Management of Labour: Second Stage

• Duration: median 50 min in nulliparous women; 20 min in multiparous women
• A prolonged second stage raises risk of postpartum hemorrhage, infection, and severe vaginal lacerations

Step 1 - Fetal Assessment Before Delivery

Fetal Stations

Fig. 176.4 - Fetal stations. The ischial spines are 0 station; the fetal head at +1 is shown approaching the perineum.

Bony Landmarks of the Fetal Skull

Fig. 176.5 - Fetal skull landmarks: biparietal diameter, sagittal suture, lambdoid suture, and fontanels.

Step 2 - Leopold Maneuvers (Pre-delivery Assessment)

Fig. 176.3 - Leopold maneuvers:

• (A) First maneuver - identifies what occupies the fundus (head vs. breech)
• (B) Second maneuver - locates the fetal back
• (C) Third maneuver - identifies the presenting part at the pelvic inlet
• (D) Fourth maneuver - assesses the cephalic prominence and engagement

Step 3 - Electronic Fetal Monitoring (CTG)

Fig. 176.6 - Fetal Heart Rate (FHR) deceleration patterns:

• (A) Early decelerations - uniform shape, coincide with contraction peak; due to head compression - benign
• (B) Late decelerations - recovery after contraction ends (>30 sec lag); due to uteroplacental insufficiency - ominous, consider urgent delivery or cesarean
• (C) Variable decelerations - sudden drop, rapid return, variable timing; due to umbilical cord compression - change maternal position; if persistent, hasten delivery

Step 4 - Preparation for Delivery

• Prepare radiant warmer, towel, scissors, two umbilical clamps (4-5 cm apart), bulb suction, bag-mask device
• Place mother in dorsal lithotomy position (or Sims/left lateral position as alternative)
• Clean and scrub vulva and perineum with sterile water or saline
• Nurse at bedside to coach and reassure

Step 5 - Delivery of the Head

• Coach controlled pushing with each contraction
• At crowning (head stretching the perineum), instruct the mother to pant and not push - this slows head passage and reduces perineal tears
• Modified Ritgen Maneuver: one towel-draped hand supports the perineum and presses gently on the fetal chin; the second hand presses on the occiput to guide the head into slight extension - this presents the smallest diameter through the pelvic outlet

Step 6 - Delivery of the Shoulders

• After head delivery, allow head to rotate toward maternal thigh naturally (restitution)
• Clear fetal face and airway
• Gentle downward traction on head delivers the anterior shoulder
• Upward motion delivers the posterior shoulder
• If shoulder delivery is delayed, consider shoulder dystocia protocol

Step 7 - Cord Clamping and Infant Care

• Keep infant low at the perineum level immediately after delivery to promote placental blood flow to infant
• Clamp cord at two points 4-5 cm apart; proximal clamp 10 cm from infant's abdomen
• Cut cord at least 1 cm from skin (preserves venous access if resuscitation needed)
• Suction nose and mouth
• Transfer infant to warmer; dry and stimulate with towel
• Apgar scores at 1, 5, and 10 minutes

Step 8 - Episiotomy (Only if Indicated)

• Cut when head is visible during a contraction and introitus opens to 3-4 cm diameter
• Mediolateral incision is preferred over midline to avoid perineal tears extending to the rectum

Fig. 176.7 - Episiotomy types: Midline (left) vs. preferred Mediolateral incision (right), which avoids third/fourth degree extensions.

Summary Table

Modified Ritgen Maneuver

Anatomy of the Maneuver - Two Hands

Step-by-Step Technique

Step 1: Crowning occurs; anticipate delivery. Step 3: Downward traction for anterior shoulder. Step 5: Body delivers spontaneously. Step 7: Placenta delivery.

• Place one hand over the occiput and apply gentle pressure to control the rate of head delivery
• With the other hand draped in a sterile towel, reach beneath the perineum (anterior to the coccyx) and gently press upward on the fetal chin
• This combination extends the neck at the correct moment, presenting the suboccipitobregmatic diameter (smallest) through the outlet

Step 2: One hand on occiput controls delivery; other hand performs the modified Ritgen maneuver pressing the fetal chin upward through the perineum.

Fig. 56.11 - The modified Ritgen maneuver: arrows show the upper hand guiding the occiput and the lower towel-draped hand pressing the chin upward-anteriorly through the perineum. (Roberts & Hedges' Clinical Procedures in Emergency Medicine, from Williams Obstetrics 22e)

When to Use It

Caution: In occiput posterior (OP) position, flexion (not extension) should be favoured. Extension in OP can dramatically increase tension on the perineum, raising risk of 3rd or 4th degree laceration.

