Prolonged Second Stage Of Labor Research Articles

Duration of the second stage of labour and risk of subsequent spontaneous preterm birth.

To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery. Retrospective cohort study. University hospital. Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded. Charts from 2007 to 2019 were reviewed. Rate of sPTB (<37weeks of gestation) in the second delivery. Of 13958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96-1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71-4.12; p<0.001), with a more pronounced risk in those with second-stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94-5.94; p<0.001). Second-stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage caesarean section, particularly if performed after a prolonged second stage. Second-stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth.

Prevalence of episiotomy practice and factors associated with it in Ethiopia, systematic review and meta-analysis.

An episiotomy is one of the most commonly performed obstetrics surgeries indicated in emergencies during the second stage of labor like fetal distress, dystocia, and tight perineum. As a result, this systematic review and meta-analysis aimed to assess the prevalence of episiotomy practice and associated factors in Ethiopia. Ten cross-sectional studies with a total population of 3718 were included in this study. The search was done using online databases like PubMed, HINARI, Web of Science, other gray, and online repositories of Universities. All the included papers were extracted and appraised using the standard extraction sheet format of JOANNA Briggs Institute. The Cochran Q-test and I2 statistics test were used to test the heterogeneity of studies. To detect the publication bias of the included studies, a funnel plot and Egger’s test were used. The pooled prevalence of episiotomy practice and the odds ratio with a 95% confidence interval were presented using forest plots. The overall pooled prevalence of episiotomy practice was 45.11% (95% CI; 37.04–53.18; I2 = 96.3%). Prolonged second stage of labor (OR: 4.79, 95% CI: 3.03, 7.57), face presentation (OR: 4.26, 95% CI: 1.21, 15.07), birth weight > 4000 g (OR: 6.71, 95% CI: 3.14–14.33), instrumental delivery (OR: 4.26, 95% CI 2.95, 6.14), and primiparity (OR: 3.70, 95% CI: 1.90, 7.2) were factors associated with episiotomy practice. The overall prevalence of episiotomy practice was higher in Ethiopia compared to studies conducted in other countries. The prolonged second stage of labor, face presentation, birth weight > 4000 g, instrumental delivery, and primiparity of women were the factors associated with episiotomy practice. Therefore, efforts should be made to prevent routine episiotomy practice through creating awareness, adjusting national guidelines, affecting the World Health Organization episiotomy policy, and monitoring the activities of the health care facilities in executing the protocols.

The mediating effect of the prolonged second stage of labor on delivery mode and urinary incontinence among postpartum women: evidence from Shandong, China.

This study was aimed at exploring the mediating role of the prolonged second stage of labor (PSSL) in the association between delivery mode and urinary incontinence (UI) among postpartum women in Shandong, China. A cross-sectional study involving postnatal women from the Women's Pelvic Floor Functional Health Center in Shandong, China, was conducted. An electronic questionnaire was used to collect the data between June 2020 and February 2021. UI was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Logistic regression and multiple linear regression were employed to explore the association among delivery mode, PSSL, and UI, and the mediating role of PSSL. Among the total of 5,586 postpartum women included in this study, the prevalence of UI was 13.3%. Among the 742 patients with UI, the prevalence of stress urinary incontinence (78.3%) was greater than urge urinary incontinence (8.6%), mixed urinary incontinence (9.3%), and others (3.8%). After adjusting for controlling variables, delivery mode was found to be significantly associated with PSSL, whereby women with vaginal delivery were more likely to be in PSSL, and women with PSSL had a higher probability of suffering from UI. PSSL played a partial mediating effect in delivery mode and UI. This study provided evidence that the effect of delivery mode on UI was partially mediated by PSSL among postpartum women in Shandong, China. Strategies to prevent PSSL should be actively adopted to reduce the risk of UI in women.

Maternal and Neonatal Outcomes in Twin Deliveries with Prolonged Second-Stage Duration of the Presenting Twin: a Retrospective Cohort Study.

