Complete Dilatation Research Articles

Use of covered Cheatham-Platinum stents in congenital heart disease

BackgroundControversy remains regarding the use of covered stents in congenital heart disease (CHD). We evaluate the possibilities and safety of covered Cheatham-Platinum (CCP) stents in CHD. MethodsSingle-center retrospective CHD-database study of all CCP stents, 2003–2012. Three study groups: aortic coarctation (CoA), right ventricular outflow tract pre-stenting for percutaneous revalvulation (RVOT), and miscellaneous. Continuous data expressed as median (range). Results114 CCP stents in 105 patients, age 16.8years (4.2–71.2).CoA group: 54 CCP stents in 51 patients: 3/54 for aneurysm exclusion, in 51/54 covering used “prophylactically” because of increased risk for vessel tear. Overall, CCP stenting increased the coarctation diameter from 6mm (0–15) to 15mm (10–20) (p<0.001).RVOT group: 39 CCP stents in 37 patients (34 with RVOT graft, 3 with transannular patch): the graft lumen had shrunken from nominal 21mm (10–26) to 13mm (5–22); with the CCP stent the RVOT was redilated to 22mm (16–26, p<0.001 vs stenosis).Miscellaneous group: 21 CCP stents in 17 patients: closure of Fontan-circuit fenestration (n=5), restoration of superior caval vein (n=2) or pulmonary artery (n=3) patency, relief of supra-pulmonary stenosis (n=2), exclusion of aberrant pulmonary arteries (n=1), cavopulmonary conduit expansion (n=2), Blalock–Taussig shunt flow reduction (n=1), and defibrillator lead protection from sharp stents (n=1). Hybrid procedures performed in 3/17 patients. CCP stent was used as rescue treatment in 2/patients to seal iatrogenic bleeding. ConclusionCCP stents can safely be applied in CHD patients. The covering allows adequate sealing of existing or expected tears, thereby increasing the safety margin with more complete dilation.

A review of evidence-based practices for management of the second stage of labor.

Management of the second stage of labor often follows tradition-based routines rather than evidence-based practices. This review of second-stage labor care practices discusses risk factors for perineal trauma and prolonged second stage and scrutinizes a variety of care practices including positions, styles of pushing, use of epidural analgesia, and perineal support techniques. Current evidence for management of the second stage of labor supports the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice of positions. Perineal compresses, perineal massage with a lubricant, and controlling the rate of fetal extension during crowning may prevent severe perineal trauma at birth. Supine positioning is not recommended. Upright positions and directed pushing can shorten the time from onset of second stage to birth and may be indicated in certain situations, although directed pushing has some associated risks. If the fetus is in the occiput posterior position, immediate pushing is not recommended, and manual rotation can be effective in correcting the malposition. Women should be informed of the potential effects of epidural analgesia on labor progress. Consultation and intervention to expedite birth may be indicated when birth is not imminent after 2 hours of active pushing, or 4 hours complete dilatation, for nulliparous women; or one hour of pushing, or 2 hours complete dilatation, for multiparous women. Each woman should be individually assessed and apprised of the potential risks to her and her fetus of a prolonged second stage of labor, and some women may choose to continue pushing beyond these time limits.

Infectious morbidity is higher after second-stage compared with first-stage cesareans

The objective of the study was to compare maternal and neonatal infectious morbidity following cesareans performed in the second and first stages of labor. We conducted a retropective cohort study of all consecutive, singleton, term, cesarean deliveries in laboring women in a single institution from 2005 to 2012. Second-stage cesareans were defined as those performed at complete cervical dilation (10 cm), and first-stage cesareans were those performed before 10 cm cervical dilation. The primary outcome was endometritis. Rates of infectious morbidity were compared in the 2 groups. Multivariable logistic regression was used to calculate adjusted risk estimates. Of 2505 cesareans meeting inclusion criteria, 400 (16.0%) were performed in the second stage, whereas 2105 (84.0%) were performed in the first stage of labor. The risk of endometritis was nearly 3-fold higher in second- compared with first-stage cesareans (4.25% vs 1.52%; crude odds ratio, 2.88; 95% confidence interval, 1.58-5.23). The risk remained significantly higher after controlling for confounders (adjusted odds ratio, 2.78; 95% confidence interval, 1.51-5.09). Second-stage cesarean is associated with an increased risk of endometritis compared with first-stage cesarean. Further studies will determine whether different infection preventive strategies are needed at second-stage cesareans to reduce endometritis.

