Does stage of labor at time of cesarean delivery affect risk of subsequent preterm birth?

Levine, Lisa D.; Sammel, Mary D.; Hirshberg, Adi; Elovitz, Michal A.; Srinivas, Sindhu K.

doi:10.1016/j.ajog.2014.09.035

Cited by 58 publications

(106 citation statements)

References 18 publications

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“…Our previous work demonstrated an increased risk of spontaneous PTB (sPTB) in a subsequent pregnancy when a full term cesarean delivery is performed in the second stage of labor as compared to when it is performed in the first stage or labor or compared to women with a term vaginal delivery 6 . Prior to this work, a term cesarean delivery in the second stage of labor was not identified as a risk factor for sPTB.…”

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confidence: 99%

Length of second stage of labor and preterm birth in a subsequent pregnancy

Levine

Srinivas

2016

American Journal of Obstetrics and Gynecology

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Background During the second stage of labor, it is plausible that the pressure of the fetal head against a completely dilated cervix may lead to changes in the cervical integrity and cervical strength lending it susceptible to premature dilation in a subsequent pregnancy. Therefore, a prolonged second stage of labor has been hypothesized to be a risk factor for cervical insufficiency and spontaneous preterm birth (sPTB). Objective To evaluate the effect that the length of second stage of labor in one pregnancy has on the risk of spontaneous preterm birth (sPTB) in a subsequent pregnancy. Study Design This was a planned secondary analysis of a large retrospective cohort study of women with two consecutive deliveries at our institution from 2005–2010. Women with a term pregnancy that reached the second stage were included; women with a prior sPTB were excluded. The primary outcome was sPTB <37 weeks. A prolonged second stage was defined as ≥3hrs. Fisher’s exact tests were used to compare categorical data. Linear and logistic regression was used to calculate odds. Results 757 women were included. The overall length of the second stage ranged from 0–7.3 hours. The sPTB rate in a subsequent pregnancy was 8.7%. There was no association between length of second stage (hours) as a continuous variable and sPTB after adjusting for confounders (aOR 0.83 [0.58–1.20]). A prolonged second stage ≥3hrs occurred in 48 (6.3%) women. Women with a second stage ≥3hours were older, less likely to be African American, and were less likely to be overweight or obese as compared to women with a second stage <3 hours. The women with second stage ≥3 hours were more likely to be nulliparous and have a larger neonate. The sPTB risk was not different between a second stage ≥3hrs (10.4%) and <3hrs (7.9%), p=0.5. The sPTB risk was; however, modified by mode of delivery in the second stage. There was no difference in sPTB rate among women with a vaginal delivery when comparing those with and without a prolonged second stage (7.4 vs. 7.8%, p=0.9). There also was no difference among women with a cesarean when comparing those with and without a prolonged second stage (11.8 vs. 14.3%, p=0.8). While not statistically significant, the absolute risk of a subsequent sPTB after a cesarean delivery with a second stage ≥3hrs is twice as high as the risk of a sPTB after a vaginal delivery with a second stage ≥3hrs (OR 2.08 [0.32–13.78]). Conclusions A prolonged second stage of labor alone does not increase the risk of sPTB in a subsequent pregnancy. Cesarean delivery after a prolonged second stage of labor may confer a possible increased risk. It is important to continue to evaluate potential risk factors for sPTB. If these risk factors are confirmed in future studies, it will aid in the counseling of women and may open the door for therapeutic strategies to be studied among these newly identified “at-risk” women.

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Length of second stage of labor and preterm birth in a subsequent pregnancy

Levine

Srinivas

2016

American Journal of Obstetrics and Gynecology

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“…3 In this study, the investigators found a 6-fold higher odds of SPTB for women with a second-stage CD compared with women with a first-stage CD (adjusted odds ratio [aOR], 5.8 [95% CI 1.08–30.8]).…”

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“…The concern about cervical lacerations or cervical extensions contributing to the increased risk has also been postulated as a possible etiology for subsequent SPTB after a second-stage CD. 3,7 …”

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“…Although several studies have failed to show a significant association between cervical lacerations or extensions in a prior pregnancy and subsequent SPTB, these studies have been limited by small sample sizes and lack of characterization of the depth/degree of these extensions into the cervix. 3,7,15,16 Larger studies are needed because this may be an area of significant concern; for example, one of these studies reported a significant increased incidence of SPTB of 13.5% with prior cervical extensions at CD vs 2.3% in controls ( P = .005). 3 …”

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confidence: 99%

“…3,7,15,16 Larger studies are needed because this may be an area of significant concern; for example, one of these studies reported a significant increased incidence of SPTB of 13.5% with prior cervical extensions at CD vs 2.3% in controls ( P = .005). 3 …”

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Cesarean in the second stage: a possible risk factor for subsequent spontaneous preterm birth

Berghella

Gimovsky

Levine

et al. 2017

American Journal of Obstetrics and Gynecology

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Second stage cesarean section and the risk of preterm birth in subsequent pregnancies

Offringa

Paret

Vayssière

et al. 2022

Intl J Gynecology & Obste

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Objective To evaluate the risk of spontaneous preterm birth on subsequent pregnancies after second stage cesarean section. Methods This is a retrospective cohort study. Women were included if they had their two consecutive births in Toulouse University Hospital in the study period. The first birth was a singleton livebirth at term (≥37 weeks of gestation), divided in three categories according to the mode of delivery: vaginal delivery (group A), cesarean section before the second stage of labor (group B), cesarean section during the second stage of labor (group C). The subsequent pregnancy was the first subsequent pregnancy, conducted after 16 weeks of gestation. The primary outcome was spontaneous preterm birth in the subsequent pregnancy, defined as delivery before 37 weeks of gestation. Secondary endpoints included preterm rupture of membranes in the subsequent pregnancy. Results Between 2003 and 2018, 7776 women (84.7%) in group A, 1263 (13.8%) in group B and 143 (1.5%) in group C were included. The adjusted odds ratio of spontaneous preterm birth before 37 weeks of gestation after second stage cesarean section was 2.4 (group C vs group A + B, 95% confidence interval: 1.2–4.8), P = 0.01). The rate of preterm rupture of membranes was also significantly higher in group C (6% vs 2% in group A, P = 0.009, 6% vs 3% in group B, P= 0.05) with OR = 3.0 (group C vs group A + B, 95% CI: 1.55–6.16, P < 0.001). Conclusion History of term second stage of labor cesarean section is an independent risk factor for spontaneous preterm birth and for preterm rupture of membrane in the subsequent pregnancy.

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Does stage of labor at time of cesarean delivery affect risk of subsequent preterm birth?

Cited by 58 publications

References 18 publications

Length of second stage of labor and preterm birth in a subsequent pregnancy

Length of second stage of labor and preterm birth in a subsequent pregnancy

Cesarean in the second stage: a possible risk factor for subsequent spontaneous preterm birth

Second stage cesarean section and the risk of preterm birth in subsequent pregnancies

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