4. Nursing actions during second stage of labor
   1. Assessment:
      1. Maternal (or couple’s) response to labor.
      2. FHR-continuous electronic monitoring, or after each contraction with fetoscope, Doppler.
      3. Vital signs.
      4. Time elapsed-average: 2 minutes to 1 hour; prolonged second stage increases risk of fetal distress, maternal exhaustion, psychological stress, intrauterine infection.
      5. Contraction pattern-average every 1½ minutes, lasting 60-90 seconds.
      6. Vaginal discharge-increases.
      7. Nausea, vomiting, disorientation, tremors, amnesia between contractions, panic.
      8. Response to regional anesthesia, if administered.
         1. Signs of hypotension-reduces placental perfusion, increases risk of fetal hypoxia.
         2. Effect on contractions-note and report any slowing of labor.
      9. Efforts to bear down-increase expulsive effects of uterine contractions.
      10. Perineal bulging with contractions-fetal head distends perineum, crowns; head born by extension.
   2. Analysis/nursing diagnosis:
      1. Pain related to strong uterine contractions, pressure of fetal descent, stretching of perineum.
      2. High risk for injury:
         1. Infection related to ruptured membranes, repeated vaginal examinations.
         2. Laceration related to pressure of fetal head exceeding perineal elasticity.
      3. Impaired skin integrity related to laceration, episiotomy.
      4. Fluid volume deficit related to hypotension secondary to regional anesthesia.
      5. Anxiety related to imminent birth of fetus.
      6. Ineffective individual coping related to prolonged sensory stimulation (contractions) and anxiety.
      7. Altered urinary elimination related to anesthesia and contractions, descent of fetal head.
      8. Sleep pattern disturbance.
   3. Nursing care plan/implementation:
      1. Goal: emotional support.
         1. To sustain motivation/control:
            1. Never leave mother and significant other alone during 2nd stage.
            2. Keep informed of progress.
            3. Direct bearing-down efforts (pushing) without holding breath" while pushing. Encourage pushing “out through vagina” and encourage mother to touch crowning head; position mirror so woman can see perineal bulging with effective efforts; minimize distractions.
         2. To allay significant other’s anxiety: reassure regarding mother’s behavior if she is not anesthetized.
         3. Support family choices.
      2. Goal: safeguard status.
         1. Precautions when putting legs in stirrups:
            1. If varicosities, do not put legs in stirrups.
            2. Avoid pressure to popliteal veins; pad stirrups.
            3. Ensure proper, even alignment by adjusting stirrups.
            4. Move legs simultaneously into or out of stirrups-to avoid nerve, ligament, and muscle strain.
            5. Provide proper support to woman not using stirrups. Do not hold legs (can cause back injury).
         2. Support woman in whatever position selected for birth (side-lying position).
         3. Cleanse perineum, thighs as ordered.
      3. Goal: maintain a comfortable environment.
         1. Free of unnecessary noise, light.
         2. Comfortable temperature (warm).
      4. Medical management:
         1. Episiotomy may be performed to facilitate birth.
         2. Forceps may be applied to exert traction and expedite birth.
         3. Vacuum extraction also used to assist birth.
      5. Birthing room birth with alternative positions (squat).
   4. Evaluation/outcome criteria:
      1. Cooperative, actively participates in birth; maintains control over own behavior.
      2. Successful, uncomplicated birth of viable infant.
      3. All assessment findings within normal limits (vital signs, emotional status, response to birth).
      4. Presence of significant other.