152: Impact of recommended changes in management of prolonged second-stage for prevention of the primary cesarean-delivery

Abstract

In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) published an Obstetric Care Consensus for safe prevention of the primary cesarean delivery (CD). The objective of our study was to assess whether implementation of the new guidelines in our department,regarding second stage of labor, decreased our primary CD rate safely. A historical cohort study of all women, reaching the 2nd stage of labor, at term, in a single university-affiliated medical center (2010-2017). Following the new ACOG and SMFM guidelines, we changed our departmental definition of 2nd stage arrest of labor from 2 and 1 hour in nulliparous or multiparous women respectively, without epidural, to 3 and 2 hours in nulliparous or multiparous women respectively; with the addition of 1 hour to each group when using epidural analgesia. We compared maternal and neonatal outcomes over three year's periods: 1st period – pre-guidelines (2010-2013) vs. 2nd period – post-guidelines (2014-2017). The primary outcome was CD rate at 2nd stage of labor. 5931 women were included in the study. The CD rate of women in the 2nd stage of labor has increased significantly from 4% in the pre-guidelines period to 5.9% in the post-guidelines period (OR 1.48, 95%CI 1.16-1.89). After a sub-analysis of specific subgroups, the CD rate increase was solely observed in nulliparous women with epidural (6.1% vs. 10.2%, P <0.001). However, the CD rate for arrest of 2nd stage of labor was statistically reduced between the two periods (72.9% vs 59.8%, P <0.05). Maternal and neonatal outcomes did not differ between the 2 periods, apart for increased odds for vaginal operative delivery in the post-guidelines period (10.6% vs. 12.3%; P <0.05) (Table 1). After adjusting for confounders, including: age, parity, birthweight, labor induction, and epidural; we have found no association between the implementation of the new guidelines and a change in CD rate performed at the 2nd stage of labor (aOR 1.25, 95%CI 0.97-1.61). (Table 2) The implementation of the new ACOG and SMFM guidelines was not associated with a reduction in the CD rate performed at the 2nd stage of labor, or a difference in maternal or neonatal outcomes. However, it was associated with an increase in CD rate in nulliparous women with an epidural during the second stage.View Large Image Figure ViewerDownload Hi-res image Download (PPT)