Page 65 - 33Elctronic Book (3) Normal Labor

Nursing Management of the Second Stage of

Labor

Assessment
• Assessment should include the following:

• Uterine contractions.
• Maternal physical and emotional status.

• Fetal well-being.

Signs and Symptoms of Second Stage of Labor

• Contractions become strong, and more frequent.
• Show is increased suddenly and becomes more blood tinged.

• Membranes rupture.
• Perineum starts to bulge and the anal orifice starts to dilate.

• Woman starts involuntary bearing down and feels the desire to defecate.
• She may be eager to sleep.
• She is apprehensive, irritable, unwilling to be touched, and may cry if

disturbed.
• She is frustrated, and unable to manage labor alone.
Nursing Diagnosis

• Pain related to descent of the fetus and stretching of vagina
and perineum.

• Fatigue related to inability to rest and pushing efforts.
• Anxiety related to unknown outcome of labor process.

• High risk of infection

Planning and Implementation
▪ Transfer to delivery room:

o Primigravida is transferred to the delivery room when the cervix is fully
dilated and the presenting part is seen.
o Multipara is transferred when the cervix is 7-8 cm (3-4 fingers).

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