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Course: Maternity Nursing

Topic: Nursing Care During Second Stage of Labour

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Module Goals

The learner will be able to:

Identify the signs of beginning stage 2 of labour
Describe the cardinal movements of labour (fetal descent and delivery)
Explain four ways a nurse can support a woman during delivery
Name three warning signs during delivery
Summarize the steps of delivering an infant during stage 2 of labour

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Stage 2 Labour: Symptoms and Signs

Begins when the cervix is fully dilated (10 cm)

Ends when infant is completely delivered

One or more of the following may occur:

The patient has an uncontrollable urge to bear down (push)
Uterine contractions increase in both frequency and duration (they are more frequent and last longer)
Perineum bulges during a contraction as it is stretched by the fetal head
The patient may become energetic, more focused, or sleepy

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According to Hesperian Health Guides- ‘A Book for Midwives’:

The only way to be certain of full cervical dilation is a vaginal examination. However, due to the risk of infection, vaginal exams should be limited and should be done every few hours, when the patient feels the urge to push, or if the fetal heart rate shows decelerations. With experience, one can usually tell by observing the mother’s behavior when the mother is ready to push.

According to Bettercare/Maternal Care/9.

If the symptoms and signs suggest that the second stage of labour has begun, an abdominal examination to assess the station of the fetal head, followed by a vaginal examination, must be done.

In primigravida, the head is usually engaged when the cervix reaches full dilation.

Multigravidae often reach full cervical dilation when the fetal head is still 3/5 or more palpable above the pelvic brim (the head is still not engaged.)

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Stage 2 Labour: Cervix Fully Dilated but Head Not Engaged

When the cervix is fully dilated, but the fetal head is not engaged, the patient should be allowed to wait before bearing down as long as:

There are no signs of fetal distress or cephalopelvic disproportion

If there are no signs of fetal distress and maternal assessment is normal; assess after an hour

If the head is not engaged after 1 hour of waiting

Carefully examine patient for cephalopelvic disproportion
Caesarean section (CS) is most likely indicated

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Progress of Labour: Descent and Engagement of

Fetal Head

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Assessment of descent and engagement of head is assessed by feeling how many fifths of the head are palpable above the brim of the pelvis: (Bettercare/Maternal Care/ 8a. Skills Examination of the abdomen in labor)

5/5 of the head palpable means the whole head is above the inlet of the pelvis.
4/5 of the head palpable means that a small part of the head is below the brim of the pelvis and can be lifted out of the pelvis with a deep pelvic grip
3/5 of the head palpable means that the head cannot be lifted out of the pelvis. On doing a deep pelvic grip, fingers will move outwards from the neck of the fetus, then inwards before reaching the pelvic brim.
2/5 of the head palpable means that most of the head is below the pelvic brim, and on doing a deep pelvic grip, your fingers only splay outwards from the fetal neck to the pelvic brim.

It also means engagement has taken place and the possibility of disproportion at the pelvic inlet can be ruled out.

1/5 of the head palpable means that only the tip of the fetal head can be felt above the pelvic brim.

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Assessment of Progress of Labour: Station

Assessed by vaginal examination
Fetal head at ‘0’ station if palpable at level of ischial spine
With every uterine contraction and attempt of bearing down, there should be some descent of the fetal head on the perineum
Fetal head is at station +4 or +5 just before birth

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Stage 2 Labour

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Cardinal Movements of Labour

Changes in the position of the fetal head as it moves through the maternal pelvis during labor and delivery
Cardinal movement for a normal vertex presentation are:

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

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According to López-Zeno, J, Glob. libr. women's med, 2008 :
Engagement: The vertex is engaged when the biparietal diameter is at the level of the pelvic inlet or lower. In clinical practice, this translates into an occiput palpable at 0 station.
Descent: This cardinal movement will usually happen concomitant with engagement, and is typically documented late in the active phase of the first stage of labor.
Flexion: As the vertex descends into the maternal pelvis, it will encounter resistance from the maternal pelvic floor muscles. This will cause the flexion of the fetal head onto the thorax.
Internal rotation: At the moment of engagement and descent of the vertex into the pelvis, the fetus will be in a transverse position. Because of the anatomic configuration of the pubococcygeus and iliococcygeus muscles, the occiput will be forced to rotate to the symphysis pubis. This is the widest area of the pelvic floor that will allow the passage of the fetus.
Extension: At the moment of the delivery of the fetal head, the combined effects of the uterine contractions and the pelvic floor result in this cardinal movement.
External rotation: This movement occurs as a consequence of the alignment of the head of the fetus with its spine as the pressure from the maternal pelvis and muscles on the fetal head is alleviated.
Expulsion: After delivery of the head, the anterior shoulder will descend under the pubic bone. As it is delivered, it will follow the external rotation of the head of the fetus.

