Duration of labor and maternal and neonatal morbidity

Abstract

Labor dystocia has been identified as a contributor to the rising cesarean delivery rate in the United States. Allowing more time for vaginal delivery, while being cognizant of maternal and neonatal outcomes, has been identified as a possible strategy to lower cesarean delivery rates. This study aimed to characterize the relationship between the duration of active phase and second-stage labor and maternal and neonatal morbidity. We present a secondary analysis of the Consortium on Safe Labor project. From labors of 66,940 nonanomalous nulliparous term singleton vertex gestations, we excluded labors for which active phase (≥6 cm dilation) or second stage durations could not be calculated and from sites that did not report determinants of morbidity. For each duration of active phase or second stage labor (grouped in 1-hour increments), the adjusted maternal and neonatal composite morbidity was estimated by and compared with the morbidity associated with a duration <1 hour total and a duration of 1 hour shorter. After exclusions, 48,144 deliveries remained. In adjusted models, compared with labor durations <1 hour total, maternal composite morbidity was significantly higher across active phase and second stage durations (both P<.001); neonatal composite morbidity was higher across the second stage (P<.001), but not active phase (P=.07) duration. These relationships appear linear with no apparent inflection point, and morbidity increases more rapidly. When compared with labor durations 1 hour shorter, significant differences persisted in maternal and neonatal composite morbidity in second stage labor only through 4 and 3 hours, respectively. Maternal and neonatal composite morbidity is greater with longer durations of active and second stage labor; however, no clear cutoff point was determined to suggest truncation of either stage of labor for reasons of morbidity. In addition, incrementally higher morbidities that were noted vs duration <1 hour total were obscured when comparison was made with labors 1 hour shorter, which suggests that focusing on short differences in duration of labor may mask important underlying trends.