivery was prolonged second stage of labour
in 45.2% of cases. The commonest maternal complication was primary postpartum
haemorrhage (9.5%). Foetal complication occurred in about 31% of vacuum
deliveries, the commonest (18.1%), being cephalhaematoma.
Conclusion:
The incidence rate of vacuum delivery is low. Thus, active training in the art of
vacuum assisted vaginal delivery is clearly needed during residency.
CONCLUSION
It is essential for any clinician practicing obstetrics to be familiar with the concepts of
fetal lie, attitude, presentation, position, and station. During labor, there will be a
series of changes in the position of the presenting part that are needed for the fetus to
pass through the maternal pelvis. Knowledge of the type of maternal pelvis is critical
for proper monitoring of this process.

36. 36
BIBLIOGRAPHY
1. Lowdermilk & Perry “Maternity Nursing”, 6th edition; Elsevier publishers;
Page no: 95-127.
2. Dutta D.C Text book of Obstetrics –Including perinatology and
Contraception, 6th Edition, New central book Agency; PP-113-137
3. Murray and McKinney “Foundations Of Maternal-NewbornAnd Women’s
Health Nursing”;5th edition; Saunders publishers; PP-237-329
4. Diane Fraser (2008)“Myles Textbook ForMidwives” ;15th edition; Elsevier
Publications; PP:251-289
5. http:// normal labour and delivery/ item/127#r17
6. http:// care of newborn/453#45
7. WebMD Archive