From the Guidelines
Arrested second stage of labor is one of the most common indications for cesarean delivery, particularly when there is no descent of the fetal presenting part for 2 hours without regional anesthesia or 3 hours with regional anesthesia in nulliparous women, and 1 hour without or 2 hours with regional anesthesia in multiparous women, as evidenced by recent studies 1. The primary causes of arrested second stage of labor include:
- Cephalopelvic disproportion (when the baby's head is too large to fit through the mother's pelvis)
- Malposition of the fetus (such as occiput posterior or transverse positions)
- Inadequate uterine contractions
- Maternal exhaustion Before proceeding to cesarean, clinicians typically attempt interventions like:
- Position changes
- Oxytocin augmentation (starting at 2 milliunits/minute and increasing gradually)
- Instrumental delivery (vacuum or forceps) if appropriate
- Maternal pushing technique optimization and rest periods The decision to proceed to cesarean should consider both maternal and fetal well-being, with continuous fetal monitoring to detect any signs of distress, as highlighted in recent research 1. Prolonged second stage increases risks of postpartum hemorrhage, infection, and birth trauma, making timely intervention crucial. Adequate documentation of labor progress, interventions attempted, and decision-making process is essential for clinical care and potential medicolegal issues. It is essential to note that the presence of cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age, and previous cesarean delivery can increase the risk of arrested second stage of labor, as discussed in the literature 1. Therefore, a thorough evaluation of these factors is necessary to determine the best course of action for each patient.
From the Research
Indications for Cesarean (C-section) in Arrested Second Stage of Labor
- The most common indications for Cesarean (C-section) in arrested second stage of labor include:
- Umbilical cord prolapse, which is an obstetric emergency that can have negative outcomes for the fetus 2, 3
- Prolonged second stage of labor, 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 4
- Uterine inactivity, obesity, cephalopelvic disproportion, and fetal malposition, which are common causes of labor abnormalities 5
- Risk factors for umbilical cord prolapse include multiparity with malpresentation, polyhydramnios, and multiple pregnancies, as well as iatrogenic causes such as amniotomy, fetal blood sampling, and insertion of a cervical ripening balloon 3
- The management of labor disorders consists of oxytocin administration, amniotomy, intrauterine pressure catheter use, and shared decision-making regarding proceeding with expectant management, operative vaginal delivery, or cesarean delivery 5
- Deliveries by Cesarean section are associated with a greater risk of fetal injuries than vaginal delivery, especially in cases of umbilical cord prolapse 6