THE SECOND STAGE OF LABOR

The second stage of labor begins once the cervix becomes fully dilated and ends with the
delivery of the neonate. Although fetal descent begins before the cervix becomes fully dilated,
the majority of fetal descent occurs once full cervical dilation is achieved. At this time, maternal
expulsion efforts may begin. 

The second stage of labor is very important because it is associated with increased maternal and
perinatal morbidity and mortality as a result of the rapidity of onset of hypoxic stress to the fetus,
as well as perineal trauma to the mother owing to the mechanical forces operating during the
final stages of labor as the hand and bony fetal head traverse the maternal soft tissues that
comprise the birth canal.

DEFINITION

Second stage of labor: The part of labor from the full dilatation of the cervix until the baby is
completely out of the birth canal. The second stage of labor is also called the stage of expulsion.

SIGNS AND SYMPTOMS

Second stage describes the period of time from when the cervix is fully dilated to when the baby
is born. 

In second stage you may have:

 longer and stronger contractions, with a one to two minute break in between

 increased pressure in your bottom

 the desire or urge to push

 shaky cramps, nausea and vomiting

 Stretching and burning feelings in your vagina.

MANAGEMENT OF A PATIENT IN SECOND STAGE OF NORMAL LABOR

 Staying with the mother: Ensure that you stay with the mother from the onset of second
stage of labor to prevent and manage any complication that may arise.

1
  Prevention of infection

 Psychological care: reassure her that pains will soon be over, encourage her to be strong
and cooperate.

 Praise and congratulate her for the effort she is making to have a successful delivery

 Physical support

 Nutrition- she may complain of hunger and thirst

 Observation – observe and record the strength, frequency and duration of uterine
contractions

- Check her pulse and foetal heart rate

- Check her blood pressure and respiration

- Bladder care – always emptying of the bladder is recommended; catheterize her to create
enough room for rotation of the fetus

- Transfer to the delivery room in second stage

- Preparation of equipment

ASSESSMENT AND POSITIONS IN LABOUR

The lateral recumbent position is also used for both spontaneous and assisted deliveries, with the
advantage of avoiding uterine compression of the aorta, the inferior vena cava, or both.

Kneeling positions may also be assumed by women in the second stage of labour. These may
vary from upright kneeling to an 'all fours' position with the pelvis and shoulders at the same
level.

The second stage begins when your cervix is fully dilated, your baby has moved deep into the
pelvis, and you are ready to push. During the tiring second stage of labor, aid the effectiveness of
your pushing with body positions such as kneeling, upright squatting, and being on all fours.

Kneeling

In a kneeling position, both your partner and the nurse can support you as you bear down.

2
Being on All Fours

Being on all fours with the hospital bed for support can be a comfortable position.

Squatting

An upright squatting position is good for pushing and can be adopted if you have firm support
from your partner. He can support you under the arms while you put your hands around the back
of his neck.

CONDUCT OF NORMAL DELIVERY

- Place her in a lateral or dorsal position

- Don your apron, scrub your hands and don gloves

- Swab the vulva and perform vaginal examination to confirm full dilatation of the cervix

- Drape her with sterile makintosh and towel

- As the head becomes visible at the vulva, ask her to bear down with contraction and rest
in between contractions to avoid exhaustion

- Ask her to hold her ankles with both hands and her chin towards her chest in a compact
position before each push

- Perform episiotomy at the height of contraction if need be.

- Cover and support the anus with pad to prevent soiling of the delivery field with faecal
matter

- When the head is crowned, grip the baby’s head by the side and instruct the mother to
stop bearing down but to pant or breath out the head

- Clear trhe baby’s air way immediately and clean the eyes from the medial to the lateral
canthus with wet swab.

- Feel the neck for cord. If the cord is present and loose, slip it over the head, but if tight,
apply artery forceps about 5cm apart and cut in between

- Allow restitution to take place

3
 - Deliver the shoulders one after the other

- Splint the head with both hands and deliver the baby towards the mother’s abdomen

- Note the time of delivery and “APGAR SCORE” at 1minute and 5minute after birth

- Give syntometrin injection

- Separate the baby from the mother by cutting the cord if this had not been done

- Show baby to the mother to identify the sex

- Weigh the baby.

EPISIOTOMY

Episiotomy: - is a deliberate incision made in the perineum to enlarge the vagina introitus as a
rule it is a planned surgical operation, but often an episiotomy is done in an emergency because
the necessity for its performance is not apparent until delivery is imminent.

