What is the step-by-step management of a prolonged (protracted) second stage of labor?

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From the Guidelines

The management of a prolonged second stage of labor should prioritize a systematic approach to identify the cause and implement appropriate interventions, with a strong emphasis on ruling out cephalopelvic disproportion (CPD) and considering cesarean delivery if CPD is suspected or cannot be ruled out with certainty. This approach is supported by recent evidence, including a 2023 study published in the American Journal of Obstetrics and Gynecology 1, which highlights the importance of thorough cephalopelvimetry to exclude the presence of disproportion.

Step-by-Step Management

The management of a prolonged second stage of labor can be broken down into several key steps:

  • Confirm the diagnosis by verifying that the second stage has exceeded the expected duration (typically >3 hours with epidural or >2 hours without epidural in nulliparous women; >2 hours with epidural or >1 hour without epidural in multiparous women)
  • Assess maternal and fetal wellbeing through continuous fetal monitoring and vital signs
  • Evaluate the "3 Ps": Powers (contractions), Passenger (fetal size and position), and Passage (pelvic adequacy)
  • Consider oxytocin augmentation if contractions are inadequate, starting at 1-2 mU/min and increasing by 1-2 mU/min every 30 minutes to a maximum of 20-40 mU/min until adequate contractions (3-5 contractions in 10 minutes) are achieved
  • Provide hydration, position changes, and encouragement for maternal exhaustion
  • Assist with manual rotation if the fetus is in occiput posterior or transverse position
  • Try different maternal positions such as squatting, lateral, or hands-and-knees to optimize the pelvic dimensions for descent issues
  • Consider an instrumental delivery (vacuum or forceps) if the cervix is fully dilated, the fetal head is engaged, and there are no contraindications

Importance of Ruling Out CPD

It is essential to rule out CPD before proceeding with vaginal delivery, as the risks of damage to the mother and fetus are significant if CPD is present. A 2023 study published in the American Journal of Obstetrics and Gynecology 1 found that fully 40% to 50% of parturients with arrest of the active phase have concomitant CPD, highlighting the importance of thorough cephalopelvimetry to exclude the presence of disproportion.

Consideration of Cesarean Delivery

If CPD is suspected or cannot be ruled out with certainty, cesarean delivery is a more prudent and safer choice. This approach is supported by recent evidence, including a 2023 study published in the American Journal of Obstetrics and Gynecology 1, which found that proceeding to cesarean delivery is a better and safer option if postarrest dilatation does not occur.

From the Research

Definition of Prolonged Second Stage of Labor

  • A prolonged second stage of labor is defined as more than 2 hours without or 3 hours with epidural analgesia in nulliparous women, and 1 hour without, or 2 hours with epidural in multiparous women 2
  • This definition diagnoses 10% to 14% of nulliparous and 3% to 3.5% of multiparous women as having a prolonged second stage 2

Management of Prolonged Second Stage of Labor

  • 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
  • The baby's heart rate should be monitored after every second contraction 3
  • Uterine fundal pressure has not been shown to be effective, and may be dangerous 3
  • Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience 3
  • Recent guidelines such as those of the World Health Organization (WHO) recommend allowing 2-3 hours for the second stage of labor 3

Use of Oxytocin Augmentation

  • The use of oxytocin in women with epidural analgesia does not result in a reduction in operative deliveries 4
  • There was no statistically significant difference between the two groups in either of the primary outcomes of caesarean section or instrumental delivery 4
  • Further research in the form of randomised controlled trials are required to determine the effectiveness of oxytocin augmentation in reducing operative deliveries 4

Evidence-Based Management

  • The second stage of labor is defined as the time from complete dilation of the cervix to delivery of the fetus 5
  • The objective of management is to provide a contemporary, evidence-based approach to management of the second stage of labor 5
  • This includes considering background maternal and fetal characteristics that impact the duration of the second stage of labor, and the recommended evidence-based management (e.g. immediate pushing, manual rotation, operative vaginal delivery) 5

Effect of Epidural Analgesia on Labor

  • Epidural analgesia during labor does not increase the risk of cesarean delivery, nor does it necessarily increase oxytocin use or instrumental delivery caused by dystocia 6
  • The duration of the active phase of labor appears unchanged, but the second stage of labor is likely prolonged by about 25 minutes 6

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Defining and Managing Normal and Abnormal Second Stage of Labor.

Obstetrics and gynecology clinics of North America, 2017

3
Research

The second stage of labor.

Best practice & research. Clinical obstetrics & gynaecology, 2020

5
Research

Evidence-based management of the second stage of labor.

Seminars in perinatology, 2020

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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