SEMINAR ON SECOND STAGE OF LABOUR

SUBMITED TO SUBMITTED BY

JYOTHI K DIVAKARAN AISWARYA S KUMAR

ASST PROFESSOR 1ST YEAR MSC.NURSING

GCON GCON

INTRODUCTION

Normal labour and delivery is a physiologic process in which the attendant closely monitor

the woman and fetus, with little medical Intervention required.

SECOND STAGE OF LABOUR / PUSHING STAGE / PELVIC STAGE

It begins with full cervical dilatation (10cm) till the birth of the baby.

DURATION :

Primi gravida - 2 hours.

Multi gravida - 30 minutes.

In a woman of higher parity with a previously dilated vagina and perineum, two or three expulsive efforts after full cervical dilatation may suffice to complete delivery.

Conversely, in a woman with a contracted pelvis or a large fetus or with impaired expulsive efforts from conduction analgesia or sedation, the second stage may become abnormally long.

RECOGNITION OF COMMENCEMENT OF II STAGE OF LABOUR

Expulsive uterine contraction

Rupture of the fore waters

Dilatation and gaping of anus

Appearance of present part

Congestion of the vulva

Show

PHASES OF SECOND STAGE OF LABOUR

Have 3 phases

* Latent phases / Propulsive phase

* Active phases / Expulsive phase

*Transition phases / Compulsive phase

LATENT PHASES / PROPULSIVE PHASE :

Descend of the fetus 2 cm below from the os to the pelvic floor .

ACTIVE PHASES / EXPULSIVE PHASE :

Descend of the fetus from the os 2cm below to the vaginal outlet ( Crowning )

Ferguson reflux : Pressure exerted by the presenting part over the cervix causing involuntary

uterine contraction

TRANSITION PHASES / COMPULSIVE PHASE :

Birth of the baby from the vaginal outlet till extension .

1.Latent phase

-Is a period of rest and relative calm

-Fetus continues to decent passively through the birth canal and rotate to anterior position as result Uterine contraction

- Woman is quiet and relax with her eyes closed between contractions.

- The urge to bear down is not well established and my not be experienced at all or only during the peak of contraction

2. Descent phase (active pushing)

- Strong urges to bear down as ferguson reflex is activated when the presenting part presses on the stretch receptor of the pelvic floor, the fetal station 1+, position is anterior.

3. Transition phase

- The presenting part on the perineum

- Bearing down is more effective for promoting birth

- woman more verbal about pain, she may scream or swear and may act out of control

PHYSIOLOGY OF II STAGE OF LABOUR

I Uterine action

Contraction becomes stronger, longer but less frequent.

Membranes rupture spontaneously.

Consequent drainage of liquor allows the hard, round fetal head to be directly applied to the vaginal tissues and aid distension.

Fetal axis pressure increasing the flexion of the head which results in smaller presenting diameter ,more rapid progress and less trauma to both mother and fetus.

Expulsive contraction.

Compulsive contraction

Involuntary uterine contraction.

II Soft tissue displacement :

As the hard fetal head descend, the soft tissue of the pelvis become displace.

Anteriorly the bladder is pushed upwards into the abdomen which cause stretching and thinning of the urethra.

Posterioly the rectum becomes flattened into the sacral curve and the pressure of the advancing head expels any residual faecal matter.

Laterly the Levator ani Muscles dilate and thins out and perineal body is flattened ,displaced ,stretched and thinned.

Duration

The duration of 2nd stage of labor is influenced by several factors :

1. Effectiveness of the primary and secondary powers of labor

2. Type and amount of analgesia used

3. Physical and emotional condition

4. Position, activity level, parity

5. Pelvic adequacy of the laboring woman (size, presentation, position of the fetus)

6. Nature of support the woman receives

If the woman has been given epidural analgesia pushing can last more than 2hrs, anaglesia reduce the urge bear down and limits the woman’s ability to attain an upright position to push

-Commonly 2nd stage of more than 2hrs may be consider prolonged in woman without analgesia and is reported to the primary of health care provider using assessment to FTR and pattern, decent of the presenting part, quality of UT contraction and the status of the woman.

- premature interventions with episiotomy or forceps or vacuum assisted birth can be avoided.

