MANAGEMENT OF SECOND STAGE OF LABOR

•	Duration.
•	Management. 
•	Complications.

Duration

1.	The second stage begins with the full dilatation of the cervix and ends with the delivery of the baby.

2.	Pelvic phase:

a.	Descent of head.

b.	Internal rotation in pelvis.

3.	Perineal phase:

a.	Head is on the pelvic floor.

b.	Sensation of bearing down.

c.	If occiput anterior, the neck extends and the baby’s face climbs up the perineum.

d.	Crowning: when the widest diameter of the fetal head has passed through the vulva.

4.	Birth of baby:

a.	Birth of head: restitution and external rotation.

b.	Delivery of anterior shoulder.

c.	Delivery of rest of body.

Management of Second Stage

1.	Clinical Identification:

a.	Increased uterine contractions.

b.	Increased blood stained discharge.

c.	Bearing down sensation. 

2.	Assessment:

a.	Time of onset of second stage: if more than 3 hours for primip or half an hour for multip, consider as prolonged second stage.

b.	Uterine contractions: a good contraction is strong in intensity, lasts 30 to 40 seconds and occurs once every 2 – 3 minutes.

c.	Abdominal palpation: assess degree of engagement.

d.	Vaginal examination: station.

e.	Fetal condition. 

3.	Position of delivery:

a.	An optimal position should:

i.	prevent fetal hypoxia.

ii.	create an efficient uterine contraction pattern.

iii.	expose the perineum well.

iv.	be comfortable for the mother.

b.	Vertical position:

i.	includes standing, sitting, squatting and kneeling positions.

ii.	improves pelvic dimension.

iii.	difficult for the accoucheur to control the birth and to manage complications.

c.	Horizontal position:

i.	includes the lateral, prone, semi-recumbent, knee elbow and dorsal positions.

ii.	advantages of lateral position: convenience, facilitate descent of fetal head and prevent supine hypotensive syndrome.

iii.	advantages of dorsal and lithotomy position: easy monitoring of fetal head, efficient analgesia, a good position to conduct assisted delivery and repair of the episiotomy and any lacerations. 

4.	Preparation for delivery:

a.	Encourage maternal bearing down efforts.

b.	Augmentation of uterine contractions with oxytocin.

5.	Controlled delivery of head:

a.	As the head descends, the perineum stretches and the anus will begin to open.

b.	When the head no longer recedes between contractions, this indicates that it has passed through the pelvic floor and delivery is imminent.

c.	The head can now be delivered by supporting the perineum with the right hand and gently pushing it down with the left hand with each contraction.

d.	A medio-lateral episiostomy can be performed at this stage – two fingers placed between the head and the perineum before making the cut to prevent injuries to the baby. 

6.	Delivery of shoulders and body:

a.	Checking the cord:

i.	once the fetal head is born, a check is made to see whether the cord is wound tightly around the neck thereby making delivery of the body difficult.

ii.	if this is the case, the cord may need to be clamped and divided before delivery of the rest of the body.

b.	If there is any meconium staining of the amniotic fluid, naso-pharyngeal suction could be performed to prevent meconium aspiration.

c.	With the next contraction, there is external rotation of the head and the shoulders can be delivered.

d.	To aid the delivery of the shoulders, the head should be pulled gently downwards and forwards until the anterior shoulder appears beneath the pubis. 

e.	The head is then lifted gradually until the posterior shoulder appears over the perineum and the baby is then swept upwards to deliver the body and legs. 

7.	Cutting and examination of cord:

a.	The cord is clamped and cut.

b.	It should be inspected for:

i.	presence of 3 vessels: one umbilical vein and 2 umbilical arteries.

ii.	staining by bilirubin or meconium.

iii.	true or false knots.

iv.	other anomalies like varices, constrictions or hematomas.

c.	Blood is then drawn from the cord for hypothyroidism and G6PD screening. 

Complications

1.	Inefficient uterine action:

a.	It can develop either primary or secondary to cephalo-pelvic disproportion (CPD).

b.	If CPD is excluded in a primigravid patient with a healthy fetus, oxytocin is started to augment the uterine contractions.

c.	However in multigravida, caution is required in augmenting labor because of the risk of uterine rupture.

2.	Malposition:

a.	With good uterine contractions, the malposition may correct itself resulting in normal delivery.

b.	If the malposition persists with a high fetal head, caesarean section may be necessary.

3.	Supine hypotensive syndrome:

a.	It occurs when parturient lies on her back, compressing the aorta and vena cava leading to hypotension.

b.	Reduced uteroplacental perfusion leads to changes in the fetal heart rate pattern and fetal hypoxia.

c.	There is a rapid recovery when the parturient turns on her side.

4.	Fetal distress:

a.	Meconium stained amniotic fluid may be a sign of fetal distress.

b.	As soon as the head is born and before the baby breathes, the mouth, hypopharynx, nostrils and nasopharynx are suctioned thoroughly.

c.	Monitoring:

i.	FHR.

ii.	Fetal scalp blood sampling: if pH > 7.25, vaginal delivery can be anticipated.

d.	Moulding / caput: the suture lines do not meet each other in early labor and may suggest a mechanical obstruction.