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Prolonged second stage labor: a risk factor for failed conversion from neuraxial analgesia to cesarean anesthesia
Abstract Number: F2A-2
Abstract Type: Original Research
BACKGROUND: Second stage of labor was not an independent risk factor for failed conversion from epidural analgesia to cesarean anesthesia in a recent meta-analysis1. The change in ACOG guidelines for labor management has led to significant prolongation of second stage duration for many patients. Our clinical impression is that women with a prolonged second stage are often difficult to anesthetize. We hypothesized that prolonged second stage labor may be a risk factors for conversion failure.
METHODS: Retrospective review of parturients with neuraxial analgesia who underwent cesarean delivery (CD) from 2011 to 2015. All demographic, obstetric and anesthetic data were collected. Excluding stat cesarean sections, patients were divided into 3 groups (no second stage (FS), second stage<240mins (SS), second stage>=240mins (PSS)). Conversion failure was defined as 1) catheter replacement for surgery, 2) large amount IV supplementation or 3) general anesthesia. Fisher’s exact test was used in identifying factors related to conversion failure, followed by logistic regression using factors with p<0.1 to determine independent risk factors. p<0.05 considered significant.
RESULTS: 1843 patients had a cesarean delivery at advanced cervical dilation or second stage were reviewed. The proportion of parturients who had PSS among patients who went into second stage labor increased from 38.2% to 54.2% (2011 to 2015; linear trend p<0.001). 30.3% (88/290) with PSS had conversion failure, which was significantly higher than SS or FS (21.4% and 20.3%, p=0.003; Table). Patients who had epidural replacement during labor had significantly higher rate of requiring large amount IV supplementation or general anesthesia during CD comparing to patients who were not replaced (31.2% vs 16.7%, p=0.000). Logistic regression found that independent risk factors for conversion failure include prolonged second stage labor (OR 1.20, 95%CI 1.05-1.39, p=0.009) and stat cesarean section (OR 1.85, 95% CI 1.21-2.83, p=0.005).
CONCLUSIONS: We found an increased incidence of patients having prolonged second stage of labor prior to CD, due to the obstetric practice change. Patients with prolonged 2nd stage labor were more likely to experience failed conversion from neuraxial labor analgesia to cesarean anesthesia, requiring significant IV supplementation or general anesthesia. Epidural catheter replacement was not associated with higher success in conversion.
1 Bauer, et al. IJOA 2012;21:294-309