Learning Objectives
By the end of this section, you will be able to:
- Describe the conditions related to dystocia, the medical intervention(s) for them, and nursing care during the second stage of labor
- Describe the conditions related to FHR patterns, the medical intervention(s) for them, and nursing care during the second stage of labor
Second stage labor is also known as the pushing stage. Complications can occur during this and any stage of labor. The laboring person is working very hard to push, and the fetus is working hard to be born. Because of the stress of pushing, the laboring person can become fatigued, and the fetus can exhibit distress. The nurse will monitor the laboring person and fetus for signs of distress. At times, the second stage can take longer than expected and may be diagnosed as prolonged second stage. At other times, the fetus has difficulty in engaging in the pelvis, causing failure to descend. The nurse works with the person to support the pushing effort and provide guidance and encouragement.
Prolonged Second Stage
Prolonged second stage labor is defined as a second stage labor lasting longer than 3 hours for a nulliparous person and longer than 2 hours for a multiparous person. Risk factors for prolonged second stage are use of epidural anesthesia, persistent occiput posterior position, and head circumference or birth weight above the 90th percentile (Lipschuetz et al., 2018). Complications to the birthing person resulting from prolonged second stage include chorioamnionitis, postpartum hemorrhage, operative vaginal birth, extended perineal lacerations, and cesarean birth. Prolonged second stage is also a risk factor for shoulder dystocia in the newborn.
Failure to Descend
Descent of the presenting part begins in active labor. During second stage labor, the fetal presenting part descends past the cervix, into the vagina, and out past the perineum. Failure to descend is defined as lack of change in the station for at least 2 hours. Many times, this is caused by fetal malpositioning, especially occiput posterior position (ACOG, 2020). Rotation of the fetal head by the health-care provider manually or with forceps can allow for increase in station and vaginal birth. At other times, failure to descend results in cesarean birth.
Laboring Person Fatigue
Second stage labor takes a great deal of energy and effort. Many times, laboring persons become fatigued and need a break from pushing. If the person can no longer continue pushing, the person is said to have labor fatigue. As discussed previously, one of the Ps of dystocia is power. With labor fatigue, the power is deficient, and second stage dystocia occurs. Labor fatigue can be prevented by waiting until the peak of the contraction to encourage the birthing person to bear down during contractions, providing food and drink to replenish calories, and allowing the fetus to descend or “labor down.” The nurse can support the laboring person and encourage these interventions to help decrease fatigue.
End-Stage Fetal Bradycardia
During the second stage, the fetal head molds to fit through the pelvis. At times, the compression and molding cause FHR decelerations. These decelerations can be early (mirror the contraction), late (uteroplacental insufficiency), or prolonged (bradycardia lasting longer than 2 minutes). Monitoring the FHR can be difficult as the fetus descends. Therefore, the nurse must compare the laboring person’s heart rate to the FHR to ensure the monitor is tracing the FHR. In cases of prolonged decelerations during the second stage, the health-care provider might expedite birth by performing an episiotomy, using forceps or a vacuum extractor, or by performing an emergency cesarean birth.
Legal and Ethical Issues
Laboring Person Fatigue and Request for Cesarean Birth
During the second stage, the laboring person can become very fatigued and discouraged. Many times, they will request to have a cesarean birth to stop pushing. They are not always making a sound decision because of their exhaustion. The nurse and health-care provider must closely evaluate the laboring person to determine if the fatigue is leading to a prolonged second stage or if the person needs a rest. Periods of rest during the second stage allow the person to relax, decrease stress, and regain focus. Rest is an important nursing intervention during second stage of labor.