Overview of Managing the Second Stage of Labor

This video shows how to support the mother’s efforts during vaginal delivery.

Second stage is the pushing stage in labor. It begins when the cervix is completely open and the woman has an urge to push. It ends when the baby is born. This video will show how to support the woman’s pushing efforts and what to do if progress is slow.

A woman’s cervix should be fully open before she starts to push – especially a first time mother. If she pushes too early an edge of cervix can swell, interfere with her progress, and even tear. You may confirm her dilation with a vaginal exam if you have been trained. But, with experience, you’ll often be able to tell when a mother has reached the pushing stage without doing an exam. Her mood often changes: she may be more irritable, withdrawn, or more focused. As her contractions come stronger and more often; she may vomit, cry out, or have an uncontrollable urge to push. Remind the woman to urinate so her bladder doesn’t interfere with her progress. But avoid pit latrines – an accidental push could land the baby inside. Encourage the woman to wait until she feels the urge to push. This will save her energy.

Her body will push naturally, and when she is encouraged and supported, she will usually find the way to push that feels right and gets the baby out. Let the mother choose the position that feels right to her. She’ll make better progress if she is in an upright position; not flat on her back. Half-sitting may be most comfortable. Lying on her side is a good position if the baby is coming quickly. It can also help prevent tears. Hands and knees can be a helpful position when a woman feels labor in her back or when the shoulders are stuck. Squatting can help bring the baby down when the birth is slow.

Show the woman how to push well. Suggest she open her legs wide, pulling her knees up towards her body and putting her chin to her chest. Have her breathe deeply and slowly between contractions. Pushing her feet against you and her companion can make her pushes more powerful. If a mother has difficulty pushing, do not scold or threaten her. Upsetting or frightening her can slow the birth. Instead encourage and work with her.

Each contraction is a new chance. Continue to check the mother’s blood pressure and pulse regularly, every half hour if possible. If they are out of range, she may be having a complication such as pre-eclampsia, dehydration, or infection.

Listen for the baby’s heartbeat after every few contractions. Pay attention to how long the baby is taking to come as the mother pushes. A woman’s first baby may take a full 2-3 hours of strong contractions and good effective pushing to be born. If she’s had a baby before, she usually takes less than an hour to push the baby out, and can sometimes even do it in one push.

The birth is normal and healthy, as long as the baby continues to move down (even very slowly), the baby’s heartbeat is normal, and the mother has strength. Pushing for a long time with no progress can cause serious problems such as a ruptured uterus or even the death of the baby or mother.

If the baby is not moving down at all after an hour of pushing with strong contractions, the mother needs help. Ask yourself ... Is she afraid or exhausted? Talk to her supportively. Encourage her to rest for a few contractions, so she can become strong again. Give her something to drink with sugar in it, to give her energy. Is her bladder full? Suggest she try to urinate. Try a change of position. Squatting or pushing on a bucket can help bring the baby down. Give her something to hold on to. Pulling with her arms as she pushes with her abdomen may help. Suggest she stimulate her nipples. Pushing straight down with 2 fingers in the vagina can increase the urge to push. If the bag of waters has not yet broken, and you know how to break it, this action can often help speed the progress of birth. Don’t do fundal pressure – this can cause the placenta to detach or the uterus to rupture.

If these measures don’t help, her baby may be in a difficult position or the baby may be too big for her pelvis. The mother should be transferred without delay to a facility that can do vacuum, forceps, and cesarean births.

This mother’s labor is progressing well. With each contraction and each push from the mother, she moves the baby further down in the vagina. Now we see a little of the baby’s head coming down the vagina during contractions. When the baby’s head stretches the vaginal opening to about the size of your palm, the head will stay at the opening - even between contractions. This is called crowning. Guide the mother to birth the head slowly, then the shoulders, then the baby’s body quickly follows. Put the baby on the mother’s abdomen. Thoroughly dry the baby and keep her in skin-to-skin contact with the mother.

Remember, the woman should start pushing when her cervix is fully open and she feels the urge to push. Let the mother choose the position that feels right to her. If the pushing stage is going too long, help her push more effectively and refer her if she’s not making progress.