The Second Stage of Labour
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
The second stage starts when the cervix reaches full dilatation (10 cm). From the time that full dilatation of the cervix is first noted, 1-2 hours may pass before the woman starts to push. Time can be allowed for the head to descend onto the pelvic floor if fetal distress & cephalopelvic disproportion are ruled out. Continue with observations as for the first stage of labour. Encourage bearing down only when the fetal head starts to distend the perineum & the woman has an urge to push.
When the woman is ready to push:
- Communicate clearly to gain co-operation – be supportive & encouraging
- Put the woman in a suitable position: propped up, sitting, squatting, kneeling, semi-Fowler’s or wedged supine. Avoid the flat supine position as the pregnant uterus may compress the aorta & inferior vena cava
- During contractions, tell the woman to take a deep breath, put her chin on her chest & push for as long as possible (up to 10 seconds at a time) to deliver the baby. She should bear down towards her anus, as if to pass stool.
- Listen to the fetal heart rate between alternate contractions
- Protect the perineum when the head crowns
- Record the times of onset of the second stage, start of pushing, & delivery
EPISIOTOMY
Indications for episiotomy include:
- Thick or rigid perineum prolonging the second stage of labour
- Appearance of a very short perineal body (high risk of third-degree tear)
- Fetal distress in the second stage of labour where episiotomy may significantly speed up delivery
- Forceps delivery (usually)
- Breech delivery (usually)
Routine episiotomy is not necessary for vacuum delivery, nor for delivery of a preterm baby
Inject local anaesthetic (lidocaine 1% solution, maximum 20 mL) into the perineum before cutting the episiotomy. Perform a mediolateral episiotomy – avoid midline, lateral or bilateral episiotomy. The cut should start at the fourchette in the midline, at an angle of 40 to 60 degrees from the midline, & be made as the head is crowning, when the fourchette is stretched and thin.
Repair of episiotomy
- Use 1/0 to 2/0 absorbable suture; polyglycolic acid suture is recommended
- Place a vaginal tampon high in the vagina with an artery forceps attached
- Make sure that the anal sphincter is not disrupted
- Insert a suture to close the apex of the episiotomy in the vaginal epithelium
- From the apex down, close the vaginal epithelium with a continuous suture
- Ensure correct alignment by checking the apposition of the hymen & the vaginal-perineal junction
- Approximate the perineal muscles & fascia with interrupted sutures
- Close the skin with interrupted sutures or a continuous subcutaneous suture
- Remove the vaginal tampon & record this in the notes
- By rectal examination, check for any stitches placed in the rectum & record this in the notes. Remove any sutures found in the rectum & repair again