The second stage of labor, also known as the “expulsive stage” or “pushing stage,” begins when the cervix is fully dilated (10 centimeters) and fully effaced (100%) and ends with the birth of the baby. Effective management during this stage is crucial for the well-being of both the mother and the baby, aiming for a safe vaginal delivery while minimizing maternal trauma and fetal compromise.

Physiology of the Second Stage:

• Uterine Contractions: Become stronger, longer, and may be less frequent (e.g., every 2-5 minutes, lasting 60-90 seconds) than in the transition phase of the first stage. These contractions are the primary force expelling the fetus.

• Fetal Descent: The fetus continues to descend through the pelvis, navigating the birth canal via the cardinal movements of labor (engagement, descent, flexion, internal rotation, extension, external rotation/restitution, expulsion).

• Maternal Pushing Efforts (Bearing Down): As the fetal head descends and puts pressure on the pelvic floor and rectum, the mother experiences an involuntary, reflexive urge to push, similar to the sensation of needing to have a bowel movement. This is known as the Ferguson reflex. Voluntary pushing efforts in conjunction with uterine contractions aid fetal expulsion.

• Duration:

  • Primigravidas (first baby): Can last from 30 minutes to 2-3 hours (or longer, especially with epidural anesthesia).

  • Multigravidas (previous births): Usually shorter, from a few minutes to 1 hour.

  • Duration can be influenced by factors like fetal size and position, pelvic adequacy, maternal effort, and anesthesia.

Key Goals of Management:

• Ensure maternal and fetal well-being.

• Facilitate a spontaneous vaginal birth.

• Prevent or minimize maternal injury (e.g., perineal trauma).

• Prevent or minimize fetal injury or compromise.

• Provide emotional support and comfort to the mother.

Components of Management:

1. Assessment and Monitoring:

   • Maternal Vital Signs: Blood pressure, pulse, respirations, and temperature monitored regularly (e.g., every 15-30 minutes, or more frequently if indicated).

   • Fetal Heart Rate (FHR): Monitored continuously (if risk factors are present or if requested) or intermittently (e.g., every 5-15 minutes during active pushing, or after each contraction) according to established guidelines. Auscultation with a Doppler or fetoscope, or continuous electronic fetal monitoring (EFM). Note baseline, variability, accelerations, and decelerations.

   • Contraction Pattern: Frequency, duration, and intensity of uterine contractions.

   • Fetal Descent and Position: Assessed by vaginal examination (VE) to determine station (relationship of the presenting part to the ischial spines), position, and engagement. VEs should be performed judiciously to minimize infection risk. Abdominal palpation (Leopold’s maneuvers) can also provide information.

   • Maternal Pushing Efforts: Effectiveness and coordination of pushing.

   • Coping and Comfort: Assess maternal pain levels, anxiety, and coping mechanisms.

   • Bladder Status: Encourage voiding to prevent bladder distension, which can impede fetal descent. Catheterization may be necessary if the mother cannot void.

2. Maternal Positioning:

   • Encourage positions that promote comfort, fetal descent, and effective pushing, and utilize gravity.

   • Upright Positions: Squatting, sitting (on birth ball, toilet, or bed), kneeling, standing, walking (if appropriate and membranes intact or head well-engaged).

   • Lateral (Side-Lying) Position: Can help slow a rapid descent, improve uteroplacental perfusion, and may be more comfortable for some women or help rotate a posterior fetus.

   • Hands and Knees Position: Can help relieve back pain (especially with occiput posterior position) and may facilitate fetal rotation.

   • Lithotomy or Semi-Fowler’s Position: Common in hospital settings, especially for provider convenience during delivery, but may not be optimal for maternal effort or perineal outcomes if used exclusively.

   • Frequent position changes should be encouraged if the mother is able.

3. Guidance and Support for Pushing Efforts:

   • Spontaneous (Physiological) Pushing: Encourage the mother to push when she feels the urge, following her body’s cues. This usually involves several short pushes (e.g., 3-5 pushes of 5-7 seconds each) with each contraction, taking breaths in between.

   • Directed Pushing (Valsalva Maneuver): Involves instructing the mother to take a deep breath, hold it, and bear down for a prolonged period (e.g., 10 seconds or more) with each contraction. This method is sometimes used, especially with epidural anesthesia where the urge to push may be diminished, but it can lead to maternal fatigue, decreased uteroplacental perfusion, and potentially more perineal trauma if not done carefully. Evidence increasingly supports spontaneous pushing when possible.

   • Open-Glottis Pushing: Pushing while exhaling or making grunting sounds, which may be less stressful for mother and baby than closed-glottis (Valsalva) pushing.

