OBSTETRICS
Prolonged Second Stage of Labour and the
Risk for Subsequent Preterm Birth
Yael Sciaky-Tamir, MD, Alon Shrim, MD, Richard N. Brown, MD, FRCOG
McGill University Health Centre, Montreal QC
Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Royal Victoria Hospital, McGill University, Montreal QC
Abstract
Objective: To assess whether prolonged second stage of labour
influences the gestational age at the subsequent delivery.
Methods: We performed a retrospective cohort study. Clinical
information was retrieved from the McGill Obstetrical and Neonatal
Database for the period of January 2001 to February 2008. We
evaluated primiparous women with term singleton pregnancies who
reached the second stage of labour. Women were divided into two
groups, according to the duration of the second stage: delivery after
more than three hours of full cervical dilatation, or delivery within
three hours. The primary outcome measured was the incidence of
spontaneous preterm births at the subsequent delivery.
Results: Among 1818 women whose records were available for
analysis, 416 women (22.9%) had a prolonged second stage of
labour in their first delivery. Women with a prolonged second stage
in their first delivery did not deliver prematurely more often in the
successive delivery than those women whose second stage was
not prolonged (rate of preterm birth 4.3% in the prolonged second
stage group and 5.5% in the normal second stage group; P = 0.3).
Conclusion: In our population of primiparous women with a singleton
term delivery, a prolonged second stage of labour lasting more
than three hours was not associated with preterm birth at their
subsequent delivery.
Rsum
Objectif: Dterminer si la prolongation du deuxime stade du travail
exerce une influence sur lge gestationnel dans le cadre de
laccouchement subsquent.
Mthodes: Nous avons men une tude de cohorte rtrospective.
Les renseignements cliniques ont t rcuprs partir de la
McGill Obstetrical and Neonatal Database pour la priode allant
de janvier 2001 fvrier 2008. Nous nous sommes penchs sur
les femmes primipares prsentant une grossesse monoftale
terme qui ont atteint le deuxime stade du travail. Ces femmes
Key Words: Cervical incompetence, preterm birth, prolonged
second stage of labour, risk factors
Competing Interests: None declared.
Received on August 29, 2014
Accepted on October 29, 2014
324 l APRIL JOGC AVRIL 2015
ont t rparties en deux groupes, en fonction de la dure du
deuxime stade: accouchement aprs plus de trois heures en
prsence dune dilatationcervicale totale ou accouchement
dans un dlai de trois heures. Lincidence de laccouchement
prterme spontan dans le cadre de la grossesse subsquente
constituait le critre dvaluation principal.
Rsultats: Chez les 1818femmes dont les dossiers taient
disponibles aux fins de lanalyse, 416femmes (22,9%) avaient
connu une prolongation du deuxime stade du travail au cours
de leur premier accouchement. Les femmes ayant connu une
prolongation du deuxime stade du travail au cours de leur
premire grossesse nont pas accouch de faon prmature
plus frquemment dans le cadre de leur grossesse subsquente
que les femmes nayant pas connu une prolongation du deuxime
stade du travail (taux daccouchement prterme: 4,3% au sein du
groupe prolongation du deuxime stade du travail et 5,5% au
sein du groupe deuxime stade normal; P=0,3).
Conclusion: Au sein de notre population de femmes primipares
ayant connu un accouchement terme la suite dune grossesse
monoftale, une prolongation du deuxime stade du travail
au-del de trois heures na pas t associe la survenue dun
accouchement prterme dans le cadre de la grossesse subsquente.
J Obstet Gynaecol Can 2015;37(4):324329
INTRODUCTION
P
reterm birth complicates 5% to 12% of pregnancies
worldwide and is responsible for significant morbidity
and mortality in neonates.1,2 It results principally from the
occurrence of spontaneous preterm labour and also to some
extent from cervical insufficiency.3,4 Among commonly
accepted pathophysiologic mechanisms responsible for
spontaneous preterm labour are inflammation, placental
abruption, infection, vascular disease or ischemia, and over-
distension of the uterus.2,5 In addition, several causes for
cervical insufficiency, which is typically responsible for late
second trimester and early third trimester birth, have been
proposed as causes of preterm birth.2,6 Uterine anomalies,
alterations in collagen content or other supportive
substances in the cervix, and exposure to diethylstilbestrol
 Prolonged Second Stage of Labour and the Risk for Subsequent Preterm Birth
are the congenital causes. Cervical trauma resulting from
gynaecological procedures such as dilatation and curettage,
cervical conization, or obstetric injury during labour
contribute to the acquired causes.6
