What is the best evidence-based treatment for a prolonged second stage of labor?

From the Guidelines

The best evidence-based treatment for a prolonged second stage of labor is to consider cesarean delivery if the estimated fetal weight is more than 4,500 g, as indicated by the American College of Obstetricians and Gynecologists 1. When managing a prolonged second stage of labor, it is essential to prioritize maternal and fetal safety. The following interventions can be considered:

• Position changes, such as side-lying, hands-and-knees, or squatting, to optimize fetal descent by altering pelvic dimensions
• Laboring rest periods of 30-60 minutes if maternal and fetal status remain reassuring, to conserve energy for effective pushing
• Directed pushing when contractions are strongest, with coaching to push for 6-8 seconds while avoiding prolonged breath-holding
• Instrumental delivery using vacuum extraction or forceps, provided the cervix is fully dilated, the fetal head is engaged, and the operator has appropriate expertise
• Oxytocin augmentation (starting at 1-2 mU/min and titrating up) if contractions are inadequate
• Adequate pain management, with epidural dosing optimized to preserve motor function while providing analgesia However, the most recent and highest quality study 1 suggests that for women with specific conditions, such as oesophageal varices, the second stage of labor may need to be expedited by operative vaginal delivery to reduce the impact of the Valsalva maneuver. Key considerations in managing prolonged second stage of labor include:
• Maternal and fetal status
• Estimated fetal weight
• Presence of any maternal medical conditions, such as oesophageal varices
• Operator expertise for instrumental delivery
• Availability of resources for cesarean delivery, if indicated.

From the FDA Drug Label

Oxytocin Injection, USP (synthetic) is indicated for the initiation or improvement of uterine contractions, where this is desirable and considered suitable, in order to achieve early vaginal delivery for fetal or maternal reasons It is indicated for (1) induction of labor in patients with a medical indication for the initiation of labor, such as Rh problems, maternal diabetes, pre-eclampsia at or near term, when delivery is in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated; (2) stimulation or reinforcement of labor, as in selected cases of uterine inertia;

The best evidence-based treatment for a prolonged second stage of labor is oxytocin augmentation. The use of oxytocin is indicated for stimulation or reinforcement of labor, as in selected cases of utering inertia. 2

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 3

Evidence-Based Management

• The American College of Obstetricians and Gynecologists (ACOG) recommends evidence-based management of the second stage of labor, including immediate pushing, manual rotation, and operative vaginal delivery 4
• Prophylactic intrapartum betamimetics should be avoided, as their usage is associated with an increase in operative vaginal deliveries 5
• Women without epidural anesthesia are recommended to give birth in any upright or lateral position 5
• The routine use of maternal stirrups in the second stage of labor is not recommended 5
• Consider avoiding water immersion during the second stage of labor, as the risks have not been adequately assessed 5

Interventions During the Second Stage of Labor

• In nulliparous women at term with epidural analgesia, delayed pushing is not recommended 5
• Pushing via a woman's own urge to push (open glottis) or pushing using the Valsalva maneuver (closed glottis) can both be considered 5
• Perineal massage and stretching of the perineum with a water-soluble lubricant in the second stage of labor is recommended 5
• The use of perineal warm packs and heating pads are recommended 5
• Manual rotation can be considered in fetuses with persistent occiput posterior position 5

Diagnosis of Prolonged Second Stage of Labor

• Waiting 1 additional hour (4 hours) for nulliparous women with epidural anesthesia before the diagnosis of a prolonged second stage of labor is recommended 5
• A mandatory second opinion before cesarean delivery in the second stage of labor is recommended 5

Uterotonic Agents

• Carbetocin is probably the most effective agent in reducing blood loss and the need for additional uterotonics 6
• Oxytocin appears to be more effective when initiated as a bolus 6
• The incidence of postpartum hemorrhage was higher in the carbetocin group than in the oxytocin group 7
• Blood transfusion was more common in the carbetocin group 7