South Australian Perinatal Practice Guidelines

Chapter 9a Delays in the second stage of labour

Maternity Care in SA

SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

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Delays in the second stage of labour 18 February 2004 24 December 2007 31 January 2012 978-1-74243-154-3 New document South Australian Perinatal Practice Guidelines Workgroup Medical, midwifery and allied health staff in South Australia public and private maternity services South Australian Perinatal Practice Guidelines Workgroup South Australian Perinatal Practice Guidelines workgroup at: cywhs.perinatalprotocol@health.sa.gov.au

Disclaimer
The South Australian Perinatal Practice Guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in this guideline is current at the time of publication and use of information and data contained within this guideline is at your sole risk. SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not sponsor, approve or endorse materials on such links. SA Health does not accept liability to any person for loss or damage incurred as a result of reliance upon the material contained in this guideline. Although the clinical material offered in this guideline provides a minimum standard it does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case. Where care deviates from that indicated in the guideline contemporaneous documentation with explanation should be provided. This guideline does not address all the elements of guideline practice and assumes that the individual clinicians are responsible to:
Discuss care with consumers in an environment that is culturally appropriate and which

enables respectful confidential discussion. This includes the use of interpreter services where necessary Advise consumers of their choice and ensure informed consent is obtained Provide care within scope of practice, meet all legislative requirements and maintain standards of professional conduct Document all care in accordance with mandatory and local requirements

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

Management of delayed second stage

Delayed progress in second stage
If birth not imminent, seek medical review: Primipara: after 2 hours Multipara: after 1 hour

Medical assessment
Exclude: Full bladder Cephalo pelvic disproportion Malpresentation of the fetal head, e.g. OP, OT, or deflexed fetal head Inelastic perineal tissues, especially in the older primipara Inadequate uterine activity / pushing effort Positive signs of obstructed labour

Management
Abdominal and pelvic assessment Insert indwelling catheter if not already in place Portable USS to help determine the position of the baby Decide on management plan in consultation with obstetrician on call

Await events
If there are no maternal or fetal complications Consult with obstetrician to confirm decision Continuous CTG Offer amniotomy if membranes intact

Active management
Expedite delivery Decide on the most appropriate type

of operative delivery
Arrange for obstetrician presence at

Primipara
If inadequate uterine

Multipara
If inadequate uterine

delivery as indicated Consider trial of forceps / ventouse in operating theatre if difficulty anticipated Consent for LSCS in case of failed instrumental / ventouse

activity, Syntocinon augmentation may begin any time during 2nd stage (as per Chapter 4 IOL PPG)

activity, consult obstetrician and use caution if Syntocinon augmentation agreed (as per Chapter 4 IOL PPG)

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

Abbreviations
ACOG CTG et al. e.g. OP OT IOL LSCS PPG SFH USS American College of Obstetricians and Gynecologists Cardiotocograph And others For example Occipito posterior Occipito transverse Induction of labour Lower segment caesarean section Perinatal Practice Guidelines Symphyseal fundal height Ultrasound

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

Table of contents
Disclaimer Management of delayed second stage flow chart Abbreviations Introduction Definitions Literature review Length of second stage Delayed descent in second stage References

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

Introduction
The guideline for management of delays in second stage of labour is intended for

women at term with low risk pregnancies and reassuring maternal and fetal status. It is not suitable for women with multiple gestation or women attempting vaginal birth after caesarean section, because in these clinical situations there is very little evidence on best practice, and management is individualised

Literature review
In women without epidural anaesthesia, use of any upright or lateral position, compared

with supine or lithotomy positions, is associated with reduced duration of second stage of labour (Gupta et al. 2004)
Length of second stage is not associated with neonatal morbidity (Janni et al. 2002;

Cheng et al. 2004; Altman & Lydon-Rochelle 2006)

Increased maternal morbidity in women with prolonged second stage may be partially

attributed to the higher rate of operative procedures and should not be solely based on the elapsed time after full dilatation (Janni et al. 2002)
The effect of prolonged second stage of labour on pelvic support and urinary and faecal

continence requires further investigation

Extremely prolonged second stage (> 4 hours) is associated with increased incidence of

postpartum haemorrhage and caesarean section (Cheng et al. 2004)

Definitions
For the purpose of this guideline, the following definitions of labour are recommended:

Passive second stage of labour

The finding of full dilatation of the cervix before (or in the absence of) involuntary

expulsive contractions

Active second stage of labour

The baby is visible Expulsive contractions with a finding of full dilatation of the cervix Active maternal effort following confirmation of full dilatation of the cervix in the absence

of expulsive contractions (NICE 2007)

Length of second stage

The length of 2nd stage varies according to:
Maternal positioning Position of the fetus Station at completion of first stage Quality of the uterine contractions Use of oxytocin augmentation Pushing efforts of the woman Type of analgesia

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

(Archie & Biswas 2003; Altman & Lydon-Rochelle 2006)

The beginning of second stage (diagnosis of complete cervical dilation) is difficult to

determine as it depends on the timing and indication for vaginal examination

The evidence suggests that, in controlled circumstances (where fetal and maternal

wellbeing is established), allowing women in second stage to rest and await fetal descent has beneficial effects including:
Reduced maternal fatigue in nulliparas Less fetal heart rate decelerations Reduced pushing time for both nulliparas and multiparas (Hansen et al.