These are not separate events, but rather closely related and some will happen simultaneously.

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Birth Process with Cardinal Movements

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3.

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Birth Process with Cardinal Movements

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8.

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Birth Process

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Stage 2 Labour- Helping Mother Deliver

Empty the bladder before bearing down
Prevent tears/lacerations by massaging or supporting the perineum
Clear/or suction the fetal nose and mouth
Check for a cord around the fetal neck (nuchal cord) right after the head is delivered
Deliver the fetal shoulders
Deliver the fetal body and give to the mother
Cut the cord

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According to Bettercare/Maternal Care/9. Second stage of labour:

Emptying bladder:

The patient should empty her bladder before starting to bear down
If unable to pass urine, then empty with a straight catheter that is done as a sterile procedure

According to Hesperian Health Guides- ‘A Book for MIdwives’:

Help mothers prevent tears:

Birth of the fetal head may tear the mother’s vaginal opening.

Some midwives do not touch the vagina or fetal at all during the birth. This is a good practice because interference can lead to infection, injury, or bleeding. Tear may be prevented by supporting the vagina during birth.

Episiotomy (manual surgical cutting of vaginal opening) should not be done to let the fetal out, except in an emergency or for a woman who has had Female genital cutting.

Support vagina opening

These instructions can be used when the fetal is facing the mother’s back.

1. Wash your hands well and put on sterile gloves.

2. Press one hand firmly on the perineum to keep the fetal chin close to his chest, making it easier for the fetal head to come out.

3. A piece of cloth or gauze is used to cover the anus to prevent the soiling of the vulva or fetal head by stool.

4. Use the other hand to gently move the top of the fetal head down towards the mother’s bottom and out of the vagina.

Use very warm cloths

· Warm clothes around the vaginal opening improve circulation making it soft and stretchy.

· Dip a clean cloth in boiled water (cooled a little bit before use) and squeeze it out.

· Press the cloth gently on the mother’s genitals.

Slow the birth of the head

· The mother’s vagina has more time to stretch and may less likely tear if the fetal head is born slowly.

· To slow the birth of the fetal head, help the mother stop pushing, or give very small pushes, right before the fetal head crowns

· To help mother stop pushing:

o Warn the mother to stop pushing before the fetal crowns.

o Tell the mother to blow hard and fast ( it is difficult to blow and push at the same time). Or,

o If the fetal head is not coming out and the mother can control her pushing, ask her to give very small pushes in between contractions - then stop and blow during the contractions. This gives her skin time to stretch.

o Each small push should move the head no more than 1 cm farther out of the mother.

· After the widest part of the fetal head (biparietal parameter) comes out, the rest of the head may come out without any pushing at all.

· Birth of the fetal head must not be slowed down if:

o there has been a gush of blood before the birth

o there is a prolapsed cord

o the fetal heartbeat is very slow

o Anticipate the fetus may be in trouble

o In any of these above cases, the baby must be born as quickly as possible.

Clear the baby’s nose and mouth

· when the fetal head is born, the baby might need help breathing by clearing his/her mouth and nose.

· mucus or water in the baby’s mouth or nose can be gently wiped with a clean cloth wrapped around a finger. Do not need suction.

· A baby who might have breathed in some waters should be held with his/her head a little lower than the rest of her body, so fluid can drain out.

· Yellow or green coloration of water in the baby’s mouth and nose indicates the meconium (baby’s stool) and risk breathing it into her lungs. The nurse may need to clean out the baby’s mouth with a suction trap or a bulb syringe (sometimes called an ear syringe).

· Only suction if there is meconium because suctioning can be causing the baby to have trouble breathing.

Check for the cord around the baby’s neck

· Cord around the fetal neck (Nuchal cord) must be felt if there is a rest between the birth of the fetal head and birth of the shoulder.

· If the cord is wrapped around the fetal neck, then:

o it should be loosened and slipped over the fetal head or shoulders

o If the cord cannot be loosened, the baby might need to be delivered around the cord. As the head begins to deliver, it should be kept close against the mother’s thigh., and let the fetus’s body somersault out around the head.

o once the baby is out, the tight cord can be unwinded and let the trapped blood flow back into the baby.

