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Prolonged second stage of labor is associated with low Apgar score


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


95 % Confidence interval


Odds ratio


Standard deviation


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The study was funded by the Swedish Research Council (No. 2008-423-57440-63, OS, and grants provided by the Stockholm County Council (ALF-project, OS, SC, 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).

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  • Prolonged labor
  • Dystocia
  • Asphyxia
  • Neonatal outcome