Received: 1 September 2020 | Revised: 24 November 2020 | Accepted: 17 December 2020

DOI: 10.1002/ijgo.13552

CLINICAL ARTICLE
Obstetrics

FIGO Good Clinical Practice Paper: Management of the second

stage of labor

Alison Wright1 | Anwar H. Nassar2 | Gerry Visser3 | Diana Ramasauskaite4 |

Gerhard Theron5 | for the FIGO Safe Motherhood and Newborn Health Committee6†

1
Department of Obstetrics and
Gynaecology, Royal Free London Teaching Abstract
Hospital, London, UK
This good clinical practice paper provides an overview of the current evidence around
2
Department of Obstetrics and
Gynecology, American University of
second stage care, highlighting the challenges and the importance of maintaining high-
Beirut Medical Center, Beirut, Lebanon quality, safe, and respectful care in all settings. It includes a series of recommenda-
3
Department of Obstetrics, University tions based on best available evidence regarding length of second stage, judicious use
Medical Center, Utrecht, the Netherlands
4 of episiotomy, and the importance of competent attendants and adequate resource to
Center of Obstetrics and Gynaecology,
Vilnius University Faculty of Medicine, facilitate all aspects of second stage management, from physiological birth to assisted
Vilnius, Lithuania
5
vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially
Department of Obstetrics and
Gynaecology, Faculty of Medicine and the most dangerous time for the baby and can have significant consequences for the
Health Sciences, Universiteit Stellenbosch, mother, including death or severe perineal trauma or fistula, especially where there
Stellenbosch, South Africa
6 are failures to recognize and repair. This paper sets out principles of care, including
International Federation of Gynecology
and Obstetrics (FIGO), London, UK the vital role of skilled birth attendants and birth companions, and the importance
of obstetricians and midwives working together effectively and speaking with one
Correspondence
Alison Wright, Department of Obstetrics voice, whether to women or to policy makers. The optimization of high-quality, safe,
and Gynaecology, Royal Free London
and personalized care in the second stage of labor for all women globally can only be
Teaching Hospital, London, UK
Email: [email protected] achieved by appropriate attention to the training of birth attendants, midwives, and
obstetricians. FIGO is committed to this aim, and will partner with WHO, ICM, and
others, alongside our more than 130 member societies.

KEYWORDS
birth, cesarean, delivery, fistulae prevention, forceps, impacted fetal head, perinatal,
physiological birth, quality, respectful maternity care, safety, second stage of labor, vacuum

1 | I NTRO D U C TI O N use of the partograph and identification of hypertension or sep-

sis, and on the third stage of labor, including active management
Historically, international health policy and programming have and hemorrhage prevention. While these are important areas, this
tended to focus on the first stage of labor, including appropriate paper specifically addresses issues of the second stage of labor.

†
FIGO Safe Motherhood and Newborn Health Committee Members are listed at end of the paper.

[The copyright line for this article was changed on 1 January 2021 after original online publication]

This is an open access article under the terms of the Creat​ive Commo​ns Attri​bution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of
Gynecology and Obstetrics

172 | wileyonlinelibrary.com/journal/ijgo
 Int J Gynecol Obstet. 2021;152:172–181.
WRIGHT et al. | 173

