From the Guidelines
Management of arrested second stage of labor should prioritize thorough cephalopelvimetry to exclude cephalopelvic disproportion (CPD) and consider cesarean delivery (CD) if CPD is suspected or cannot be ruled out with certainty. The approach to managing arrested second stage of labor involves a 2-phased evaluation, starting with assessment for known associations or causes of the arrest, such as CPD, and then intervening appropriately based on the findings 1. It is crucial to recognize that approximately 40% to 50% of parturients with arrest of the active phase have concomitant CPD, highlighting the importance of careful evaluation 1.
Key considerations in the management include:
- Evaluating maternal position and encouraging upright or lateral positions to optimize pelvic dimensions
- Ensuring adequate hydration and considering bladder emptying if necessary
- Implementing oxytocin augmentation if contractions are inadequate, with careful monitoring of contraction frequency and fetal heart rate 1
- Considering instrumental delivery using vacuum or forceps if the fetal head is engaged and the cervix is fully dilated, with appropriate analgesia
- Proceeding to cesarean delivery if these measures fail or are contraindicated, especially if there is suspicion or evidence of CPD 1
Throughout the management process, continuous fetal monitoring is essential to detect signs of distress, and maternal vital signs should be regularly assessed 1. The underlying causes of arrest, such as malposition, inadequate contractions, or maternal exhaustion, should be identified and addressed specifically when possible. Given the potential risks associated with CPD and the importance of safe vaginal delivery, erring on the side of caution with earlier intervention, including CD, is often the most prudent approach 1.
From the FDA Drug Label
Following delivery of the placenta, for routine management of uterine atony, hemorrhage and subinvolution of the uterus. For control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. The management of arrested second stage of labor is not directly addressed in the provided drug label. The FDA drug label does not answer the question.
From the Research
Management of Arrested Second Stage of Labor
The management of arrested second stage of labor involves several key considerations, including:
- Defining arrest in the second stage of labor, which is typically characterized by no progress for ≥4 hours in nulliparas or 3 hours in multiparas with an epidural 2
- Identifying the causes of labor abnormalities, such as uterine inactivity, obesity, cephalopelvic disproportion, and fetal malposition 3
- Using oxytocin administration to augment labor and promote progress 4, 5
- Considering the use of amniotomy, intrauterine pressure catheter, and shared decision-making regarding expectant management, operative vaginal delivery, or cesarean delivery 3
- Weighing the risks and benefits of each option and personalizing the decision for each mother-baby dyad 3
Key Considerations
Some key considerations in the management of arrested second stage of labor include:
- The importance of precise administration of oxytocin using infusion pumps, institutional safety checklists, and trained nursing staff to closely monitor uterine activity and fetal heart rate changes 4
- The potential risks of extending the duration of labor, including postpartum hemorrhage, intraamniotic infection, and potentially an increase in neonatal adverse outcomes 3
- The need for standardized care and protocols to ensure patient safety, such as oxytocin protocols 5
Relevant Studies
Relevant studies have demonstrated the effectiveness of oxytocin augmentation and active management of labor in reducing the incidence of cesarean delivery and promoting progress in labor 4, 2, 5. However, the evidence for augmentation alone on the risk of cesarean delivery is unclear, with varying evidence 5.