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National Collaborating Centre for Women's and Children's Health (UK). Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth. London: RCOG Press; 2007 Sep. (NICE Clinical Guidelines, No. 55.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

15Complicated labour: second stage

15.1. Delay in the second stage of labour

Introduction

Delay in the second stage of labour has been defined in a number of ways and there is no universal consensus. This is discussed in Chapter 8.

The definition of the onset of the active second stage of labour: (from Chapter 8)

  • the baby is visible
  • expulsive contractions with a finding of full dilatation of the cervix, or other signs of full dilatation of the cervix
  • there is active maternal effort, following confirmation of full dilatation of the cervix, in the absence of expulsive contractions.

Clinical question

Do duration and progress of the first and second stages of labour affect outcomes?

Discussion

The GDG discussed the definition of delay in the first stage of labour based on the evidence presented in Chapter 8 and made the following recommendations.

Recommendations on duration and definition of delay in the second stage of labour

Nulliparous women:

  • Birth would be expected to take place within 3 hours of the start of the active second stage in most women.
  • A diagnosis of delay in the active second stage should be made when it has lasted 2 hours and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent. [repeated from Section 8.2]

Parous women:

  • Birth would be expected to take place within 2 hours of the start of the active second stage in most women.
  • A diagnosis of delay in the active second stage should be made when it has lasted 1 hour and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent. [repeated from Section 8.2]

15.1.1. Indication for instrument-assisted vaginal birth

Overview of available evidence

No randomised controlled trial was identified.

Evidence statement

There is no high-quality evidence to compare indications for assisted vaginal birth.

15.1.2. Interventions for delay in the second stage

Introduction

The review refers to women without epidural analgesia, and who have not had a previous caesarean section.

Oxytocin versus expectant management

Description of included studies

There is no study identified comparing oxytocin infusion with expectant management, for management of women without epidural analgesia who have a delayed second stage of labour.

Evidence statement

There are no high-quality studies looking at the use of oxytocin for delay in the second stage of labour, for women without epidural analgesia.

Oxytocin versus instrumental births

Description of included studies

There is no study identified comparing these two interventions.

Evidence statement

There is no high-level evidence on effectiveness and safety of oxytocin infusion for management of the second stage of labour, compared with instrumental vaginal birth.

GDG interpretation of the evidence

While there is no evidence on starting oxytocin in the second stage of labour for parous women, the GDG consider the potential risks of uterine rupture are such that we cannot recommend it.

Recommendations on interventions for delay in the second stage of labour

Where there is delay in the second stage of labour, or if the woman is excessively distressed, support and sensitive encouragement and the woman’s need for analgesia/anaesthesia are particularly important.

Consideration should be given to the use of oxytocin, with the offer of regional analgesia, for nulliparous women if contractions are inadequate at the onset of the second stage

In nulliparous women, if after 1 hour of active second stage progress is inadequate, delay is suspected. Following vaginal examination, amniotomy should be offered if the membranes are intact.

Women with confirmed delay in the second stage should be assessed by an obstetrician but oxytocin should not be started.

Following initial obstetric assessment for women with delay in the second stage of labour, ongoing obstetric review should be maintained every 15–30 minutes.

15.1.3. Instrument to be used

Clinical question

What are the indications for the use of ventouse or forceps?

Ventouse versus forceps

Description of included studies

The evidence for this subsection was drawn from a good quality systematic review550 including ten trials, plus three additional recent trials.551–553 [EL = 1+] The systematic review was published in April 1999, and the last search was performed in February 1999. The trials included in the systematic review were conducted in USA, Denmark, Sweden, UK, South Africa and Greece. The recent trials were conducted in Sri Lanka,551 Pakistan552 and Ireland.553 There are two follow-up studies of trials using the same population that were included in the systematic review, which investigated long-term outcomes of mothers and their children. These studies were conducted in the UK (published in 1999 and 1998).554,555

