Second stage of labor beyond 4 h in nulliparous patients with epidural analgesia: implications and outcomes—a retrospective cohort

Abstract

Purpose: To evaluate the obstetric outcomes in nulliparas with epidural who exceeded the 95th percentile duration of 4 h. Methods: This retrospective cohort included all term, singleton deliveries of nulliparas with epidural analgesia and second stage duration > 3 h, from 2014 to 2021. Maternal and neonatal outcomes were evaluated by comparing second stage duration 3–4 h vs. > 4 h. Results: A total of 2,798 deliveries were included, with 2273 in the 3–4 h group (mean duration 3.42 ± 0.28 h) and 525 in the > 4 h group (mean duration 4.38 ± 0.42 h). Compared to the 3–4 h group, the > 4 h group had lower rate of vaginal deliveries (80.4% vs. 93%, p < 0.001), relatively higher rate of vacuum extractions (VE) (56.0% vs. 42.4%, p < 0.001) and higher rate of cesarean deliveries (CD) (19.6% vs. 7.0%, p < 0.001). The > 4 h group had higher rates of macrosomia and large for gestational age birthweights (7.0% vs. 4.0%, p < 0.003 and 11.8% vs. 8.9%, p = 0.039, respectively). Shoulder dystocia, neonatal subgaleal hematoma and failed VE were more common in the > 4 h group (2.7% vs. 1.1%, 9.0% vs. 3.3% and 4.4% vs. 1.0%, respectively, p < 0.01 for all), as well as the composite neonatal trauma outcome (11.2% vs. 4.1%, p < 0.001). Multivariable logistic regression adjusted for confounders including obesity, hypertensive disorders, diabetes, macrosomia and delivery mode, revealed that a duration of > 4 h was associated with increased risks of shoulder dystocia, subgaleal hematoma and failed VE. Conclusion: Most patients achieve vaginal delivery even after a duration of > 4 h. However, it is associated with increased risks of neonatal birth trauma and failed VE.