What are the step-by-step management protocols for the second stage of labor?

From the Guidelines

The second stage of labor should be managed by discouraging prolonged bearing down efforts and considering low forceps or vacuum-assisted delivery to reduce exertion and shorten the second stage, as this approach prioritizes maternal cardiovascular benefit and minimizes risks associated with increased exertion and strong contractions. According to the study by 1, the primary consideration during the second stage of labor should be maternal cardiovascular benefit, and spontaneous vaginal birth is preferable in women whose cardiac condition is well controlled with an apparently healthy fetus.

Key Considerations

• The second stage of labor is a time of increased exertion and strong contractions, and prolonged bearing down efforts must be discouraged to prevent adverse maternal and fetal outcomes.
• Low forceps or vacuum-assisted delivery can be used to reduce exertion and shorten the second stage of labor, as recommended by 1.
• Epidural analgesia is preferred during labor as it stabilizes cardiac output, and an experienced anaesthesiologist should be consulted for analgesia and anaesthesia.
• The left lateral position has been suggested to ensure adequate venous return from the inferior vena cava, but a sitting-up position may be needed for women in cardiac failure.

Management Protocols

• Allow the woman to push in her preferred position, which may include semi-recumbent, side-lying, hands-and-knees, or squatting positions.
• Encourage spontaneous pushing when the woman feels the urge rather than directed pushing with prolonged breath-holding.
• Provide continuous support and coaching, guiding the woman to push with contractions using short pushes of 6-7 seconds with normal breathing between efforts.
• Monitor fetal heart rate every 5-15 minutes in low-risk pregnancies and continuously in high-risk situations.
• Perform perineal support as the head crowns to reduce the risk of tears, using warm compresses and gentle counterpressure.

Operative Vaginal Delivery

• Consider operative vaginal delivery when indicated, and use vacuum or forceps by trained providers.
• The decision to perform an operative vaginal delivery should be based on the individual patient's needs and medical condition, as recommended by 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage of oxytocin is determined by uterine response. The following dosage information is based upon the various regimens and indications in general use. Induction or Stimulation of Labor Intravenous infusion (drip method) is the only acceptable method of administration for the induction or stimulation of labor. Accurate control of the rate of infusion flow is essential An infusion pump or other such device and frequent monitoring of strength of contractions and fetal heart rate are necessary for the safe administration of oxytocin for the induction or stimulation of labor.

The FDA drug label does not answer the question.

From the Research

Step-by-Step Management Protocols for the Second Stage of Labor

The following protocols are based on evidence-based practices:

• Delayed pushing, spontaneous (nondirected) pushing, and maternal choice of positions are recommended for management of the second stage of labor 2.
• Perineal compresses, perineal massage with a lubricant, and controlling the rate of fetal extension during crowning may prevent severe perineal trauma at birth 2.
• Supine positioning is not recommended, while upright positions and directed pushing can shorten the time from onset of second stage to birth and may be indicated in certain situations 2.
• If the fetus is in the occiput posterior position, immediate pushing is not recommended, and manual rotation can be effective in correcting the malposition 2.
• Women should be informed of the potential effects of epidural analgesia on labor progress 2.
• Consultation and intervention to expedite birth may be indicated when birth is not imminent after 2 hours of active pushing, or 4 hours complete dilatation, for nulliparous women; or one hour of pushing, or 2 hours complete dilatation, for multiparous women 2.

Maternal and Fetal Monitoring

• The baby's heart rate should be monitored after every second contraction 3.
• Maternal heart rate, blood pressure, oxygen saturation, respiratory rate, sedation, nausea/vomiting, itching, satisfaction, and fetal/neonatal outcome should be recorded 4.

Decision-Making for Operative Delivery

• Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience 3.
• The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians 5.

Recommendations for Care

• The mother should receive emotional support and encouragement to bear down instinctively when she feels the urge to do so, in the position she feels enables her to push most effectively, but not the supine position 3.
• Uterine fundal pressure has not been shown to be effective, and may be dangerous 3.
• Recent guidelines such as those of the World Health Organization (WHO) recommend allowing 2-3 hours for the second stage of labor 3.