Awareness of time in labor does not preclude investigation of other factors contributing to maternal and neonatal morbidity

Abstract

We appreciate the comments of Ragusa et al regarding our recent publication.1Ragusa A. Rinaldo D. Svelato A. Too long does not always mean too much.Am J Obstet Gynecol. 2021; 224: 416Abstract Full Text Full Text PDF Scopus (2) Google Scholar,2Blankenship S.A. Raghuraman N. Delhi A. et al.Association of abnormal first stage of labor duration and maternal and neonatal morbidity.Am J Obstet Gynecol. 2020; 223: 445.e1-445.e15Abstract Full Text Full Text PDF Scopus (12) Google Scholar With our retrospective study design, we do not suggest causality but rather demonstrate an association of abnormal first stage of labor duration with maternal and neonatal morbidity. We agree that it is important to identify and intervene to correct the underlying causes of prolonged labor that contribute to associated morbidity. Underlying etiologies of prolonged labor include, but are not limited to, fetal size, maternal anthropometry, hypertensive disorders, nulliparity, labor induction, fetal head malposition, and inadequate uterine contractility. It is important to note that the causes of labor dystocia targeted by Ragusa et al,1Ragusa A. Rinaldo D. Svelato A. Too long does not always mean too much.Am J Obstet Gynecol. 2021; 224: 416Abstract Full Text Full Text PDF Scopus (2) Google Scholar such as “maternal stress” and “poor metabolic control,” are vague and lack high-quality evidence as contributors to abnormal labor. We comment that our study is limited in understanding the extent to which underlying risk factors for labor dystocia impact first stage of labor progression and resultant morbidity; moreover, future studies should evaluate how prolonged first stage of labor duration modifies the effect these risk factors have on maternal and neonatal morbidity. Underlying etiologies of prolonged labor duration are not always clear and are not all modifiable in the intrapartum period; thus, utilizing labor duration as a surrogate marker may be helpful to highlight the association of these underlying etiologies with morbidity. In addition, we appreciate the authors’ previous work suggesting that “comprehensive management” of labor has been shown to reduce the need for obstetrical interventions, including cesarean delivery.3Ragusa A. Gizzo S. Noventa M. Ferrazzi E. Deiana S. Svelato A. Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term.Arch Gynecol Obstet. 2016; 294: 753-761Crossref PubMed Scopus (16) Google Scholar,4Svelato A. Ragusa A. Manfredi P. General methods for measuring and comparing medical interventions in childbirth: a framework.BMC Pregnancy Childbirth. 2020; 20: 279Crossref PubMed Scopus (7) Google Scholar Our reference to expectantly managing a prolonged first stage of labor does not imply a lack of etiologic therapies but rather refers to continued active intrapartum management to achieve vaginal delivery compared with premature iatrogenic intervention with cesarean delivery. The referenced comprehensive labor management strategy is routinely practiced at our institution and is already reflected in our cohort. In addition, although Ragusa et al1Ragusa A. Rinaldo D. Svelato A. Too long does not always mean too much.Am J Obstet Gynecol. 2021; 224: 416Abstract Full Text Full Text PDF Scopus (2) Google Scholar report adverse outcomes in a low-risk community population remained unchanged irrespective of labor duration, their findings are unlikely to be generalizable to our high-risk population, with increased risk of both prolonged labor duration and adverse outcomes. In conclusion, we agree that centimetric curves of cervical dilation serve as a screening tool for labor dystocia. Labor partographs may provide obstetricians with an early warning signal for when more active labor management is indicated to address modifiable risk factors for labor dystocia and thereby facilitate women’s ability to express their potential for vaginal delivery while mitigating morbidity with the goal to achieve a positive childbirth experience. Too long does not always mean too muchAmerican Journal of Obstetrics & GynecologyVol. 224Issue 4PreviewWe read with concern the recent “Association of abnormal first stage of labor duration and maternal and neonatal morbidity.”1 The question is about the authors’ choice to compare a variable (in this case labor duration) with outcomes related to a complex event, such as childbirth. Because of the retrospective nature of the study, classifying first stage of labor duration as an independent variable may lead to incorrect considerations.2 In fact, the association between the duration of first stage of labor and maternal morbidity is namely an association and does not mean a causal relationship. Full-Text PDF