A 32-year-old multigravida (G3P2) at 40 weeks gestation is admitted to the labor ward with strong, regular uterine contractions every 2 minutes. Vaginal examination reveals complete cervical dilation (10 cm), complete effacement, and the fetal head at +2 station. The patient has an urge to push. Fetal heart rate is 138 bpm with normal variability. What is the most appropriate next step in management?

Explanation

## Diagnosis: Second Stage of Labor — Manage with Active Pushing ### Diagnostic Criteria for Second Stage The patient has entered the **second stage of labor**, which is defined by: | Criterion | Patient Status | |-----------|----------------| | Cervical dilation | Complete (10 cm) ✓ | | Cervical effacement | Complete (100%) ✓ | | Fetal station | +2 (below the level of the ischial spines) ✓ | | Maternal urge to push | Present ✓ | | Fetal heart rate | Normal (138 bpm, normal variability) ✓ | ### Management of Second Stage **Key Point:** The second stage of labor extends from complete cervical dilation until delivery of the fetus. It is divided into two phases: 1. **Latent (passive) phase:** Fetal descent occurs with maternal contractions; pushing is not yet encouraged (especially in epidural anesthesia). 2. **Active (descent/pushing) phase:** Mother actively pushes with contractions to facilitate descent and delivery. This patient has a clear urge to push and is at +2 station, indicating she is in the **active phase** and ready for directed pushing. ### Appropriate Management - **Encourage active pushing** with each contraction - **Support the perineum** to prevent severe laceration - **Monitor fetal heart rate** continuously (every 5 minutes or after each contraction) - **Prepare for assisted delivery** (vacuum or forceps) if descent is slow or if maternal exhaustion occurs - **Prepare for spontaneous vaginal delivery** if progress is normal **Clinical Pearl:** In a multigravida with +2 station and active pushing urge, delivery is typically imminent. The second stage in multiparas is usually shorter (average 5–30 minutes) than in primiparas (average 30 minutes–2 hours). **High-Yield:** Prolonged second stage is defined as: - **Primigravida:** >3 hours (or >2 hours with epidural) - **Multigravida:** >2 hours (or >1 hour with epidural) This patient is well within normal limits and has no indication for operative intervention at this time.