MANAGEMENT OF SECOND STAGE OF LABOR IN ENGLISH
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MANAGEMENT OF SECOND STAGE OF LABOR-
The transition from the
first stage to the second stage is evidenced by the following features:
Ø Increasing intensity of uterine contractions
Ø Bearing-down efforts
Ø Urge to push or defecate with descent of the
presenting part
Ø Complete dilatation of the cervix as
evidenced on vaginal examination
Ø The patient should be in bed.
Ø Constant
supervision is mandatory and the FHR is recorded at every 5 minutes.
Ø Vaginal
examination is done at the
beginning of the second stage not only to confirm its onset but to detect any
accidental cord prolapse.
Ø The position and the station of the head are
once more to be reviewed and the progressive descent of the head is ensured.
Ø Provide
proper Position: Positions
of the woman during delivery may be lateral, squatting or partial sitting (45°).
Dorsal position with 15° left lateral tilt is commonly favored as it avoids
aortocaval compression and facilitates pushing effort.
Ø Proper
scrubing should be done and
puts on sterile gown, mask and gloves and stands on the right side of the
table.
Ø Prparation
of external genitalia and
inner side of the thighs is done with cotton swabs soaked in Savlon or Dettol
solution.
Ø One
sterile sheet is placed beneath the buttocks of the patient and one over the
abdomen.
Ø Sterilized leggings are to be used.
Ø Essential aseptic procedures are
remembered as 6 Cs:
(a) Clean hands,
(b) Clean mother,
(c) Clean delivery surfase,
(d) Clean cutter ,
(e) Clean cord tie and
(f) Clean cord stump
Ø catheterize
the bladder, if it is full.
Ø The patient is encouraged for the
bearing-down efforts during uterine contractions. This facilitates descent of
the head. When the scalp is visible for about 5 cm in diameter, flexion of the
head is maintained during contractions.
Ø Flexion
of head is maintained by
pushing the occiput downward and backward by using thumb and index fingers of
the left hand while pressing the perineum by the right palm with a sterile
vulval pad.
Ø The process is repeated during subsequent
contractions until the subocciput is placed under the symphysis pubis.
Ø At this stage, the maximum diameter of the
head (biparietal diameter) stretches the vulval outlet without any recession of
the head even after the contraction is over, and it is called “crowning of
the head”
Ø The purpose of increasing the flexion of the
head is to ensure that the small suboccipitofrontal diameter 10 cm (4")
distends the vulval outlet instead of larger occipitofrontal diameter 11.5 cm
Ø When the perineum is fully stretched and
threatens to tear especially in primigravidae, episiotomy is done at this stage
after prior infiltration with 10 mL of 1% lignocaine.
Ø Slow delivery of the head in between the
contractions is to be regulated. This is done when the suboccipitofrontal
diameter emerges out. This is accomplished by pushing the chin with a sterile
towel covered fingers of the right hand placed over the anococcygeal region
while the left hand exerts pressure on the occiput
Ø The forehead, nose, mouth and the chin are
thus born successively over the stretched perineum by extension.
Ø Immediately following delivery of the head,
the mucus and blood in mouth and pharynx are to be wiped with sterile gauze
piece on a little finger.
Ø mechanical or electrical sucker may be used.
This simple procedure prevents the serious consequence of mucus blocking the
air passage.
Ø The eyelids are then wiped with sterile dry
cotton swabs using one for each eye starting from the medial to the lateral
canthus to prevent eye infection.
Ø The neck is then palpated to exclude the
presence of any loop of cord round the neck.
Ø If it is found and if loose enough, it should
be slipped over the head or over the shoulders as the baby is being born. But
if it is sufficiently tight enough, it is cut in between two pairs of Kocher’s
forceps placed 1 inch apart.
Ø Delivery of the shoulders: Not to be hasty in
delivery of the shoulders. Wait for the uterine contractions to come and for
the movements of restitution and external rotation of the head to occur
Ø During the next contraction, the anterior
shoulder is born behind the symphysis. If there is delay, the head is grasped
by both hands and is gently drawn posteriorly until the anterior shoulder is
released from under the pubis. By drawing the head in upward direction, the
posterior shoulder is delivered out of the perineum
Ø Delivery of the trunk: After the delivery of
the shoulders, the fore finger of each hand are inserted under the axillae and
the trunk is delivered gently by lateral flexion
Ø Soon after the delivery of the baby, it
should be placed on a tray covered with clean dry linen with the head slightly
downward (15°).
Ø The tray is placed between the legs of the
mother and should be at a lower level than the uterus to facilitate
entry of more blood from the placenta to the infant by gravity.
Ø Air
passage (oropharynx) should be cleared of mucus and liquor by gentle suction.
Ø Apgar
rating at 1 minute is to be recorded.
Ø Delay
in clamping for 2–3 minutes
or till cessation of the cord pulsation facilitates transfer of 80–100 mL blood
from the compressed placenta to a baby when placed below the level of uterus.
Ø The cord is clamped by two Kocher’s forceps,
the near one is placed 5 cm away from the umbilicus and is cut in between.
Ø Two separate cord ligatures or plastic cord
clamps are applied 1 cm apart proximal one being placed 2.5 cm away from the
navel.
Ø The
cut end is then covered with sterile gauze piece after making sure that there
is no bleeding.
Ø A quick check is made to detect any gross
abnormality and the baby is wrapped with a dry warm towel. The identification
tape is tied both on the wrist of the baby and the mother
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