· rarely does a tight cord prevent a baby from being born.

· If the fetal head is born and the body is not coming, most likely shoulders are stuck.

· Cutting the cord before the birth of the baby cuts off fetal oxygen supply until the baby breathes which makes an emergency.

· Rarely there is a necessity to cut the cord before the birth of the fetus. Medical hemostats and blunt-tipped scissors are used for clamping and cutting the cord in these situations. Care must be taken to prevent cutting into the mother or fetal neck in the process.

· The mother must push hard and get the baby out fast if the cord had to be cut before the birth of the fetus.

Deliver the fetus shoulder

· Turn the fetal head to face towards the mother’s leg after the fetal head is born, and should wait for the next contraction.

· Ask the mother to give a gentle push as soon s she feels the contraction.

· Usually doing so, the fetal shoulder will slip right out, soon followed by the rest of the fetus.

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Case study:

A multiparous patient presents in labour at 18:00. The fetal head is palpable 3/5 above the pelvic brim, and the cervix is found to be 7 cm dilated. The vaginal examination is repeated at 21:00 when the alert line indicates that the cervix should be fully dilated. The examination confirms that the cervix is fully dilated. However, the fetal head is still not engaged. Preparations are made for the patient to start bearing down.

Should the patient start bearing down now that she has reached full dilation of the cervix? Why?

What signs and symptoms would indicate the patient should start bearing down?

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Stage 2 Labour: Delivery Positions

Delivery positions depend on the patient’s choice and the circumstances under which the delivery is conducted
The position chosen should allow for the best maternal effort for bearing down
Upright positions advance ease of birth due to gravity, increasing the strength of contractions, helping to turn fetus to a favourable position
If lying down, use the lateral position with a pillow between knees
Mother should not lie on supine position during labor and delivery

Compression of maternal inferior vena cava results in poor supply of blood to the fetus due to poor placental perfusion and may cause lack of oxygen to the fetus resulting in fetal distress

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According to Harrington, L, Glob. libr. women's med.,(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10127):
Maternal position affects the frequency and intensity of uterine contractions during labor
Caldeyro-Barcia and colleagues demonstrated that lateral positions were associated with more effective uterine contractions (i.e stronger intensity and lower frequency) than the supine position (lying on back)
there is evidence that lateral positions are associated with a higher cardiac output, decreased heart rate, and increased stroke volume compared with the supine position.
Squatting has been advocated to increase the diameter of the pelvic outlet by as much as 2.0 cm, to increase the bearing down urge, to facilitate the delivery of the placenta, and to prevent supine hypotensive syndrome.
In additions standing, kneeling, squatting, and lateral positions have been associated with maintaining an intact perineum as a result of more even application of fetal head at the introitus, which distributes pressure across the perineum, rather than concentrating the pressure at a single point.

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Stage 2 Labour: Delivery Positions

Dorsal position:

Easier for care provider to manage delivery
May cause postural hypotension, which may result in fetal distress
Placing a firm pillow under one of the patient’s hips to turn her 15 degrees on to her side can prevent postural hypotension

Lateral position (on her side):

Prevents postural hypotension
Provides a good view of the vulva and perineum, pelvic muscles relaxed
Delivery can be better controlled
Useful in situations where patient is unable to cooperate

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Stage 2 Labour: Delivery Positions

The upright position (i.e., vertical or squatting position)

The patient sits on her heels and supports herself on outstretched arms
Advantages

Maternal effort becomes more effective
The duration of the second stage is shortened
Fewer patients need assisted delivery

The semi-Fowler’s position (patient back lifted to 45 degrees from the horizontal)

May be used instead of the upright position
This partial sitting position comfortable for both patient and care provider

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Stage 2 Labour: Delivery Positions

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Stage 2 Labour: Pushing

Patient should start bearing down (voluntary pushing) only when:

Fetal head distends the perineum
Patient has a strong urge to bear down

Pushing too early

Partially closed cervix will block the fetus from emerging
Cervix may swell and stop opening, causing longer labor
Patient will become fatigued

If pushing for more than 30 minutes without progress, perform a vaginal exam

If cervix is still felt, assist the patient to the knee-chest position
Help patient stay in this position without pushing for an hour

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Nursing Management for Effective Pushing

Instruct the patient when and how to bear down
At the height of contraction:

