Mother Initiative Tutorial

Normal labor: The second stage

Alison James Midwifery Lecturer Margaret Fisher Associate Professor in Midwifery

Plymouth University and The Royal College of Midwives,

United Kingdom

This tutorial is designed to re-inforce previous training – and should,

therefore, not be regared as sufficient guidance by itself 1

This tutorial tells you what happens in the second stage of labor

it follows on directly from the tutorial on the first stage of labor

The second stage of labor

starts from when the cervix

(neck of the womb) has dilated

to 10cm

The second stage of labor

finishes when the baby

is born

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Signs that the second stage of labor has begun include:

The woman’s contractions are expulsive (strong), may occur less often and may last longer

The woman is likely to feel an urge to push as the fetus descends onto the pelvic floor

A heavy blood-stained mucus vaginal discharge (show) may be seen

There may be external signs including swollen vulva and anal dilation

The presenting part may be visible (head if cephalic, bottom if breech)

Strong contractions

Urge to push

Discharge

External signs

Top of head

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The sequence of events in the second stage of labor

The presenting part (head or

breech) descends into the

pelvis

If everything progresses

normally, passive movements

by the fetus through the birth

canal lead to the ‘mechanism

of labor’

Every presentation or fetal position which can

deliver vaginally has a mechanism of labour.

This tutorial will only explain what

happens in a normal vertex presentation.

See tutorials on ‘Breech delivery’ and

‘Malpositions’for other births.

Mechanism of

labor

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The Mechanism of Labor (1) in the case of normal vertex presentation

There is descent of the fetus

The head, neck and spine flex

(bend forwards)

The fetus rotates (turns) to fit into

the widest part of the mother’s

pelvis

The head is born under the pubic

arch (crowning) and the neck

extends, with the brow, face and

chin being born

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The Mechanism of Labor (2) in the case of normal vertex presentation

The head untwists itself on the

neck (restitution)

The shoulders turn to fit into the

widest part of the mother’s pelvis

(internal rotation) and the head

rotates externally

The shoulders, trunk and limbs

are born by lateral flexion

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What should you see if the second stage of labor is progressing normally?

The mother should continue to

have expulsive contractions

and push with each of these

The presenting part should

advance steadily until the

baby is born

The length of the second stage

may vary from woman to

woman, but should not last

longer than about 2 hours.

It may be very quick if it is her

second or more baby

Strong contractions

Urge to

push

Fetal descent

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What should the midwife do to care for the woman in the second stage of labor?

Continue to care for the woman’s

comfort and support (see tutorial

‘Normal labour: First stage’)

Check that the woman and the

fetus are well– this includes

checking her pulse, blood

pressure and the fetal heart

rate which should be listened to

every 5 minutes or after every

contraction. It may slow down

slightly while she is pushing but

should recover to 110-160 beats

per minute between contractions

Comfort Pulse

Blood pressure

Fetal heart rate

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What preparations should the midwife make for the birth?

Make sure the area is safe and

warm for the baby to be born

Keep everything as clean as

possible to prevent infection

Make sure there is enough light

for you to see what you are doing

Make sure equipment is

available. This could include:

towels, warm water, gloves,

swabs, cord clamp or tie, cord

scissors, syringe, needle,

oxytocic (such as syntocinon,

syntometrine, ergometrine),

ambubag and mask for

resuscitation of baby, clock

Safe Clean

Light Equipment

9

What care should be given when the baby is born?

If labor progresses normally the

baby should deliver itself.

Support the head and body as

the baby is born

Check that the baby is

breathing and its colour is

becoming normal

Dry the baby and place it on

the mother’s abdomen against

her skin to keep it warm (skin

to skin contact)

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Delivery of the placenta

If the placenta delivers naturally

(physiological third stage) the

cord does not need to be tied

off until it has come out of the

vulva and stopped pulsating.

Keep the cord clean and do not

apply anything to it

See tutorial ‘Normal labour: The third

stage’ for information about how to

deliver the placenta.

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PROBLEMS (1) The mother may need to be taken to medical assistance

if you identify any problems. These can include:

The fetal heart rate becomes

very fast (more than160bpm)*

or slow (below 100bpm)*

The liquor (fluid from around

the fetus) is green (meconium-

stained) or pink/ red (blood-

stained) or clots are passed

The second stage goes on

too long and an assisted

delivery may be needed (see

tutorials on ‘Vacuum and

forceps deliveries’) [insert link]

160

100

* bpm = beats per minute

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Problems to look for (2)

The presenting part is

not the crown of the

head (vertex), face or

breech (bottom). The

baby may not be able

to be born safely

vaginally, and if this is

the case the woman

needs to be taken to

medical assistance

urgently

With transverse lie the

baby cannot be born

vaginally and urgent

medical assistance

must be sought 13

Problems to look for (3)

Female Genital

Mutilation (FGM)

If the woman has had

FGM you may need to

perform an anterior

episiotomy to give

enough space for the

baby to be born

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Problems to look for (4)

The baby does not breathe

or the heart rate is below 100

beats per minute (see tutorial

on ‘Neonatal resuscitation’)

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Summary of normal second stage of labor

It should not last more than about

2 hours for the first baby, and

1 hour for the second or more

Progress should be seen – the

presenting part should descend

and you should be able to see

signs of the mechanism of labour

The only vaginal loss should be

clear liquor or a mucus ‘show’

The mother and fetus should

remain well

Subsequent

births

First

birth

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The third stage of labor now begins

Third stage of labor

Starts from when the baby

is born

Finishes when the placenta

(afterbirth) has come away

from the mother, and when

her bleeding stops

See the tutorial on ‘Normal labor:

The third stage – physiological and

active management’ for more

information

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