Management of second stage in labor.ppt.ppt

That PPT is All management of women in Second Stage Of Labor

1. MANAGEMENT OF
SECOND STAGE OF
LABOUR
PRESENTED BY:
THOKOZIRE LIPATO
THIRD YEAR 2020
10/01/2023

2. BROAD OBJECTIVE
To equip student midwives with
knowledge, skills and positive attitudes in
managing women during second stage of
labour.

3. SPECIFIC OBJECTIVES
Define second stage of labour
Define management of second stage of labour
Describe the events that take place during the
second stage of labour.
Explain the diagnosis of second stage
Explain instruments required during Second
stage

4. SPECIFIC OBJECTIVES CONT….
Describe preparation of second stage of
labour.
Describe the care of the mother and
observations required.

5. DEFINITION OF SECOND STAGE
OF LABOUR
The second stage of labour begins from
full dilation of the cervix to the delivery of
the baby.
It lasts 15 -30 minutes for multipara and
40 minns to 1 hour for primigravida
(Sellers, P.M(2011)

6. Management of second stage
Encompasses midwifery care provided to
the labouring woman from the time the
cervix is fully dilated (10 cm) to expulsion
of the baby. (Michele et.,al 2012)

7. Diagnosis of second stage of labour
Could be done through:
1.Conclusive /diagnostic signs
2.Anticipatory signs

8. Conclusive sign of 2
nd
stage of
labour
1.Full dilatation of cervix confirmed on
vaginal examination

9. Anticipatory signs of 2
nd
stage
of labour
1.Expulsive contractions
2.Spontaneous rupture of membranes
3.Behaviour signs
4.Foetal signs
5.Trickling of blood
6.Pouting and gaping of anus
7.Gaping of vulva
8.Appearance of presenting part
9.Bulging of the perineum

10. Anticipatory signs
of 2
nd
stage of labourcont’d
1.expulsive contractions
Contractions:
-become very strong
-Felt frequently
-last longer and
-are expulsive in nature

11. Anticipatory signsof 2
nd
stage
of labourcont’d
2. Spontaneous rupture of membranes
◦May rupture when woman starts to bear
down
◦It is unreliable sign unless taken with
other signs

12. Anticipatory signs
of 2
nd
stage of labourcont’d
3. Behaviour signs
◦The urge to bear down becomes compulsive
and cannot control her actions e.grelaxing as
before.
◦Flushed look; sweating or shivering during a
contraction
◦May be flushed if dehydrated
◦May sweat especially if temperature is high

13. Behaviour signs cont…
◦May shiver in between contractions if
temp is low.
◦Some women vomit at onset of 2
nd
stage due to Painful contractions

14. Anticipatory signs
of 2
nd
stage of labourcont’d
4. Foetal signs
•Foetal heart rate patterns changes
•If recorded during a contraction, it
may fade and take longer to return
to normal after contraction hence
need for more close observations

15. Anticipatory signsof 2
nd
stage
of labourcont’d
5. Trickling of blood
◦May be noticed at the vaginal orifice due to
some lacerations of the cervix and vaginal
mucosa
6.Pouting and gaping of the anus
◦The anus will start to pout as it is pushed
outwards.
◦As the head descends further, the anus will
gape and the shiny anterior wall will be visible
◦This is a fairly reliable sign of 2
nd
stage

16. Anticipatory signs
of 2
nd
stage of labourcont’d
7. Gaping of vulva
◦When the head reaches the perineum, it is
directed forwards and upwards following
the curve and the vulva starts to gape –
indicates the presenting part is below the
level of the ischial spines and the cervix is
fully dilated.

17. Anticipatory signs
of 2
nd
stage of labourcont’d
8. Appearance of presenting part
◦An almost positive sign of second
stage, especially if the head is
presenting and mature baby =
conclusive.
◦Sometimes large caput and moulding
could be visible.

18. Anticipatory signs
of 2
nd
stage of labourcont’d
9. Bulging of the perineum
•Caused by the hard head that is
compressing the perineum as the
woman is bearing down during a
contraction.

