968: Extending the second stage of labor in nulliparous women with epidural analgesia: a cost-effectiveness analysis

Abstract

In an effort to prevent primary cesarean deliveries, ACOG has recommended an increase of one hour in the time spent in the second stage before diagnosing a prolonged second stage of labor. In nulliparous women with epidural analgesia, this translates to an increase from 3 to 4 hours. A subsequent small randomized trial of nulliparous and multiparous women showed an increased rate of spontaneous vaginal delivery by extending the second stage by one hour. The purpose of this study is to examine the differences in outcomes with an extended second stage and determine if this new recommendation is cost effective. A cost-effectiveness analysis model was built using TreeAge Pro 2019 software with model inputs derived from the literature. We used a theoretical cohort of 152,000 women, approximately the number of nulliparous U.S. women reaching 3 hours of second stage with an epidural. We compared maternal outcomes and costs associated with expectant management of the second stage until 4 hours versus delivery at 3 hours. Perinatal outcomes included mode of delivery, chorioamnionitis, postpartum hemorrhage, third- and fourth-degree perineal lacerations and maternal deaths. Secondary outcomes included cost per quality-adjusted life years (QALY; willingness-to-pay threshold set to $100,000/QALY). Sensitivity analyses were performed to determine the robustness of baseline assumptions. In a cohort of 152,000 women, expectant management to 4 hours was the dominant strategy as it was cost saving and resulted in more overall QALYs (Table 1). Sensitivity analysis indicated that expectant management until 4 hours was cost-effective as long as the probability of cesarean delivery at 4 hours was below 41.8%, and was the dominant strategy below 38.2% (baseline input: 19.5%). Expectant management of the second stage of labor until 4 hours is a cost-effective strategy to prevent primary cesarean deliveries, decrease costs, and improve maternal outcomes.