2nd Stage Management

Prepared by:

Dr. Kasturi Malla

Senior Consultant Gynecologist & Obstetrician: Government of Nepal

Visiting Professor: CTGU
February, 2009
 Diagnosis
 Definite sign   Suggestive
Cx os fully dilated symptoms
= 10cm 1. Bearing down
efforts
 Suggestive sign  2. Defecation reflex
Increasing uterine 3. Feeling of fullness
contractions of bladder
4. Feeling of
stretching of
perineum
 Principles

1. To assist slow and steady birth

2. To prevent perineal injury

3. To prevent fetal complication

4. To give relative comfort to the pt.

 Prepare for delivery 1
 Keep on bed
1. on dorsal position
2. slight head up
3. slight lateral tilt

 FHR q5min

 Administer analgesics if needed

 Prepare for delivery 2
 Scrub, wear lower leg boot, sterile gown,
mask and gloves.

 Toileting of external genitalia

 Draping of perineum up to the abdomen

 Catheterize
 Prepare for delivery 3

 Perform p/v exam to-

1. confirm Dx,

2. exclude complication
Meconeum
Cord
Conduct delivery
1. Head delivery

2. Shoulder delivery

3. Trunk delivery
 Head delivery
Principles
1. Keep head flexed

2. Prevent early extension

3. Regulate slow exit out of the pelvic

outlet

4. Deliver in between contractions

5. episiotomy
 Head delivery 1
 Encourage bearing down effort

 Push occiput down and back to

maintain flexion by lt. thumb and
index finger

 Support perineum by rt. palm with a

pad
 Head delivery 2
 Watch for Crowning to occur

 Do episiotomy over the bulged

thinned out vulva

 Slow delivery of head in between

contractions:- in the order of
forehead  nose  mouth  chin
 Head delivery 3

 Suction of pharynx then nose

 Wipe out eye lids

 Feel cord round the neck if any 

slip it over or cut between the
clamps
 Shoulder delivery
 Wait till Restitution If slow:-
and External 1. Grasp head
rotation of head 2. Apply gentle
traction backward
 Watch for to deliver
spontaneous ant.one
delivery 3. Lift up to deliver
post.one
 Trunk delivery

 Keep fingers on either axilla

 Apply gentle pull for lateral flexion

 Immediate newborn care 1
 Receive baby in a clean and dry linen

 Gentle suction

 Cord clamp/Ligature with 1”stump

 Apgar scoring: 1 & 5min

 Immediate newborn care 2
 Keep warm

 Mop with a soft cloth

 Examine for congenital anomaly if

any

 Wrap with a warm cloth

 Palpate the abdomen to rule out the
presence of an additional baby and
proceed with active management of
the third stage.
Active Management of the Third
Stage
 Active management of the third
stage of labour (active delivery of the
placenta) helps prevent post partum
haemmorrhage. It includes:
• Immediate oxytocin;
• Controlled Cord traction; and
• Uterine massage.
 Oxytocin
 Within 1min. Of delivery of baby,palpate
the abdomen to rule out the presence of
an additional baby,Give Oxytocin 10 units
IM (effective after 2-3 mins.,has minimal
side effects). If oxytocin not available,
give ergometrine 0.2mg IM or
prostaglandins ( Do not give to women
with pre-eclampsia, eclampsia or high BP
because it increases the risk of
convulsions and CVA )
 Controlled Cord traction
 Clamp the cord close to the perineum by
sponge holding forceps within 1 min. of
delivery. Hold the clamped cord and end of
the forceps with one hand.
 Place the other hand just above the
women’s pubic bone and stabilise the
uterus by applying counter traction during
controlled cord traction. This helps prevent
inversion of the uterus.
 Keep slight tension on the cord and await
a strong uterine contraction (2-3 mins )
 When the uterus becomes rounded or the cord
lenghens, very gently pull downwards on the cord
to deliver the placenta. Continue to apply counter
traction to the uterus with the other hand.
 If during 30-40 secs, placenta does not descend
(no placental seperation ), do not continue to pull
on the cord
• Gently hold the cord and wait till the uterus well
contracted again. With the next contraction, repeat the
same traction
• Hold the placenta with two hands and turn it untill the
membranes are twisted, slowly pull to complete the
delivery. Remove any pieces of placental membranes
• If a portion of the maternal surface is
missing or there are torn membranes
with vessels, suspect retained placental
fragments
• If inversion occurs, reposition the uterus
• If the cord is pulled off, manual removal
of placenta may be necessary
 Uterine Massage
 Immediately massage the fundus of
the uterus through the women’s
abdomen untill the uterus is
contracted.
 Repeat uterine massage every 15
mins. For the first 2 hours
 Ensure the uterus does not become
relaxed after stopping the uterine
massage
 Examination for Tears
 Examine the women carefully and
repair any tears to the cervix or
vagina or episiotomy.
 Initial Care Of the Newborn
 Check baby’s breathing and colour every 5
mins
 If cyanotic or breathing <30 or >60
breaths per min give oxygen by nasal
catheter or prongs
 Check warmth by feeling the feet every 15
mins If temp.<36.5 deg cen.rewarm the
baby
 Check the cord bleeding
 Apply antimicrobial drops to baby’s eyes
 Encourage breastfeeding, if ready
 Avoid seperating mother from
baby whenever possible. Do not
leave mother and baby
unattended at any time.