Several reports have proposed that prolonged second stage
of labour represents a period of vulnerability in which
there is a potential risk for long-term cervical injury.7,8 The
aim of our study was to examine whether a prolonged
second stage of labour in a delivery at term increases the
risk for subsequent preterm birth.
METHODS
We conducted a retrospective cohort study of women
who gave birth in consecutive pregnancies at the McGill
University Health Centre in Montreal, Quebec. Clinical
information was retrieved from the McGill Obstetrical
and Neonatal Database (MOND), for the period of
January 2001 to February 2008. The MOND database is
a computerized obstetric and neonatal database that was
created in 1978. Maternal and neonatal data are coded soon
after discharge for all deliveries at the McGill University
Health Centre in Montreal, Quebec. A dedicated medical
coding clerk codes the maternal and infant charts; three
professionals (a nurse, an obstetrician, and a neonatologist)
assess items that require interpretation to be coded.
We included in the study cohort all primiparous women
with a singleton pregnancy who had a trial of labour at
term (>37+0 weeks) and who reached the second stage
of labour. The cohort was divided into study and control
groups according to the duration of the second stage of
labour in this index pregnancy; the study group included
women who delivered after a prolonged second stage,
defined as longer than three hours, and the control group
consisted of women who delivered after a second stage
of normal duration (within three hours of full cervical
dilatation). All women were assessed in their subsequent
delivery. In order to exclude cases of iatrogenic preterm
labour, we excluded women who had labour induced for
their subsequent delivery for all reasons other than preterm
premature rupture of membranes, chorioamnionitis,
vaginal bleeding, and cervical dilatation, which are
factors or diagnoses that might themselves contribute to
spontaneous preterm births. In addition, we searched for
specific risk factors for preterm birth in this population.
Analysis was done in three steps: first, demographic and
obstetric data were collected and compared for women in
both groups, including gestational age at delivery, duration
of the second stage of labour, birth weight, rate of
macrosomia (defined as birth weight above 4000g), type
of analgesia, and mode of delivery (spontaneous vaginal,
instrumental, or Caesarean section).
Next, we focused on women in each group whose prenatal
care and delivery in their next pregnancy were at our
institution. We compared the two groups for differences in
obstetric risk factors for preterm birth.
Finally, in those women who had a subsequent delivery at
our institution, we compared the gestational age at delivery
and the rate of preterm birth in the two groups.
Statistical analysis was performed using SPSS version 11
(IBM Corp., Armonk NY), using multiple linear regression,
Student t test and chi square or Fisher exact as appropriate.
Significance was set at a P value of 0.05.
Ethics approval for the study was provided by the MUHC
Research Ethics Board.
RESULTS
During the study period, 2497 primiparous women gave
birth at the McGill University Heath Centre and then had a
subsequent delivery at the same institution. Of these, 1818
women had a spontaneous onset of labour in their second
pregnancy, or had labour induced for reasons potentially
associated with or related to spontaneous preterm birth.
Of these 1818 women, 416 had a prolonged second
stage of labour in their first pregnancy (study group) and
1402 had a second stage of normal duration in their first
pregnancy (control group) (Figure).
Demographic and labour-related data for the index
deliveries are presented in Table 1. Women in the study
group delivered babies with a higher mean (SD) weight
(3564g419 vs. 3373g418; P<0.001), a higher rate
of macrosomia (13% vs. 6.9%; P<0.001), and higher rates
of both instrumental delivery (20.4% vs. 11.3%; P<0.001)
and Caesarean section (18.3% vs. 1.5%; P<0.001). In
addition, this group had a higher rate of use of epidural
analgesia (93.3% vs. 83.7%; P<0.001).
The two groups did not differ with regard to any of the
known risk factors for preterm birth that were recorded,
other than marital status and smoking (Table 2).
Obstetric data from the subsequent delivery for the
study and control groups are presented in Table 3. The
two groups did not differ significantly in either the mean
gestational age at delivery or the rate of preterm birth
(4.3 % vs. 5.5 %; P=0.3). As in their index delivery, the
study group had a significantly longer mean duration
of the second stage of labour (0.9 hours1.1 vs. 0.7
APRIL JOGC AVRIL 2015 l 325
Obstetrics

