Whats New with the No financial disclosures related to this talk - - PowerPoint PPT Presentation

What’s New with the Second Stage of Labor: When to Start and Stop

Aaron B Caughey, MD, PhD Professor and Chair Department of Obstetrics and Gynecology Oregon Health & Science University caughey@ohsu.edu

Financial Relationships

• No financial disclosures related to this talk
• Medical Advisor to:
• Celmatix, Mindchild
• Bob’s Red Mill

Objectives

 Second stage of labor

 Epidemiology of second stage

 Methodologic Challenges

 When to stop - how long is too long?  When to start

 Delayed vs. Immediate Pushing

Question

36 y.o. G1P0 at 40 wks GA with an epidural has now pushed for 2 hours (from +1 to +2). What is the plan?

A.

continue to push for up to 1 more hour

B.

continue to push for up to 2 more hours

C.

continue to push for up to 3 more hours

D.

Begin conversation about OVD

E.

Begin conversation about cesarean

c

• n

t i n u e t

• p

u s h f

• r

u p . . c

• n

t i n u e t

• p

u s h f

• r

u p . . c

• n

t i n u e t

• p

u s h f

• r

u p . . B e g i n c

• n

v e r s a t i

• n

a b

• .

. B e g i n c

• n

v e r s a t i

• n

a b

• u

. . .

42% 42% 1% 9% 7%

Labor: Friedman Curve

First stage Second stage

Friedman EA. Primigravid labor. Obstet Gynecol 1955 ACOG Practice bulletin. Dystocia and augmentation of labor. No 49; Obstet Gynecol 2003

 Second stage of labor



Nulliparas: 2 hours



Multiparas: 1 hour

Second Stage of Labor

 Hamilton – 1861 – suggested 2 hours as

prolonged second stage

 Duration of the second stage of labor

 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

Second Stage of Labor

 ACOG: Prolonged second stage of labor

 Nulliparas: 2 hours without regional anesthesia

3 hours with regional anesthesia

 Multiparas: 1 hour without regional anesthesia

2 hours with regional anesthesia

ACOG Practice bulletin. Dystocia and augmentation of labor. No 49; Obstet Gynecol 2003

Zhang: Labor Curve

 Second stage of labor in nulliparous women

Zhang J et al. Reassessing labor curve in nulliparous women. Am J Obstet Gynecol 2002

Station Time (minutes) 1%ile Median 95%ile +1 to +2 1 16 176 +2 to +3 1 7 38

Second Stage of Labor

Friedman Study (n=500) Zhang Study (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 Studying the Second Stage

Second Stage of Labor: 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

• utcomes?

Second Stage of Labor: How long is too long?

 6791 nulliparas reached second stage (1996-99)

 Increased maternal morbidity with prolonged 2nd stage  No differences neonatal outcomes

5 10 15 20 25 30 35 40

CD OpVD PeriLac Chorio PPH

2nd Stage 0-2hrs (n=6259) 2nd Stage 2-4 hrs (n=384) 2nd Stage >=4hrs (n=148)

% p<0.001 for all

Myles et al. Maternal & neonatal outcomes in patient with a prolonged 2nd stage. Obstet Gynecol 2003

Cheng YW, Hopkins LM, Caughey AB. How long is too long: Is a prolonged second stage of labor associated with worse maternal and neonatal outcomes? Am J Obstet Gynecol, 2004;191:933-8

Second Stage of Labor: How long is too long?

Cheng YW, Hopkins LM, Caughey AB. How long is too long: Is a prolonged second stage of labor associated with worse maternal and neonatal outcomes? Am J Obstet Gynecol, 2004;191:933-8

Second Stage of Labor: How long is too long?

Second Stage - How long is too long?

 Nova Scotia Atlee Perinatal Database (1988-2006)

 Term, singleton pregnancies delivered in 2nd stage  11,470 (9%) prolonged; 110,206 no prolonged 2nd stage

Allen et al. Maternal and Perinatal outcomes with increasing duration of 2nd stage. Obstet Gynecol 2009

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: 2nd stage <2 hrs (baseline rate); aOR by 2nd stage duration compared to referent

Summary - How long is too long?



Varied evidence



Maternal outcomes worse



Unclear impact on neonatal outcomes



Consider causal models for maternal outcomes

Summary - How long is too long?



