How long is too long? re: 2nd stage of labor

Specialties Ob/Gyn

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Hi guys,

As you may or may not know, I'm still in a learning curve in L&D. I just wanted to run something by you and compare experiences.

Had a pt who was declared c/c/0 at 7am. She was a primip w/ an epidural and had no urge to push at that point. So we let her labor down a bit. At 7:45 she stated she had a strong urge to push (still at 0 station) so I went in to help her push. By 10:15 she was crying, stating the pain was too bad (after 2 pca epidural boluses) and was writhing away from her pushes, no longer pushing effectively. I called her MD who was in a c/s (she was tended to by the attendings). So next I called the chief resident who was also busy but promised to come to the room asap. At this point she was by my judgement at +1 or +2. The CNM covering the residents who were in conference (see where this gets fuzzy???) was available and she rounded up that chief resident and another attending. They talked c/s but I felt that it was not necessary at this point since the fhr was reassuring with no decels. So they decided to bolus the epidural and give her 25 benadryl IV to rest for 30 min.

Soooo... when her attending (different attending thant the one who ordered the benadryl) came around and saw me at the nurse's station, he asked about the pt. I told him the situation and he was upset to say the least. At this point is was around 11:30. He went over this risks of a prolonged 2nd stage with me, and I told him that I understood, but I had a CNM, chief, and attending ordering this for the pt and I thought he needed to talk to them about it. Of course he didn't!

So the pt finally delivered at 1300 w/VE (7 pulls!). Baby went to NICU for 2 hrs and was released to NBN, and mom had a 1st degree tear.

So I guess I'm wondering what's the longest 2nd stage you guys have seen, and what was the outcome? At what point during pushing do you call the docs bc things aren't progressing??

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As a doula at a hospital I've recently seen a pt whose pushing stage lasted about 2.75 hours. The baby was fine and she was doing well (without an epidural). Although she was begging the docs to do an episiotomy (baby was too high at that point) as well as forceps (still too high at that point) she was able to bring the baby down to where they could use a VE. Baby did well, episiotomy was not required. It all went very well despite the longer 2nd stage.

I'm amazed at something in your story though. The doc had 7 popoffs from the VE??? They are only allowed 3 at our hospital. If they aren't successful after 3 popoffs, they then consider moving on to something else.

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It seems that she pushed 2 1/2 hours, got a rest and started again. I have seen pts actually push for longer, but I am not a fan of it. The part that bothers me is the vacuum...I hate when they ***DRAG*** a head to the perineum. It really shouldn't be that hard, and if the head barely makes it, what about those shoulders? I don't think you could have done anything different, you spoke to lots of "providers" who are ultimately responsible. And her attending should have made a decision earlier, say before going back to the OR with another pt and then grumbling about the 2nd stage stuff. What did he think you should have done?

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

It can vary. Some moms push well/effectively for 3 hours or even a bit more. If baby/mom are tolerating it well, and there is no real reason to suspect a true problem, it's not out of range. Also particularly when epidurals are present, a mom can be comply dilated for 2 or more hours even, before she begins to push. This is called "laboring down" and is very effective in saving mom's energy and fetal oxygen reserves.

If mom has been pushing roughly 1 1/2- 2 hours and not making much progress, (or the baby is stuck in OP or some other unfavorable position) I call the doctor to evaluate the situation.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

our docs would never have 7 pop-offs. I meant to clarify that. There is a problem there if they are having that many pop-offs, either in training or technique.

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I'm so sorry, I meant to write 7 pulls, not pop offs!

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I'm so sorry, I meant to write 7 pulls, not pop offs!

You did. :)

The longest second stage I've seen is 3 hours of actual pushing. However, I have had patients labor down for an hour or so, and have had patients push for an hour, then rest to labor down some more to start pushing again. Were there seven pulls because baby was just a tight squeeze or because Mom wasn't really effectively pushing. I think as long as there isn't a lot of molding and/or caput and mom and baby are doing fine, resting and starting again are ideal.

