Preparation for the Second Stage of Labour

Preparation for the Second Stage of Labour

Preparation for second stage is the organized clinical, environmental, equipment and team readiness undertaken when full cervical dilatation is approaching or confirmed, so that vaginal birth, immediate newborn care and emergency response can be performed safely and respectfully.

Preparation is not merely arranging a delivery tray. It combines reassessment of the woman and fetus, confirmation that vaginal birth remains appropriate, infection prevention, consent and communication, readiness for neonatal resuscitation, anticipation of postpartum haemorrhage and a clear escalation plan.

Learning objectives

• Recognize when preparation should begin and distinguish passive from active second stage.
• Prepare the woman, companion, room, birth surface, medicines and equipment without abandoning surveillance.
• Allocate team roles and anticipate maternal or fetal complications.
• Apply respectful maternity care, infection prevention and accurate documentation.

Clinical foundations

What is the second stage?

It begins at full cervical dilatation (10 cm) and ends with complete birth of the baby. A passive phase may occur after full dilatation before an involuntary urge to push; the active or expulsive phase is characterized by expulsive contractions, active maternal bearing down and increasing visibility or descent of the presenting part.

When should preparation start?

• Before full dilatation: begin when birth appears near—for example strong expulsive contractions, increasing perineal pressure, bulging perineum, maternal grunting, anal gaping or rapid descent.
• Immediately after confirmation: complete final checks once full dilatation is confirmed and document the start of second stage.
• Earlier in high-risk labour: prepare theatre, blood, senior obstetric and neonatal help when there is previous caesarean birth, multiple pregnancy, abnormal presentation, fetal compromise, major haemorrhage risk, severe hypertension, prematurity or maternal illness.

Rapid readiness assessment

Step-by-step preparation

1. Call for appropriate help and assign roles. Identify the lead skilled birth attendant, assistant responsible for uterotonic and maternal observations, and person capable of neonatal resuscitation. State who will summon theatre, blood or senior help.
   Role allocation prevents delay and duplicated or omitted actions during sudden haemorrhage, shoulder dystocia or neonatal depression.
2. Explain findings and obtain cooperation. Tell the woman that birth is approaching, what assessments and procedures are proposed, and invite questions. Maintain privacy, dignity and confidentiality; support the companion of her choice where safe.
   Clear communication reduces fear and supports informed, respectful care.
3. Prepare a warm, private environment. Close unnecessary windows, ensure good light, a clean adjustable birth surface, adequate space, running water or alcohol hand rub, sharps container and functioning communication/referral system.
4. Support the woman’s chosen position. Offer upright, lateral, kneeling, squatting or semi-recumbent positions unless a clinical indication requires modification. Avoid routine flat supine positioning because it may cause aortocaval compression and discomfort.
5. Promote comfort and physiological needs. Encourage oral fluids if not contraindicated, help her empty the bladder, provide clean pads, mouth care, cool cloths, reassurance and non-pharmacological pain support. Do not routinely shave the perineum or give an enema.
6. Perform hand hygiene and standard precautions. Use appropriate personal protective equipment. Prepare a sterile delivery set without contaminating it, and use clean technique for contact with the birth canal.
7. Prepare the birth equipment. Include sterile gloves, clean drapes/towels, gauze, two cord clamps or ties, sterile scissors/blade, kidney dish, receiver for placenta, pads, measuring container, suturing set, good light and waste containers.
8. Prepare emergency maternal equipment. Check suction and oxygen where available, bag-mask for adult support, intravenous cannulas and fluids, blood collection tubes, urinary catheter equipment where indicated, emergency trolley and referral/transport arrangements.
9. Prepare uterotonic and prescribed medicines. Have oxytocin 10 IU ready for intramuscular administration after birth and after excluding another baby, according to national protocol. Prepare local anaesthetic and sutures only if episiotomy or repair may be indicated; label every drawn medicine and confirm dose, route and expiry.
10. Prepare immediate newborn care and resuscitation. Ensure warm dry towels, cap/blanket, clock, identification materials, cord equipment and a firm warm resuscitation surface. Test a self-inflating bag with correctly sized masks and have suction available for obstruction—not for routine suction of a vigorous newborn.
11. Continue surveillance. In active second stage, follow the national protocol for frequent fetal heart assessment (Uganda guidance specifies every 5 minutes), assess contractions and descent, and observe maternal pulse, blood pressure, respirations, bleeding and behaviour. Record findings contemporaneously.

Equipment checklist

Risk anticipation and escalation

• Abnormal fetal heart rate, fresh bleeding, cord prolapse or collapse: call emergency help, initiate indicated intrauterine resuscitative actions, prepare expedited birth and transfer/theatre.
• No descent or suspected obstruction: stop ineffective prolonged pushing, reassess position, presentation, pelvis, contractions and bladder; obtain senior obstetric review. Never apply fundal pressure.
• Meconium: ensure a practitioner skilled in newborn resuscitation is present; do not perform routine intrapartum suction.
• High postpartum-haemorrhage risk: alert the team, secure venous access if indicated, ensure uterotonic availability and blood/referral readiness.
• Preterm or multiple birth: arrange extra warm towels, appropriately sized masks, neonatal help and equipment for each baby.

Common errors and prevention

• Preparing too late: use a standardized readiness check before expulsive pushing begins.
• Focusing on equipment while neglecting monitoring: one staff member remains with the woman continuously.
• Directed pushing before full dilatation: confirm stage and allow physiological urge unless clinical management requires otherwise.
• Routine episiotomy: assess selectively; it is not a routine component of normal birth.
• Unlabelled pre-drawn medicines: label immediately and use independent checking where possible.
• Cold newborn area: prepare warmth before birth; hypothermia develops rapidly after delivery.

Documentation and handover

Record the time full dilatation was confirmed, maternal observations, fetal heart pattern, contractions, descent, membranes/liquor, position offered or chosen, companion and consent, bladder care, medicines prepared/administered, personnel present, risk factors, escalation and time senior help was contacted. Continue the Labour Care Guide or locally approved record through the end of second stage.

Revision questions

1. Define the passive and active phases of second stage.
2. Describe the preparation of the room, woman, team and newborn station.
3. Explain five findings that require escalation before vaginal birth.
4. Why should routine supine position, routine episiotomy and routine newborn suction be avoided?

References

• Uganda Ministry of Health. Essential Maternal and Newborn Clinical Care Guidelines for Uganda.
• World Health Organization. WHO Labour Care Guide: User’s Manual.
• WHO recommendations: intrapartum care for a positive childbirth experience.