The Care of Woman

during the Second Stage

of Labor

The second stage of labor is the time from full cervical

dilation to birth of the newborn.
 Even a woman who have taken childbirth
education classes and who believe they
are well prepared for any length or type of
contraction are surprised at the intensity
of the pushing sensation they feel in this
stage of labor. Because the feeling to push
becomes so strong, some women react to
this by growing argumentative and angry,
or by crying and screaming.

 If the woman has not received an epidural

for pain management, she should push
with contractions and rest in between.

 Also, encourage a woman to assume any

position that is comfortable for them and
breathe any way that is natural for them,
except holding their breath while they
push, because holding the breath for
prolonged time, impairs blood return from
the vena cava (a Valsalva maneuver)
 A support plays a vital role during second stage
labor because all the preparations done up to this
point may still not be enough to sustain a woman
during these final contractions unless she feels well
supported.

Women need to have an experienced healthcare

person with them as they enter this stage of labor to
reassure them that the change of contraction is
normal and to give knowledgeable support everything
is all right.
A general timetable for second stage care is shown in BOX 15.7
 •Be certain to assess fetal heart sound at the beginning pf the second stage to be certain
the start of the baby’s passage into the birth canal is not occluding the cord and
interfering with fetal circulation.
 •Assisting a woman into whatever position she feels will be most effective for pushing (eg
squatting, sitting upright, leaning forward against her partner) to help align the fetal
presenting part with the cervix, increase pelvic diameter, and use the fetal weight to help
descent so that a prolonged second stage does not occur.
 •A danger of a prolonged second stage is chorioamnionitis (Membrane infection),
increase rate of cesarean birth, and future urinary incontinence.
  •For multipara, convert a birthing room into a birth room by
opening sterile packs of supplies on waiting tables when the
cervix had dilated.
 •Be certain drape and materials used for birth are sterile so no
microorganism can be accidentally introduced into the uterus.
 •A table arranged with equipment such as sponges, drapes,
scissors, basins, clamps, vaginal packing sterile gown, gloves, and
towels can be left, if covered, for up to 8 hours.
 •A birthing bed is “broken “or the foot folded down to allow the
primary care provider ready access to support a crowning

PREPARING 
newborn head.
•Be certain that once a bed is broken, some remains continuously
at the foot of the bed so is the fetus is born suddenly, the head
THE PLACE and body can be supported and born safely.
 •Some providers do not choose to “break the bed”, instead will
OF BIRTH accommodate the woman according to her birthing position of
choice, whether be side-lying, hands and knees, standing or on a
birthing stool.
 •To provide for baby care, open the partition at the end of the
room to reveal the “baby island”, or newborn care area. Such area
includes a radiant heat warmer, equipment for suction and
resuscitation, supplies for eye care and identification of the
newborn.
 •Turn on the radiant heat warmer in advance, so the bottom
mattress is pleasantly warm to the touch at the time of the birth.
 •Place sterile towel s and blankets on the warmer so they will also
be warm when use to dry and cover the infant to help prevent
hypothermia.
  LITHOTOMY POSITION
POSITIONING  LATERAL OR SIMS POSITION
 DORSAL RECUMBENT POSITION
FOR BIRTH  SEMI- SITTING OR SQUATING
LITHOTOMY
 Was the preferred position for
POSITION birth because its offers a clear
view of the perineum.
LATERAL OR • The side-lying position is especially useful in
promoting rest and relaxation between pushing
SIMS contractions.
• Some research suggests that this is the most
POSITION effective birthing position for preventing tears.
 DORSAL
RECUMBENT • Dorsal Recumbent position, the
POSITION patient lie down on bed with
knees bended and feet are flat on
(ON THE the surface of bed along with face
looking upward. In this position,
BACK WITH the examination of pelvic region
becomes easy.
KNEES
FLEXED)
 SEMI-
SITTING OR • An upright squatting position is good for pushing
and can be adopted if you have firm support from
SQUATING your partner. He can support you under the arms
while you put your hands around the back of his
neck.
 POSITIONING FOR BIRTH

 LATERAL OR SIMS POSITION

 DORSAL RECUMBENT POSITION
 SEMI- SITTING OR SQUATING
• Using these position plus warm compresses to the
perineum place less tension on the perineum and
result in fewer perineal tears
 • Women may not only use a warm water tub for
THE WATER labor comfort and relaxation but also give birth
under water. The increased bouncy they feel
BIRTH from the water helps them change position
easily, a sitting posture help with fetal descent.
 PROMOTING EFFECTIVE SECOND STAGE OF
PUSHING

 Pushing during second stage of labor, a woman should

wait to feel the urge to push even though a pelvic exam
has revealed she fully dilated.

