Nursing Care During the Second Stage of Labor

Core Concepts

Descent phase versus active pushing phase

In the descent phase the presenting part continues through the pelvis even though the person may not feel the urge to push. Pushing is often discouraged until the urge is strong or descent is well advanced, because early pushing wastes energy. The active pushing phase begins when the urge to bear down is strong and the person works with each contraction; some push spontaneously, others need guidance.

The cardinal movements of labor

The fetus adapts to the pelvis through the cardinal movements: engagement, descent, flexion (chin tucks to present the smallest diameter), internal rotation (head aligns with the outlet), extension (head emerges over the perineum), external rotation or restitution (head aligns with the shoulders), and expulsion (shoulders and body are born). These movements explain progress — for example, why an occiput-posterior position usually means slower descent and "back labor."

Nursing assessment during the second stage

• Fetal heart rate: Continuous or intermittent monitoring per institutional protocol and risk status; non-reassuring patterns are reported promptly.
• Contractions: Frequency, duration, and strength (by palpation, or intrauterine pressure catheter if ordered); pushing is timed to contractions.
• Maternal status: Vital signs, fatigue, coping, urge to push, and bladder distention (a full bladder slows descent).
• Progress: Perineal bulging, crowning (the widest part of the presenting part visible and not receding between contractions), and station per examination by the provider or midwife.

Supporting the pushing effort

Pushing technique is debated, and institutional practices vary. Open-glottis pushing (short efforts with breath released) is linked in some research to less exhaustion and fewer FHR decelerations, while closed-glottis (Valsalva) pushing (sustained breath-holding) may shorten pushing time but can stress the fetus and pelvic floor. The nurse follows the care plan, supports the person's preferred position (squatting, side-lying, semi-sitting, hands-and-knees), and avoids prolonged directed pushing that overrides the person's own urge.

Preparing for birth and immediate newborn care

Before birth the nurse ensures the bed is set up, the newborn warmer is ready, and resuscitation equipment is checked per unit protocol; a newborn resuscitation–trained team member is present or immediately available. The nurse also anticipates the plan for perineal support, cord-clamping timing (early versus delayed clamping is a practice decision with its own evidence base), and immediate newborn care such as drying, warming, and airway clearance if needed.

Emotional, cultural, and communication support

Second stage is exhausting and vulnerable. The nurse offers encouragement, clear explanations, and a calm presence; honors the person's cultural preferences, birth plan, and support person's role; and communicates frequently with the provider or midwife about progress, FHR findings, and the person's condition. Findings are documented and reported rather than assumed.

Clinical Scenario: A Long Second Stage with an OP Baby

Maya, a first-time parent at 40 weeks, reaches full dilation after a long first stage and begins pushing with an epidural in place. Because she cannot feel contractions clearly, the nurse watches the monitor and coaches short open-glottis efforts rather than long breath-holds. Descent is slow; the provider's exam shows the head is occiput-posterior (OP) — the "sunny-side up" position that explains Maya's deep back pain and sluggish progress. The nurse suggests side-lying or hands-and-knees positions to encourage rotation, notes the bladder is distended (the provider orders straight catheterization), and keeps watching the FHR for late decelerations. After an hour the head rotates, crowning occurs, and the provider guides the birth with perineal support. The nurse documents the FHR pattern, positions tried, pushing technique, and the time of birth.

Common Confusions