MECHANISM OF NORMAL LABOUR / CARDINAL MOVEMENTS OF LABOUR

DEFINITION

As the fetus descends, soft tissue and bony structures exert pressures which force the fetus to negotiate the birth canal by a series of passive movements collectively known as Mechanism of labor.

PRINCIPLES

Descent takes place throughout the labor.

Whichever part leads and first meets resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis.

Whatever emerges from the pelvis will pivot around the public bone.

CHARECTERISTICS

Lie is longitudinal

Attitude is one of good flexion

Presentation is cephalic presentation

Position is right or left occipito anterior

Denominator is the occiput

Presenting part is the posterior part of the anterior parietal bone

Occiput pointing left / right ileo pectinal eminence

Sagital sutures lies on right / left oblique diameter

Presenting diameter is suboccipito frontal 10cm

CARDINAL MOVEMENTS

1) Descend

2) Flexion

3) Internal rotation of the head

4) Extension of the head

5) Restitution

6) Internal rotation of the shoulder

7) External rotation of the head

8)Lateral flexion of the body

1) Descend:

Descent is brought about by the force of the uterine contractions, maternal bearing-down (Valsalva) efforts, and, if the patient is upright, gravity.

In primi gravida it occurs during latter weeks of pregnancy

It will be aided by

Forces of uterine contraction and retraction

Rupture of fore waters

Full cervical dilatation

Maternal efforts speeds progress

Slope of the pelvic floor muscle

2) Flexion:

FLEXION. Partial flexion exists before labor as a result of the natural muscle tone of the fetus. During descent, resistance from the cervix, walls of the pelvis, and pelvic floor cause further flexion of the cervical spine, with the baby's chin approaching its chest.

In the occipitoanterior position, the effect of flexion is to change the presenting diameter from the occipitofrontal to the smaller suboccipitobregmatic.

In the occipitoposterior position, complete flexion may not occur, resulting in a larger presenting diameter, which may contribute to a longer labor.

This increases throughout the labor

Because of uterine contraction, fetal axis pressure will be exerted more on the occiput than the sinciput causing good flexion

Because of flexion the suboccipito frontal 10cm is reduced into suboccipito bregmatic 9.5cm

The occiput is the leading part

2) INTERNAL ROTATION.

In the occipitoanterior positions, the fetal head, which enters the pelvis in a transverse or oblique diameter, rotates so that the occiput turns anteriorly toward the symphysis pubis. Internal rotation probably occurs as the fetal head meets the muscular sling of the pelvic floor.

It is often not accomplished until the presenting part has reached the level of the ischial spines (zero station) and therefore is engaged.

In the occipitoposterior positions, the fetal head may rotate posteriorly so the occiput turns toward the hollow of the sacrum. Alternatively, the fetal head may rotate more than 90 degrees, positioning the occiput under the pubic symphysis and thus converting to an occipitoanterior position

4)CROWNING

The occiput slips beneath the sub-pubic arch and crowning take place

The presenting part engages the vaginal outlet and it will not recede backward.

The sub-occipito bregmatic diameter 9.5cm distends the vaginal outlet.

Occurs when the largest diameter of the fetal head is encircled by the vulvar ring.

At this time, the vertex has reached station +5. When necessary, an incision in the perineum (episiotomy) may aid in reducing perineal resistance, although current management is to allow the fetus to deliver without an episiotomy.

5) INTERNAL ROTATION OF THE HEAD:

Because of gutter – shaped and slope of pelvic floor gives resistance

The slope of the pelvic floor determines the direction of rotation

The second principle applied. The occiput is the leading part and meets the pelvic floor resistance and it will rotate 1/8 of the circle forward until it comes under the symphysis pubis.

Because of internal rotation there is a twist at the neck.

The sagital suture move from right or left oblique to Antero – posterior diameter

6) EXTENSION:

The head is born by rapid extension as the occiput, sinciput, nose, mouth, and chin pass over the perineum.In the occipitoposterior position, the head is born by a combination of flexion and extension.At the time of crowning, the posterior bony pelvis and the muscular sling encourage further flexion.The forehead, sinciput, and occiput are born as the fetal chin approaches the chest.Subsequently, the occiput falls back as the head extends, and the nose, mouth, and chin are born.

Once crowning occur fetal head can extend

Third principle applied

The fetal head pivot around the the pubic bone

This releases sinciput, face and chin sweeps the perineum and born by a movement of extension.