Chorioamnionitis



Is it that simply longer labor leads to more infections?

OR



Women with pre-chorio / chorio have longer labors?

Summary - How long is too long?



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?

OVD vs. Expectant Management

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

OVD vs. Expectant Management

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

How long is too long? - Summary

 If progress is being made, duration of the 2nd 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).

ACOG / SMFM, Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Obstetric Care Consensus Document

• 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?

A.

Labor down until urge to push

B.

Labor down for up to 2 hours

C.

Discuss options of pushing and laboring down with patient

D.

Start pushing

L a b

• r

d

• w

n u n t i l u r g e t

• .

. . L a b

• r

d

• w

n f

• r

u p t

• 2

. . . D i s c u s s

• p

t i

• n

s

• f

p u s h i n . . . S t a r t p u s h i n g

12% 22% 58% 8%

Delayed Pushing – “Laboring Down”



Brought to us by the epidural



Facilitated by the loosening of the “3 hour” rule for second stage



Attempts to address the association between epidural and

• perative vaginal deliveries

Delayed Pushing - PEOPLE



Largest RCT was the PEOPLE study (Pushing Early or Pushing Late with Epidural)



Multi-site trial from Canada, et al. with a total of 1862 nulliparous women randomized into two groups



“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

 PEOPLE: 1,862 with epidural;1994-1996

Fraser et al. Multicentered, RTC of delayed pushing for nulliparas in the second stage with continuous epidural analgesia. Am J Obstet Gynecol 2000

Delayed Push (n=926) Early Push (n=936) RR 95% CI

Duration 2nd stage (min)

187min (86- 314) 123min (49- 248)

• “Difficult” delivery

Midpelvic procedures Low-pelvic procedure Cesarean delivery

17.8 % 9.3 % 3.5 % 5.0 % 22.5 % 13.0 % 3.8 % 5.7 % 0.79 0.66-0.95 0.72 0.55-0.93 0.93 0.58-1.49 0.88 0.60-1.29

Other OVD

24.5% 24.3% NS

Delayed Pushing - PEOPLE

 Maternal Outcomes

Fraser et al. Multicentered, RTC of delayed pushing for nulliparas in the second stage with continuous epidural analgesia. Am J Obstet Gynecol 2000

Delayed Push (n=926) Early Push (n=936) RR (95% CI) P value 3rd/4th degree lac 9.3 % 9.5 % NS Fever (38’ C) 8.5% 4.5% 1.88 (1.31-2.71) EBL>500ml 17.6 % 16.8 % NS

Delayed Pushing - PEOPLE

 Neonatal Outcomes  No difference – Respiratory, blood cultures,

fractures, Apgars

Fraser et al. Multicentered, RTC of delayed pushing for nulliparas in the second stage with continuous epidural analgesia. Am J Obstet Gynecol 2000

Delayed Push (n=926) Early Push (n=936) RR (95% CI) P value Abnormal uapH (<7.10) 4.5% 1.8% 2.45 (1.35-4.43) Ventilation 6.9% 6.3% NS

Optimizing Management of the Second Stage of Labor To assess the effectiveness of immediate vs. delayed pushing at complete cervical dilation in nulliparous women on:

1)

Rate of spontaneous vaginal delivery

2)

Composite neonatal morbidity, and

3)

Maternal pelvic floor dysfunction

Optimizing Management of the Second Stage of Labor Study Sites:

1)

Washington University (Cahill, Tuuli)

2)

UAB (Tita)

3)

U Penn (Srinivas)

4)

OHSU (Caughey) Enrolling 3200 women - 2014-2018

Optimizing Management of the Second Stage of Labor

Optimizing Management of the Second Stage of Labor Optimizing Management of the Second Stage of Labor

Future Research Directions

 Large, prospective, observational, multicenter

study of second stage

 Prospective, interventional trials:

 Prolonged second stage definitions  3 hours vs. 4/5/6 hours  Epidural use / regimens  Manual rotation / Operative vaginal delivery  Etc.

Question

36 y.o. G1P0 at 40 wks GA with an epidural is at 0 station. What is the plan?

A.

Labor down until urge to push

B.

Labor down for up to 2 hours

C.

Discuss options of pushing and laboring down with patient

D.

Start pushing

L a b

• r

d

• w

n u n t i l u r g e t

• .

