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Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity.

ABSTRACT: OBJECTIVE:To assess the morbidity associated with continuing the second-stage duration of labor, weighing the probability of spontaneous vaginal birth without morbidity compared with birth with serious maternal or neonatal complications. METHODS:In a retrospective cohort, we analyzed singleton, vertex births at 36 weeks of gestation or greater without prior cesarean delivery (n=43,810 nulliparous and 59,605 multiparous women). We calculated rates of spontaneous vaginal birth and composite serious maternal or neonatal complications. Results were stratified by parity (nulliparous or multiparous) and epidural status (yes or no). Competing risks models were created for 1) spontaneous vaginal birth with no morbidity, 2) birth with maternal or neonatal morbidity, and 3) no spontaneous vaginal birth and no morbidity, and our main interest was in comparing number 1 against number 2. RESULTS:Rates of spontaneous vaginal birth without morbidity were slightly higher after the first half hour (greater than 0.5-1.0 hours) for nulliparous women, after which rates decreased with increasing second-stage duration. For multiparous women, rates of spontaneous vaginal birth without morbidity decreased with increasing second-stage duration. For illustration, for a nulliparous woman with an epidural at 3.0 hours of the second stage of labor who extended by another 1.0 hour, her likelihood of delivering by spontaneous vaginal birth was 31.4% compared with her likelihood of birth with any serious complication in the subsequent hour, which was 7.6%. The percentage of cesarean deliveries for nonreassuring fetal heart rate tracing were higher for women without compared with women with an epidural. CONCLUSION:Rates of spontaneous vaginal birth without serious morbidity steadily decreased for increasing second-stage duration except for the first half hour for nulliparous women. We did not observe an inflection point at a particular hour mark for either spontaneous vaginal delivery without morbidity or births with morbidity. Our findings will assist in decision-making for extending second-stage duration.

SUBMITTER: Grantz KL

PROVIDER: S-EPMC5785437 | biostudies-other | 2018 Feb

REPOSITORIES: biostudies-other

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Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity.

Grantz Katherine L KL Sundaram Rajeshwari R Ma Ling L Hinkle Stefanie S Berghella Vincenzo V Hoffman Matthew K MK Reddy Uma M UM

Obstetrics and gynecology 20180201 2

<h4>Objective</h4>To assess the morbidity associated with continuing the second-stage duration of labor, weighing the probability of spontaneous vaginal birth without morbidity compared with birth with serious maternal or neonatal complications.<h4>Methods</h4>In a retrospective cohort, we analyzed singleton, vertex births at 36 weeks of gestation or greater without prior cesarean delivery (n=43,810 nulliparous and 59,605 multiparous women). We calculated rates of spontaneous vaginal birth and c ...[more]

PMID: 29324600

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Project description:ObjectiveTo assess neonatal and maternal outcomes when the second stage of labor was prolonged according to American College of Obstetricians and Gynecologists guidelines.MethodsElectronic medical record data from a retrospective cohort (2002-2008) from 12 U.S. clinical centers (19 hospitals), including 43,810 nulliparous and 59,605 multiparous singleton deliveries at 36 weeks of gestation or greater, vertex presentation, who reached 10-cm cervical dilation were analyzed. Prolonged second stage was defined as: nulliparous women with epidural greater than 3 hours and without greater than 2 hours and multiparous women with epidural greater than 2 hours and without greater than 1 hour. Maternal and neonatal outcomes were compared and adjusted odds ratios calculated controlling for maternal race, body mass index, insurance, and region.ResultsProlonged second stage occurred in 9.9% and 13.9% of nulliparous and 3.1% and 5.9% of multiparous women with and without an epidural, respectively. Vaginal delivery rates with prolonged second stage compared with within guidelines were 79.9% compared with 97.9% and 87.0% compared with 99.4% for nulliparous women with and without epidural, respectively, and 88.7% compared with 99.7% and 96.2% compared with 99.9% for multiparous women with and without epidural, respectively (P<.001 for all comparisons). Prolonged second stage was associated with increased chorioamnionitis and third-degree or fourth-degree perineal lacerations. Neonatal morbidity with prolonged second stage included sepsis in nulliparous women (with epidural: 2.6% compared with 1.2% [adjusted odds ratio (OR) 2.08, 95% confidence interval (CI) 1.60-2.70]; without epidural: 1.8% compared with 1.1% [adjusted OR 2.34, 95% CI 1.28-4.27]); asphyxia in nulliparous women with epidural (0.3% compared with 0.1% [adjusted OR 2.39, 95% CI 1.22-4.66]) and perinatal mortality without epidural (0.18% compared with 0.04% for nulliparous women [adjusted OR 5.92, 95% CI 1.43-24.51]); and 0.21% compared with 0.03% for multiparous women (adjusted OR 6.34, 95% CI 1.32-30.34). However, among the offspring of women with epidurals whose second stage was prolonged (3,533 nulliparous and 1,348 multiparous women), there were no cases of hypoxic-ischemic encephalopathy or perinatal death.ConclusionsBenefits of increased vaginal delivery should be weighed against potential small increases in maternal and neonatal risks with prolonged second stage.Level of evidence: II.