Flow chart of study population

n = 2497

Primiparous women with term

spontaneous onset of labour

2156 vaginal birth

244 instrumental delivery
97 Caesarean section

n = 679 n = 1818

Induction of labour or Spontaneous onset of labour

elective Caesarean section at second delivery (or
at second delivery induction of labour for
accepted reasons)

= RESEARCH GROUP

n = 416 n = 1402
STUDY GROUP CONTROL GROUP
Prolonged second stage Normal second stage
at index delivery at index delivery ( 3 h)

hours0.8; P<0.001), delivered babies with higher mean
birth weight (3500g539 vs. 3428g495; P=0.01),
and had a higher incidence of macrosomic infants (13.7%
vs. 10.3%; P=0.05).
DISCUSSION
It has been hypothesized that a prolonged second stage of
labour might result in, or contribute to, a degree of intrinsic
damage to the cervix, and that this in turn might result
in an increased incidence of preterm birth in subsequent
pregnancies.6,7 In our study, primiparous women who
delivered at term in their first delivery after a prolonged
second stage (>3 hours) did not deliver prematurely more
often in their next delivery than women whose second
stage was not prolonged.
We found that women who had a prolonged second stage
of labour in the index pregnancy were more likely to have
had an instrumental vaginal delivery or Caesarean section
and to have had epidural analgesia, as has been described
previously.9,10 When compared with the control population,
these women gave birth to larger babies and had a greater
proportion of macrosomic babies; this might account, in
part, for the longer duration of the second stage and the
subsequent mode of delivery.11 We found that these women
also tended to have a longer second stage of labour in their
subsequent delivery, and to have larger babies than the
control population.
In order to control for recurrent pregnancy losses or second
trimester losses that might have occurred between the
two deliveries, we performed a multiple linear regression
analysis with gravidity as the independent variable. The
gravidity at the first delivery, and the increase in gravidity
between the first and second delivery had no correlation
with the gestational age at the second delivery. In addition,
the two groups of women had similar prevalences of risk
factors for preterm birth in their subsequent delivery,
including social drug use, alcohol consumption during
pregnancy, and low education level.12,13 The only differences
in risk factors were the rate of smoking and marital status.
Being single or separated is cited by some authors as a risk
factor for preterm birth.2,4 Women in our study group were

326 l APRIL JOGC AVRIL 2015

 Prolonged Second Stage of Labour and the Risk for Subsequent Preterm Birth

Table 1. Demographic and labour characteristics for primiparous women who reached the
second stage of labour in their first pregnancy
Prolonged second Normal second
stage (> 3 h) stage ( 3 h)
Characteristic n = 416 n = 1402 P
Mean maternal age, years SD 30.2 4.2 29.1 4.5 < 0.001
Mean gestational age at delivery, weeks SD 40.0 1.1 39.7 1.2 < 0.001
Mean birth weight, g SD 3564 419 3373 418 < 0.001
Macrosomic babies, > 4000 g, n (%) 54 (13.0) 97 (6.9) < 0.001
Instrumental delivery, n (%) 85 (20.4) 159 (11.3) < 0.001
Caesarean section, n (%) 76 (18.3) 21 (1.5) < 0.001
Epidural analgesia, n (%) 388 (93.3) 1174 (83.7) < 0.001
Mean duration of second stage, hours SD 4.6 1.9 1.4 0.8 < 0.001

Table 2. Risk factors for preterm birth identified during the subsequent pregnancy
Prolonged second Normal second
stage (> 3 h) in the stage ( 3 h) in
index pregnancy index pregnancy
Risk factors for preterm birth n = 416 n = 1402 P
Smoking in pregnancy 9 (2.2) 61 (4.4) 0.04
Alcohol consumption in pregnancy* 1 (0.24) 8 (0.6) 0.69
Social drugs in pregnancy 1 (0.24) 7 (0.5) 0.69
Low education status 16 (3.9) 83 (5.9) 0.10
Marital status; single/separate 23/412 (5.6) 163/1390 (11.7) <0.001
3 miscarriages or abortions 13 (3.1) 58 (4.1) 0.35
All data are shown as n (%).
*Alcohol use defined as one drink or more per day.
Social drugs data (marijuana use only).
Low education status defined as six years of schooling or less.
Total number of patients in this category reflects incomplete data for some women.