To assess the risk of adverse maternal and neonatal outcomes as a function of the presenting twin second-stage duration. A retrospective cohort study of deliveries taking place in an academic medical center between 2005 and 2019. The study group included women with twin pregnancies with the first fetus in vertex presentation, who attempted vaginal delivery with epidural analgesia and attained the second stage of labor. Prolonged second stage (PSS) was defined as when exceeding the 95th percentile of presenting twin second-stage duration recorded among all parturients who achieved spontaneous vaginal deliveries in our center during the study period, stratified by parity: 3 h in nulliparas and 1 h in multiparas. Women with and without PSS were compared. The primary outcome was a composite of adverse maternal outcomes. A univariate analysis was conducted and followed by multivariate analysis. During the study period, 1,337 parturients (36% of twin deliveries) met study criteria, of these 22% (298) were nulliparous and 78% (1,039) were multiparous. The second stage of labor of the presenting twin was prolonged in 41 (13.8%) of the nulliparas and 64 (6.2%) multiparas. Prolonged second stage was associated with episiotomy, chorioamnionitis, endometritis, and blood product transfusion, as well as vacuum deliveries of the first and second twin, second-stage cesarean, and a higher rate of composite adverse maternal outcome in nulliparous (41.5% vs. 20.2%, p<0.01) and with higher rates of episiotomy, postpartum hemorrhage, and vacuum deliveries of the first and second twin, but a similar rate of composite adverse maternal outcome in multiparous women (7.8% vs. 9.3%, p=0.68); moreover, the composite adverse neonatal outcome was not increased in nulliparous (36.6% vs. 38.5%, p=0.81) nor in multiparous women (21.9% vs. 23.6%, p=0.75). Prolonged second stage of labor of the presenting twin was associated with an adverse composite maternal outcome in nulliparous and with postpartum hemorrhage in multiparous. Further larger studies are warranted to reinforce our findings.

“I Felt Something Coming Down Below”: A Case of POP

Pelvic floor disorders, which includes pelvic organ prolapse (POP), have shown an increasing prevalence among women worldwide. (Wu 2014) It is perceived as embarrassment and affect the women’s quality of life. A 68-year-old housewife, Para 3, complained of a 50-cent coin size lump coming down from her vagina since 2019, which could be reduced back manually inside the vagina. The symptom exacerbated by straining and carrying heavy objects. Ignoring the symptom, causing the lump to increase in size and protruded out from her vagina for the past 2 months. She had 3 SVD with maximum birth weight of 3.75kg and a prolonged second stage of labour in her second pregnancy. She was not aware and never practiced pelvic floor exercise nor taken any HRT. There were no urinary symptoms nor constipation. Her BMI is 25.2kg/m2. Abdominal examination was unremarkable. On speculum examination, vagina was atrophic and third degree uterine prolapse was evident. She was arranged to have Vaginal hysterectomy, anterior colporrhaphy and sacrospinous fixation done. The positive risk factors in this case are multiparity, menopausal status, a history of prolonged labor and frequent heavy lifting. The delay in presentation is due to lack of awareness. It was also found in a study that feeling of embarrassment and social stigma could be the reason. (Abhyankar 2019) Pelvic Floor exercise and avoidance of heavy lifting may be beneficial at onset of symptom. For conclusion, POP awareness is crucial to empower women to prevent POP and seek treatment as soon as they are symptomatic.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S24

Postpartum haemorrhage and associated factors among mothers who gave birth in South Gondar Zone public health facilities, Ethiopia: a cross-sectional study

BackgroundPostpartum haemorrhage is one of the direct and the leading causes of maternal morbidity and mortality. There are many risk factors of postpartum haemorrhage, which vary in different settings. Therefore,...

The impact of prolonged second stage in twins on perinatal outcomes.

To assess the duration of the second stage of labor in twin pregnancies in relation to maternal and neonatal outcomes. A retrospective study between 2014 and 2020. Eligible cases were twin pregnancies that reached the second stage. The pre-defined groups were based on the total time spent in the second stage of labor; Group 1 (<1h), group 2 (1-2h), and group 3 (>2h), which was considered the prolonged second stage group. Among the 439 planned vaginal births, successful vaginal delivery of both twins was achieved in 63.8%. Prolonged second stage was observed in 25.8% (89/345). Nulliparity (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.5-13.4) and use of epidural analgesia (OR 5.45, 95% CI 1.2-24.7), were the only independent variables significantly associated with prolonged second stage. Prolonged second stage was associated with a greater risk of intrapartum cesarean delivery (32.6%, P<0.001), combined delivery (10.1%, P<0.001), chorioamnionitis (8.3%, P=0.006) and a admission to neonatal intensive care unit of at least one of the twins (30.3%, P=0.02). Prolonged second stage of labor affects maternal and fetal outcome in twin pregnancies.

