Second Stage of

Labor

Stage of
Expulsion
Stage II of Labor, the stage of expulsion,
begins with full cervical dilation (10 cm) and
ends with the birth of the newborn. Maternal
efforts to bear down occur involuntarily during
contractions that are 1.5–2 min apart, lasting
60–90 sec. The average rate of fetal descent is
1 cm/hr for nulliparas, 2 cm or more per hr for
multiparas.
• Activity/Rest
-Reports of fatigue
-May report inability to self-initiate
pushing/relaxation techniques
-Lethargic
-Dark circles under eyes
• Circulation
-BP may rise 5–10 mm Hg in between contractions.
• Ego Integrity
-Emotional responses may range from feelings of
fear/irritation to relief/joy.
-May feel a loss of control or the reverse as she is
now actively involved in bearing down.
• Elimination
-Involuntary urge to defecate/push with contractions,
combining intraabdominal pressure with uterine
pressure.
-May have fecal discharge while bearing down.
-Bladder distension may be present, with urine
expressed during pushing efforts.
• Pain/Discomfort
-May moan/groan during contractions.
-Amnesia between contractions may be
noted.
-Reports of burning/stretching sensation of
the perineum.
-Legs may tremble during pushing efforts.
-Uterine contractions strong, occurring 1.5–2
min apart and lasting 60–90 sec.
-May fight contractions, especially if she did
not participate in childbirth preparation
classes.
• Respiratory
• Safety
-Diaphoresis often present
-Fetal bradycardia appearing as early
decelerations on electric monitor during
contractions (head compression) or variables
(cord compression)
• Sexuality
-Cervix fully dilated (10 cm) and 100% effaced.
-Increased vaginal bloody show.
-Rectal/perineal bulging with fetal descent.
-Membranes may rupture at this point if still intact.
-Increased expulsion of amniotic fluid during
contractions.
-Crowning occurs; caput is visible just before birth
in vertex presentation.
 Assessment
• Signs of imminent delivery
• Progress of descent
• Maternal/fetal vital signs
• Maternal pushing efforts
• Vaginal distension
• Bulging of perineum
• Crowning
• Birth of baby
 Nursing diagnosis
• Pain [acute]
• Skin/Tissue Integrity, risk for
impaired
• Injury, risk for fetal

Planning
• Facilitate normal progression of labor
and fetal descent.
• Promote maternal and fetal well-
being.
• Support client’s/couple’s wishes
regarding delivery experience,
• NURSING DIAGNOSIS: Pain [acute]
• May Be Related To: Mechanical pressure of
presenting part, tissue dilation/stretching, nerve
compression, muscle hypoxia, intensified
contractile pattern
• Possibly Evidenced By: Verbalizations,
distraction behavior (e.g., restlessness), facial
mask of pain, narrowed focus, autonomic
responses
• DESIRED OUTCOMES/EVALUATION
Verbalize reduction of pain.
• CRITERIA—CLIENT WILL: Use appropriate
techniques to maintain control. Rest between
contractions.
 INTERVENTIONS
• Identify degree of
discomfort and its sources.
• Provide comfort measures,
such as mouth care;
perineal care/massage;
clean, dry linen and
underpads; cool
environment (68°F–72°F
[20°C–22.1°C]), cool, moist
cloths to face and neck; or
hot compresses to
perineum, abdomen, or
back, as desired.
• Monitor and record uterine
activity with each
contraction.
RATIONALE
• Clarifies needs; allows for
appropriate intervention.
• Promotes psychological
and physical comfort,
allowing client to focus on
labor, and may reduce the
need for analgesia or
anesthesia.
• Provides information/legal
documentation about
continued progress; helps
identify abnormal
contractile pattern, allowing
prompt assessment and
intervention.
 INTERVENTIONS RATIONALE

• Assist client in assuming • Proper positioning with

optimal position for
bearing down; (e.g.,
squatting or lateral
recumbent, semi-
Fowler’s position
(elevated 30–60
degrees). Assess
effectiveness of efforts
to bear down.
• Encourage client to • Complete relaxation
relax all muscles and
rest between
contractions.
relaxation of perineal
tissue optimizes
bearing-down efforts,
facilitates labor
progress, reduces
discomfort, and reduces
need for forceps
application.
between contractions
promotes rest and helps
limit muscle
strain/fatigue.
• NURSING DIAGNOSIS: Skin/Tissue
Integrity, risk for impaired
• Risk Factors May Include:
Precipitous labor, hypertonic contractile
pattern, adolescence, large fetus, forceps
application
• DESIRED
OUTCOMES/EVALUATION Relax
perineal musculature during bearing-down
efforts.
• CRITERIA—CLIENT WILL: Be free of
preventable lacerations.
 INTERVENTIONS
• Assist client/couple with
proper positioning,
breathing, and efforts to
relax. Ensure that client
relaxes the perineal floor
while using abdominal
muscles in pushing.
• Offer use of birthing bed in
upright position.
Encourage squatting,
Fowler’s position, or
standing while pushing, if
these positions are not
contraindicated.
RATIONALE
3. Helps promote gradual
stretching of perineal and
vaginal tissue. If maternal
tissue within the birth
canal or perineum resists
gradual stretching as the
presenting part of the
fetus descends, trauma or
lacerations of the cervix,
vagina, perineum, uretha,
and clitoris are possible.
5. Upright positions reduce
duration of labor, enhance
forces of gravity, reduce
need for episiotomy, and
maximize uterine
contractility.
 INTERVENTIONS
Collaborative
• Assess for bladder fullness;
catheterize prior to delivery,
as appropriate.
• Assist with midline, or
mediolateral episiotomy, if
necessary.
• Maintain accurate delivery
records of location of
episiotomy and/or lacerations.
Record type and timing of
forceps if used.
RATIONALE
3. Reduces bladder trauma from
presenting part.
5. Although controversial,
episiotomy may prevent
tearing of perineum in cases
of a large infant, rapid labor,
and insufficient perineal
relaxation. It may shorten
stage I of labor, especially
when forceps are used.
6. Ensures proper
documentation of events
occurring during delivery
process; identifies specific
problems affecting postpartal
recovery; e.g., maternal tissue
trauma is increased with
forceps application, which
may result in possible
lacerations or extension of
episiotomy, increased
level of postpartal discomfort.
NURSING DIAGNOSIS: Injury, risk for
fetal