Table 3. Characteristics of the subsequent labour and delivery

Prolonged second Normal length
stage (> 3 h) in the second stage ( 3 h) in
index pregnancy index pregnancy)
Characteristics n = 416 n = 1402 P
Maternal age, years SD 32.5 4.3 31.6 4.5 < 0.001
Gestational age at delivery, weeks SD 39.3 1.9 39.3 1.7 0.8
Preterm birth, < 37.0 week, n (%) 18 (4.3) 77 (5.5) 0.3
Mean birth weight, g SD 3500 539 3427 495 0.01
Macrosomic babies, > 4000 g, n (%) 57 (13.7) 145 (10.3) 0.05
Mean duration of second stage, hours SD 0.9 1.1 0.7 0.8 < 0.001

APRIL JOGC AVRIL 2015 l 327

Obstetrics
less likely to be single or separated. Determining whether
this may have had contributed protectively to the risk of
preterm birth was beyond the scope of our study.
The duration of the second stage of labour has been
studied extensively with regard to its effect on successful
vaginal delivery, neonatal outcome, and early maternal
complications,9,10,14 but little attention has been paid
to its possible effect on a subsequent delivery. Clinical
observation has led some investigators to suggest that
trauma to the cervix, sustained during the second stage
of labour, might contribute to the etiology of cervical
incompetence. Vyas et al. found a significant increase in
the risk for preterm birth in women who had experienced
a prolonged second stage in a previous delivery, and
hypothesized that structural injury occurs during that
period.7 Koyama et al. described their experience with
two cases of prolonged second stage in women at term,
both of whom eventually delivered by Caesarean section.8
These women had a preterm birth in their next pregnancy.
The authors suggested that the mechanical insult during
surgery to the completely effaced cervix was the underlying
contributor to cervical insufficiency.8
The ability of the cervix to support a pregnancy to full term
relies on its strength and the loads imposed upon it during
pregnancy.15 An insult to the cervix during delivery might
theoretically affect the intrinsic strength of the cervix. Such
an injury might be caused from the prolonged stretching
of the tissues by the descending fetal head, or by direct
mechanical injury to the cervical tissue during a Caesarean
section at full dilatation. Our findings do not support this
theory. The cervix undergoes qualitative changes as it
progresses through the stages of ripening and dilatation;
there is a decrease in the collagen concentration due to an
increase in collagen solubility and degradation, together with
an increase in both hyaluronan and glycosaminoglycans.16
We speculate that these changes in collagen structure and
tissue organization17 protect the cervix from any mechanical
injury that might otherwise be acquired consequent to either
prolonged distension or a surgical incision.
It is also possible that such an injury, sustained during
labour, is effectively repaired when the cervical tissue is
replenished with mature collagen.16,17
One of the strengths of this study is the large size of
our study cohort (1818 women). Obstetric risk factors
for preterm birth across both study groups were similar.
Although we assessed only primiparous women who
delivered a singleton fetus at term, we determined that
gravidity had no influence on gestational age at the time
of the second delivery. This allowed us to control for
328 l APRIL JOGC AVRIL 2015
risk factors for preterm birth that might have arisen from
pregnancy losses, including second trimester miscarriages,
recurrent miscarriages, and abortions or miscarriages
managed with dilatation and curettage.
Our study has some limitations. We used a retrospective
approach, and were consequently unable to extract data on
some risk factors (such as ethnic origin and BMI) that were
not consistently available from the records for the period
under study.
Another limitation in our study was the lack of detail with
respect to the proportions of the second stage of labour
that had passive or active (i.e., with pushing) management.
We believe, however, that this information is unlikely
to have had a major influence on our results, because
stretching of the cervix is present in all cases of prolonged
second stage of labour, whether or not maternal pushing
efforts are made.
To our knowledge, this is the largest study to date to
have specifically addressed the question of whether
a prolonged second stage of labour might increase
the risk of subsequent preterm birth. Cervical trauma
(e.g., amputation, conization, laceration) has long been
recognized as a risk factor for cervical insufficiency and
preterm birth. The findings of this study however, provide
further evidence for the recuperative abilities of the cervix.
This recuperative ability is most likely associated with the
physiological changes that the cervix undergoes during
labour and delivery and in the immediate postpartum
period when the cervix is replenished with collagen.
Sustained trauma, particularly outside of this period,
would not benefit from these restorative processes. This
further emphasizes that the pathogeneses of preterm birth
and of cervical insufficiency are complex and multifaceted.
CONCLUSION
In a group of primiparous women delivering at term, those
who experienced a second stage of labour of greater than
three hours duration did not have an increase in the risk
for preterm birth at their next delivery.
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