A Review of Evidence‐Based Practices for Management of the Second Stage of Labor

Abstract

Management of the second stage of labor often follows tradition-based routines rather than evidence-based practices. This review of second-stage labor care practices discusses risk factors for perineal trauma and prolonged second stage and scrutinizes a variety of care practices including positions, styles of pushing, use of epidural analgesia, and perineal support techniques. Current evidence for management of the second stage of labor supports the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice of positions. Perineal compresses, perineal massage with a lubricant, and controlling the rate of fetal extension during crowning may prevent severe perineal trauma at birth. Supine positioning is not recommended. Upright positions and directed pushing can shorten the time from onset of second stage to birth and may be indicated in certain situations, although directed pushing has some associated risks. If the fetus is in the occiput posterior position, immediate pushing is not recommended, and manual rotation can be effective in correcting the malposition. Women should be informed of the potential effects of epidural analgesia on labor progress. Consultation and intervention to expedite birth may be indicated when birth is not imminent after 2 hours of active pushing, or 4 hours complete dilatation, for nulliparous women; or one hour of pushing, or 2 hours complete dilatation, for multiparous women. Each woman should be individually assessed and apprised of the potential risks to her and her fetus of a prolonged second stage of labor, and some women may choose to continue pushing beyond these time limits.

Maternal and Neonatal Outcomes With Early Compared With Delayed Pushing Among Nulliparous Women

“…Specifically, women who delayed pushing had an average total second stage that was longer shown by an adjusted mean difference of 107.2 minutes (95% CI 105.1-109. 3) and an average total time actively pushing that was longer shown by an adjusted mean difference of 10.4 minutes (95% CI 8.5-12.3).…”

“…While the American College of Obstetricians and Gynecologists has no explicit position statement on delayed pushing, midwifery and some obstetric literature recommend consideration of delayed pushing for one to two hours, or until the woman experiences the urge to push, for appropriate patients. [2][3][4] Similarly, the International Federation of Gynecology and Obstetrics recommends waiting up to four hours for the nulliparous women to experience the urge to push before initiating active pushing. 5 While a long second stage 6,7 and prolonged active pushing in the second stage 8 have been associated with an increased risk of adverse maternal and neonatal outcomes, data on the maternal and neonatal risks associated with delayed pushing are conflicting.…”

Second Stage of Labor

“…3,54 With better ability for intrapartum fetal monitoring, some clinicians propose that waiting for a strong urge to push can maximize the efficiency of maternal expulsive effort and reduce risk of maternal exhaustion and need for operative delivery. 53,55 In addition to epidural analgesia potentially affecting maternal expulsive effort and efficiency, some studies suggest that epidural analgesia may be associated with fetal head malposition (eg, occiput posterior or transverse position) at delivery as a result of fetal occiput malrotation during labor. [56][57][58] One study that evaluated changes in fetal position during labor using serial ultrasound examination reported that regardless of fetal head position early in labor, final fetal position is established close to delivery.…”

Outcome of labor in vertex malposition in Cameroon

“…This has been observed elsewhere. 6,9,10 For prevention or correction of VM, more studies, such as specific maternal positions to be adopted during labor, should be carried out especially among the sub-Saharan women, given the poor maternal and neonatal outcomes associated with VM.…”

“…12,13 Manual rotation may correct the malposition. 10,14 No recent study to our knowledge has evaluated the outcome of labor in cases of VM in sub-Saharan women. Hence, this study was aimed at evaluating labor outcome in such women.…”