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

Abstract

Objectives-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 ≥ 36 weeks of gestation without prior cesarean (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

Joint Modelling of Competing Risks and Current Status Data: An Application to a Spontaneous Labour Study

“…Recently, Grantz et al . () have combined the mode of delivery with morbidity status at delivery into multiple competing causes to analyse the data. Though this latest analytical strategy accounts for the competing causes, it is still limited in its ability to compare changes in risks for competing causes of delivery with changes in risks of morbidities over time.…”

“…Consistent with Grantz et al . (), any maternal or neonatal morbidity comprised of serious maternal complications including postpartum haemorrhage, blood transfusion, Caesarean hysterectomy and intensive care unit admission or death, as well as neonatal serious complications including shoulder dystocia with fetal injury (clavicular fracture, Erbs palsy, Klumpkes palsy or hypoxic ischaemic encephalopathy), a need for continuous positive airway pressure resuscitation or higher, neonatal intensive care unit length of stay greater than 72 h, sepsis, pneumonia, hypoxic–ischaemic encephalopathy or periventricular leukomalacia, seizure, intracranial haemorrhage or periventricular haemorrhage, asphyxia or neonatal death.…”

“…We defined the duration of the second stage of labour as the difference between the date and time of birth from the date and time of 10‐cm cervical dilation as recorded in the maternal medical record. We used the same analytic cohort corresponding to the studies of the second stage of labour, using the same exclusion and inclusion criteria as presented in the primary papers on second‐stage labour for the CSL (Laughon et al ., ; Grantz et al ., ). In particular, women who had an antepartum stillbirth, prior uterine incision or failed to reach the second stage of labour were excluded; deliveries which had recorded date and time of birth in the maternal medical record were included.…”

“…Recently, Grantz et al . () assessed the recommendations under a competing risks framework for multiple modes of delivery with or without morbidities. However, they did not simultaneously assess the competing risks that are associated with each mode of delivery and risks for the onset of morbidities given baseline maternal characteristics.…”

“…There have been several studies to reveal the association of maternal and neonatal outcomes to the length of the second stage of labour (Myles and Santolaya, 2003;Cheng et al, 2004), or to the mode of delivery during the second stage of labour (Murphy et al, 2001;Myles and Santolaya, 2003;Allen et al, 2009), but none of them thoroughly investigated both of the events jointly. Recently, Grantz et al (2018) assessed the recommendations under a competing risks framework for multiple modes of delivery with or without morbidities. However, they did not simultaneously assess the competing risks that are associated with each mode of delivery and risks for the onset of morbidities given baseline maternal characteristics.…”