Fetal Descent in Labor

Studies using contemporary populations and modern statistical methods have redefined our understanding of cervical dilation in labor. However, modern norms for fetal descent in labor have not been developed. We sought to estimate norms for fetal descent and estimate the expected fetal station for given cervical dilations. A retrospective cohort study of consecutive-term, vertex singletons who delivered vaginally. Detailed history, labor, and delivery information, including cervical examinations, were collected. A repeated-measures analysis was used to construct average descent curves. Interval-censored regression was used to estimate duration of labor between levels of station and to estimate the median station at a given dilation. Each analysis was stratified by parity and labor type (spontaneous compared with induced or augmented). Of 4,618 consecutive-term spontaneous vaginal deliveries, 1,526 (33%) were nulliparous. Sixty-one percent were augmented or induced. Multiparous women had faster fetal descent at all stations except from +2 to +3 station. The median time to descend from one station point to another ranged from 0.1 to 1.6 hours, but the 95th percentiles encompassed over 12 hours at the same high-station among nulliparous women who achieved vaginal delivery. Fetal descent was more rapid in women who labored spontaneously without augmentation. Multiparous women tended to have a higher station than nulliparous women until late in the first stage. Multiparous women and women who are not augmented or induced have faster fetal descent. There is wide variation in the expected station by increments of dilation. However, 95% of women have a fetal station of 0 or lower at complete cervical dilation.

644: Custom labor curves: predicting labor progress with individual patient characteristics

Recent studies have changed our understanding of the labor curve, and identified maternal and fetal factors which influence normal progress. Because any individual patient possesses a combination of these factors, it is imperative to develop custom labor curves incorporating an individual’s characteristics. The aim of this study was to develop a first stage predictive model for individual women admitted for delivery. A retrospective cohort study of consecutive non-anomalous term births who reached complete dilation. Women missing time or covariate values or those who presented at 10cm dilation were excluded. Interval censoring was used to account for the fact that the exact time a woman progresses from one centimeter to the next is unknown. Previously described maternal and fetal factors which influence first stage labor duration including obesity (BMI ≥ 30kg/m2), prior vaginal delivery, regional anesthesia, induced or augmented labor (vs. spontaneous), and fetal gender were used in the model to predict labor progress. Each increment of 1cm change was modeled. An exponential function and interval-censored time-to-event analysis was used to estimate the median time elapsed in hours, adjusting for covariates. Of 5,388 patients, 5,027 met inclusion criteria. We developed custom labor curves which show that a combination of an individual’s characteristics produce a specific expectation of normal progress through the first stage. The change from the average population estimate (black curve) to when various combinations of patient characteristics are taken into account (colors) illustrates that the individual factors can change the expectation of first stage progress by hours (figure). Using novel analytic techniques, we have developed the first truly custom labor curves. After validation, we will be able to produce custom labor curves by inputting patient characteristics known at admission into the model. We anticipate this will refine the diagnosis of arrest and reduce iatrogenic cesareans.

Maternal inflammatory markers and term labor performance

We sought to examine the relationship between maternal markers of inflammation and labor performance. A nested cohort study was performed utilizing an established cohort of term nulliparous patients. Maternal blood was collected at the onset of regular, painful contractions in patients undergoing labor induction or at admission in patients with spontaneous labor. Levels of cytokines including interleukin (IL)-1, IL-6, and tumor necrosis factor-α were determined using standard multiplex methodology. Maternal demographic data were collected prospectively. Detailed retrospective chart review was performed to extract data on cervical dilation, effacement, and station during labor. Subjects were excluded if they failed to achieve complete dilation. Mixed effects modeling was used to examine the association between serum cytokine quartiles and labor progress in the latent and active phases. In all, 334 women were included in our analysis. The lowest quartile of IL-6 was associated with slower latent labor (P = .001). In contrast, the highest quartiles of IL-1 and tumor necrosis factor-α were associated with slower active labor (P = .03 and .0002, respectively). Proinflammatory activation is important in labor initiation. However, once active labor is established, excess inflammation can be detrimental to efficient labor progress. These data may explain, in part, the known associations among clinical chorioamnionitis, cesarean delivery, and postpartum hemorrhage.