The suboccipito frontal diameter 10cm distends the vaginal outlet

7) RESTITUTION:

The occiput moves one-eighth of a circle towards the side from it started

Because of this the twist in the neck of the fetus which resulted from internal rotation is now corrected by a slight un twisted movement

8) INTERNAL ROTATION OF THE SHOULDER:

Now the shoulder is the leading part which meets the pelvic floor resistance

Again second principle applied

So from oblique diameter it will turn to Antero – posterior diameter

9) EXTERNAL ROTATION OF THE HEAD:

The head rotate in same direction as restitution and the occiput of the fetal head now lies laterally

10) LATERAL FLEXION:

Anterior shoulder deliver by downwards and backward movement and posterior shoulder deliver by upward and forward movement

Body will be delivered by lateral flexion

.

MANAGEMENT OF THE SECOND STAGE OF LABOR

With full dilatation of the cervix, which signifies the onset of the second stage of labor, a woman typically begins to bear down, and with descent of the presenting part she develops the urge to defecate.

Uterine contractions and the accompanying expulsive forces may last 1 /2 minutes and recur at an interval no longer than 1 minute.

Maternal Expulsive Efforts

In most cases, bearing down is reflexive and spontaneous during second-stage labor, but occasionally a woman may not employ her expulsive forces to good advantage and coaching is desirable.

Her legs should be half-flexed so that she can push with them against the mattress. Instructions should be to take a deep breath as soon as the next uterine contraction begins, and with her breath held, to exert downward pressure exactly as though she were straining at stool.

She should not be encouraged to "push" beyond the time of completion of each uterine contraction.

Instead, she and her fetus should be allowed to rest and recover.

During this period of active bearing down, the fetal heart rate auscultated immediately after the contraction is likely to be slow, but should recover to normal range before the next expulsive effort.

Research evidence

Gardosi and associates (1989) have recommended a squatting or semisquatting position using a specialized pillow.

They claim that this shortens second-stage labor by increasing expulsive forces and by increasing the diameter of the pelvic outlet.

Eason and colleagues (2000) performed an extensive review of positions and their effect on the incidence of perineal trauma.

They found that the supported upright position had no advantages over the recumbent one.

As the head descends through the pelvis, feces frequently are expelled by the woman.

With further descent, the perineum begins to bulge and the overlying skin becomes stretched. Now the scalp of the fetus may be visible through the vulvar opening.

At this time, the woman and her fetus are prepared for delivery.

Preparation for Delivery

Delivery can be accomplished with the mother in a variety of positions.

The most widely used and often the most satisfactory one is the dorsal lithotomy position.

In many birthing rooms delivery is accomplished with the woman lying flat on the bed.

For better exposure, leg holders or stirrups are used.

In placing the legs in leg holders, care should be taken not to separate the legs too widely or place one leg higher than the other, as this will exert pulling forces on the perineum that might easily result in the extension of a spontaneous tear or an episiotomy into a fourth-degree laceration.

The popliteal region should rest comfortably in the proximal portion and the heel in the distal portion of the leg holder.

The legs are not strapped into the stirrups, thereby allowing quick flexion of the thighs backward onto the abdomen should shoulder dystocia develop.

The legs may cramp during the second stage, in part, because of pressure by the fetal head on nerves in the pelvis.

Such cramps may be relieved by changing the position of the leg or by brief massage, but leg cramps should never be ignored.

Preparation for delivery should include vulvar and perineal cleansing.

If desired, sterile drapes may be placed in such a way that only the immediate area about the vulva is exposed.

In the past, the major reason for care in scrubbing, gowning, and gloving was to protect the laboring woman from the introduction of infectious agents.

Spontaneous Delivery

Delivery of the Head

With each contraction, the perineum bulges increasingly, and the vulvovaginal opening becomes more dilated by the fetal head, gradually forming an ovoid and finally an almost circular opening.

This encirclement of the largest head diameter by the vulvar ring is known as crowning.

Unless an episiotomy has been made, the perineum thins and, especially in nulliparous women, may undergo spontaneous laceration.

The anus becomes greatly stretched and protuberant, and the anterior wall of the rectum may be easily seen through it.

Considerable controversy exists concerning whether an episiotomy should be cut.

Individualization and NO routine cut of an episiotomy is advocated.

