WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

CLINICAL GUIDELINES
WOMEN AND NEWBORN HEALTH
OBSTETRICS AND MSERVICE
IDWIFERY
INTRAPARTUM CARE King Edward Memorial Hospital
SECOND STAGE OF LABOUR

LABOUR (SECOND STAGE): MANAGEMENT

Key words: second stage, labour, birth, 2nd stage, intrapartum, latent descent phase,
active pushing, allow for descent, urge to push, ineffective pushing, directed pushing,
continuous fetal heart rate monitoring

BACKGROUND INFORMATION

The definition of second stage labour commencement is described as when the cervix
is fully dilated. The duration of second stage is therefore based on when the woman’s
cervix is assessed as being fully dilated by the midwifery or medical staff.
The second stage of labour can be described as the:
 Latent, Passive or Descent phase, and the
 Active or Pelvic Floor phase.1

LATENT / PASSIVE / DESCENT PHASE

This phase in second stage is defined when the cervix is found to be fully dilated prior
to, or in the absence of involuntary expulsive contractions.1 During this passive phase
the presenting part descends toward the pelvic outlet, and rotation and flexion occurs.2

ACTIVE / PELVIC FLOOR PHASE

The onset of the active phase of second stage labour is recognised when following / on
confirmation of full dilation of the cervix :
 the fetal presenting part is visible
 there are expulsive contractions and other signs indicating full dilatation.
 there is active maternal effort in the absence of expulsive contractions.1

KEY POINTS

1. Duration of second stage of labour should be dictated by clinical judgement which

includes analgesia use, maternal and fetal condition, and progress of the
presenting part through the pelvis.
2. In the event of delay in second stage of labour the woman shall be reviewed by
the medical team and the Labour and Birth Suite Co-ordinator.
3. Provided there are no contra-indications delayed pushing may be appropriate if
the woman has no urge to push.
4. Arrange medical team review if birth is not imminent during the active phase of
second stage labour for:
 nulliparous women (without epidural) – 2 hours
 multiparous women (without epidural) – 1 hour.1
Note: For time limitations in second stage, see ‘Duration of Second Stage’ below.

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 1 of 8
 5. If a woman without regional analgesia has no urge to push 1 hour after diagnosis
of full cervical dilatation perform a vaginal examination (VE) and assessment.1
Discuss with the medical obstetric team.
6. The woman should be allowed to find her own technique and pattern of pushing. 1
Directed pushing should be reserved for situations such as ineffective pushing
techniques1 or fetal compromise.
7. An upright posture in second stage for women without epidurals may provide
benefits, however may increase risk of blood loss over 500mL. Women who give
birth on their backs have a higher incidence of assisted delivery and episiotomy, but
less blood loss.3 For women with epidurals, there is insufficient evidence on second
stage positioning, and women are encouraged to position comfortably.4
8. Epidural analgesia should continue to be part of management in second stage
unless declined by maternal request.
9. Perform continuous cardiotocograph monitoring if the active phase of second
stage labour is prolonged5 (beyond 1 hour-multipara; or ≥2hours nullipara6), and
birth is not imminent.
10. A paediatric RMO or above must be present for all births where the woman has a
history of taking SSRI / SNRI or other psychotrophic medication during pregnancy.

MANAGEMENT OF UNCOMPLICATED SECOND STAGE

TOPIC MANAGEMENT ADDITIONAL INFORMATION

Confirm Perform a VE to confirm second stage
second in the following circumstances:
stage  when there is a delay in the first
stage of labour7
 evidence of caput succedaneum
at previous VEs7
 if the woman has an urge to push
and there is no presenting part on
view
 prior to administering an epidural
top-up.7
Maternal  Contractions– 30 minutely1
Observation  Pulse –15 minutely (to differentiate observations may need to be
from FHR)1
 1
Blood pressure – 1 hourly
 Temperature –4 hourly1
 Urine output – empty bladder
The second stage of labour does
not need to be confirmed by VE if
good progress of the presenting
part is made, the contractions are
regular and strong, she does not
have an epidural, and the
presenting part is visible at the
introitus.7
Frequency of maternal
increased if the medical or
physical condition requires closer
monitoring.
The compression of a full bladder

