A 32-year-old multiparous woman (G3P2) at term presents to the labor ward with strong uterine contractions occurring every 1–2 minutes, lasting 60–70 seconds. On examination, the cervix is fully dilated (10 cm) and 100% effaced; the fetal head is at +2 station. The patient reports an intense urge to push and feels pressure in the rectum. Fetal heart rate is 138 bpm with good variability. The patient spontaneously bears down with contractions. What is the most appropriate next step in management?

Explanation

## Management During the Second Stage of Labor **Key Point:** This patient is in the **second stage of labor** (full dilation to delivery of fetus). The appropriate management is **active pushing with contractions** and preparation for vaginal delivery. No intervention is needed; this is normal labor progression. ### Clinical Diagnosis of Second Stage | Finding | Patient | Second Stage Criterion | |---------|---------|------------------------| | Cervical dilation | 10 cm (full) | 10 cm (complete) | | Cervical effacement | 100% | 100% | | Fetal station | +2 | Typically −2 to +5 | | Contractions | Every 1–2 min, 60–70 sec | Strong, frequent | | Urge to push | Present, intense | Present (Ferguson reflex) | | Rectal pressure | Present | Present (sign of descent) | **High-Yield:** The **second stage of labor** has two phases: 1. **Latent (early) phase**: Full dilation achieved; head descends passively; patient may not feel urge to push immediately (especially with epidural) 2. **Active (descent/pushing) phase**: Patient has strong urge to push; active bearing down occurs; head descends and rotates; delivery imminent This patient is in the **active phase of the second stage** — the correct management is **expectant support and active pushing**. **Clinical Pearl:** In multiparous women, the second stage is typically shorter (30–60 minutes) than in nulliparous women (60–120 minutes). This patient's strong contractions, full dilation, and fetal station of +2 indicate rapid progress — vaginal delivery is expected soon. **Mnemonic: PUSH** — **P**ush with contractions, **U**rge to push present, **S**tation advanced (+2), **H**ead low in pelvis ### Why Not Other Interventions? - **Ergot alkaloid**: Contraindicated before full dilation (risk of tetanic uterine contraction and uterine rupture); not needed here as contractions are already strong and frequent - **Artificial rupture of membranes (ARM)**: Not indicated; membranes may already be ruptured, and ARM does not accelerate descent in the second stage if contractions are adequate - **Cesarean delivery**: No indication; patient is progressing normally with good fetal heart rate and descent; cesarean is reserved for arrest of descent or fetal distress [cite:Williams Obstetrics 26e Ch 16]