An episiotomy will increase the risk of a tear into the external anal sphincter or the rectum, or both.

Conversely, anterior tears involving the urethra and labia are much more common in women in whom an episiotomy is not cut.

Ritgen Maneuver

When the head distends the vulva and perineum enough to open the vaginal introitus to a diameter of 5 cm or more, a towel-draped, gloved hand may be used to exert forward pressure on the chin of the fetus through the perineum just in front of the coccyx.

Concurrently, the other hand exerts pressure superiorly against the occiput.

it is customarily designated the Ritgen maneuver, or the modifiedRitgen maneuver.

This maneuver allows controlled delivery of the head.

It also favors extension, so that the head is delivered with its smallest diameters passing through the introitus and over the perineum.

Research implications

Mayerhofer and colleagues (2002) have challenged the use of the Ritgen maneuver on the grounds that this procedure was associated with more third-degree perineal lacerations and more frequent use of episiotomy.

They preferred the "hands-poised" method, in which the attendant did not touch the perineum during delivery of the head.

This method had similar associated laceration rates and neonatal outcomes as the modified Ritgen maneuver, but with a lower incidence of third-degree tears.

Delivery of the Shoulders

After its delivery, the fetal head falls posteriorly, bringing the face almost into contact with the maternal anus.

The occiput promptly turns toward one of the maternal thighs and the head assumes a transverse position.

This movement of restitution (external rotation) indicates that the bisacromial diameter (transverse diameter of the thorax) has rotated into the anteroposterior diameter of the pelvis.

Most often, the shoulders appear at the vulva just after external rotation and are born spontaneously.

If delayed, immediate extraction may appear advisable.

The sides of the head are grasped with two hands, and gentle downward traction is applied until the anterior shoulder appears under the pubic arch.

Some practitioners prefer to deliver the anterior shoulder prior to suctioning the nasopharynx or checking for a nuchal cord to avoid shoulder dystocia.

Next, by an upward movement, the posterior shoulder is delivered.

The rest of the body almost always follows the shoulders without difficulty; but with prolonged delay, its birth may be hastened by moderate traction on the head and moderate pressure on the uterine fundus.

Hooking the fingers in the axillae should be avoided because this may injure the nerves of the upper extremity, producing a transient or possibly a permanent paralysis.

Traction, furthermore, should be exerted only in the direction of the long axis of the neonate, for if applied obliquely it causes bending of the neck and excessive stretching of the brachial plexus.

Immediately after delivery of the newborn, there is usually a gush of amnionic fluid, often tinged with blood but not grossly bloody.

Clearing the Nasopharynx

To minimize aspiration of amnionic fluid, particulate matter, and blood once the thorax is delivered and the newborn can inspire, the face is quickly wiped and the nares and mouth are aspirated.

Nuchal Cord

Following delivery of the anterior shoulder, a finger should be passed to the fetal neck to determine whether it is encircled by one or more coils of the umbilical cord.

Nuchal cords are found in about 25 percent of deliveries and ordinarily do no harm.

If a coil of umbilical cord is felt, it should be slipped over the head if loose enough.

If applied too tightly, the loop should be cut between two clamps and the neonate promptly delivered

Clamping the Cord

The umbilical cord is cut between two clamps placed 4 to 5 cm from the fetal abdomen, and later an umbilical cord clamp is applied 2 to 3 cm from the fetal abdomen.

A plastic clamp (Double Grip Umbilical Clamp) that is safe, efficient, and fairly inexpensive is used.

Timing of Cord Clamping

If after delivery, the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the fetoplacental circulation is not immediately occluded by clamping the cord, an average of 80 mL of blood may be shifted from the placenta to the neonate.

This provides about 50 mg of iron, which reduces the frequency of iron deficiency anemia later in infancy.

Some policies use to clamp the cord after first thoroughly clearing the airway, all of which usually requires about 30 seconds.

The newborn is not elevated above the introitus at vaginal delivery or much above the maternal abdominal wall at the time of cesarean delivery.

Accelerated destruction of erythrocytes, as found with maternal alloimmunization, forms additional bilirubin from the added erythrocytes and contributes further to the danger of hyperbilirubinemia.

MIDWIFERY CARE DURING SECOND STAGE OF LABOR

-Latent phase

* Encourages woman to listen to her body

* Continues support measures allowing woman to rest

* Suggest an upright position to encourage progression of decent

-Decent phase

* Encourage respiratory of short breath holds and open glottis pushing.

