6/16/2017 Financial Relationships Second Stage of Labor: • No financial disclosures related to this talk When to Start and Stop • Medical Advisor to: • Celmatix, Mindchild • Bob’s Red Mill Aaron B Caughey, MD, PhD Professor and Chair Department of Obstetrics and Gynecology Oregon Health & Science University caughey@ohsu.edu Question Objectives 36 y.o. G1P0 at 40 wks GA with an epidural labored down for 1 hour (from 0 to +1) and now has pushed for 2 hours (from +1 to +2). What is � Second stage of labor the plan? � Epidemiology of second stage 40% 35% continue to push for up to 1 more A. � Methodologic Challenges hour � When to stop - how long is too long? continue to push for up to 2 more B. � When to start hours 12% continue to push for up to 3 more � Delayed vs. Immediate Pushing C. 6% 6% hours Begin conversation about OVD D. Begin conversation about cesarean D V . E. . . . . . . . O . . . . e o o o c t t t t u t o u p p p o u u u b a b r r r o o o a n f f f o n h h h i o t s s s a t i u u u a s p p p r s e r o o o v e t t t v n e e e o n u u u c o n n n c n t i t i t i i n n n n g i e g o o o e B c c c B 1
6/16/2017 Labor: Friedman Curve Second Stage of Labor � Second stage of labor � Hamilton – 1861 – suggested 2 hours as Nulliparas: 2 hours � prolonged second stage Multiparas: 1 hour � � Duration of the second stage of labor First stage Second stage � Nulliparas: 54 minutes � Multiparas: 19 minutes � Use of regional anesthesia increases the mean duration of second stage by 25 minutes Hamilton G. Classical observations and suggestions in obstetrics. Edinburgh Med J. 1861 Zhang et al. Does epidural prolong labor & increase risk of cesarean delivery. Am J Obstet Gynecol 2001 Kilpatrick et al. Characteristics of normal labor. Obstet Gynecol 1989 ACOG Practice bulletin. Dystocia and augmentation of labor. No 49; Obstet Gynecol 2003 Friedman EA. Primigravid labor. Obstet Gynecol 1955 Second Stage of Labor Zhang: Labor Curve � ACOG: Prolonged second stage of labor � Second stage of labor in nulliparous women Time (minutes) � Nulliparas: 2 hours without regional anesthesia Station 1 % ile Median 95 % ile 3 hours with regional anesthesia +1 to +2 1 16 176 � Multiparas: 1 hour without regional anesthesia +2 to +3 1 7 38 2 hours with regional anesthesia ACOG Practice bulletin. Dystocia and augmentation of labor. No 49; Obstet Gynecol 2003 Zhang J et al. Reassessing labor curve in nulliparous women. Am J Obstet Gynecol 2002 2
6/16/2017 Second Stage of Labor Studying the Second Stage Friedman Study Zhang Study (n=500) (n=1,162) Year of data collection early 1950s 1992 - 1996 Birthweight 2.5-4.0kg 85 % 100 % Induction of labor 4 % 0 % Epidural anesthesia 8 % 48 % Oxytocin augment. 9 % 50 % Low forceps/vacuum 51 % 13 % Zhang J et al. Reassessing labor curve in nulliparous women. Am J Obstet Gynecol 2002 Friedman EA. Primigravid labor. Obstet Gynecol 1955 Studying the Second Stage Second Stage of Labor � Challenges of studying labor duration � Non-normal distribution � Median, 95 th centile 3
6/16/2017 2 nd Stage of Labor: Nulliparas 2 nd Stage of Labor: Multiparas 100 100 Percent Pregnant Percent Pregnant 50 50 Epidural Epidural No Epidural No Epidural 25 25 p<0.001 by Log-rank p<0.001 by Log-rank 0 0 0 2 4 6 8 10 0 2 4 6 8 10 Second Stage of Labor (hour) Second Stage of Labor (hour) Cheng YW, et al. The second stage of labor and epidural use: a larger effect than previously suggested. Cheng YW, et al. The second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014 Obstet Gynecol. 2014 Second Stage of Labor: Results: Second stage of labor How long is too long? � Hard to even know the natural course Median 95%ile � Particularly with epidural Nulliparas 50 min 201 min � What about outcomes with shorter or longer No Epidural 138 min second stage? Nulliparas 126 min 339 min � How do interventions improve these Epidural outcomes? Multiparas 14 min 84 min No Epidural Multiparas 40 min 262 min Epidural p<0.001 Cheng YW, et al. The second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014 4