Immediate stent recoil in an anastomotic vein graft lesion treated by cutting balloon angioplasty

Saphenous vein graft (SVG) anastomotic lesions can have significant fibromuscular hyperplasia and may be resistant to balloon angioplasty alone. Stents have been used successfully to treat these lesions. There are no reports of immediate stent recoil following such treatment in the literature. We describe immediate and persistent stent recoil in an anastomotic SVG lesion even after initial and post-deployment complete balloon dilatation of the stent and its successful treatment by cutting balloon angioplasty.

Immediate stent recoil in an anastomotic vein graft lesion treated by cutting balloon angioplasty

Saphenous vein graft (SVG) anastomotic lesions can have significant fibromuscular hyperplasia and may be resistant to balloon angioplasty alone. Stents have been used successfully to treat these lesions. There are no reports of immediate stent recoil following such treatment in the literature. We describe immediate and persistent stent recoil in an anastomotic SVG lesion even after initial and post-deployment complete balloon dilatation of the stent and its successful treatment by cutting balloon angioplasty.

Terminal Fetal Heart Decelerations and Neonatal Outcomes

To describe the incidence and characteristics of terminal fetal heart rate decelerations and to estimate their association with acidemia. A 5-year retrospective cohort study of all women with singleton, nonanomalous gestations who labored and reached complete dilation at or after 37 weeks of gestation. The 30 minutes of electronic fetal monitoring before delivery were interpreted by two formally trained research nurses, blind to clinical data, using American College of Obstetricians and Gynecologists guidelines. Terminal decelerations (decelerations without recovery of 120 seconds or more) defined the exposure. Terminal bradycardia (10 minutes or more) was secondarily explored. Univariable and multivariable analyses were performed to estimate risk of acidemia (umbilical cord gas arterial pH level 7.10 or less). Of 5,388 women meeting inclusion criteria, 951 (17.7%) experienced a terminal deceleration whereas 4,437 (82.3%) did not. The incidence of acidemia among the 951 women with a terminal deceleration was low (1.3%; n=12). However, acidemia (adjusted odds ratio [OR] 18.6; 95% confidence [CI] 5.0-68.9) and higher-level nursery admission (adjusted OR 5.4; 95% CI 1.9-15.3) were more likely if the terminal deceleration was 10 minutes or more. Terminal decelerations were longer among neonates with acidemia (6.7 minutes compared with 3.2 minutes; P<.01). For every additional 120 seconds of duration beyond the first 120 seconds, there was a corresponding decrease in umbilical cord gas pH level by 0.042 (95% CI 0.040-0.048; P<.01). More than 98% of term fetuses with terminal decelerations deliver with normal umbilical cord gas pH levels. However, bradycardia is associated with increased risk of acidemia and higher-level nursery admission. This information can be incorporated into clinical decision-making regarding urgency of delivery. II.

The timing of amniotomy, oxytocin and neuraxial analgesia and its association with labour duration and mode of birth

The objective was to study the association of different timings of intrapartum interventions with labour duration and mode of birth. A longitudinal cohort study of 2,090 nulliparae and 1,873 multiparae with a singleton in cephalic presentation was conducted. We assessed the association between, on the one hand, the timing of augmentation with oxytocin, neuraxial analgesia and amniotomy, and, on the other hand, the time to complete dilatation, spontaneous or operative vaginal delivery or caesarean delivery, using a Cox regression model accounting for standard confounders. From amniotomy onwards labour was accelerated. In multiparae, amniotomy was associated with an initial 6.6-fold acceleration, decreasing first stage duration until the hazard ratio reached around 3.5, where the intervention was performed 5 h after labour onset; thereafter, acceleration continued with a hazard ratio of around 3. In nulliparae, neuraxial analgesia was associated with a shorter first stage when administered between 7 and 11 h after labour onset; the later it was performed, the less likely was spontaneous birth and the more likely an operative vaginal birth in nulliparae or a caesarean section in multiparae. The start of oxytocin augmentation was associated with acceleration towards both full dilatation and caesarean section during first stage and an increased risk of operative vaginal birth during second stage. The later oxytocin augmentation started, the more likely it was that spontaneous birth would be retarded in multiparous women. Applying amniotomy, oxytocin and neuraxial analgesia at their optimal timing may improve the progress and outcome of labour.

