Reconsidering second stage labor guidelines

New data may result in fewer instrumented deliveries and cesarean sections for second stage arrest.

Reconsidering second stage labor guidelines
Reconsidering second stage labor guidelines

About a year ago, I was called to the hospital in the middle of the night. A patient of mine had arrived in labor, with her cervix almost fully dilated, so I broke the speed limit and got there as quickly as I could.

By the time I arrived, she was completely dilated and ready to push. We pushed together for about an hour with little progress. Frustrated and uncomfortable, the patient asked if it was too late to get her epidural. At first I laughed and said yes, but then I reconsidered. I decided that an epidural and some rest might be exactly what she needed.

The fetal heart rate was reassuring and the patient was in no distress, so she had her epidural placed and went to sleep for about three hours. When she awoke, the baby had made good descent in her pelvis. She pushed actively and effectively for about 30 minutes and had an easy spontaneous vaginal birth.

I have long believed in the benefits of a practice called “laboring down.” This term basically means we let the uterine contractions and gravity work on their own, without maternal pushing efforts, until the baby is closer to crowning.

This often saves the mother an hour or more of active pushing, which can be exhausting and draining. It also helps avoid forceps or vacuum assisted birth secondary to maternal exhaustion.

But the practice of laboring down has drawn some criticism in that it prolongs the second stage of labor. The second stage of labor is defined as the time from when the mother's cervix is completely dilated until the birth of the baby.

Thankfully, we have progressed beyond the confines of the antiquated Freidman's curve, which stated that the second stage of labor should last between one and two hours, depending on whether the mother was nulliparous or multiparous.

It is my opinion that the use of Friedman's curve to dictate appropriate length of labor has resulted in too many unnecessary cesarean sections for second stage arrest. Times have changed since Freidman published his curve in 1955, making his data all but obsolete. Today maternal obesity rates and average birth weight are increased. The use of forceps is much less common and epidural anesthesia is very common.

The American College of Obstetricians and Gynecologists' (ACOG) most recent guidelines from 2003 state that normal second stage labor is between one and three hours, depending on parity and whether the mother has epidural anesthesia.

However, in a recent study published in Obstetrics and Gynecology, it is suggested that normal second stage labor can last as long as 5.6 hours for women with epidurals having their first birth. For first time moms without epidurals, more than 3.3 hours of second stage was considered abnormally long. The new study found than in multiparous women, second stage labor can last as long as 4.25 hours with an epidural and 1.35 with no epidural.

Midwives have long been proponents of patience and watchful waiting. This new study supports those practices, and could conceivably lead to a change in ACOG guidelines. Eventually, my hope is that this data leads to a decrease in unnecessary interventions like instrumented deliveries and cesarean sections for so-called second stage arrest.

Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.


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