Second-stage labor: How long is too long?

Research output: Contribution to journalArticle

26 Citations (Scopus)

Abstract

The management of labor has come under increased scrutiny due to the rapid escalation of cesarean delivery in the United States. A workshop of the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the American Congress of Obstetricians and Gynecologists was convened to address the rising cesarean delivery rates and one of their recommendations was that the accepted upper limit of the second stage of labor should be increased to ≥4 hours in nulliparous women with epidural analgesia and to ≥3 hours in parous women with epidural. This led to the inaugural Obstetric Care Consensus series document, "Safe Prevention of the Primary Cesarean Delivery," wherein the workshop recommendations on second-stage labor were promulgated nationally. The result is that the now acceptable maximum length of the second stage of labor exceeds the obstetric precepts that have been in use for >50 years. In this Clinical Opinion, we review the evidence on infant safety, vis-à-vis length of the second stage of labor. Our examination of the evidence begins at the outset of the 20th century and culminates in the very recent (2014) recommendation to abandon the long accepted obstetric paradigm that second-stage labor >3 hours in nulliparous women with labor epidural is unsafe for the unborn infant. We conclude that the currently available evidence fails to support the Obstetric Care Consensus position that longer second-stage labor is safe for the unborn infant. Indeed, the evidence suggests quite the opposite. We suggest that when infant safety is at stake the evidence should be robust before a new clinical road is taken. The evidence is not robust.

Original languageEnglish (US)
Pages (from-to)484-489
Number of pages6
JournalAmerican Journal of Obstetrics and Gynecology
Volume214
Issue number4
DOIs
StatePublished - Apr 1 2016

Fingerprint

Second Labor Stage
Obstetrics
National Institute of Child Health and Human Development (U.S.)
Safety
Education
Epidural Analgesia
Primary Prevention

Keywords

  • cesarean delivery
  • epidural analgesia
  • infant outcome
  • prolonged
  • second stage of labor
  • second-stage labor

ASJC Scopus subject areas

  • Obstetrics and Gynecology

Cite this

Second-stage labor : How long is too long? / Leveno, Kenneth J.; Nelson, David B.; McIntire, Donald D.

In: American Journal of Obstetrics and Gynecology, Vol. 214, No. 4, 01.04.2016, p. 484-489.

Research output: Contribution to journalArticle

@article{7cf23045b4524a23ba0af93d410be6d0,
title = "Second-stage labor: How long is too long?",
abstract = "The management of labor has come under increased scrutiny due to the rapid escalation of cesarean delivery in the United States. A workshop of the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the American Congress of Obstetricians and Gynecologists was convened to address the rising cesarean delivery rates and one of their recommendations was that the accepted upper limit of the second stage of labor should be increased to ≥4 hours in nulliparous women with epidural analgesia and to ≥3 hours in parous women with epidural. This led to the inaugural Obstetric Care Consensus series document, {"}Safe Prevention of the Primary Cesarean Delivery,{"} wherein the workshop recommendations on second-stage labor were promulgated nationally. The result is that the now acceptable maximum length of the second stage of labor exceeds the obstetric precepts that have been in use for >50 years. In this Clinical Opinion, we review the evidence on infant safety, vis-{\`a}-vis length of the second stage of labor. Our examination of the evidence begins at the outset of the 20th century and culminates in the very recent (2014) recommendation to abandon the long accepted obstetric paradigm that second-stage labor >3 hours in nulliparous women with labor epidural is unsafe for the unborn infant. We conclude that the currently available evidence fails to support the Obstetric Care Consensus position that longer second-stage labor is safe for the unborn infant. Indeed, the evidence suggests quite the opposite. We suggest that when infant safety is at stake the evidence should be robust before a new clinical road is taken. The evidence is not robust.",
keywords = "cesarean delivery, epidural analgesia, infant outcome, prolonged, second stage of labor, second-stage labor",
author = "Leveno, {Kenneth J.} and Nelson, {David B.} and McIntire, {Donald D.}",
year = "2016",
month = "4",
day = "1",
doi = "10.1016/j.ajog.2015.10.926",
language = "English (US)",
volume = "214",
pages = "484--489",
journal = "American Journal of Obstetrics and Gynecology",
issn = "0002-9378",
publisher = "Mosby Inc.",
number = "4",

}

TY - JOUR

T1 - Second-stage labor

T2 - How long is too long?

