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Financial Relationships Whats New with the No financial disclosures related to this talk Second Stage of Labor: Medical Advisor to: When to Start and Stop Celmatix, Mindchild Bobs Red Mill Aaron B Caughey, MD, PhD

  1. Financial Relationships What’s New with the • No financial disclosures related to this talk Second Stage of Labor: • Medical Advisor to: When to Start and Stop • 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 has now pushed for 2 hours (from +1 to +2). What  Second stage of labor is the plan?  Epidemiology of second stage 42% 42% continue to push for up to 1 more hour A.  Methodologic Challenges continue to push for up to 2 more B.  When to stop - how long is too long? hours  When to start continue to push for up to 3 more C. 9% 7%  Delayed vs. Immediate Pushing hours 1% Begin conversation about OVD D. . . Begin conversation about cesarean . . . . . . . . . o u p p p b E. o u u u a b r r r n a o o o o f f f n i o h h h t s s s a i s t u u u a p p p r s e v r o o o e n v t t t e e e o n c u u u o n c n n n i n t i t i t i g n n n e i g o o o B e c c c B

  2. 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

  3. 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 Second Stage of Labor: Studying the Second Stage How long is too long?  Hard to even know the natural course  Particularly with epidural  What about outcomes with shorter or longer second stage?  How do interventions improve these outcomes?

  4. 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 Cheng YW, Hopkins LM, Caughey AB. How long is too long: Is a prolonged second stage of labor associated Myles et al. Maternal & neonatal outcomes in patient with a prolonged 2 nd stage. with worse maternal and neonatal outcomes? Am J Obstet Gynecol, 2004;191:933-8 Obstet Gynecol 2003 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 Cheng YW, Hopkins LM, Caughey AB. How long is too long: Is a prolonged second stage of labor associated Allen et al. Maternal and Perinatal outcomes with increasing duration of 2 nd stage. with worse maternal and neonatal outcomes? Am J Obstet Gynecol, 2004;191:933-8 Obstet Gynecol 2009

  5. 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. 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 is at 0 station. What is the plan? 58% Labor down until urge to push A. Labor down for up to 2 hours B. Discuss options of pushing and C. 22% laboring down with patient 12% 8% Start pushing D. g . n . . . . . i . . n h o . i s t 2 h u s e o p g u t p t r p r u a u f l o t i S t r s n o n u f o n n i w t w p o o o d d s r s r u o o b c b s a a D i L L

  7. Delayed Pushing – “Laboring Down” Delayed Pushing - PEOPLE Largest RCT was the PEOPLE  Brought to us by the epidural study (Pushing Early or Pushing  Late with Epidural) Facilitated by the loosening of the  “3 hour” rule for second stage Multi-site trial from Canada, et al.  with a total of 1862 nulliparous Attempts to address the women randomized into two  association between epidural and groups operative vaginal deliveries “Delay” = ~2 hrs  Fraser et al. Multicentered, RTC of delayed pushing for nulliparas in the second stage with continuous epidural analgesia. Am J Obstet Gynecol 2000 Delayed Pushing - PEOPLE Delayed Pushing - PEOPLE  PEOPLE : 1,862 with epidural;1994-1996  Maternal Outcomes Delayed Early Push RR 95% CI Delayed Push Early Push RR (95% CI) Push (n=926) (n=936) (n=926) (n=936) P value Duration 2 nd stage (min) 187min (86- 123min (49- ---- 3 rd /4 th degree lac 9.3 % 9.5 % NS 314) 248) Fever (38’ C) 8.5% 4.5% 1.88 (1.31-2.71) “Difficult” delivery 17.8 % 22.5 % 0.79 0.66-0.95 Midpelvic procedures EBL>500ml 17.6 % 16.8 % NS 9.3 % 13.0 % 0.72 0.55-0.93 Low-pelvic procedure 3.5 % 3.8 % 0.93 0.58-1.49 Cesarean delivery 5.0 % 5.7 % 0.88 0.60-1.29 Other OVD 24.5% 24.3% NS Fraser et al. Multicentered, RTC of delayed pushing for nulliparas in the second stage with Fraser et al. Multicentered, RTC of delayed pushing for nulliparas in the second stage with continuous epidural analgesia. Am J Obstet Gynecol 2000 continuous epidural analgesia. Am J Obstet Gynecol 2000

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