Review findings

Labour events

Meta-analysis of nine trials showed that ventouse-assisted birth was more likely to be associated with failed birth with selected instruments compared with forceps-assisted birth (n = 2849, OR 1.69 [95% CI 1.31, 2.19]).556 Another recent trial in Pakistan showed the same association (n = 442, RR 2.04 [95% CI 1.14, 3.70]).552 There was no evidence of differences in rates of CS (meta-analysis of seven trials, n = 1662, OR 0.56 [95% CI 0.31, 1.02]). Meta-analysis of 12 trials showed a significant reduction of the use of anaesthesia with ventouse-assisted birth (n = 5051, OR 0.59 [95% CI 0.51, 0.68]).

Women’s complications

Meta-analysis of trials in the systematic review showed that ventouse-assisted birth significantly reduced significant maternal injury (seven trials, n = 2582): OR 0.41 [95% CI 0.33 to 0.50] and severe perineal pain at 24 hours (two trials, n = 495): OR 0.54 [95% CI 0.31 to 0.93]. The Pakistani trial showed that ventouse-assisted birth significantly reduced cervical tears (n = 442: RR 0.19 [95% CI 0.04 to 0.86]) and third-degree perineal trauma (n = 442): RR 0.58 [95% CI 0.04 to 0.86]) compared with forceps-assisted birth.

Newborn outcomes

Meta-analysis of trials in the systematic reviews showed that ventouse-assisted birth increased incidence of cephalhaematoma (six trials, n = 1966): OR 2.38 [95% CI 1.68 to 3.37] and retinal haemorrhage (five trials, n = 445): OR 1.99 [95% CI 1.35 to 2.96]. The Pakistani trial also showed an increase in the incidence of cephalhaematoma with the use of ventouse (n = 442): RR 7.14 [95% CI 1.59 to 33.33]. There was a non-significant increase in the number of babies whose birth was assisted with ventouse who had a lower Apgar score at 5 minutes (five trials, n = 1545): OR 1.67 [95% CI 0.99 to 2.81]. Meta-analysis of trials showed that there was no evidence of a difference in Apgar score less than 7 at 1 minute (meta-analysis of three trials, n = 822): OR 1.13 [95% CI 0.76 to 1.68]; and the Sri Lanka trial (n = 50): RR 0.85 [95% CI 0.24 to 3.03]; scalp or face injuries (not cephalhaematoma) (six trials, n = 2330): OR 0.89 [95% CI 0.70 to 1.13]; use of phototherapy (four trials, n = 1648): OR 1.08 [95% CI 0.66 to 1.77]; perinatal death (seven trials, n = 1800): OR 0.80 [95% CI 0.18 to 3.52]; follow-up/re-admission by hospital (one trial,557 n = 232): OR 1.33 [95% CI 0.58 to 3.05]; hearing abnormal (confirmed/suspected) (one trial,557 n = 232):OR 1.66 [95% CI 0.54 to 5.06]; and strabismus or vision abnormality suspected (one trial,557 n = 232): OR 1.38 [95% CI 0.47 to 4.05]. The Sri Lanka study also showed no evidence of differences in neonatal complications (n = 50): RR 1.00 [95% CI 0.72 to 1.39].

Mental and psychological outcomes and women’s satisfaction

Meta-analysis of three trials showed that maternal worries about the baby, significantly increased with ventouse-assisted birth (n = 561): OR 2.17 [95% CI 1.19 to 3.94]. The Irish study investigated women’s satisfaction and showed no evidence of a difference (would choose CS for next birth): RR 0.53 [95% CI 0.23 to 1.27]. In the systematic review, only two trials included women’s assessment of pain during birth.558,559 One trial comparing methods of instrumental birth contained a substudy of the views of women and obstetric and midwifery staff.559 A subsample of 66 of the 304 women participating in the trial were interviewed between the first and eighth day postpartum. Women scored the pain of the birth itself on a 4-point scale ranging from ‘not painful at all’ to ‘extremely painful’. Despite receiving more analgesia, 12 of the 33 women who had undergone a forceps birth considered the birth had been ‘very’ or ‘extremely’ painful compared with seven of the 33 who had undergone a vacuum extraction. Similar findings were reported by another study, which found 27% (n = 28) of women considered their forceps birth to have been ‘unbearable’ compared with 18% (n = 19) of women who had undergone vacuum extraction: OR 1.5 [95% CI 0.5 to 4.2].558

