The Pushing Stage of Labour

Two second stages, not one

Almost every confusion about how long pushing "should" take comes from mixing up two phases that NICE defines separately.

The passive second stage is "when there is full dilatation of the cervix ... before or in the absence of involuntary or active pushing." NICE notes this passive stage "may be up to 2 hours when a woman with an epidural in place has been advised to delay pushing."

The active second stage begins when "the baby is visible" or when "there is involuntary or active pushing with full dilatation of the cervix."

The timings that follow all count from the start of the active stage. Being fully dilated at 2am does not start the clock if you are not pushing yet.

How long the active stage is expected to take

NICE sets an expectation and a series of review points for each of four groups. The pattern is identical: birth is expected within a window; the clinical picture is reassessed after a set period of pushing; and if birth is not imminent after a longer period, you are referred for senior review.

First baby, no epidural

"Birth would be expected to take place within 3 hours of the start of the active second stage in most women." After one hour of active pushing the team reassesses progress, contractions, and your and the baby's wellbeing. If birth is not imminent after two hours of pushing, you are referred for senior review and a decision on place and mode of birth.

Second or later baby, no epidural

Birth is expected "within 2 hours of the start of the active second stage in most women." The first reassessment comes after 30 minutes of active pushing. If birth is not imminent after one hour of pushing, senior review follows.

First baby, with an epidural

The same three-hour expectation and the same one-hour and two-hour review points — but NICE adds that these women "may have had a passive stage of up to 2 hours after full dilatation before commencing active pushing."

Second or later baby, with an epidural

Two hours expected, reassessment at 30 minutes, senior review if birth is not imminent at one hour, with a possible passive stage of up to one hour beforehand.

The NHS states the headline more simply: "If you're having your 1st baby, this pushing stage should last no longer than 3 hours. If you've had a baby before, it should take no more than 2 hours."

What happens at each review point

NICE spells out the decision tree, and it is more nuanced than a stopwatch. At the first reassessment:

• If there are signs of progress — rotation or descent of the presenting part — you are encouraged to continue pushing.
• If there are no signs of progress, a vaginal examination is offered, and breaking the waters is considered if the membranes are still intact.
• If there is still no progress, delay is diagnosed and the case is escalated for senior review.

So the question at one hour is not "has the baby been born" but "is anything moving". Progress buys time.

What the team is watching

During the second stage NICE asks midwives to keep taking your emotional and psychological needs into account, to assess "the woman's behaviour, the effectiveness of pushing and the baby's wellbeing", to assess the frequency, strength and duration of contractions, and to keep considering your position, hydration, coping and pain relief.

Monitoring intensifies. If your baby's heart rate is being listened to intermittently, NICE requires auscultation "immediately after a contraction for at least 1 minute, at least every 5 minutes" — up from every 15 minutes in the first stage — with your own pulse palpated at the same time to tell the two heartbeats apart. A vaginal examination is offered hourly in the active second stage, or sooner if you want one, assessing the position of the head, descent, and caput and moulding.

If pushing is not moving things

The first responses are practical, not surgical. NICE says that if pushing is ineffective or you ask for help, teams should "offer strategies to assist birth, such as support, change of position, emptying of the bladder and encouragement."

If delay is confirmed and you are transferred to obstetric-led care, an obstetrician should assess you in person before oxytocin is even considered — confirming the baby's presentation, position and heart rate, distinguishing fetal from maternal heart rate, confirming there are no signs of obstructed labour, and confirming that contractions are infrequent or ineffective. If oxytocin is started in the second stage, the dose is increased no more often than every 30 minutes. After that first assessment, obstetric review continues every 15 to 30 minutes.

When birth needs to be expedited

NICE's list of what must be weighed before speeding things up is a useful window into the decision: the degree of urgency, the findings on abdominal and vaginal examination, the mode of birth and choice of instrument, the anticipated difficulty and likelihood of success, your location, any time needed to transfer, the need for extra pain relief, and your preferences. The team should explain why and what the options are, tell everyone how urgent it is, and record the time the decision was made.

Forceps or ventouse are offered "if there is concern about the baby's wellbeing, there is a prolonged second stage or the woman requests assistance." If you decline, NICE tells teams to discuss the remaining options, advise you that "your choices may be limited by clinical safety or degree of urgency (for example, if a caesarean birth is no longer an option because the baby's head is too low in the pelvis)", and support your decision.

The last few minutes

When the head is almost out, the NHS says your midwife will ask you to stop pushing and take short breaths, "blowing them out through your mouth", so the head is born slowly and the perineum has time to stretch. Once the head is born, "the rest of their body is usually born during the next 1 or 2 contractions."

NICE asks that the time from birth to the onset of regular breathing is recorded, and that Apgar scores are noted at one and five minutes — done while your baby is on you, not away from you.