Project description:ObjectiveTo evaluate maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor.MethodsRetrospective study of 2,518 women carrying singleton fetuses at 37 weeks of gestation or greater who underwent attempted forceps-assisted delivery, attempted vacuum-assisted vaginal delivery, or cesarean delivery from a low station in the second stage of labor. Primary outcomes were stratified by parity and included a maternal adverse outcome composite (postpartum hemorrhage, transfusion, endometritis, peripartum hysterectomy, or intensive care unit admission) and a neonatal adverse outcome composite (5-minute Apgar score less than 4, respiratory morbidity, neonatal intensive care unit admission, shoulder dystocia, birth trauma, or sepsis).ResultsIn nulliparous patients, the maternal adverse composite was not significantly different between women who underwent attempted forceps (12.1% compared with 10.8%, adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.40-1.34) or vacuum (8.3% compared with 10.8%, adjusted OR 0.68, 95% CI 0.40-1.16) delivery compared with cesarean delivery. Among parous women, the maternal adverse composite was not significantly different with attempted forceps (10.7% compared with 12.5%, adjusted OR 0.40, 95% CI 0.09-1.71) or vacuum (11.3% compared with 12.5%, adjusted OR 0.44, 95% CI 0.11-1.72) compared with cesarean delivery. Compared with neonates delivered by cesarean, the neonatal adverse composite was significantly lower among neonates born to nulliparous women who underwent attempted forceps (9.4% compared with 16.7%, adjusted OR 0.44, 95% CI 0.27-0.72) but not among those who underwent vacuum delivery (11.9% compared with 16.7%, adjusted OR 0.68, 95% CI 0.44-1.04). Among parous women, the neonatal adverse composite was not significantly different after attempted forceps (4.1% compared with 12.5%, adjusted OR 0.28, 95% CI 0.06-1.35) or vacuum (12.5% compared with 12.5%, adjusted OR 1.03, 95% CI 0.28-3.87) compared with cesarean delivery.ConclusionA trial of forceps delivery from a low station compared with cesarean delivery was associated with decreased neonatal morbidity among neonates born to nulliparous women.Level of evidenceII.

Project description:BackgroundThe cesarean delivery (CD) rate has been increasing globally. Trial of labor after cesarean delivery (TOLAC) has been used as a key method for the reduction of the CD rate. Little is known, however, about the association between the second-stage duration of TOLAC and adverse maternal and neonatal outcomes. This study evaluated the association between perinatal outcomes and the duration of second-stage labor in women undergoing TOLAC.MethodsA 10-year retrospective cohort study was performed at the Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, between January 2010 and January 2020. Women undergoing TOLAC who reached the second stage of labor were included in this study. Duration of the second stage of labor was examined as a categorical variable (group I: <0.5 h, group II: 0.5-2 h and group III: ≥2 h) and as a continuous variable to evaluate the association with adverse perinatal outcomes by using multivariable regression models and a Cox proportional hazards regression model adjusting for potential confounders.ResultsOf the 1,174 women who met the inclusion criteria, the median (interquartile range) length of the second stage was 0.5 h (0.3-0.9 h). Among them, 1,143 (97.4%) delivered vaginally and 31 underwent an unplanned CD. As the second-stage duration increased, operative vaginal delivery (OVD), CD, and postpartum hemorrhage (PPH) rates increased. Women in group III had higher risks of OVD (aOR = 11.34; 95% CI [5.06-25.41]), CD (aOR = 4.22; 95% CI [1.32-13.43]), and PPH (aOR = 2.43; 95% CI [1.31-4.50]) compared with group I. Correspondingly, blood loss and the oxytocin used to treat PPH increased significantly, while the postpartum hemoglobin reduced significantly in group III compared with group I. The incidence of uterine rupture, uterine atony, cervical laceration, red blood cell transfusion, and intensive care unit admission were similar in all three groups. Neonatal outcomes were not affected by the second-stage duration.ConclusionsWomen undergoing TOLAC with second-stage duration of ≥2 h have higher odds of OVD, unplanned intrapartum CD, and PPH.

