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Management of the Second Stage





Category: 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 comfortable 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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Previous: Examination of the Patient



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