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Management of the second stage of labor

Management of the second stage of labor . Mrs. Mahdia Samaha . Begins with complete dilation of the cervix and ends with delivery of fetus Duration of Second Stage - Primigravida: 50 minutes Multiparous: 20 minutes or less Contractions Interval: 2 to 3 minutes Duration: 50 to 100 seconds.

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Management of the second stage of labor

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  1. Management of the second stage of labor Mrs. Mahdia Samaha

  2. Begins with complete dilation of the cervix and ends with delivery of fetus • Duration of Second Stage - • Primigravida: 50 minutes • Multiparous: 20 minutes or less • Contractions • Interval: 2 to 3 minutes • Duration: 50 to 100 seconds

  3. Signs of the second stage of labor: • Increase in apprehension and irritability. • S.R.O.M. • Sudden appearance of sweat on upper lip • Bloody show • Low grunting sounds from the woman • Rectal and perineal pressure • Involuntary bearing down

  4. Signs of progress of second stage of labor: • Bulging of the perineum • Labial separation • Advancing and retreating of the fetal head during and between maternal pushing effort. • Crowning: fetal head is visible at the perineum.

  5. Nursing Interventions: • Position the client: • Lithotomy position • Semi sitting position • Lateral/ side lying • Sitting on birthing stool • Squatting position • kneeling with hands on bed and knees comfortably apart.

  6. Nursing Interventions: • Provide continuous comfort measures • Instruct the woman on the organized pushing technique • Monitor FHR • Explanation to the client • Psychological support • Upright position • Observe V/S • Pain management

  7. Nursing Interventions: • Continuous nursing presence • Appraise maternal efforts • Prepare for and assist with delivery by: 1- preparing the delivery bed 2- prepare perineal area 3- Offer a mirror 4- explain all procedures 5- Delivery instrument 6- Receive new born , cover with blanket on the womans abdomen 7- Provide initial care and assessment of the newborn

  8. Episiotomy Indications • Perform to avoid unecessary tearing when head is crowning • Controlled delivery avoids need for episiotomy in most cases. • Anesthetize with pudendal block • Put two fingers into the vagina along the posterior wall • Place one blade of scissors between fingers inside vagina, other blade outside vagina toward anus • Cut to approximately 1 inch away from anus during a contraction

  9. Indications of episiotomy • to facilitate delivery when the fetal status is non-reassuring: • epidural anesthesia • onset of persisting moderate to severe variable fetal heart rate decelerations while still some minutes from spontaneous delivery. • To allow spontaneous delivery and avoid the need for operative vaginal intervention. 2. shoulder dystocia 3. breech delivery 4. operative vaginal delivery 5. occiput posterior presentation

  10. Benefits of episiotomy • decrease the incidence of first- and second-degree periurethral and vaginal lacerations. • Although an episiotomy may be simpler to repair than a spontaneous laceration, it is associated with a higher incidence of third- and fourth-degree lacerations

  11. Complications of episiotomy • Pain and edema are the most frequent postepisiotomy findings. Treatement: regimen of sitz baths several times a day is encouraged in the immediate postpartum period. • Dyspareunia may be a complaint of some women for up to 3 months postpartum. • Infection can be one of the most serious complications of episiotomy

  12. Birth • Delivery of head - CONTROL head to prevent explosive delivery and subsequent tearing • Check for presence of cord around neck • Aspirate oral and nasal cavities with bulb syringe • Deliver anterior shoulder with downward pressure • Complete delivery and HANG ON TO BABY!

