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Prolonged second stage of labor is associated with low Apgar score

Abstract

There is no consensus on the effects of a prolonged second stage of labor on neonatal outcomes. In this large Swedish population-based cohort study, our objective was to investigate prolonged second stage and risk of low Apgar score at 5 min. All nulliparous women (n = 32,796) delivering a live born singleton infant in cephalic presentation at ≥37 completed weeks after spontaneous onset of labor between 2008 and 2012 in the counties of Stockholm and Gotland were included. Data were obtained from computerized records. Exposure was time from fully retracted cervix until delivery. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs). Adjustments were made for maternal age, height, BMI, smoking, sex, gestational age, sex-specific birth weight for gestational age and head circumference. Epidural analgesia was included in a second model. The primary outcome measure was Apgar score at 5 min <7 and <4. We found that the overall rates of 5 min Apgar score <7 and <4 were 7.0 and 1.3 per 1000 births, respectively. Compared to women with <1 h from retracted cervix to birth, adjusted ORs of Apgar score <7 at 5 min generally increased with length of second stage of labor: 1 to <2 h: OR 1.78 (95 % CI 1.19–2.66); 2 to <3 h: OR 1.66 (1.05–2.62); 3 to <4 h: OR 2.08 (1.29–3.35); and ≥4 h: OR 2.71 (1.67–4.40). We conclude that prolonged second stage of labor is associated with an increased risk of low 5 min Apgar score.

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Abbreviations

BMI:

Body mass index; body weight/length2, kg/m2

CI:

95 % Confidence interval

OR:

Odds ratio

SD:

Standard deviation

References

  1. Nordstrom L, Achanna S, Naka K, Arulkumaran S. Fetal and maternal lactate increase during active second stage of labour. BJOG Int J Obstet Gynaecol. 2001;108(3):263–8.

    Article  CAS  Google Scholar 

  2. Georgieva A, Moulden M, Redman CW. Umbilical cord gases in relation to the neonatal condition: the EveREst plot. Eur J Obstet Gynecol Reprod Biol. 2013;168(2):155–60. doi:10.1016/j.ejogrb.2013.01.003.

    Article  PubMed  Google Scholar 

  3. ACOG Committee Opinion No. 348, November 2006. Umbilical cord blood gas and acid–base analysis. Obstet Gynecol. 2006;108(5):1319–22.

    Article  Google Scholar 

  4. ACOG Practice Bulletin Number 49, December 2003. Dystocia and augmentation of labor. Obstet Gynecol. 2003;102(6):1445–54.

    Article  Google Scholar 

  5. Altman MR, Lydon-Rochelle MT. Prolonged second stage of labor and risk of adverse maternal and perinatal outcomes: a systematic review. Birth. 2006;33(4):315–22. doi:10.1111/j.1523-536X.2006.00129.x.

    Article  PubMed  Google Scholar 

  6. Le Ray C, Audibert F, Goffinet F, Fraser W. When to stop pushing: effects of duration of second-stage expulsion efforts on maternal and neonatal outcomes in nulliparous women with epidural analgesia. Am J Obstet Gynecol. 2009;201(4):361 e1–e7. doi:10.1016/j.ajog.2009.08.002.

  7. Cheng YW, Hopkins LM, Caughey AB. How long is too long: does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes? Am J Obstet Gynecol. 2004;191(3):933–8. doi:10.1016/j.ajog.2004.05.044.

    Article  PubMed  Google Scholar 

  8. Marsal K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B. Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatr. 1996;85(7):843–8.

    Article  PubMed  CAS  Google Scholar 

  9. Berglund S, Pettersson H, Cnattingius S, Grunewald C. How often is a low Apgar score the result of substandard care during labour? BJOG Int J Obstet Gynaecol. 2010;117(8):968–78. doi:10.1111/j.1471-0528.2010.02565.x.

    Article  CAS  Google Scholar 

  10. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anaesth Analg. 1953;32(4):260–7.

    CAS  Google Scholar 

  11. Ehrenstein V. Association of Apgar scores with death and neurologic disability. Clin Epidemiol. 2009;1:45–53.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Armstrong L, Stenson BJ. Use of umbilical cord blood gas analysis in the assessment of the newborn. Arch Dis Child Fetal Neonatal Ed. 2007;92(6):F430–4. doi:10.1136/adc.2006.099846.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  13. Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics. 1981;68(1):36–44.

