The following guidelines are intended only as a general educational resource for hospitals
and clinicians, and are not intended to reflect or establish a standard of care or to replace
individual clinician judgment and medical decision making for specific healthcare
environments and patient situations.
Second Stage Management Guideline
(DRAFT 10.15.14)
Background:
FHR monitoring and interpretation in the second stage can be difficult. It can be challenging to
distinguish maternal from fetal heart rates and there are numerous case reports of intrapartum demise in
the presence of what providers thought was a reassuring fetal heart rate. In retrospect the maternal and
not the fetal heart rate was being monitored.
The second stage is a time when loss of situational awareness and presence of tunnel vision can
limit medical decision making.
The use of a standardized checklist or documentation template can be a useful tool for
maintaining situational awareness. Regular debriefings using a standardized tool have been shown to
improve communication and team based care, which generally lead to improved patient outcomes in other
areas of medicine. (Level A) In obstetrics, a standardized institutional approach to the management of
complex processes, such as the use of oxytocin for labor augmentation, has shown to improve outcomes
(Level A). Based on this evidence, we recommend that organizations develop a standardized approach to
second stage management that includes regular debriefings of the care team.
We recognize that there has been minimal research on the optimal management of the second
stage and there is no data to show that following the recommendations in this document will improve
maternal or neonatal outcomes. The available literature on second stage management is primarily from
secondary analysis of observational studies, many of which were performed in settings with high
operative vaginal delivery rates. The recommendations in this guideline in no way represent a standard
of care. Each recommendation will need to be evaluated by the local organization to determine if they
will improve care in their clinical setting, with consideration of their local resources and care processes.
We anticipate there will be substantial modification of the tools included in this guideline as our
experience grows. However, there is abundant evidence that using check lists and standardized care
process accompanied by teamwork helps create high reliability systems and generally improves patient
care and outcomes, making this endeavor worthwhile.
Patients and their families have varied knowledge of the birth process and bring unique
perspectives based on their own and other family member’s values and prior experiences. Conflicting
messages from care team members regarding labor progress and ongoing plans can be exceptionally
challenging for patients and their families. Regular assessments of the labor process and communication
with the patient and family are important if they are to participate in decision making and have their
perspective considered. Scheduled patient and family updates will promote patient centered care.
Scope: All women progressing to complete dilation
Definitions:
 Second Stage: The second stage begins when the patient is fully dilated.
 Prolonged Second Stage: (Level A*)
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Nulliparous women: 4 hours with an epidural and 3 hours without an epidural
Multiparous women: 3 hours with an epidural and 2 hours without an epidural
(*Based on data from the Consortium on Safe Labor, a multicenter retrospective
study evaluating women with singleton, non-anomalous term gestations, vertex presentation
and spontaneous onset of labor who had vaginal delivery and normal perinatal outcome
defined as 5’ Apgar > 7 and admission to normal newborn nursery. This study defined the
onset of the second stage as the time when complete dilation was reached, and did not report
data on the time spent actively pushing vs in passive descent.)
Arrest of Second Stage: There does not appear to be a universally agreed upon definition for
arrest of the second stage. The NICHD publication “Preventing the First Cesarean Delivery”,
using data from the Consortium on Safe Labor, suggests that an arrest disorder be diagnosed
when there has been no descent or rotation in a nulliparous women for 4 hours with and 3 hours
without an epidural and in a multiparous woman for 3 hours with and 2 hours without an epidural.
Because there are no outcome studies evaluating the use of this definition, and it does not
differentiate the time spent actively pushing from that spent in passive descent, we chose to leave
arrest of the second stage undefined, and instead use lack of progress for > 1 hour while actively
pushing in our decision making algorithm. (Level C)
Category 1 FHR Tracing: Baseline 110-160 with moderate variability, no late or variable
decelerations. Accelerations are not required. Early decelerations are permitted.