A third study concluded that there were significantly fewer women in the vacuum extractor group requiring epidural or spinal anaesthesia (25.4% versus 32.7%) or general anaesthetics (1% versus 4%) compared with the forceps group.560 The authors concluded that less analgesia is required for vacuum extraction compared with the use of forceps. However, the results reflect the choice of analgesia made prior to the start of the procedure by the attending anaesthetist and obstetrician rather than that requested or desired by the women themselves. No assessment was made of the pain experienced during the procedure and the women’s views on the type of analgesia provided were not recorded.

Medium- and long-term outcome

The UK follow-up study of the trial showed a significantly lower incidence with use of ventouse of anal sphincter defects (RR 0.58 [95% CI 0.32 to 0.92]); and higher maximum anal squeeze pressure (ventouse mean = 38, forceps mean = 53, P = 0.02); but no evidence of difference in anal incontinence (RR 1.47 [95% CI 0.44 to 4.92]); and maximum anal resting pressure (ventouse mean = 55, forceps mean = 60, P = 0.32) at the end of the 5-year follow-up period.555 Another study using the same population showed no evidence of differences in both bowel and urinary habits of the women after 5 years.554 This study also investigated long-term outcome of the babies, and showed no evidence of differences in visual problems among the children (OR 0.9 [95% CI 0.38 to 2.5]) or child development.

The Irish long-term study (follow-up = 3 months) showed that there was a significant reduction in altered continence (RR 0.35 [95% CI 0.17 to 0.71]) and a tendency of higher anal pressure among women who had given birth assisted by ventouse compared with forceps-assisted birth: resting pressure (mmHg) (ventouse median = 63, forceps median = 54, P = 0.05); squeeze pressure (mmHg) (ventouse median = 96, forceps median = 86, P = 0.11); squeeze increment (mmHg) (ventouse median = 25, forceps median = 27, P = 0.12); vector symmetry index (RR 0.77 [95% CI 0.39 to 1.54]). There was no evidence of differences in continence score (ventouse mean = 3, forceps mean = 3, P = 0.17); faecal urgency less than 5 minutes (RR 0.72 [95% CI 0.34 to 1.54]); and perineal discomfort (RR 0.78 [95% CI 0.37 to 1.64]).

Soft ventouse versus hard ventouse

Description of included studies

One good quality systematic review including nine trials and 1375 women was identified.561 [EL = 1+] This was published in February 2000 and the last search was performed in February 2000. The included trials were conducted in Saudi Arabia, Nepal, the UK, Sweden, South Africa, the Netherlands, Malaysia, Greece and Thailand.

Review findings

Labour events

Meta-analysis of nine trials showed there was a significant increase of failure to deliver when the instrument chosen was with the soft cups, as oppose to the hard cups (n = 1368 women): OR 1.65 [95% CI 1.19 to 2.29]. No other outcome was reported.

Women’s outcomes

Meta-analysis of six trials showed there was no evidence of a difference in significant maternal injury (n = 1137 women): OR 0.85 [95% CI 0.57 to 1.27].