Besides the risks of the second stage of labor to the woman, abnormalities. If deemed to be high-risk, monitor continuously,
there are data to suggest that the most dangerous time in an individ- using cardiotocograph, where available.
ual's life is at the time of one's own birth.1 • Monitor the maternal pulse and blood pressure in every case, and
This good clinical practice paper is an update of the FIGO Safe more frequently where there is a pre-existing problem of hyper-
Motherhood and Newborn Health Committee's 2012 paper pub- tension, pre-eclampsia, anemia, or cardiac disease.
2
lished in International Journal of Gynecology & Obstetrics. It is not • Augment contractions with an intravenous oxytocin infusion
intended to be a systematic review of the literature, rather a docu- during the second stage—when necessary, and only where safe
ment to strengthen frameworks for service provision and to enable to do so—if contractions have become infrequent, providing the
providers to improve care for women, in line with evidence-based fetal heart rate remains normal. This may avoid the need for as-
recommendations. In particular, it aims to highlight important global sisted vaginal delivery (AVD) or transfer to a facility.
clinical and policy issues requiring attention relating to care in the • Encourage active pushing if the cervix is fully dilated with less
second stage of labor. than 2/5 of the head palpable per abdomen and when the urge to
6
According to the World Health Organization (WHO), the second bear down is present (unless epidural in situ), with encourage-
stage of labor is defined as the period of time between full cervical ment to adopt any position for pushing preferred by the woman
dilatation and birth of the baby, during which the woman has an invol- except lying completely supine.
untary urge to bear down, as a result of expulsive uterine contractions.3 • Observe progressive descent and rotation of the presenting part.
There is currently wide variation in the recommended length of This includes observing progressive distension of the perineum
the second stage and until this debate is resolved it is vital that global and performing vaginal examination when required, especially
research into maternal and fetal outcomes related to second stage where labor progress appears to be slow.
length is prioritized. • Facilitate the birth with continuous communication with the
In most cases, during the second stage of labor, despite utero- woman and appropriate support of the perineum and control of
placental circulation being reduced, there is enough reserve to the presenting part, to avoid significant perineal tears and obstet-
maintain oxygenation of the fetus until birth. However, there is ric anal sphincter injury (OASI).
potential for both the fetal and maternal condition to deteriorate • Perform an episiotomy only where a significant (more than second
rapidly during the second stage. Deterioration can occur in preg- degree) tear or OASI is judged to be likely, or to expedite delivery
nancies with known risk factors, such as pre-eclampsia or fetal in the presence of fetal distress (restrictive, rather than routine
growth restriction, but also, sometimes unpredictably, in appar- use).
ently low-risk pregnancies.4 Thus, antenatal risk assessment and • Use vacuum or forceps for AVD where indicated for suspected
progress in the first stage of labor, such as represented by a normal fetal compromise or non-advancement of the fetal head, provid-
partogram, are not necessarily reliable predictors of normal out- ing an appropriately skilled professional is available.
comes and birth attendants must remain vigilant in all cases during • Consider second stage cesarean birth if AVD is not safely feasi-
the second stage. ble, usually because the head is at a high station. In this case the
Important potential complications arising in the second stage attending team should anticipate and prepare to avoid the poten-
of labor are fetal hypoxia leading to birth asphyxia; failure of the tial associated complications. Suppression of contractions should
presenting part to rotate or descend appropriately; and worsen- be considered while preparing for cesarean delivery, especially
ing or new maternal hypertension and pre-eclampsia. Women with where the decision to delivery time may be delayed.
pre-existing cardiac disease or severe anemia may be at risk of heart
failure during the second stage owing to the additional circulatory
demands of active pushing. Thus, high-quality and safe care in the 2 | WO R K I N G W ITH M I DW I V E S
second stage of labor is essential to prevent stillbirth and newborn
complications arising from asphyxia, as well as maternal mortality It is crucial that obstetricians work together with midwifery col-
and morbidity from complications such as vesicovaginal fistula, anal leagues and that obstetricians and midwives speak with one voice
sphincter injury, sepsis, hemorrhage, and worsening of hypertensive when speaking to managers and policy makers. FIGO has a very
disease. 5 close relationship with the International Confederation of Midwives
During the second stage of labor, birth attendants should ob- (ICM), and the two organizations increasingly liaise on guidelines
serve these 10 key principles of second stage care: and policies. ICM supports, represents, and works to strengthen
professional associations of midwives throughout the world. There
• Continuously provide accurate and honest information, support, are currently 143 Midwives’ Associations, representing 124 coun-
and encouragement to the woman and her birth companion(s) and tries across every continent. ICM sets the international definition
ensure she has the autonomy to make informed choices (unless and scope of practice of a midwife (updated 2017) and defines the
she explicitly lacks the capacity to do so). Essential Competencies for Midwifery Practice (updated 2019). In
• Listen frequently (every 5 minutes, or after every contraction, addition, ICM provides global standards for midwifery education
whichever comes first) to the fetal heart, to detect fetal heart and for midwifery regulation (both updated in 2011). These globally
174 | WRIGHT et al.