The incision may be made in the midline from the centre of the fourchette (median) or may
commence from the centre away from the rectum at an angle of at least 45 0 from the midline
(mediolateral). Comparing with mediolateral episiotomy

The use episiotomy during childbirth was first described in “1742” by the early “1870s”
episiotomy was a routine practice for all “nullipara” and most “multipara”. The proposed
benefits were facilitation of delivery, reduction in the incidence of 3 rd or 4th degree perineal tears,
bette surgical healing, less sexual dysfunction, prevention of pelvic floor relaxation resulting in
less urinary and fecal/flatal incontinence as well as a pelvic organ prolapse and reduction in fetal
asphyxia, cranial trauma and intracranial hemorrhage.

Indication of Episiotomy

1. Tight perineum

2. Foetal distress

3. Forceps delivery

4. Button holing of the perineum

4
5. Slow advance of foetal head

6. During delivery of the after-coming head of breech

7. Mal-presentation and mal-position

8. Mothers with cardiac problems

9. Mothers with respiratory disease

10. Pre-edampsia and edampsia

11. Mothers with previous history of pelvic repair or surgical delivery

Types of Episiotomy

i. Midline episiotomy

ii. Mediolateral episiotomy

iii. J-shape episiotomy

iv. Lateral episiotomy

i. MIDLINE EPISIOTOMY: Advantage of the midline episiotomy are that it does not
cut through muscle, the two sides of the incised area are anatomically balanced,
making surgical repair easier, and blood loss is less than with mediolateral episiotomy

ii. MEDIOLATERAL EPISIOTOMY: the mediolateral episiotomy is the technique

approved for use by midwive in the UK. The incision is made starting at the midline
of the posterior fourchette and aimed towards the ischial tuberosity to avoid the anal
spincter. In addition to the skin and sub-cutaneous tissues, the bulbospongiosus and
the transverse perineal muscles are cut.

iii. J-SHAPE EPISIOTOMY: this is a modification of the posterior lateral episiotomy. A

midline incision is made and carried on to a point 2.5cm above the anal orifice. From
this point the incision is directed postero-lateral in order to avoid the anal sphincter
and canal.

5
 iv. LATERAL EPISIOTOMY: in this type of episiotomy, a lateral incision is made
across the labia majora. It involves cutting across the path of the blood vessels and
damage to the bartholins gland suturing may not be easy.

Procedure for Episiotomy

 It is a sterile procedure

 Make sure the requirements are ready

 Explain procedure to the mother and obtain her consent

 Position her in a dorsal or lithotomy position

 Perform vulva swabbing using antiseptic lotion such a hibitane 1:200 or savlon 1:100

 Infiltrate the perineum with xylocaine of about 10mls. It start to take effect in about 1-
2minutes

 Insert two (2) fingers of the left hand between the perineum and foetal head

 Wait for the perineum to be stretched to avoid premature incision which leads to severe
bleeding

 Avoid overstretching of the perineum which may lead to delayed healing, lax pelvic
muscle or vaginal or perineal tear.

 Perform the incision with a sharp cut to avoid interrupted cut

 The incision should be at the height of contraction and 2.5cm away from the center of the
fourchette.

 The incision should not be more than 3cm long.

 Deliver the baby

 Clean by soaking blood withy pad

 Suture the incision and makre mother and baby comfortable

 Wash, sterilize and store instruments for future use

6
Repair of Episiotomy

An episiotomy should be repaired promptly to reduce blood loss and prevent infection. Repair of
an episiotomy is undertaken in three stages:

- Repair of the vaginal mucosa

- Repair of the muscle layer

- Repair of the skin layer

The repair of the episiotomy starts from the apex of the vaginal wound number 0 or 1 chronic
catgut mounted on a half-curved, round-bodied needle is used. Continuous or interrupted stitches
are inserted starting from the apex to the fourchettes and bringing the two edges of the wound
together, the same suturing materials and needle are used to stitches the muscle of the pelvic
floor and perineal body to secure good apposition but care should be taken not to damage the
rectum.
PSYCHOLOGICAL SUPPORT OF EPISIOTOMY

1. Reassure her that the pains will soon be over and that she will have her baby within a short
while.

2. Give tactful and genuine answers to her questions

Encourage her to be strong and to cooperate

Praise and congratulate her for the effort she is making to have a successful delivery.

1. Initiation and Maintenance of Respiration: Initiation of respiration is a critical step in

ensuring the baby's well-being. Here's what you should do:

 Positioning: Place the baby on their back on a clean, dry surface. Clear any mucus or
fluids from the baby's mouth and nose using a bulb syringe if available.

 Stimulation: Gently rub the baby's back or feet to stimulate their breathing. This helps
initiate the baby's breathing reflex.