* Stresses normality and benefits of grunting sounds and expiratory vocalizations.

* Encourage bearing down effort with urge to push.

* Encourage maternal movement and position changes upright , if decent is not occurring

* Discourage long breath hold (no longer than 5 to 7sec)

* Place the woman in lateral recumbent position to slow decent

Transitional phase (8-10cm)

* Encourage slow, gentle pushing

* Explains that “blowing away the contraction” facilitates a slower birth of the head

* Coaches woman to relax mouth, throat and neck to promote relaxation of pelvic floor

* Apply warm compress to perineum to promote relaxation

Preparing For Birth

1.Maternal position

2.Bearing-down efforts

3.Fetal heart rate and pattern

4.Support of the father or partner

5.Supplies, instruments, and equipment

Maternal Position

-The woman my want to assume various position for childbirth, and she should be encourage and assisted in attaining and maintaining her position of choice

-Hason(1998) found that sitting and side Lying are the most common position assumed by women for their bearing down effort and birth

Upright position:

- Facilitate birth and fetal decent

- Reduce the duration of the 2nd stage of labor

- Reduce the need for episiotomy, forceps, or vacuum extractor

Mechanism Of Upright position

1. Straighten the longitudinal axis of the birth canal

2. Use gravity to direct the fetal head toward the pelvic inlet

3. Enlarge pelvic dimensions and restrict the encroach of the sacrum and coccyx into the pelvic outlet

4. Increase uteroplacental circulation

5. Enhance the woman’s ability to bearing down effectively

- Provides potential psychologic advantage it allows the mother to see the birth as occur, and maintain eye contact with attendant.

-Upright position slightly increase the risk for 2nd degree laceration and blood loss greater than 500ml

(Donsante & shorten,2002)

Evidence

-Use of supine position is associated with negative maternal, fetal and neonatal hemodynamic out comes.

-Upright positions were associated with a slight reduction in second stage duration, reduction in assisted deliveries, reduction in epsiotomies increase in second degree tear, and fewer abnormal fetal heart rate.

Robert J. Best practices in second stage of labor care.2007

Squatting position

-Is highly effective to facilitating the decent and birth of the fetus, and is one of the best positions for the 2nd stage of labor.

- Firm surface is required.

- Woman need side support.

Standing position

-Uses the standing position for bearing down, her weight is born on both femoral heads, allowing the pressure in the acetabulum to cause the transverse diameter of the pelvic outlet to increase by up to 1cm (if the occiput has not rotated from the lateral to the anterior position.

Birthing chair

-Used to provide women with a good physiologic position to enhance her bearing down effort during childbirth, although some women feel restricted by a chair

- Most birthing chair are designed if emergency occurs, the chair can be adjusted to horizontal or trendelenburg position

Side-Lying position

-With the upper part of the woman’s leg held by the midwife or placed on a pillow low, is an effective for the 2nd stage of labor

Semi-sitting position

-Use to maintain good uteroplacental circulation and to enhance the woman’s bearing down effort

The episiotomy rate for nulliparas highest in this position(Shorten, Donsante, &shorten,2002)

Hands –and knees position

- Is an effective position for birth because it enhances placental perfusion.

- Help rotate the fetus from posterior to an anterior position.

-Facilitate the birth of the shoulders if the fetus is large.

- Reduce perineal trauma.

Birthing Bed

-The Birthing bed used according to the woman’s needs.

- At the same time is excellent exposure for examinations, electrode placement and birth.

- The bed can be positioned for administration of anesthesia.

- The bed can be used to transport the woman to the operating room if C/S necessary.

Bearing down efforts

-Is an involuntary response to the Ferguson reflex.the midwife should encourage women to push as they feel like pushing (spontaneous pushing).

-The midwife should monitor the woman’s breathing , so that the woman does not hold her breath for more than 5 to 7 seconds at time and should remind her to ventilate her lung fully by taking deep breaths before and after each contraction, this help maintain adequate O2 For the mother and fetus.

Perineal management

- Warm compress

- Massage

- Kegel’s exercises in the prenatal and postpartum periods

- Good nutrition, hygienic measures

- As advocates, encourage women to use alternative birthing positions and use spontaneous bearing down effort.

