Conducting the Second Stage of Labour

Conducting the Second Stage of Labour

Conducting second stage is the skilled, respectful care given from full cervical dilatation until complete birth of the baby. It includes continuous support, close maternal and fetal surveillance, promotion of physiological descent, controlled birth, rapid recognition of complications and a safe transition to immediate newborn and third-stage care.

The aim is not merely to “deliver the baby,” but to achieve birth with minimum avoidable trauma, preserved fetal oxygenation, prompt emergency response and a positive experience for the woman.

Principles and objectives

• Maintain maternal and fetal safety while supporting normal physiology.
• Respect the woman’s dignity, informed choices, privacy, companion and preferred birth position.
• Avoid unnecessary intervention, including routine episiotomy, routine suction and fundal pressure.
• Recognize poor progress, fetal compromise, obstruction, shoulder dystocia and haemorrhage early.
• Provide warmth, breathing support when needed, delayed cord clamping where appropriate, skin-to-skin care and early breastfeeding.

Preconditions for planned vaginal birth

• Full cervical dilatation has been confirmed.
• Presentation and position are known and vaginal birth is not contraindicated.
• Maternal condition and fetal heart findings are acceptable or an expedited vaginal birth plan has been made by the appropriate clinician.
• There is ongoing descent or a documented assessment of progress.
• A skilled attendant, assistant, clean delivery set, uterotonic, newborn warmth and functioning resuscitation equipment are ready.
• A pathway exists for senior obstetric review, assisted birth, caesarean birth, blood transfusion and neonatal care.

Ongoing observations

Step-by-step conduct of a normal cephalic birth

1. Confirm readiness and communicate. Review findings, explain the plan, obtain consent for examinations/procedures, call the assistant and verify maternal and newborn emergency equipment.
   Clear roles and informed cooperation prevent delay during an unexpected complication.
2. Position and support the woman. Help her adopt a comfortable upright, lateral, kneeling, squatting or semi-recumbent position. Protect privacy and permit her companion where safe. Avoid routine supine positioning.
3. Encourage physiological pushing. When there is an involuntary urge in the expulsive phase, encourage bearing down with contractions and rest/breathe between them. Avoid prolonged directed closed-glottis pushing as a routine. If fetal compromise requires expedited birth, coordinated pushing may be advised by the responsible clinician.
4. Maintain infection prevention. Perform hand hygiene, wear appropriate protective equipment, open the sterile set aseptically and use clean drapes. Do not repeatedly touch the vaginal opening or perform unnecessary examinations.
5. Observe descent and perineal stretching. Watch for progressive opening of the vulva and crowning—the widest diameter of the head remains visible and no longer recedes between contractions.
6. Control birth of the head. Encourage gentle breathing or small controlled efforts as the head crowns. Support slow extension and protect the perineum using the locally taught evidence-based technique; do not forcibly hold the head back.
   A slow controlled birth allows tissues to stretch and may reduce severe perineal trauma.
7. Use episiotomy selectively. Do not perform it routinely. Consider it when an expedited birth is clinically required, for some assisted vaginal births, or when access is needed for specific complications. Explain and obtain consent where possible, infiltrate adequate local anaesthetic, use the recommended mediolateral technique, and document indication and repair.
8. After the head is born, pause and assess. Note the time, wipe the face only if needed, allow restitution and external rotation, and check for a cord around the neck. Do not routinely suction a vigorous baby. If a loose nuchal cord is present, slip it over the head or shoulders; if tight and preventing birth, use an appropriate manoeuvre or clamp and cut only when necessary.
9. Deliver the shoulders gently. With the next contraction and maternal effort, guide the head gently downward only as needed for the anterior shoulder, then upward for the posterior shoulder. Avoid forceful traction.
10. Deliver and secure the body. Support the baby firmly because the body is slippery. Note exact birth time and place the baby immediately skin-to-skin on the mother’s abdomen/chest on a warm dry cloth if stable.
11. Dry, assess breathing and maintain warmth. Dry thoroughly, remove wet cloth, cover mother and baby and assess tone and breathing. If the baby is not breathing or is gasping, call for neonatal resuscitation, transfer to the warm firm surface and begin protocol-based initial steps and ventilation without delay.
12. Exclude an additional baby. Palpate the abdomen before administering a uterotonic.
13. Give prophylactic uterotonic. Following Uganda protocol, administer oxytocin 10 IU intramuscularly within one minute after birth once another baby has been excluded. Confirm patient, medicine, dose, route, expiry and document time.
14. Manage the cord appropriately. For a stable mother and baby, delay clamping for approximately 1–3 minutes while continuing assessment and warmth. Clamp and cut with sterile equipment. If immediate resuscitation away from the mother is necessary and intact-cord resuscitation is unavailable, prioritize effective ventilation according to protocol.
15. Assess adaptation. Record Apgar components at one and five minutes while providing needed care; never delay resuscitation to calculate a score. Initiate breastfeeding as soon as mother and baby are ready, ideally within the first hour.
16. Transition safely to third stage. Observe for placental separation, perform controlled cord traction only when trained and according to protocol, maintain uterine support, inspect placenta/membranes after delivery and monitor bleeding and uterine tone.

Episiotomy: indication, care and precautions

Episiotomy is a surgical incision of the perineum to enlarge the vaginal outlet. It is selective, not routine. Before cutting, confirm an appropriate indication, explain, provide local anaesthesia unless an effective regional block exists, wait for effect, protect the presenting part and use the technique specified by national/facility guidance. After birth, inspect under good light, exclude extension and repair anatomically with adequate analgesia and asepsis.

