18.3: Nursing Care During the Second Stage of Labor
By the end of this section, you will be able to:
- Obtain assessment data on the birthing person and fetus during the second stage of labor
- Discuss nursing interventions during the second stage of labor
- Explain the nursing actions when monitoring the fetus during the second stage of labor
- Explain the nursing actions when monitoring the birthing person for complications during the second stage of labor
- Explain the nursing actions when preparing for a vaginal delivery
Nursing care during the second stage of labor involves assisting the birthing person with pain management, positioning, and efforts to bear down during the contractions and birth. The laboring person is now completely dilated and feeling the urge to push. Successful coordination of the person’s bearing-down efforts and contraction pattern is an essential part of the nurse’s role during the second stage of labor. At the same time, the nurse also continues to monitor the birthing person’s progress, emotional and physical response, and fetal adaptation while preparing for the birth of the newborn.
Assessment of the Laboring Person and Fetus during the Second Stage of Labor
During the second stage of labor, nursing care is focused on providing essential support for both the laboring person and the fetus. The nurse will closely monitor the progression of contractions, the descent of the fetus through the birth canal, and the fetal heart rate. The nurse is a source of encouragement and guidance through the second stage and supports the birthing person with pain management. Ensuring the birthing person’s and support person’s comfort, safety, and informed decision making remains a priority for the nurse, as the health-care team readies for the safe delivery of the baby. Continuous assessment, communication, and collaboration are key components during the second stage of labor.
Monitoring the Physical Response of the Person during the Second Stage of Labor
Maternal vital signs are routinely assessed at least every 30 minutes during the second stage of labor unless otherwise determined by order or protocol (Table 18.6). The nurse should assist the patient into a position of the birthing person’s choosing and provide support and encouragement, or guidance with pushing. If the birthing person desires, the nurse may provide the birthing person with sips of water or ice chips (Milton, 2024).
| Assessment Data | Second Stage of Labor |
|---|---|
| Vital signs |
Every 30 minutes
Temperature
|
| Contraction pattern | Intermittently or continuously every 15 minutes, documented at the same interval as FHR |
| Progress in descent | As indicated based on pressure, perineal bulging or crowning, abnormalities in the FHR |
| Pain | Hourly, or more frequently as needed |
| Emotional response | Continuous |
| Intake and output | Continuous |
The nurse continues to monitor contraction strength and frequency during the second stage of labor. The contraction pattern is typically assessed every 15 minutes. During the strongest part of the contractions, the nurse coaches the birthing person through the bearing down effort s and monitors for fatigue. If necessary, additional instructions for bearing down are provided between contractions when indicated.
The nurse also monitors the descent of the fetus through the pelvis by assessing the fetal station and presence of crowning. As the fetus descends, the nurse provides updates to the birthing person and their support persons. These updates aid in keeping the birthing person motivated to keep the bearing-down efforts most effective (Milton, 2024).
Monitoring the Fetal Response to the Second Stage of Labor
The fetal heart rate is monitored during the second stage of labor, assessing for patterns that can indicate fetal compromise (Table 18.7). Abnormal patterns are associated with hypoxemia. which may lead to hypoxia, resulting in metabolic acidosis. The type and frequency of fetal monitoring are determined by provider order, protocol, and clinical situation (AWHONN, 2018). Fetal monitoring may be done intermittently, continuously with an external fetal monitor, or internally with a fetal scalp electrode . The nurse should be in regular contact with the provider, relaying critical information about the fetal monitoring findings and implementing interventions when compromise is identified.
| Fetal Assessment Data | Second Stage of Labor | |
|---|---|---|
| Low risk without oxytocin | With risk factors or oxytocin | |
|
FHR baseline
FHR variability Periodic changes |
Every 5–15 minutes | Every 5–15 minutes |
Nursing Interventions during the Second Stage of Labor
In many cases, the nurse is at the bedside frequently during the second stage of labor and exclusively during pushing. The role of the nurse during the second stage of labor is to assess the labor progress, monitor the fetal heart rate and contraction patterns, guide and support the birthing person, and aid the provider.
