Stage of

expulsion
(2 stage)
nd
» involuntary uterine contractions and
contractions of the diaphragmatic and
abdominal muscles

Power/Forces
 ˃Descent – may be preceded by engagement.
˃Flexion- as descent occurs, pressure from the pelvic
floor causes the chin to bend forward onto the chest.
˃Internal Rotation – from AP to transverse, the AP to
AP
˃Extension – as head comes out, the back of the neck
stops beneath the pubic arch. The head extends and
the forehead, nose, mouth and chin upper.
˃External Rotation (also called restitution) – anterior
shoulder rotates externally to the AP position.
»Expulsion – delivery of the rest of the body
Mechanisms of labor/Fetal position
changes (D FIRE ERE)
 ˃ When positioning legs on lithotomy, put them up at the same time to
prevent injury to the uterine ligaments
» As soon as the fetal head crowns, instruct mother
not to push, but to pant (rapid and shallow
breathing to prevent rapid expulsion of the baby).

» If panting is deep and rapid, called

hyperventilation, the patient will experience
lightheadedness and tingling sensation of the
fingers leading to carpopedal spasms because of
respiratory alkalosis.

Nursing care
» Management:
» let the patient breathe into a
brown paper bag to recover lost
carbon dioxide; a cupped hand
over the mouth and nose will
serve the same purpose.
 Assist in episiotomy (incision
made in the perineum
primarily to prevent lacerations).
» purposes:
˃ Prevent prolonged severe stretching of
muscles supporting the bladder or rectum
˃ Reduce duration of second stage when
there is hypertension or fetal distress
˃ Enlarge outlet, as in breech presentation or
forceps delivery
» Types of episiotomy:
» Median – from middle portion of the lower
vaginal border directed towards the anus

» Mediolateral – begun in the midline but directed

laterally away from the anus. Often
done because it prevents 4th degree
laceration should it occur despite
episiotomy.
» Natural Anesthesia

» is used in episiotomy
» i.e., no anesthetic is injected
because pressure of fetal
presenting part against the
perineum is so intense that nerve
endings for pain are momentarily
deadened Local anesthesia- xylocaine
Apply the Modified Ritgen’s Maneuver**

+Cover the anus with sterile towel and

exert upward and forward pressure on
the fetal chin, while exerting gentle
pressure with two fingers on the head
to control emerging head. This will not
only support the perineum, thus
preventing lacerations, but will also
favor flexion so that the smallest
suboccipitobregmatic diameter of the
fetal head is presented.
» Ease the head out and
immediately wipe the nose and
mouth of secretions to establish a
patent airway (remember: the
first and most important principle
in the care of the newborn is
establish and maintain a patent
airway). The head should be
delivered in between
contractions.
» Insert 2 fingers into the vagina so as
to feel for the presence of a cord
looped around the neck (nuichal
cord).
» If so, but loose, slip it down the
shoulders or up over the head; but if
tight, clamp the cord twice, an inch
apart, and then cut it in between.
» Immediately after delivery, the
newborn should be held below
the level of the mother’s vulva
for a few minutes to encourage
flow of blood from the placenta
to the baby
» The infant is held with its head in a
dependent position (head lower
than the rest of the body) to allow
for drainage of secretions.
»Remember: never stimulate
a baby to cry unless you have
drained him out of his secretions.
»Wrap the baby in a
sterile towel to keep
him warm.
»Remember:
Chilling increase the
body’s need for oxygen
»Put the baby on the
mother’s abdomen.
»The weight of the baby
will help contract the
uterus
» Cutting the cord is postponed until
the pulsations have stopped
because it is believe that 50 – 100
ml. of blood is flowing from the
placenta to the baby at this time.

» After cord pulsations have stopped,

clamp it twice, an inch apart and
then cut in between.
Show the baby to the
mother, inform her of the
sex and time of delivery
then give the baby to the
circulating nurse.
» Placental Stage

» Signs of placental separation

˃ A.Uterus becoming round and firm
again, rising high to the level of the
umbilicus (Calkin’s sign)– the earliest
sign of placental separation
˃ B. Sudden gush of blood from the
vagina
˃ C. Lengthening of the cord
»Types of placental delivery
»Schultz – if placenta separates first at its
center
and last at its edges, it tends to fold on itself like
an umbrella and presents the fetal surface which is
shiny (“Shiny” for Schultz); 80% of placentas
separate in this manner.

