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Management of the Second Stage

Categories: Obstetrics or Midwifery

After the rupture of the membranes the
labor proceeds faster and a termination may be expected within a

reasonable time. There is a short lull in the pains, usually, after the

waters have escaped and during this time the patient should remove her

clothing and put on a night dress, and to prevent its being soiled roll it

well up under the arms and retain it there. After labor it can be very

easily pulled down and made comforta
le for the patient. A folded, clean,

sterile sheet is now placed about the body and extremities and held in

place by a cord around the waist. The opening in the sheet should be in

the right side, as this will allow the assistance being given as needed.

The powerful force of the abdominal muscles is now brought into action;

the force is best utilized with the woman lying on her back.



She should now be encouraged to bear down during the pains and she will be

greatly assisted by pulling on a sheet or long towel tied to the foot of

the bed, or by holding the hand of the nurse. A support for her feet

frequently aids the woman. Pressing low on her back relieves her to some

extent. In the intervals between the pains she should rest, do nothing,

and be perfectly passive. It is now that an anesthetic may be used to

relieve the suffering. She should not be put completely under its

influence for that is not only unnecessary, but injurious. Chloroform when

used should be given on a handkerchief opened and loosely held over the

woman's face, and administered drop by drop on the handkerchief. The

handkerchief should be placed over the face at the beginning of the pain

and be taken away as soon as the pain is stopped. The woman inhales the

chloroform during the pains and their sharpness is blunted. Given in that

way it is not considered dangerous. It should only be pushed to

unconsciousness during a forceps delivery, and even then it is not always

necessary to render the woman unconscious. I have used the forceps without

giving an anesthetic. They should be placed without causing any special

pain, and assist in delivery without causing any more pain when the head

is down low. Of course if the forceps must be used when the head is high

up a greater amount of anesthetic is needed.



Dr. Manton, of Detroit, says:--"The dangers of anesthetics are the same

when employed for obstetric purposes as in surgery, and then use should be

governed by the same rules in each instance." As soon as the head begins

to dilate the vulvar opening, the patient should be turned on her left

side with her knees drawn up and her body lying diagonally across the bed,

with the buttocks close to and parallel with the edge. This position

allows the physician to give better assistance and is no harder for the

patient.






The physician with his hands thoroughly sterilized and with a clean

sterilized gown, seats himself on the edge of the bed and watches the

progress of the labor, ready to assist the woman at any moment. And at

this time he can do much by words of encouragement and proper directions

to the laboring woman how to use her pains so as to get the most from

them; and also by manipulation of the soft parts and the head. The head

advances more and more with each succeeding pain, and the perineum is put

on the stretch, each contraction is followed by a resting pause during

which the head slips back a little and relieves the perineum. Tear of the

perineum is liable to take place when the head is about to escape through

the vulvar opening, especially if the contractions are strong, the woman

bears down forcibly and the interval between the pains is short, so that

the head is forced out before the parts have time to completely dilate and

soften. Here is where the physician's work comes in, by holding the head

back and fully flexed (bent), chin upon the breast, and keeping the back

of the head (occiput) well up towards the bone in front (pubic arch) until

thc perineum is completely dilated.



The effect of the pains can be lessened, if necessary, also, by telling

the woman to open her mouth and not to bear down during the pain for a few

times. In this way the perineum will dilate properly and be torn little,

if at all, and perhaps much future trouble for the woman saved. I always

tell my patient why I ask her to do certain things in labor and I have

never found any woman who, when able, was not willing to do as I asked. A

torn perineum is not desirable, because even when sewn up immediately

after labor, it may not unite thoroughly, and thus cause displacements of

the womb in the future. A little time and care at the time of labor will

save the perineum and every woman is willing to do her share when the

conditions are plainly explained to her. It takes only a few minutes

longer, and only a few more pains to bear. When the head begins to stretch

the opening, the left hand of the physician should be carried over the

woman's abdomen and between the thighs, her right leg being supported by a

pillow placed between her knees, and this left hand presses the back of

the head (occiput) forward and against the "pubic arch." The right hand

may also press the head upward by being placed against the posterior

portion of the dilated perineum. The edge of the perineum should now be

closely watched. A small towel wrung out of a bowl of hot water placed

handy on a chair, should be held constantly against the perineum to hasten

the softening and dilatation of these tissues. Plenty of hot water and

small towels should be at hand. The head advances with each pain and again

recedes until the parts are properly dilated, and the perineum slips

backward over the child's face.






If torn, it should be sewed before the physician leaves, as it can be done

easily and without pain to the mother. As the head of the child emerges,

the anesthetic should be pushed, or the woman told to open her mouth and

cry out. This lessens the pain and the child's head emerges slower, and

the perineum is saved. The child's head should be received in the hand.

After the head is born, there is a lull for a few moments. Then the

shoulders rotate into the proper position and are easily born. There may

then be a flow of watery fluid for a few seconds. Before this time the

physician has examined to see whether the cord is around the child's neck,

released it if it has been, and also cleaned out the child's mouth. The

child usually cries a little about this time and it is soon seen whether

it needs quick attention. The perineum should be guarded also while the

shoulders are being born as it can be torn by them. The shoulders are

generally born without any help. The child's head is held in the

physician's hand. As soon as the body is born, the child should be laid

upon the bed behind the mother's thighs, and the cord pulled down to

prevent it pulling upon the after-birth. After the beating in the cord has

ceased, generally from five to ten minutes have elapsed, the cord is then

tied, tight enough so it will not bleed afterward, about one or one and

one half inches (some say more) from the body and tied a second time an

inch or so from the first ligature, and the cord cut between the two

ligatures. Care should be taken so as not to cut a finger or toe of the

baby. If the cord is very thick it is best to pinch it at the point of

tying and the contents stripped away before the first ligature is applied.

After the cord is cut it should be wiped off to determine that bleeding

from the vessels has been permanently cut off, and if not it should be

tied again. The child is now taken up by placing the back of its neck in

the hollow between the thumb and forefinger, and the other hand over the

backbone. It should then be placed in a warm receiving blanket, and put in

a safe place.



Management of the Third Stage,--The contractions of the womb are renewed

and with the second or third the after-birth may be expressed. The top

(fundus) of the womb is grasped by the hand through the relaxed abdominal

walls, and squeezed, and at the same time make a downward pressure. The

after-birth is loosened from the womb and slides through the vagina and

outlet, and it may be caught in a tray which has been placed between the

patient's legs, or by the hand and given a few twists in order to roll the

membranes together; while this is being done, gentle rubbing should be

applied to the womb, when the membranes will slip out without tearing; no

drawing on the cord should be done in delivering the after-birth.



From the time of the birth of the head to the delivery of the after-birth

the womb must be controlled by the firm pressure of the hand on the

abdomen. It is well for the nurse, when the after-birth is separating from

the womb to follow the womb, throughout this whole stage, by keeping her

hand upon it and if, while the physician is attending to the child, the

womb softens and enlarges she should at once notify him. There may be

bleeding within the womb. After the womb is empty, friction should be made

over the womb whenever it softens at all in order to stimulate the womb to

perfect contraction, and it should be kept up at intervals for one hour

after the after-birth and membranes have been delivered.



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