AU - Leveno, Kenneth J.

AU - Nelson, David B.

AU - McIntire, Donald D.

PY - 2016/4/1

Y1 - 2016/4/1

N2 - The management of labor has come under increased scrutiny due to the rapid escalation of cesarean delivery in the United States. A workshop of the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the American Congress of Obstetricians and Gynecologists was convened to address the rising cesarean delivery rates and one of their recommendations was that the accepted upper limit of the second stage of labor should be increased to ≥4 hours in nulliparous women with epidural analgesia and to ≥3 hours in parous women with epidural. This led to the inaugural Obstetric Care Consensus series document, "Safe Prevention of the Primary Cesarean Delivery," wherein the workshop recommendations on second-stage labor were promulgated nationally. The result is that the now acceptable maximum length of the second stage of labor exceeds the obstetric precepts that have been in use for >50 years. In this Clinical Opinion, we review the evidence on infant safety, vis-à-vis length of the second stage of labor. Our examination of the evidence begins at the outset of the 20th century and culminates in the very recent (2014) recommendation to abandon the long accepted obstetric paradigm that second-stage labor >3 hours in nulliparous women with labor epidural is unsafe for the unborn infant. We conclude that the currently available evidence fails to support the Obstetric Care Consensus position that longer second-stage labor is safe for the unborn infant. Indeed, the evidence suggests quite the opposite. We suggest that when infant safety is at stake the evidence should be robust before a new clinical road is taken. The evidence is not robust.

AB - The management of labor has come under increased scrutiny due to the rapid escalation of cesarean delivery in the United States. A workshop of the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the American Congress of Obstetricians and Gynecologists was convened to address the rising cesarean delivery rates and one of their recommendations was that the accepted upper limit of the second stage of labor should be increased to ≥4 hours in nulliparous women with epidural analgesia and to ≥3 hours in parous women with epidural. This led to the inaugural Obstetric Care Consensus series document, "Safe Prevention of the Primary Cesarean Delivery," wherein the workshop recommendations on second-stage labor were promulgated nationally. The result is that the now acceptable maximum length of the second stage of labor exceeds the obstetric precepts that have been in use for >50 years. In this Clinical Opinion, we review the evidence on infant safety, vis-à-vis length of the second stage of labor. Our examination of the evidence begins at the outset of the 20th century and culminates in the very recent (2014) recommendation to abandon the long accepted obstetric paradigm that second-stage labor >3 hours in nulliparous women with labor epidural is unsafe for the unborn infant. We conclude that the currently available evidence fails to support the Obstetric Care Consensus position that longer second-stage labor is safe for the unborn infant. Indeed, the evidence suggests quite the opposite. We suggest that when infant safety is at stake the evidence should be robust before a new clinical road is taken. The evidence is not robust.

KW - cesarean delivery

KW - epidural analgesia

KW - infant outcome

KW - prolonged

KW - second stage of labor

KW - second-stage labor

UR - http://www.scopus.com/inward/record.url?scp=84962082218&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84962082218&partnerID=8YFLogxK

U2 - 10.1016/j.ajog.2015.10.926

DO - 10.1016/j.ajog.2015.10.926

M3 - Article

C2 - 26546847

AN - SCOPUS:84962082218

VL - 214

SP - 484

EP - 489

JO - American Journal of Obstetrics and Gynecology

JF - American Journal of Obstetrics and Gynecology

SN - 0002-9378

IS - 4

ER -