PROLONGED SECOND STAGE OF LABOR

•	Definition.
•	Causes and effects. 
•	Assessment.
•	Management.

Definition

1.	Normal duration is less than 60 minutes for nulliparas and less than 30 minutes for multiparas.

2.	The second stage is prolonged when it is greater than:

a.	2 hours in a primigravida.

b.	1 hour in a multigravida.

3.	In clinical practice, assisted delivery is considered if the duration is more than one hour from the start of bearing-down efforts.

4.	The cervix may be fully dilated but with no bearing-down effort because of high head or epidural analgesia.

Causes and effects

1.	Causes

a.	Inefficient uterine activity.

b.	Poor maternal effort.

c.	Feto-pelvic disproportion.

d.	Conduction analgesia.

2.	Effects on mother:

a.	Exhaustion.

b.	Dehydration.

c.	Ketosis.

d.	Operative delivery.

e.	Infection.

f.	Postpartum haemorrhage.

g.	Uterine rupture.

3.	Fetal risks:

a.	Fetal infection.

b.	Fetal distress.

c.	Difficult delivery.

Assessment

1.	General:

a.	Mother: pulse, BP, temperature.

b.	Fetus: FHR and presence of meconium.

2.	Abdominal examination to determine:

a.	Size of fetus.

b.	Descent of the head.

3.	Vaginal examination:

a.	Station of the head.

b.	Degree of caput, moulding and position of the vertex.

c.	Identification of the fetal ear will give a clue to the level of descent and position of the vertex.

d.	Descent and rotation of the head with bearing-down effort during contractions will indicated the likelihood of vaginal delivery.

Management

1.	The course of management depends on the presence of:

a.	Maternal and fetal distress.

b.	Cephalo-pelvic disproportion.

2.	Inadequate uterine contractions:

a.	Uterine contractions should be at a frequency of four to five minutes every 10 minutes, each lasting more than 40 seconds.

b.	If needed, oxytocin infusion should be used / increased after excluding fetal distress and disproportion.

c.	If there is no progress despite good contractions and bearing-down efforts for one hour, an assisted vaginal delivery should be considered.

d.	If the successful outcome of assisted vaginal delivery is in doubt, it is best performed in the operating theatre with an anaesthetist and paediatrician in attendance.

3.	In direct OP position with the head at the perineum, delivery can be achieved, face-to-pubis, with good mediolateral epsiostomy. 

4.	Fetal distress: assisted delivery or LSCS can be attempted.

5.	CPD is detected by the following which warrants LSCS:

a.	Caput / moulding.

b.	No descent.

c.	2/5th head palpable per abdomen.

6.	A higher incidence of postpartum haemorrhage from uterine atony and / or trauma is not uncommon after prolonged second stage of labor, and should be anticipated and managed appropriately.