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??

I think the longest I have ever seen a pt complete was 10 hours. This was a midwife pt and in the morning when the doctors arrived I can say they were not happy at all. We pushed and rested and pushed and rested. Probably pushed a total of 5-6 hours. It was quite ridiculous. Miraculously the baby finally emerged and had about 6 inches of caput. I'm not kidding. I have never seen a head look that bad. It really looked like a football.

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

just wow.

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I pushed for over 5 hours with no drugs. My daughter was facing the wrong way. I had a CNM and didn't find it bad at all. Of course, my ctx were not close either and also weren't very painful. I think I would have ripped her head off if she or a dr tried to section me. My and the baby's vitals were good. I ended up with a superficial tear. I think I had 3 or 4 stitches. If I hadn't been so eager after 5 hours I probably wouldn't have torn. But instead of gently pushing her out when she crowned I gave a great big whopper of a push.

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The longest second stage I've seen was 9 hours- the patient was one of our midwives, she pushed inneffectively for a couple hours, got an epidural and rested/labored down awhile, then pushed for a couple more hours. When her son was born, she lifted him to her chest and exclaimed "he was acynclitic!" when she saw his crooked caput :)

She was such a trooper. The practice she works for is amazing, they really trust in womens' ability to labor and birth. It's nice to work with people like that.

I've seen some other extended second stages, but that's the one that sticks out in my mind the most.

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Thanks for all your replies! It's reassuring to know that others have seen prolonged 2nd stages w/good outcomes. I just wonder what the attending meant when he said that over 3 hrs leads to "unfavorable" outcomes often. I can imagine yes, but do you think that's often the case if the FHR remains reassuring throughout (really not even earlys or variables)?

On the same note of pushing w/epidurals, we usually tell the mom when she has the urge to push to let us know. This pt let me know and she was still at 0 station. Do you think I should have discouraged her from pushing right then? She said she felt intense pressure like she "had to poop." And that's normally the feeling I think they need to start pushing. She did push pretty effectively, but that baby just had a tight nuchal cord.

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

I think the attending is referring strictly to statistics------prolonged 2nd stages DO lead to csections, oftentimes, for a variety of reasons, as you can imagine. It depends on so many variables and opinions---as to whether the outcomes are "favorable" or not.

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Specializes in Stroke Seizure/LTC/SNF/LTAC.

I had a primip complete at 0600; by change of shift, she had been pushing for an hour, and was allowed to rest..here's where I come in. New OB nurse, with a preceptor who could've cared less about being at work that day (it was Labor Day - seriously!) So I come in to a "natural" labor- no epidural, nothing for pain, just a loving husband and a gutsy mama. I mean, this little lady was NOT having a c/s if she could help it. Anyhoo, she proceeded to push on and off (mostly on) for the next 6-7 hours dozing in between contractions, and delivered a healthy baby boy at around 1330 that PM. I must add that she was the patient of a CNM who was very experienced in home births and was not at all intimidated by the length of time this was taking. Baby was born howling, great Apgars, and mommy was actually energized after holding him in her arms. So, I guess I'll agree with most of you and say the length is not the real issue; it's FHT and mommy's endurance.

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The longest 2nd stage I've seen was 8 hours. Mom was fully at the beginning of my shift, had no urge to push so rested for a couple of hours. We did directed pushing for a couple of hours. Contractions spaced out so we did nipple stim and oxytocin. Mom rested for a couple more hours and finally baby was delivered just as I was leaving.

7 Pulls with a vacuum is excessive. Our facility only allows three attempts.

The logest continuous 2nd stage I've seen was 6 hours. We tried to get mom to rest but she insisted on pushing the entire time.

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Specializes in Pediatric Pulmonology and Allergy.
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

Congratulations to you on your successful homebirth! I had my last two at home and it was amazing to learn how my body really knows exactly what to do and will tell me just how to position myself for maximum comfort and safety in birth. I also sensed which stage of labor I was in without anyone telling me. I think when you're prepared for a homebirth you just pay better attention to those signals than when you're in a hospital expecting the doctors and nurses to know everything.

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Congratulations to you on your successful homebirth! I had my last two at home and it was amazing to learn how my body really knows exactly what to do and will tell me just how to position myself for maximum comfort and safety in birth. I also sensed which stage of labor I was in without anyone telling me. I think when you're prepared for a homebirth you just pay better attention to those signals than when you're in a hospital expecting the doctors and nurses to know everything.

Thanks. :) We were prepared to deliver at home, since I arrived at the birth center completely dilated with my third. I knew I was NOT going to suffer through transition in the car again :uhoh3: , so had decided that if I felt anywhere close, we were staying home. Needless to say, we wouldn't have made it. Now, I can't imagine doing it differently.

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