Take a deep breath, put chin to chest, bear down with the contraction
Use open-glottis method bearing down in the abdomen, instead of the closed-glottis pushing (Simpson, 2006)
Encourage the patient to hold her legs or some firm object
Bear down as long as possible (more effective than a many short efforts)
Breathe out and take a quick deep breath if needed and bear down again

Encourage patient to rest between the contractions

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Nursing Management During Pushing

Listen to fetal heart between contractions to determine the baseline fetal heart rate

Assess fetal heart using fetoscope or by observing the fetal monitor strip if using a fetal monitor

Immediately after every second contraction
Fetal heart rate should remain at baseline rate
If fetal heart rate is slower at the end of contraction and takes 30 seconds or more to return to the baseline, this is called a late deceleration and is an indication that fetus is not getting enough oxygen (Immediately turn patient to side, provide oxygen if available, obtain further assessment by health care provider)

*Discontinue Oxytocin if infusing

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Nursing Management During Pushing

Continued……

*Intrauterine resuscitation/suppress uterine contractions
Assess frequency and duration of the uterine contractions
Assess for vaginal bleeding

Record progress of labour in partograph

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Nursing Management: Progress of Labour

If there are two contractions in 10 minutes, each lasting 40 seconds or more without progress in the descent of the head after four attempts at bearing down, then assess the patient for assisted delivery
In primigravida with inadequate uterine contractions and moulding of 2+ or less:

Use 1 unit of oxytocin
Patient must start bearing down when strong contractions start

No progress in descent of the head and 3+ moulding

Inform physician for urgent assessment, emergency CS indicated,
Patient should not bear down, but concentrate on breathing during contraction
Intrauterine resuscitation and suppressing uterine contractions

Contact info: info@nursesinternational.org

According to Bettercare/Maternal Care/8. Monitoring and managing the first stage of labour:

· With every uterine contraction and attempt at bearing down, there should be some descent of the fetal head on to perineum

· Method for administering 1 unit Oxytocin during the second stage of labor, where indicated:

1. 1 unit of oxytocin in 1 liter of Plasmalyte B, Ringer’s lactate, or rehydration fluid.

2. Use set which delivers 20 drops per ml

3. Start with 15 drops per minute, and increase the rate at intervals of 30 minutes to 30 drops/ minute, and then to 60 drops/minute, until the patient gets at least 3 contractions lasting at least 40 seconds every 10 minutes.

· Method of suppressing uterine contractions where indicated:

o Give 3 nifedipine 10 mg capsules by mouth ( a total of 30 mg), or

o Give 250 micrograms (0.5 ml) Salbutamol slowly intravenously, i.e 0.5 ml Salbutamol is diluted with 9.5 ml sterile water and given slowly intravenously over 5 minutes, provided there are no contraindications

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Episiotomy

A surgical incision made by the healthcare provider to aid difficult delivery.
Indications:

When the infant needs to be delivered without delay
To aid the delivery of the presenting part when the perineum is tight causing poor progress
When there is a high risk of third-degree tear/laceration
To allow more space for operative or manipulative deliveries, e.g., forceps deliveries

Types:

Mediolateral or oblique
Midline

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Episiotomy is performed by a skilled practitioner and according to national and professional scope of practice regulations

According Bettercare/Maternal Care/9a. Skills: Performing and repairing an episiotomy:

Episiotomy should not be done routinely if not indicated.

Preparation for an episiotomy:

· Inject local anaesthetic into the perineum. Usually, 10-15 ml of 1% lignocaine supplies adequate analgesia for performing an episiotomy.

· An episiotomy should not be done without analgesia.

· Local anaesthesia is injected below the skin and vaginal epithelium in the area where the episiotomy will be cut

· be very careful not to inject local anaesthesia into the presenting part of the fetus.

Types

· Mediolateral or oblique:

o used most frequently

o is safe

o requires the least experience

· Midline

o has the danger of extending into the rectum to become a third-degree tear.

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Episiotomy: Mediolateral Incision Method

Incision should only be started during a contraction when presenting part is stretching the perineum
If done too early may cause severe bleeding
Making incision:

Two fingers are slipped between the perineum and the presenting part
On the other hand, an incision is started in the midline and most posterior in the vaginal opening
Scissors pointed at 45-degree angle away from anus
Usually directed to the patient’s left but can also be to the right

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Case study:

A 39-week pregnant primigravida, complains of labour pain at 18:00. The fetal head is palpable 3/5 above the pelvic brim, and the cervix is found to be 7 cm dilated. The vaginal examination is repeated at 21:00 when alert line indicates the cervix should be fully dilated. The examination confirms that the cervix is fully dilated, and the fetal head is engaged. The patient is asked to bear down, but the labour does not progress after pushing for 30 minutes.

