Second Stage of labour

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Second Stage of labour
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Second Stage of labour-

Definition

  • The second stage of labour is the period from full dilatation of the cervix (10 cm) until the birth of the baby.
  • It starts with the full dilatation of the cervix and ends with the expulsion of the fetus from the birth canal.

Types of Second Stage of Labour


1. Passive Second Stage/Propulsive Phase

  • Begins when cervix becomes fully dilated.
  • Uterine contractions continue.
  • Mother may not yet feel a strong urge to bear down.
  • Fetus descends gradually due to uterine contractions.

2. Active Second Stage/Expulsive Phase

  • Mother develops a strong urge to push.
  • Active bearing down efforts start.
  • Ends with delivery of the baby.
    .

Events in the Second Stage of Labour

Full cervical dilatation (10 cm)
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Strong uterine contractions
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Rapid descent of presenting part
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Urge to bear down develops
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Maternal bearing down efforts begin
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Increased intra-abdominal pressure
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Further descent of fetal head
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Flexion of fetal head
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Internal rotation of head
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Bulging of perineum
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Gaping of anus
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Crowning of fetal head
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Extension of head
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Delivery of head
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Restitution
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External rotation
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Delivery of anterior shoulder
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Delivery of posterior shoulder
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Expulsion of body
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Birth of baby
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Uterus contracts firmly after delivery

 

Nursing Management of Women in second Stage of Labour-

Objectives

  • Ensure safe birth of the baby
  • Maintain maternal and fetal well-being
  • Prevent maternal exhaustion
  • Prevent fetal hypoxia and birth trauma
  • Prevent perineal injury
  • Prepare for active management of the third stage of labour

Management of Second Stage of Labour

1. Recognition of Second Stage

Observe for-

  • Full cervical dilatation (10 cm)
  • Strong uterine contractions every 2–3 minutes
  • Involuntary bearing-down efforts
  • Bulging perineum
  • Dilatation of anus
  • Visible presenting part at vulva

2. Preparation of Mother

  • Explain progress of labour and procedures
  • Reassure and encourage the woman
  • Maintain privacy and dignity
  • Place mother in a comfortable position
  • Clean vulva and perineum with antiseptic solution
  • Empty bladder before delivery

3. Preparation of Delivery Room and Equipment

Ensure availability of:

  • Sterile delivery set
  • Sterile gloves and gown
  • Cord clamps/ties and scissors
  • Warm towels and baby linen
  • Suction apparatus/mucus extractor
  • Neonatal resuscitation equipment
  • Oxytocin 10 IU for AMTSL
  • Emergency drugs and oxygen

4. Maternal Monitoring

General Condition

Observe-

  • Pulse every 15–30 minutes
  • Blood pressure every 30 minutes
  • Respiration and hydration status
  • Signs of exhaustion or distress

Uterine Contractions

Assess-

  • Frequency
  • Duration
  • Intensity

Normal contractions-

  •  Every 2–3 minutes
  • Last 60–90 seconds

5. Fetal Monitoring

Fetal Heart Rate (FHR)

  • Auscultate after every contraction or at least every 5 minutes

Normal:

  • 110–160 beats/minute

Observe for-

  • Bradycardia (<110 bpm)
  • Tachycardia (>160 bpm)
  • Meconium-stained liquor

6. Encourage Effective Bearing-Down Efforts

During contractions-

  • Take a deep breath
  • Hold breath
  • Push down using abdominal muscles

Between contractions-

  • Relax completely
  • Breathe normally
  • Conserve energy

Do not encourage pushing before full cervical dilatation.

7. Bladder Care During Second Stage of Labour

  •  Ensure the bladder is empty before and during the second stage.
  • Encourage the woman to pass urine every 2–4 hours.
  • If unable to void and the bladder is distended, perform aseptic catheterization.

Importance

  • Facilitates descent of the fetal head
  • Promotes effective uterine contractions
  • Prevents prolonged labour
  • Reduces risk of bladder injury and postpartum hemorrhage

8. Pain Relief During Second Stage of Labour

  • Reassure and support the mother continuously.
  • Encourage deep breathing and relaxation techniques.
  • Provide a comfortable position and maintain privacy.
  • Use analgesia or anesthesia as prescribed.
  • Encourage rest between contractions.

Benefits

  • Reduces pain and anxiety
  • Increases maternal comfort
  • Promotes effective pushing efforts
  • Prevents maternal exhaustion

9. Maternal Position During Second Stage of Labour-Place the mother in a comfortable and safe position.

Common Positions:-

  • Lithotomy position
  • Semi-recumbent position
  • Squatting position
  • Left lateral position

Benefits

  • Promotes fetal descent
  • Facilitates effective bearing-down efforts
  • Improves maternal comfort
  • Enhances uteroplacental circulation

10. Conduct of Delivery

During Crowning

Crowning:- The fetal head remains visible at the vulva and does not recede between contractions.

