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OBSTETRICS

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

Résumé

Objectif : Déterminer si la prolongation du deuxième stade du travail exerce une influence sur l’âge gestationnel dans le cadre de l’accouchement subséquent

Méthodes : Nous avons mené une étude de cohorte rétrospective Les renseignements cliniques ont été récupérés à partir de la McGill Obstetrical and Neonatal Database pour la période allant de janvier 2001 à février 2008 Nous nous sommes penchés sur les femmes primipares présentant une grossesse monofœtale à terme qui ont atteint le deuxième 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

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ont été réparties en deux groupes, en fonction de la durée du deuxième stade : « accouchement après plus de trois heures en présence d’une dilatation cervicale totale » ou « accouchement dans un délai de trois heures » L’incidence de l’accouchement préterme spontané dans le cadre de la grossesse subséquente constituait le critère d’évaluation principal

Résultats : Chez les 1 818 femmes dont les dossiers étaient disponibles aux fins de l’analyse, 416 femmes (22,9 %) avaient connu une prolongation du deuxième stade du travail au cours de leur premier accouchement Les femmes ayant connu une prolongation du deuxième stade du travail au cours de leur première grossesse n’ont pas accouché de façon prématurée plus fréquemment dans le cadre de leur grossesse subséquente que les femmes n’ayant pas connu une prolongation du deuxième stade du travail (taux d’accouchement préterme : 4,3 % au sein du groupe « prolongation du deuxième stade du travail » et 5,5 % au sein du groupe « deuxième stade normal »; P = 0,3)

Conclusion : Au sein de notre population de femmes primipares ayant connu un accouchement à terme à la suite d’une grossesse monofœtale, une prolongation du deuxième stade du travail au-delà de trois heures n’a pas été associée à la survenue d’un accouchement préterme dans le cadre de la grossesse subséquente

J Obstet Gynaecol Can 2015;37(4):324–329

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 4000 g), 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 (3564 g ± 419 vs. 3373 g ± 418; 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 hours ± 1.1 vs. 0.7

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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

● 244 instrumental delivery ● 97 Caesarean section n = 679 Induction of labour or elective
● 244 instrumental delivery ● 97 Caesarean section n = 679 Induction of labour or elective

n = 679

Induction of labour or elective Caesarean section at second delivery

n = 1818

Spontaneous onset of labour at second delivery (or induction of labour for accepted reasons)

= RESEARCH GROUP

induction of labour for accepted reasons) = RESEARCH GROUP n = 416 STUDY GROUP Prolonged second
induction of labour for accepted reasons) = RESEARCH GROUP n = 416 STUDY GROUP Prolonged second

n = 416

STUDY GROUP

Prolonged second stage at index delivery

n = 1402

CONTROL GROUP

Normal second stage at index delivery (≤ 3 h)

hours ± 0.8; P < 0.001), delivered babies with higher mean birth weight (3500 g ± 539 vs. 3428 g ± 495; 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,

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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

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

Characteristic

Prolonged second stage (> 3 h) n = 416

Normal second stage (≤ 3 h) 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

Risk factors for preterm birth

Prolonged second stage (> 3 h) in the index pregnancy n = 416

Normal second stage (≤ 3 h) in index pregnancy 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

Characteristics

Prolonged second stage (> 3 h) in the index pregnancy n = 416

Normal length second stage (≤ 3 h) in index pregnancy) 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

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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 organization 17 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

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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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