Category 2 FHR Tracing: Not Category I or III
Category 3 FHR Tracing: Absent variability AND either recurrent late or variable
decelerations or bradycardia; Sinusoidal pattern.
Significant Decelerations:
o Variable decelerations lasting longer than 60 seconds and reaching a nadir more than 60
bpm below baseline or to less than 60 bpm
o Late decelerations (of any depth)
o Prolonged decelerations: > 15 bpm below baseline, lasting > 2 minutes but less than 10
minutes
Guideline
 Second Stage Onset: The second stage of labor begins when a patient is fully dilated.
o In women planning an unmedicated birth, the start of the second stage may be marked by the
commencement of involuntary pushing efforts. However, if the fetal head is not visualized
within 15 minutes, then a vaginal exam should be performed to confirm complete dilation and
to document station.
 Second Stage Algorithm Initiation: The Second Stage Algorithm shall be initiated when the patient
starts pushing with the intention to effect delivery regardless of cervical dilation. For example if a
patient starts pushing with an anterior lip with the purpose of effecting delivery, the algorithm should
begin.
 Debriefings: Debriefings should begin at the point the patient becomes fully dilated, or begins
pushing to effect delivery, and should be conducted hourly, or more frequently based on the patient
status.
o Some institutions may wish to perform their debriefings outside of the patient room, to permit
more frank discussion. Patient should be informed that debriefings will be happening early
in the labor process. (Level C)
o For institutions choosing to hold debriefings in the patient room, a standardized signal should
be created for a clinician to indicate that the debriefing needs to be moved outside of the
room. For example, one institution has chosen to use a pink card that is kept on the fetal
monitor. If the pink card is picked up and displayed, this signals that a conversation needs to
occur outside the room.
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To help promote situational awareness, ideally, an individual who is not directly involved in
the care of the patient care should attend the debriefing. (Level C)
o The provider should be physically present for the debriefing in the following settings
 Category II FHR Tracing.
 After 1 hour of active pushing without progress.
 Or any time the RN requests their presence.
o In the setting of labor management by a midwife, if delivery does not occur after 2 hours of
pushing, the covering physician should be updated with all of the items that were discussed in
the debriefing.
o If changes to the plan of care are made during the debriefing, the patient and family should be
updated and the occurrence of the update documented in the chart.
Debriefing Checklist/Documentation: A standardized checklist or documentation tool should be
used during the debriefing, to ensure that a systematic evaluation is performed. The tool should be
individualized for each organization, to account for available resources, existing documentation tools
and care processes. The debriefing tool is not meant to replace standard documentation. Below is a
list of items to consider placing within the debriefing tool.
o Estimated fetal weight
o Time fully dilated, station and position
o Time pushing commenced, station and position.
o Station and position after each hour of active pushing
o Maternal heart rate between contractions
o FHR evaluation with particular focus on baseline, variability, presence of significant
decelerations
o Contraction frequency and quality
o Quality of maternal efforts
o Plan: to include interventions, time of next assessment
o If writing a note with each debriefing, consider the following:
 Making the note multi-authored
 Listing individuals present for the debriefing
 Documenting patient and family updated
Maternal Pulse: Maternal pulse should be performed at the onset of the second stage and hourly
thereafter (Level C)
o If the maternal pulse is within 20 BPM of the fetal heart, continuous maternal pulse
monitoring should be considered. In lieu of continuous maternal pulse monitoring, the
maternal and fetal heart rates should be simultaneously assessed at a minimum of every 15
minutes to ensure that the fetal heart rate is being monitored.
o Fetal heart rate accelerations during contractions are rare during the second stage. If present,
the maternal and fetal heart rates should be simultaneously assessed, to ensure that the fetal
heart rate is being monitored. (Level A)
Intermittent Auscultation: The FHR should return to baseline within 30 seconds of the conclusion
of the contraction and should be maintained at baseline until the start of the next contraction, for a
minimum of 30 seconds. If baseline is not achieved for 30 seconds between contractions, continuous
EFM should be performed.
