management of 2nd stage

Question 1

when does 2nd stage begin and end

Answer 1

complete dilation

delivery

Question 2

what happens during the first phase of 2nd stage (passive fetal descent)

Answer 2

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

Question 3

what is the reflex called when the urge to bear down becomes reflexive

Answer 3

ferguson’s

Question 4

what happens during the second phase of 2nd stage (expulsive phase)

Answer 4

pushing or bearing down until delivery of the infant

begins after fetus has descended and rotated into proper position

Question 5

premature urge to push is common with

Answer 5

posterior babies bc of the occiput pressing on rectum

Question 6

premature urge to push can cause prolonged pushing that can result in

Answer 6

cervical edema
cervical laceration
maternal exhaustion

Question 7

criteria for allowing mom to push as her body guides her

Answer 7

baby is at least +1 station
position is OT or OA
cervix is soft and yielding and dilated to 8 or 9

Question 8

disadvantages of a traditional pushing technique

Answer 8

maternal exhaustion
dependence on others to push instead of instinct
higher need for instrumental delivery
increased perineal trauma

Question 9

disadvantages of valsalva pushing

Answer 9

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

Question 10

when would you use valsalva pushing

Answer 10

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

Question 11

advantages of involuntary pushing

Answer 11

Less FHT decelerations
Less maternal fatigue
Equal Apgars as women who push with Valsalva technique

Question 12

advantages of upright position

Answer 12

preferred by mother
shorter 2nd stage
reduction in episiotomies
fewer FHT abnormalities

Question 13

disadvantages of upright position

Answer 13

increase in 2nd degree lacerations

increase PPH > 500 ml

Question 14

advantages of mobility

Answer 14

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

Question 15

advantages of lateral delivery

Answer 15

fewer lacerations
good placental perfusion
slows delivery

Question 16

advantages of birthing chairs

Answer 16

supported, upright position

Question 17

disadvantages of birthing chairs

Answer 17

increased perineal edema
increased perineal lacerations
increased blood loss

Question 18

advantages of emotional support in 2nd stage

Answer 18

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

Question 19

coaching techniques

Answer 19

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

Question 20

ideal length of 2nd stage for multip/primip

Answer 20

1hr/2hr

Question 21

variables to assess during 2nd stage

Answer 21

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

Question 22

episiotomy

Answer 22

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

Question 23

3 tasks to do simultaneously while delivering the head

Answer 23

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

Question 24

what to do with a nuchal cord

Answer 24

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

Question 25

when do you check for a nuchal cord?

Answer 25

after the head is delivered

Question 26

shoulder delivery

Answer 26

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

Question 27

body delivery

Answer 27

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