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.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Reports of fatigue
May report inability to self-initiate pushing/relaxation techniques
Lethargic
Dark circles under eyes
Circulation
BP may rise 5–10 mm Hg in between contractions.
Ego Integrity
Emotional responses may range from feelings of fear/irritation to relief/joy.
May feel a loss of control or the reverse as she is now actively involved in bearing down.
Elimination
Involuntary urge to defecate/push with contractions, combining intraabdominal pressure with uterine pressure.
May have fecal discharge while bearing down.
Bladder distension may be present, with urine expressed during pushing efforts.
Pain/Discomfort
May moan/groan during contractions.
Amnesia between contractions may be noted.
Reports of burning/stretching sensation of the perineum.
Legs may tremble during pushing efforts.
Uterine contractions strong, occurring 1.5–2 min apart and lasting 60–90 sec.
May fight contractions, especially if she did not participate in childbirth preparation classes.
Respiratory
Respiratory rate increases.
Safety
Diaphoresis often present
Fetal bradycardia appearing as early decelerations on electric monitor during contractions (head compression) or variables (cord compression)
Sexuality
Cervix fully dilated (10 cm) and 100% effaced.
Increased vaginal bloody show.
Rectal/perineal bulging with fetal descent.
Membranes may rupture at this point if still intact.
Increased expulsion of amniotic fluid during contractions.
Crowning occurs; caput is visible just before birth in vertex presentation.
NURSING PRIORITIES
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.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Reports of fatigue
May report inability to self-initiate pushing/relaxation techniques
Lethargic
Dark circles under eyes
Circulation
BP may rise 5–10 mm Hg in between contractions.
Ego Integrity
Emotional responses may range from feelings of fear/irritation to relief/joy.
May feel a loss of control or the reverse as she is now actively involved in bearing down.
Elimination
Involuntary urge to defecate/push with contractions, combining intraabdominal pressure with uterine pressure.
May have fecal discharge while bearing down.
Bladder distension may be present, with urine expressed during pushing efforts.
Pain/Discomfort
May moan/groan during contractions.
Amnesia between contractions may be noted.
Reports of burning/stretching sensation of the perineum.
Legs may tremble during pushing efforts.
Uterine contractions strong, occurring 1.5–2 min apart and lasting 60–90 sec.
May fight contractions, especially if she did not participate in childbirth preparation classes.
Respiratory
Respiratory rate increases.
Safety
Diaphoresis often present
Fetal bradycardia appearing as early decelerations on electric monitor during contractions (head compression) or variables (cord compression)
Sexuality
Cervix fully dilated (10 cm) and 100% effaced.
Increased vaginal bloody show.
Rectal/perineal bulging with fetal descent.
Membranes may rupture at this point if still intact.
Increased expulsion of amniotic fluid during contractions.
Crowning occurs; caput is visible just before birth in vertex presentation.
NURSING PRIORITIES
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.
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