Middle calyx access in complete supine percutaneous nephrolithotomy

Background: Middle calyx access has been underused in percutaneousnephrolithotomy (PCNL), especially in the supine position.We compared the safety and efficacy outcomes between middlecalyx and lower calyx accesses in the complete supine PCNL in anon-randomized single-surgeon clinical study.Methods: Between February 2008 and October 2011, 170 patientsunderwent posterior subcostal single tract complete supine PCNLwith one-shot dilation and middle calyx (n = 48) and lower calyx(n = 122) accesses. Stone location and surgeon decision determinedtarget calyx for access. Inclusion criteria were pelvis stones,staghorn stones and multiple location stones. Exclusion criteriawere renal anomalies, only upper calyx stones, only middle calyxstones and only lower calyx stones. Important parameters werecompared between the two groups. A p value of &lt;0.05 was consideredsignificant.Results: Two groups were similar in important patient- and stonerelatedparameters. Mean operative time (60.7 minutes), meanpostoperative hospital stay (1.84 days) and mean hemoglobin drop(0.67 g/dL) in the middle calyx group were significantly lesser thanin the lower calyx group (80.1 minutes, 2.19 days, 1.36 g/dL). Themiddle calyx group (89.6%; 79.6%) had a higher stone-free rate(p = 0.054) and efficiency quotient than the lower calyx group(76.2%; 61.6%). In the middle calyx group (10.4%; 2.1%), complicationand transfusion rates were lesser (p &gt; 0.05) than lowercalyx group (14.8%; 7.4%). No significant difference (p = 0.40)was seen between two groups using the modified Clavien classificationof complications.Interpretation: Middle calyx can be an optimal access in PCNLwith the complete supine position for many of upper urinary tractstones due to its superior outcomes.

Labor Induction for Premature Rupture of Membranes Using Vaginal Misoprostol versus Dinoprostone Vaginal Insert

To compare labor induction outcomes using vaginal misoprostol versus dinoprostone insert in women with premature rupture of membranes (PROM) and an unfavorable cervix. Charts of singleton gestations beyond 34 weeks with PROM and an unfavorable cervix from 2008 to 2011 were reviewed. Group assignment was determined by initial induction agent used. Dinoprostone was administered as a 10-mg vaginal insert left for up to 12 hours. Misoprostol was administered vaginally as a 25-μg tablet every 4 hours for up to six doses. Times to active labor, complete dilatation, and delivery and incidence of adverse outcomes (intrapartum fever, tachysystole, fetal heart rate abnormalities) were compared. Ninety-eight women were included. Baseline characteristics between groups were not different. Median times to active labor (7 versus 11 hours, p < 0.001) and complete dilatation (13.5 versus 19 hours, p < 0.001) were shorter in the misoprostol group. In the misoprostol group, 41.7 and 88.4% of patients delivered vaginally within 12 and 24 hours, respectively, compared with 20.8 and 58.0% in the dinoprostone group (p < 0.001). There was no difference in incidence of adverse outcomes. Vaginal misoprostol is more effective than dinoprostone insert for induction secondary to PROM without increasing the incidence of adverse outcomes.

Index of Suspicion in the Nursery

A 1-day-old boy presents to the NICU with the mouth deviating to right side while crying, inability to close the left eye, absence of wrinkles on the left side of the forehead, and a normal appearing face when in repose. This infant was born at 38-weeks’ 5 days of gestation via cesarean delivery to a 28-year-old primi-gravida woman with a significant history of chronic hypertension, for which she took labetalol throughout her pregnancy. She was admitted for induction of labor for nonreactive stress test and an amniotic fluid index less than 5. She had a prolonged second stage of labor. She pushed for more than 3 hours after complete dilation of the cervix but without success. She was taken for cesarean delivery for failure to progress. A low transverse cesarean delivery was performed. No forceps or vacuum were used to deliver the infant. Birthweight was 3,840 g. The infant was born limp, cyanotic, with heart rate below 100 per minute, and with no respiratory effort. Bag-mask ventilation and chest compressions were started. The infant responded well to resuscitation. Apgar scores were 1 and 8 at 1 and 5 minutes, respectively. The infant was transferred to the NICU for further management. On physical examination, the infant is noted to have caput succedaneum located over the left temporo-parieto-occipital region. The infant’s face significantly deviates to the right side, whereas the left eye stays open; he is noted to have absent wrinkles on the left side of the forehead while crying, and there is flattening of the left sided naso-labial fold, as noted in Fig 1. The remainder of the physical examination is considered to be normal except for a 1.0 × 1.0 cm superficial lesion over the left mastoid region, just behind the left ear, as noted in Fig 2. …

Does Delayed Pushing in the Second Stage of Labor Impact Perinatal Outcomes?

