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Neonatal and Maternal Outcomes With Prolonged Second Stage of Labor

Laughon, S. Katherine MD, MS; Berghella, Vincenzo MD; Reddy, Uma M. MD, MPH; Sundaram, Rajeshwari PhD; Lu, Zhaohui MS; Hoffman, Matthew K. MD, MPH

doi: 10.1097/AOG.0000000000000278
Contents: Original Research
Journal Club
Correction

OBJECTIVE: To assess neonatal and maternal outcomes when the second stage of labor was prolonged according to American College of Obstetricians and Gynecologists guidelines.

METHODS: Electronic 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.

RESULTS: Prolonged 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.

CONCLUSIONS: Benefits of increased vaginal delivery should be weighed against potential small increases in maternal and neonatal risks with prolonged second stage.

LEVEL OF EVIDENCE: II

Prolonged second stage is associated with vaginal delivery rates of 80–87% for nulliparous women and 89–96% for multiparous women but with small increases in maternal and serious neonatal morbidity.

Epidemiology Branch, the Biostatistics and Bioinformatics Branch, and Glotech, Inc, Division of Intramural Population Health Research, and the Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania; and the Division of Education & Research, Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware.

Corresponding author: S. Katherine Laughon, MD, MS, Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd Room 7B03, Bethesda, MD 20892; e-mail: laughonsk@mail.nih.gov

Supported by the Intramural Research Program of the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The Consortium on Safe Labor was funded by the Intramural Research Program of the NICHD through Contract No. HHSN267200603425C.

For a list of institutions involved in the Consortium, please see the Appendix online at http://links.lww.com/AOG/A497.

Presented at the Annual Society for Maternal-Fetal Medicine Meeting, February 11–16, 2013, San Francisco, California.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists.