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Lundborg L, Åberg K, Sandström A, Liu X, Tilden EL, Bolk J, Ladfors LV, Stephansson O, Ahlberg M. First stage of labour duration and associated risk of adverse neonatal outcomes. Sci Rep 2023; 13:12569. [PMID: 37532775 PMCID: PMC10397187 DOI: 10.1038/s41598-023-39480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
Prior evidence evaluating the benefits and harms of expectant labour duration during active first stage is inconclusive regarding potential consequences for the neonate. Population-based cohort study in Stockholm-Gotland region, Sweden, including 46,040 women (Robson 1), between October 1st, 2008 and June 15th, 2020. Modified Poisson regression was used for the association between active first stage of labour duration and adverse neonatal outcomes. 94.2% experienced a delivery with normal neonatal outcomes. Absolute risk for severe outcomes increased from 1.9 to 3.0%, moderate outcomes increased from 2.8 to 6.2% (> 10.1 h). Compared to the reference, (< 5.1 h; median), the adjusted relative risk (aRR) of severe neonatal outcome significantly increased beyond 10.1 h (> 90th percentile) (aRR 1.53, 95% CI 1.26, 1.87), for moderate neonatal outcome the aRR began to slowly increase beyond 5.1 h (≥ 50 percentile; aRR 1.40, 95% CI 1.24, 1.58). Mediation analysis indicate that most of the association was due to a longer active first stage of labour, 13% (severe neonatal outcomes) and 20% (moderate neonatal outcomes) of the risk was mediated (indirect effect) by longer second stage of labour duration. We report an association between increasing active first stage duration and increased risk of adverse neonatal outcomes. We did not observe a clear labour duration risk threshold.
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Affiliation(s)
- Louise Lundborg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Katarina Åberg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ellen L Tilden
- Department of Nurse-Midwifery, Oregon Health & Science University School of Nursing, Portland, OR, USA
- Department of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine, Portland, OR, USA
| | - Jenny Bolk
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden
| | - Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Mia Ahlberg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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Hamilton EF, Romero R, Tarca AL, Warrick PA. The evolution of the labor curve and its implications for clinical practice: the relationship between cervical dilation, station, and time during labor. Am J Obstet Gynecol 2023; 228:S1050-S1062. [PMID: 37164488 PMCID: PMC10445404 DOI: 10.1016/j.ajog.2022.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 03/18/2023]
Abstract
The assessment of labor progress is germane to every woman in labor. Two labor disorders-arrest of dilation and arrest of descent-are the primary indications for surgery in close to 50% of all intrapartum cesarean deliveries and are often contributing indications for cesarean deliveries for fetal heart rate abnormalities. Beginning in 1954, the assessment of labor progress was transformed by Friedman. He published a series of seminal works describing the relationship between cervical dilation, station of the presenting part, and time. He proposed nomenclature for the classification of labor disorders. Generations of obstetricians used this terminology and normal labor curves to determine expected rates of dilation and fetal descent and to decide when intervention was required. The analysis of labor progress presents many mathematical challenges. Clinical measurements of dilation and station are imprecise and prone to variation, especially for inexperienced observers. Many interrelated factors influence how the cervix dilates and how the fetus descends. There is substantial variability in when data collection begins and in the frequency of examinations. Statistical methods to account for these issues have advanced considerably in recent decades. In parallel, there is growing recognition among clinicians of the limitations of using time alone to assess progress in cervical dilation in labor. There is wide variation in the patterns of dilation over time and most labors do not follow an average dilation curve. Reliable assessment of labor progression is important because uncertainty leads to both over-use and under-use of cesarean delivery and neither of these extremes are desirable. This review traces the evolution of labor curves, describes how limitations are being addressed to reduce uncertainty and to improve the assessment of labor progression using modern statistical techniques and multi-dimensional data, and discusses the implications for obstetrical practice.
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Affiliation(s)
- Emily F Hamilton
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada; PeriGen Inc, Cary, NC.
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Adi L Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI
| | - Philip A Warrick
- PeriGen Inc, Cary, NC; Department of Biomedical Engineering, McGill University, Montreal, Canada
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Li PC, Tsui WL, Ding DC. The Association between Cervical Length and Successful Labor Induction: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1138. [PMID: 36673893 PMCID: PMC9859365 DOI: 10.3390/ijerph20021138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 06/17/2023]
Abstract
This study aimed to determine whether transvaginal sonographic measurement of cervical length before labor induction can predict successful induction. This retrospective study recruited 138 pregnant women who underwent labor induction at 37-41 weeks of gestation. Cervical length was measured using transvaginal ultrasonography before labor induction. Labor was induced according to the hospital protocol. Age, gestational age (GA), parity, body mass index (BMI), Bishop score, hemoglobin level, maternal disease, and epidural anesthesia were also recorded. Labor induction outcomes, including cesarean section for failed induction, time of induction, and the three labor stages, were assessed. From December 2018 to December 2021, 138 women were recruited for our study, including 120 and 18 women with successful and failed labor induction, respectively. Shorter cervical length (≤3.415 cm, OR = 6.22, 95% CI = 1.75-22.15) and multiparity (OR = 17.69, 95% CI = 2.94-106.51) were associated with successful induction. Higher BMI was associated with failed induction (OR = 0.87, 95% CI = 0.75-0.99). Age, GA, Bishop score, and fetal birth weight were not associated with successful labor induction. The ROC curve showed a cervical length cutoff value of 3.415 cm, revealing 76.8% of the area under the curve. In conclusion, a shorter cervical length (≤3.415 cm) was associated with a higher chance of successful labor induction (76.8%). This parameter might be used to predict the chance of successful labor induction. This information could help better inform clinician discussions with pregnant women concerning the chance of successful labor induction and consequent decision-making. Nevertheless, further large-scale clinical trials are warranted.