Should the nurse perform an episiotomy to hasten the labour? Why?

What would the appropriate thing for the nurse to do regarding the management of this patient?

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Should the nurse perform an episiotomy to hasten the labour? why?

There are no indications for episiotomy for this patient at this time.

What would the appropriate thing for the nurse to do regarding the management of this patient?

The nurse would try to assess different factors that could be causing poor progress of labour such as the mother is

Fear, anxiety
Exhaustion
Full bladder
Needs to change positions

Cephalopelvic disproportion is ruled out after finding of engagement of fetal head.

After identifying the cause nurse would provide care addressing those issues, such as:

Reduce patient’s fear and tension through support and encouragement
Compassion and letting the patient talk about her fears can help the patient relax
Ensure that only supportive family and friends attend the delivery.
Help patient welcome contractions by explaining that the discomfort is normal and the contractions it help to bring the baby down
Encourage the patient to take a deep breath after each contraction to help the muscle relax
(Imagery)Ask her to picture the cervix or the womb opening up and letting her baby out
Praise her and
Give a massage, warm bath, apply warm clothes to her body
If full bladder, help patient urinate or if necessary put in a catheter
Encourage changing positions to squat or hand-and-knees, walking
Give the patient something to hold on to, like a doorknob or rope tied to the ceiling
Tell the patient what good work she is doing, remind her how strong she is.
If the labour still does not progress, vaginal examinations are done. If the cervix is felt then put the patient in a knee-chest position, which will lift the pressure of the fetus off of the cervix, allows the swelling to go down, and cervix start opening again.
Help the patient stay in the knee-chest position for an hour or so. Once the cervix is fully dilated, encourage the woman to bear down again.

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Prolonged Second Stage of Labour

Criteria for prolonged second stage of labour

Primigravida: Stage lasts longer than 45 minutes without delivery of the infant
Multigravida: Stage lasts longer than 30 minutes without delivery of the infant

Some causes of prolonged labour in the second stage of labour are

Fear and anxiety
Exhaustion
Full bladder
Mother needs to change positions
Fetal is in difficult or impossible birth position
Fetus does not fit through the mother’s pelvis

A prolonged second stage of labour is a serious concern that requires immediate and appropriate management

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Prolonged Second Stage of Labour: Nursing Management

Following care can be given if cephalopelvic disproportion or impossible birth position is ruled out:

Reduce patient’s fear and tension with support and encouragement
Remind patient that contractions help to bring the fetus down
Give a massage, warm bath, apply warm clothes to her body
If full bladder, help patient urinate or if necessary perform catheterization
Encourage position changes: squatting, hand-and-knees, walking
Give the patient something to hold on to, like a doorknob or rope tied to the ceiling
Praise patient’s efforts

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Prolonged Second Stage of Labour: Medical Management

Conduct assisted delivery if

Cephalopelvic disproportion has been excluded, and
1/5 of the head or no fetal head remains above the pelvic brim

If cephalopelvic disproportion is present, surgical intervention (Cesarean section (CS) is indicated

Inform doctor for urgent assessment, emergency CS indicated,
Reposition the patient to her side and instruct her not to bear down, but concentrate on breathing during contraction
Initiate intrauterine resuscitation and suppression of uterine contractions

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Shoulder Dystocia

The condition where the anterior fetal shoulder is lodged behind the symphysis pubis following the delivery of the fetal head
Indicators of shoulder dystocia:

After delivery of the fetal head, it retracts back to the perineum and does not undergo normal rotation
More prelevant with large infants and obese patients
External rotation, lateral flexion, and traction fail to deliver shoulder

Risk factors:

Prolonged labour
Assisted deliveries
Rapid labour
A large fetus
Maternal obesity
Diabetes mellitus
Shoulder dystocia in previous pregnancy

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Shoulder Dystocia

Complications of shoulder dystocia:
Postpartum hemorrhage, cervicovaginal lacerations, fourth-degree lacerations of the rectum, bladder atony, and uterine rupture, fracture of clavicle or humerus, brachial plexus injury
Management:

Recognition of risk factors during antepartum and intrapartum is the first step of its management
When fetal macrosomia is suspected, the patient should be thoroughly counseled regarding the risks and benefits of a trial of vaginal delivery by an expert
Shoulder dystocia during delivery should be managed urgently
by expert doctors/midwives

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According to Bettercare/Maternal Care/9. Second stage of labour,

The earlier these signs of shoulder dystocia are recognized, the better is the chance that this complication will be successfully managed.