accepted definitions, competencies, and standards are used through- Assuring safety and quality of second stage care, and provision
out the world by midwives and others working to strengthen mid- of the 10 key elements above, requires the presence of a second
wifery in the maternal and newborn health sector. ICM’s Philosophy birth attendant trained to assist11—e.g. to maintain auscultation of
and Model of Midwifery Care describes pregnancy and childbirth as the fetal heart and support for the mother while the midwife or
a usually normal physiological process that midwives strive to pro- obstetrician puts on sterile gloves in preparation for the delivery. If
mote, protect, and support through care that is based on respect, complications occur the second birth attendant can then call for help
compassion, and human rights.7-9 and initiate emergency care, while not detracting from the continu-
ous care provided to the mother by the skilled attendant. To achieve
this, facilities providing maternity care need to structure their staff
3 | R E S PEC TFU L C A R E allocation and skill mix to recognize the extra care requirements in
the second stage. Whilst this is challenging in settings where bud-
Every woman has the right to dignity, respect, and skilled care during gets or shortages of skilled staff are major constraints (as can also
pregnancy and childbirth but not every woman receives it.10 occur in high-income settings), serious efforts to provide effective
There is a recent, much welcomed interest in respectful care, care at this critical stage can reduce the burden of emergency in-
and increasingly organizations are attempting to define and articu- terventions for asphyxiated babies and mothers with preventable
late what is meant by this. As with all aspects of maternity care, in complications.
accordance with a rights-based and respectful care approach, the Special consideration is needed in delivery settings where only
individual needs of the woman and her companion during the second one skilled attendant is available, such as home births or small health
stage of labor should be taken into consideration, therefore person- centers. In these cases, birth planning needs to involve relatives,
alizing her care. Special consideration is required for culturally based traditional birth attendants, or non-clinical staff to assist in the role
birth preferences, especially where these are unusual or a minority of the second birth attendant. Such assistants need to be briefed
within a healthcare setting. It is understood that lack of attention about their role and arrangements made for them to be accessible
to respectful care by maternity care providers is a major barrier to and present for the birth.
the utilization of health facilities in many countries, as reflected in
health surveys that show reasonable uptake of antenatal care but
low rates of delivery in health facilities, and further work is required 4.2 | Duration of the second stage of labor
in this area.
Many facilities do not allow partners or companions to remain National and international organizations vary in their recommenda-
with women during labor. Whilst outdated hospital regulations may tions of what is an acceptable duration of the second stage, with
contribute, this may be partly due to the design of shared delivery ongoing international debate and some groups defending a longer
rooms that lack privacy, such as partitions and curtains. During the duration. This demonstrates the need for more robust and targeted
COVID-19 pandemic, these restrictions were also put in place to research into the duration of the passive and active second stage
minimize spread of the infection. and maternal and fetal outcomes.
According to NICE guidelines (2014),
For a nulliparous woman:
4 | S PEC I FI C S O F S ECO N D S TAG E C A R E
• birth would be expected to take place within 3 hours of the start
4.1 | Birth attendants of the active second stage in most women.
• diagnose delay in the active second stage when it has lasted
This is the stage in labor where the contribution of a qualified and 2 hours and refer the woman to a healthcare professional trained
skilled birth attendant is probably the most critical in ensuring a safe to undertake an operative vaginal birth if birth is not imminent.
outcome, besides technical knowledge.
While attending a delivery the timing of active pushing should For a multiparous woman:
be guided so that this is encouraged only when the cervix is fully
dilated, when the presenting part has engaged in the pelvis, and • birth would be expected to take place within 2 hours of the start
the woman feels the urge to push (unless epidural is being used). of the active second stage in most women.
The skilled attendant also has the role of encouraging the mother to • diagnose delay in the active second stage when it has lasted
adopt positions for active pushing that are comfortable and mechan- 1 hour and refer the woman to a healthcare professional trained
ically beneficial —for example, squatting or sitting. In many hospitals to undertake an operative vaginal birth if birth is not imminent.12
in low-resource countries, lying supine in labor has been encour-
aged, a tendency which may be exacerbated by a lack of available The American College of Obstetricians and Gynecologists (ACOG)
cushions or the use of non-flexible delivery beds where the upper Practice Bulletin No. 49 on Dystocia and Augmentation of Labor de-
part cannot be elevated. fines a prolonged second stage as more than 2 hours without or 3
WRIGHT et al. | 175

