From the Guidelines
Cesarean delivery is the recommended treatment for a prolonged second stage of labor, especially if there is evidence of cephalopelvic disproportion (CPD) or other complications, as it is a safer option for both the mother and the fetus. According to the most recent and highest quality study 1, a prolonged second stage of labor is a strong association with CPD and related potential risks, and thorough cephalopelvimetry is vital to exclude the presence of disproportion. The study suggests that if evidence of CPD is found, cesarean delivery is a more prudent and safer choice.
Some key points to consider in the management of a prolonged second stage of labor include:
- Ensuring proper maternal positioning to optimize pelvic dimensions and fetal descent
- Providing adequate hydration, emotional support, and considering changing the pushing technique to directed pushing with rest periods between contractions
- Using oxytocin augmentation if progress remains inadequate, but with caution and careful monitoring of fetal status and maternal exhaustion
- Considering instrumental delivery, such as vacuum extraction or forceps, if the fetal head is engaged, cervix fully dilated, and membranes ruptured, but only if adequate analgesia is provided
- Prioritizing cesarean delivery if these measures fail or are contraindicated, or if there is evidence of CPD or other complications.
It is essential to note that the decision to intervene should consider maternal exhaustion, fetal status, and progress of descent, and that prolonged second stage increases risks of postpartum hemorrhage, perineal trauma, and fetal compromise, making timely recognition and appropriate intervention essential for optimal maternal and neonatal outcomes. The American College of Obstetricians and Gynecologists (ACOG) also recommends cesarean delivery in cases of suspected fetal macrosomia or prolonged second stage of labor 1.
From the FDA Drug Label
Oxytocin Injection, USP (synthetic) is indicated for ... (2) stimulation or reinforcement of labor, as in selected cases of uterine inertia; The treatment for a prolonged second stage of labor may include oxytocin (IV) for stimulation or reinforcement of labor in selected cases of uterine inertia 2.
- Key points:
- Oxytocin (IV) is indicated for stimulation or reinforcement of labor
- Uterine inertia is a condition where the uterus fails to contract properly during labor
- Oxytocin (IV) may be used to treat uterine inertia in a prolonged second stage of labor
From the Research
Treatment for Prolonged Second Stage of Labor
The treatment for a prolonged second stage of labor may involve various management strategies.
- Evidence-based management includes immediate pushing, manual rotation, and operative vaginal delivery 3.
- The American College of Obstetricians and Gynecologists (ACOG) defines a prolonged second stage 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 4.
- Oxytocin augmentation of labor may be used to help progress labor, as seen in studies on trials of labor after cesarean section 5.
- In cases where the second stage of labor is prolonged, operative delivery may be considered to minimize maternal and neonatal morbidity 3, 6.
Management Guidelines
Management guidelines for the second stage of labor vary depending on factors such as parity and the use of epidural analgesia.
- For nulliparous women with epidural analgesia, a prolonged second stage of labor is defined as more than 3 hours 4.
- For parous women with epidural analgesia, a prolonged second stage of labor is defined as more than 2 hours 4.
- The accepted upper limit of the second stage of labor has been increased to ≥4 hours in nulliparous women with epidural analgesia and to ≥3 hours in parous women with epidural 6.