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MANAGEMENT OF SECOND-STAGE LABOR. The onset: full dilatation of the cervix bear down descent of the presenting part the urge of defecate uterine contraction & expulse force. MANAGEMENT OF SECOND-STAGE LABOR. Duration -50 min in nulliparous

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management of second stage labor
MANAGEMENT OF SECOND-STAGE LABOR
  • The onset: full dilatation of the cervix
  • bear down

descent of the presenting part

the urge of defecate

  • uterine contraction & expulse force
management of second stage labor2
MANAGEMENT OF SECOND-STAGE LABOR
  • Duration

-50 min in nulliparous

20 min in multiparous

-become abnormally long

:a contracted pelvis

a large fetus

impaired expulsive effort from conduction analgesia

or intense sedation

management of second stage labor3
MANAGEMENT OF SECOND-STAGE LABOR
  • Fetal heart rate

-low risk: 15 min

high risk: 5 min

-slowing of the FHR

: due to fetal head compression

: reduce placental perfusion

: recovery after the contraction and expulsive

effort cease

slide4
-descent of the fetus

:obstruct umbilical cord blood flow

(tighten loop or cord neck)

->uninterrupted maternal expulsive effort can

be dangerous to the fetus

-maternal tachycardia in second stage

:common, must not be mistaken for a normal FHR

management of second stage labor5
MANAGEMENT OF SECOND-STAGE LABOR
  • Maternal expulsive efforts

-bearing down: reflex and spontaneous

but, does not employ expulsive force

and coaching is desirable

-leg: half-flexed

deep breath & breath held

exert downward pressure

-She should not be encouraged to “push” beyond

the time of completion of each uterine contraction

slide6
-Gardosi(1989): squatting or semi-squatting

using a specialized pillow

-> shortens second labor

-in increasing bulging of the perineum

:encouragement is very important

-> FHR is likely to be slow

-feces is frequently expelled

perineum begins to bulge , tense and glistening

scalp may be visible

management of second stage labor7
MANAGEMENT OF SECOND-STAGE LABOR
  • Preparation for delivery

-the dorsal lithotomy posiyion

: increase the diameter of the pelvic outlet

: using leg holder and stirrup

->result in spontaneous tear or fourth degree

-not strapped into the stirrup

: allowing quick flexion of the thighs back onto

the abdomen -> shouder dystocia

-vulvar and perineal cleansing

: sterile drape and gowning, gloving

spontaneous delivery
SPONTANEOUS DELIVERY
  • Delivery of the head

-”crowning: : encirclement of the largest head

diameter by the vulvar ring

-unless episiotomy ; spontaneous laceration

-It is now clear that an episiotomy will increase the

risk of a tear into the external anal sphincter and

the rectum

-unless episiotomy. anterior tears involving the

urethra and labia are mush more common

spontaneous delivery9
SPONTANEOUS DELIVERY
  • Ritgen maneuver

- By the time the head distends the vulva and

perineum enough to open the vaginal introitus to

a diamater of 5 cm or more

- one hand: a towel-draped, gloved hand may be

exert forward pressure on the chin of

the fetus through the perineum just

in frint if the coccyx

the other hand: exerts pressure superiorly against

the occiput

spontaneous delivery11
SPONTANEOUS DELIVERY
  • Delivery of shoulder

-the occiput : turns toward one of the maternal thigh

fetal head: transverse position

external rotation: bisacromial diameter had rotated

into the anterioposterior dimeter

of the pelvis

-sucking the nasopharinx or checking for a cord

-downward traction : ant. shoulder under the pubis

upward movement: post. shoulder is delivered

slide12
-the rest of the body almost always follows the

shoulder without difficulty

-prolonged delay : more tracton

pressure on the fundus

-traction should be exerted only in the direction of

the long axis of the infant, for if applied obliquely

it causes bending of the neck and stretching of

the bradhial plexus

spontaneous delivery13
SPONTANEOUS DELIVERY
  • Clearing the nasopharynx

-prevent of aspiration of amnionic fluid, debris, blood

-the face: quickly wiped

nares and mouth : aspirated

  • Nuchal cord

-after head dilevered, ascertain the umbilical cord

-occur 25%, ordinarily do no harm

-drawn down or cut (too tightly)

spontaneous delivery14
SPONTANEOUS DELIVERY
  • Clamping the cord

-between two clams: 4 or 5cm and later 2 or 3cm

from the fetal abdomen

-timing of cord clmaping

:after delivery, the infant is placed at the level

of vagina for 3 min, the fetoplacental circulation

is not occluded

:80 ml of blood – shift to the fetus (50 mg of Fe)

:after first clearing the airway (30 secend)

-> then clamps the cord

management of the third stage
MANAGEMENT OF THE THIRD STAGE

-after delivery of the infant, the height of fundus

and its consistency are ascertained

-No massage is practiced

-the hand is simply rested on the fudus frequency

: become atony and filled with blood

management of the third stage16
MANAGEMENT OF THE THIRD STAGE
  • Signs of the placental separation

1. uterus : globular, firmer

the earliest sign

2. a sudden gush of blood

3. uterus : rise in the abdomen because the

placenta passes down

4. the umbilical cord protruded out of the vagina.

