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Expulsive Stage of Labor: Process and Duration

The expulsive stage is the second stage of labor, during which the baby is pushed through the birth canal until delivery is complete.

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Things worth knowing about "Expulsive stage"

The expulsive stage is the second stage of labor, during which the baby is pushed through the birth canal until delivery is complete.

What is the Expulsive Stage?

The expulsive stage (also called the second stage of labor) begins when the cervix is fully dilated to approximately 10 cm and ends with the complete birth of the baby. This is the most physically demanding phase of labor, during which the mother actively pushes the baby through the birth canal with each contraction.

How the Expulsive Stage Works

During this stage, strong and regular contractions propel the baby through the pelvis and birth canal. The mother actively assists by bearing down with each contraction. As the baby descends, it rotates through the birth canal in a process known as fetal descent and rotation, typically being born head-first in what is called the vertex presentation.

Duration of the Expulsive Stage

The length of this stage varies depending on several factors, including whether it is a first or subsequent birth:

First-time mothers: typically 30 to 60 minutes, but may last up to 2 hours
Mothers who have given birth before: usually shorter, often between 10 and 30 minutes

Pushing and Breathing Techniques

Effective pushing is best coordinated with contractions. Midwives and healthcare professionals guide the mother with breathing and pushing techniques. Uncoordinated or premature pushing can cause exhaustion or perineal trauma. Directed pushing versus spontaneous pushing may be recommended based on individual circumstances.

Medical Monitoring

Throughout the expulsive stage, the baby's heart rate is continuously monitored, typically using cardiotocography (CTG). This allows healthcare providers to detect early signs of fetal distress or oxygen deprivation. The progress of labor and the condition of the perineum are also closely observed.

Possible Interventions

In some cases, medical interventions may be necessary to assist or expedite delivery:

Episiotomy: A surgical incision of the perineum to prevent uncontrolled tearing
Vacuum extraction or forceps delivery: Instruments used to assist delivery when the baby is not progressing through the birth canal
Oxytocin administration: A uterotonic medication used if contractions weaken or become insufficient

Possible Complications

Although most deliveries proceed without complications, the following issues can occasionally arise during the expulsive stage:

Prolonged second stage: The stage lasts longer than medically recommended and may require intervention
Shoulder dystocia: The baby's shoulders become impacted after delivery of the head, requiring emergency maneuvers
Abnormal fetal heart rate patterns: May indicate fetal hypoxia and require rapid action

Birthing Positions

Mothers may push in a variety of positions during the expulsive stage. While the supine or semi-recumbent position is commonly used in hospital settings, other positions can also facilitate delivery:

Squatting
Hands-and-knees (all-fours) position
Lateral (side-lying) position
Standing or kneeling

References

World Health Organization (WHO): WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva, 2018. Available at: https://www.who.int/publications/i/item/9789241550215
Cunningham, F.G. et al.: Williams Obstetrics. 25th edition. McGraw-Hill Education, New York, 2018.
National Institute for Health and Care Excellence (NICE): Intrapartum care for healthy women and babies. Clinical guideline CG190. London, 2014 (updated 2022). Available at: https://www.nice.org.uk/guidance/cg190

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