Risk Factors May Include:

Malpresentations/positions, precipitous
delivery, or cephalopelvic disproportion
(CPD)

DESIRED OUTCOMES/EVALUATION: Be
free of preventable trauma or other
complications.
 INTERVENTIONS
• Assess fetal position, station,
and presentation.
• Monitor labor progress and
rate of fetal descent.
RATIONALE
2. Malpresentations such as face,
mentum (chin), or brow may
prolong labor and increase the
likelihood that cesarean delivery
will be necessary, because lack
of neck flexion increases the
diameter of the fetal head as it
passes through the pelvic outlet.
Breech presentation usually
necessitates surgical
intervention, owing to the high
risk of spinal cord injuries
resulting from hyperextension of
the fetal head during vaginal
delivery.
3. Precipitous labor increases the
risk of fetal head
trauma because skull bones
do not have adequate
time to adjust to dimensions
of the birth canal.
 INTERVENTIONS
• Note color of amniotic fluid.
• Transfer to delivery room, as
appropriate, when vertex is
visible at introitus in nullipara,
or when multipara is 8 cm
dilated.
• Remain with client and
monitor pushing efforts as
head emerges. Instruct client
to pant during process.
RATIONALE
2. Meconium-stained amniotic fluid,
greenish in color, may indicate
fetal distress caused by hypoxia
in a vertex presentation or to
compression of fetal intestinal
tract in breech presentation.
3. If delivery is to occur in area
separate from the labor setting,
transfer at this time ensures that
infant is born where emergency
medications and equipment are
available, if needed.
4. Ensures that trained personnel
are present and reduces
possibility of trauma to fetal
vertex; allows gradual
accommodation of skull bones to
birth canal and overriding of
sutures.
Mechanisms of
Labor
There are eight classical steps in the normal mechanism of
labor as following here:

Engagement
• This is also called lightening or dropping
• The fetus nestles into the pelvis
• This is when the presenting part is at the level of the
ischial spines or at a zero (0) station. Before this time, it
is referred as "floating."

Descent
• This process starts from the time of engagement until
birth and is assessed by the station.
• The fetal head undergoes as it begins its journey through
the pelvis.
• As the fetal head engages and descends, it assumes an
occiput transverse position because that is the widest
pelvic diameter available for the widest part of the fetal
head.
 Flexion
While descending through the pelvis, the
fetal head flexes so that the fetal chin is
touching the fetal chest. This functionally
creates a smaller structure to pass
through the maternal pelvis. When flexion
occurs, the occipital (posterior) fontanel
slides into the center of the birth canal and
the anterior fontanel becomes more
remote and difficult to feel. The fetal
position remains occiput transverse.
 Internal Rotation
With further descent, the occiput rotates anteriorly and
the fetal head assumes an oblique orientation. In
some cases, the head may rotate completely to the
occiput anterior position.
 Extension
As the previously flexed head slips out from under the pubic bone, the fetus is
forced to extend his head so that the head is born pushing upward out of the
vaginal canal. The natural curve of the lower pelvis and the baby's head
being pushed outward forces distention of the perineum and vagina. As it
moves through the vaginal canal, the chin lifts up (extends) and the head is
delivered. During this maneuver, the fetal spine is no longer flexed, but
extends to accommodate the body to the contour of the birth canal.
 Restitution
After the head emerges, the fetal head becomes in a realignment.
External Rotation
The shoulder of fetus externally rotates after head emerging and
restitution
• The shoulder is in the anteroposterior diameter of the pelvis.
 Expulsion
• This is the birth of entire body.
(a)The top of the anterior shoulder is seen next just under the
pubis.
(b) Gentle downward pressure by the physician delivers the
anterior shoulder.
(c) The head is gently raised to deliver the posterior shoulder.
(d) The rest of the body follows the head, which then completes
expulsion.
(e) The fetus remains completely passive as it moves through
the birth canal.

The first four movements (descent, flexion, engagement, and

internal rotation) do not have to occur in any specific order.

A general understanding of how the fetus may present itself

during labor will help you to understand why some labors are
so long and difficult. In addition, this will help you in
understanding what the fetus must go through during the
process of presenting himself out of the patient's womb.