Management:-

  • Support the perineum with one hand
  • Control extension of the fetal head with the other hand
  • Ask the mother to pant rather than push forcefully
  • Allow gradual delivery of the head

Advantages

  • Prevents perineal tears
  • Prevents rapid expulsion of the head
  • Reduces fetal trauma

11. Check for Nuchal Cord

After delivery of the head:

  • Feel around the neck for umbilical cord

If loose:

  • Slip over the baby's head

If tight-

  • Clamp and cut between two clamps

12. Delivery of Shoulders and Body

Anterior Shoulder

  • Gentle downward traction

Posterior Shoulder

  • Gentle upward traction

Trunk and Legs

  •  Deliver gently without force

13. Immediate Care of the Newborn

  • Receive baby on a warm sterile towel
  • Dry immediately and thoroughly
  • Maintain warmth (skin-to-skin contact if possible)
  • Clear airway if required (mouth then nose)
  • Assess breathing and crying
  • Perform APGAR scoring at 1 and 5 minutes
  • Eye care-Clean the baby's eyes with sterile cotton/gauze soaked in clean water or normal saline.Wipe from the inner corner (near the nose) to the outer corner
  • Vitamin K-Within 6 hours after birth
  1. >1500 g: 1 mg IM once
  2. ≤1500 g: 0.3–0.5 mg/kg IM once

Delayed Cord Clamping

  • Clamp cord after 1–3 minutes if baby is stable

Benefits-

  • Approximately 80–100 mL of additional blood is transferred from the placenta to the newborn.
  • This provides about 40–50 mg/kg of extra iron to the infant.

14. Episiotomy (If Indicated)

Indications

  • Rigid perineum
  • Large baby
  • Instrumental delivery
  • Breech delivery
  • Fetal distress requiring rapid birth

15. Prevention of Postpartum Hemorrhage

After birth-

  • Administer Oxytocin 10 IU IM within 1 minute of birth as part of Active Management of Third Stage of Labour (AMTSL)

16. Documentation

Record:

  • Time of full dilatation
  • Time of birth
  • Duration of second stage
  • Maternal vital signs
  • Fetal heart rate findings
  • Sex and condition of baby
  • APGAR score
  • Episiotomy/tear
  • Drugs administered

Articles Required During Second Stage of Labour

1. Sterile Articles

  • Sterile gloves
  • Sterile gown/apron
  • Sterile drapes and towels
  • Sterile gauze pieces/swabs
  • Cotton swabs

2. Delivery Tray Instruments

  • Artery forceps (Kocher’s forceps)
  • Sponge holding forceps
  • Scissors
  • Episiotomy scissors
  • Needle holder
  • Dissecting forceps
  • Cord clamp
  • Sterile blade

3. Suturing Materials

  • Suture materials (chromic catgut/vicryl)
  • Syringe and needles
  • Local anesthetic (Lignocaine)

4. Cord Care Articles

  • Cord clamp/tie
  • Sterile cord scissors
  • Kidney tray for placenta

5. Maternal Care Articles

  •  Mackintosh and draw sheet
  • Perineal pads
  • Bedpan
  • Receiver for waste
  • Measuring jar

 6. Newborn Care Articles

  •  Warm sterile towels
  • Baby receiving sheet
  • Mucus sucker/bulb syringe
  • Neonatal ambu bag and mask
  • Radiant warmer
  • Baby cap and clothing

7. Drugs and Solutions

  • Oxytocin injection
  • Emergency drugs
  • Antiseptic solution
  • IV fluids

8. Monitoring Equipment

  • Fetoscope/Doppler
  • BP apparatus
  • Thermometer
  • Stethoscope
  • Pulse oximeter (if available)

9. Emergency Equipment

  • Oxygen cylinder
  • Suction apparatus
  • Resuscitation tray
  • Emergency tray for PPH management

Procedure

Steps Rational 
Provide a comfortable position i.e.. Lying on her back with legs flexed. To promote comfort and relaxation.
Assessment: Monitor uterine contractions and PV findings. To assess the progress of labor.
Assess the parameters i.e.presentation, lie, attitude, position, station, cervical dilatation, effacement, etc. Helps in examining the progress of labor.
Maintain the chart of progress i.e.. partograph. To determine abnormalities, if any.
Observe the color of the liquor if membranes are ruptured. Presence of meconium-stained liquor is an indication of fetal distress.
Monitor fetal heart rate and continue to check the mother's vital signs. Fetal heart rate decreases during contraction; it recovers after contraction.
Ask the mother to empty the bladder and administer oxytocin if ordered.  
After confirmation of the 2nd stage of labor: Arrange all the articles after opening the delivery pack. To save time.
Place the woman in a dorsal position with knees bent at the lower end of the delivery bed.  
Place a clean plastic sheet under the mother. Permits more access to the perineum to assess the progress clearly.
Wear a plastic apron, mask, cap and shoe cover. Wash your hands and dry them. Wear sterile gloves.  
Drape the woman's perineum and delivery area. To make the perineum free from microorganisms.