. . L a b

• r

d

• w

n f

• r

u p t

• 2

. . . D i s c u s s

• p

t i

• n

s

• f

p u s h i n . . . S t a r t p u s h i n g

4% 71% 18% 7%

How long is too long?

Friedman E, Sachtleben M. Dysfunctional Labor II. Obstet Gynecol . 1961;17:566-78

How long is too long?

Friedman E, Sachtleben M. Dysfunctional Labor II. Obstet Gynecol . 1961;17:566-78

Thank You

No negative neonatal effects with inc duration AFTER controlling for confounding factors Maternal Morbidity inc sig after 2 hours for IP fever, and PPH

 Secondary Analysis of Fetal Pulse OxTrial  Nulliparous women N=5341  96% epidural use, 87% oxytocin use, 38.6% IOL  75% NSVD, 18.5% OVD, 7.4% CD  In >3 hours of 2nd Stage labor, increased risk for:  Chorioamnionitis  3rd & 4th deg lacerations  PPH (atony)  No negative neonatal outcomes

2 4 6 8 10 12 14

0-2 Hours (n=4662) 2-3 Hours (n=550) >=3 Hours (n=257)

Second Stage of Labor

 5158 multiparas reached second stage (1991-2001)

 Increased maternal complications  Increased neonatal morbidity % 5minApgar<7 UA pH<7.0 NICU Neo Morbidity Prolong Hosp

Cheng et al. Duration of 2nd stage of labor in multiparous women. Am J Obstet Gynecol 2007 p<0.001 p<0.001 p=0.002 p=0.006 p=0.015

Epidural and Second Stage

 Cochrane Systematic Review

 5 RCTs (462 participants)  Assess impact of discontinuing epidural on:

 Rates of instrumental delivery and outcomes  Analgesia and satisfaction with labor care

Torvaldsen S et al. Cochrane Database of Systematic Reviews 2009.

Epidural and Second Stage

 Discontinuing vs continuing epidural:

 Instrument delivery : RR=0.84 [0.61-1.15]  Cesarean delivery: RR=0.98 [0.34-2.25]  Spontaneous VD: RR=1.11 [0.95-1.30]  Malposition: RR=1.36 [0.73-2.56]  Inadequate pain relief: RR=3.68 [1.99-6.80]  5-min Apgar<7: RR=3.92 [0.45-34.2]  Duration of 2nd stage: -5.8min [-12.9-1.30]

Torvaldsen S et al. Cochrane Database of Systematic Reviews 2009.

Positioning in Second Stage

 Positioning in women with epidural:

Upright vs. Neutral

 2 trials (281 participants)

RR 95% CI Instrumental delivery 0.77 0.46-1.28 Cesarean delivery 0.57 0.28-1.16

Roberts et al. Meta-analysis of upright position in 2nd stage. Acta Obstet Gynecol Scand 2005

Second Stage of Labor

 Challenges of studying labor duration

 Non-normal distribution

 Median, 95th centile

2nd Stage of Labor: Nulliparas

25 50 100 2 4 6 8 10

Second Stage of Labor (hour)

Percent Pregnant Epidural No Epidural

p<0.001 by Log-rank

Cheng YW, et al. The second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014

Median 95%ile Nulliparas No Epidural 50 min 201 min Nulliparas Epidural 126 min 339 min Multiparas No Epidural 14 min 84 min Multiparas Epidural 40 min 262 min

Results: Second stage of labor

p<0.001

138 min

Cheng YW, et al. The second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014

Delayed Pushing - Meta

 Delayed pushing vs. Active pushing

 Meta-analysis of 7 RCTs (n=2,827)

Relative Risk 95% CI Spontaneous VD 1.08 1.01 – 1.15 Operative VD 0.77 0.77 – 0.85 Cesarean delivery 0.80 0.57 – 1.12 Duration of pushing (hrs)

• 0.19
• 0.27 – -0.12

Perineal lacerations 0.88 0.72 – 1.07 Episiotomies 0.97 0.88 – 1.06

Broncato et al. A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the 2nd stage of labor. J Obstet Gynecol Neonatal Nurs 2008

Summary: Second Stage of Labor

 Delayed vs. Active

 Sounds good  Data are mixed  Is benefit only achieved in settings of poor patience?  Potential tradeoffs between:  Mode of delivery  Fever / pH  ? Pelvic floor