QuestionSBA
QuestionChoice
Oxytocin has multiple obstetric uses, including as an induction agent, to accelerate stage 2 of labour and reduce the risk of postpartum haemorrhage. There is no current indication for requiring oxytocin at this stage. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible.
53054
c
Oxytocin infusion
QuestionChoice
Forceps delivery may be required where the labour is not progressing or delivery requires expediting. This is not required for this case. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible; transient bradycardia is not significant in this context.
53055
d
Attempt forceps delivery
QuestionChoice
The labour is progressing well with the head now in the birth canal and visible. The cardiotocography trace does not represent any significant pathology. Therefore, an emergency caesarian section is not required at this stage.
53053
b
Emergency caesarian section
QuestionChoice
Foetal bradycardia is defined as a heart rate of less than 110 bpm sustained for over 5–10 min. Upon pressure to the foetal head, mild, transient bradycardia is common due to a vagal response and will improve spontaneously after the pressure is relieved. The labour is otherwise progressing well with no other abnormalities described on the cardiotocography. The foetus has now descended into the birth canal with the head visible and so vaginal delivery can continue at present.
53052
a
Continue with vaginal delivery
QuestionChoice
Ventouse delivery may be required where labour is not progressing or delivery requires expediting. This is not required for this case. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible; transient bradycardia is not significant in this context.
53056
e
Attempt ventouse delivery
QuestionComment
Fetal bradycardia causes: cord compression, epidural anaesthesia, fetal head compression due to rapid fetal descent /cervical dilatation, etc.
Values between 100 and 110 bpm may occur in normal fetuses, especially in postdate pregnancies. 
57622
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EventualAsystole
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# Summary

The second stage of labour commences with full cervical dilation and concludes with the delivery of the foetus. The main signs during this stage include the desire of the mother to push and the repositioning of the foetus in preparation for birth. A prolonged second stage of labour is defined by specific time frames for nulliparous and multiparous women, both with and without epidural. Management of a prolonged second stage can involve an instrumental delivery or, in some cases, a caesarean section, which is associated with increased maternal morbidity.


# Definition



The second stage of labour is defined as the period beginning with complete cervical dilation and ending with the delivery of the foetus.


# Signs and Symptoms



The hallmark signs and symptoms of the second stage of labour include:

- Foetal head flexion, descent, and engagement into the pelvis
- Foetal internal rotation to face the maternal back
- Foetal head extension to deliver the head
- Foetal external rotation (restitution) after delivery of the head, positioning the shoulders in the AP position
- Delivery of the anterior shoulder first, followed by the rest of the foetus
- Maternal desire to push

# Management


The management of a prolonged second stage involves:

- Instrumental delivery: This can be implemented if possible and conditions are favourable.
- Caesarean section: This may be considered if instrumental delivery is not possible or contraindicated. However, a caesarean section in the second stage is associated with increased maternal morbidity.
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Transient foetal bradycardia during labour can occur due to vagal stimulation and typically resolves spontaneously, allowing for continued vaginal delivery.
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Obstetrics and gynaecology
A primiparous 30-year-old woman is 39 + 6 weeks pregnant. She is in stage 2 of labour and has been pushing for 30 min. The midwife supports the foetus' head as it descends through the birth canal and becomes visible. At this moment, the cardiotocography shows a heart rate of 100 bpm for 1 min, before returning to a heart rate of 140–150 bpm.

What is the next best step in management?
a