hours with epidural analgesia in nulliparous women, and 1 hour with- or if fetal compromise is suspected, monitoring in the second stage
out or 2 hours with epidural in multiparous women. This definition should be more frequent.
diagnoses 10% to 14% of nulliparous and 3% to 3.5% of multiparous Equipment in good working order and devices that simplify
women as having a prolonged second stage. Although in some ways detection of the fetal heartbeat should be available. The birth
modern obstetric population and practice have evolved with time, attendant should have the skills to interpret the fetal heart rate
current labor management is still largely based on data established and take appropriate action when needed. Whilst the traditional
by Friedman in the 1950s.13 Pinard stethoscope may be adequate in very quiet labor rooms,
Controversy remains regarding the total length of second stage it is often difficult to use reliably, especially in the second stage.
and as to whether pushing should be “delayed”. Some advocate for Wide availability of handheld Doppler devices with battery
a longer second stage and have shown that approximately 78% of backup and/or wind-up recharging technology should be part of
nulliparous women delivered vaginally even after 4 hours of push- standard equipment provision for safe and high-quality care in
ing.14 A recent systematic review and meta-analysis of the literature the second stage. Service planners and managers should there-
in AJOG evaluating the effect of delayed versus immediate pushing fore prioritize procurement and regular maintenance of such
in women with neuroaxial analgesia showed that delayed pushing in devices.
the second stage does not affect the mode of delivery, although it However, the recent Delphi consensus statement on fetal mon-
reduces the time of active pushing at the expense of a longer second itoring concluded that there is a gap between international recom-
stage. This review also found that prolongation of labor was associ- mendations and what is physically possible in many labor wards in
ated with a higher incidence of chorioamnionitis and low umbilical low-resource settings. Research on how to effectively implement
cord pH. Based on these findings, these authors conclude that de- the consensus on fetal assessment at admission and use of hand-
layed pushing cannot be routinely advocated for the management of held Doppler during labor and delivery is crucial to support staff in
the second stage.15 achieving the best possible care in low-resource settings.17
WHO, in its 2018 recommendations for intrapartum care for a
positive childbirth experience, does not differentiate between the
passive and active aspects of the second stage, nor whether an epi- 4.4 | Position of the woman during the second
dural is in situ or not. Women should be informed that the duration stage of labor
of the second stage varies from one woman to another. In first labors
birth is usually completed within 3 hours, whereas in subsequent la- Position changes during labor to enhance maternal comfort and pro-
bors birth is usually completed within 2 hours.16 FIGO recommends mote optimal fetal positioning can be supported, so long as adopted
that care providers follow these WHO recommendations. positions allow appropriate maternal and fetal monitoring and treat-
ments and are not contraindicated by maternal medical or obstetric
complications.
4.3 | Maternal and fetal monitoring during the Studies looking at optimizing the position of birth to achieve
second stage spontaneous vaginal delivery and to avoid AVD have tended to cat-
egorize women into those with epidural (generally low dose) and
The following observations are recommended in the second stage those without.
of labor. All observations should be recorded on the partograph to The use of any upright or lateral position in the second stage of labor,
assess whether escalation, intervention, or transfer of care may be compared with supine or lithotomy positions, is associated with a re-
needed. duction in AVDs in women not using epidural.18 A randomized trial in-
cluded 3236 nulliparous women with a low-dose epidural to determine
• Half-hourly documentation of the frequency of contractions whether being upright in the second stage of labor increases the chance
• Hourly blood pressure of spontaneous vaginal birth compared with lying down. Significantly
• Continued 4-hourly temperature fewer spontaneous vaginal births occurred in women in the upright
• Frequency of passing urine group compared with the lying down group (35.2% vs 41.1%; adjusted
• Offer a vaginal examination hourly in the active second stage, or risk ratio 0.86, 95% confidence interval 0.78–0.94). This represents a
in response to the woman's wishes (after abdominal palpation) 5.9% absolute increase in the chance of spontaneous vaginal birth in
• Perform intermittent auscultation of the fetal heart rate immedi- the lying down group.19 These results are interesting, especially given
ately after a contraction for at least 1 minute, at least every 5 min- the apparently contrary data regarding position in women without an
utes. Palpate the woman's pulse every 15 minutes to differentiate epidural, and clearly further work is required in this area.
between the two heartbeats.12 Currently, the advice is that women should be supported to birth
in a position of their own choice. All birthing facilities should there-
The above are the minimum observations and assume a healthy fore have adequate space, equipment, and skilled care providers to
(low-risk) mother and fetus. If the woman's blood pressure is raised, facilitate that.
176 | WRIGHT et al.

