Delayed Second Stage of Labor

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The second stage of labour is said to be delayed if there is no delivery of the baby even after 2 hours of full dilation of the cervix in a first pregnancy and 1 hour in a woman with previous pregnancies.

There are various causes of delay in the second stage of labor, all of which are closely linked to each other.

For example, the second stage can get delayed due to lack of proper contraction of the uterus which again can be due to either a malposition of the fetus or due to cephalopelvic disproportion (CPD) .

Causes of Delayed Second Stage of Labor

The second stage of labour may be delayed due to:

  • Uterine Inertia: Uterine inertia is a type of incoordinate uterine action. It is usually secondary to a prolonged first stage causing the uterine muscles to become tired. The intensity of uterine contraction is diminished, duration of contraction is diminished and the gap between two contractions increases. The woman in labor feels a lessening of the severity of the labor pains.

  • Malpresentation of the Foetus: If malpresentations like face presentation or occipito-posterior positions are present, the progress of labor is delayed. Compound presentations in which two parts of the foetus present at the mouth of the uterus at the same time, (e.g. the head and one arm), can also cause delayed second stage of labor.

  • Undiagnosed Contracted Pelvis: A pelvis which is mildly contracted near the outlet (Cephalo-pelvic Disproportion) may often go undiagnosed until the second stage of labor. Sometimes, even if the contraction is diagnosed, a 'trial of labor' is allowed to see if the woman can deliver vaginally. The second stage may, however, get delayed and delivery by forceps or vacuum aspiration required.

  • Obstruction in the Vagina: An obstruction in the vagina like a vaginal septum or a tumor can cause delayed second stage.

  • Improper use of Anesthesia: Heavy use of anesthesia and other sedatives in the first stage or early second stage can leave the woman in labor unable to push in the second stage.

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    Assessment of Delayed Second Stage of Labor

    Once a diagnosis of delay in the second stage is made, the woman should be assessed for:

  • Full bladder - a full bladder may prevent adequate uterine contractions or prevent descent of the fetal head. A catheter should be introduced if teh woman is unable to pass urine spontaneously.

  • Cephalo pelvic disproportion - A CPD missed in the first stage of labor.

  • Malpresentation of the fetal head, e.g. a occipito posterior position in which the fetus faces the mothers abdomen instead of the back. This can increase the diameter of the presenting part of teh head and delay the second stage of labor.

  • Inelastic perineal tissues, especially in the older primipara

  • Inadequate uterine activity or pushing effort due to fatigue of the muscles - this is frequently seen in cases of prolonged labor.

  • Positive signs of obstructed labour.

    Management / Treatment of Delayed Second Stage of Labor

    If the head is high up:

    • Since the cervix is fully dilated in the second stage of labour, but the presenting part of the foetus is very high up, an attempt is made to increase labour pains with the help of medicines like oxytocin.

      If, after 1 hour, there is no progress and the presenting part is still high up, caesarian section is done.

    • If presenting part is high up and there are signs of foetal distress, an immediate caesarian section is done.
    If the head is at the vaginal outlet:
    • If the greatest diameter of the head is below the narrowest part of the pelvic canal (at the level of the ischial spine), then labour pains are augmented by medicines like oxytocin and a normal delivery expected.
    • If there are signs of fetal distress, and the head is low down, Forceps Delivery or Vacuum Extraction of the foetus is done.
    • Forceps Delivery or Vacuum Extraction of the foetus is also done where there is maternal distress due to prolonged labour.
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