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spontaneous vaginal, operative vaginal, and second stage cesareans.
Length of the second stage was compared using the Kruskal-Wallis
test.
RESULTS: Of the 91353 term deliveries during the study period,
32837 were singletons with no exclusion criteria. Ninety-two percent
(n¼30327) attempted a vaginal delivery, of whom 84.6% (n¼25655)
reached the second stage Duration of the second stage of labor was
available for 25241 (19740 spontaneous vaginal, 3311 operative
vaginal, and 2190 cesarean deliveries). The length of the second stage
of labor was significantly longer in those with epidurals (P<0.01).
The median and 95th percentile for the length of the second stage
were 1.9 hours and 5.6 hours respectively in those with an epidural,
and 42 minutes and 3.4 hours respectively in those without an
epidural (Table). Using previously suggested criteria for prolonged
second stage, of those delivering vaginally (spontaneous/operative
vaginal delivery), 11.9% (n¼2143) of those with an epidural had a
second stage >4 hours and 6.0% (307) of those without an epidural
had a second stage >3 hours.
CONCLUSION: This cohort of nulliparous singleton term deliveries
demonstrates an approximately two-fold increase in the median
duration of the second stage and a 2 hour increase in the 95th
percentile in those with epidurals. Less restrictive guidelines on
second stage duration for nulliparas with epidurals may increase
vaginal delivery rates. However, more information is needed to
determine when the benefits of continuing in the second stage are
outweighed by low likelihood of vaginal delivery and increased risks
for adverse outcomes.
with an epidural. Complication rates were compared between those
with and without a prolonged second stage using a Pearson chi2 test.
For the deliveries where body mass index (BMI) and maternal age
were available, a generalized linear model was used to compare
outcomes for prolonged second stage adjusting for advanced
maternal age, obesity, and epidural.
RESULTS: A total of 25241 nulliparous singletons attempting vaginal
delivery were included in the study cohort. Of these 79.4%
(n¼20029) had an epidural. For those with an epidural, prolonged
second stage (>4 hours) was associated with increased operative
delivery and all adverse maternal and newborn outcomes evaluated
with the exception of shoulder dystocia. For those without an
epidural, prolonged second stage (>3 hours) was associated with
increased operative delivery, shoulder dystocia, 3rd/4th degree tears,
NICU admit, and newborn resuscitation (Table 1). For the sub-
population of 23631 with maternal BMI and age available, the
increased risk for operative delivery and adverse outcomes, aside
from shoulder dystocia, persisted after adjustment for advanced
maternal age, obesity, and epidural (Table 2).
CONCLUSION: This study of nulliparous singleton term deliveries
demonstrates increased rates of operative delivery and adverse
maternal and newborn outcomes with prolonged second stage based
on a definition of >4 hours for those with an epidural and >3 hours
for those without an epidural. More research is needed to determine
how long is too long in the second stage.

365 Outcomes associated with prolonged second

stage of labor in nulliparas
Vivienne Souter1, Angela J. Chien2, Ellen Kauffman1,
Kristin Sitcov3, Aaron B. Caughey4
1
Obstetrics Clinical Outcomes Assessment Program, Seattle, WA,
2
EvergreenHealth, Kirkland, WA, 3Foundation for Health Care Quality,
Seattle, WA, 4Department of Obstetrics and Gynecology, Oregon Health &
Science University, Portland, OR
OBJECTIVE: To evaluate maternal and newborn outcomes associated
with prolonged duration of the second stage of labor in
nulliparas.
STUDY DESIGN: Retrospective cohort study using data from a multi-
center quality improvement program based in Washington State.
Nineteen hospitals participating in the program for all or part of the
study period were included. The study cohort was restricted to
singleton deliveries at 37+0-42+6 weeks’ gestation between Jan 1,
2012 and Dec 31, 2016. Exclusion criteria were antepartum stillbirth,
fetal anomalies, missing data for mode of delivery or cervical dilation
at cesarean, unknown duration or impossible values for the second
stage, or second stage >12 hours. Mode of delivery and selected
maternal and newborn outcomes were evaluated for prolonged
second stage, defined as >3 hours without an epidural and >4 hours

S226 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2018