title: Prolonged Second Stage: What Is the Optimal Length?
abstract: OBJECTIVE
  Prolonged second stage of labor is a clinical dilemma in which controversy exists on whether extending labor in nulliparous women with epidural anesthesia decreases the incidence of cesarean delivery without increasing maternal or neonatal risks.
  
  
  OBJECTIVE
  This narrative review was conducted to assess the current literature on management of and risks associated with a prolonged second stage in nulliparous women with epidurals.
  
  
  METHODS
  A review of the current literature was performed to evaluate the incidence of cesarean delivery and the maternal and neonatal outcomes.
  
  
  RESULTS
  A total of 11.5% of nulliparous women with epidurals have a prolonged second stage; 80.2% of these women deliver vaginally. There is 1 randomized controlled trial on prolonged second stage in nulliparous women with epidurals. In this study, extending the second stage beyond current guidelines decreased the incidence of cesarean delivery by 55% and did not increase maternal or neonatal risks. Most patients (75.6%) with a prolonged second stage delivered by 5 hours and had a vaginal delivery (80.5%). Women with a fetus in occiput anterior position or who presented in spontaneous labor had decreased risk of cesarean delivery (by 83% and 89%, respectively). Maternal risks include postpartum hemorrhage, chorioamnionitis, and third- and fourth-degree lacerations. Neonatal risks may have a small absolute increase.
  
  
  CONCLUSIONS
  The change of a vaginal delivery is high (over 80%) beyond 3 hours in the second stage. Maternal and neonatal risks need to be further explored by larger, better-designed retrospective reviews or trials.
authors.affiliation: Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, George Washington University School of Medicine and Heath Sciences, Washington, DC.
authors.forename: Alexis C
authors.initials: AC
authors.lastname: Gimovsky
authors.affiliation: Professor and Division Director, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Berghella
mesh_terms: D000767:Anesthesia, Epidural / Q000009:adverse effects / Q000379:methods; D002585:Cesarean Section / Q000379:methods; D005260:Female; D006801:Humans; D007748:Labor Stage, Second; D007744:Obstetric Labor Complications / Q000209:etiology / Q000517:prevention & control; D010298:Parity; D011247:Pregnancy; D011256:Pregnancy Outcome; D018570:Risk Assessment; D014219:Trial of Labor