• Possible indications: urgent need to shorten birth because of fetal compromise when vaginal birth is imminent; selected operative vaginal birth; rigid scarred perineum or manoeuvres where additional access is essential.
• Risks: pain, bleeding, extension to anal sphincter/rectum, infection, wound breakdown, dyspareunia and pelvic-floor morbidity.
• Nursing/midwifery care: monitor bleeding and pain, inspect the wound, maintain hygiene, administer prescribed analgesia, teach pelvic-floor and danger signs, and arrange review for severe tears.

Failure to progress in second stage

Do not respond to elapsed time alone. Reassess the “powers, passenger, passage, position and person”:

• Powers: contraction adequacy and effective pushing; exclude uterine hyperstimulation.
• Passenger: fetal size, attitude, presentation, position, caput and moulding.
• Passage: pelvic adequacy, soft-tissue obstruction and a full bladder.
• Position: support position change and mobility if safe; some malpositions rotate with time and movement.
• Person: hydration, analgesia, fear, exhaustion, disease, informed preferences and fetal status.

Correct reversible problems, summon senior review and decide whether continued support, assisted vaginal birth or caesarean birth is safest. Instrumental birth requires a trained clinician, full dilatation, ruptured membranes, known head position, adequate pelvis, engaged head, appropriate analgesia, empty bladder, consent and immediate backup if unsuccessful.

Obstetric emergencies during birth

Shoulder dystocia

Suspect when the head delivers but retracts against the perineum (“turtle sign”) or shoulders do not deliver with usual gentle traction. Announce the emergency, call obstetric, neonatal and anaesthetic help, note the time, ask the woman to stop pushing briefly, perform McRoberts positioning and suprapubic pressure according to the trained protocol. Never use fundal pressure. Proceed through recognized internal manoeuvres or posterior arm delivery by a trained practitioner; prepare neonatal resuscitation and document the sequence and timings.

Abnormal fetal heart rate

Call for help, stop oxytocin if running, position to avoid aortocaval compression, correct hypotension/dehydration as indicated, assess for cord prolapse or rapid descent and expedite birth by the safest available route. Do not give routine maternal oxygen when she is not hypoxaemic; follow local emergency guidance.

Cord prolapse

Call emergency help, relieve pressure on the cord by elevating the presenting part with a gloved hand, position the woman to reduce compression, avoid handling the cord, keep an exposed cord warm and moist, and prepare immediate operative birth unless vaginal birth is truly imminent and faster.

Maternal collapse or major bleeding

Activate the obstetric emergency response. Use an ABCDE approach, position appropriately, give oxygen for hypoxaemia, obtain large-bore intravenous access, draw blood, begin indicated fluids/blood pathway, identify the cause and expedite birth while resuscitation continues.

Immediate maternal care after birth

• Congratulate the mother, explain the baby’s condition and preserve uninterrupted skin-to-skin contact where safe.
• Assess uterine tone, vaginal bleeding, placenta completeness, pulse, blood pressure, bladder and pain.
• Systematically inspect the cervix/vagina/perineum when indicated; identify and grade trauma. Severe third- or fourth-degree tears require appropriate senior repair.
• Provide prescribed analgesia, hygiene, warm fluids/food when safe and emotional support.
• Observe closely during the first hours, because postpartum haemorrhage and deterioration may occur rapidly.

Immediate newborn care

• Warmth through drying, skin-to-skin contact and covering the head/body.
• Rapid assessment of breathing and tone; prompt bag-mask ventilation for apnoea or gasping according to neonatal resuscitation protocol.
• No routine suction of mouth/nose in a vigorous newborn; clear only visible obstruction or when clinically indicated.
• Delayed cord clamping when the baby does not require immediate separated resuscitation.
• Identification, birth weight when temperature is stable, vitamin K and eye/cord care according to national policy.
• Support breastfeeding within the first hour and monitor temperature, colour, breathing and feeding.

Documentation

Record time full dilatation was confirmed; start of active pushing; maternal and fetal observations; position; contractions and descent; time of head and complete birth; sex; Apgar components/scores; resuscitation; cord clamping; uterotonic name, dose, route and time; placenta time/completeness; estimated or measured blood loss; uterine tone; tears/episiotomy and repair; newborn temperature/weight and feeding; persons present; complications, manoeuvres, referrals and communication with the family.

Common unsafe practices

• Fundal pressure, forceful traction or pushing before full dilatation.
• Routine episiotomy, routine enema/shaving or routine suction of a vigorous newborn.
• Leaving the woman alone or ignoring her preferred position and consent.
• Delaying response to abnormal fetal heart findings while completing paperwork.
• Giving oxytocin before excluding another baby or using an unlabelled syringe.
• Assuming a good Apgar score replaces ongoing newborn observation.

Revision questions

1. Describe the conduct of a normal cephalic birth from full dilatation to third-stage transition.
2. State the maternal and fetal observations required during active second stage.
3. Explain selective episiotomy and list its complications.
4. Outline the first actions for shoulder dystocia and cord prolapse.
5. Describe immediate care of a stable newborn and a non-breathing newborn.

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.
• WHO consolidated guidelines for prevention, diagnosis and treatment of postpartum haemorrhage.