4.5 | Use of oxytocin during the second help shorten the second stage of labor and reduce the need for
stage of labor second stage cesarean birth and should be considered. 23,24
Before performing an AVD, a thorough assessment of the situ-
Oxytocin must be used with great caution, as if not appropriately used ation is necessary, and all prerequisites considered (Appendix A). 25
this drug is potentially dangerous for mother and fetus. Intramuscular AVD should only be attempted by healthcare providers who are
oxytocin administration before delivery is absolutely contraindicated. trained and qualified to recognize the indications and who are skilled
Intravenous oxytocin can be used in the second stage of labor, with and equipped to perform the AVD safely. Appropriate training in
the aim of reducing the need for cesarean birth or AVD, if the contrac- technique and decision-making is essential to ensure high-quality
tion pattern is deemed inadequate and providing the fetal presenta- and safe care for mother and baby; inadequate training has been
tion, position, and heart rate have been confirmed to be normal. It is shown to be a key contributor to adverse outcomes. 26
vital that a thorough and complete assessment of the situation and In those countries where care providers other than obstetri-
examination of the woman is performed to exclude cephalo-pelvic dis- cians are required to perform AVD, appropriate training for them
proportion or obstructed labor, prior to commencing oxytocin. and supportive legislation should be in place. 27 In the absence of
One review showed no statistically significant difference in AVD formal legislation there should be a written document enabling the
between women in spontaneous labor with epidural analgesia who care provider to intervene and stating the circumstances under
were augmented with oxytocin and those who received placebo. The which this can be done. The aim of this policy is to enable provid-
authors did comment that, owing to the limited number of women ers to use their skills without fear of criticism arising from concerns
included in the studies, further research in the form of randomized about professional scope of practice, as well as ensuring safe care.
controlled trials is required. 20 “Hands-on” training in AVD as well as other aspects of second
Intravenous oxytocin should only be administered according stage management is essential. Details of a recommended workshop
to a facility protocol (describing indications, dose, and intrave- are shown in Appendix B. It must be acknowledged, however, that
nous route) by a trained care provider, with contractions regularly isolated workshops are not in themselves adequate and must be
palpated and monitored (should not be more than five in 10 min- followed up by ongoing support and supervision on the labor ward,
utes). Infusions based on counting drops in an intravenous giving especially in settings where AVD has become less commonly used.
set can result in inaccurate oxytocin dosing. If an infusion pump Hospitals and facilities need to provide appropriate obstetric instru-
is not available, the resulting contraction frequency and strength ments and ensure that care providers are appropriately trained and
should be observed extremely carefully to avoid hyperstimula- competent to use them.
tion. Where one-to-one care is not feasible, these risks may out- Regarding the choice of instrument for AVD, this is depen-
weigh the potential benefits and oxytocin should be used with dent on a balance of clinical circumstance and practitioner expe-
extreme caution, if at all. rience.12 A Cochrane review has included evidence from 10 trials
evaluating the relative merits of vacuum versus forceps delivery. 28
Overall, vacuum delivery appears to be associated with reduced
5 | I NTE RV E NTI O N S TO PRO M OTE maternal trauma compared with forceps, whilst the failure rate ap-
PH YS I O LO G I C A L VAG I N A L B I RTH A N D pears to be reduced with forceps. However, when looking at out-
R E D U C E TH E N E E D FO R AV D A N D comes following use of vacuum and forceps it should be noted that
C E SA R E A N B I RTH there is a paucity of randomized trials in this area and therefore
comparative data should be interpreted with caution. Whichever
Various interventions have been shown to increase rates of sponta- instrument is used, AVD should not be about force, but about
neous vaginal birth, including adequate hydration, different positions flexion and realignment. The importance of identifying the flexion
for birth, respectful care, and the presence of a birth companion. point is crucial. This is certainly the key to any successful vacuum
Continuous support for women during childbirth by one-to-one delivery and is often overlooked, especially by those who receive
birth attendants, especially when the care provider is not a member of little to no training. Handheld vacuum devices such as the Kiwi
staff, has been shown to reduce the need for AVD21 and data regarding Omni Cup have become popular as these are easy to use, with
access to a doula birth attendant suggest that increasing access to doula the attendant being able to control the suction. Cheaper, reusable
care for at-risk women who desire intrapartum doula support may facili- options are currently being developed. Simple, risk-based infor-
22
tate decreases in rates of 'non-indicated' cesarean deliveries. mation for women and care providers regarding vacuum and for-
ceps is summarized in the consent advice from the Royal College
of Obstetricians and Gynaecologists. 29
6 | A S S I S TE D VAG I N A L D E LI V E RY ( AV D) Currently undergoing testing by WHO and global partners is
a new low-cost device for AVD, the Odon device. This device is
If the aim for physiological vaginal birth is not achieved despite the applied using a simple inserter and although the mechanism is not
above measures, or when abnormalities in the fetal heart rate are yet completely understood, it appears to work on the principle
detected, the use of AVD (by vacuum extractor or forceps) may of flexion of the head, facilitating delivery. The Odon has been
WRIGHT et al. | 177

