Kala II Memanjang
Kala II Memanjang
Kala II Memanjang
Result
Increased maternal morbidities were generally consistent with reports from previous studies
including postpartum hemorrhage, maternal febrile morbidity/infection and perineal trauma.
(410) It was reassuring that we did not observe significantly increased risks for other
serious maternal complications including need for blood transfusion, cesarean hysterectomy,
or ICU admission. Specific neonatal risks associated with a prolonged second stage similar
to previously reported included an increased risk of 5 minute Apgar score < 4 (except
nulliparous women without an epidural; note Apgar score < 7 in the literature) and neonatal
intensive care unit (NICU) admission (912). In contrast to studies that found no differences
in neonatal outcomes including more serious complications such as seizures or sepsis (48),
we observed a doubling of the rates of neonatal sepsis (except in multiparous women
without an epidural. Novel findings included an increased risk of neonatal asphyxia for
second stage of labor that exceeded College guidelines in nulliparous women, and a 6-fold increase
in perinatal mortality for deliveries without an epidural even though overall
absolute rates for both outcomes were low (<0.5%).
The mechanism for increased morbidity cannot necessarily be attributed to the duration
of
2nd stage, as the underlying reasons for longer duration may also contribute to
morbidity.
For example, chorioamnionitis and increased fetal size are associated with both longer
labor
duration and increased maternal and neonatal morbidity. (1719) Complications may
also
have been partly due to the increased in operative vaginal delivery, but our findings in
a
sensitivity analysis that morbidity was increased even among nulliparous women with a
non-operative delivery indicates that prolonged duration of 2nd stage may be an
independent
risk for morbidity. (15) The reason that perinatal mortality was increased only in
deliveries
without an epidural is also unknown, but perhaps prolonged second stage attributed to
epidural use is associated with less risk than prolonged second stage due to other
pathways.
Our study was limited by lack of data on delayed versus active pushing which has been
shown to have a mean increase of 57 minutes in the second stage in a meta-analysis;
however, delayed pushing has been associated with increased maternal febrile morbidity
and
decreased umbilical cord pH in some studies indicating that duration itself may be
important. (20) A randomized control trial of delayed versus active pushing would be
useful
to study the impact on duration of second stage on maternal and neonatal outcomes
There is
also the possibility that some of our findings were false positives given the large number
of
comparisons. Caution is also warranted given the retrospective data and lack of
information
on long term maternal outcomes including incontinence and childhood neurologic
impairment. Nonetheless, the major strength of our study was the large numbers from
multiple institutions across the U.S. with rich patient level data allowing us to investigate
rare neonatal morbidities at term.
Thank You