Project description:BackgroundThis study aimed to investigate the effect of maternal age and duration of labor on perinatal and neonatal outcomes. The results of this study are expected to provide a basis to aid maternal and child health care personnel to implement health education for late childbearing women.MethodsThis was a retrospective observational study, wherein 9,241 parturients were included from 2016 to 2018. Parturients were divided into three groups based on age: <28 (n=2,911), 28-30 (n=3,631), and >30 (n=2,699) years. According to the total duration of labor, those who did not undergo cesarean section (CS) were subgrouped into <420 minutes (n=4,065) and ≥420 minutes (n=4,094) groups. A multivariate logistic regression model was used to investigate associations between age/total duration of labor group factors to different postpartum outcomes, including a switch to emergency CS, puerperal morbidity, abnormal fetal heart rate, and meconium-stained amniotic fluid (MSAF).ResultsThe rates of postpartum outcomes significantly differed in maternal age groups, including switch to emergency CS (9.07% vs. 13.03% vs. 11.23%; P<0.001), puerperal morbidity (6.32% vs. 6.46% vs. 5.00%; P=0.035), and abnormal fetal heart rate (25.34% vs. 28.21% vs. 25.67%; P=0.017). Of the comparisons between labor time groups, it was found that participants with longer labor time were also significantly higher in the use of episiotomy/forceps (46.61% vs. 69.77%; P<0.001), bleeding amount (381.35±108.02 vs. 389.60±146.40 mL; P=0.004), oxytocin use (25.03% vs. 39.56%; P<0.001), puerperal morbidity (1.98% vs. 6.86%; P<0.001), abnormal fetal heart rate (20.07% vs. 25.15%; P<0.001), and MSAF (26.53% vs. 31.91%; P<0.001). Multivariate logistic regression analysis showed that as age increased, the ORs of switching to emergency CS (1.58 and 1.87, both P<0.001) and having abnormal fetal heart rate (1.20 and 1.38; both P<0.01) also increased. Participants with longer labor time groups the ORs of puerperal morbidity (2.33; P<0.001) and MSAF (1.13; P=0.023) also increased.ConclusionsWith the adjustment of covariates. Higher maternal age seems associated to the risk of switching to emergency CS and having abnormal fetal heart rate; longer total duration of labor seems associated to the risk of puerperal morbidity and MSAF.

Project description:BackgroundOxytocin is effective in reducing labor duration, but can be associated with fetal and maternal complications such as neonatal acidosis and post-partum hemorrhage. When comparing discontinuing oxytocin in the active phase with continuing oxytocin infusion, previous studies were underpowered to show a reduction in neonatal morbidity. Thus, we aim at evaluating the impact of discontinuing oxytocin during the active phase of the first stage of labor on the neonatal morbidity rate.MethodsSTOPOXY is a multicenter, randomized, open-label, controlled trial conducted in 20 maternity units in France. The first participant was recruited January 17th 2020. The trial includes women with a live term (≥37 weeks) singleton, in cephalic presentation, receiving oxytocin before 4 cm, after an induced or spontaneous labor. Women aged < 18 years, with a lack of social security coverage, a scarred uterus, a multiple pregnancy, a fetal congenital malformation, a growth retardation <3rd percentile or an abnormal fetal heart rate at randomization are excluded. Women are randomized before 6 cm when oxytocin is either continued or discontinued. Randomization is stratified by center and parity. The primary outcome, neonatal morbidity is assessed using a composite variable defined by an umbilical arterial pH at birth < 7.10 and/or a base excess > 10 mmol/L and/or umbilical arterial lactates> 7 mmol/L and/or a 5 min Apgar score < 7 and/or admission in neonatal intensive care unit. The primary outcome will be compared between the two groups using a chi-square test with a p-value of 0.05. Secondary outcomes include neonatal complications, duration of active phase, mode of delivery, fetal and maternal complications during labor and delivery, including cesarean delivery rate and postpartum hemorrhage, and birth experience. We aim at including 2475 women based on a reduction in neonatal morbidity from 8% in the control group to 5% in the experimental group, with a power of 80% and an alpha risk of 5%.DiscussionDiscontinuing oxytocin during the active phase of labor could improve both child health, by reducing moderate to severe neonatal morbidity, and maternal health by reducing cesarean delivery and postpartum hemorrhage rates.Trial registrationClinical trials NCT03991091 , registered June 19th, 2019.

Dataset Information

Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity.

Publications

Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity.

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