Physiology and Mangement of 2nd stage labour

Physiology and Mangement of 2nd stage labour

1. Physiology and MANAGEMENT OF 2 ND STAGE OF LABOUR Mrs.jagadeeswari.J m.Sc nursing Physiology and MANAGEMENT OF 2 ND STAGE OF LABOUR

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 1/8 th 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 1/8 th 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 1/8 th 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 To achieve delivery of a normal healthy child with minimal physical and psychological maternal effects 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 lying

30. cont… walking standing

31. Cont… Leaning or kneeling forward with support 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 To maintain flexion of the head . 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 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.. Uterine contractions FHR for every 5minutes-15minutes Descend and station of fetal head 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 .

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