According to Gherman, R, Gonik, B, Glob. libr. women's med.:

Management of shoulder dystocia

The anticipation of shoulder dystocia through recognition of risk factors during antepartum and intrapartum is the first step of its management.
Every effort should be made to prepare a rapid, systematic, and well-coordinated stepwise plan.
When fetal macrosomia is suspected, the patient should be thoroughly counseled regarding the risks and benefits of a trial of vaginal delivery.

McRoberts maneuver is the initial technique for the dislodging of the anterior shoulder.

Needs two assistants
Involves flexion of the mother's legs onto her abdomen which is associated with an increase in the mean angle of inclination between the symphysis pubis and the sacral promontory
Simultaneously, suprapubic pressure is applied either posteriorly or laterally, which can displace lodged shoulder into oblique diameter and effect delivery.

Fetal manipulation:

In Woods (corkscrew) maneuver, the posterior shoulder is pushed through a clockwise 180 degrees arc by applying pressure on the anterior surface of the posterior shoulder.
In the reverse Woods maneuver or Rubin maneuver, the pressure is applied to the posterior surface of the anterior shoulder to effect counterclockwise rotation of the posterior shoulder.

Should the above maneuvers fail:

The expert provider can pass a hand into the vagina following the posterior arm to the elbow. After pressure is applied at the antecubital fossa to flex the fetal forearm, the arm is swept out over the infant’s chest and delivered over the perineum.
Rotation of the fetal trunk to bring the posterior arm anteriorly may be required.

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Breech Delivery

There are three breech presentations:

Frank breech (straight legs)
Complete breech (folded legs)
Footling breech (feet first)

Complications of Breech births:

Cord prolapse
Fetal head stuck at the cervix
Fetal death from the cord getting pinched between fetal head stuck at the mother’s pelvis if fetal body delivers first

Frank Breech

Complete breech

Footling breech

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Case Study:

A patient who progresses during the first stage of labour until a cervical dilatation of 7 cm and reaches full dilatation after 5 hours. At the last examination, 3/5 of the fetal head is still palpable above the pelvic brim, while 3+ moulding is found on vaginal examination. The patient is prepared for the second stage of labour and is asked to bear down with contractions.

What would be the most likely cause of a prolonged second stage in this patient?

Should the nurse allow the patient to bear down? Why?

How should this patient be managed further if she is at a clinic?

Contact info: info@nursesinternational.org

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Cultural Considerations

In some communities, circumcision of girls (also called female genital cutting) is common; The female genital cutting (FGC) causes scars that may not stretch enough to let the fetus deliver.
If the mother has been circumcised, the scar of the circumcision may need to be incised before the fetal head starts to crown

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References:

Assegid, M. (2003). Obstetric and Gynecological Nursing: Lecture notes for nursing students. In collaboration with The Ethiopia Public Health Training Initiatives, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Retrieved from: https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_students/ob-gyn-body.pdf

Bettercare (n.d.). Maternal Care/9. Second stage of labour. Retrieved from: https://bettercare.co.za/learn/maternal-care/text/09.html#9-the-second-stage-of-labour

Bettercare (n.d.). Maternal Care/8. Monitoring and managing the first stage of labour. Retrieved from: https://bettercare.co.za/learn/maternal-care/text/08.html#8-monitoring-and-managing-the-first-stage-of-labour

Contact info: info@nursesinternational.org

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References:

Harrington, Lisa. Normal Labor and Delivery, Global Library of Women’s Medicine. (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10127 Retrieved on 24 September 2020, from: https://www.glowm.com/section_view/item/127

Hesperian Health Guides- ‘A Book for Midwives: Chapter 12’. Retrieved from: https://en.hesperian.org/hhg/A_Book_for_Midwives:What_happens_during_stage_2_of_laborLópez-Zeno, J. Presentation and Mechanisms of Labor, Glob. libr. women's med.,(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10126. Retrieved from: https://www.glowm.com/section_view/item/126

Simpson KR. When and how to push: providing the most current information about second-stage labor to women during childbirth education. The Journal of Perinatal Education. 2006 ;15(4):6-9. DOI: 10.1624/105812406x151367. Retrieved from: http://europepmc.org/article/MED/17768429#impact

Contact info: info@nursesinternational.org

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References:

World Health Organization (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.). Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

Contact info: info@nursesinternational.org

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