Cervical Dilation at the Time of Epidural Catheter Insertion Is Not Associated With the Degree of Prolongation of the First or Second Stages of Labor, or the Rate of Instrumental Vaginal Delivery

(Acta Obstet Gynecol Scand. 2020;99:1039–1049) Although epidural analgesia (EA) is used in over 60% of deliveries in Western countries with high patient satisfaction, it has been associated with risk of prolonged second stage of labor and instrumental vaginal delivery. The optimal time to administer EA based on cervical dilation is unknown, and whether the timing of its administration affects the duration of the first and second stages of labor or maternal or fetal outcomes. The aim of this study was to determine if the cervical dilation at the time of epidural placement impacts the duration of the first and/or second stage of labor and correlates with the rate of instrumental vaginal delivery.

Prophylactic manual rotation of occiput posterior and transverse positions to decrease operative delivery: the PROPOP randomized clinical trial

Persistent occiput posterior and occiput transverse positions are the most common malpositions of the fetal head during labor and are associated with prolonged second stage of labor, cesarean deliveries, instrumental deliveries, severe perineal tears, postpartum hemorrhage, and chorioamnionitis. Manual rotation is one of several strategies described to deal with these malpositions. This study aimed to determine if the trial of prophylactic manual rotation at the early second stage of labor is associated with a decrease in operative deliveries (instrumental and/or cesarean deliveries). We conducted a multicenter, open-label, randomized controlled trial in 4 French hospitals. Women with singleton term pregnancy and occiput posterior or occiput transverse position confirmed by ultrasound at the early second stage of labor and with epidural analgesia were eligible. Women were randomly assigned (1:1) to either undergo a trial of prophylactic manual rotation of occiput posterior or occiput transverse position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative delivery (instrumental and/or cesarean deliveries). The secondary outcomes were length of the second stage of labor, maternal complications (postpartum hemorrhage, operative complications during cesarean delivery, episiotomy and perineal tears), and neonatal complications (Apgar score of <5 at 10 minutes, arterial umbilical pH of <7.10, neonatal injuries, neonatal intensive care unit admission). The main analysis was focused on intention-to-treat analysis. From December 2015 to December 2019, a total of 257 women (mean age, 30.4 years; mean gestational age, 40.1 weeks) were randomized: 126 were assigned to the intervention group and 131 were assigned to the standard group. Operative delivery was significantly less frequent in the intervention group compared with the standard group (29.4% [37 of 126] vs 41.2% [54 of 131]; P=.047; differential [intervention-standard] [95% confidence interval]=-11.8 [-15.7 to-7.9]; unadjusted odds ratio [95% confidence interval]= 0.593 [0.353-0.995]). Women in the intervention group were more likely to have a significantly shorter second stage of labor. Trial of prophylactic manual rotation of occiput posterior or occiput transverse positions during the early second stage of labor was statistically associated with a reduced risk of operative delivery. This maneuver could be a safe strategy to prevention operative delivery.

Intrapartum Epidural Analgesia and Low Apgar Score Among Singleton Infants Born at Term: A Propensity Score Matched Study

(Acta Obstet Gynecol Scand. 2020;99:1155–1162) While the infant mortality in at-term births is low in Western countries, a recent trend has developed wherein birth asphyxia (based on low Apgar score) is the leading cause of death in term infants in the Netherlands who were admitted to a neonatal intensive care unit (NICU). Therefore, additional attention should be given to term neonates with low Apgar scores, and research on NICU admission should be emphasized as part of the assessment of perinatal health in this group of patients. The underlying risks for asphyxia include hypertensive disorders, maternal diabetes (both preexisting and gestational), non-cephalic presentation at birth, prolonged second stage of labor, and intrapartum epidural analgesia (EA). As EA is not generally used in the Netherlands, although its popularity has slowly increased in recent years, this environment is ideal for analyzing the effects of EA on full-term infants. This study aimed to assess the effects of EA on low Apgar score and subsequent NICU admission in term, singleton births and to analyze other underlying risk factors.

