Abstract
BackgroundCurrent guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. Our goal was to increase the evidence base for these providers by: 1) describing the lengths of second stage labor in freestanding birth centers, and 2) determining whether proportions of postpartum women and newborns experiencing complications change as length of second stage labor increases.MethodsThis study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers Perinatal Data Registry, including women giving birth in freestanding birth centers January 1, 2007 to December 31, 2016. We plotted proportions of postpartum women and newborns transferred to hospital care against length of the second stage of labor, and assessed significance of these with the Cochran-Armitage test for trend or chi-square test. Secondary maternal and newborn outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher’s exact test.ResultsSecond stage labor exceeded 3 hours for 2.3% of primiparous women and 2 hours for 6.6% of multiparous women.Newborn transfers increased as second stage increased from < 15 minutes to > 2 hours (0.6% to 6.33%, p for trend = 0.0008, for primiparous women, and 1.4% to 10.6%, p for trend < 0.0001, for multiparous women.) Postpartum transfers for multiparous women increased from 1.4% after second stage < 15 minutes to greater than 4% for women after second stage exceeding 2 hours (p for trend < 0.0001.)ConclusionsComplications requiring hospitalization of postpartum women and newborns become more common as the length of the second stage increases. Birth center guidelines should consider not just presence of progress but also absolute length of time as indications for transfer.
Highlights
Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage
Study Design & Population This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers (AABC) Perinatal Data Registry v.2.0 and 3.0 TM (PDR)
We found that 2.3% of healthy nulliparous women giving birth in freestanding birth centers, and 6.6% of parous women, had prolonged second stages of labor
Summary
Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. In 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a consensus statement on safe prevention of the primary cesarean delivery [9] This statement recommends that absent maternal or fetal indications for cesarean, women may push for at least 3 hours for a first birth and 2 hours for a subsequent birth before providers perform an operative delivery for arrest of descent. Longer second stages might be appropriate based on individual circumstances, including the use of neuraxial analgesia. This new guideline increased by an hour the time many women were given for the second stage of labor, and widely affected clinical practice [10]
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