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  3 rd & 4 th degree perineal laceration  For each hour of 2 nd stage, chance of spontaneous VD decrease progressively  Duration > 2 h:  spontaneous VD in: 1/4 nulliparous, 1/3 multiparous  ≤ % 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 2 nd 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)

 2 nd stage increase concomitantly with increasing first stage  First stage >15.6 h(95 th percentile),16% risk of 2 nd stage=3h(95th percentile)  First stage ˂ (95 th percentile),4% risk of 2 nd stage=3h(95 th percentile)

 Specific absolute Max length of time in 2 nd 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 95 th percentile(hours) by parity Parity 0 Median hours (95 th percentile) Parity 1 Median hours (95 th 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 2 nd stage reasonable before operative delivery or C/S

 Prevention:  Volume replacement(250cc/h instead of 125 cc/h),decrease 2 nd stage duration  Pelvic floor muscle training program from 20-36w (8-12 intensive muscle contraction twice/day, relative to control decrease 2 nd stage duration,but overall duration, similar)

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