Objective To estimate maternal, neonatal, and labor outcomes associated with delayed pushing. Study Design A retrospective cohort study of all consecutive women admitted to a single institution in labor at term who reached the second stage of labor. Pregnancies with multiple fetuses or major anomalies were excluded. Delayed pushing was defined as initiation of pushing ≥60 minutes after complete dilatation. Primary outcome was mode of delivery. Multivariable logistic regression was used to control for confounding. Results Of the 5290 women who met inclusion criteria, 471 (8.9%) employed delayed pushing, and 4819 (91.1%) pushed immediately. Delayed pushing was associated with increased rates of cesarean, operative vaginal delivery, maternal fever, and lower arterial cord pH. Duration of the second stage and length of time spent pushing were significantly longer with delayed pushing. Conclusion Delayed pushing is associated with lower rates of spontaneous vaginal delivery and increased adverse maternal and neonatal outcomes.

Combination of Foley Bulb and Vaginal Misoprostol Compared With Vaginal Misoprostol Alone for Cervical Ripening and Labor Induction

To test the hypothesis that use of the Foley bulb plus vaginal misoprostol will result in shorter induction-to-delivery time compared with vaginal misoprostol alone. We randomized 123 women undergoing induction of labor with singleton pregnancies at 24 weeks of gestation or greater with an unfavorable cervix (Bishop score 6 or lower) to Foley bulb plus vaginal misoprostol (n=56) or vaginal misoprostol alone (n=61). Women with fetal malpresentation, multifetal gestation, spontaneous labor, contraindication to prostaglandins, nonreassuring fetal heart rate tracing, intrauterine growth restriction, anomalous fetus, fetal demise, or previous cesarean delivery or other significant uterine surgery were excluded. The primary outcome measure was induction-to-delivery time. Secondary outcomes were mode of delivery, tachysystole with fetal decelerations, terbutaline use, postpartum hemorrhage, chorioamnionitis, neonatal Apgar scores, and neonatal intensive care unit admission. Analysis followed the intention-to-treat principle. The mean induction-to-delivery time was shorter with the combination of the Foley bulb and vaginal misoprostol when compared with vaginal misoprostol alone (15.3±6.5 compared with 18.3±8.7 hours, difference -3.1 hours, 95% confidence interval [CI] -5.9 to -0.30). The combination also resulted in shorter induction to complete cervical dilation time (13.7±5.9 compared with 17.1±8.7 hours, difference -3.5 hours, 95% CI -6.7 to -0.4). There were no differences in labor complications or adverse neonatal and maternal outcomes. A combination of the Foley bulb and vaginal misoprostol resulted in a shorter induction-to-delivery time when compared with vaginal misoprostol alone without increasing labor complications. ClinicalTrials.gov, www.clinicaltrials.gov, NCT01279343. I.

Predicting Cesarean in the Second Stage of Labor

To develop a prediction model for cesarean delivery (CD) in the second stage of labor using classification and regression tree (CART) analysis. Retrospective cohort of term women who reached 10-cm dilation. The primary outcome was CD at 10-cm dilation. Logistic regression and CART analysis were performed to identify factors that best predict second-stage CD. Only factors known at the time a patient reaches 10-cm dilation were used. Of 5,388 subjects who reached 10 cm, 88 (1.6%) underwent CD. The logistic regression model identified 4 risk factors for CD and produced an area under the receiver operator characteristic curve of 0.75 (95% confidence interval 0.70 to 0.81). CART analysis identified the most important variable in predicting second-stage CD was a station at or higher than 0 at complete dilatation, but correctly classified only 19.3% of CD. Second-stage cesarean cannot be reliably predicted based on antenatal and intrapartum characteristics by logistic regression or CART techniques.

