Managing the second stage of labor: An evidence-based approach
Continuously assessing and monitoring maternal, fetal, and modifiable factors in the second stage of labor may aid clinicians in weighing the appropriateness of expectant management against operative delivery
Maternal support person
Continuous support during labor may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labor, and decreased cesarean birth.29 In a randomized trial of 412 healthy nulliparous women, women in labor were assigned to either a support group that received continuous support from a doula or an observed group that was monitored by an inconspicuous observer. Continuous labor support significantly reduced the rate of CDs and forceps deliveries.30,36 Indeed, during the COVID-19 pandemic, doulas have found innovative ways to continue to provide this essential support through virtual health.38
Prevention of perineal tears
Evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree perineal tears.31 A meta-analysis of observational studies showed a significant reduction in the risk of OASI.32
Second stage steps: Recap
Throughout the second stage of labor, the decision to continue with expectant management or intervene with either an operative vaginal delivery or a CD is complex and requires consistent assessment and integration of multiple factors. An evidence-based approach to second stage labor management includes active pushing that is either Valsalva pushing or spontaneous, coached or uncoached, but most importantly, at the start of the second stage when a patient reaches complete dilation. Reassessment should occur at regular intervals to determine progress, after ensuring maternal and fetal well-being.
If there has been no advancement in station, an attempt at manual rotation or titration of epidural analgesia should be considered. Importantly, fetal descent with adequate pushing should be demonstrated throughout the second stage.
Additional considerations that improve outcomes include warm compresses or perineal massage to prevent third- and fourth-degree tears and the presence of a continuous support person to reduce the risk for an operative delivery.
Delivery should be expected within 2 hours for multiparous women and 3 hours for nulliparous women in the second stage. Prolonging the second stage beyond these thresholds should be individualized and occur only in the setting of assured maternal and fetal well-being.
CASE An alternative management strategy
Despite Ms. J.’s great active pushing effort for 60 minutes, the presenting part remains at 0 station and occiput transverse. Ms. J. is counseled regarding the risks and benefits of an attempt at manual rotation of the fetal head, and she wishes to proceed. The fetal position remains occiput transverse.
After another hour of active pushing, the FHR becomes Category II with repetitive variable decelerations. At this time, Ms. J. is informed that there has been no descent, and she is counseled on the risks and benefits of continued pushing versus CD. Through shared decision-making, she consents to a CD. She undergoes a primary CD without complication. The birth weight was 4,100 g, and 5- and 10-minute Apgar scores were 8 and 9, respectively. The umbilical cord arterial pH was 7.13.
Ms. J. and her baby were discharged home on postoperative day 4. ●
