What is the management for a prolonged second stage of labor?

Management of Prolonged Second Stage of Labor

The management of prolonged second stage of labor should include assisted vaginal delivery with forceps or vacuum extraction when spontaneous delivery cannot be achieved rapidly, as this reduces maternal exertion and shortens the second stage. 1

Definition and Diagnosis

• Prolonged second stage is traditionally defined as:

  • 2 hours without epidural anesthesia in nulliparous women

  • 3 hours with epidural anesthesia in nulliparous women

  • 1 hour without epidural in multiparous women

  • 2 hours with epidural in multiparous women

Risk Factors for Prolonged Second Stage

• Epidural anesthesia
• Persistent occiput posterior position
• Fetal head circumference or birth weight above 90th percentile 2
• Cephalopelvic disproportion (CPD)
• Maternal exhaustion
• Ineffective uterine contractions

Management Algorithm

1. Assessment Phase

• Evaluate for cephalopelvic disproportion (CPD)
  • Thorough cephalopelvimetry is vital to exclude disproportion 1
  • Assess for excessive molding, deflexion, or asynclitism of fetal head
  • Differentiate between molding and true descent through suprapubic palpation
  • Rule out malposition (occiput posterior/transverse)

2. Maternal Position Optimization

• Avoid supine position 3
• Encourage upright or lateral positions that maximize pelvic dimensions
• Allow mother to choose position that enables most effective pushing

3. Pushing Technique Modification

• Discourage prolonged bearing down efforts 1
• Allow instinctive pushing when urge is felt rather than directed pushing
• Provide adequate rest periods between contractions

4. Oxytocin Augmentation

• Consider oxytocin (Pitocin) if inadequate contractions are identified
• Indicated for stimulation or reinforcement of labor in selected cases of uterine inertia 4
• Monitor response to ensure enhancement of contractions without hyperstimulation

5. Assisted Vaginal Delivery

• Where spontaneous delivery cannot be achieved rapidly, use forceps or vacuum extraction 1
• Reduces maternal exertion and shortens second stage
• Consider early recourse to instrumental delivery if:
  • Maternal exhaustion
  • Fetal compromise
  • Lack of progress despite adequate contractions

6. Cesarean Delivery

• Indicated when:
  • Evidence of CPD is found or cannot be ruled out with reasonable certainty 1
  • No progress despite oxytocin augmentation within 2-4 hours
  • Fetal distress
  • Failed instrumental delivery attempt

Special Considerations

Maternal Cardiac Disease

• For women with cardiac disease, prolonged bearing down efforts must be discouraged 1
• Consider early instrumental delivery to reduce cardiovascular stress
• Epidural analgesia is preferred as it stabilizes cardiac output

Hepatic Adenomas

• For women with hepatic adenomas >5 cm, prevention of prolonged second stage and consideration of assisted delivery may reduce risk of hemorrhage 1

Congenital Fibrinogen Disorders

• In suspected afibrinogenemia or hypofibrinogenemia, avoid prolonged second stage 1
• Early recourse to cesarean section if second stage is prolonged
• Avoid invasive fetal procedures (scalp monitoring, forceps, vacuum)

Monitoring During Management

• Continuous fetal heart rate monitoring (after every second contraction) 3
• Regular assessment of maternal vital signs and hydration status
• Ongoing evaluation of descent and rotation of fetal head

Potential Complications of Prolonged Second Stage

• Maternal:

  • Increased risk of postpartum hemorrhage 5
  • Higher rates of third/fourth-degree perineal tears 2
  • Maternal exhaustion and fever

• Fetal/Neonatal:

  • Risk of fetal acidosis
  • Potential for shoulder dystocia if vaginal delivery occurs 1
  • Increased risk of NICU admission 2

Pitfalls to Avoid

• Uterine fundal pressure is not recommended and may be dangerous 3
• Delaying intervention based solely on arbitrary time limits when other signs of obstruction are present
• Attempting vaginal delivery when there are clear signs of CPD
• Excessive fluid administration during management, which can lead to pulmonary edema in susceptible patients 1
• Making decisions based solely on elapsed time rather than maternal and fetal condition

Recent evidence suggests that allowing more time (up to 4 hours) for the second stage may be reasonable in selected cases with adequate fetal monitoring, but intervention should not be delayed if there are signs of maternal or fetal compromise 1, 5.