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Impact of prolonged second stage on epidural failure rate
Abstract Number: F-30
Abstract Type: Original Research
Background: The American College of Obstetrics and Gynecology recently changed the recommendations for the length of labor and second stage (2ndSt) to continue as long as the fetus tolerates. Since this change we have seen more parturients with a 2ndSt of over 5 hours. We observed that it is more challenging to convert a labor analgesic to epidural anesthesia, and general anesthesia (GA) is frequently required. Previous research has not identified length of 2ndSt as a risk factor for GA.(1) We hypothesize this was because 2ndSt was uniformly short and terminated by time, not by fetal descent. The aim of this study was to determine if the need for GA is related to the length of 2ndSt.
Methods: Data for conversion of labor epidural analgesia to cesarean anesthesia was collected from two years prior to the guideline change (2011/2012: Period 1) and two years after (2014/2015: Period 2). Patient demographic data, labor course, obstetric and anesthetic factors, and anesthetic technique were recorded. We also determined if the catheter was replaced immediately prior to cesarean. We compared conversion success on non-STAT cesareans with cesarean done during 2ndSt. Rates of GA were compared in periods. To assess the impact of the change of practice for Period 2, we compared rates of GA by length of 2ndSt. Chi-square and trend analysis were used. P<0.05 considered significant.
Results: Total cesarean: 999, 41 were STAT (rate of GA was 4.6% and rate of supplementation 12.9%). 2ndSt cesarean 333 (GA: 4.8%, supplementation: 13.8%). There were no differences in the rates of supplementation between periods. The incidence of 2ndSt >300 min increased from Period 1 to 2 (12.4% to 38.7% p<0.001). During Period 1 (n=134 non-STAT) there was no difference in the rate of general anesthesia (P=0.55). During Period 2 (n=190 non-STAT) we found a statistically significant increase in GA rate by length of 2ndSt (P<0.05; Figure). Replacing the epidural catheter immediately before CS did not reduce the rate of GA (Not repl. 4.2% vs. 10.5% repl. P=0.22).
Conclusions: A parturient whose second stage is allowed to progress beyond five hours is at an increased risk of requiring GA for cesarean delivery. Our findings highlight the importance of preparedness for conversion failure. Replacement of the epidural catheter may not be the only solution, as we found no improvement in conversion.
Reference: 1) IJOA 2012; 21:294-309.