  13. Birth • Clear airway, Assess respirations, Resuscitate if necessary • Clamp cord when pulsations cease • Leave 3 - 6 inches of cord on baby • Obtain blood for fetal labs from the placental stub of cord

  14. Immediate care of the newborn • Reassess Airway and Respirations • Keep warm and dry • Allow for maternal bonding • Stimulation of nipples during attempts at breastfeeding will aid in release of oxytocin by posterior pituitary gland resulting in uterine contraction and hemorrhage control

  15. APGAR SCORE • Taken at 1 minute and 5 minutes after delivery • Score of zero to two is given for each category • The higher the score, the more vigorous and “healthy” the child is considered to be

  16. APGAR SCORE • APPEARANCE: • 2: Completely Pink • 1: Hands and Feet are blue • 0: Paleness and blue color over entire body • PULSE: (most important sign) • 2: Greater than 100 BPM • 1: Detectable rate below 100 BPM • 0: No heart rate detected

  17. APGAR SCORE • Muscle tone: (flexing and muscle tone of limbs and resistance to straightening) • 2: Normal muscle tone • 1: Limp to normal muscle tone • 0: No resistance to straightening • ACTIVITY: (response to irritation) • 2: Infant cries in response to flick • 1: Weak cry or head movement in response • 0: No response

  18. APGAR SCORE • RESPIRATORY: (Second most important) • 2: Regular respirations and vigorous cry • 1: Weak cry • 0: No respiratory response • Scoring: • 7 to 10 provide supportive care • 4 to 6 indicates moderate depression • < 4 requires aggressive resuscitation

  19. Delivery of the placenta • Delivery of the placenta can be accomplished by either expectant or active management of the third stage of labor. • Normally, the placenta separates spontaneously from the uterine wall within approximately 5 minutes of delivery, but may take as long as 20 to 30 minutes. No attempt should be made to extract the placenta before its separation.

  20. Signs of separation • Uterus rises to become globular • Increase (gush) of blood from vagina • Lengthening of cord • The fundus changing to a firm consistency

  21. Expectant management of third stage of labor: • Do not PULL cord. Apply gentle traction • Check Placenta for completeness • Check the cord for 3-vessels, 2 small arteries and one larger vein • Recover missing pieces of placenta as necessary • Massage uterus to aid in hemostasis • IV Oxytocin can be given if available to aid uterine contractions and aid in hemostasis

  22. Assess any perineal trauma: • Firm fundus with bright- red blood trickling: laceration • Boggy fundus with red blood flowing: uterine atony • Boggy fundus with dark blood clots: retained placenta.

  23. Active Management • After delivery of the anterior shoulder, or immediately after birth of the infant, give the patient an oxytocic drug to stimulate uterine contraction. • Clamp and cut the cord. • Wait for a strong uterine contraction and then apply controlled cord traction while applying counter traction above the pubic bone. • If the placenta is not delivered, wait until the next contraction.

  24. Advantages of active management of the third stage • Decrease the length of third stage • Decrease maternal blood loss • lower risk for postpartum hemorrhage and postpartum anemia, and decreased need for transfusion.

  25. Disadvantages • Increased incidence of nausea, vomiting, and headache. • Hypertension is also increased if an ergometrine is used

  26. Manual Extraction • Indications: If the placenta has not delivered after 30 minutes if separation has occurred without delivery of the placenta Purpose: to reduce excessive blood loss. Alternative: Injection of oxytocin into the umbilical vein. Complication: Intrauterine bacterial contamination, but is not a common complication.

  27. Active Prophylaxis against Postpartum Atony • Gentle but firm external fundal message should always be part of postpartum management. • oxytocin agent either IM with the delivery of the anterior shoulder (10 U oxytocin) or in IV drip after the delivery of the placenta (20 U in 1,000 ml of 5% dextrose in water at 100 drops per minute). • Side effect: marked hypotension if administered as an intravenous bolus.

  28. Active Prophylaxis against Postpartum Atony • Methylergonovine maleate (Methergine), 0.2 mg intramuscularly, often produces sufficient uterine contractility to correct atony. • contraindicated in patients who are hypertensive (hypertension may be aggravated), and should be avoided as well in patients who are hypotensive • Side effect: peripheral vasoconstriction in a patient in hypovolemic shock may result in digit loss secondary to vascular insufficiency.

  29. Management of the fourth stage of labor: • Assess V/S Q 15 min. • Assess fundal height, position, and firmness Q15min. • Assess the perenium and episiotomy • Assess the woman comfort • Assess lochia

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