2nd Stage of Labour

Question 1

What is the definition of the second stage of labour according to NICE guidelines 2023?

Answer 1

-Passive second stage of labour: when there is full dilation of the cervix before or in the absence of involuntary or active pushing
-The passive second stahe of labour may be up to 2 hours when a woman with an epidural in place has been advised to delay pushing
-Onset of the active 2nd stage of labour is when:
the baby is visible or
there is involuntary or active pushing with dilatation of the cervix.

Question 2

What did MacDonald and Johnson (2023) find about the 2nd stage of labour?

Answer 2

contractions- studies indicate these are slower
Fetal back uncurls from flexed attitude, lower segment stretches, fetal axis pressure helps descend fetus through birth canal.
Expulsion of fetus aided by voluntary muscles of diaphragm and abdominal wall.
Pressure from fetal presentation stimulus nerve receptors of pelvis floor resulting in the desire to bear down- Ferguson reflex.

Question 3

What happens to the pelvic floor during the 2nd stage?

Answer 3

Advancing fetus stretches vagina and displaces pelvic floor.
* Anteriorly Bladder is pushed upand drawn into the abdomen –less likely to be damaged.
* Posteriorly pelvic floor pushed down in front of the presenting part.
* The rectum is compressed.
* The perineal body becomes elongated and flattened.

Question 4

What are the two parts of the 2nd stage?

Answer 4

Passive and active

Question 5

What is the definition of an ACTIVE 2nd stage?

Answer 5

The baby is visible or there is involuntary or active pushing with full dilation of the cervix.

Question 6

What are some signs that a woman is in the second stage of labour?

Answer 6

• She’s telling you “I’m pushing!” “The baby is coming!” “I’m having a poo!”
• Vomiting
• Spontaneous rupture of membranes (not always though!) /bulging membranes
• Powerful expulsive contractions, lasting at least 60 seconds
• Rectal pressure/Anal dilatation
• Involuntary urge to push (Ferguson’s reflex)
• Appearance of the presenting part
• Cleft/purple line
• Prominent Rhomboid of Michaelis

Question 7

What do the NICE 23 guidelines advise on a woman’s position and pushing in the second stage?

Answer 7

Advise a woman with an epidural in place during the second stage of labour that:
Lysing flat on her back can lead to a decrease in bp and may reduce placental bf
lying on her side may increase the chance of SVD, but she can use any other positions she finds comfortable to give birth, including upright positions.

Question 8

What are the disadvantages of directed pushing (also known as ‘cheerleading’ or valsalva’s manouvre’)?

Answer 8

It can reduce O2 to the fetus
More frequent trauma to the birth canal
Increased injury to future pelvic floor function
Should be avoided and women should be guided with THEIR OWN URGE TO PUSH.

Question 9

What is the ideal head, position and moulding of the fetus?

Answer 9

Head ideally flexed which reduces engaging longitudinal diameter
Position ideally with the occiput anterior in the pelvis
Moulding of the fetal skull as it descends through the pelvis.

Question 10

What does the curve of carus create?

Answer 10

A curve of 90 degrees to be negotiated by the fetus.

Question 11

What is meant by the labour mechanism: Descent?

Answer 11

The fetus begins to descend into the pelvis due to the force of gravity and downward pressure of the contractions.

Question 12

What is meant by the labour mechanism: flexion

Answer 12

As the fetus descends, the chin touches the chest and attitude of flexion is adopted. This increases further when the head meets the resistance of the birth canal.

Question 13

What is meant by the labour mechanism: Internal rotation-head

Answer 13

As the occiput reaches the resistance of the pelvic floor, it rotates. The slope of the pelvic floor aids this rotation and allows the head to emerge in the longest diameter

Question 14

What is meant by the labour mechanism: crowning

Answer 14

The head has crowned when it escapes under the pubic arch and no longer recedes between contractions because the widest transverse diameter of the head is born (biparietal)

Question 15

What is meant by the labour mechanism: extension.

Answer 15

With slight extension the forehead, face and chin pass over the perineum and the head is born.

Question 16

What is meant by the labour mechanism: restitution

Answer 16

When the head is born it will turn to the left or right so as to realign with the shoulder.

Question 17

What is meant by the labour mechanism: Internal rotation-shoudlers

Answer 17

The shoulders then rotate and lie in the anterior posterior position.

Question 18

What is meant by the labour mechanism: lateral flexion.

Answer 18

Birth of the shoulders by lateral flexion to accommodate the curve of carus.

Question 19

How is MPP (manual perineal protection) performed?

Answer 19

One hand on baby’s head at crowning to slow and maintain flexion. Guarding the perineum with the other hand, squeezing towards to middle to reduce central pressure, with other fingers curled up and pressing against premium, whilst encouraging slow, controlled breathing..

Question 20

What are the two approaches for guarding the perineum?

Answer 20

Hands on- guarding the perineum and flexing the baby’s head
Hands poised- with hands off the perineum and baby’s head but in readiness

Question 21

What are some interventions to reduce perineal trauma according to NICE 23

Answer 21

• Discuss the woman’s preferences for techniques to reduce perineal trauma during birth and support her choices.
• Offer to apply a warm wet compress to the perineum and continue this until birth (Once PP distends the perineum)
• Consider massage of the perineum with a water-soluble lubricant in the second stage of labour
• Do not carry out a routine episiotomy during spontaneous vaginal birth.
• Inform any woman with a history of severe perineal trauma that her risk of repeat severe perineal trauma is not increased in a subsequent birth, compared with women having their first baby

Question 22

What do the NICE 2017 guidelines give evidence on about the absolute time limits of physiological labour?

Answer 22

Suggest that obstetric advice should be sought if active pushing second stage in longer than 2 hours in nulliparous or 1 hour in multiparous women and the birth is not imminent (flexibility)

Question 23

What are the time limits of physiological labour according to Oladap et al 2018

Answer 23

Setting time limits is less effective than paying attention to steady progress and maternal and fetal wellbeing.

Question 24

What is the role of the midwife in the second stage according to NICE 2023?

Answer 24

Half-hourly documentation of the frequency of contractions
* Hourly blood pressure
* Continued 4-hourly temperature
* Frequency of passing urine
* Offer a vaginal examination hourly in the active second stage, or in response to the woman’s wishes (after abdominal palpation and assessment of vaginal loss).In addition:
* Continue to take the woman’s emotional and psychological needs into account.

Question 25

How should assessing progress happen in the 2nd stage?

Answer 25

The woman’s behaviour.
* The effectiveness of pushing and the baby’s wellbeing, taking into account the baby’s position and station at the onset of the second stage.
* These factors will assist in deciding the timing of further vaginal examination and any need for transfer to obstetric led care.
* Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least 1 minute, at least every 5 minutes.
* Palpate the woman’s pulse every 15 minutes to differentiate between the two heartbeats.
* Ongoing consideration should be given to the woman’sposition, hydration, coping strategies and pain reliefthroughout the second stage.

Question 26

What is classed as effective record keeping in the second stage of labour (the minimum expected documentation)?

Answer 26

Documentation throughout the 2nd stage including timings of;
* Full dilatation
* Onset of active 2nd stage
Descent
* When the presenting part is visible
* Head crowns
* Head born
* Baby born

Question 27

What is the importance of effective record keeping?

Answer 27

Records are a legal document
* Clear accurate and relevant to the sphere of practice
* Examined by any court (or NMC FtP committee) for up to 25 years
* Accurate and without falsification – encourage others to do the same
* Attribute any entries you make to yourself – clearly written, dated and timed
* Kept securely
* Avoid abbreviations, jargon and speculation