Transcript MANAGEMENT OF SECOND-STAGE LABOR  The onset: full dilatation of the cervix  bear down descent of the presenting part the urge of defecate  uterine.

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
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 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
-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 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
-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 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
 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 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 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
-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 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 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
-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 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
- 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 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 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 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
-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 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 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 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 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
-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 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
 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
 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 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 REPAIR
 Midline versus mediolateral episiotomy
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 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 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