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Am J Perinatol 2024; 41(S 01): e312-e317
DOI: 10.1055/a-1877-8770
Original Article

Maternal Morbidity in the Second Stage of Labor: Analysis to Simulate the Clinical Choice

Sarah E. Little
1   Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
,
Mark A. Clapp 
2   Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston, Massachusetts
,
Sarah Lassey
1   Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
,
Radek Bukowski
3   Division of Maternal-Fetal Medicine, University of Texas, Austin, Texas
,
William H. Barth Jr
2   Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston, Massachusetts
,
Julian Robinson
1   Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
› Author Affiliations
Funding None.
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Abstract

Objective The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice.

Study Design The study design comprises secondary analysis of the Consortium for Safe Labor, which included 228,688 deliveries at 19 hospitals between 2002 and 2008. We included the 107,675 women who were undergoing a trial of labor without a prior uterine scar or history of substance abuse, who reached the second stage, with a liveborn, nonanomalous, vertex, singleton, at term of at least 2,500 g. Maternal complications included postpartum fever, hemorrhage, blood transfusion, thrombosis, intensive care unit (ICU) admission, hysterectomy, and death. For maternal complications, we simulated the clinical choice by comparing operative vaginal or cesarean deliveries to continued expectant management at every hour in the second stage. For neonatal complications, we modeled the risk of severe neonatal complication by second stage duration for spontaneous vaginal deliveries only, adjusting for maternal demographics, comorbidities, and delivery hospital. Severe neonatal complications included death, asphyxia, hypoxic-ischemic encephalopathy (HIE), seizure, sepsis with prolonged stay, need for mechanical ventilation, and 5-minute Apgar score <4.

Results Maternal morbidity was higher with operative vaginal/cesarean delivery versus continued expectant management for every hour in the second stage, a difference that was statistically significant at hour 2 (18.4 vs. 14.7%; p <0.01). Overall, 951 (0.88%) deliveries were complicated by a severe neonatal complication. A second stage over 4 hours was associated with an adjusted odds of severe neonatal complication of 2.10 (95% confidence interval [CI]: 1.32–3.34) as compared with women who delivered in the first hour.

Conclusion There is a trade-off between maternal and neonatal morbidity in the second stage of labor. Serious neonatal complications rise throughout, however, there is no time at which maternal morbidity is improved with a cesarean or operative vaginal delivery. Strategies are needed to identify neonates at highest risk of complication for targeted intervention.

Key Points

  • Severe neonatal complications increase with every hour in the second stage.

  • Shortening the second stage is associated with higher maternal complications at every hour.

  • There is a trade-off between maternal and neonatal morbidity in the second stage.

Keywords

labor - second stage - neonatal complications - maternal morbidity

Note

This study was presented at the 40th Annual Meeting of the Society of Maternal-Fetal Medicine, Dallas, Texas February 3 to 8, 2020.




Publication History

Received: 27 August 2021

Accepted: 03 June 2022

Accepted Manuscript online:
16 June 2022

Article published online:
12 September 2022

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