Why It Works - The Biomechanics

• As the head extends, its presenting diameter increases - uncontrolled extension leads to perineal tearing
• The maneuver allows the clinician to time and control extension, guiding the smallest diameter (suboccipitobregmatic ~9.5 cm) through the outlet
• The sterile towel protects against fecal contamination from the anus

Key Points to Remember

1. The lower hand is placed anterior to the coccyx (not over it) to reach the fetal chin
2. Always use a sterile towel over the lower hand - prevents anal contamination
3. Instruct the mother to pant, not push during crowning - this works synergistically with the maneuver
4. The maneuver assists natural extension; avoid forcing the chin to "pop" out suddenly - this tears the perineum
5. After head delivery, pass a finger around the neck to check for nuchal cord (occurs in ~20% of deliveries)

Ritgen Maneuver vs. Modified Ritgen Maneuver

Historical Origin

The Core Comparison

Hand Position - The Key Anatomical Point

The modified Ritgen maneuver: upper hand guides the occiput (arrow upward); lower towel-draped hand presses the chin anteriorly through the perineum (arrow forward) - from Williams Obstetrics 22e via Roberts & Hedges.

When Each is Used

What the Evidence Shows

• No significant reduction in severe perineal lacerations (3rd/4th degree) with Ritgen's maneuver (RR 0.69, 95% CI 0.10-4.61)
• Higher postpartum pain in the Ritgen group (RR 1.95, 95% CI 1.13-3.38)
• Conclusion: Ritgen's maneuver during labour is not protective for severe perineal tears and is associated with more postpartum pain

Important caveat: The RCT by Jönsson et al. (PMID 18669713) specifically tested the modified Ritgen (during contraction) vs. standard perineal support in 1,623 nulliparous women and found no significant reduction in 3rd/4th degree tears.

Summary: The One-Line Difference

The Ritgen Maneuver

Definition

In modern obstetrics, what is practiced is the Modified Ritgen Maneuver - the original maneuver was performed between contractions; the modified version is performed during a contraction (see below).

The Two Hands

Step 2 of vertex delivery: upper hand on occiput provides gentle downward pressure to slow delivery; lower hand (the Ritgen hand) presses the fetal chin upward through the perineum.

How It Works - The Biomechanics

• Too fast / uncontrolled extension → chin pops through perineum → 3rd or 4th degree laceration
• Controlled extension (Ritgen) → smallest diameter (suboccipitobregmatic ~9.5 cm) presents → perineum protected

Fig. 56.11 (Williams Obstetrics 22e, via Roberts & Hedges): Sagittal cross-section of the Ritgen maneuver. Upper arrow = occiput pressure. Lower arrow = towel-draped hand lifting chin forward and upward through the posterior perineum.

Step-by-Step Technique

Vertex delivery sequence: Step 1 (crowning), Step 3 (anterior shoulder), Step 5 (body delivery), Step 7 (placenta).

• Upper hand: palm over the occiput, gentle downward pressure
• Lower hand: draped in sterile towel, reach to posterior perineum anterior to coccyx, palpate the fetal chin and press upward and anteriorly
• Instruct the mother to pant, not push - this synergises with the maneuver to slow passage

• The lower hand lifts the chin → the neck extends → head delivers face-down
• Do NOT let the chin "pop" suddenly through the perineum - this is the most common cause of laceration
• In most cases controlled extension can be achieved without explosive delivery

• Allow the head to rotate toward the maternal thigh (restitution)
• Clear the face and airway
• Check for nuchal cord (present in ~20% of deliveries) - slip it over the head or doubly clamp and cut if tight

When to Use It

Important Practical Points

1. Always use a sterile towel on the lower hand - prevents fecal contamination from the anus
2. The lower hand is placed anterior to the coccyx, not over it - this is the correct anatomical approach to the fetal chin
3. The maneuver assists natural extension - it does not replace maternal pushing effort
4. Panting by the mother between pushes is the non-instrumental equivalent and works synergistically
5. If episiotomy is needed, cut it before applying the maneuver, when the introitus opens to 3-4 cm
6. After head delivery, always check for nuchal cord before proceeding to shoulder delivery

What the Evidence Says

• A 2020 meta-analysis (Aquino et al., PMID 30696316) of 3 RCTs (1,589 women) found the Ritgen maneuver does not significantly reduce severe perineal lacerations (RR 0.69, 95% CI 0.10-4.61) and is associated with higher postpartum pain (RR 1.95, 95% CI 1.13-3.38)
• The 2024 Cochrane Review (Dwan et al., PMID 39465967) (17 RCTs, 13,695 women) found low-certainty evidence across all perineal techniques - no single technique is definitively superior
• Despite mixed evidence, the Ritgen maneuver remains widely taught as it provides the clinician with active control of head delivery, which is especially valuable in emergency or rapid delivery situations