Maternal and Neonatal Complications Resulting From Vacuum-Assisted and Normal Vaginal Deliveries.

BackgroundOperative vaginal delivery is a procedure that is performed using forceps or vacuum to extract an infant from the birth canal. It has many indications, one of which is prolonged second stage of labor. Although rare, vacuum extraction (VE) can lead to various neonatal and maternal complications. The objective of this study was to compare the rates of different neonatal and maternal complications between vacuum-assisted deliveries and spontaneous vaginal deliveries.MethodsThis is a retrospective cohort study that was conducted in King Abdulaziz Medical City, Jeddah (KAMC-J), Saudi Arabia. The data were collected from the Labor and Delivery Unit at KAMC-J. A total of 745 samples was included (586 delivered spontaneously and 157 delivered by VE). Analysis was performed using the Statistical Package for Social Sciences (SPSS) Version 27.0.ResultsThe median age was 30 years (IQR=36-34). Of all deliveries, vacuum was used in 21.1%. Perineal tear was the most frequent maternal complication (20.9%), while caput succedaneum was the commonest neonatal complication (11.8%). Post-partum hemorrhage was significantly higher among vacuum deliveries (RR=18.8; 95% CI: 5.5-64.15), as well as cephalohematoma (RR=28.9; 95% CI: 8.79-95.04) and caput succedaneum (RR=18.6; 95% CI: 10.99-31.49). The first-minute Apgar score was lower with VE (p < 0.001), and higher perineal tear degrees were reported with VE (p < 0.001).ConclusionThe rates of maternal and neonatal complications were significantly higher among vacuum-assisted deliveries. The most serious neonatal complication was subgaleal hematoma, which is considered life-threatening. Further research is recommended to investigate subgaleal hematoma risk factors.

Neurohumoral and biochemical markers of prolonged second stage of labor

Objective:to study the role of neurohumoral and biochemical changes in the pathogenesis of prolonged second stage of labor.Material and methods.To achieve the above objective, we examined 35 parturient women with prolonged second stage of labor and 45 parturient women with physiological labor. We studied the levels of progesterone, estradiol, relaxin, serotonin, cholesterol, thiobarbituric acid reactive substances (TBARS), total antioxidant capacity of plasma, products of final protein oxidation, as well as the total concentrations of nitrite and nitrate ions (NOx) in blood plasma.Results.In the women with prolonged second stage of labor, the levels of estradiol and progesterone were significantly higher than in those with physiological childbirth (p1 = 0.037, p2 = 0.029). The women giving birth by operation had higher estradiol (p = 0.017) and progesterone (p = 0.07) levels than those giving birth physiologically. The level of relaxin was lower in the women with prolonged second period of labor than in those with physiological labor (p = 0.084), especially in the case of operative delivery (p = 0.041), the risk of which increases 4.1 times when the relaxin concentration is less than 36.4 ng/l. Compared to the patients giving physiological childbirth, the patients with prolonged second stage of labor who delivered by cesarean section had significantly higher TBARS levels (p = 0.043). Its concentration &gt; 180.3 μmol/l increases the risk of cesarean section almost by 12 times (p = 0.003).Conclusion.The hormonal aspect of the pathogenesis of prolonged second stage of labor is characterized by higher concentrations of steroid hormones — estradiol and progesterone, as well as by a lower level of relaxin in plasma. The biochemical aspect of the pathogenesis is represented by an increased concentration of lipid peroxidation products, which can be identified with severe physical fatigue in childbirth. The detected changes can be applied in the complex diagnostics of prolonged second stage of labor.