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Affiliation(s)
- Pei-Chen Li
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan
| | - Wing Lam Tsui
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
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Muacevic A, Adler JR. Effectiveness of Jacobson Relaxation and Lamaze Breathing Techniques in the Management of Pain and Stress During Labor: An Experimental Study. Cureus 2023; 15:e33212. [PMID: 36733553 PMCID: PMC9887925 DOI: 10.7759/cureus.33212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/01/2023] [Indexed: 01/03/2023] Open
Abstract
Background and objective The mother's ability to tolerate labor discomfort has an impact on how the labor progresses. Good pain management will boost mothers' ability to labor collaboratively and will shorten the time it takes for the uterus to open completely. Many women prefer not to use pharmaceutical or invasive pain relief during labor, which may have contributed to the popularity of complementary pain relief approaches. This study aimed to assess the effectiveness of the Jacobson relaxation technique and Lamaze breathing technique in the management of pain and stress during labor. Methods Thirty-six women aged between 25 and 35 years were randomly assigned to two groups for the purpose of this study. Group A received the Jacobson relaxation technique while Group B received the Lamaze breathing technique for four weeks. The patients were instructed to practice breathing techniques at the time of labor. The outcomes measure included the Numerical pain Rating Scale (NPRS) and Perceived Stress Scale (PSS), which would be measured before and after the delivery. Results The subjects showed improved labor pain and anxiety following the physiotherapy intervention. The results were found to be statistically significant (p<0.05). Conclusion Based on our findings, physiotherapy intervention plays an integral role in the multidisciplinary approach to relieving labor pain and helping patients have a normal vaginal delivery.
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Johansson K, Granfors M, Petersson G, Bolk J, Altman M, Cnattingius S, Liu X, Sandström A, Stephansson O. The Stockholm-Gotland perinatal cohort-A population-based cohort including longitudinal data throughout pregnancy and the postpartum period. Paediatr Perinat Epidemiol 2022; 37:276-286. [PMID: 36560891 DOI: 10.1111/ppe.12945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Register-based reproductive and perinatal databases rarely contain detailed information from medical records or repeated measurements throughout pregnancy and delivery. This lack of enriched pregnancy and birth data led to the initiation of the Swedish Stockholm-Gotland Perinatal Cohort (SGPC). OBJECTIVES To describe the strengths of the SGPC, as well as the unique research questions that can be addressed using this cohort. POPULATION The SGPC is a prospectively collected, population-based cohort that includes all births (from 22 completed gestational weeks onwards) between 1 January 2008 and 15 June 2020 in the Stockholm and Gotland regions of Sweden (N 335,153 singleton and N 11,025 multiple pregnancies). DESIGN Descriptive study. METHODS The SGPC is based on the electronic medical records of women and their infants. The medical record system is used for all antenatal clinic visits and admissions, delivery and neonatal admissions, as well as postpartum clinical visits. SGPC has been further enriched with data linkages to 10 Swedish National Health Care and Quality Registers. PRELIMINARY RESULTS In contrast to other reproductive and perinatal databases available in Sweden, including the Medical Birth Register and the Pregnancy Register, SGPC contains highly detailed medical record data, including time-varying serial measurements for physiological parameters throughout pregnancy, delivery, and postpartum, for both mother and infant. These strengths have enabled studies that were previously inconceivable; the effects of serial measurements of pregnancy weight gain, changes in haemoglobin counts and blood pressure during pregnancy, fetal weight estimations by ultrasound, duration of stages and phases of labour, cervical dilatation and oxytocin use during delivery, and constructing reference curves for umbilical cord pH. CONCLUSIONS The SGPC-with its rich content, repeated measurements and linkages to numerous health care and quality registers-is a unique cohort that enables high-quality perinatal studies that would otherwise not be possible.
