What is the management for a primigravida at 7 cm dilation, 100% effaced, with a fetal head at +3 station, who has been pushing for 4 hours with epidural anesthesia and a category 1 fetal heart rate tracing?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
DS

Dainyal Siddiqui, MD

Internal Medicine

MJ

Manuel Jimenez, MD

Cardiology

FP

Franz Pierre-Louis, MD

Infectious Disease

Article Review Status
Submitted
Under Review
Approved

Last updated: April 7, 2025 • View editorial policy

From the Guidelines

This patient requires an operative vaginal delivery using forceps or vacuum assistance due to prolonged second stage of labor, which is defined as pushing for more than 3 hours in a nulliparous woman with epidural anesthesia, as evidenced by the American Journal of Obstetrics and Gynecology study 1.

Key Considerations

  • The patient has been pushing for 4 hours, exceeding the recommended time frame, and is exhausted, which increases the risk of maternal and fetal complications.
  • The fetal head is at +3 station, and the cervix is completely dilated, indicating a favorable position for delivery.
  • The left occiput anterior position is optimal for delivery, and the fetal heart rate tracing is category 1, indicating a reassuring fetal status.
  • The estimated fetal weight is 3.4 kg (7.5 lb), which is not excessively large, and the patient has no chronic medical conditions or complications during pregnancy.

Management Approach

  • Before proceeding with operative vaginal delivery, the epidural anesthesia should be optimized to ensure adequate pain control while allowing some sensation for pushing.
  • The obstetrician should explain the procedure to the patient, obtain consent, and prepare for a possible cesarean delivery if operative vaginal delivery is unsuccessful.
  • Oxytocin augmentation may also be considered to strengthen contractions, as suggested by the study 1, which found that oxytocin infusion can enhance uterine contractions and promote progress in cervical dilatation.
  • The study 1 also emphasizes the importance of thorough cephalopelvimetry to exclude the presence of cephalopelvic disproportion (CPD), which is a significant concern in cases of prolonged second stage labor.

Rationale

  • Prolonged second stage labor increases the risks of maternal complications, such as infection and hemorrhage, and fetal complications, such as asphyxia.
  • Operative vaginal delivery is a safer and more effective option than continuing to push, especially given the patient's exhaustion and the favorable fetal position.
  • The study 1 supports the use of operative vaginal delivery in cases of prolonged second stage labor, highlighting the importance of careful evaluation and management to minimize risks and ensure a successful outcome.

From the Research

Management of Prolonged Second Stage of Labor

The patient has been pushing for 4 hours and is exhausted, with no complications during pregnancy and no chronic medical conditions. The estimated fetal weight is 3.4 kg, and vital signs are normal, with a category 1 fetal heart rate tracing.

Risks and Outcomes

  • A study published in 2019 2 found that allowing a longer duration of the second stage of labor decreased the rate of primary cesarean delivery, but increased the rate of operative vaginal deliveries, third- and fourth-degree lacerations, and shoulder dystocia.
  • A systematic review published in 2023 3 compared maternal and perinatal morbidity, mortality, and other adverse outcomes after vacuum extraction versus second-stage cesarean section, and found that vacuum extraction should be the recommended mode of birth to prevent unnecessary cesarean sections and reduce perinatal and maternal deaths.
  • A narrative review published in 2016 4 found that extending the second stage of labor beyond current guidelines decreased the incidence of cesarean delivery by 55% and did not increase maternal or neonatal risks.
  • A study published in 2002 5 found that a prolonged second stage of labor was not associated with low Apgar scores, umbilical artery pH levels, or admission to the NICU, but was associated with an increased rate of maternal blood loss and third-degree anal sphincter tears.

Guidelines and Recommendations

  • The World Health Organization recommends allowing 2-3 hours for the second stage of labor 6.
  • The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommend allowing a longer duration of the second stage of labor to decrease the rate of primary cesarean delivery 2.
  • Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience 6.

References

1
Guideline

the active phase of labor.

American Journal of Obstetrics and Gynecology, 2023

3
Research

Vacuum extraction or caesarean section in the second stage of labour: A systematic review.

BJOG : an international journal of obstetrics and gynaecology, 2023

4
Research

Prolonged Second Stage: What Is the Optimal Length?

Obstetrical & gynecological survey, 2016

6
Research

The second stage of labor.

Best practice & research. Clinical obstetrics & gynaecology, 2020

Related Questions

What is the best delivery method for a deflexed fetus in an arrested second stage of labor: forceps, cesarean section (C-section), or vacuum extraction?
What are the techniques and management strategies for episiotomy (perineal incision), perineal tears, and repair of perineal lacerations, including anatomy, procedure, and recommendations?
What are the indications for choosing between operative vaginal delivery and cesarean section (C-section) in a protracted second stage of labor?
What is the step-by-step management of a prolonged (protracted) second stage of labor?
What are the step-by-step management protocols for the second stage of labor?
What are the characteristic skin findings in anogenital warts (human papillomavirus, HPV)?
What is the assessment of a 32-year-old woman, gravida (number of times pregnant) 2, para (number of viable births) 1, at 28 weeks gestation, with a normal prenatal course, no chronic medical conditions, and laboratory results showing rubella nonimmunity, Rh-negative blood type, and negative serologies for human immunodeficiency virus (HIV), rapid plasma reagin (RPR), hepatitis B surface antigen, and chlamydia?
What is the treatment for severe cheilitis with perioral dermatitis?
What is the treatment for severely chapped lips with straw-colored dermatitis around the lips, also known as actinic cheilitis (inflammation of the lips) with eczematous dermatitis (skin inflammation)?
What is the management plan for a 34-year-old woman, gravida 5 para 4, at 39 weeks gestation with a history of uncomplicated pregnancy, prepregnancy body mass index (BMI) of 33 kg/m2, and a weight gain of 18 kg, who presents with contractions and spontaneous rupture of membranes, and develops recurrent variable decelerations after receiving neuraxial anesthesia, which resolve with amnioinfusion?
What is the accepted term for Alcohol Use Disorder (AUD)?

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.

Ask a new Question. Chat with the Guidelines