Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Am J Perinatol. 2024 May;41(S 01):e312-e317. doi: 10.1055/a-1877-8770. Epub 2022 Jun 16.
The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice.
The study design comprises secondary analysis of the Consortium for Safe Labor, which included 228,688 deliveries at 19 hospitals between 2002 and 2008. We included the 107,675 women who were undergoing a trial of labor without a prior uterine scar or history of substance abuse, who reached the second stage, with a liveborn, nonanomalous, vertex, singleton, at term of at least 2,500 g. Maternal complications included postpartum fever, hemorrhage, blood transfusion, thrombosis, intensive care unit (ICU) admission, hysterectomy, and death. For maternal complications, we simulated the clinical choice by comparing operative vaginal or cesarean deliveries to continued expectant management at every hour in the second stage. For neonatal complications, we modeled the risk of severe neonatal complication by second stage duration for spontaneous vaginal deliveries only, adjusting for maternal demographics, comorbidities, and delivery hospital. Severe neonatal complications included death, asphyxia, hypoxic-ischemic encephalopathy (HIE), seizure, sepsis with prolonged stay, need for mechanical ventilation, and 5-minute Apgar score <4.
Maternal morbidity was higher with operative vaginal/cesarean delivery versus continued expectant management for every hour in the second stage, a difference that was statistically significant at hour 2 (18.4 vs. 14.7%; <0.01). Overall, 951 (0.88%) deliveries were complicated by a severe neonatal complication. A second stage over 4 hours was associated with an adjusted odds of severe neonatal complication of 2.10 (95% confidence interval [CI]: 1.32-3.34) as compared with women who delivered in the first hour.
There is a trade-off between maternal and neonatal morbidity in the second stage of labor. Serious neonatal complications rise throughout, however, there is no time at which maternal morbidity is improved with a cesarean or operative vaginal delivery. Strategies are needed to identify neonates at highest risk of complication for targeted intervention.
· Severe neonatal complications increase with every hour in the second stage.. · Shortening the second stage is associated with higher maternal complications at every hour.. · There is a trade-off between maternal and neonatal morbidity in the second stage..
本研究旨在以接近临床选择的方式分析第二产程中的产妇发病率。
本研究设计包括对安全分娩联盟的二次分析，该联盟包括 2002 年至 2008 年间 19 家医院的 228688 例分娩。我们纳入了 107675 名正在进行试产且无子宫瘢痕或药物滥用史的女性，这些女性进入第二产程，分娩出活产、非畸形、头位、单胎、体重至少为 2500 克。产妇并发症包括产后发热、出血、输血、血栓形成、入住重症监护病房（ICU）、子宫切除术和死亡。对于产妇并发症，我们通过在第二产程的每小时比较阴道助产或剖宫产与继续期待管理，模拟临床选择。对于新生儿并发症，我们仅通过第二产程时间为阴道分娩建模严重新生儿并发症的风险，调整产妇人口统计学、合并症和分娩医院。严重新生儿并发症包括死亡、窒息、缺氧缺血性脑病（HIE）、癫痫发作、败血症伴延长住院时间、需要机械通气和 5 分钟 Apgar 评分<4。
与第二产程每小时继续期待管理相比，阴道助产/剖宫产的产妇发病率更高，这在第 2 小时具有统计学意义（18.4%比 14.7%；<0.01）。总体而言，951 例（0.88%）分娩并发严重新生儿并发症。第二产程超过 4 小时与严重新生儿并发症的调整比值比为 2.10（95%置信区间[CI]：1.32-3.34），而第一小时分娩的产妇则为 1.00。
第二产程中存在产妇和新生儿发病率之间的权衡。然而，随着时间的推移，严重的新生儿并发症不断增加，没有任何时间可以通过剖宫产或阴道助产来改善产妇发病率。需要制定策略来识别并发症风险最高的新生儿，以便进行针对性干预。
第二产程每小时严重新生儿并发症增加。
缩短第二产程与每小时更高的产妇并发症相关。
第二产程中存在产妇和新生儿发病率之间的权衡。
