2nd Stage of Labor

INTRODUCTION
Labor is the rythamic contraction and relaxation of the uterine muscles with progressive
effacement and dilation of the cervix,leading to expulsion of the products of conception.
The second stage of labour begins with complete dilation of cervix and ends with the birth of the
baby. It is known as the stage of expulsion. The period is characterized by maternal
restlessness,discomfort,desire for pain relief , a feeling that the process is never ending and
demands to birth attendants to get the birth process over as quickly as possible.
DEFINITION
LABOR:
Series of events that takes place in the genital organs in an effort to expel the viable products of
conception( fetus,placenta and the membranes) out of the womb through the vagina into the
outer world is called labour.
NORMAL LABOR:
Labor is called normal if it fulfills the following criteria-
• spontaneous in onset and term
• With vertex presentation
• without undue prolongation
• Natural termination with minimal aids
• without having any complications affecting the health of mother and/or the baby.
SECOND STAGE OF LABOR:
The second stage of labor has been defined as the phase between full dilatation of the cervical os
and the birth of the baby.
PHYSIOLOGY OF SECOND STAGE OF LABOR:
The physiological changes results from a continuation of the same forces,which have been at
work during the first stage of labor.
Descend: descend of the fetal presenting part , which began during the first stage of labor and
reached its maximum speed towards the end of the first stage of labor, continues its rapid pace
through the second stage of labor until reaching the pelvic floor.
Uterine contraction: contractions during the second stage are frequent, strong and slightly longer
that is approximately every 2minutes,lasting 60-90 seconds. They are of strong intensity and
become expulsive in nature. After painful contractions, mother experienced during the transition,
the women usually feels relief to be in second stage and be able to push if she so desires.
Rupture of membranes: the membranes often rupture spontaneously at the onset of the second
stage. The consequent drainage of liquor allows the fetal head to be directly applied to the
vaginal tissues and aid distention. Fetal axis pressureincreses flexion of the head, which results in
smaller presenting diameters,more rapid progress and less trauma to both mother and fetus.As
the fetus further descends into the vagina,pressure from the presenting part stimulates nerve
receptors in the pelvic floor and the women experience the need to push.
Soft tissue displacement: as the hard fetal head descends, the soft tisssues of pelvis become
displaced. Anteriorly , the bladder is pushed upward into the abdomen where it is at less risk of
injury during fetal descent. Posteriorly , the rectum becomes flattened into the sacral curve and
pressure of the advancing head expels any residual fecal matter. The perineal body is flattened,
stretched and thinned. 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.
PHASES OF SECOND STAGE OF LABOR:
PROPULSIVE- From full dilation until head touches the pelvic floor is called propulsive phase.
EXPULSIVE- Since the time mother has irresistible desire to bear down and push until the
baby is delivered called expulsive phase.
RECOGNITION OF THE SECOND STAGE OF LABOR:
1.PRESUMTIVE SIGN-
• Expulsive uterine contraction
• Expulsive rupture of the forewater
• Dilatation and gaping of the anus
• Show
• Appearance of presenting part
2.CONFIRMATORY SIGN-Confirmation of full dilation of the cervical os by PV examination.
MAIN MOVEMENTS FETUS IN SECOND STAGE OF LABOR:
• DESCENT
• FLEXION
• INTERNAL ROTATION OF THE HEAD
• EXTENSION OF THE HEAD
• RESTITUTION
• INTERNAL ROTATION OF THE SHOULDERS
• LATERAL FLEXION
MEDICAL MANAGEMENT OF SECOND STAGE OF LABOR:
PRINCIPLES OF MANAGEMENT OF SECOND STAGE OF LAOUR:
• To assist in the natural expulsion of the fetus slowly and steadily
• To prevent perineal injuries
GENERAL MEASURES:
• The patient should be in bed.
• Constant supervision is mandatory and FHR is recorded at every 5 minutes.
• To administer inhalation analgesics if available.
• Vaginal examination should be done at the beginning of second stage of labor.
PREPARATION FOR DELIVERY:

