Maternal and neonatal outcomes of prolonged second stage of labor with delayed pushing: A study of French Perinatal practices before and after guideline changes

Abstract

Objective

To describe the rate of prolonged second stage of labor in France before and after the publication of labor guidelines and to investigate the association of prolonged second stage with postpartum hemorrhage (PPH), perineal tears, and neonatal morbidity.

Methods

Data were obtained from the 2016 and 2021 French National Perinatal Surveys. For this cross-sectional analysis, we included patients with singleton pregnancies who gave birth to a term live neonate in cephalic presentation. Patients who did not reach full dilation, with a prior cesarean delivery or without an epidural were excluded. Prolonged second stage was defined as a duration from full dilation to delivery exceeding 3 h for nulliparous and 2 h for multiparous patients. Endpoints were severe PPH (>1000 ml blood loss or need for transfusion/embolization/surgery), severe perineal tears (third- and fourth degree), and neonatal morbidity (arterial cord pH < 7.10, 5-minute Apgar < 7, or NICU admission). Comparisons between periods were made using chi-square, Fisher, or Wilcoxon tests. Multivariable logistic regression and propensity score matching were used to control for confounders.

Results

Of 27,297 patients in the surveys, 13,063 met inclusion criteria (6,695 in 2016; 6,368 in 2021). Prolonged second stage was more frequent in 2021 (nulliparous: 24.9 % vs 11.4 %; multiparous: 14.9 % vs 10.2 %, both p < 0.01). Severe PPH increased (2.1 % in 2021 vs 1.3 % in 2016, p < 0.01), while severe perineal tears and neonatal morbidity did not differ significantly. Nulliparous patients with prolonged second stage had higher rates of severe PPH (3.4 % vs 1.6 %, p < 0.01) and severe perineal tears (2.1 % vs 1.3 %, p = 0.03), but not neonatal morbidity. Multiparous patients with prolonged second stage showed higher severe PPH (3.3 % vs 1.2 %, p < 0.01), but no significant differences in perineal tears or neonatal morbidity. Multivariable and propensity score analyses confirmed these associations.

Conclusion

Following the 2017 guidelines, the rate of prolonged second stage of labor in France increased, accompanied by higher severe PPH risk but not severe perineal tears or neonatal morbidity. Balanced clinical strategies are needed to optimize maternal and neonatal outcomes.