6/16/2017 Second Stage of Labor: Second Stage of Labor: How long is too long? How long is too long? � 6791 nulliparas reached second stage (1996-99) � Increased maternal morbidity with prolonged 2 nd stage � No differences neonatal outcomes 40 2nd Stage 0-2hrs (n=6259) 35 2nd Stage 2-4 hrs (n=384) 30 2nd Stage >=4hrs (n=148) 25 % 20 p<0.001 for all 15 10 5 0 CD OpVD PeriLac Chorio PPH Myles et al. Maternal & neonatal outcomes in patient with a prolonged 2 nd stage. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Is a prolonged second stage of labor associated Obstet Gynecol 2003 with worse maternal and neonatal outcomes? Am J Obstet Gynecol, 2004;191:933-8 Second Stage of Labor: Second Stage - How long is too long? How long is too long? � Nova Scotia Atlee Perinatal Database (1988-2006) � Term, singleton pregnancies delivered in 2 nd stage � 11,470 (9%) prolonged; 110,206 no prolonged 2 nd stage Nulliparas <2 hr 2-3 hr 3-4 hr 4-5 hr >5 hr PP hemorrhage 6.0 % 1.30 1.53 1.59 1.75 Blood transfusion 0.5 % 0.89 0.62 0.53 0.64 OB trauma 0.2 % 1.45 1.84 2.07 2.18 Endomyometritis 2.3 % 1.30 1.63 1.51 1.49 Referent: 2 nd stage <2 hrs (baseline rate); aOR by 2 nd stage duration compared to referent Allen et al. Maternal and Perinatal outcomes with increasing duration of 2 nd stage. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Is a prolonged second stage of labor associated Obstet Gynecol 2009 with worse maternal and neonatal outcomes? Am J Obstet Gynecol, 2004;191:933-8 5
6/16/2017 Summary - How long is too long? Summary - How long is too long? Chorioamnionitis � Varied evidence � Maternal outcomes worse � Is it that simply longer labor leads � Unclear impact on neonatal outcomes � to more infections? Consider causal models for � OR maternal outcomes Women with pre-chorio / chorio � have longer labors? Summary - How long is too long? OVD vs. Expectant Management PPH / Perineal lacerations � Is it that simply longer labor leads � to more bleeding / injury? OR Women with longer second stages � eventually are delivered via cesarean / op vag delivery leading to complications? Cheng YW, Shaffer BL, Bianco K, Caughey AB. Timing of operative vaginal delivery and associated perinatal outcomes in nulliparous women. J Matern Fetal Neonatal Med. 2011;24:692-7 6
6/16/2017 How long is too long? - Summary OVD vs. Expectant Management � If progress is being made, duration of the 2 nd stage alone DOES NOT mandate intervention by operative delivery. � A specific absolute maximum length of time spent in second stage of labor beyond which all women should undergo operative delivery has not been identified. � Before diagnosing arrest of labor in second stage, if maternal and fetal conditions permit, allow for following: � At least 2 h of pushing in multiparous women � At least 3 h of pushing in nulliparous women � Longer durations may be appropriate on individualized basis (eg, with use of epidural analgesia or with fetal malposition). Cheng YW, Shaffer BL, Bianco K, Caughey AB. Timing of operative vaginal delivery and associated perinatal outcomes in nulliparous women. J Matern Fetal Neonatal Med. ACOG / SMFM, Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Obstetric Care Consensus Document 2011;24:692-7 No. 1. Safe Prevention of the Primary Cesarean Delivery. Obstet Gynecol. 2014 Mar;123:693-711. ‘Prolonged’ Second Stage Question – When to Start? 36 y.o. G1P0 at 40 wks GA with an epidural labored down is at 0 station. What is the plan? A. Labor down until urge to push 47% B. Labor down for up to 2 hours 25% C. Discuss options of pushing and 20% laboring down with patient 8% D. Start pushing g s n h r i s u . h u . . s p o u h g o n p 2 i t h t o s r e u a g t t r p p S u u f l o t i r n o s f n u o n n w t i w p o o d o d r s o s r u o b c b a s a L i D L 7
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