Pushing Techniques

Pushing techniques can be either

(1) delayed or

(2) nondirected.

Delayed pushing waiting for fetal descent or initiation of Ferguson's reflex before pushing begins (ie, not pushing until the urge is felt even with complete cervical dilatation).

The Ferguson's reflex is a physiologic response that is activated when the presenting part of the fetus is at least at a +1 station and is usually accompanied by spontaneous bearing-down efforts.

Delayed pushing can be used with epidural anesthesia/analgesia as women cannot feel the urge to push.

Clinical practice recommends assessing women's knowledge of pushing techniques to include presence of Ferguson's reflex.

Also referred to as laboring down

Nondirected pushing use of nontraditional pushing techniques such as open glottis or tug-of-war techniques.

Open glottis pushing for 4 to 6 seconds followed by slight exhaling (essentially pushing while exhaling/grunting) and repeating this pattern for 5 or 6 pushes/uterine contraction.

There is minimal change in maternal blood pressure, thus minimal, if any, change in the FHR pattern. This method also relaxes the perineum, allowing the gentle delivery of the fetal head. Closed glottis pushing (holding breath for the count of 10) is not recommended.

Tug-of-war uses the natural bearing down effort of the abdominal muscles. A gown or short sheet can be tied in a knot at both ends. When the mother has the urge to push, she grabs one end of the gown or sheet and pulls as much as she can while the coach or nurse provides resistance by holding the other end. (Alternative way is to tie knot in one end and tie other end to squat bar of labor bed.) This method also causes minimal change in the maternal blood pressure, relaxes the perineum, and has been found to decrease the second stage of labor as much as 20 minutes.

Use of birthing aids such as birthing balls, squat bars, birthing stools, and cushions to support the woman and her fetus.

Fetal Heart Rate and Pattern

- FHR must be checked if there is loss of variability, or if deceleration pattern developed.

-The woman can be turned on her side.

- O2 can be administer by mask at 8 to 10 L/m to mother.

-If FHR does not become reassuring immediately the primary health care provider should be notified.

Support of the Father

- During 2nd stage, woman needs continuous support and coaching.

-The support person who attends the birth in a delivery room is instructed to put on a cover gown, mask, hat, and shoes cover as agency policy.

- Partners are encourage to be present at the birth of their babies as cultural and personal expectation and beliefs.

- In this way the psychologic closeness of the family unit is maintained, and the partner can continue to provide the supportive care given during labor.

-The woman and her partner need to have an equal opportunity to initiate attachment process with the baby.

Supplies, Instruments, and Equipment

-The birthing table should be prepared during the transition phase for nulliparous, and during the active phase for multiparous woman.

- Standard procedures for gloves,sterile packages, unwrapped sterile instruments and handling them to the primary health care provider.

-Radiant warmer and equipment are readied for the support and stabilization of the baby.

Birthing Room

-Prepare the woman for delivery

-The circulating nurse continues to support the woman.

- The nurse auscultates FHR or evaluates the monitor every 5 to 15 minutes.

- Oxytocin may be prepared to be administered after delivery of the placenta.

- midwife attending the birth my need to wear cap, protective eyewear, masks gown and gloves.

- The woman draped with sterile drapes

- midwife contact with the parents is maintained by touching, verbal comforting, explaining the reasons for care and sharing in the parents’ joy at birth of their baby.

Immediate Assessment and Care of the Newborn

- The care given after the birth focuses on assessing and stabilizing the newborn.

- The midwife must watch the infant for any signs of distress and initiate appropriate interventions.

- A brief assessment of the newborn can be performed includes checking the airway and Apgar Score.

PERINEAL TRAUMA RELATED TO CHILD BIRTH

- Lacerations:

-Most acute injuries or laceration of the perineum, vagina, uterus and their supportive tissues occur during child birth.

- Laceration if not repair lead to genitourinary and sexual problem (pelvic relaxation, uterine prolapse, cystocele, rectocele, dyspareunia, urinary and anaL bowel dysfunction).

- Immediate repair:

* Promotes healing

* Limits residual damage

* Decreases the possibility of infection

- Primary health care provider continue to inspect the perineum carefully and evaluate lochia to

identify any missed damage during the early postpartum period.

