The second stage of labor extends from full cervical dilatation (10 cm) to the delivery of the baby. Complications in this stage arise due to maternal exhaustion, fetal distress, or mechanical obstructions.
1. Prolonged Second Stage of Labor
Definition:
- Primigravida: Lasting >2 hours (or >3 hours with epidural).
- Multigravida: Lasting >1 hour (or >2 hours with epidural).
Causes:
- Ineffective maternal pushing (Exhaustion, Epidural).
- Cephalopelvic Disproportion (CPD).
- Malposition (Occiput Posterior, Transverse).
- Large baby (Macrosomia).
Management:
- Assess fetal & maternal condition (FHR monitoring).
- Encourage effective pushing.
- Operative vaginal delivery (Forceps/Vacuum) if fetal distress or failure to progress.
- Cesarean section if failure of vaginal delivery.
2. Obstructed Labor
Definition:
Failure of descent of the fetal head despite good uterine contractions due to mechanical obstruction.
Causes:
- Cephalopelvic Disproportion (CPD).
- Malpresentations (Brow, Face, Shoulder).
- Fetal anomalies (Hydrocephalus, Conjoined twins).
Clinical Features:
- Failure of fetal descent.
- Bandl’s ring (Pathological uterine retraction ring).
- Severe maternal distress, dehydration, & tachycardia.
- Fetal distress (Bradycardia, Meconium-stained liquor).
Management:
- Immediate C-section (Definitive treatment).
- Avoid oxytocin augmentation in CPD cases.
- Monitor for maternal complications (Ruptured uterus, Postpartum hemorrhage).
3. Fetal Distress in Second Stage
Definition:
Signs of fetal hypoxia during labor, leading to risk of perinatal asphyxia.
Causes:
- Prolonged labor or maternal exhaustion.
- Cord compression or Cord prolapse.
- Placental insufficiency.
Signs of Fetal Distress:
- Fetal bradycardia (<110 bpm) or tachycardia (>160 bpm).
- Meconium-stained amniotic fluid.
- Late decelerations on CTG (Cardiotocography).
Management:
- Maternal oxygen, Left lateral position.
- Stop oxytocin if hyperstimulation.
- Immediate delivery (Operative vaginal delivery or C-section).
4. Perineal Tears & Obstetric Trauma
Definition:
Tears in the perineum, vagina, or cervix due to rapid or difficult delivery.
Types of Perineal Tears:
- 1st Degree: Involves vaginal mucosa & perineal skin.
- 2nd Degree: Extends into perineal muscles.
- 3rd Degree: Involves anal sphincter.
- 4th Degree: Extends into rectal mucosa.
Risk Factors:
- Macrosomia (Large baby).
- Operative vaginal delivery (Forceps/Vacuum).
- Precipitate labor (Rapid delivery).
Management:
- Immediate repair of tears under anesthesia.
- Antibiotics & Pain relief.
- Stool softeners for 3rd & 4th-degree tears.
5. Shoulder Dystocia
Definition:
Failure of the fetal shoulders to deliver after the head due to impaction against the maternal pubic symphysis.
Risk Factors:
- Macrosomia (>4 kg baby).
- Maternal diabetes.
- Prolonged second stage of labor.
Complications:
- Maternal: Postpartum hemorrhage, Vaginal tears.
- Fetal: Brachial plexus injury (Erb’s palsy), Hypoxia.
Management (HELPERR Maneuvers):
- H: Call for Help (Obstetric team).
- E: Evaluate for Episiotomy (to enlarge vaginal opening).
- L: Legs (McRoberts Maneuver) – Hyperflex mother’s legs.
- P: Suprapubic Pressure – Push fetal shoulder down.
- E: Enter (Internal maneuvers) – Rotate fetal shoulders.
- R: Remove Posterior Arm – To reduce diameter.
- R: Roll the patient (Gaskin Maneuver) – Move to all fours.
If maneuvers fail → Emergency C-section.
6. Uterine Rupture
Definition:
Tearing of the uterine wall, leading to fetal expulsion into the abdominal cavity.
Risk Factors:
- Previous C-section or uterine surgery.
- Prolonged labor or obstructed labor.
- Excessive oxytocin use.
Clinical Features:
- Sudden severe abdominal pain.
- Cessation of contractions.
- Loss of fetal station (Head moves back up).
- Fetal distress or absent fetal heart rate.
- Maternal hypovolemic shock.
Management:
- Emergency laparotomy & C-section.
- Repair or hysterectomy (If severe rupture).
Summary Table: Complications of Second Stage of Labor
|
Complication |
Definition |
Management |
|
Prolonged Second Stage |
>2 hrs (primigravida) or >1 hr (multigravida) |
Operative delivery, C-section |
|
Obstructed Labor |
Failure of descent despite contractions |
C-section |
|
Fetal Distress |
Hypoxia, abnormal CTG |
Oxygen, Left lateral, C-section |
|
Perineal Tears |
Injury to vaginal/perineal tissue |
Immediate suturing |
|
Shoulder Dystocia |
Impaction of shoulders |
HELPERR maneuvers, C-section |
|
Uterine Rupture |
Complete uterine wall tear |
Emergency laparotomy |
Key Takeaways
- Prolonged labor can lead to obstructed labor, fetal distress, or uterine rupture.
- Shoulder dystocia is an emergency requiring special maneuvers.
- Perineal tears must be repaired immediately to prevent complications.
- Uterine rupture is life-threatening and requires immediate surgery.