Encouraging Bearing-Down Efforts during the Second Stage of Labor
The direct contact of the fetus on the pelvic floor usually initiates the maternal urge to push. This sensation may be dulled when the birthing person has an epidural in place. The role of the nurse during this stage of labor is to provide motivation and encouragement for the birthing person. The strategies implemented may include emphasizing to the birthing person the benefits of relaxation of the perineum or coordinating bearing-down efforts with the contraction pattern via the tocodynamometer in a birthing person with an epidural. The nurse will coach the birthing person to maximize pushing efforts and coordinate pushing and breathing efforts. The nurse will also provide feedback to the birthing person about their pushing efforts and maintain continuous communication with the provider about the pushing progress.
In open glottis pushing , the laboring person follows their body’s spontaneous, natural urges to push without specific instructions or holding their breath or can be directed to bear down while exhaling. Directed open glottis pushing contrasts with the traditional closed glottis or Valsalva pushing technique, in which the laboring person is instructed to hold their breath and push forcefully for a specified duration during each contraction (Barasinski et al., 2020). During open glottis pushing, the laboring person continues to breathe normally. They take deep breaths in and exhale naturally as they feel the urge to bear down and push. There is no forced breath-holding. Open glottis pushing allows for more natural pushing efforts. Studies suggest that there is no difference in the incidence of perineal lacerations between open and closed glottis pushing (Barasinski et al., 2020).
Changing positions during labor can be highly beneficial in aiding the descent of the fetus through the birth canal (Huang et al., 2019). Different positions can help optimize the alignment of the fetal head with the pelvis, facilitate uterine contraction s, and reduce pressure on specific areas, potentially making the labor process more efficient and comfortable. It’s important to note that the effectiveness of positions may vary for each laboring person, and the choice of position should be based on comfort and what feels most effective during labor. Continuous communication with the health-care team and a supportive birthing environment are essential to ensure safety and to optimize the labor process.
Promoting Relaxation and Rest during the Second Stage of Labor
The role of the nurse in promoting relaxation and rest during the second stage of labor may vary based on the pain control decisions of the birthing person. For a birthing person who has an epidural, the nurse can assist the person with positioning and creating a calm, quiet environment. For a birthing person who has chosen analgesia or nonpharmacologic methods, the nurse can support the person with positioning, bearing down, and breathing techniques (Heim & Makuch, 2023).
Providing Comfort Measures during the Second Stage of Labor
The second stage of labor can bring discomfort that the nurse can assist in alleviating. Warm compresses may be applied to the perineum or lower back, and the nurse or support person may apply pressure to or massage the lower back. Cool cloths can also be applied to the birthing person’s forehead or neck. To encourage family-centered care, the nurse can teach the family or friends of the birthing person to apply these techniques.
Monitoring for Complications during the Second Stage of Labor
The second stage of labor brings about the potential for complications that may affect the laboring person or the fetus. The nurse continues to monitor maternal vital signs, discomfort, and pain while supporting pushing. The nurse should continually assess for complications of the laboring person, including bladder distention , perineal tears, excessive bleeding, and slow or lack of progress in descent (Milton, 2024). These complications are outlined in (Table 18.8). (Please see further discussion of shoulder dystocia in Chapter 19 Complications of Labor and Birth.)