HUBUNGAN PENDAMPING SUAMI DENGAN KALA DUA LAMA PADA IBU BERSALIN

Old labor is one of the fourth leading causes of maternal mortality in Indonesia. The incidence of old childbirth in 2007 and 2012 is still the same, namely 5%.This study aims to study the relationship between birth companion and the incidence of prolonged second stage of labor among women in labor. This study used a survey analytical research design with a cross sectional approach. The study sample were 124 women in labor in Sakura Ward of Central Bengkulu Regional Hospital in 2019, who were taken by total sampling. Data to be analysed in this study were secondary data, that were collected using a checklist and data collection form as the study instruments. The results showed that of the 124 mothers who gave birth, 28.2% experienced prolonged second stage of labor and 71.8% did not experience it, 46.8% were not accompanied by their husbands and 53.2 were accompanied by their husbands. There was a significant relationship between the presence of a birth companion and the incidence of prolonged second stage of labor among women in labor. Women in labor who were not accompanied by their husbands were at risk of experiencing prolonged second stage of labor by 3.529 times compared to them who were accompanied by their husbands. It was concluded that there was a significant relationship between husbands companion and the incidence prolonged second stage of labor among women in labor. It is expected that this study can improve health services and appropriate screening to the incidence of prolonged second stage of labor among women in labor. Furthermore, husbands are expected to be present as the birth companion.

Ultrasound before operative vaginal delivery: why and how.

Safe management of the second stage of labor is important. Wait for spontaneous delivery, operative vaginal deliveries and second stage cesarean sections are all options when prolonged second stage occurs. The important question is which option to choose. Fetal head station and fetal head position are used to decide mode of delivery; this has traditionally been decided by performing a digital vaginal examination. Studies have shown that theses clinical examinations of both fetal head station and position are unreliable and that ultrasound might be better option. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) published in 2018 guidelines on intrapartum ultrasound and recommends that ultrasound is performed for ascertainment of fetal head position and station before considering or performing an instrumental vaginal delivery for slow progress or arrested labor in the second stage. The determination of the fetal head position, fetal head station and the movement of the fetal head can easily be determined with the help of ultrasound and can help the clinicians in making the right decision on how to proceed when prolonged second stage of labor is diagnosed.

Severe maternal and neonatal morbidity after attempted operative vaginal delivery

Operative vaginal delivery is a critical tool in reducing primary cesarean delivery, but declining operative vaginal delivery rates and concerns about provider skill necessitate a clear understanding of risks. These risks are ambiguous because most studies compare outcomes of operative vaginal delivery with that of spontaneous vaginal delivery rather than outcomes of cesarean delivery in the second stage of labor, which is usually the realistic alternative. This study aimed to compare severe maternal and neonatal morbidity by mode of delivery of patients with a prolonged second stage of labor who had a successful operative vaginal delivery, a cesarean delivery after failed operative vaginal delivery, or a cesarean delivery without an operative vaginal delivery attempt. We used a population-based database to evaluate nulliparous, term, singleton, vertex live births in California between 2007 and 2012 of patients with prolonged second stage of labor. Birth certificates and the International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses and procedures were used for ascertainment of exposure, outcome, and demographics. Exposure was mode of delivery of patients who had any operative vaginal delivery attempt vs cesarean delivery without operative vaginal delivery attempt. The outcomes were severe maternal morbidity and severe unexpected newborn morbidity, defined using established indices. Anticipating that the code for prolonged second stage of labor would represent only a fraction of true operative vaginal delivery candidates, a secondary analysis was conducted removing this restriction to explore granular outcomes in a larger cohort with unsuccessful labor. Multivariable logistic regression was used to compare outcomes by mode of delivery adjusted for measured confounders. Sensitivity analyses were done excluding patients with combined vacuum-forceps-assisted delivery and birthweight of >4000 g. A total of 9239 births after prolonged second stage of labor were included, where 6851 (74.1%) were successful operative vaginal deliveries, 301 (3.3%) were failed operative vaginal deliveries, and 2087 (22.6%) were cesarean deliveries without operative vaginal delivery attempts. Of successful operative vaginal deliveries, 6195 (90.4%) were vacuum assisted and 656 (10.6%) were forceps-assisted. Of failed operative vaginal deliveries where operative vaginal delivery type was specified, 83 (47.4%) were vacuum assisted, 38 (21.7%) were forceps-assisted, and 54 (30.9%) were combined vacuum-forceps-assisted. Of note, all 54 combined vacuum-forceps-assisted operative vaginal delivery attempts that we identified failed. The outcomes of patients with failed operative vaginal delivery differed from those with successful operative vaginal delivery, such as higher rates of comorbidities, use of combined operative vaginal delivery, and birthweight of >4000 g. Successful operative vaginal delivery was associated with reduced severe maternal morbidity (adjusted odds ratio, 0.55; 95% confidence interval, 0.39-0.78) without a difference in severe unexpected neonatal morbidity (adjusted odds ratio, 0.99; 95% confidence interval, 0.78-1.26). In contrast, failed operative vaginal delivery was associated with increased severe maternal morbidity (adjusted odds ratio, 2.14; 95% confidence interval, 1.20-3.82) and severe unexpected neonatal morbidity (adjusted odds ratio, 1.78; 95% confidence interval, 1.09-2.86). In addition, findings were similar in the secondary analysis of 260,585 patients with unsuccessful labor. In this large cohort of nulliparous, term, singleton, vertex births, successful operative vaginal delivery was associated with a 45% reduction in severe maternal morbidity without differences in severe unexpected neonatal morbidity compared with cesarean delivery after prolonged second stage of labor. Operative vaginal delivery infrequently failed and was associated with a 214% increase in severe maternal morbidity and a 78% increase in severe unexpected neonatal morbidity; furthermore, combined operative vaginal deliveries were major contributors to this, as all combined operative vaginal deliveries failed. Optimization of operative vaginal delivery success rates through means such as improved patient selection, enhanced provider skill, and discussions against combined operative vaginal delivery could reduce maternal and neonatal complications.