Passive Descent vs Active Pushing
o Passive descent has been recommended in women with epidural analgesia for up to 3 hours or
until the fetal vertex can be seen on the perineum.
o There are 9 randomized controlled trials (RCT) evaluating this practice and 2 meta-analyses.
There is significant heterogeneity in the RCT which use delay for different lengths of time,
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have different criteria for commencing active pushing and evaluate different outcomes. In
general, the time for passive descent ranged from 1 to 3 hours.
o The RCT evaluating delayed pushing were performed at institutions with high rates of
operative vaginal deliveries, ranging from 19% to 75%, with four the studies having operative
vaginal delivery (OVD) rates of 40% or higher.
o Taken together, delayed pushing results in a significant decrease in rotational or mid-pelvic
instrumental delivery (22%-31%) secondary to increased spontaneous vaginal deliveries but
no difference in the cesarean section rate or overall rate of spontaneous vaginal delivery. The
meta-analysis by Roberts did not find a significant decrease in the time spent in active
pushing and found no difference in maternal or neonatal outcomes with the exception of an
increased rate of fever in the second stage. The meta-analysis by Brancato, which did not
include two of the studies used by Roberts, found a small but significant increase in the rate
of SVD (RR 1.08 95%CI 1.01-1.15) and a significant decrease the time spent actively
pushing (0.19 hours). It is not clear from the Brancato article why they choose to exclude
two of the RCT used by Roberts. Neither analysis found an increased rate of adverse
neonatal outcomes. The included studies delayed pushing from 1 hour to 3hours. (Level A)
o It is impossible to know, based on the available data, the impact of delayed pushing on the
length of active pushing or the rate of second stage cesarean section in today’s era of low
rates of operative vaginal delivery. (Level C)
o The available data suggests that delayed pushing does not have a significant impact on
neonatal outcomes, although there may be an increased risk of maternal fever. (Level A)
o FIGO (Federation of International Obstetricians and Gynecologist) in their 2012 guidelines
on second stage management recommend delaying pushing until the fetal vertex is engaged
and the woman has a strong desire to push for up to 4 hours in nulliparous women and
women with epidural analgesia.
o Passive descent is not appropriate in the following settings:
 Chorioamnionitis, unless there is a medical indication for passive descent (in this
setting, need to have a reassuring FHRT and anticipate delivery within 1-2 hours).
(Level C)
 Category 2 fetal heart rate tracing with significant decelerations. (Level C)
 Failure of the fetal head to descend past 0 station after 2 hours. (Level C)
Active Pushing Optimal Duration: The optimal duration of active pushing is unknown. However,
data from a secondary analysis of the Pushing Early or Pushing Late with Epidural trial, that included
1862 nulliparous women with epidural analgesia in the second stage, showed that the rate of vaginal
delivery of a neonate with a 5’ Apgar of > 7 and UA pH > 7.10 is 10% after 3 hours of active
pushing(Le Ray). While the likelihood of spontaneous vaginal delivery was low after 3 hours, there
was no increase in adverse neonatal outcomes in women who pushed for more than 3 hours compared
to those who pushed for less than an hour. Of note, the rate of operative vaginal delivery in this study
was 40%, again raising the question of its applicability to current obstetric practice. After 2 hours,
the risk of postpartum hemorrhage and intrapartum fever increased significantly with each hour spent
actively pushing as compared to women delivering in < 1 hour of active pushing.
o After 2 hours of active pushing, clinicians should consider obtaining a type & screen and
placing an IV due to the increased risk of postpartum hemorrhage. (Level A)
o After 2 hours of active pushing, if delivery is not imminent, clinicians should assess the
resources needed to facilitate an operative delivery. (Level A)
Operative Delivery: Operative delivery should be considered for the following indications:
 Minimal or absent variability for > 1 hour without significant FHR decelerations.
 Minimal or absent variability for > 30 minutes with significant FHR decelerations.