Perineal Lacerations

Degree of laceration:

1. First degree: laceration extends through the skin and structures superficial to muscle.

2. Second degree: Laceration extends through muscles of the perineal body

3. Third degree: Laceration continues through the anal sphincter muscle.

4. Fourth degree: Laceration involves the anterior rectal wall.

- Special attention must be paid to third and fourth stage laceration so that woman retains fecal continence.

- Measures are taken to promote soft stools (e.g. roughage, fluid, activity, and stool softeners) to increase comfort and healing.

- Antimicrobial therapy may be used

- Enemas and suppositories are contraindication

Vaginal & Urethral laceration

- Vaginal laceration occur in conjunction with perineal laceration

- Vaginal laceration tend to extend up the lateral walls and if deep enough involve the levator ani muscle.

- Vaginal vault laceration may be circular and result from forceps rotation especially in the

cephalopelvic disproportion, rapid fetal decent.

Cervical Injuries

- Occur when the cervix retracts over the advancing fetal head.

- Cervical injuries when extend to vaginal vault or beyond it into the lower uterine segment serious bleeding may occur.

- Cervix laceration can have adverse effect on future pregnancies and child birth.

- This laceration occur at the angles of the external os, most are shallow, bleeding is minimal.

Evidence

-The highest rate of trauma have consistently been observed in first births or operative vaginal deliveries (forceps or vacuum extraction).

-Rate of trauma appear to increase with infant birth weight, maternal weight gain in pregnancy, and fetal malposition.

- Use of episiotomy increases serious trauma to genital tract, especially third and fourth degree laceration.

Leah L .Reduction Genital Tract Trauma at Birth. 2003.

EPISIOTOMY

- Is an incision in the perineum to enlarge the vaginal outlet.

Indication:

1. Facilitates vacuum or forceps assisted birth

2. Fetal distress

3. Facilitates the birth of large baby

4. Premature baby

Type of episiotomy

1. Median: -Is most commonly used

- It is effective

-Easily repaired

-Least painful

- Midline episiotomy are associated with a higher incidence of third and fourth degree of laceration.

2. Mediolateral: Is used in operative births when need for posterior extension.

- Fourth degree laceration may be prevented, third degree may occur.

- Blood loss is greater, painful, difficult repair than midline.

Risk Factor associated with perineal trauma

1.Nulliparity

2. Maternal position

3. Pelvic inadequacy

3. Fetal malpresentation and position 4. Large baby

5. Use of instruments to facilitate birth

6. Prolong second stage of labor

7. Fetal distress

8. Rapid labor

Evidence

- Episiotomy should not be used unless indicated . Measures should be taken to avoid perineal trauma during labor to establish bonding early between mother and infant & to minimize perineal discomfort after birth.

Karacam Z. Effects of episiotomy on bonding and mothers health. 2003

IMPORTANT NURSING DIAGNOSIS IN SECOND STAGE OF LABOUR

 Acute pain related to contraction – related hypoxia, dilatation of tissues and pressure on adjacent structures as evidenced by verbal reports, restlessness, muscle tension and narrowed focus

Risk for impaired fetal gas exchange related to mechanical compression of head or cord / maternal position / prolonged labour affecting placental perfusion / effects of maternal anaesthesia / hyperventilation

Risk for impaired skin / tissue integrity related to untoward stretching / laceration

Risk for deficient fluid volume related to lack of intake or excessive vascular loss

Risk for fetal injury related to descent / pressure changes / compromised circulation / environmental exposure

Impaired urinary elimination related to decreased fluid intake ,mechanical compression of the bladder as evidenced by urine retention,slowed progression of labour

Fatigue related to discomfort,pain,overwhelming psychologic demands,increased energy demands

High risk for maternal infection related to repeated invasive procedures,traumatized tissue,exposure to pathogens,rupture of membranes

Anxiety related to labour pain,outcome as evidenced by verbalization,facial expression

Reference

Adelele Pilleteri,Maternal And Child Health Nursing,6th Edition Wilkins Publishers,Pg No 740-750

D.C.Dutta Textbook Of Obstetrics 6th Edition New Central Publications Pg No 115-140 Indian Academy Of Pediatrics Training Manual Of Newborn Resuscitation Guidelines For Antenatal Care And Skilled Birth Attenders By The Ministry Of Health

And Family Welfare.Govt Of India April 2010.