Second Stage of Labour: Management King Edward Memorial Hospital

Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 8
 TOPIC MANAGEMENT ADDITIONAL INFORMATION
regularly. Monitor for signs of may result in bladder damage2
urinary retention.1 and delay descent of the fetus.
 Vaginal examinations (VE)– Offer Contractions may need to be
1 hourly in the active phase or at more closely monitored if delay in
the woman’s request, after second stage is suspected.
assessing: Assess progress (maternal
 Amniotic fluid – frequent behaviour, pushing effectiveness,
monitoring of colour & odour fetal wellbeing, position & station)
 Abdominal palpation – prior to to assist timing of VE’s & need for
1
vaginal examination or to assess obstetric review.
progress of labour.1
Fetal Auscultate the fetal heart rate (FHR) The maternal pulse should be
Observation after each contraction or at least 5 monitored if there is suspected
minutely during the active second fetal bradycardia or any other
1, 5
stage of labour. FHR anomaly to differentiate the
Auscultation should be performed two rates.1
toward the end and for at least 30-60
seconds after each contraction during
active pushing.1, 5
Continuous fetal monitoring should be Consider instrumental vaginal
used if the active second stage is birth if concern for fetal
5
prolonged (≥2hrs nullipara or ≥ 1 hr wellbeing.1
multipara6) and birth is not imminent. Use continuous CTG if risk
See Clinical Guidelines, O&M, factors for fetal compromise are
Intrapartum Care, Fetal Heart Rate present antenatally or develop
Monitoring: Intrapartum for indications intrapartum.5
for continuous cardiotocograph
monitoring (CTG).
Analgesia See Clinical Guidelines, O&M, Pain Consideration of pain relief
Management in Labour. continues through second stage.1

Maternal Support the women to adopt a Women lying on their backs to

Positioning comfortable position.4 give birth have increased risk of
Women can be encouraged to use an assisted births and episiotomy,
upright position.3 but less blood loss.3
A woman lying on her back may
Discourage the woman from lying cause vena cava compression
supine or semi-supine.1 leading to supine hypotension
Second Stage of Labour: Management King Edward Memorial Hospital
Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 8
 TOPIC MANAGEMENT ADDITIONAL INFORMATION
Encourage postural changes.1 and reduced placental perfusion.2
Postural changes may be a
beneficial intervention to rectify
asynclitism or malposition of the
fetus. It may also prevent
neurological injuries caused from
exaggerated flexion of the legs
and sustained bearing down by
women.8
Duration of Time limitations for duration of second Prolonged phase of coached
second stage should be determined by clinical active pushing is associated with
stage assessment of the: maternal injury to the perineal
 progression and descent of the structures.9
presenting part1 Women with regional / epidural
 maternal wellbeing analgesia may have a weakened
 fetal wellbeing1 urge to push, altering the
Note: If a woman without regional/ physiological mechanisms of
epidural analgesia has no urge to push labour, resulting in increased
after 1 hour of her cervix being fully assisted births. Delayed pushing
dilated, perform further assessment1 increases time but assists
and VE. Inform the medical team. passive descent and increases
If there are inadequate contractions at maternal urge to push with
the beginning of second stage, benefits such as reduced
consideration can be given to oxytocin maternal fatigue & perineal
with an offer of regional / epidural injury.9
analgesia.1 Effects on maternal and neonatal
10
outcomes remains uncertain
and research on the optimal time
to push is being reviewed.9
 Without Nulliparous women – Birth is expected to take place
epidural  Diagnose delay if birth is not within 3 hours of commencement
imminent 2 hours from the start of of active second stage for most
active second stage1: nulliparous women.1
 Arrange medical review by In a nulliparous women, ≥2
professional trained to perform hours of pushing without descent
operative vaginal birth.1 indicates prolonged second
 Inform the Labour and Birth stage.11, 12