19. REQUIREMENTS
Trolley with:
Sterile delivery pack: 1 pair of scissors,
gallipot with cotton wool and gauze
swabs, 2 kidney dishes, perineal pads and
3 draping towels and 2 forceps and 2 cord
clamps
Episiotomy pack: Sterile Episiotomy
Scissors; Needle holder, gallipot, cotton
swabs, gauze and di-forceps.

20. REQUIREMENTS CONT….
Chromic 0, 2/0
Razor blade/surgical blade
Pairs of sterile gloves
Chlorohexidine 0.25% solution for cleansing the
vulva
Lignocaine 1% solution
10 cc syringe

21. REQUIREMENTS cont’d
6 Infection Prevention Buckets for:
◦Dry waste (with bin liners)
◦Contaminated waste (with bin liners)
◦Contaminated linen, Instruments,
Soapy water
◦O.5% chlorine water for glove rinsing
◦Placenta and blood

22. REQUIREMENTS cont’d
o1 sharp container
o1 cc syringe for oxytocin
oTimer/wall clock

23. REQUIREMENTS cont’d
Personal protective equipment
◦Heavy duty apron
◦Face mask
◦Eye goggles
◦Closed shoes/gumboots
Resuscitation equipment for baby
Receiving blanket or chitenje for baby

24. PREPARATION
Prepare the necessary equipment
Explain the findings to the woman and
her support person, tell them what is
going to be done, listen to her and
respond to her questions and concerns to
gain her consent and cooperation.

25. Preparation cont’d
Review the bearing down technique (if mother is in
Dorsal position)
◦When a contraction is felt, the woman should flex
her knees and pull the thighs
◦Curve the back, with the chin on the sternum
◦Keep knees wide apart
◦Relax the pelvic floor while bearing down
◦Hold the thighs, take a deep breath, close the lips
and glottis then push
◦A long sustainable push is more effective than
numerous short ones

28. Preparation cont’d-the bearing down
technique
oTell the woman not to cry to hold the
breath.
oIf a contraction is still present but she needs
to take another breath, instruct her to inhale
deeply and bear down again.
oDo not bear down in between contractions.

29. Preparation cont’d
Ensure privacy
Keep the delivery bed and surrounding area clean
Bring the delivery trolley to the patients bed side
Provide emotional support and re-assurance
Put on personal protective barriers
Ensure the bladder is empty
Encourage woman to adopt position of choice
(squatting, semi-fowlers, Dorsal)

30. OBSERVATIONS DURING DELIVERY
◦Foetal heart rate in between
contractions
◦Strength and regularity of contraction
◦Advancement (descent) of presenting
part
◦Condition of the mother
Perineum for tear and make episiotomy if
necessary

31. ACTUAL DELIVERY
Put on apron, boots and goggles
Wash hands thoroughly with soap and
water then dry with sterile towel or air dry.
Put on sterile surgical gloves on both
hands. Double gloving is recommended
Clean the woman’s vulva with
chlorohexidine solution 0.25% using a 6
swab technique

32. ACTUAL DELIVERY CONT…
Place one sterile drape from the delivery
pack under woman’s buttocks, second one
on the abdomen and third one to receive
the baby.
The midwife stands on the right side of
the bed (if right handed) facing towards
the woman if in supine position.

33. ACTUAL DELIVERY CONT…
The woman should be encouraged to
assume a position for pushing that is
comfortable and aids in the descend of
the foetus.
Note time and the woman should push
in response to her natural bearing down
reflex

34. ACTUAL DELIVERY CONT…
Help her rest between contractions
Offer encouraging feedback after each push
and praise her effort
Place the second and third fingers of left hand
on the occiput and maintain down ward flexion
of the head until crowning occurs.
Support the perineum to prevent extensive
perineal tears.

35. ACTUAL DELIVERY CONT…
When crowning has occurred instruct the
mother to pant.
Observe imminent signs of perineal tear and
do episiotomyif present.
Allow spontaneous birth of the head
Discard the perineal pad
Quickly check the cord around the neck.

37. CORD FELT ON THE NECK
If the cord is around the neck but loose,
slip over the head.
If the cord is around the neck but can
not reach over the neck, relax the cord so
that it can slip backward over the
shoulders as the shoulders are born.
If the cord is tightly around the neck,
clamp the cord with two artery forceps,
placed in 3 cms apart and cut in between.

