management of 2nd stage Flashcards
when does 2nd stage begin and end
complete dilation
delivery
what happens during the first phase of 2nd stage (passive fetal descent)
complete dilation until urge to push
contraction interval increases
presenting part rotates to best possible position for delivery
descent into pelvis causes the urge to bear down to become reflexive
what is the reflex called when the urge to bear down becomes reflexive
ferguson’s
what happens during the second phase of 2nd stage (expulsive phase)
pushing or bearing down until delivery of the infant
begins after fetus has descended and rotated into proper position
premature urge to push is common with
posterior babies bc of the occiput pressing on rectum
premature urge to push can cause prolonged pushing that can result in
cervical edema
cervical laceration
maternal exhaustion
criteria for allowing mom to push as her body guides her
baby is at least +1 station
position is OT or OA
cervix is soft and yielding and dilated to 8 or 9
disadvantages of a traditional pushing technique
maternal exhaustion
dependence on others to push instead of instinct
higher need for instrumental delivery
increased perineal trauma
disadvantages of valsalva pushing
decrease of maternal venous return
decrease maternal cardiac output
decrease arterial BP
decrease oxygenation of mother and placenta
subsequent gasping for breath causes petechial hemorrhages
fetal acidosis and hypoxia
when would you use valsalva pushing
successful in getting a baby past a tight spot or if baby is OP because mom is pushing longer and harder; also great if mom is anxious or lacking focus
advantages of involuntary pushing
Less FHT decelerations
Less maternal fatigue
Equal Apgars as women who push with Valsalva technique
advantages of upright position
preferred by mother
shorter 2nd stage
reduction in episiotomies
fewer FHT abnormalities
disadvantages of upright position
increase in 2nd degree lacerations
increase PPH > 500 ml
advantages of mobility
Increase placental perfusion Optimize fetal alignment and descent Shorter 2nd stage Fewer episiotomies Fewer lacerations Fewer abnormal FHT Less severe pain Squatting increases pelvic space and avoids vena cava compression Often preferred by women
advantages of lateral delivery
fewer lacerations
good placental perfusion
slows delivery
advantages of birthing chairs
supported, upright position
disadvantages of birthing chairs
increased perineal edema
increased perineal lacerations
increased blood loss
advantages of emotional support in 2nd stage
Decreases catecholamine due to stress, fear, etc.
Prevents decreased uterine contractions due to catecholamine release
decreases need for pain meds
Shorter labor
Decreased need for instrumental or cesarean delivery
Supports woman’s normal bodily functions
coaching techniques
Encourage woman to delay pushing until her body directs her to do so- usually about +1- +2 station
Only direct the mother’s pushing efforts when necessary, otherwise let her instincts guide her
Allow her to let air escape as she pushes
Help her into positions of her choice, encouraging changes every 20-30 minutes
Coach her to relax the perineum as she pushes
Reassure her that the intensity of sensations especially of the perineum are normal
Make her aware of her progress (which may include rotation of the baby’s head, which is not visible)
Offer her a mirror or the chance to touch the baby’s head for encouragement
Suggest the toilet as a place to push as it is upright and often a comfortable place for women to let go
ideal length of 2nd stage for multip/primip
1hr/2hr
variables to assess during 2nd stage
Woman’s preferences Position Delivery location What happens to baby immediately after birth Cutting of cord Cord blood Placental delivery technique Vital signs FHT and tolerance of second stage Amniotic fluid status-clear vs. meconium Effectiveness of pushing Mother’s emotional status Estimated fetal weight compared to other deliveries, any information form ultrasound regarding biparietal diameter, fetal size estimation Pelvimetry Mother’s bladder status Anticipated length of second stage Involvement of significant others
episiotomy
If an episiotomy is needed, preferably perform it when the head is expected during that contraction.
Perform the episiotomy at the peak of the UC when the perineum is most thinned and natural anesthesia prevents as much maternal sensation.
Use local anesthetic.
Protect the anal sphincter by drawing it together from either side
3 tasks to do simultaneously while delivering the head
Flex the head to deliver with the smallest presenting diameter
Press head downward toward anus away from clitoral area, maintain this pressure till head has passed through the introitus
Apply counterpressure to the emerging head as necessary to slow its movement and facilitate stretching of the mother’s tissue
what to do with a nuchal cord
if loose slip it over baby’s head
if tight, clamp and cut cord before delivery
or deliver baby through loop by slipping the cord past the shoulders as they emerge, keeping the baby close to the mother’s body or thigh to prevent traction on the cord
when do you check for a nuchal cord?
after the head is delivered
shoulder delivery
Watch for restitution
Have mother bear down while you traction the anterior shoulder posteriorly to deliver the anterior shoulder- shoulder delivery is complete when the axilla is visualized
Deliver the posterior shoulder by bringing the baby’s head anteriorly, slipping your hand under the posterior shoulder to support the emerging trunk and to keep the posterior hand from tearing the perineum by pressing it to the infant’s trunk until it is fully delivered
body delivery
Lift the baby’s body in the direction of the curve of Carus
Assess color, respiration, tone, reflex, heart rate and decide on course of action, give baby to mom or consider resuscitative action
Healthy baby is covered in blanket, or dried off in mom’s arms, suctioned if needed, hat is placed on head
