Many babies aren’t interested in following a timetable, meaning that some women just need a little more time to get through the pushing phase than current guidelines recommend.

In fact, allowing a mom in labor just a little more time to deliver her baby can cut the chance of cesarean birth in half.

woman in labor in the hospital

Labor time & cesarean risk

The second stage of labor starts when the cervix is fully dilated, and ends with the actual birth. What can cause the second stage — also called the pushing stage — to be longer than expected?

According to the American College of Obstetricians and Gynecologists, in guidelines released in March 2014, “Parity [number of previous pregnancies carried to viability], delayed pushing, use of epidural analgesia, maternal body mass index, birth weight, occiput posterior position, and fetal station at complete dilation all have been shown to affect the length of the second stage of labor.”

When women in labor are given more time to deliver their baby than current guidelines recommend, their incidence of cesarean delivery drops by 55 percent, say

Their study, by researchers at Thomas Jefferson University, is the first to formally test what happens when women in the second stage of labor (fully dilated) are given four hours, instead of three, if they did have an epidural.

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Not only was the incidence of cesarean delivery reduced by more than 50 percent, there were no associated negative health consequences to the mother or child, says the study’s lead author, Alexis C Gimovsky, MD, a Maternal Fetal Medicine Fellow at The Sidney Kimmel Medical College of Thomas Jefferson University. The results were published in the March 2016 issue of the American Journal of Obstetrics and Gynecology,

Labor guidelines from the 1800s need to be updated

The findings suggest that the two-hour rule, which dates back to the 1800s, needs to be updated, she says. “This was a small study, so a formal change in guidelines should be based on a larger sample of women. But this study shows what we have observed in practice — there is benefit to allowing women to labor longer.”

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The current guidelines do allow some flexibility, so some obstetricians already provide extra time to labor, on a case-by-case basis, Dr Gimovsky says. “But, for the sake of reducing the number of cesareans that are performed in this country, we should further investigate expanding the time frame.”

An expensive, possibly risky, often avoidable complication

About 30 percent of deliveries in the US end with a cesarean, which can put a woman at risk for a number of complications in following pregnancies, can impact fetal health, and which are very costly, she says.

About 10 to 15 percent of the cesareans for first time mothers result from the two-hour rule, she adds. Allowing three hours if a woman has had an epidural — medicine that relieves labor pain by blocking nerve signals — was added on to labor guidelines by the American College of Obstetricians and Gynecologists in the 1980s.

Different labor groups

In this study, Dr Gimovsky and the study’s senior author, Vincenzo Berghella, MD, Director of Maternal Fetal Medicine at Thomas Jefferson University Hospital, enrolled 78 first time mothers who were between 36-41 weeks of gestation. They were randomized to an “extended labor” group that allowed for at least one additional hour of labor, or to a “usual labor” group that followed current delivery guidelines. At time of delivery, all of the study participants chose to have an epidural. Almost half of the women had an induced labor.

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They found that incidence of cesarean delivery was about 19.5 percent (8 out of 41 women) in the extended labor group and about 43 percent (16 of 37 women) in the usual labor group. There were no statistically significant differences in maternal or neonatal morbidity outcomes between the groups.

Gimovsky noted that many expecting mothers were eager to join the study, suggesting “a majority of women are highly motivated to have a vaginal delivery,” she says. “Changing the guidelines may help many women reach that goal.”


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About: Article Reference: A. Gimovsky and V. Berghella, "42: Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines," Am J Obstet Gynecol,DOI: 10.1016/j.ajog.2015.12.042 (2016). There was no financial support for this research, and Dr Gimovsky and Dr Berghella declared no conflict of interest.

Photo credit(s): Photo thanks to Parentingupstream

Original publication date: March 16, 2016

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