2002)
There is no evidence for setting a time limit for active (pushing) phase of second stage

unless there is a lack of descent (ACOG 2003)

Individual practitioners need to take into account their own capabilities and local

practices when determining how long to leave a woman in the second stage before deciding on expediting delivery

Nulliparous women
Normal length of second stage is 30 minutes to 3 hours (median duration: 50 minutes) Prolonged second stage should be considered when active second stage exceeds: 3 hours with regional anaesthesia 2 hours if no regional anaesthesia is used (ACOG 2003) Medical review should be requested after active second stage has lasted 2 hours if birth

is not imminent
Amniotomy should be offered if the membranes are intact

Multiparous women
Normal length of second stage is 5 30 minutes (median duration: 20 minutes) Prolonged second stage should be considered if active second stage exceeds: 2 hours with regional anaesthesia 1 hour if no regional anaesthesia is used (ACOG 2003) Medical review should be requested after active second stage has lasted 1 hour if birth

is not imminent
Amniotomy should be offered if the membranes are intact

Delayed descent in second stage

A prolonged second stage of labour warrants clinical reassessment of the woman, fetus

and expulsive forces

Assess fetal size, adequacy of the pelvis, fetal wellbeing, and maternal

pushing efforts

Exclude the following:

Full bladder Cephalo-pelvic disproportion Careful review of the notes, including recent scan results and SFH

measurements

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

Abdominal palpation Vaginal examination including a pelvic assessment, examination of the

fetal head for caput and moulding

Malpresentation of the fetal head, e.g. occipito-posterior or occipito transverse, or

deflexed fetal head

Inadequate uterine activity Inelastic perineal tissues, especially in the older primipara

Observe for the following possible indicators of obstructed labour

Maternal and fetal tachycardia Hypertonus with frequent, strong contractions Vaginal bleeding Haematuria Maternal temperature Constant severe abdominal pain Physiologic retraction ring (Bandls ring) Catheterise the bladder Abdominal and pelvic assessment Ultrasound can improve the accuracy of determining the position of the baby Provided there are no maternal or fetal complications, in consultation with an

obstetrician, decide whether there is any advantage to waiting

If there is a reason for the second stage to be expedited, decide on the most

appropriate type of instrumental delivery, e.g. simple forceps, rotational forceps or ventouse
Consider trial of forceps / ventouse in operating theatre if difficulty is anticipated

Syntocinon augmentation in the second stage

Syntocinon augmentation in the second stage for a nulliparous woman is a safe option

to overcome inadequate uterine activity. Extreme caution should be exercised in a multiparous woman
Oxytocin administration can begin at any time during the second stage, particularly in

nulliparous women with epidural anaesthesia, OR where contractions are assessed to be inadequate OR there is lack of progress
Women who are already receiving oxytocin at the onset of the second stage should

continue to receive it during the second stage

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SA Perinatal Practice Guideline: Chapter 9a Delays in the second stage of labour

References
1. Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2. Available from: URL: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002006/fra me.html 2. Archie CL, Biswas MK. The course & conduct of normal labor & delivery, In: DeCherney AH & Nathan L, editors. Current Obstetrics & Gynecologic Diagnosis & Treatment. McGraw-Hill; 2003. 3. Altman MR, Lydon-Rochelle MT. Prolonged second stage of labor and risk of adverse maternal and perinatal outcomes: a systematic review. Birth 2006; 33: 315-322 (Level I). 4. Janni W, Schiessl B, Peschers U, Huber S, Strobl B, Hantschmann P, et al. The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome. Acta Obstet Gynecol Scand 2002; 81: 214-221. 5. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes? AJOG 2004; 191: 933-938. 6. National Institute for Clinical Excellence (NICE) (2007). Intrapartum care. Care of healthy women and their babies during childbirth. NICE clinical guideline number 55. National Collaborating Centre for Womens and Childrens Health. RCOG Press, London. Available from URL: http://www.nice.org.uk/nicemedia/live/11837/36280/36280.pdf 7. American College of Obstetricians and Gynecologists (ACOG). Dystocia and augmentation of labor. ACOG Practice Bulletin Number 49. Obstet Gynecol 2003; 102:1445-1454. 8. Sprague AE, Oppenheimer L, McCabe L, Brownlee J, Graham ID, Davies B. The Ottawa hospitals clinical practice guideline for the second stage of labour. JOGC 2006: 769-779. 9. Hansen SL, Clark SL and Foster JC. Active pushing versus passive fetal descent in the second stage of labor: A randomized controlled trial. Obstet Gynecol 2002; 99:29-33 (Level II). 10. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, et al. A guide rd to effective care in pregnancy and childbirth, 3 ed. Oxford: Oxford University Press; 2000 (Level I). 11. ODriscoll K, Strong JM. (1975). The active management of labour. Clinics Obstet Gynaecol 1975; 3:1.

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