Stage II of Labor (Nursing)

00:01 All right, we've reviewed stage 1.

00:03 Now it's time to move on to stage 2.

00:07 Remember, stage 2 begins with complete dilation of the cervix, and it ends with delivery of the baby.

00:16 So just like in stage 1, there are two phases.

00:20 Bad or good? they're also called the same thing.

00:23 We have an early phase and we have an active phase.

00:27 The early phase really is more about the fetal making its descent.

00:32 It's very passive, there's not a lot of maternal urge to push, nothing like that, unlike active phase where the patient is really bearing down.

00:41 this is going to be a time when they really feel that urge to push and a lot of pressure.

00:45 So early - passive descent, active - as the name implies, active pushing, this is stage 2.

00:53 Let's break it down just a little bit more.

00:56 So in the latent phase of stage II, we have passive descent, which again means there's not a lot of active pushing on the part of a client.

01:05 The fetus actually rotates as it makes its way through the pelvis, it doesn't just come through like a basketball, it's going to turn like a corkscrew.

01:14 And so the fetus is actually going to rotate as a part of this descent into the pelvis.

01:20 The client is actually not necessarily going to feel a lot of urge to bear down even though the baby's coming down, it's not going to be very strong.

01:29 Now, when we get to the active phase, things are going to change.

01:32 Once the fetus is low enough that it hits the pelvic floor, it's going to actually make contact with baroreceptors.

01:39 And that is going to make the patient feel like, 'Oh, goodness, I'm really feeling a lot of pressure.' Sometimes they will verbalize that, sometimes as the nurse, you'll hear it.

01:49 They may be talking to you and they start to do this involuntarily because that urge to push is so strong.

01:56 And so during that active phase, we're going to take advantage of that urge.

01:59 And then we're going to encourage the client to actually start to push that fetus out.

02:06 At the very last part, and we're going to talk about crowning in a few slides, but we're actually going to see the baby's head sort of emerge between the labia and that's called crowning.

02:15 So that's going to let us know that the baby's coming very soon.

02:19 Now there's some things that may affect how stage 2 progresses.

02:24 So one of the things is the position of the fetus.

02:27 So when we talk about the five P's, we talk about our passenger.

02:31 If the fetus is not in the most optimal position, then it's going to make second stage hard.

02:36 So think about the fact that if I were standing up here, and I had my arms and legs all stretched out, and I were trying to get into a nice tight little dress, that would be very difficult.

02:46 But if I squeeze and I put on my Spanx, and everything like that I can get in it.

02:50 So if we keep the baby sort of nice and compact, it's going to make it easier for it to pass through the pelvis.

02:56 And that's how this works.

02:58 So a baby that's in a good position is going to come out easily.

03:03 A baby thats sprawled out like this will not.

03:05 Depending on how the comfort is managed, So sometimes when a patient or client has an epidural, then it may slow down that urge to push and we may find a slight slowing of second stage.

03:17 There's been some debate about this, but we're still not 100% sure.

03:21 It definitely can make a difference though.

03:24 The position of the mother.

03:25 Do you remember earlier we talked about the importance of ambulation and then how that helps to get the fetus to move and to come down? So having the client lie on their back for 2 or 3 or 8 or 10 hours is not going to be very effective, and when we get to stage 2, it absolutely makes a difference.

03:42 We want the fetus to come out and gravity is our friend, so moving is going to be really important.

03:48 Remember, I just said 8 to 10 to 12 hours? sometimes the client just gets tired.

03:54 And so that second stage, that active part, if you've given all that you've got, it's very difficult to go through second stage.

04:01 So sometimes getting a little bit of rest makes all the difference.

04:05 And also the size of the fetus, so not just the position but if we have an 11 pound fetus, that's going to be a lot different than a 6 or 7 pound.

04:14 So these are factors that definitely might affect second stage.

04:18 So what is the nurse doing? Well, remember, we're usually doing a lot of pushing during second stage.

04:25 So we want to talk to the patient about what effective pushing might look like.

04:31 We want to avoid closed glottis pushing.

04:34 So I'm going to walk you through that difference because it sounds a little strange.

04:39 So let's do that.

04:40 So if I were to push with a closed glottis that means I'm holding my breath.

04:46 Right? So my face is going to turn all red and that's not what we want.

04:50 We want to encourage the client to push with an open glottis so don't hold your breath.

04:54 So when you push, (exhaling) Right, I can still move air, I can still breathe because if I'm holding my breath, I'm not getting oxygen, the fetus is not getting oxygen, No good. All right? Remember the bladder, full bladder, baby sitting on top of bladder can't descend.

05:12 So we want to monitor the bladder and make sure that it's empty.

05:17 Hopefully, we're going to have a baby soon.

05:19 And typically, we need to have a warmer ready in case there are complications, and the baby needs to go to the warmer, so we're going to turn it on.

05:26 So we're going to preheat the warmer, so we're not placing a nice warm baby on a cold warmer, that wouldn't be good.

05:33 And then we're going to notify the delivery team especially in cases when there may be complications, so if there's meconium, or maybe the baby hasn't really been doing very well on the fetal monitor, and we have some concerns, we want everybody there.

05:46 So we're going to call them during second stage, so that once the baby's out, everybody's in place.

05:53 So I told you, I would tell you about crowning, and this is what it is.

05:56 So at the end of second stage, you see our baby here in the graphic, we can see the little hair sort of poking out between the labia.

06:04 So this is how we know second stage is hopefully coming to an end soon.

06:08 The labia are stretched around that presenting part.

06:11 and this is when the client will feel an intense amount of pressure and an intense amount of stretching and pain.

06:18 We actually call this the 'Ring of Fire.' And I don't think I have to explain why that might be.

06:25 So we have done all of this laboring in order to help get the baby out.

06:31 So there's actually a process called the mechanisms of labor that really breaks this down.

06:36 I want to show this to you so you can actually see the magic in order.

06:41 So we have engagement where the fetus is actually moving down to the level of the ischial spines.

06:46 And then we have descent.

06:48 So that is actually going to lead to flexion of the baby's head, and it's going to make the baby more compact, did you see that? I can go back and do that again, so up and down.

06:59 So you see how the baby becomes more compact, and it makes it easier for it to come out.

07:04 Then remember we talked about rotation of the fetus.

07:08 So that's what's going to happen with internal rotation.

07:11 Here we go.

07:12 Turn, turn, turn, turn.

07:15 So that's internal rotation, the fetus, it's making its way out.

07:19 And then we have extension.

07:21 So we've gone through the crowning, and now the fetus is poking its head out.

07:25 So now the head is out so that everybody can see the baby's wonderful face.

07:31 And then we have external rotation, a little bit of turn.

07:34 And then we have expulsion with delivery of the baby.

07:38 Tada! So that is the end of stage 2.

07:44 Now I want to show you one more thing that might affect that descent because this is pretty interesting.

07:50 It's called synclitism and asynclitism.

07:53 Remember, we want the baby to be compact, but we also need the fetus to be lined up well, so that it doesn't run into anything on the way out.

08:01 So when we have synclitism, that means that the baby's head is sort of equidistant between the sacrum and the pubic bone, so it's sort of in the middle.

08:10 If we have asynclitism, that means the head is sort of leaning one way or the other.

08:15 So if you think about the baby and its trajectory, if we have the head crooked, then the head's going to smash up against the pelvis and not make its way out.

08:23 So this is one of the things we want to check for when we do our digital exams to make sure that the baby's position and presentation is effective.