abnormal second – stage labor. multiple short term & long term maternal & neonatal...
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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)