Influence of the second stage of labor on maternal and neonatal outcomes in vaginal births after caesarean section: a multicenter study in Germany

Duration time of labor progression for pregnant women of vaginal birth after cesarean in Hubei, China

OBJECTIVE

There have been limited reports on the duration of labor progression in pregnant women undergoing vaginal birth after cesarean (VBAC). This study aimed to investigate the duration of labor progression during VBAC in Hubei, China.

METHODS

A total of 359 pregnant women undergoing VBAC were enrolled as the VBAC group, meeting the following criteria: singleton pregnancy, gestational age ≥ 37 weeks, live birth, history of cesarean delivery, and a willingness to attempt a vaginal delivery. At the same time, 359 primiparas successfully undergoing vaginal delivery were randomly enrolled in the control group at a 1:1 ratio. Subsequently, the durations of the first, second, and third stages of labor were comparatively analyzed between the two groups.

RESULTS

The duration of the first, second, and total stages of labor in the VBAC group was significantly shorter than that in the control group (p < 0.05). There was no significant difference in the duration of the third stage of labor between the two groups (p > 0.05). The amount of blood loss, the rate of postpartum hemorrhage (PPH), and episiotomy were higher in the VBAC group than in the control group (p < 0.05). The rate of labor analgesia and intrapartum fever in the VBAC group was significantly lower than that in the control group (p < 0.05).

CONCLUSION

The duration of labor progression of the first, second, and total stages of VBAC is shorter than that in primiparous women in our observation in China.

Clinical analysis of complete uterine rupture during pregnancy

BACKGROUND

Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture.

METHODS

Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People's Hospital between January 2015 and December 2022 were analyzed retrospectively.

RESULTS

In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1-40+3 weeks), and the average bleeding volume was 1896.97 ml (200-6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%).

CONCLUSIONS

The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

Maternal outcomes using delayed pushing versus immediate pushing in the second stage of labour: An umbrella review

INTRODUCTION

Different systematic reviews have been developed in the last decades about maternal risks of immediate pushing and delayed pushing, depending on the duration of the second stage of labour, but they do not provide conclusive evidence.

AIM

The main aim of this overview of systematic reviews was to assess the maternal outcomes using delayed pushing and immediate pushing in the second stage of labour in women receiving epidural analgesia.

METHODS

We searched systematically in PubMed (Medline), EMBASE, CINAHL, and Scopus (October 26th, 2023). Methodological quality was analysed using AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. The outcome measures were the duration of the second stage of labour, duration of active pushing, caesarean section, instrumental vaginal birth, spontaneous vaginal birth, fatigue score, perineal lacerations, postpartum haemorrhage, and rate of episiotomy. Seven systematic reviews with and without meta-analysis were included.

RESULTS

Results showed that delayed pushing increases the total time of the second stage of labour, although delayed pushing decreases the duration of active pushing with moderate quality of evidence. Mixed results were found with respect to the variables instrumental vaginal birth, spontaneous vaginal birth, and fatigue score although the results favour delayed pushing or show no statistically significant differences with respect to immediate pushing. No favourable results were ever found for immediate pushing with respect to delayed pushing, with a limited quality of evidence. Even so, delayed pushing seems to be associated with a significant increase in spontaneous vaginal birth rates. The results found no significant differences between the immediate pushing and delayed pushing groups in the caesarean section rates, perineal lacerations, postpartum haemorrhage, and episiotomy ratio, with a limited quality of evidence.

CONCLUSIONS

This study shows that delayed pushing during the second stage of labour produces at least the same maternal outcomes as immediate pushing, although we note that delayed pushing produces an increase of the duration of the second stage of labour, a shorter duration of the active pushing and a tendency to increase spontaneous vaginal birth and to reduce the instrumental vaginal birth rates and fatigue scores. This should be considered clinically. This review was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42023397616).

Second stage duration and delivery outcomes among women laboring after cesarean with no prior vaginal delivery

BACKGROUND

We aimed to evaluate the association of the duration of the second stage with labor after cesarean (LAC) success and other outcomes among women with one prior cesarean delivery (CD) and no prior vaginal births.

METHODS

All women undergoing LAC that reached the second stage of labor from March 2011 to March 2020 were included in this retrospective cohort study. The primary outcome was the mode of delivery by second stage duration. The secondary outcomes included adverse maternal and neonatal outcomes. We allocated the study cohort into five groups of second stage duration. Further analysis compared <3 to ≥3 h of second stage based on prior studies. LAC success rates were compared. Composite maternal outcome was defined as the presence of uterine rupture/dehiscence, postpartum hemorrhage, or intrapartum/postpartum fever.

RESULTS

One thousand three hundred ninety seven deliveries were included. Vaginal birth after cesarean (VBAC) rates decreased as the second stage length time interval increased: 96.4% at <1 h, 94.9% at 1 to <2 h, 94.6% at 2 to <3 h, 92.1% at 3 to <4 h and 79.5% at ≥4 h (p < 0.001). Operative vaginal and CDs were significantly more likely as second stage duration time interval increased (p < 0.001). The composite maternal outcome was comparable among groups (p = 0.226). When comparing the outcomes of deliveries at <3 h versus ≥3 h, the composite maternal outcome and neonatal seizure rates were lower in the <3 h group (p = 0.041 and p = 0.047, respectively).

CONCLUSION

Vaginal birth after cesarean rates decreased as second stage time interval length increased. Even with prolonged second stage, VBAC rates remained relatively high. Increased risk of composite adverse maternal outcomes and neonatal seizures were observed when the second stage lasted 3 h or more.

Is early childhood development impeded by the birth timing of the younger sibling?

Background

This study investigated whether the timing of birth of the younger siblings was associated with the risk of the older siblings’ developmental vulnerability in early childhood.

Methods

Linkage of population-level birth registration, hospital, and perinatal datasets to Australian Early Development Census (AEDC) records (2009–2015), enabled follow-up of a cohort of 32,324 Western Australia born singletons. Children with scores <10^th percentile on an individual AEDC domain (Physical Health and Wellbeing; Social Competence; Emotional Maturity; Language and Cognitive Skills (school-based); and Communication Skills and General Knowledge) were classified as developmentally vulnerable. Modified Poisson Regression was used to estimate relative risks (RR) for associations between post-birth interpregnancy intervals (IPIs) and developmental vulnerability.

Results

Relative to post-birth IPIs of 18–23 months, post-birth IPIs of <6 and 6–11 months were associated with an increased risk of children being classified as DV1 (aRR 1.21, 95% CI: 1.11–1.31) and DV2 (aRR 1.31, 95% CI: 1.15–1.49); and DV1 (aRR 1.10, 95% CI: 1.03–1.17) and DV2 (aRR 1.21, 95% CI: 1.09–1.34), respectively. Post-birth IPIs of <6 months were associated with an increased risk on four of the five AEDC domains. Post-birth IPIs of 48–60 months were associated with an increased risk of developmental vulnerability; however, the risk was statistically significant for DV1, DV2 and the domains of Emotional Maturity and Language and Cognitive Skills (school-based).

Conclusions

Developmental vulnerability was associated with having a closely spaced younger sibling (<12 months post-birth IPIs). Optimising birth spacing should be further investigated as a potential means for improving child development outcomes.

Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods

Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.