Second Stage of Labour Management
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Direct answer
The second stage of labour runs from full cervical dilatation to delivery of the baby, and its management aims for a safe vaginal birth. Conventional limits are about two hours for nulliparous and one hour for multiparous women, extended by about an hour with regional analgesia, though current guidance favours individual judgement. Spontaneous pushing, controlled head delivery and careful perineal protection form the core of management.
What you must remember
- Definition: the second stage begins at full dilatation and ends with delivery of the baby, not the placenta.
- Duration limits: about two hours for nulliparous and one hour for multiparous women, with an extra hour allowed under regional analgesia.
- Pushing: spontaneous pushing in a position of the woman's choice is preferred over directed Valsalva pushing in healthy women.
- Ritgen manoeuvre: supports the perineum and guides controlled extension of the head to limit perineal trauma.
- Episiotomy: restricted use, and mediolateral is preferred over midline, which carries a higher risk of anal sphincter injury.
- Perineal tears: third degree involves the anal sphincter complex, and fourth degree extends into the rectal mucosa.
- Fetal monitoring: intermittent auscultation or CTG identifies fetal compromise that may prompt assisted delivery.
- Prolonged second stage: failure to progress or fetal compromise leads to consideration of instrumental delivery.
A stepwise approach to the second stage
The second stage is managed as a sequence in which each step protects both the mother and the baby. Most avoidable harm occurs at head delivery and during perineal protection, so those steps deserve the most attention.
- Confirm the stage: Check full dilatation, the station and the membranes, and confirm the presentation before any pushing begins. Record the time of full dilatation, since the duration limits are measured from that point.
- Position and pushing: Encourage upright or semi-recumbent positions and spontaneous pushing guided by the woman's own urge to bear down. Coach her to push with the contractions and to breathe between efforts rather than holding her breath.
- Head delivery: Use the Ritgen manoeuvre or hands-on support to control extension, so the head delivers slowly. The head should be eased over the perineum rather than allowed to shoot out.
- Perineal protection: Support the perineum with warm compresses and a guarding hand, and avoid routine episiotomy. Episiotomy is reserved for specific indications such as operative delivery or fetal distress.
- Shoulders and body: Deliver the anterior shoulder with gentle downward traction and the posterior shoulder with upward traction, watching for shoulder dystocia.
- Review: Examine the perineum after delivery, classify any tear and repair it under good light with adequate analgesia.
Where second stage questions catch students
Second stage questions test pushing technique, tear classification and when to stop waiting.
- Trap: Insisting on directed pushing for hours in a healthy woman Correct: spontaneous pushing is preferred, and prolonged effort without progress should prompt review.
- Trap: Performing a routine midline episiotomy Correct: episiotomy is restricted, and mediolateral is preferred if one is needed, since midline raises anal sphincter injury risk.
- Trap: Calling a sphincter tear a second-degree laceration Correct: any injury involving the anal sphincter is third degree, and rectal mucosa involvement makes it fourth degree.
- Trap: Continuing a prolonged second stage despite fetal distress Correct: assisted delivery is needed once fetal compromise develops.
Frequently asked questions
What are the duration limits for the second stage of labour?
Conventional limits for the second stage of labour are about two hours for nulliparous and one hour for multiparous women, extended by about an hour under regional analgesia. Current guidance allows individual judgement when the mother and fetus are well and progress is being made.
How do third-degree and fourth-degree perineal tears differ?
A third-degree perineal tear involves the anal sphincter complex, and a fourth-degree tear extends through the sphincter into the rectal mucosa. Both need careful repair, and fourth-degree tears need closer follow-up for bowel symptoms.
What is the Ritgen manoeuvre used for?
The Ritgen manoeuvre is used at head delivery to control extension of the fetal head and reduce perineal trauma. Support is applied to the perineum while the head is guided upwards, so it extends slowly over the perineum.
Which episiotomy is preferred in an assisted birth?
Mediolateral episiotomy is preferred over midline because midline episiotomy carries a higher risk of extension into the anal sphincter. Mediolateral incisions have their own bleeding and healing drawbacks, but restricted use is the principle in all cases.