    PubMed  CAS  Google Scholar 

  14. Ehrenstein V, Pedersen L, Grijota M, Nielsen GL, Rothman KJ, Sorensen HT. Association of Apgar score at five minutes with long-term neurologic disability and cognitive function in a prevalence study of Danish conscripts. BMC Pregnancy Childbirth. 2009;9:14. doi:10.1186/1471-2393-9-14.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Odd DE, Rasmussen F, Gunnell D, Lewis G, Whitelaw A. A cohort study of low Apgar scores and cognitive outcomes. Arch Dis Child Fetal Neonatal Ed. 2008;93(2):F115–20. doi:10.1136/adc.2007.123745.

    Article  PubMed  CAS  Google Scholar 

  16. Sun Y, Vestergaard M, Pedersen CB, Christensen J, Olsen J. Apgar scores and long-term risk of epilepsy. Epidemiology. 2006;17(3):296–301. doi:10.1097/01.ede.0000208478.47401.b6.

    Article  PubMed  Google Scholar 

  17. Menticoglou SM, Manning F, Harman C, Morrison I. Perinatal outcome in relation to second-stage duration. Am J Obstet Gynecol. 1995;173(3 Pt 1):906–12.

    Article  PubMed  CAS  Google Scholar 

  18. Saunders NS, Paterson CM, Wadsworth J. Neonatal and maternal morbidity in relation to the length of the second stage of labour. Br J Obstet Gynaecol. 1992;99(5):381–5.

    Article  PubMed  CAS  Google Scholar 

  19. Cohen WR. Influence of the duration of second stage labor on perinatal outcome and puerperal morbidity. Obstet Gynecol. 1977;49(3):266–9.

    PubMed  CAS  Google Scholar 

  20. Janni W, Schiessl B, Peschers U, Huber S, Strobl B, Hantschmann P, et al. The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome. Acta Obstet Gynecol Scand. 2002;81(3):214–21.

    Article  PubMed  Google Scholar 

  21. Rouse DJ, Weiner SJ, Bloom SL, Varner MW, Spong CY, Ramin SM, et al. Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol. 2009;201(4):357 e1–7. doi:10.1016/j.ajog.2009.08.003.

    Article  Google Scholar 

  22. Hagelin A, Leyon J. The effect of labor on the acid–base status of the newborn. Acta Obstet Gynecol Scand. 1998;77(8):841–4.

    Article  PubMed  CAS  Google Scholar 

  23. Allen VM, Baskett TF, O’Connell CM, McKeen D, Allen AC. Maternal and perinatal outcomes with increasing duration of the second stage of labor. Obstet Gynecol. 2009;113(6):1248–58. doi:10.1097/AOG.0b013e3181a722d6.

    Article  PubMed  Google Scholar 

  24. Laughon SK, Berghella V, Reddy UM, Sundaram R, Lu Z, Hoffman MK. Neonatal and maternal outcomes with prolonged second stage of labor. Obstet Gynecol. 2014;. doi:10.1097/AOG.0000000000000278.

    PubMed Central  PubMed  Google Scholar 

  25. Bleich AT, Alexander JM, McIntire DD, Leveno KJ. An analysis of second-stage labor beyond 3 hours in nulliparous women. Am J Perinatol. 2012;29(9):717–22. doi:10.1055/s-0032-1314894.

    Article  PubMed  Google Scholar 

  26. Yli BM, Kro GA, Rasmussen S, Khoury J, Noren H, Amer-Wahlin I, et al. How does the duration of active pushing in labor affect neonatal outcomes? J Perinat Med. 2012;40(2):171–8. doi:10.1515/JPM.2011.126.

    Google Scholar 

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Acknowledgment

The study was funded by the Swedish Research Council (No. 2008-423-57440-63, OS, http://www.vr.se/inenglish/researchfunding) and grants provided by the Stockholm County Council (ALF-project, OS, SC, http://www.forskningsstod.sll.se/Ansokan/start.asp). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard

This study was approved by the regional ethical vetting board in Stockholm, Sweden, nr 2009/275-31 and 2012/365-32. Patient data was retrieved from a medical record system, and there was no informed consent prior to inclusion in the study.

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Correspondence to Maria Altman.

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Altman, M., Sandström, A., Petersson, G. et al. Prolonged second stage of labor is associated with low Apgar score. Eur J Epidemiol 30, 1209–1215 (2015). https://doi.org/10.1007/s10654-015-0043-4

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  • DOI: https://doi.org/10.1007/s10654-015-0043-4

Keywords

  • Prolonged labor
  • Dystocia
  • Asphyxia
  • Neonatal outcome