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I guess if Fh was reassuring they were willing to let it drag on. It seems rather prolonged. Did the pt. push effectively at first or not? I have seen a lot of pt's. w/ epidural NEVER get the urge and get in the rhythm to push. Ususally we will turn the epidural off if this is occurring. I have had epidural turned off when pt. is protesting loudly but not pushing well, but doc will usually come in and help coach her w/ each push for a while if he she decides this and pt. is really agitated about it. This seems to help her to focus. I think because they are not turning it off and then just staying away, she feels more supported. Also it helps physician to see how pt. is pushing and if it's really any use or not to proceed. A few months ago, I had a pt. w/ an epid. who never felt the urge to push. She had an ant. lip abt. 45 min. later, she still had it. We repositioned her and she was sleeping well in between exams. I couldn't see any earlies and she was just snoozing away. I went in again and thought well maybe I will cath her. She was fully +2 and still no urge to push. She was incidentally able to move well. Doc was sleeping in call room. We set her up and she pushed about 3x and delivered. This lady just laboured down and did primarily because doc was asleep, as he would've had her push the lip away 2 hours before and she would not have gotten the marvelous pain relief and sleep that she did. If efm looks good or if auscultation is reassuring, there is no need to keep intervening. As for the vac, unfortunately although the manufacturers say x3, I have also seen the vac used as you describe w/ much the same outcome. :uhoh21: If her attending thought the 2nd stage was too long at 1130, I am wondering why he didn't call for C/S then. Thankfully, outcome wasn't worse.

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She was fully +2 and still no urge to push. She was incidentally able to move well. Doc was sleeping in call room. We set her up and she pushed about 3x and delivered. This lady just laboured down

I discovered, it is possible to have a baby w/o pushing. :p With my 4th, my water broke when I was home alone with the kids. When my husband got home an hour later, I was feeling pressure (and couldn't feel my cervix, I thought at the time I just couldn't reach it, but think I was probably close to complete). 45 minutes later after being coaxed out of the bathtub to get dressed and feeling really doubtful about being able to make it to the hospital due to the feelings of intense pressure, I got back in the tub, knelt down, and out slid baby. No pushing at all. Just gravity and the force of the contractions. :chuckle

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So I guess I'm wondering what's the longest 2nd stage you guys have seen, and what was the outcome? At what point during pushing do you call the docs bc things aren't progressing??

This summer I had a primip who was complete at 3:30 am. At 4:30 am she still didn't have an urge to push, so the OB requested I lighten up the epidural a little. At 5 am she could tell "something was happening", so we started pushing.

At 7 am she brought the vertex down all of 1 cm. The OB came in and started discussing C-section with her. Unfortunately at that time the anesthesiologist and his backup were involved in a multiple trauma case and couldn't respond. While the new anesthesia people were walking in for the day, the OB walked back in the room to talk to the patient (we weren't pushing anymore at this point) and he claims "something came to me". FHT's were stable and mom was stable and not really uncomfortable.

Her epidural was given a heavy bolus by the ologist at 7:30 and she went to sleep for 3 hours. (this is where I left to go home to bed). When she woke up she could feel a lot of pressure but no pain, and the baby was at a +3. She pushed for half an hour and had a baby around 11 am; terrific apgars, no tears, and very very happy that she had "escaped" a C-birth. Of course I was home asleep by this time, but I asked him about the birth a day or so later. He said when he walked in the room he could hear our senior CNM "whispering" that she needed more time, and so he did "what he thought the midwife would do".

In all my years this is the longest I've EVER seen a MD (or midwife for that matter) allow nature to take its course. The family was very happy about everything!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Wow, I must have been tired....I read "pop offs" in place of pulls. Never the less, 7 pulls is pretty much as well. By this point, our dr's would have probably moved on to section the baby out----after 3 pulls......

Sorry for the misread. That'll teach me! :chuckle duh.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I discovered, it is possible to have a baby w/o pushing. :p With my 4th, my water broke when I was home alone with the kids. When my husband got home an hour later, I was feeling pressure (and couldn't feel my cervix, I thought at the time I just couldn't reach it, but think I was probably close to complete). 45 minutes later after being coaxed out of the bathtub to get dressed and feeling really doubtful about being able to make it to the hospital due to the feelings of intense pressure, I got back in the tub, knelt down, and out slid baby. No pushing at all. Just gravity and the force of the contractions. :chuckle

indeed. This is a great story to tell, thank you for sharing!!!!

That is why laboring down is so effective and useful----IF doctors can be patient enough , that is. Whether there is an epidural in place or not, it is often NOT useful to have a mom push without any urge or desire to---it usually comes in time. Even with an epidural in place, the nerves get pressed enough, and the "great pressure" takes over, and many moms will report almost unbearable pressure or even a desire to push. THIS is the time to have them push, not before.

That is a distinct advantage we have at night. We are able to manage this w/o the physician frequently checking in at progress and being anxious to "get it over with".....The ute can truly labor down a baby w/o mom doing ANY work for a few hours, to just crowning, in many cases, if you let it!

And I do believe in repositioning a mom frequently, particularly for persistent anterior lips or OP presentation. Sometimes, in all the moving about the baby "corkscrews" around and then comes down----fast! The worst position USUALLY is on her back. Get momma on her sides, and sitting way up (if she and baby tolerate it)----and sit back and watch what happens!

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