 Pushing is usually best done from semi- fowler position

which legs raised against the abdomen, squatting, or on
all four rather lying flat to allow gravity to aid the effort .
 PROMOTING EFFECTIVE SECOND STAGE OF
PUSHING

 A mother can use the short and long push.

 Holding a breath during contraction could cause
Valsalva maneuver.
 Ask her pant with contraction .
 Demonstrating panting with her may be most
effective.
 Be sure she inhaling adequately with panting.
PERINEAL CLEANING AND MASSAGE
• Massaging perineum as the fetal
head enlarges the vaginal opening
helps to keep it supple and prevent
tearing.

When you should NOT do it?

• If you have placenta previa (a low–
lying placenta) or any other
condition where there is bleeding
from the vagina during the second
half of pregnancy.
• If you are suffering from vaginal
herpes, thrush or any other vaginal
infection, as massage could spread
the infection and worsen the
condition.
ADVANTAGES
• It increases the elasticity (stretchiness) of the perineum. It improves the perineum’s
blood flow and ability to stretch more easily and less painfully during the birth of
your baby.
• Tears in the perineum are less likely and you are less likely to need an episiotomy.
This is a cut to the perineum that is sometimes performed to speed up the birth of
your baby or to try to prevent a more severe tear.
• It helps you focus on the feeling of letting your perineum open up.

• Your perineum is less likely to be painful after the birth of your baby.

• It can be particularly helpful if you have previous scar tissue or a rigid perineum,
which can occur in some horse riders or dancers. But all women can benefit from
doing perineal massage.
Procedure for massaging Perineum

• Get comfortable and relaxed in a place where you feel safe, secure and will not be
interrupted.
• You might find it easier to use a mirror for the first few tries, to help you see what you are
doing.
• Put a water-soluble lubricant, or natural oil like olive or coconut oil, on your thumbs and
the perineum.
• Place thumbs just inside the vagina to a depth of three to five centimeters. Gently press
downward towards the rectum and to the sides of the vagina at the same time to stretch
the opening, until a very slight burning, stinging, or tingling sensation is felt.
• Work the lubricant in slowly and gently, maintaining the pressure and pulling the perineum
forward a little as you sweep your thumbs from side to side of the vagina in a ‘U’ shaped
motion for approximately two to five minutes.
• The massage can be done in one direction at a time i.e. from side to side, or the thumbs
can be swept in opposite directions.
• Try different ways until you find which is more comfortable for you.
• Focus on relaxed breathing while trying to consciously relax the pelvic floor muscles and
allowing the tissues to stretch.
• Relax and repeat once. For most benefit, aim for a massage every day or every other day.
 • To remove vaginal or rectal secretions and
prepare the cleanest environment for the
birth of the baby, the care provider may clean
the perineum.

EQUIPMENT:
• STERILE GLOVES
PERINEAL • STERILE SMALL BASIN

CLEANING • 6 (5) CHERRY BALLS

• 7.5 % BETADINE SOLUTION
• RING OR PICKUP FORCEPS
• TRAY
• (PREP KIT IF AVAILABLE)
 • EXPLAIN THE PROCEDURE TO THE PATIENT.
• PERFORM HAND HYGIENE PRIOR TO ANY
CONTACT WITH THE PATIENT.
• EXPOSE ONLY THE AREA TO BE PREPPED
TO ENSURE PRIVACY AND WARMTH OF THE
PROCEDURE PATIENT.
• TUCK DRIP TOWEL OR DRAPE UNDER THE
PATIENT PERINEAL AREA
• DON STERILE GLOVES
• POUR THE BETADINE TO THE BOWL AND
DIP OR SOAK THE CHERRY BALLS
• PERFORM APPLICABLE PERINEAL SKIN
PREPARATION TECHNIQUES .
The pattern for cleaning the Perineum
THE BIRTH
• As soon as the head of a
RITGEN MANUEVER
fetus is prominent
(approximately 8cm across)
at the vaginal opening, one
technique to help the fetus
achieve extension and
allow the smallest head
diameter to present is for
the care to place sterile
towel over the rectum and
press forward on the fetal
chin while the other hand
presses downward on the
occiput.
 The woman is asked to continue pushing until the occiput of the fetal head
is firmly at the pubic arch. The head is then gently born between contractions if
possible.