• .POSITION: Position of the woman during delivery may be lateral,squatting or partial
sitting. Dorsal position with 15 degree left lateral tilt is commonly favored.
• The accoucher scrubs up and puts on sterile gown,mask,gloves and stands on the right
side of the table.
• Toileting the external genitalia and inner side of the thighs is done with cotton swabs
shocked in savlon or dettol. One sterile sheet is palced beneath the buttocks of the
patient and one over the abdomen. Sterile leggings are to be used.
• Catheterized the bladder.
CONDUCTION OF DELIVERY:
The assistance required in spontaneous delivery is divided into three phases-
• Delivery of head
• Delivery of shoulders
• Delivery of trunk
Delivery of head:
In this phase following criteria is followed:
Prevention of perineal laceration:
• More attention should be paid not to the perineum but to the controlled delivery of
head.
• Delivery by early extension is to be avoided.
• Spontaneous forcible delivery of the head is to be avoided.
• To deliver the head in between contractions.
• To perform timely episiotomy.
• To take care during delivery of shoulders.
Episiotomy: At this stage when the maximum diameter 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.when the perineum is fuuly strtched and threatens to tear eoisiotomy is done at this stage
after prior infiltration with 10ml of 1% lignocaine.
After episiotomy – ask the woman to give only small pushes
- to control birth of the head place the fingers of one hand against the babys
head to keep it flexed.
-continue to gently support the perineum as the baby’s head delivers.
Care following delivery of the head;
Immediately following the delivery of head ,the mucus and blood mouth and pharyns are to be
wiped with sterile gauze piece on a little finger.The neck is then palpated to exclude the presence
of any loop of cord. If it is loose enough then it should be slipped over the head .but if it is
sufficientlt tight enough then it is cut between two pairs of kocher’s forceps placed 1 inch apart.
Delivery of shoulders:
• Lift the baby”s head anteriorly to deliver the shoulder that is posterior.
• Support the rest of the baby’s body with one hand as it is slide out.
Delivery of trunk:
After the delivery of the shoulders, the fore finger of each hand is inserted under the axillae
and the trunk is delivered gently by lateral flexion.
IMMEDIATE NEWBORN CARE:

• Soon after the delivery baby should be placed on a tray covered with clean dry
linen.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 placenta to infant.
• Air passage should be cleared by gentle suction
• APGAR rating at 1 minute and at 5 minutes is to be recorded.
• The cord is clamped by two kocher’s forcep , the near one is placed 5cm away from
the umbilicus and is cut in between.cord is usually clamped with a cord clamp after
cleaning the airway after about 1-2 minutes of birth.
• Quick check is made to detect any gross abnormality and the baby is wrapped with a
dry warm towel.
NURSING MANGEMENT OF SECOND STAGE OF LABOR:
ASSESSMENT:
• Asses for maternal blood pressure,pulse,respiration every 5-15 minutes.
• Asses for FHR in every 10-15 mins.
• Assess for cervical dilation
• Asses fetal descent
• Asses uterine contraction
• Assess amount of bloody show.
• Assess woman’s response to labor.
NURSING DIAGNOSIS:
• Pain related to labor process
• Risk for infection related to rupture of membrane
• Anxiety related to knowledge deficiet
PLANNING:
• To reduce pain
• To reduce risk for infection
• To reduce anxiety
INTERVENTION:
• Reducing pain
-assess the pain level by pain scale.
-give comfortable position to patient.
-promote a quiet ,focused environment to enhance pushing efforts.
-continue assessment of maternal BP,FHR, uterine contraction
• Reducing risk for infection
-provide clean bedsheet on bed.
-the obstretician or midwifery should wash hands and should use sterile mask gown.
-all instruments should be sterilized.
-perineal area should be cleaned by savlon swab
-environment should be clean
• Reducing anxiety
-inform woman about labour process
-give psychological support to mother
-encourage her to share feelings
RECENT RESEARCH ON MANAGEMENT OF SECOND STAGE OF LABOR:
Colsogia E, Fumagalli S, Inzis I, Borelli S, Nespoli A conducted a study on “Management of the
second stage of labor in women with epidural analgesia : A qualitative study exploring Midwives
experiences in Northern Italy” with objective to explore midwives experiences of the
management of second stage of labor in women with epidural analgesia. The findings of the
study were- the time allowed by midwives for the passive phase of 2 nd stage of labor ranged from
0-2 hours, semi sitting and lithotomy positions are most used respectively labor and at birth.
Midwives also reported their experience of providing different care to women with epidural
analgesia when compared to women without epidural mainly due to more medicalised approach
and the midwives sense of usefulness when caring for women not experiencing labour pain.
CONCLUSION:
The second stage of labor begins with full dilation of cervix and ends with delivery of the fetus.
In most of the cases the labor progresses uneventually,without any need of active intervention
but in few cases complications may occur. In this presentation we discussed about introduction
and definition of labor and second stage of labor,physiology of labor, phases of labor,recognition
of labor,medical and nursing management of labor,recent information about second stage of
labor.
REFERENCES:
• Jacob Annamma. A Comprehensive textbook of Midwifery &Gynecological Nursing

fourth edition.jaypee brothers medical publishers (p) limited. page no 191-209
• DUTTA DC Textbook of Obstetrics. 8th edition .jaypee brothers medical publishers (p)
limited .page no 134-161
• https://doi.org/10.1016/j.midw.2019.07.013

2nd Stage of Labor

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INTRODUCTION

PREPARATION FOR DELIVERY:

IMMEDIATE NEWBORN CARE:

• Jacob Annamma. A Comprehensive textbook of Midwifery &Gynecological Nursing

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