Clean the perineal area and buttocks with cotton swabs dipped in antiseptic solution. Use one cotton ball for each stroke separately in the given order:

  • Mons pubis to the clitoris
  • Clitoris to fourchette (downward)
  • Labia minora
  • Labia majora
  • Thighs in long strokes (away from perineum)
  • Anus (one circular stroke)
  
Delivery of head: After the crowning take place, hold the fetal head with sterile towel/pad with one hand and maintain it in the flexion position. This type of control maintains flexion and prevents pressure on perineum.
Use a clean pad with the other hand to support the perineum. It is done to support the lower edge of the perineum by pinching so as to avoid tearing or trauma.
Encourage the mother to stop pushing, and bear down only during a contraction.Perform episiotomy, if needed. To enable the physician to control the pace of the fetal head delivery. Precipitated delivery of the head can lead to perineal injury/trauma
Once the head is delivered, examine the baby's neck for the umbilical cord It helps in the detection of nuchal cord, which avoids descend of the fetus as well as delivery of the body.
Cord assessment: If the cord is loose around the neck, then slide it over the head of the baby. If the cord around the neck is tight, then clamp the cord about 3 cm apart and cut in the middle. To prevent the tightening of the cord around the neck. Tightening can cause fetal hypoxia and death.
Wipe out the mucus from the baby's face with clean gauze. To facilitate breathing.

Delivery of shoulders:

Wait for the next contraction and watch for restitution and external rotation of the head.

 To allow time for rotation of shoulders to the anteroposterior diameter of the outlet.
Proceed to delivery when the shoulders reach the A-P diameter of the pelvic outlet.  
Deliver one shoulder at a time.  
With the next contraction, use a gentle downward traction towards the mother's sacrum to deliver the anterior shoulder This allows the anterior shoulder to pass under the maternal pubic symphysis.
The posterior shoulder is delivered by applying a gentle upward traction holding each side of the head. It is necessary to apply the least amount of traction during the delivery of fetal shoulders to reduce the risk of traction-induced perineal injury and fetal brachial plexus injuries.
Delivery of rest of the body: Grasp the baby around the chest and lift the baby towards the mother's abdomen. Rest of the delivery of the body is spontaneous and requires minimal efforts by the mother.
Note down the time of birth.  
Cord cutting: Clamp the cord when the pulsation stops (normally 1-3 minutes). In full-term vaginal deliveries, delay in cord clamping helps in preventing neonatal anemia.
The cord is clamped with two clamps and then cut between the clamps leaving about 1 inch or 3 cm from the abdomen of the baby.  
After the cord cutting, clean the newborn and dry him. After drying, wrap the baby in a clean, dry and warm cloth. Wipe both eyes with gauze. To avoid heat loss.
Once delivery is complete, place the baby on the mother's abdomen. Inform the mother of the sex of baby.  

APGAR Scoring:Evaluate APGAR scores at one-minute and five minutes.

 This test helps in checking a baby's heart rate, muscle tone, and other signs to detect the need for extra medical or emergency care.
If the baby is not crying and meconium is present then suction the mouth first and then the nose. Assess the baby for breathing. To make the airway patent and initiate breathing.
Put an identification tag on the newborn. To have correct identification.
Skin-to-skin contact: If the APGAR scores are within normal limits, transfer the infant to the mother immediately and place it on her abdomen. Early skin-to-skin contact between the newborn and mother helps to increase mother-infant bonding, initiation of breastfeeding and minimizes heat loss by the infant.

Expulsion of the placenta:

Feel the contraction of the uterus by placing a hand over the fundus and observe the signs of placental separation.

 Contraction and separation of the placenta usually occur in 5 minutes.
After the descent of placenta, ask the mother to beardown. Bearing down efforts along with contractions helps in the expulsion of the placenta
As soon as the placenta delivers, grasp it in cupped hands and place na clean tray for examination later on.  
Assessment: Examine mother's vulva, vagina and perineum. For any laceration or trauma.
Massage the uterus. To make the uterus contract for expulsion of any retained blood clots.
Perform episiotomy suturing layer by layer if done.  
Clean the vulva, vagina and perineum with an antiseptic solution. To avoid chances of infection.
Place perineal pad. To stop bleeding.
Make the mother comfortable.  

 

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