This helps to:

• Prevent the head from being expelled too rapidly
• Creating a major pressure change in the skull
• Reduces the possibility of a perineal tear.

Immediately after birth of the baby’s head, the primary care provider passes
his or her fingers around the newborn’s neck to determine whether a loop of
umbilical cord is encircling the neck.

• If such a loop is felt, it is gently loosened and drawn down over the fetal head.
• If is too tightly coiled to allow this, it is clamped and cut before the shoulders are
born.
• Instruct the mothers to focus on
her breathing. Having her “breathe
heavily” to help her stop pushing
and prevent a forceful birth.
• Ask the woman to pant or give
only small pushes with
contractions as the baby’s head
delivers.
• Continue to gently support the
perineum as the baby’s head
delivers.
• Once the baby’s head delivers, ask
the woman no to push.
• Suction the baby’s mouth and
nose
After expulsion of the fetal head,
external rotation occurs or turn to
one side.
• Gentle pressure is then exerted
downward on the side of the
infant’s head by the primary care
provider, so the anterior shoulder
is born.
• Slight upward pressure on the side
of the head allows the anterior
shoulder to nestle against the
symphysis pubis and the posterior
shoulder to be born.
• The remainder of the body then
slides free without any further
difficulty.
• A child is considered born
when the whole body is born.

• The newborn is immediately

laid on the mother’s naked
abdomen and covered with a
warmed blanket and cap to
conserve heat and encourage
mother-infant bonding
 •Cutting the cord is part of the
CUTTING stimulus that initiates a first
breath or marks the newborn's
AND most important transition into the
outside world.
CLAMPIN •The timing of cord clamping,
G THE however, varies depending on the
parent's preference and the
CORD maturity of theinfant.
The umbilical cord continues to pulsate for a few minutes after birth and then the
pulsation ceases.

Delaying cutting (also called physiologic clamping) until pulsation ceases and
maintaining the infant at a uterine level allows as much as 100 ml more of blood to
pass from the placenta into the fetus than if the infant were held in a superior
position or the cord was immediately cut.

Delaying cutting therefore helps ensure an adequate red blood cell and white cell
count in the newborn

The timing of cord clamping is individualized because late clamping of the cord this
way could cause over infusion with placental blood and the possibility of
polycythemia and hyperbilirubinemia in a susceptible newborn, a particular concern
if the infant is preterm.
Before cutting, the cord is clamped with two
hemostats placed 8 to 10 in. from the infant's
umbilicus.
The woman's partner or support person may then
have the privilege of cutting the cord between the
hemostats.

 A cord blood sample is often obtained to provide a

ready source of infant blood if blood typing or
other emergency measures,
Such as establishing whether fetal acidosis was
present
Blood may also be taken for cord blood banking, so
the family has stem cells available if needed in the
future.
The vessels in the cord
are then counted to be
certain three are
present and an
umbilical clamp is
applied to replace the
forceps (Fig. 15.28).

Some umbilical clamps

in hospitals have an
alarm attached that will
ring if the infant is
taken further than set
hospital boundaries, a
precaution against
newborn
abduction.
INTRODUCING THE INFANT

After the cord is cut, it is time for the new parents to spend quality
time with their newborn. The infant can remain on the mother's
abdomen for skin-to-skin contact.

• If the woman's partner or support person wants to hold the infant

• dry the infant well with a warmed towel
• wrap him or her in a sterile blanket,
• and cover the head with a wrapped towel or cap.
• Be certain to handle newborns gently but firmly as they are
slippery from amniotic fluid and vernix.
Most newborns receive prophylactic eye
ointment against the possibility of a
chlamydia infection.

Don't administer this until after the

parents have had this chance to see their
infant for the first time (and the infant has
had a chance to see them)

This initial contact is also the optimal time

for a mother to begin breastfeeding
because an infant seems to be hungry at
birth and sucking at the breasts stimulates
the release of endogenous oxytocin
THANK YOU!!!