Stage II of labor, the stage of expulsion, begins with full cervical dilation (10 cm) and ends with the birth of the newborn. Maternal efforts to bear down occur involuntarily during contractions that are 1.5–2 min apart, lasting 60–90 sec. The average rate of fetal descent is 1 cm/hr for nulliparas, 2 cm or more per hr for multiparas.
1. Facilitate normal progression of labor and fetal descent.
2. Promote maternal and fetal well-being.
3. Support client’s/couple’s wishes regarding delivery experience, maintaining safety as a priority.
Nursing diagnosis for Stage 2 of Labor - Expulsion Stage: Pain may be related to mechanical pressure of presenting part, tissue dilation/stretching, nerve compression, muscle hypoxia, intensified contractile pattern possibly evidenced by verbalizations, distraction behavior (e.g., restlessness), facial mask of pain, narrowed focus, autonomic responses.
Nursing intervention with rationale:
1. Identify degree of discomfort and its sources.
Rationale: Clarifies needs; allows for appropriate intervention.
2. Provide comfort measures, such as mouth care; perineal care/massage; clean, dry linen and underpads; cool environment (68°F–72°F [20°C–22.1°C]), cool, moist cloths to face and neck; or hot compresses to perineum, abdomen, or back, as desired.
Rationale: Promotes psychological and physical comfort, allowing client to focus on labor, and may reduce the need for analgesia or anesthesia.
3. Review information with client/couple about type of regional analgesia/anesthesia available at this stage specific to the delivery setting (e.g., local, pudendal block, lumbar epidural reinforcement) or use of transcutaneous electrical nerve stimulation (TENS), acupressure/acupuncture. Review advantages/disadvantages, as appropriate.
Rationale: Although client is under the stress of labor and discomfort levels may interfere with normal decision-making skills, she still needs to be in control and make her own informed decisions regarding anesthesia. Note: The option of a nerve root block should be restricted to a hospital setting where emergency equipment is available.
4. Monitor and record uterine activity with each contraction.
Rationale: Provides information/legal documentation about continued progress; helps identify abnormal contractile pattern, allowing prompt assessment and intervention.
5. Provide information and support related to progress of labor.
Rationale: Keeps couple informed of proximity of delivery; reinforces that efforts are worthwhile and the “end is in sight.”
6. Encourage client/couple to manage efforts to bear down with spontaneous, rather than sustained, pushing during contractions. Stress importance of using abdominal muscles and relaxing pelvic floor.
Rationale: Anesthetics may interfere with client’s ability to feel sensations associated with contractions, resulting in ineffective bearing down. Spontaneous, rather than sustained, efforts to bear down avoid negative effects of Valsalva’s maneuver associated with reduced maternal and fetal oxygen levels. Relaxation of the pelvic floor reduces resistance to pushing efforts, maximizing effort to expel the fetus.
7. Observe for perineal and rectal bulging, opening of vaginal introitus, and changes in fetal station.
Rationale: Anal eversion and perineal bulging occur as the fetal vertex descends, indicating need to prepare for delivery.
8. Assist client in assuming optimal position for bearing down; (e.g., squatting or lateral recumbent, semi-Fowler’s position (elevated 30–60 degrees). Assess effectiveness of efforts to bear down.
Rationale: Proper positioning with relaxation of perineal tissue optimizes bearing-down efforts, facilitates labor progress, reduces discomfort, and reduces need for forceps application.
9. Assess bladder fullness. Catheterize between contractions if distension is noted and client is unable to void.
Rationale: Promotes comfort, facilitates fetal descent, and reduces risk of bladder trauma caused by presenting part of fetus.
10. Assist with administration of opiates (e.g., fentanyl [Sublimaze], morphine) into epidural space via indwelling catheter. Have ephedrine, 10 mg, or naloxone (Narcan), 0.4 mg, available as an antidote, depending on agent used.
Rationale: Intraspinal narcotic, acting on opiate receptors within the spinal column, blocks pain for as long as 11 hr. Literature reveals mixed results regarding use of morphine via indwelling catheter in stage II