Second Stage Prolongation in a Woman with a Previous Caesarean
A 29-year-old G3P2 (one previous caesarean for breech, one vaginal birth) at 40 weeks plus 3 days is in the second stage of labour in a midwife-led unit 45 minutes from the referral hospital by ambulance. Membranes ruptured spontaneously 8 hours ago and the fluid was clear. She has been pushing for 1 hour 50 minutes. The fetal head is at station +1, right occiput posterior, with caput and moulding palpable. Contractions are 4 in 10 minutes lasting 50 seconds. Fetal heart rate is 138 beats/min with normal variability on intermittent auscultation. Maternal pulse 92/min, blood pressure 118/74 mmHg, temperature 37.2 C. She is exhausted and asks for pain relief. The unit has no obstetrician and no operating theatre.
1. Is this second stage normal or prolonged, and what is your assessment of the risk of uterine rupture?
Read the worked answer
Second stage assessment: for a woman with a previous caesarean, second stage should be actively managed and not allowed to drift. Pushing for nearly 2 hours with a fetal head at +1, occiput posterior, and palpable caput and moulding indicates slow progress and possible cephalopelvic disproportion or persistent occiput posterior position. This is not a normal second stage in this context and needs action, not just more time.
Rupture risk: a previous caesarean increases the risk of scar dehiscence or rupture, especially with a prolonged second stage, a poorly applied head, and strong contractions. The absence of fetal heart rate abnormality and stable maternal vitals are reassuring but do not exclude an early dehiscence. Risk factors present here are: previous caesarean, prolonged second stage, occiput posterior position, and a head that is not descending well. The absence of a theatre on site means any deterioration would be catastrophic.
Key point: the decision is not whether to keep waiting but whether to continue in a setting that cannot manage a rupture. This woman should be transferred for obstetric review unless delivery is imminent and safe.
2. The ambulance will take 45 minutes and the doctor advises transfer. What do you do before and during transfer, and what would make you decide to deliver on site instead?
Read the worked answer
Before transfer:
- Escalate and document the decision and the reason for transfer; the doctor's advice should be recorded in writing.
- Secure IV access, take blood for group and save if possible, and keep the woman nil by mouth.
- Give analgesia that is safe in labour and does not mask deterioration; avoid intramuscular opioids close to delivery because of neonatal respiratory depression.
- Empty the bladder, which can improve descent.
- Continue fetal heart auscultation every 5 minutes and after each contraction; record maternal pulse and blood pressure every 15 minutes and watch for scar tenderness, sudden pain, or bleeding.
- Arrange a midwife escort, oxygen, resuscitation equipment for mother and newborn, and a neonatal bag and mask.
During transfer: position for comfort, continue monitoring, and keep the referral hospital informed of the estimated arrival time.
When to deliver on site instead: if delivery is imminent (head visible, perineum stretching, urge to push uncontrollable), or if there are signs of uterine rupture (sudden severe abdominal pain, scar tenderness, loss of contraction pattern, fetal bradycardia, maternal tachycardia or hypotension, vaginal bleeding), or if the fetal heart rate becomes non-reassuring and the head is on the perineum. In those situations, prepare for an assisted or spontaneous delivery with immediate readiness for maternal resuscitation and newborn resuscitation, and call for emergency backup. The principle is that a birth that cannot wait should not be transferred.