7
  Assisted Breathing: If the baby doesn't start breathing on their own, you can provide
gentle assistance. Cover the baby's mouth and nose with a clean cloth or your mouth and
give small puffs of air.

 Chest Compressions: If the baby's heart rate remains low and they're not breathing, you
may need to perform chest compressions. Place two fingers on the center of the baby's
chest and give very gentle compressions.

2. Assessment of Baby using Apgar score: The APGAR score is a quick assessment tool used
to evaluate a newborn's physical condition shortly after birth. It consists of five parameters, each
scored on a scale of 0 to 2:

 Appearance (skin color)

 Pulse (heart rate)

 Grimace response (reflexes)

 Activity (muscle tone)

 Respiration (breathing)

Each parameter's score is added up to give a total score out of 10. A score of 7 to 10 is generally
considered healthy, 4 to 6 requires some medical attention, and below 4 indicates the need for
immediate medical intervention.

3. Provision of Warmth: Maintaining the baby's body temperature is essential, especially in the
first hours after birth:

 Skin-to-Skin Contact: Place the baby on the mother's chest, skin-to-skin. This provides
warmth and regulates the baby's body temperature. It also promotes bonding and
breastfeeding.

 Dry and Wrap: Dry the baby gently with a clean, soft towel and then wrap them in a
dry, warm blanket or cloth. Make sure the baby's head is covered, leaving the face
uncovered.

8
  Avoid Overheating: It's important not to overdress the baby, as overheating can be
harmful. A good rule of thumb is to dress the baby in one layer more than what you're
comfortable wearing in the same environment.

 Warm Environment: If you're in a rural setting, ensure that the room is adequately
warm. You can use warm clothing, blankets, or even a heater if available.

SUMMARY/CONCLUSION

 The second stage of labour begins when the cervix is completely dilated and ends when the
baby is delivered. Close attention, skilled care and prompt action are needed from you for a
safe clean birth.

 The signs of second stage are when the mother feels an uncontrollable urge to push, she
holds her breath or grunts during contractions, she starts to sweat, her mood changes, her
external genitals or anus begin to bulge out during contractions, she feels the baby’s head
begin to move into the vagina, a purple line appears between her buttocks.

 Check the mother’s vital signs, the fetal heart beat and the descent of the baby’s head at
intervals to ensure that labour is progressing normally.

 Watch for warning signs that labour is not progressing sufficiently during the second stage
and take appropriate action to refer the mother.

 Support the mother’s pushing during the time of actual delivery.

 If the cord is trapped around the baby’s neck, cut it before the body is delivered — but make
sure the mother pushes hard to get the baby out fast.

 Maintain cleanliness throughout the entire process of labour and delivery to prevent infection
to the mother and baby.

 Keep the newborn baby warm and make sure it is breathing well.

 Initiate early breast feeding.

9
REFERENCES

Friedman EA. Labor: Clinical Evalutation and Management, 2nd edn. New York: Appleton-
Century-Crofts, 1978.

Friedman EA. The Labor Curve. Clin Perinatol 1981;8(1):15-25.

Harper LM, Caughey AB, Odibo AO, et al. Normal progress of induced labor. Obstet

Gynecol 2012;119:1113.

ISUOG practice guideline. Intrapartum ultrasound. Ultrasound Obstet Gynecol 2018;52:128–39.

Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and
cesarean delivery in nulliparous women at term. Am J Obstet Gynecol 2015;213(5):673 e1-8

The WHO partograph. World Health Organization (2008) Managing Prolonged and Obstructed
Labour.

Tutschek B, Braun T, Chantraine F, et  al. A study of progress of labour using intrapartum
translabial ultrasound, assessing head station, direction, and angle of
descent. BJOG 2011;118:62.

Wei SQ, Luo ZC, Xu H, Fraser WD. The effect of early oxytocin augmentation in labor: a meta-
analysis. Obstet Gynecol 2009;114:641.

Youssef A, Bellussi F, Montaguti E, et al. Agreement between two- and three-dimensional methods

for the assessment of the fetal head-symphysis distance in active labor. Ultrasound Obstet
Gynecol 2014;43:183–8.

Zhang J, Duan T. The physiologic pattern of normal labour progression. BJOG 2018;125:955.

Zhang J, Troendle J, Mikolajczyk R, et al. The natural history of the normal 1st stage of

10
 labor. Obstet Gynecol 2010;115:705–10.

Zhu BP, Grigorescu V, Le T, et al. Labor dystocia and its association with interpregnancy
interval. Am J Obstet Gynecol 2006;195:121.

11