Prolonged second stage effect on pelvic floor dysfunction: a follow up survey to a randomized controlled trial

Background Pelvic floor dysfunction is a group of disorders that can significantly impact quality of life due to persistent urinary and anal incontinence. Data evaluating the effect of prolonged second stage of labor and postpartum pelvic floor dysfunction is heterogenous and limited. Objective To evaluate whether extending the length of labor in nulliparous women with prolonged second stage affects the presence of self-reported pelvic floor dysfunction after a randomized controlled trial of prolonged second stage. Study design We conducted a planned follow up survey to our randomized controlled trial of prolonged second stage of labor using the Pelvic Floor Distress Inventory-20 (PFDI-20). The primary outcome was the PFDI-20 summary score. Secondary outcomes included urinary and fecal incontinence, prolapse, and patient satisfaction. Women surveyed were nulliparous patients with epidural anesthesia, previously enrolled in a randomized controlled trial that assigned them to extended labor, at least 1 additional hour in the second stage if they were undelivered after three hours, or to usual labor, defined as expedited delivery after three hours in the second stage. Women were surveyed at 12 − 36 months postpartum. Results Thirty-four of the seventy-eight women responded to the survey (43.6%). 17 women (50.0%) were from the extended labor group and 17 from the usual labor group (50.0%). Maternal demographic data were not significantly different between groups. The PFDI-20 summary score was 13.8 ± 23.3 in the extended labor group and 13.1 ± 20.9 in the usual labor group (p = 0.9). The Pelvic Organ Prolapse Distress Inventory-6 was 1.2 ± 2.9 in the extended labor group and 2.7 ± 6.4 in the usual labor group (p = 0.4). The Colorectal-Anal Distress Inventory-8 was 0.8 ± 2.8 in the extended labor group and 2.1 ± 4.0 in the usual labor group (p = 0.6). The Urinary Distress Inventory-6 was 11.8 ± 21.1 in the extended labor group and 8.3 ± 14.5 in the usual labor group (p = 0.6). Maternal and neonatal outcomes, as well as patient satisfaction, were not statistically significantly different between groups. Conclusion Extending the length of labor in nulliparas with singleton gestations, epidural anesthesia, and prolonged second stage did not have an impact on PFDI-20 scores at 12–36 months postpartum. However, our study was underpowered to detect small, but potentially clinically important, differences. Clinical Trial Number NCT02101515 (Study Registration Date March 28, 2014) https://clinicaltrials.gov/ct2/show/NCT02101515

Maternal and Neonatal Outcomes Following a Prolonged Second Stage of Labor: A Meta-analysis of Observational Studies

(Abstracted from Eur J Obstet Gynecol Reprod Biol 2020;252:62–69) Prolonged second stage of labor and its impact on maternal and neonatal outcomes have been the focus of a number of research articles. Yet, strict consensus on these outcomes remains unclear.

