Management of the prolonged second stage of labour
Whatever the limits applied to the second stage, a proportion of fetuses will remain undelivered despite the mother’s best efforts. A prolonged second stage can be approached as follows:
1.
Ensure uterine contractions are optimal and consider oxytocin augmentation if appropriate—this step is best considered before the agreed limits of the second stage are reached. If delayed pushing is practised, an opportune time to start oxytocin augmentation is when active bearing-down efforts by the mother commence. If ACOG recommendations for a longer period of bearing down are adopted, commencing augmentation after 1 hour of pushing would seem reasonable.2. Consider operative vaginal delivery by forceps or ventouse, if appropriate. In the presence of malposition, rotational operative vaginal delivery or manual rotation to the occiput anterior position followed by operative vaginal delivery may be possible. Operative vaginal delivery is discussed further in Chapter 33. Manual rotation to the occiput anterior position by an experienced clinician appears to be effective (22) and is a promising intervention, especially in light of the decreasing use of rotational forceps for these deliveries.
3. Caesarean section if operative vaginal delivery is not possible.
In deciding between operative vaginal delivery and caesarean section, careful consideration of the clinical situation including abdominal and vaginal examination findings, the fetal heart rate pattern, and maternal cooperation is essential. The experience of the obstetrician is also a key factor in choosing the appropriate mode of delivery.