Current Resources for Evidence‐Based Practice January/February 2013

Current Resources for Evidence‐Based Practice January/February 2013

Unattended Home Labor until Complete Cervical Dilatation Ending with Hospital Delivery: Analysis of 238 Pregnancies

Objectives. Hospital fear and avoidance of the routine hospital obstetrical interventions cause some women with low-risk pregnancies to spend most of the active labor period at home, and subsequently they present to the hospital for delivery. Our aim was to analyze the maternal and neonatal outcomes of pregnancies with a planned hospital birth, yet spending the first stage of labor at home without a health provider and completing the delivery in the hospital setting. Methods. We retrospectively compared 238 pregnancies having home labor plus hospital delivery (study group) with 476 pregnancies that had spent the whole labor in the hospital setting, considering various maternal and neonatal outcomes. Results. Cesarean and episiotomy rates were lower (P < 0.0001 and P < 0.001, resp.), but neonatal intensive care unit admissions of the infants were more prevalent (P < 0.01) in the study group. Other maternal and neonatal outcomes including neonatal mortality were comparable. Conclusion. Although our preliminary data generally do support the safety of home active labor plus hospital delivery for low-risk pregnancies, the clinical implications of current data warrant further prospective trials.

Percutaneous dilatational tracheostomy: collaborative team approach for safe airway management

Since Jackson first standardized the technique in 1909 [1], surgical tracheostomy (ST) has been the golden standard surgical procedure by which to manage the airway in critically ill patients. An alternative procedure, cricothyrotomy (cricothyroidotomy) [2], has also been utilized as a surgical option to secure the failed airway in selected emergency situations. To simplify the tracheostomy procedure, Shelden (1950) described the technique of percutaneous dilatational tracheostomy (PDT). However, due to the increased potential to induce extra injury to arteries and the esophagus, the PDT as proposed by Sheldon did not gain popularity among intensive care physicians and airway surgeons. In 1985, Ciaglia et al. [3] introduced a novel PDT method to create a stoma by a series of graduated dilators following needle puncture into the trachea. This method involved the relatively easy Seldinger technique to introduce the serial dilators and a tracheostomy tube. The Griggs guidewire dilating forceps (GWDF) technique introduced in 1990 was aimed at enlargening a small tracheal aperture with a guidewiredilating forceps especially manufactured for this purpose [4]. In 1998, a modification of the Ciaglia technique was introduced (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer kit; Cook Critical Care, Bloomington, IN). The Ciaglia Blue Rhino (CBR) technique incorporated a single, sharply tapered dilator with a hydrophilic coating, allowing complete dilation of the stoma in one step [5]. Although all of these methods have the potential to be improved and refined, the CBR is—mainly due to its simplified concept—currently the most popular PDT technique worldwide. In Japan, as in other countries, PDT is becoming a wellknown procedure. It is being performed as one of the technical options to secure the airway in multiple situations by physicians of various specialties. However, although this procedure is gaining in popularity in Japan, critical information on its indications, contraindications, and safety issues, including potential risks, have not yet been precisely defined and discussed. Thus, while the handiness of this technique is attractive to anesthesiologists and critical care physicians the best approach to perform PDT for successful airway management still needs to be considered and decided upon. K. Saito (&) Department of Otolaryngology–Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan e-mail: koichiro@ja2.so-net.ne.jp

Medical and Nonmedical Factors Influencing Utilization of Delayed Pushing in the Second Stage

To evaluate factors impacting selection to delayed pushing in the second stage of labor. This case-control study was a secondary analysis of a large retrospective cohort study. Cases included women who delayed pushing for 60 minutes or more in the second stage of labor. Controls began pushing prior to 60 minutes from the time of diagnosis of complete dilation. Demographic, labor, and nonmedical factors were compared among cases and controls. Logistic regression modeling was used to identify factors independently associated with delayed pushing. We identified 471 women who delayed pushing and 4819 controls. Nulliparity, maternal body mass index > 25, high fetal station at complete dilation, regional anesthesia use, and start of second stage during staffing shift change were independent factors associated with increased use of delayed pushing. On the other hand, black race and second-stage management during night shift were associated with lower odds of employing delayed pushing. Delayed pushing was more commonly employed in nulliparous women, but 38.9% of multiparous women also delayed pushing. We identified multiple factors associated with use of delayed pushing. This study helps to define current patterns of second-stage labor management.