| Complication | Nursing Assessment |
|---|---|
| Prolonged second stage | Assess cervical dilation and descent of the fetus. |
| Monitor uterine contractions for frequency and strength. | |
| Evaluate the laboring person’s pushing efforts. | |
| Observe the fetal heart rate for signs of distress. | |
| Assess for signs of exhaustion or distress in the laboring person. | |
| Assess for distended bladder. | |
| Fetal distress | Continuously monitor the fetal heart rate. |
| Document heart rate patterns (e.g., decelerations). | |
| Evaluate maternal vital signs for signs of infection or fever. | |
| Assess amniotic fluid color, odor, and meconium presence. | |
| Notify the health-care provider of the presence and associated symptoms. | |
| Shoulder dystocia | Assist with maneuvers such as McRoberts and suprapubic pressure, as directed by the health-care provider. |
| Document the time of occurrence and actions taken. | |
| Assist with the evaluation for maternal and fetal injuries. | |
| Rapid delivery | Notify the health-care provider. |
| Support the baby’s head and guide the shoulders if the health-care provider is not present. | |
| Ensure a safe and controlled birth process. | |
| Document the time of birth and any complications. |
The second stage of labor is a time of increased stress on the fetus. The nurse must monitor the fetal heart rate to ensure the safe delivery of the newborn. The nurse should monitor for an abnormal fetal heart rate with pushing and notify the health provider when indicated. The nurse must also monitor the birthing person’s progress for any risk of shoulder dystocia , a situation in which the head of the newborn is delivered but a shoulder is trapped behind the birthing person’s pubic bone during the delivery. If a shoulder dystocia does occur, the nurse must be prepared to react and assist the provider in repositioning maneuvers, or cesarean birth, to deliver the newborn (Milton, 2024). (Please see further discussion of shoulder dystocia in Chapter 19 Complications of Labor and Birth.)
Communication with the Health-Care Provider
Communication with a health-care provider who is not at the bedside should continue regularly and consistently throughout the second stage of labor and during pushing. The nurse is responsible for the continued assessment of the birthing person and the fetal heart rate pattern and descent of the fetus through the pelvis. The provider should be aware of any potential maternal complications, abnormal fetal heart rate patterns, progress of the second stage, and pushing efforts. Any changes in maternal or fetal status should be reported immediately to the health-care provider.
Perineal Hygiene
Perineal hygiene is recommended during the second stage. Hygiene includes keeping the perineum clean using warm water poured over the perineum or using wet washcloths (Figure 18.2). The standardized method of perineal hygiene requires the nurse to cleanse the perineum from the pubic hair line to the anus (front to back). The nurse should be aware of any hospital policies for perineal cleansing and will assist the provider when appropriate and required.
Perineal Cleansing
Perineal cleansing during delivery is an important aspect of hygiene and infection prevention. Here are the steps for perineal cleansing:
- Gather supplies: Ensure that you have all the necessary supplies ready, including clean gloves, warm water, mild soap or antiseptic solution (per facility policy), clean washcloths or sterile sponges, and a clean towel.
- Verify if the patient has any allergies.
- Hand hygiene: Perform proper hand hygiene by washing your hands thoroughly with soap and water and drying them with a clean towel or disposable paper towels. Don sterile gloves to maintain aseptic technique.
- Position the patient: Assist the laboring person into a comfortable position for perineal cleansing, such as a lithotomy position (lying on the back with knees bent and feet in stirrups) or a position of their choice that allows easy access to the perineal area.
- Privacy and consent: Ensure the patient’s privacy and obtain their consent for the procedure.
- Warm water: Using warm water, wet a clean washcloth or sterile sponge. Squeeze out excess water to avoid excessive dripping.
- Cleansing motion: Gently cleanse the perineal area from front to back, starting with the pubic hair line and moving toward the rectal area. Use a separate area of the washcloth or sponge for each stroke, maintaining a one-way cleaning motion to prevent contamination from the rectum to the vaginal area.
- Pay attention to folds: Pay special attention to the folds and creases in the perineal area, ensuring thorough cleansing. Avoid excessive scrubbing or irritation, as the perineal area may be sensitive during labor.
- Rinse: After cleansing, use a clean, damp washcloth or sponge to ensure the area is clean and any soap or antiseptic solution is removed from the perineum. Again, use a front-to-back motion.
- Pat dry: Gently pat the perineal area dry with a clean towel or sterile gauze. Avoid rubbing, as this can irritate the skin.