Second Stage of Labour: Management King Edward Memorial Hospital

Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 8
 TOPIC MANAGEMENT ADDITIONAL INFORMATION
Suite Co-ordinator.
 Suspect delay if inadequate progress If transfer may be required,
(rotation/descent) after 1 hour of consider ease / difficulty of
active second stage :1
access to appropriate services.11
 Offer VE &then amniotomy (if
intact membranes)1
Multiparous women – Birth is expected within 2 hours
 Diagnose delay if birth is not from the start of the active stage
imminent 1hour from of labour for most multiparous
1
commencement of the active phase women.
of second stage,1 and: A multipara has a prolonged
 Arrange medical review11 by second stage if without descent:
professional trained to perform  after ≥1hr, without epidural
an assisted vaginal birth.1  after ≥2 hrs (including ≥1hr of
 Inform the Labour and Birth active pushing) with epidural.11
Suite Co-ordinator.
 Suspect delay if inadequate
progress (rotation/descent) after 30
min of active second stage.1
 Offer VE & then amniotomy (if
intact membranes)1
 With Nulliparous & multiparous women – Effective neuraxial analgesia
epidural If there is no urge to push and / or the increases duration of second
fetal head is not visible allow pushing stage of labour, therefore need
to be delayed for at least 1 hour, and for intervention should not be
longer if the woman wishes, for mandated solely on duration in
descent. After this time, encourage these circumstances.13
active pushing.1 The best time to commence
Once active stage commenced, see pushing with an epidural remains
time frames as per “Without epidural” unknown, however allowing time
above. for fetal descent has shown
benefits.9
Regardless of parity, women with
regional / epidural analgesia
should birth <4hours from
diagnosis of full dilatation.1
Delay in  Offer encouragement, support & If there is delay or the woman is
second analgesia as required excessively distressed be
Second Stage of Labour: Management King Edward Memorial Hospital
Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 8
 TOPIC MANAGEMENT
stage1  Obstetric review if confirmed delay
before use of oxytocin
 Then continue obstetric review 15-
30 minutely
 Consider instrumental vaginal birth
 Advise women to have a caesarean
birth if vaginal birth not possible.1
Pushing Encourage spontaneous or involuntary
technique pushing.1, 14
Reserve directed / coached pushing
for women who have:
 difficulty pushing effectively1
 requested strategies to assist
birth1
 a prolonged second stage
 a non-reassuring fetal heart rate.15
Support and  offer sips of fluids2 / ice chips
comfort  if the woman experiences leg
cramps, offer massage to the calf
muscle, extend the leg and use
dorsiflexion to the foot2
 offer sponging of the woman’s
face and neck2
 provide aids to assist pushing e.g.
birth stools, pillows, birth balls,
mirrors
Birth See Clinical Guideline, O&M,
Intrapartum Care, Second Stage of
Labour: Birth Management.
Second Stage of Labour: Management
Clinical Guidelines: Obstetrics & Midwifery
(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
ADDITIONAL INFORMATION
sensitive to the woman’s needs.
Offer an assisted birth when
previous care has not helped.1
Directed pushing involving breath
holding of >10 seconds can
increase fetal hypoxic effects,
urinary / perineal trauma, and
adverse effects on maternal, fetal
or neonatal outcomes.9
Coached pushing in second
stage has a negative impact on
the first void function and bladder
capacity. It also causes detrusor
over-activity and impairs pelvic
floor function.15
Strategies to assist birth include
support, change of position,
bladder emptying &
encouragement.1
Continue to consider the
woman’s emotional and
1
psychological needs.
Due to maternal exertion in
second stage the woman may
feel hot and have a dry mouth /
lips.2
The support person can assist
with these tasks, thereby helping
reduce the woman’s discomfort.2
A paediatric RMO or above must
be present at the birth when the
woman has a history of SSRI /
SNRI or other psychotrophic
medications.
King Edward Memorial Hospital
Perth Western Australia
Page 6 of 8
 TOPIC MANAGEMENT ADDITIONAL INFORMATION
Document Document observations on the
Partogram (MR270).1
Document all interventions or changes
to the maternal/fetal
condition/management on the
Integrated Progress Notes (MR250).

Note: This table provides guidance for an uncomplicated second stage and the plan of
care may be altered by the medical team if complications develop. Care should be
individualised as required. If the birth requires expediting at any time due to
maternal or fetal reasons, assess degree of urgency, clinical findings (abdominal
and vaginal, maternal and fetal), choice of birth mode / instruments required,
anticipated difficulty, location, whether transfer required, analgesic requirements
and the woman’s preferences. Discuss reasons and options with the woman and
her support person and inform the team regarding level of urgency. Additionally,
record the time that a decision is made to expedite the birth. 1

See also specific KEMH clinical guidelines in Obstetrics & Midwifery, Intrapartum Care
regarding Birth Management, Instrumental Vaginal Delivery, Caesarean Section and
Vaginal Birth After Caesarean.

