18.2 Nursing Care 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).

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 efforts 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.

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 contractions, 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.)

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.

Figure 18.2 Perineal Hygiene Keeping the perineum clean during the second stage of labor maintains perineal hygiene and decreases the risk for infection. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)