designed for ease of use with minimal training in low-resource decrease the length of the second stage of labor in cases of fetal dis-
settings. WHO is implementing a three-phased study protocol, tress. There are some conflicting data regarding a policy of restricted
but until the device has been fully evaluated it cannot be recom- episiotomy (episiotomy only when necessary) versus a policy of rou-
mended for routine use. 30 tine episiotomy regarding maternal and fetal outcomes. FIGO is clear
According to new evidence from 2019,31 benefit of a single dose in its support of restrictive rather than routine use of episiotomy.34
of prophylactic antibiotic after AVD has been shown, although this When performing episiotomy, mediolateral episiotomy is gener-
has not yet been universally included in guidelines. ally recommended,35 especially for AVD, where it appears to pro-
tect against OASI. A mediolateral episiotomy should be performed
at 60 degrees.35 A large observational study from the Netherlands
7 | VAG I N A L B R E EC H of 28 732 assisted vaginal births concluded that mediolateral episi-
otomy is protective against OASI in both vacuum extraction (9.4% vs
Vaginal breech delivery is undertaken when a woman opts for this, 1.4%) and forceps birth (22.7% vs 2.6%).36
or where the balance of risk is considered to favor it over cesarean An episiotomy should always be performed under adequate an-
delivery, which may occur where access to cesarean delivery is lim- algesia, whether anesthesia is already in place for labor, such as epi-
ited. All skilled attendants need to be familiar with the diagnosis of dural, or by administering a local infiltration.
breech presentation in labor and with maneuvers for vaginal breech
delivery using simulation, because in many settings it is increasingly
unlikely that birth attendants will undertake enough vaginal breech 10 | O B S TE TR I C A N A L S PH I N C TE R
deliveries to maintain competency without simulation training. I N J U RY (OA S I)/S E V E R E PE R I N E A L TR AU M A

