2nd stage of labour

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It includes  EVENTS  CLINICAL COURSE  MANAGEMENT of 2 nd stage of labour


EVENTS in 2 nd stage of labour Begins with complete dilatation of cervix and ends with expulsion of fetus. This stage is concerned with descent ,delivery of fetus through birth canal. It has 2 phases propulsive phase expulsive phase


PROPULSIVE PHASE It is from full dilatation until head touches the pelvic floor. EXPULSIVE PHASE Its the time the mother has irresistable desire to “BEAR DOWN” and push until the baby is delivered.


DELIVERY OF THE FETUS It is accomplished by downward thrust offered by uterine contractions Voluntary contractions of ABD muscles. There is always tendency to push the fetus back into the uterine cavity by elastic recoil of tissues of vagina pelvic floor. This is effectively counterbalanced by power of uterine retractions .


Thus with increasing contractions and retractions the upper uterine segment becomes more thicker while the lower is becomes thinner. Endowed with the power of retractions the fetus is gradually expelled from the uterus against the resistance offered by pelvic floor. The expulsive force of uterine contractions is added by voluntary contractions of ABD muscles BEARING DOWN efforts


CLINCAL COURSE It includes Pain Bearing down efforts Status of Membranes Descent of fetus Vaginal examination Maternal and fetal signs


PAIN intensity increases gradually comes at an interval of 2-3min lasts for about 1-2min 2.BEARING DOWN EFFORTS Its an additional voluntary expulsive effort appear during Expulsive Phase Exerted by Abd . Muscles Initiated by Nerve reflex. Set ups due to stretching of vagina by presenting part Starts spontaneously with full dilatation of cervix Pre mature Bearing Down efforts suggests uterine dysfunction and slowing of FHR


Membranes are ruptured There is a gush of liquor amnii per vaginum Rupture may delayed sometimes till the head bulges out through Introitus Sometimes rupture may nt occurs at all and it leads to the baby “BORN IN A CAUL” DESCENT OF FETUS Features of fetal descent are evident from vaginal and abd . examainationsSTATUS OF MEMBRANES STATUS OF MEMBRANES


ABDOMINAL FINDINGS Progressive descent of head in relation to Brim Rotation of Ant.shoulder to midline Change in position of FHR FHR shifted downwards and medially VAGINAL FINDINGS Descent of head in relation to ischial spines Gradual rotation of head evidenced by position of sagittal suture and occiput in relation to quadrants of pelvis


VAGINAL SIGNS Distention of perinium due to descent of head vulval opening looks like slit through scalp hair is visible During each contraction perinium markedly distended Overlying skin becomes tense, glistening. Vulval opening becomes circular. Adjoining anal sphincter stretched. The max dia. of head[ biparietal ] stretches vulval outlet this is called crowning of head. After little pause the bearing down efforts expels the shoulders and trunk of fetus. Immediatly a gush of liquor [hind water] flows out often which is blood tinged.


MATERNAL SIGNS Features of exhaustion Decreased respiration Increased perspiration During bearing down efforts face is congested and neck veins are prominent Immediatly after expulsion of fetus the mother have a sigh of relief. FETAL EFFECTS Slowing of FHR during contraction Which becomes back to normal before next contraction.


MANAGMENT PRINCIPLE To assist normal expulsion of fetus, slowly and steadily. To prevent perineal injuries. GEN.MEASURES Pt should be in bed Constant supervision Record FHR for each 5min Administrate inhalational analgesics Vaginal examination- to detect cord prolapse


PREPARATION FOR DELIVERY POSITION Lateral or partial sitting Dorsal position with 15dgre lateral tilt it is the most commonest position it avoids aorto-caval compression Facilitates pushing effects Sterile gowns, masks, gloves and stands on right side of table.


ASEPTIC PROCEDURES It includes 3“C”s Clean hands Clean surface Clean cutting and ligation of cord Catheterize the bladder if it is full .


CONDUCTION OF DELIVERY It includes 3 phases Delivery of head Delivery of shoulders Delivery of trunk DELIVERY OF HEAD PRINCIPLES to be followed are Maintain flexion of head Prevent its early extension Regulate its slow escape out of vulval outlet


Pt is encouraged for bearing down efforts during uterine contractions. it facilitates descent of head. When scalp is visible for about 5cm in Dia. flexion of head is maintained during contraction This process is repeated during subsequent contractions until the sub- occiput is placed under symphysis pubis. At this stage the Max Dia. of head stretches the vulval outlet


When perineum is fully stretched and threatens to tear especially in primi gravidae Episiotomy is done at this stage by 10ml of 1% lignocaine Slow delivery of head in between contractions is to be regulated. This is done when sub- occipitofrontal dia. is emerges out.


CARE FOLLOWING DELIVERY OF HEAD Mucus and blood sucked from the mouth and pharynx. Eyelids are whiped with sterile cotton swab Palpate the neck to exclude any loop of cord TO PREVENT PERINEAL LACERATIONS Delivery by early extension is to be avoided Spontaneous forcible delivery of head is to be avoided To deliver head in between contractions Perform timely episiotomy Take care during delivery of shoulders


DELIVERY OF SHOULDERS Not to be hasty to deliver shoulders Wait for uterine contractions Movements of restitution and Ext. rotation of head Traction on head should be gentle to avoid excessive stretching of neck causing injuries to brachial plexus neck haematoma # of clavicle


DELIVERY OF TRUNK After delivery of shoulders the fore fingers of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion


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