   • Coaching and Encouragement: Provide clear, calm instructions, positive reinforcement, and continuous emotional support. Involve the support person(s).

   • Rest Between Contractions: Encourage relaxation and deep breathing between contractions to conserve energy.

4. Perineal Management:

   • Goal: To facilitate a gentle birth of the fetal head and minimize perineal trauma (tears or episiotomy).

   • Techniques to Reduce Perineal Trauma:

     • Perineal Massage: During the second stage (and antenatally) may help increase tissue elasticity.

     • Warm Compresses: Applied to the perineum during pushing can reduce pain and may reduce severe tears.

     • Controlled Delivery of the Head: Encouraging the mother to pant or give small pushes as the head crowns (widest part of the head is visible at the vaginal opening) to allow the perineum to stretch gradually.

     • Support of the Perineum: Gentle manual support of the perineum by the healthcare provider as the head delivers (e.g., Ritgen maneuver, modified Ritgen maneuver, or hands-off approach) – evidence on the best technique is mixed, and provider experience is key.

   • Episiotomy: A surgical incision made in the perineum to enlarge the vaginal opening.

     • Routine episiotomy is NOT recommended. It does not prevent severe tears, may increase pain, blood loss, and risk of infection.

     • Restrictive or Selective Episiotomy: May be indicated in specific situations, such as fetal distress requiring expedited delivery, shoulder dystocia, or if a severe spontaneous tear seems imminent. The decision should be based on clinical judgment.

     • Common types: Midline or mediolateral.

5. Delivery of the Fetus:

   • Crowning: When the largest diameter of the fetal head is encircled by the vulvar ring.

   • Delivery of the Head: Occurs by extension. The provider may guide the head to prevent rapid expulsion.

   • Checking for Nuchal Cord: After the head is delivered, the provider checks if the umbilical cord is wrapped around the baby’s neck. If present and loose, it can be slipped over the head; if tight, it may need to be clamped and cut before delivery of the shoulders.

   • Restitution and External Rotation: The head naturally turns to align with the shoulders.

   • Delivery of the Anterior Shoulder: Gentle downward traction on the fetal head to deliver the anterior shoulder under the symphysis pubis.

   • Delivery of the Posterior Shoulder: Gentle upward traction on the fetal head to deliver the posterior shoulder over the perineum.

   • Delivery of the Body and Extremities: The rest of the body usually follows smoothly.

6. Immediate Care of the Newborn:

   • Note the exact time of birth.

   • Dry the infant and place skin-to-skin on the mother’s abdomen or chest (if both are stable) to promote bonding, warmth, and early breastfeeding.

   • Assess Apgar scores at 1 and 5 minutes (and later if needed).

   • Suction mouth and nose only if there is obvious obstruction or meconium-stained fluid and the baby is not vigorous. Routine suctioning is not recommended.

   • Clamp and cut the umbilical cord (delayed cord clamping for at least 1-3 minutes is recommended for term and preterm infants who do not require immediate resuscitation, as it improves iron stores and other outcomes).

7. Pain Management:

   • Continue support for coping strategies used in the first stage.

   • If an epidural is in place, ensure it is providing adequate analgesia. Adjustments may be needed.

   • Other options (though less common to initiate during second stage if not already in place) could include pudendal block for perineal anesthesia or nitrous oxide.

8. Documentation:

   • Thorough documentation of all assessments, interventions, maternal and fetal responses, time of birth, Apgar scores, and any complications.

Potential Complications and Interventions:

• Fetal Distress: Indicated by non-reassuring FHR patterns. Interventions may include maternal position changes, oxygen administration, IV fluid bolus, amnioinfusion (if membranes ruptured), and preparation for operative vaginal delivery (vacuum or forceps) or Cesarean section if unresolved.

• Failure to Progress / Prolonged Second Stage: May be due to malposition (e.g., occiput posterior), cephalopelvic disproportion, or ineffective pushing. May require augmentation with oxytocin (if contractions are inadequate), operative vaginal delivery, or Cesarean section.

• Shoulder Dystocia: A SITA (obstetric emergency) where the anterior shoulder becomes impacted behind the symphysis pubis after delivery of the head. Requires specific maneuvers (e.g., McRoberts maneuver, suprapubic pressure, Woods screw maneuver, delivery of posterior arm) to dislodge the shoulder.

• Maternal Exhaustion: Provide support, encouragement, and consider options to assist delivery if pushing is ineffective.

• Perineal Lacerations: Classified by degrees (1st to 4th). Require careful assessment and repair after delivery of the placenta.