»Duncan – if placenta separates first at its edges,

it slides along the uterine surface and presents with
the maternal surface which is raw, red, beefy, and
irregular and “dirty” (“Dirty” for Duncan). Only
about 20% of placentas separate this way.
» Nursing Care
–Do not hurry the expulsion of the
placenta by forcefully pulling out
the cord or doing vigorous fundal
push as this can cause uterine
inversion.

–Just watch for the signs of placental

separation.
» Tract the cord slowly, winding it
around the clamp until the
placenta spontaneously comes
out, slowly rotating it so that no
membranes are left inside the
uterus, a method called Brandt
– Andrews maneuver.
» Take note of the time of
placental delivery.
» It should be delivered within 20
minutes after the delivery of the
baby.
» Otherwise, refer immediately to
the doctor as this can cause
severe bleeding in the mother.
» Inspect for completeness of
cotyledons; any placental
fragment retained can
also cause severe
bleeding and possible
death.
Palpate the uterus to determine
degree of contraction.
» If relaxed boggy or non -
contracted, first nursing action
» is to:
1. massage gently and properly.
2. An ice cap over the abdomen
will also help contract the uterus
since cold causes vasoconstriction.
» Inject oxytocin (Methergin = 0.2
mg./ml. or Syntocinon = 10U/ml)
IM
» to maintain uterine contractions,
thus prevent hemorrhage.

Note: oxytocin are not given before

placental delivery.
» Inspect the perineum for lacerations.

» Any time the uterus is firm following

placental delivery, yet bright red vaginal
bleeding is gushing forth from the
vaginal opening, suspect lacerations
(tend to heal more slowly because of
ragged edges)
» Categories of lacerations
» First degree – involves the vaginal mucous
membranes and perineal skin
» Second degree – involves not only the muscles,
vaginal mucous membranes and skin, but also
the muscles.
» Third degree – involves not only the vaginal
mucous membranes and skin, but also the
external sphincter of the rectum
» Fourth degree – involves not only the external
sphincter of the rectum, the muscles, vaginal
mucous membranes and skin, but also the m
mucous membranes of the rectum.
» The newly – delivered mother
may suddenly complain of chills
due to decreased blood
pressure, fatique or cold
temperature in the delivery
room.
» Management: provide
additional blankets to keep her
warm.
»May give initial
nourishment; e.g., milk,
coffee or tea
»Allow patient to sleep in
order to regain lost of
energy.
»Fourth Stage
»– first 1 – 2 hours after
delivery which is said to be
the most critical stage for
the mother because of
unstable vital signs.
»Assessment
Fundus – should be checked every
15 minutes for 1 hour then every
30 minutes for the next 4 hours.
Fundus should be firm, in the
midline, and during the first 12 hours
postpartum, is a little above the
umbilicus.
First nursing action: non-
contracted uterus: massage.
»Lochia
»should be moderate in amount.
»Immediately after delivery, a
perineal pad can be completely
saturated after 30 minutes.
»If saturated in 15 minutes or
earlier, may mean hemorrhage.
» Bladder
» – a full bladder is evidenced by
a fundus which is to the right
of the midline and dark – red
bleeding with some clots.
»Will prevent adequate
uterine contraction.
Perineum
– is normally tender,
discolored and edematous. It
should be clean, with intact
sutures.
Blood pressure and pulse rate may
be slightly increased from
excitement and effort of
delivery, but normalize within
one hour.
»Lactation
» suppressing agents (estrogen – androgen preparations)

» are given within the first hours postpartum to prevent

breast milk production in mothers who will not (or
cannot) breastfeed.

» E.g., diethylstilbestrol, TACE, Parlodel and deladumone.

These drugs tend to increase uterine bleeding and

retard menstrual return
» Rooming – in concept
» mother and baby are together while in the hospital

» providing opportunities for developing a positive

relationship between parents and newborn
(maternal – infant bonding)

» Eye – to –eye contact is immediately established,

releasing the maternal caretaking responses