6.1b Second Stage of Labor Flashcards
Second Stage of Labor
- Begins at full cervix dilation and ends at birth of baby
Length of Second Stage Factors
- Age
- BMI
- Emotional State
- Adequacy of Support
- Level of fatigue
- Fetal size/position/presentation
Second Stage Labor Time Limit
First birth
3 hours without epidural
4 hours with epidural
Multiple birth
2 hours without epidural
3 hours with epidural
Prolonged second stage occurs when limits have been exceeded
Latent Phase
- Passive descent
- Patient is often quiet and relaxed
- Not a strong urge to bear down
DELAYED PUSHING
- Increases duration of second stage of labor
- Increases risk of hemorrhage/infection
- Decreases pushing time
- Reduction in likelihood of operative vaginal birth
- Improvements in chance of vaginal birth
Active Phase
- Pushing descent phase
- Ferguson reflex - Strong urge to bear down activated by baby passing through stretch receptors of the pelvic floor
- Oxytocin is released to produce stronger contractions
Objective Sign of Second Stage of Labor
- Inability to feel cervix during vaginal examination
- This means that it is fully dilated and effaced
- Sometimes patients want to bear down prematurely before cervix is fully dilated. Encourage them to breathe through their contractions or assume side lying/hands-knees position to prevent pushing.
Symptoms of Second Stage of Labor
- Increased frequency/intensity of contractions
- Urge to push (feels like need for bowel movement)
- Vomiting
- Increased bloody show
- Uncontrolled shivering
- Verbalization of inability to cope
- Involuntary bearing down efforts
Physical Assessment during 2nd stage of labor
- BP, Pulse, RR every 5-30 minutes
- FHR every 5-15 minutes (depending on risk)
- Assess vaginal show, signs of descent, changes in appearance/mood/energy/partner involvement every 10-15 minutes
- Assess every contraction and bearing down effort
Latent Phase Interventions
- Help patient rest to conserve energy
- Promote fetal descent by encouraging position change, pelvic rock, ambulation and showering
Active Phase Interventions
- Do not leave patient alone
- Help patient change positions and encourage bearing down
- Help patient relax between contractions
- Provide comfort/pain relief
- When head is emerging patient should pant during contractions and gently push between
- Inform patient regarding progress
- Offer mirror to watch birth
- Encourage patient to touch fetal head when visible
Labor Positions
- Important to help baby navigate through pelvis
- Changing positions provides relief and pain management
POSITIONS - Standing/walking (gravity)
- Sitting (gravity)
- Squatting (relieves pressure off back)
- Hands-Knees (takes pressure off spine)
- Leaning/Kneeling Forward (relieves pressure of back)
- Stay active in early active labor
Latent Phase
- Passive descent, not too intensive contractions
- Station 0-2
- No urge to bear down
- Patient is quiet
Active Phase
- Contractions become overwhelmingly strong/expulsive
- Contractions happen every 2-3 minutes and eventually every 1-2 minutes
- Contractions last around 90 seconds
- Fetal station is at 2-4
- Significant increase in dark red bloody show
- Increased urge to bear down
- Patient may start grunting
Bearing Down
- Ferguson Reflex
- Prolonged breath holding
Bearing Down Techniques
- Valsalva maneuver (closed glottis pushing) is discouraged. Causes intrathoracic and cardiovascular pressure which reduces cardiac output and perfusion to placenta
- Open glottis pushing for 6-8 seconds is encouraged
FHR
- Concern if baseline slows, minimal variability or late/prolonged
- First action is to turn patient to their side
- Second action administer oxygen at 10L/min through non-rebreather mask
- If these do not help, notify provider
Supporting Normal Labor
Step 1 - Allow labor to begin on its own
Step 2 - Encourage freedom of movement
Step 3 - Provide support and decrease use of epidural anesthesia
Step 4 - Avoid routine implementation of interventions
Step 5 - Support non-directed pushing in non-supine positions to shorten labor
Step 6 - Encourage skin to skin contact after birth and foster early breastfeeding
Vertex Position Phases
- Birth of head
- Birth of shoulders
- Birth of body/extremities
Crowning
- Biparietal diameter (widest pat of head) distends the vulva before birth.
- When the babies head becomes visible
Episiotomy
- Incision to enlarge the perineum
- Done around the time you see crowning
Hands-On Birthing Approach
- Prevents fetal intracranial injury and protects maternal tissue
Ritgen Maneuver (modified)
- Apply pressure from coccygeal region to extend head during birth
Nuchal Cord
- Umbilical cord encircles the neck.
- Either untangle the cord or clamp the cord twice and cut between the clamps
Time of Birth
- Precise time when entire body is out of the mother
- Allow immediate skin to skin contact and delay cord clamping if conditions allow for it.
- Do not clamp umbilical cord for 1-5 minutes after birth (or when cord stops pulsating)
- Optimal time is around 3 minutes
Lotus Birth
- Cord is never clamped or cut
- Cord and placenta remain attached until cord naturally separates a few days after birth
Post-Birth Care
- Focuses on assessment and stabilizing the baby
- At least 2 nurses should be present
- 1 nurse focuses on newborn while the other nurse helps physician with placenta delivery
- Assessment is done immediately even if during skin to skin contact
- Priorities include maintaining patent airways, supporting respiratory effort, preventing stress by drying the baby and covering in a warm blanket.
Perineal Trauma
- Warm compress, perineal massage, and stretching may decrease trauma
- Massage during last month of pregnancy has shown to work for first time vaginal births
- Usually nulliparous patients have more pronounced trauma
Perineal Trauma Risk Factors
- Maternal Nutritional Status
- Birth position
- Pelvic anatomy
- Fetal presentation
- Fetal position (breech, occiput)
- Large babies (macrosomic)
- Use of forceps or vacuum
- Prolonged 2nd stage of labor
- Rapid labor
Perineal Laceration Degrees
1st degree - Superficial skin/structures
2nd degree - Extends through muscle
3rd degree - Extents through anal sphincter
4th degree - Extends through anal sphincter and rectal mucosa
Vaginal Vault Lacerations
- Circular
- Results from forceps use, rapid fetal descent, or precipitous birth (rapid birth)
Cervical Injuries
- Most are shallow with minimal bleeding
- If there are extensive lacerations, surgeon may artificially enlarge the cervix or deliver before full dilation
Episiotomy
- Procedure to enlarge the vaginal outlet
Midline Episiotomy - Higher incidence of 3-4 degree lacerations
Mediolateral Episiotomy - More painful - Should be avoided if possible