Every attempt should be made to ensure that OASI or third- and fourth-
8 | PA I N R E LI E F D U R I N G TH E S ECO N D degree tears (sometimes referred to as “severe perineal trauma”) do not
S TAG E O F L A B O R occur, by supporting the perineum and controlling the presenting part.
When they do occur, all birth attendants should be trained in recogni-
Where there is a delay in the second stage of labor, or if the woman tion and escalation for appropriate repair.37 Various interventions have
is excessively distressed, support and sensitive encouragement and been shown to prevent third- and fourth-degree tears, such as the use
the woman's potential requirement for analgesia/anesthesia are par- of a warm compress on the perineum during the second stage.38
12
ticularly important considerations.
Pain relief options should be discussed with the woman prior
to the onset of labor and offered according to her wishes, facility 11 | S ECO N D S TAG E C E SA R E A N B I RTH
protocols, and available resources. Women should be encouraged to
prepare a personalized care and support plan (PSCP), including pain Simulation training in the specific challenges of second stage cesarean
relief preferences, in conjunction with their care provider. The need delivery should be provided wherever cesarean services exist. Training
for pain relief is highly variable between individuals and should be in- should include decision-making regarding whether AVD or cesarean de-
dividually assessed. Care providers should not base assumptions of livery would be the safer option, and skills and drills in how to deliver an
“coping” on visible pain behavior. There is debate regarding epidural impacted fetal head at a cesarean birth. In settings where it is available,
analgesia and its effect on the second stage of labor. The PEOPLE the fetal pillow can be used to assist with disimpacting the fetal head.39
study showed that the inability to sustain optimal epidural analgesia
is associated with an increased risk of adverse second-stage obstet-
ric outcomes.32 12 | FE M A LE G E N ITA L M U TI L ATI O N
Epidural or regional analgesia is not consistently available, es- ( FG M)
pecially in some low- and middle-income countries, and availability
should be considered when offering choice.33 FIGO and WHO are absolutely opposed to all forms of FGM and
Local anesthesia should be used for perineal infiltration prior are absolutely opposed to healthcare providers performing FGM
to performing an episiotomy, and the practice of cutting an incision (medicalization of FGM). If presenting in labor, especially in the sec-
without anesthesia should now be obsolete. For AVD, a pudendal ond stage, presence of grade 3 FGM with obstruction of the vaginal
block may be used. introitus following infibulation requires attending staff to be appro-
priately trained in deinfibulation. Best practice consists of antenatal
identification of women with FGM and the offer of deinfibulation
9 | E PI S I OTO M Y before the onset of labor, supported by appropriate counseling, to
facilitate safety in the second stage.40 If not performed antenatally,
An episiotomy is an incision made in the perineum, either when a sig- when a woman presents in labor, deinfibulation should be under-
nificant tear is judged to be likely or for a breech presentation, or to taken when the tissues are stretched as the fetal head descends.
178 | WRIGHT et al.

Deinfibulation should be performed before evaluating the need for dangerous and may be associated with poor outcomes because of the
episiotomy, which may therefore not be required. additional delay. Thus, every effort should be made to provide the AVD
component of Basic Emergency Obstetric Care, so that safe delivery can
be performed at a health center, without the need for transfer.
13 | FU N DA L PR E S S U R E

There is currently insufficient evidence to draw conclusions on the 15 | S ECO N D S TAG E O F L A B O R I N TH E

beneficial or harmful effects of fundal pressure and therefore it is COV I D -19 PA N D E M I C
generally accepted that more research is required in this area.41
Although fundal pressure is still used in some settings, given its There is no evidence that the second stage of labor should be man-
safety is as yet unproven, WHO and FIGO do not recommend its use.42 aged differently during the COVID-19 pandemic, unless the woman
is clinically deteriorating. Appropriate PPE should be worn by at-
tendants of labor, including in the second stage, in accordance with
14 | I M PLI C ATI O N S FO R H E A LTH local guidelines 44 and there may need to be some restriction on the
S YS TE M S I N LOW- A N D M I D D LE- I N CO M E number of attending companions.
CO U NTR I E S