- Dispose of supplies: Properly dispose of any used supplies, such as gloves and disposable washcloths, in accordance with health-care facility protocols.
- Reassure and comfort: Throughout the procedure, provide emotional support, reassurance, and explanations to the patient, maintaining open communication and addressing any concerns.
Perineal cleansing is essential for maintaining hygiene and preventing infection during labor and delivery. It is also an opportunity to provide comfort and support to the laboring person. Nurses and health-care providers should follow facility policies and guidelines while performing perineal cleansing to ensure safe and effective care.
Nursing Actions to Prepare for the Birth and the Time of Birth
During the second stage of labor, the nurse will begin to prepare for the birth of the newborn. A delivery table is usually set up in the labor and birth suite before the onset of the second stage of labor (Milton, 2024). The delivery table will contain sterile drapes, delivery equipment used by the provider, and instruments to complete repairs to the perineum if necessary (Figure 18.3). The contents of the delivery table will vary based on hospital and provider preferences.
The infant warmer should be available during delivery, allowing the rapid initiation of resuscitation of the neonate if necessary. The warmer should be stocked before the birthing person is placed in the room, and its contents should be verified by the nurse before delivery (Ahmed et al., 2018). (See Table 18.9 for a list of equipment and supplies to have ready for delivery in the warmer.) The warmer should be turned on by the nursing staff before delivery, allowing enough time for the warmer to preheat to the desired temperature (Figure 18.4). The labor nurse should also make sure oxygen and suction are set up and working. The nurse will communicate with other nursing staff, the nursery nurse, and the neonatal intensive care unit (NICU) to coordinate and prepare for delivery/resuscitation as needed (Ahmed et al., 2018).
| Type | Equipment |
|---|---|
| Resuscitation equipment | Neonatal resuscitation bag and mask |
| Suction bulb or catheter | |
| Endotracheal tube s (various sizes) | |
| Laryngoscope with blades (sizes 0 and 1) | |
| Stylet for endotracheal tube | |
| Meconium aspirator (if indicated) | |
| Oxygen equipment | Oxygen source (wall outlet or portable) |
| Oxygen mask and tubing (neonatal sizes) | |
| Thermoregulation | Radiant warmer or heat lamp |
| Prewarmed blankets or towels | |
| Hat and warm clothing for the newborn | |
| Monitoring and assessment | Neonatal stethoscope |
| Blood pressure cuff (neonatal size) | |
| Pulse oximeter with neonatal probe | |
| Thermometer (preferably electronic) | |
| Apgar scoring materials (Apgar score sheet) | |
| Clock or timer for timing interventions | |
| Umbilical cord care | Sterile umbilical cord clamp s or ties |
| Sterile scissors | |
| Antiseptic solution (e.g., chlorhexidine) for cord care | |
| Suction and oral care | Bulb syringe or mechanical suction device |
| Sterile saline solution for suctioning | |
| Oral suction catheters (if indicated) | |
| Emergency equipment | Neonatal bag-valve-mask (BVM) resuscitator |
| Cardiopulmonary resuscitation (CPR) board or firm surface | |
| Emergency medications (e.g., epinephrine, naloxone) and syringes | |
| Miscellaneous | Newborn diapers |
| Identification bands for parents and baby | |
| Baby blanket or swaddle |
The delivery of the newborn results in the collaboration of multiple health-care providers, which may be overwhelming to the birthing person and their family (Weiseth, 2022). The nurse should discuss the need for each member of the team and their role with the birthing person. In addition to the primary nurse assigned to the laboring person and the delivery provider, an additional nurse should attend the delivery solely to support the newborn, complete a newborn assessment, and initiate resuscitation with the neonatal resuscitation team when warranted. It would not be uncommon to find at least two nurses, the primary provider, a respiratory therapist (per facility policy), and support staff at the bedside during the delivery, all available for the safe delivery and support of the birthing person and newborn during the initial moments following birth (Weiseth, 2022).