In the second stage of labor, which statement is true: oxytocin is contraindicated, pushing can be delayed, epidural is too late, or operative birth is indicated after 2 hours of full dilation?

Management of Second Stage of Labor

Pushing can be delayed until there is an urge to push during the second stage of labor.

Understanding Second Stage of Labor

The second stage of labor begins with complete cervical dilation (10 cm) and ends with delivery of the fetus. During this stage, several management approaches can be considered:

Delayed vs. Immediate Pushing

• Delayed pushing allows women to wait until they feel an urge to push rather than immediately pushing when complete dilation is reached
• Research demonstrates that delayed pushing results in:
  • Significantly shorter pushing time (25.4 minutes less on average) 1
  • Less maternal fatigue (0.67 points lower fatigue score) 1
  • Better fetal oxygenation with fewer oxygen desaturation events 2
  • Fewer variable fetal heart rate decelerations 2
  • Higher 1-minute Apgar scores (by 0.19 points) 1
  • No significant increase in overall second stage duration 3

Oxytocin Considerations

Oxytocin is not contraindicated during the second stage of labor, but requires careful management:

• Should be discontinued if signs of fetal distress (late decelerations) appear 4
• Must be discontinued immediately if uterine hyperactivity occurs 4
• Requires careful titration based on uterine activity 4

Special Considerations for Specific Conditions

Vascular Liver Disease and Portal Hypertension

For women with portal hypertension or esophageal varices:

• Excessive pushing and repeated Valsalva maneuvers should be avoided as they can precipitate variceal bleeding 5
• A shortened second stage with assisted delivery is recommended to reduce pushing 5

Cardiac Conditions

For women with cardiac disease:

• The second stage should be conducted in a high-care area with experience managing pregnancies with cardiac disease 5
• Continuous invasive hemodynamic monitoring is recommended 5
• Contractions should descend the fetal head without maternal pushing to avoid unwanted effects of Valsalva maneuver 5

Positioning During Second Stage

• Women without epidural anesthesia are recommended to give birth in upright or lateral positions 6
• Lateral positioning attenuates the hemodynamic impact of uterine contractions 5
• Routine use of stirrups is not recommended 6

Epidural Considerations

Epidural analgesia remains effective during the second stage of labor and does not preclude its use. For women with epidurals:

• Delayed pushing has shown particular benefits, including less fetal oxygen desaturation 2
• Pushing technique can be either open-glottis (following woman's urge) or closed-glottis (Valsalva) 6

Duration of Second Stage

The traditional 2-hour limit for the second stage of labor is not an absolute indication for operative delivery. Current evidence suggests:

• Waiting an additional hour (up to 4 hours) for nulliparous women with epidural anesthesia before diagnosing prolonged second stage is recommended 6
• A mandatory second opinion before proceeding to cesarean delivery in second stage is recommended 6

Conclusion

Among the statements presented, the one that is true is that pushing can be delayed until there is an urge to push. This approach has demonstrated benefits for both maternal and fetal outcomes, particularly in women with epidural anesthesia.