3 Prophylactic Manual Rotation of Persistent Occiput Posterior to decrease operative Delivery: a Multicentric Randomized Trial

Persistent occiput posterior (POP) positions are the commonest malpresentations of the fetal head during labor and are associated with prolonged second stage of labor, cesarean, instrumental deliveries, obstetrical anal sphincter injuries, postpartum hemorrhage and chorioamnionitis. Manual rotation is one of several strategies described to deal with POP. The literature suggests that manual rotation of POP could decrease operative deliveries but no randomized study has confirmed these findings. The aim of this study was to determine if the trial of prophylactic manual rotation during the early second stage of labor is associated with a decrease risk of operative deliveries (instrumental and/or cesarean deliveries). This study was a prospective, randomized, controlled trial conducted in four French hospitals. Women with singleton term pregnancy and POP position confirmed by ultrasound at early second stage of labor and with epidural analgesia were eligible and randomized (1:1) to either receive the trial of prophylactic manual rotation of POP position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative deliveries (instrumental and/or cesarean deliveries). From December 2015 to December 2019, 257 women were randomized: 126 assigned to the intervention group and 131 to the standard group. The groups did not differ in baseline characteristics. Operative delivery was significantly less frequent in the intervention (I) group compared to the standard (S) group (29.4 vs. 41.2%, p=.047, Differentiel (I-S) [95% confidence interval, CI] = -11.8 [-15.7;-7.9]; relative risk [95% CI] = 0.71 [0.51-1.00]). Women in the intervention group were more likely to have a significant shorter second stage of labor and have a neonate with a significant higher Apgar score at 5 minutes. The were no differences in other secondary outcomes. Trial of prophylactic manual rotation of persistent POP positions during the early second stage of labor is associated with a decrease risk of operative delivery.

Risk Factors for Postpartum Hemorrhage and its Severe Forms with Blood Loss Evaluated Objectively - A Prospective Cohort Study.

To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively. This is a complementary analysis of a prospective cohort study that included pregnant women delivering vaginally. The total blood loss was obtained through the sum of the volume collected from the drape with the weight of gauzes, compresses and pads used by women within 2 hours. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. The risk factors for postpartum bleeding were evaluated using linear and logistic regression. We included 270 women. The mean blood loss at 120 minutes was 427.49 mL (±335.57 mL). Thirty-one percent (84 women) bled > 500 mL and 8.2% (22 women) bled > 1,000 mL within 2 hours. Episiotomy, longer second stage of labor and forceps delivery were related to blood loss > 500 mL within 2 hours, in the univariate analysis. In the multivariate analysis, only forceps remained associated with bleeding > 500 mL within 2 hours (odds ratio [OR] = 9.5 [2.85-31.53]). Previous anemia and episiotomy were also related to blood loss > 1,000mL. Prolonged second stage of labor, forceps and episiotomy are related to increased incidence of PPH, and should be used as an alert for the delivery assistants for early recognition and prompt treatment for PPH.

Liver laceration presented as intraabdominal bleeding in a newborn with hypoxic-ischemic encephalopathy

Abstract Objectives Birth injuries usually occur with two different mechanisms: trauma due to mechanic stress during labor and hypoxic-ischemic injury. Sometimes these two mechanisms can occur at the same time with a complex clinical picture. Case presentation The baby girl was born at 372/7 weeks after a prolonged second stage of labor, weighing 3,725 g, and was admitted to the Neonatal Intensive Care Unit with the diagnosis of hypoxic-ischemic encephalopathy. During follow up she developed multiorgan failure and severe anemia. On the third postnatal day, abdominal bleeding was detected. Laceration in the liver capsule was found and appeared to be the source of bleeding. Conclusions Abdominal bleeding secondary to mechanical laceration of the liver is hard to diagnose and may coexist with perinatal asphyxia.