Newborn outcomes

Meta-analysis of eight trials showed that use of soft cups significantly reduced significant scalp trauma (n = 1337): OR 0.45 [95% CI 0.34 to 0.60]. Otherwise, meta-analysis showed no evidence of a difference in Apgar score less than 7 at 1 minute (four trials, n = 866): OR 1.21 [95% CI 0.80 to 1.83]; less than 7 at 5 minutes (five trials, n = 765): OR 0.68 [95% CI 0.35 to 1.33]; incidence of cephalhaematoma (four trials, n = 538): OR 0.70 [95% CI 0.34 to 1.44]; incidence of phototherapy or jaundice (six trials, n = 1137): OR 0.73 [95% CI 0.50 to 1.07]; severe retinal/intracranial haemorrhage (two trials, n = 218): OR 0.84 [95% CI 0.27 to 2.64]; and neonatal death (one trial, n = 72): OR 1.26 [95% CI 0.08 to 20.85].

Evidence statement

There is high-quality evidence comparing ventouse-and forceps-assisted birth. Ventouse is associated with a lower incidence of success, less perineal/genital injury, less perineal pain in the short- and long-term, but with more cephalhaematoma and retinal haemorrhage in babies. When there is failure to achieve birth with the first instrument, there is an increased risk of trauma to the baby with the use of sequential instruments.

There is no evidence of differences between ventouse and forceps in CS rate, long-term babies’ outcomes and women’s satisfaction and psychological outcomes.

There is moderate level of evidence on soft versus hard ventouse-assisted birth. Soft cup ventouse seems to be associated with higher failure to achieve vaginal birth, but with lower significant scalp trauma on babies. There is no evidence of differences in other major outcomes including long-term outcomes.

Failed/successful instrumental vaginal birth and CS

Description of included studies

One UK cohort study compared women with successful instrumental vaginal birth (n = 184), immediate CS (n = 102) and attempted instrumental vaginal birth and then CS (n = 107).562 [EL = 2+]

Review findings

CS versus assisted vaginal birth

The UK study showed that women with CS had more blood loss (blood loss more than 1 litre) (OR 2.82 [95% CI 1.10 to 7.62]); more opiates required (OR 10.93 [95% CI 6.44 to 18.91]); more incidents of urinary catheter required for longer than 24 hours (OR 3.09 [95% CI 1.39 to 6.88]); and a longer hospital stay (6 days or more) (OR 3.47 [95% CI 1.58 to 7.62]); compared with instrumental birth, controlling for various confounders. More babies born via CS were admitted to a neonatal unit (OR 2.64 [95% CI 1.16 to 6.02]); but less babies with CS had trauma from the birth (OR 0.37 [95% CI 0.20 to 0.70]; or serious trauma OR 0.34 [95% CI 0.08 to 1.42]), compared with babies who had had an instrumental birth. There is no evidence of a difference in Apgar score < 7 at 5 minutes (OR 2.81 [95% CI 0.48 to 16.74]).

Evidence statement

There is limited evidence on assisted vaginal birth on women’s and babies’ outcomes, compared with CS. Limited evidence showed women with CS were more likely to lose more blood, and stay in hospital longer, while babies born with CS were more likely to be admitted to a neonatal unit, but less likely to have trauma, compared with assisted vaginal birth.

Recommendations on instruments used for delay in the second stage of labour

Instrumental birth should be considered if there is concern about fetal wellbeing, or for prolonged second stage.

On rare occasions, the woman’s need for help in the second stage may be an indication to assist by offering instrumental birth when supportive care has not helped.

The choice of instrument depends on a balance of clinical circumstance and practitioner experience.

Instrumental birth is an operative procedure that should be undertaken with tested effective anaesthesia.

If a woman declines anaesthesia, a pudendal block combined with local anaesthetic to the perineum can be used during instrumental birth.

Where there is concern about fetal compromise, either tested effective anaesthesia or, if time does not allow this, a pudendal block combined with local anaesthetic to the perineum can be used during instrumental birth.

Caesarean section should be advised if vaginal birth is not possible.*

*

See ‘Caesarean section’ (NICE clinical guideline 13).

Copyright © 2007, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

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Cover of Intrapartum Care
Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth.
NICE Clinical Guidelines, No. 55.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2007 Sep.

NICE (National Institute for Health and Care Excellence)

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