Best Practices for Nursing Management in the Second Stage of Labour

The second stage of labour begins when the cervix is fully dilated and ends with the birth of the baby. This is potentially the most dangerous time for both mother and baby, requiring nurses to provide vigilant care, expert guidance, and emotional support. Understanding the principles of effective nursing management during this critical phase can significantly improve outcomes and ensure a safe delivery.

Understanding the second stage of labour 🔗

The second stage of labour is defined as the period between full cervical dilatation and the birth of the baby. During this time, the mother experiences an involuntary urge to bear down as a result of expulsive uterine contractions. For first-time mothers, birth usually occurs within three hours, while subsequent labours typically conclude within two hours.

Nurses play a central role during this stage by coordinating the mother’s bearing-down efforts with her contraction pattern, monitoring both maternal and fetal status, and preparing for potential complications. The goal is to support physiological birth while remaining prepared to intervene when necessary.

Continuous assessment and monitoring 🔗

Effective nursing management starts with thorough, ongoing assessment. Maternal vital signs should be assessed at least every 30 minutes during the second stage, including blood pressure, pulse, and temperature. The nurse must also monitor contraction patterns, typically assessing them every 15 minutes.

Fetal heart rate monitoring becomes even more critical during the second stage. The fetal heart should be auscultated immediately after each contraction for at least one minute, at minimum every five minutes. This frequent monitoring helps detect early signs of fetal distress, such as bradycardia or variable decelerations, which require immediate intervention.

Assessing descent and progress 🔗

The nurse monitors the descent of the fetus through the pelvis by assessing fetal station and observing for crowning. Regular vaginal examinations may be performed hourly during active pushing, or in response to the mother’s needs. These assessments help determine whether labour is progressing normally or if intervention may be required.

Guiding effective pushing techniques 🔗

One of the nurse’s most important responsibilities is coaching the mother through effective pushing. Current research suggests that women should be allowed to find their own technique and pattern of pushing, as directed pushing should be reserved for situations involving ineffective pushing or fetal compromise.

For women without epidural analgesia, pushing should be encouraged only when the cervix is fully dilated, the presenting part has engaged in the pelvis, and the woman feels the natural urge to push. The nurse provides encouragement during contractions and allows the mother to rest between them, helping her conserve energy for the final phase of delivery.

Open-glottis versus closed-glottis pushing 🔗

Evidence supports the use of open-glottis pushing, where the mother breathes during bearing-down efforts, rather than the traditional Valsalva maneuver of holding breath while pushing. This technique may reduce perineal trauma and improve oxygen delivery to the fetus.

Optimizing maternal positioning 🔗

The nurse should support the mother in adopting positions that facilitate descent and rotation of the baby. For women without epidurals, upright or lateral positions may reduce the need for assisted vaginal delivery compared to supine or lithotomy positions. These positions can include squatting, sitting, kneeling, or side-lying.

However, for women with epidural analgesia, recent studies suggest different considerations. The nurse must balance evidence-based positioning with the mother’s comfort, safety requirements, and the ability to monitor both mother and fetus effectively.

Preparing the sterile delivery environment 🔗

Creating and maintaining a sterile environment is essential for infection prevention. The delivery table should be set up during the active phase of the first stage of labour, containing sterile drapes, delivery instruments, and equipment for potential perineal repairs.

The nurse performs perineal cleansing during the second stage to maintain hygiene and prevent infection. This also provides an opportunity to offer comfort and support to the labouring mother. All procedures must follow strict aseptic technique to minimize infection risk.

Anticipating and managing shoulder dystocia 🔗

Shoulder dystocia is an obstetric emergency that occurs when the baby’s shoulder becomes impacted behind the mother’s pubic bone after delivery of the head. This condition requires immediate recognition and prompt treatment to minimize maternal and neonatal complications.

Risk factors and recognition 🔗

Risk factors include fetal macrosomia, maternal diabetes, prolonged second stage of labour, and previous shoulder dystocia. The classic sign is the “turtle sign,” where the baby’s head retracts back against the perineum after delivery.

Nursing interventions 🔗

If shoulder dystocia occurs, the nurse must act quickly. First, instruct the mother to stop pushing. Immediately call for help from the healthcare provider, neonatal team, and additional nursing staff. The nurse should prepare to assist with maneuvers such as McRoberts position, where the mother’s legs are hyperflexed against her abdomen, and suprapubic pressure to dislodge the impacted shoulder.

Recognizing and responding to umbilical cord prolapse 🔗

Umbilical cord prolapse occurs when the umbilical cord slips down into the cervix or vagina before the baby. This is an uncommon but life-threatening emergency that can deprive the baby of oxygen and cause permanent damage if not managed immediately.

Immediate nursing actions 🔗

If cord prolapse is suspected, the nurse should immediately notify the obstetrician and prepare for emergency delivery. Key interventions include manually elevating the fetal presenting part to relieve cord compression, positioning the mother in knee-chest or Trendelenburg position, administering oxygen, and preparing for either immediate vaginal delivery if birth is imminent, or emergency cesarean section.

The nurse who is elevating the presenting part must maintain this position continuously until delivery occurs, sometimes even accompanying the mother to the operating room while maintaining manual elevation.

Providing emotional support and encouragement 🔗

Beyond technical skills, the nurse serves as a vital source of emotional support during the second stage. Continuous support during childbirth has been shown to reduce the need for assisted vaginal delivery and improve overall birth outcomes.

The nurse provides regular updates on progress, offers words of encouragement, and helps the mother stay focused and motivated. Allowing the mother’s chosen support person to remain with her, ensuring privacy and dignity, and respecting the mother’s preferences all contribute to a positive birth experience. Clear communication about what is happening and what to expect next helps reduce anxiety and promotes cooperation.

Pain management support 🔗

The nurse should assess the mother’s pain levels and offer appropriate relief options, whether through breathing techniques, position changes, or pharmacological methods. If the mother has an epidural in place, ensuring it continues to provide adequate pain relief can improve the pushing experience and reduce the risk of adverse outcomes.

Documentation and communication 🔗

Thorough documentation of all assessments, interventions, and maternal-fetal responses is essential. The nurse must communicate regularly with the healthcare provider about the mother’s progress, any concerning fetal heart rate patterns, and readiness for delivery. This ensures the provider can arrive in time for delivery or intervene promptly if complications arise.

What do you think? How can nurses best balance the need for continuous monitoring with the goal of supporting a mother’s autonomy and preferences during the second stage of labour? What strategies have you found most effective in preparing for potential complications while maintaining a calm, supportive environment?

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC7898872/
2. https://openstax.org/books/maternal-newborn-nursing/pages/18-2-nursing-care-during-the-second-stage-of-labor
3. https://www.ncbi.nlm.nih.gov/books/NBK470427/
4. https://my.clevelandclinic.org/health/diseases/22311-shoulder-dystocia
5. https://www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC6109652/
7. https://www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html