indicating that the placenta has descended

-usually within 5 min, sometimes within 1min

slide17
- when placenta has separated, ascertain uterus

firmly

->mother: bear down , incease abdominal pressure

if fail or impossible: pressure on the fundus

propel the detached placenta

management of the third stage18
MANAGEMENT OF THE THIRD STAGE
  • Delivery of the placenta

-traction in the umbilical cord must not be used

to pull the placenta out of the uterus

-the uterus is lifted cephalad with the abdominal

hand. This maneuver was stopped as the placenta

passes through the introitus

-if the membranes start to tear, they are grasped

with a clamp and removed by gentle traction

management of the third stage19
MANAGEMENT OF THE THIRD STAGE
  • Manual removal of placenta

-the placenta will not separate promptly (preterm)

-there is brisk bleeding and the placenta cannot be

delivered -> manual removal

-proof of this practice has not been established

and most obstetricians await spontaneous placental

separation unless bleeding is excessive

management of the third stage20
MANAGEMENT OF THE THIRD STAGE
  • “Fourth stage” of labor

-the hour immediately following delivery is critical

and it has been designated by some as the

“fourth stage of labor”

-postpartum hemorrhage

uterine atony

observation of vaginal excessive bleeding

-check vital sign every 15 minutes for the first hour

oxytocin agent
OXYTOCIN AGENT

-after placenta delivery, the primary mechanism

by which hemostasis is vasoconstriction produced

by a well-contracted myometrium

-oxytocin (Pitocin, Syntocinon)

ergonovine maleate (Ergotrate)

methylergonovine maleate (Methergine)

oxytocin agent22
OXYTOCIN AGENT
  • Oxytocin

-the synthetic form of the octapeptide oxytocin

-not effective by mouth

-half-time of IV : 3 minutes

-before delivery : the uterus is sensitive to oxytocin

->so violently as to kill the fetus

ruptued itself

after delivery these dangers no longer exist

oxytocin agent23
OXYTOCIN AGENT
  • Cardiovascular effects

-deleterious effect: IV injetion of a bolus

decreased maternal BP (5 unit)

decreased arterial BP

->increased cardiac output

-not be given IV as a large bolus

dilute solution by continuous IV infusion

IM in a dose of 10 unit

-direct injection of uterus (trasnvagina or abdomen)

:also proven effective

oxytocin agent24
OXYTOCIN AGENT
  • Antidiuresis

-water intoxication: maternal convulsion

-continuous IV inj (20 unit) : decreased urine flow

-not in electrolyte-free aqueous dextrose solution

: normal saline or lactated Ringer solution

-need for high dose of oxytocin

: concentration should be increased rather than

increasing the rate flow of a more dilute solution

oxytocin agent25
OXYTOCIN AGENT
  • Ergonovine and methylergonovine

-an alkaloid from lysergic acid

-effects

:use IV, IM , PO

:powerful myometrial contraction

:persist for hours

:sensitivity of uterus is very great

:the response is sustained

with little tendency toward relaxation

slide26
-But, sometimes induce severe hypertension

:also colvulsion or cadiac arrest (Browning(1974))

-because of the frequency of hypertension,

do not use these alkaloids routinely

oxytocin agent27
OXYTOCIN AGENT
  • Oxytocics after delivery

-standard practice

:20 unit of oxytocin per liter

:a rate of 10 ml/min after delivery of placenta

for a few minutes until the uterus remains firmly

contracted and bleeding is controlled

:transfer to postpartum unit

->rate is reduced to 1 to 2 ml/min

lacerations of the birth canal
LACERATIONS OF THE BIRTH CANAL
  • First-degree: fourchette, perineal skin, vaginal

mocasal membrane

  • Second-degree: fascia and muscle of the perineal

body

usuallu extend upward on one or

both sides of the vagina

  • Third-degree: involve the anal sphincter
  • Fourth-degree: rectal mocosa

expose the lumen of the rectum

involve the region of the urethra

episiotomy and repair
EPISIOTOMY AND REPAIR
  • Purposes of episiotomy

- easier to repair

postoperative pain is less

healing improved

-prevented pelvic relaxation (cystocele, rectocele

urinary incontinence)

-but, increased incidence of anal sphincter and

rectal tears

episiotomy and repair30
EPISIOTOMY AND REPAIR
  • Timing of episiotomy

-early : bleeding

late : laceration

-when the head is visible during a contraction to

a diameter of 3 to 4 cm

episiotomy and repair31
EPISIOTOMY AND REPAIR
  • Midline versus mediolateral episiotomy
episiotomy and repair32
EPISIOTOMY AND REPAIR
  • Timing of the repair of episiotomy

-after the placenta has been delivered

  • Technique

-hemostasis and anatomical restoration without

excessive suturing are essential

-suture material: 3-0 chromic catgut

episiotomy and repair33
EPISIOTOMY AND REPAIR
  • Fourth-degree laceration

-approximate the torn edges

of the rectal mucosa with

muscularis sutures placed

approximately 0.5 cm apart

-this muscular layer then is

covered with a layer of

fascia

-stool softener, prophylactic

antimicrobials

-enema should be avoided

episiotomy and repair34
EPISIOTOMY AND REPAIR
  • Pain after episiotomy

-ice pack

aerosol sprays containing a local anesthesia

-If pain is severe or persistent

:vulvar, paravaginal or ischioractal hematoma or

perineal hematoma