17 Feb Second Stage of Labor and the Epidural: Hospitals Need To Rethink Their Guidelines
A recent article in the New York Times has sparked an important discussion about the relationship of epidural use and the length of the second stage of labor for first time mothers. In the March 2014 Obstetrics and Gynecology Journal, the study Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested highlighted a significant finding that could change the way medical professionals view and handle the pushing stage of labor.
The researchers at University of California San Francisco performed a retrospective study between 1976 and 2008 involving 42,268 participants who delivered vaginally with normal neonatal outcomes. Approximately half the women in the study used epidural anesthesia. The results are rather eye opening. “Compared with women without epidural use, the 95th percentile length of second stage for nulliparous (first time mothers) women was 197 minutes without epidural and 336 minutes with epidural, a difference of 2 hours and 19 minutes. For multiparous (a woman who has already given birth) women, the 95th percentile length of second stage was 81 minutes without epidural and 255 minutes with epidural, a difference of 2 hours and 54 minutes. (1) Historically, doctors allot one hour difference between those with an epidural and those without before intervening with interventions such as pitocin, foreceps, vacuum extraction or cesarean. It is now clear that there may need to be a longer waiting period before these interventions are introduced.
The results of this study may lead to reexamining ACOG (American College of Obstetrics and Gynecology) guidelines for handling prolonged second stage. “In a nulliparous woman, the diagnosis of a prolonged second stage should be considered when the second stage exceeds 3 hours if regional anesthesia has been administered or 2 hours if no regional anesthesia is used. In multiparous women, the diagnosis can be made when the second stage exceeds 2 hours with regional anesthesia or 1 hour without. (2)
Based on ACOG’s guidelines compared to the results of this in particular study, intervention is being used almost 2 1/2 hour earlier then necessary for first time moms with an epidural and almost 1 1/2 hours for 1st time moms without an epidural. This opens up the question, Are we jumping the gun to “failure to progress” and deciding the “baby is too big” by limiting the pushing phase and not looking at the well being of the mother and baby and instead looking at hospital protocol and schedule? And are women given enough time to experiment with different birthing positions until they find the most advantageous? During my days as a doula, I witnessed many mothers being made aware of their deadline with the clock during the pushing stage. Most hospitals have a set time allotted for the second stage of labor and if a woman has used up her time, a cesarean is often decided upon. Perhaps by adjusting the time table, our national cesarean rate can start to decrease. (The US is hovering around 1/3 of births taking place via cesarean.) Isn’t it more important to examine how both mother and baby are handling the pushing stage instead of going by a set of rules and schedules? This brings me back to my favorite three questions of labor. Is mom ok? Is baby ok? Can we have more time?
While I have mainly been focusing on the results of this newly published study, I do feel the need to rebut one comment from the New York Times article made by Dr. Barbara Leighton, a professor of anesthesiology at Washington University in St. Louis School of Medicine. While Dr. Leighton supports revising ACOG recommendations, she believes that the current study did not prove that longer labor is caused by epidural anesthesia. (3) However, one can come to the conclusion that both ACOGs current guidelines and the information from this new emerging study both recognize that women who have received an epidural on average take longer to complete the second stage of labor, then there is a correlation between epidural use and a prolonged second stage. Here are some factors supporting why epidurals may may prolong the second stage of labor: Epidural use limits the mother’s mobility which can hinder the baby from moving into the optimal birthing position. The lack of sensation may also lead to the mother needing more time to coordinate the muscles needed to push since she is numb from the waist down. Finally, with epidural use, the mother is more limited in her birthing positions which may also account for the extra time needed for a vaginal birth. The most common birthing position for mothers with an epidurals is the lithotomy position (lying down on the back). Strictly from an anatomical viewpoint, laying flat on the back results in the NARROWEST pelvic opening and places pressure on the sacrum and tailbone. This will decrease the space in the pelvic outlet and possibly prevent the baby from descending and rotating properly for a vaginal birth.
Again, we come back to the concept of looking at the individual instead of set rules. I remember one doctor I worked with at St. Lukes/Roosevelt once saying that the best piece of advice he received from his mentor was “get a comfortable chair because birth is on it’s own schedule”.
(1) Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested
Cheng, Yvonne W. MD, PhD; Shaffer, Brian L. MD; Nicholson, James M. MD, MSCE; Caughey, Aaron B. MD, PhD
(2) ACOG PRACTICE BULLETIN CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIANÂGYNECOLOGISTS NUMBER 49, DECEMBER 2003
(3) Study Suggests Misplaced Fears in Longer Childbirths
(4) Contemporary Cesarean Delivery Practice in the United States