38. ACTUAL DELIVERY CONT…
Clean secretions with clean gauze or
cotton swabs from mouth, nostrils then
eyes to ensure clear airway and prevent
infection.
Wait for the restitution, external rotation
of the head which is accompanied by
internal rotation of the shoulders, so that
the smallest diameter is presented
thereby preventing tears to birth canal.

39. DELIVERY OF THE SHOULDERS
Place hands on each side of the baby’s
head (biparietal)
Ask the woman to bear down until
anterior shoulder escapes from under the
pubic arch. The midwife continues hold
the baby’s head between the hands.
The mother is then asked to stop bearing
down and to pant again.

40. DELIVERY OF THE SHOULDERS
The head is lifted up gently towards the
mother’s symphysis pubis and abdomen,
allowing posterior shoulder to slip free of
the perineum.

41. DELIVERY OF THE SHOULDERS

42. DELIVERY OF THE BODY
When the body emerges from the
vaginal orifice, Move the top most hand
from the head to support the rest of the
baby’s body
Grasp around the thorax at the same
time support back of the head and carry it
over the symphysis pubis up to the
abdomen.

43. DELIVERY OF THE BODY
Note the time and sex of the baby.
Quickly wipe the baby (starting with
mouth, nose then eyes) while assessing
the breathing if there will be need for
further resuscitation.

44. APGAR SCORING AT 5&10
MINUTES

45. ACTUAL DELIVERY CONT…
Mechanisms of LabourDuring the Second Stage
MECHANISM DEFINITION
Engagement The widest diameter of the presenting part crossesthe
maternal pelvic brim
Descent Downward movement of the leading bony edge of the
presenting part inside the birth passage
Flexion Maximum movement of the fetalchin towards the fetalchest
wall when the sinciputpresses against the film pelvic floor
muscles due to ongoing uterine contractions, leading to the
flexion of the fetalneck
Internal rotation Rotation of the fetalocciput due to contractions from a
transverse or oblique diameter to an anteroposterior
Extension Upward movementof the sinciputas the fetalhead emerges
from the resistance offered by symphysispubis

46. ACTUAL DELIVERY CONT…
Mechanism of Labour
Restitution Restoration of anatomy as the fetusattempts to correct
the twisting of the neck during internal rotation
External Rotation Rotation of the occiput outside the mothers birth
passage as the fetalshoulders undergo internal rotation
Delivery of the ShouldersOnce the delivery of the fetalhead has occurred and
following the internal rotation of the shoulders, the
secondstage of labour is completed when the fetal
shoulders, trunk, buttocks and legs are delivered

47. ASSIGNMENT 1
Read on:
◦Different positions adopted in
labour
◦Advantages and disadvantages
◦Why certain positions are preferred
compared to others in a Malawian
context

48. ASSIGNMENT 2
Formulate a care plan
Include the following:
1.3 priority midwifery diagnosis:
2.Midwifery goal on each midwifery diagnosis
3.2 priority interventions in respective to the midwifery
diagnosis
4.Indicate clear rationale for each Midwifery intervention
5.Include evaluation under each midwifery intervention

49. SUMMARY
Management of second stage of labour
comprises of midwifery care provided to the
labouring woman from the time the cervix is
fully dilated (10 cm) to expulsion of the baby.
(Michele et.,al 2012)
Fully cervical dilatation(10cms) is considered
as conclusive sign of the second stage of labour.
During preparation of delivery make sure that
the woman has been told the bearing down
techniques.

50. REFERENCES
Fraser, D.M., Cooper, M.A & Nolte, A.G.W(2006) Myles text
book for midwives(African edition). Edinburgh, Churchill
Livingston
Sellers, P.M(2004) Midwifery (volume1)Lansdowne, Juta and
Co, Ltd.
Michele R. Davidson, Marcia L. London, Patricia A. Wieland
Ladewig. Olds' maternal-newborn nursing & women's
health across the lifespan (2012) 9th ed, Upper Saddle
River