Clinical interventions (AVD, cesarean) during the second stage 16 | R ECO M M E N DATI O N S
of labor should only be offered or advised where labor is not pro-
gressing normally and/or where there are concerns about mother • Women should be informed that the duration of the second stage
and baby and, crucially, should only be initiated when appropriately varies from one woman to another. In first labors, birth is usually
12
trained staff and equipment are in place. completed within 3 hours whereas in subsequent labors, birth
Probably the biggest problems currently affecting second stage is usually completed within 2 hours (in accordance with WHO
care in many low- and middle-income countries are inadequate recommendations)
numbers of skilled healthcare attendants and non-respectful ma- • Birthing facilities must offer every woman respect and privacy
ternity care (which may well be related). There are concerns that where possible and allow her to be accompanied by her choice
birth attendants do not have the means or time to monitor the fetus, of a supportive person (husband, friend, mother, relative), unless
combined with a lack of access and knowledge regarding AVDs and there are infection control measures in place (e.g., during the
inadequate facilities and experience to perform a safe second stage COVID-19 pandemic)
cesarean delivery. • Psychosocial support, education, communication, choice of posi-
Close attention to the maternal and the fetal condition during tion, and pharmacological methods which are appropriately used
the second stage is essential to provide the necessary clinical re- during the first stage are also useful in relieving pain and distress
assurance that no interventions are necessary, or otherwise. If the in the second stage of labor
conditions deviate from normal, options for immediate intervention • There should be at least two people assisting at every birth,
or referral (depending on the care setting) should be defined clearly whether it is another health professional, family member, second
in local protocols and guidelines to allow timely access to emergency birth attendant, or village health worker. Arrangements for having
obstetric and neonatal care. another person besides the primary skilled attendant should be
Depending on the level of the healthcare system where the care planned for during the antenatal period
is provided, the skilled attendant and the assistant should have ac- • Monitoring of the fetal heart must be continued during the sec-
cess to equipment for AVD and neonatal resuscitation and should ond stage to allow early detection of fetal compromise
have the appropriate skills to use that equipment. • Health facilities and skilled attendants should be provided with
In settings where only one skilled attendant is available, briefing handheld battery-powered or handheld Dopplers for fetal heart
of relatives or non-clinical staff about their roles is required. auscultation after every contraction, particularly in the active
In many settings, there are challenges with consistent provision phase of the second stage. These should be added to lists of es-
of aspects of second stage care at various levels of the health sys- sential commodities
tem. According to Service Provision Assessments in several African • Routine episiotomy should not be practiced. Restrictive (judi-
countries, AVD was notably lacking.43 This means that expediting cious) use of episiotomy is recommended
delivery of the baby in the second stage would not be possible, even • Women without an epidural should not be encouraged to push
when an abnormal fetal heart rate is detected. until they feel an urge to push, unless the recommended second
Policy makers need to develop and implement sustainable plans stage duration is exceeded
for ensuring that the necessary human resources, skills, and equipment • Local anesthetic should be given for any episiotomy, perineal tear
are in place in a structured manner at every level of the health system. repair, or AVD where regional analgesia is either not available,not
Transfer to another facility during the second stage of labor is potentially appropriate, or not requested
WRIGHT et al. | 179

2. FIGO Safe Motherhood and Newborn Health (SMNH) Committee.

• The lack of access to AVD appears to be a major deficit in ob- Management of the second stage of labor. Int J Gynaecol Obstet.
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addressed. Skills necessary for safe AVD, safe second stage, ce- 3. WHO recommendation on definition and duration of the second
stage of labour. 17 February 2018.
sarean birth and related decision-making must be integrated into
4. Janni W, Schiessl B, Peschers U, et al. The prognostic impact of a
pre-service and in-service education for all skilled attendants
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• Provision of critical skills for second stage management needs to Acta Obstet Gynecol Scand. 2002;81(3):214-221.
be supported by policies as well as simulation training and linkage 5. Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Factors related
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nalmi​d wives.org/asset ​s/files/​d efin​i tion​s-files/​2 018/06/eng-de-
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https://www.inter​natio​nalmi​dwives.org/asset​s/files/​gener​al-files/​
the woman and neurodevelopmental parameters in the child.)
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WRIGHT et al. | 181

A P P E N D I X B : QSSS RCOG/FIGO workshop modules. The workshop style will be small group teaching together
Quality and Safety in the Second Stage (QSSS) with practical, “hands on” methods and a small proportion of lec-
This workshop is for doctors working in maternity services and ture time.
any other professionals competent to perform cesarean delivery. It This workshop has the potential to reduce unnecessary cesarean
is part of the ongoing RCOG QSSS training package which promotes sections and, where they are performed, to minimize complications,
not only the appropriate, safe, and successful use of operative vagi- saving women's lives. Other benefits may be to reduce rates of ob-
nal delivery (vacuum and forceps) but also focuses on clinical deci- stetric anal sphincter injuries and increase the accurate identifica-
sion making in the second stage of labor to enable high-quality and tion and grading of the injuries, as well as reducing rates of iatrogenic
safe care for women at the end of their labor. and obstructive fistula.
The workshop will also include other quality improvement is- There is also a professional and advocacy aspect to QSSS. We
sues in second stage of labor management such as the prevention believe that there is a role for the RCOG and FIGO in clearly recom-
of obstetric anal injuries and techniques to minimize the compli- mending that doctors in training should gain skills in assisted vaginal
cations of second stage cesarean section. Our experienced inter- delivery, rather than seeing cesarean section as the “easy option”
national faculty come from high- and low-resource environments when there are problems in the second stage of labor.
and we will consider the impact of resource when delivering the