MID2003 SECOND STAGE OF LABOUR

Flashcards for the second stage of labor and perineal care during childbirth.

Second Stage of Labour

From full cervical dilatation to the birth of the baby with two phases: Passive (latent) and Active.

Signs of onset of second stage

• absence of palpable cervix (10cm dilated)

• birth

• urge to push

Passive Second Stage of Labour

Full dilatation of the cervix prior to, or in the absence of, involuntary expulsive contractions.

Active Second Stage of Labour

Commencement of pushing until birth of the baby.

Spontaneous Pushing

Supporting the woman to follow their own instincts in response to optimal physiological descent.

Directed Pushing (Valsalva Manoeuvre)

Asking the woman to take a deep breath at the start of a contraction, and hold the breath while pushing as long and as hard as possible.

Maternal observations during 2nd stage

15 minutely

• maternal pulse

½ hourly

• uterine activity

• PV loss

• maternal position

• progress and descent of presenting part

hourly:

• blood pressure

• temp

• RR

• abdo palp

Neonatal observations during 2nd stage

passive phase

• FHR every 15 minutes

active phase

• FHR every 5 minutes or after each contraction

Ongoing bladder care

• encourage regular voiding 2-3 hrs

• deflating idc balloon if in situ

Nuchal Cord

Cord around the baby's neck at birth, present in 10-37% of births.

Water Immersion

The use of breast deep, warm bath or pool water as a form of relaxation and/or pain relief in labour.

Water Birth

The birth of a baby directly into the water while the mother remains submerged.

Benefits of water immersion

• calming and relaxing

• feeling of weightlessness can relieve pressure on joints

Water immersion with pain reduction

• hydrothermic effect - heat from warm water leads to peripheral vasodilation which releases muscle spasms to reduce pain

• hydrokinetic effect - feeling of weightlessness can relieve and become less anxious

Pelvic Floor

The soft tissues that hold the pelvic organs in position, consisting of 6 layers of tissue.

Anatomy of the pelvic floor

The anatomy of the pelvic floor includes muscles, ligaments, and connective tissues that support the bladder, bowel, and uterus or prostate. It plays a crucial role in urinary and fecal continence, as well as sexual function.

Perineal Body

Triangular structure located between the lowest part of the introitus and the anus (also known as the perineum), controls defaecation and childbirth

Effects of pregnancy on the pelvic floor

• hormonal changes - high levels of progesterone reduces the tone of the smooth muscle

• connective tissue changes - relaxin softens connective tissue

• physical tissue - uterus displaces and distorts bladder

Effects of birth on the pelvic floor

• muscular, nerve and connective tissue damage

• resulting in incontinence or pelvic organ prolapse.

First Degree Perineal Tear

Tear in the skin and underlying superficial tissue (not muscle).

Second Degree Perineal Tear

Involves the perineal muscles but not the anal sphincter.

Third Degree Perineal Tear

Involves all tissues above & the anal sphincter.

Fourth Degree Perineal Tear

Involves the perineal structures, EAS, IAS and rectal mucosa.

Maternal risk factors associated with severe perineal trauma

• nullipara

• ethnicity (asian/indian births)

• VBAC

• under 20yrs of age

• short perineal length

• previous 3rd/4th degree tear

Fetal risk factors associated with severe perineal trauma

• large baby over 4kg or large head

• shoulder dystocia

Intrapartrum risk factors associated with severe perineal trauma

• instrumental birth (forceps or vacuum)

• prolonged 2nd stage (over 60mins)

• epidural

• midline episiotomy

• oxytocin use

• position (lithotomy or deep squatting)

Indications for episotomy

• if risk for 3rd or 4th degree tears

• instrumental births

• fetal indications like abnormal ctg

Immediate care post birth for all women

• assess bleeding and extent of trauma

• provide supportive care and pain management

• monitor vital signs and fetal well-being

• initiate breastfeeding and skin-to-skin contact

Antenatal Perineal Massage - antenatal practice to reduce perineal trauma

The practice of massaging the perineum in the antenatal period using different lubricants and oils.

Perineal Dilators - antenatal practice to reduce perineal trauma

An inflatable silicone balloon inserted in the vagina to stretch the perineum.

Hands-on Technique (Perineal) - intrapartum practice to reduce perineal trauma

The perineum is supported with the dominant hand, applying counter-pressure with the non-dominant hand.

Warm Compress (Perineal) - intrapartum practice to reduce perineal trauma

Applying a warm compress to the perineum when the head is crowning.

Maternal position - intrapartum practice to reduce perineal trauma

Different positions during labor that can optimize fetal positioning and reduce the risk of perineal injury.