Perinatal Outcomes with Longer Second Stage of Labor: A Risk Analysis Comparing Expectant Management to Operative Intervention

Abstract

Objective The aim of this study is to assess the impact of a prolonged second stage of labor on maternal and neonatal outcomes by comparing women who had expectant management versus operative intervention beyond specified timeframes in the second stage of labor.

Study Design Retrospective cohort including live singletons at ≥36 weeks who reached the second stage of labor. Expectant management (second stage >3, 2, 2, and 1 hour in nulliparas with an epidural, nulliparas without an epidural, multiparas with an epidural, and multiparas without an epidural, respectively) was compared with those who had an operative delivery (vaginal or cesarean) prior to these timeframes. The primary maternal outcome was a composite of postpartum hemorrhage, chorioamnionitis, operative complications, postpartum infections, and intensive care unit admission. The primary neonatal outcome was a composite of cord blood acidemia, 5-minute Apgar's score <5, chest compressions or intubation at birth, sepsis, seizures, birth injury, death, transfer to a long-term care facility, and respiratory support for >1 day.

Results Among 218 women, 115 (52.8%) had expectant management. Expectant management was associated with a significantly increased risk of the maternal composite (adjusted odds ratio [aOR]: 1.99, 95% confidence interval [CI]: 1.09–3.64) but not the neonatal composite (aOR: 1.54, 95% CI: 0.71–3.35).

Conclusion Expectant management of a prolonged second stage was associated with a higher rate of adverse maternal outcomes, but the rate of adverse neonatal outcomes was not significantly increased.

Keywords

cesarean - perinatal outcomes - prolonged labor - prolonged second stage - second stage of labor

Note

This study was presented as a poster at the Society for Maternal–Fetal Medicine 38th Annual Pregnancy Meeting, Dallas, TX, January 29 to February 3, 2018.

Publication History

Received: 08 August 2019

Accepted: 13 February 2020

Article published online:
24 March 2020

• References

• 1 Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Mathews TJ. Births: final data for 2015. Natl Vital Stat Rep 2017; 66 (01) 1-70
• 2 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176 (04) 455-460
• 3 Guise JM, Denman MA, Emeis C. , et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 2010; 115 (06) 1267-1278
• 4 Silver RM, Landon MB, Rouse DJ. , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
• 5 Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205 (6, Suppl): S2-S10
• 6 Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med 2011; 24 (11) 1341-1346
• 7 Caughey AB, Cahill AG, Guise JM, Rouse DJ. American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
• 8 Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol 2012; 120 (05) 1181-1193
• 9 American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin number 49, December 2003: dystocia and augmentation of labor. Obstet Gynecol 2003; 102 (06) 1445-1454
• 10 Caughey AB, Sundaram V, Kaimal AJ. , et al. Systematic review: elective induction of labor versus expectant management of pregnancy. Ann Intern Med 2009; 151 (04) 252-263 , W53-63
• 11 Rouse DJ, Weiner SJ, Bloom SL. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol 2009; 201 (04) 357.e1-357.e7
• 12 Le Ray C, Audibert F, Goffinet F, Fraser W. When to stop pushing: effects of duration of second-stage expulsion efforts on maternal and neonatal outcomes in nulliparous women with epidural analgesia. Am J Obstet Gynecol 2009; 201 (04) 361.e1-361.e7
• 13 Allen VM, Baskett TF, O'Connell CM, McKeen D, Allen AC. Maternal and perinatal outcomes with increasing duration of the second stage of labor. Obstet Gynecol 2009; 113 (06) 1248-1258
• 14 Laughon SK, Berghella V, Reddy UM, Sundaram R, Lu Z, Hoffman MK. Neonatal and maternal outcomes with prolonged second stage of labor. Obstet Gynecol 2014; 124 (01) 57-67