Management of the Second Stage of Labour
The second stage of labour should be managed with a focus on maternal positioning, judicious use of interventions, and extended time limits before diagnosing arrest—specifically allowing up to 3-4 hours in nulliparous women with epidural analgesia before considering operative delivery. 1, 2
Definition and Duration
The second stage of labour begins at complete cervical dilatation (10 cm) and ends with delivery of the infant 3. This stage typically lasts 30 minutes to 2 hours 3.
Normal Duration Limits
Current evidence supports extending the traditional time limits before diagnosing prolonged second stage:
- Nulliparous women without epidural: Up to 2 hours 2
- Nulliparous women with epidural: Up to 3-4 hours (waiting the additional hour is recommended) 1, 2
- Multiparous women without epidural: Up to 1 hour 2
- Multiparous women with epidural: Up to 2 hours 2
These extended time frames are safe when continuous fetal monitoring is maintained and do not increase neonatal morbidity 4.
Maternal Positioning
Women without epidural analgesia should give birth in any upright or lateral position they prefer 1. For women with epidural analgesia, the optimal position remains unclear, so neither recumbent nor upright positions can be specifically recommended over the other 1.
Avoid routine use of maternal stirrups during the second stage 1.
Pushing Techniques
In nulliparous women at term with epidural analgesia, immediate pushing (not delayed pushing) is recommended 1.
Both pushing methods are acceptable 1:
- Open glottis pushing (spontaneous urge to push)
- Closed glottis pushing (Valsalva maneuver)
Traditional verbal coaching or ultrasound-assisted coaching may both be considered 1.
Interventions to Avoid
The following interventions are NOT recommended:
- Fundal pressure in any form 1
- Routine episiotomy 1
- Prophylactic intrapartum betamimetics (associated with increased operative vaginal deliveries) 1
- Ritgen's maneuver (no demonstrated benefits) 1
- Perineal hyaluronidase injection 1
- Perineal gel 1
- Water immersion during second stage (risks inadequately assessed) 1
Recommended Perineal Protection Measures
The following interventions reduce perineal trauma:
- Perineal massage and stretching with water-soluble lubricant 1
- Warm perineal packs and heating pads 1
- "Hands-poised" position over "hands-on" method for fetal delivery 1
- Perineal protection devices may be considered 1
Management of Malposition
For persistent occiput posterior position, manual rotation can be considered 1.
Oxytocin Use
Oxytocin may be used for stimulation or reinforcement of labour in selected cases of uterine inertia 5. However, uterotonic stimulation should be used cautiously to avoid unsafe uterine hyperstimulation 3.
Warning Signs and Complications
A prolonged deceleration phase (8-10 cm dilatation) is a harbinger of second stage abnormalities 3, 6. When the deceleration phase is prolonged and accompanied by failure of descent, this signals:
- Increased risk of shoulder dystocia 3, 6
- Potential cephalopelvic disproportion (CPD) 3
- Possible need for cesarean delivery 3
If CPD is suspected or cannot be ruled out with reasonable certainty, cesarean delivery is the safer choice 3, 6.
Decision-Making for Operative Delivery
Before proceeding to cesarean delivery in the second stage:
- Mandatory second opinion is recommended 1
- Rule out CPD through assessment of maternal factors (diabetes, obesity, pelvic size/shape) and fetal factors (macrosomia, malposition, asynclitism, molding) 3
- Differentiate true descent from molding via serial suprapubic palpation of the fetal skull base 3
Key Clinical Pitfalls
Common errors to avoid:
- Rigid adherence to outdated Friedman curve time limits without considering modern epidural use 7, 2
- Premature diagnosis of arrest before allowing adequate time (especially with epidural) 1, 2
- Routine interventions (episiotomy, fundal pressure) that lack evidence of benefit 1
- Failure to recognize warning signs during the deceleration phase that predict second stage complications 3, 6