Abnormal second – stage labor

Multiple short term & long term maternal &

neonatal outcomes should be considered

Based on maternal outcome:

Longer D ,increased adverse outcome:

Puerperal infection , chorioamnionitis

Postpartum hemorrhage

3rd & 4th degree perineal laceration

For each hour of 2nd stage , chance of spontaneous VD decrease progressively Duration > 2 h: spontaneous VD in: 1/4 nulliparous , 1/3 multiparous ≤ 30 -50 % operative vaginal delivery

By 5 hours , chance of spontaneous delivery in subsequent hour=10-15%(2009)

Based on neonatal outcome:

Nulliparous:5- min Apgar score˂ 4

Umbilical artery PH ˂ 7

Intubation in delivery room

NICU admission

Neonatal sepsis

No relation to duration of 2nd stage ≥ 5 h/duration of active

pushing ≥ 3 h (with appropriate monitoring)(2009)

Multiparous:

With D >2(3) h , increased risk of :

o 5-min Apgar score ˂ 7

o NICU admission

Duration unrelated to neonatal sepsis/major trauma(2007)

2nd stage increase concomitantly with increasing first stage

First stage >15.6 h(95th percentile),16% risk of 2nd stage=3h(95th percentile)

First stage ˂ (95th percentile),4% risk of 2nd stage=3h(95th percentile)

Specific absolute Max length of time in 2nd stage beyond

which all women should undergo operative delivery ?????

Multiple studies showed that contemporary norms

are different from those cited by Friedman.

Data from Consortium on Safe Labor used to

revise definition of contemporary normal labor

progress(zhang,2010)

19 U.S hospital;62,415 parturient

Contemporary estimates of median and 95th percentile(hours) by parity

Parity 0 Median hours(95th percentile)

Parity 1 Median hours(95th percentile)

Changes in cervix

4-5 cm 1.3(6.4) 1.4(7.3)

5-6 cm 0.8(3.2) 0.8(3.4)

6-7 cm 0.6(2.2) 0.5(1.9)

7-8 cm 0.5(1.6) 0.4(1.3)

8-9 cm 0.5(1.4) 0.3(1.0)

9-10cm 0.5(1.8) 0.3(0.9)

Duration of second stage

With epidural analgesia 1.1(3.6) 0.4(2.0)

Without ,,,,,,,,,,,,,,,,,, 0.6(2.8) 0.2(1.3)

Arrest:

Nulliparous women :no progress( descent, rotation) ≥ 3 h

(≥ 4h with epidural anesthesia)

Multiparous women :no progress( descent, rotation) ≥ 2 h

(≥ 3h with epidural anesthesia)

Etiology & risk factors of abnormal second stage

o Parity

o Birth weight

o Delayed pushing

o Epidural analgesia

o Occiput posterior

o Station at complete dilation

Management

NO INTERVENTION FOR DELIVERY AS LONG AS FHR IS N + SOME PROGRESS

Before Dx arrest of labor , pushing at least:

2h in multiparous / 3h in nulliparous

Should be allowed

Longer(may be appropriate) with:

o epidural analgesia (one additional hour)

o Fetal malposition

As long as labor progress & good maternal & fetal condition

Indication of operative intervention:

Category III FHR tracing

Suspected CPD:• Lack of progress + clinical suspicious of:• Macrosomia• Malposition• Small maternal pelvis

• Radiographic pelvimetry, not recommended

Ineffective interventions in arrest disorders

Epidural discontinuation late in labor compare to continuation

until labor

Changing maternal position(upright ; lateral; hands/knee

instead of supine)(no strong evidence,4 min shorter)

Other Management To Reduce C/S In Second Stage

Operative vaginal delivery

Manual rotation of fetal occiput

Operative vaginal delivery

with increase in C/S and decrease in vacuum/forceps during past 15 years,

serious neonatal morbidity with operative vaginal delivery=unplanned C/S

(Intracerebral hemorrhage , death)(2010)

Incidence of Intracranial hemorrhage with vacuum =forceps=C/S

Forceps assisted vaginal delivery associate with decrease risk of seizure , IVH,

subdural hemorrhage v.s vacuum or C/S ,risk with vacuum= C/S (2011)

≤ 3% operative vaginal delivery change to C/S

Failure in mid-pelvic station( 0 and +1) &OT/OP > low(≥ +2) / outlet operative delivery

Low/outlet procedure by experienced & well trained physician

(in non macrosomic fetus); should be considered safe& acceptable

alternative to C/S

Number of adequately trained provider for forceps and vacuum delivery is decreasing

Training residents in operative vaginal delivery can lower C/S Safely & should be encouraged

Manual rotation of fetal occiput

Fetal malposition(OP,OT),increase C/S& neonatal complication Forceps rotation of occiput ,still reasonable, rarely in USA

Manual rotation of occiput , alternative , safe reduction of C/S

(9% v.s 41%)(without cord prolapse , birth trauma , neonatal acidemia)

( society of Obstetricians and Gynecologists of Canada)

Proper assessment of fetal position(especially with abnormal descent) Digital exam , Intrapartum US

Manual rotation of occiput in fetal malposition in 2nd stage

reasonable before operative delivery or C/S

Prevention:

Volume replacement(250cc/h instead of 125 cc/h),decrease 2nd stage duration

Pelvic floor muscle training program from 20-36w

(8-12 intensive muscle contraction twice/day, relative to control decrease 2nd stage duration ,but overall duration , similar)

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