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Affiliation(s)
- Kari Johansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Michaela Granfors
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Petersson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Bolk
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs´ Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset Karolinska Institutet, Stockholm, Sweden
| | - Maria Altman
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Pediatric Rheumatology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Cnattingius
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Tilden EL, Snowden JM, Bovbjerg ML, Cheyney M, Lapidus J, Wiedrick J, Caughey AB. The duration of spontaneous active and pushing phases of labour among 75,243 US women when intervention is minimal: A prospective, observational cohort study. EClinicalMedicine 2022; 48:101447. [PMID: 35783483 PMCID: PMC9249551 DOI: 10.1016/j.eclinm.2022.101447] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Friedman's curve, despite acknowledged limitations, has greatly influenced labour management. Interventions to hasten birth are now ubiquitous, challenging the contemporary study of normal labour. Our primary purpose was to characterise normal active labour and pushing durations in a large, contemporary sample experiencing minimal intervention, stratified by parity, age, and body mass index (BMI). METHODS This is a secondary analysis of the national, validated Midwives Alliance of North America 4·0 (MANA Stats) data registry (n = 75,243), prospectively collected between Jan 1, 2012 and Dec 31, 2018 to describe labour and birth in home and birth center settings where common obstetric interventions [i.e., oxytocin, planned cesarean] are not available. The MANA Stats cohort includes pregnant people who intended birth in these settings and prospectively collects labour and birth processes and outcomes regardless of where birth or postpartum care ultimately occurs. Survival curves were calculated to estimate labour duration percentiles (e.g. 10th, 50th, 90th, and others of interest), by parity and sub-stratified by age and BMI. FINDINGS Compared to multiparous women (n = 32,882), nulliparous women (n = 15,331) had significantly longer active labour [e.g., median 7.5 vs. 3.3 h; 95th percentile 34.8 vs. 12.0 h] and significantly longer pushing phase [e.g., median 1.1 vs. 0.2 h; 95th percentile 5.5 vs. 1.1 h]. Among nulliparous women, maternal age >35 was associated with longer active first stage of labour and longer pushing phase, and BMI >30 kg/m² was associated with a longer active first stage of labour but a shorter pushing phase. Patterns among multiparous women were different, with those >35 years of age experiencing a slightly more rapid active labour and no difference in pushing duration, and those with BMI >30 kg/m² experiencing a slightly longer active labour but, similarly, no difference in pushing duration. INTERPRETATION Nulliparous women had significantly longer active first stage and pushing phase durations than multiparous women, with further variation noted by age and by BMI. Contemporary US women with low-risk pregnancies who intended birth in settings absent common obstetric interventions and in spontaneous labour with a live, vertex, term, singleton, non-anomalous fetus experienced labour durations that were often longer than prior characterizations, particularly among nulliparous women. Results overcome prior and current sampling limitations to refine understanding of normal labour durations and time thresholds signaling 'labour dystocia'. FUNDING OHSU Nursing Innovation and OHSU University Shared Resources.
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Affiliation(s)
- Ellen L. Tilden
- Department Nurse-Midwifery, School of Nursing, Oregon Health and Science University , 577, 3181 SW Sam Jackson Park Rd., Portland, OR 97214, USA
- UpLift Lab, Oregon State University, Corvallis, OR, USA
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Corresponding author at: Department Nurse-Midwifery, School of Nursing, Oregon Health and Science University , 577, 3181 SW Sam Jackson Park Rd., Portland, OR 97214, USA.
| | - Jonathan M Snowden
- UpLift Lab, Oregon State University, Corvallis, OR, USA
- Oregon Health and Science University/Portland State University School of Public Health, Portland, OR, USA
| | - Marit L. Bovbjerg
- UpLift Lab, Oregon State University, Corvallis, OR, USA
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Melissa Cheyney
- UpLift Lab, Oregon State University, Corvallis, OR, USA
- Department of Anthropology, Oregon State University, Corvallis, OR, USA
| | - Jodi Lapidus
- Oregon Health and Science University/Portland State University School of Public Health, Portland, OR, USA
- Oregon Health and Science University Biostatistics and Design Program, Portland, OR, USA
| | - Jack Wiedrick
- Oregon Health and Science University/Portland State University School of Public Health, Portland, OR, USA
- Oregon Health and Science University Biostatistics and Design Program, Portland, OR, USA
| | - Aaron B. Caughey
- Department Nurse-Midwifery, School of Nursing, Oregon Health and Science University , 577, 3181 SW Sam Jackson Park Rd., Portland, OR 97214, USA
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
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Lundborg L, Åberg K, Sandström A, Liu X, Tilden E, Stephansson O, Ahlberg M. Association between first and second stage of labour duration and mode of delivery: A population-based cohort study. Paediatr Perinat Epidemiol 2022; 36:358-367. [PMID: 34964511 DOI: 10.1111/ppe.12848] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied. OBJECTIVES To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery. METHODS A population-based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm-Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second-stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first-stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios. RESULTS Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non-linear trend is seen, demonstrated by a plateau in the second-stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80). CONCLUSIONS Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second-stage duration, with applications in obstetric and perinatal epidemiology.
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Affiliation(s)
- Louise Lundborg
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Åberg
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sandström
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women´s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Xingrong Liu
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ellen Tilden
- Department of Nurse-Midwifery, Oregon Health & Science University School of Nursing, Portland, OR, USA.,Department of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine, Portland, OR, USA
| | - Olof Stephansson
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women´s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Mia Ahlberg
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women´s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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