 Moderate variability and significant FHR decelerations and lack of progress for 1 hour.
 If a decision is made to continue labor, a consultation with a second provider, not
involved in direct patient care should be considered. (See the enclosed algorithm for
management of category 2 tracings for more detailed information.) (Level C). If a
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clinician not involved in the patient’s care is not available, clinicians may want to
consider calling a colleague at another institution to review the second stage.
Epidurals: Epidurals should be adjusted to enhance the patient’s pushing efforts. This will vary
with each patient. Some women require complete relief to push effectively, while other women push
more effectively with increased sensation.
Organization Measures of Second Stage Management
1. Presence of a Second Stage Management Work Group present at organization
2. Organization specific Second stage management guideline Staff educated on guideline
3. Providers education on second stage management guideline
4. Providers present for huddle for all Category II tracings
5. Checklist or documentation tool to use during hourly huddles
6. Checklist or documentation tool contains the follow items: (build this like the PPH tool kit)
a. Estimated Fetal weight
b. Time fully dilated and station
c. Time pushing commenced and station
d. Hourly assessments of :
e. Maternal heart rate between contractions
f. FHR including baseline
g. FHR variability
h. Presence of significant decelerations
i. Contraction frequency and quality
j. Quality of maternal efforts
k. Fetal Station and position
l. Plan: to include interventions, time of next assessment
m. Individuals present for each hourly assessment
n. Patient/Family update with changes in plan
7. Standard method for documenting the occurrence of debriefings or writing notes
8. QI project to address use of the guideline and frequency of debriefings
9. PPH assessment incorporated into the first huddle at onset of the second stage
SSM Patient Measures: For all women reaching the second stage
1. Documentation of hourly debriefings starting at onset of second stage and continuing to
delivery (yes/no/NA delivery within 15’ of complete)
2. 5’ Apgar < 7 (yes/no)
3. If 5’ Apgar < 7, was a cord gas obtained (yes/no/NA)
4. Delivery route: (SVD, Operative Vagina, Cesarean Section)
5. If this was a planned home delivery, was the patient transported during the second stage?
(yes/no/NA)
Based on the highest level of evidence found in the data, recommendations are provided and graded
according to the following categories:
Level A—Recommendations are based on good and consistent scientific evidence.
Level B—Recommendations are based on limited or inconsistent scientific evidence.
Level C—Recommendations are based primarily on consensus and expert opinion.
References:
Brancato, R.M., S. Church, P.W. Stone. A Meta-Analysis of Passive Descent Versus Immediate Pushing
in Nulliparous Women With Epidural Analgesia in the Second Stage of Labor. JOGNN. 2008, Vol. 37,
Issue 1.
Clark, S.L., M.P. Nageotte, T.J. Garite, R.K. Freeman, D.A. Miller, K.R. Simpson,…G.D.V. Hankins.
Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J
Obstet Gynecol. August 2013, 89-97.
Le Ray C, Audibert F, Goffinet F, Fraser W. When to stop pushing: effects of duration of second-stage
expulsion efforts on maternal and neonatal outcomes in nulliparous women with epidural analgesia. Am J
Obstet Gynecol 2009;201(4): 361.e1-7.
Murray, M.L., Maternal or Fetal Heart Rate? Avoiding Intrapartum Misidentification. JOGNN, 33, 93104; 2004.
Roberts CL, S. Torvaldsen, C.A. Cameron, E. Olive. Delayed versus early pushing in women with
epidural analgesia: a systematic review and meta-analysis. BJOG. 2004;111:1333-40.
Spong C.Y., V. Berghella, K.D. Wenstrom, B.M. Mercer, G.R. Saade. Preventing the first cesarean
delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human
Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and
Gynecologists Workshop. Obstetrics and Gynecology. 2012, 120(5):1181-1193.
Zhang J, Landy HJ, Branch W, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of
spontaneous labor with normal neonatal outcomes. Obstetrics and Gynecology. 2010; 116:1281–7.