Second Stage of Labour: Management King Edward Memorial Hospital

Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 7 of 8
 REFERENCES / STANDARDS
1. National Institute for Health and Care Excellence. Intrapartum care: Care of healthy women and their babies during
childbirth: CG190. NICE. 2014. Available from: http://www.nice.org.uk/guidance/cg190/resources/guidance-
intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf.
2. Downe S, Marshall J. Physiology and care during the transition and second stage phases of labour. In: Marshall J,
Raynor M, editors. Myles textbook for midwives. 16th ed. Edinburgh: Churchill Livingstone Elsevier; 2014. p. 367-93.
3. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia
(Review). The Cochrane Database of Systematic reviews. 2012(5). Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002006.pub3/pdf.
4. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural
anaesthesia (Review). Cochrane Database of Systematic Reviews. 2013(1). Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008070.pub2/pdf.
5. RANZCOG. Intrapartum fetal surveillance: Clinical guideline- 3rd ed. RANZCOG. 2014. Available from:
https://www.ranzcog.edu.au/intrapartum-fetal-surveillance-clinical-guidelines.html.
6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Maternal suitability for models of
care, and indications for referral within and between models of care: C-Obs 30. RANZCOG. 2015. Available from:
http://www.ranzcog.edu.au/college-statements-guidelines.html.
7. Baston H. The second stage of labour. The practising midwife. 2004;7(3):30-6.
8. Roberts J, Hanson L. Best practices in second stage labor care: Maternal bearing down and positioning. J Midwifery
Womens Health. 2007;52(3):238-45. Available from:
http://www.sciencedirect.com.kelibresources.health.wa.gov.au/science/article/pii/S1526952306006295.
9. Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down
methods for the second stage of labour (Protocol). Cochrane Database of Systematic Reviews. 2011(5). Available
from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009124/pdf.
10. Tuuli MG, Frey HA, Odibo AO, et al. Immediate compared with delayed pushing in the second stage of labor.
Obstetrics & Gynecology. 2012;120(3):660-68.
11. Australian College of Midwives. National midwifery guidelines for consultation and referral: ACM; 2014.
12. Ministry of Health. Guidelines for consultation with obstetric and related medical services (referral guidelines).
Wellington, NZ: Ministry of Health; 2012. Available from:
http://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdf.
13. Cambic CR, Wong CA. Labour analgesia and obstetric outcomes. Br J Anaesth. 2010;105(S1):i50-60.
14. Prins M, Boxem J, Lucas C, Hutton E. Effect of spontaneous pushing versus valsalva pushing in the second stage of
labour on mother and fetus: A systematic review of randomised trials. BJOG. 2011;118(6):662-70.
15. Schaffer JI, Bloom SL, Casey BM, et al. A randomized trial of the effects of coached vs uncoached maternal pushing
during the second stage of labour on postpartum pelvic floor structure and function. American Journal of Obstetrics
and Gynecology. 2005;192:1692-6.

National Standards – 1- Care Provided by the Clinical Workforce is Guided by Current Best Practice;
9- Recognising and Responding to Clinical Deterioration in Acute Health Care
Legislation -
Related Policies – KEMH Clinical Guidelines: O&M, Intrapartum Care:
 Fetal Heart Rate Monitoring: Intrapartum; Fetal Surveillance (Intrapartum): LBS QRG; Fetal Compromise
(Acute): Management if Suspected
 Birth Management; Paediatric Attendance for ‘At Risk’ Births; Instrumental Vaginal Delivery
 Vaginal Birth After Caesarean Section (VBAC): Intrapartum Management
Other related documents –
RESPONSIBILITY
Policy Sponsor Nursing & Midwifery Director OGCCU
Initial Endorsement October 2001
Last Reviewed October 2015
Last Amended
Review date October 2018
Do not keep printed versions of guidelines as currency of information cannot be guaranteed.
Access the current version from the WNHS website.
© Department of Health Western Australia 2015
Copyright disclaimer available at: http://www.kemh.health.wa.gov.au/general/disclaimer.htm
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Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia

(B5.9.1) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 8 of 8