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The editorial in the Anaesthesia journal discusses the importance of a patient-centric approach to labour analgesia, focusing on the combined spinal-epidural (CSE) technique. The article highlights the benefits and challenges of CSE compared to the dural puncture epidural (DPE) technique, emphasizing patient satisfaction and outcomes. The study by Zang et al. compares the quality of labour analgesia between CSE and DPE, indicating no significant differences in outcomes. The editorial suggests that CSE may offer more efficient pain relief, but further research is needed to determine the best approach for labour analgesia. [Extracted from the article]

During vaginal delivery, the delivery requires the fetal head to mold to accommodate the geometric constraints of the birth canal. Excessive molding can produce brain injuries and long-term sequelae. Understanding the loading of the fetal brain during the second stage of labor (fully dilated cervix, active pushing, and expulsion of fetus) could thus help predict the safety of the newborn during vaginal delivery. To this end, this study proposes a finite element model of the fetal head and maternal canal environment that is capable of predicting the stresses experienced by the fetal brain at the onset of the second phase of labor. Both fetal and maternal models were adapted from existing studies to represent the geometry of full-term pregnancy. Two fetal positions were compared: left-occiput-anterior and left-occiput-posterior. The results demonstrate that left-occiput-anterior position reduces the maternal tissue deformation, at the cost of higher stress in the fetal brain. In both cases, stress is concentrated underneath the sutures, though the location varies depending on the presentation. In summary, this study provides a patient-specific simulation platform for the study of vaginal delivery and its effect on both the fetal brain and maternal anatomy. Finally, it is suggested that such an approach has the potential to be used by obstetricians to support their decision-making processes through the simulation of various delivery scenarios. [ABSTRACT FROM AUTHOR]

• The rate of OASI was 4.2 % in 215 241 nulliparous and 1.4 % in 325 814 multiparous women. • In nulliparous women, the number needed to treat (NNT) for the use of MLE to prevent one OASI is 31 in general. • The NNT is 9 In the group with a birth weight ≥ 4000 g and a duration of the second stage of labour ≥ 120 min. Analysis of the association of mediolateral episiotomy (MLE) with obstetric anal sphincter injury (OASI) in women with spontaneous vaginal delivery. Design. Population-based cohort study with data from the Netherlands Perinatal Registry, describing 541 055 women who delivered a singleton live born infant in cephalic presentation spontaneously at term. Risk indicators for OASI were tested using univariate and multivariate analysis. Additional analysis for the interaction of MLE with other risk indicators was performed. The rate of OASI was 4.2 % in 215 241 nulliparous and 1.4 % in 325 814 multiparous women. In nulliparous and multiparous women MLE was associated with a reduction of OASI (adjusted OR (aOR) 0.3, 95 % CI 0.30–0.34 and aOR 0.32, 95 % CI 0.30–0.34). The association of MLE with a reduced rate of OASI was stronger in high birthweight and in prolonged 2nd stage groups. In nulliparous women, the number needed to treat (NNT) for the use of MLE to prevent one OASI is 31 in general. With MLE, the OASI rate reduced from 11.5 % to 2.9 with a NNT of 12 in the group with a birth weight ≥ 4000 g and a duration of the second stage of labour of 60–120 min. The NNT is 9 In the group with a birth weight ≥ 4000 g and a duration of the second stage of labour ≥ 120 min (reduction rate of OASI from 14.2 % to 3.5 %). Use of MLE is associated with a reduction of OASI in spontaneous vaginal delivery. In nulliparous women, an episiotomy with an anticipated birth weight > 4000 g and a duration of the 2nd stage of more than 60 min should be considered. [ABSTRACT FROM AUTHOR]

Objective: To determine the trends of instrumental vaginal delivery (IVD) and cesarean section (CS) at the Lagos University Teaching Hospital (LUTH), Nigeria, over 16 years, from 2002 to 2017. Methods: A retrospective cross‐sectional study. The case records of all women who had IVD and CS during the study period were reviewed. The trends in the IVD and CS rates were evaluated using join point regression modeling. The average annual percent change (AAPC) and annual percent change (APC) with associated 95% confidence interval of segmental trends were calculated. Results: The overall IVD rate was 1.36%. Vacuum delivery rate was higher than forceps (0.79% vs 0.57%). The CS rate was 44.9 per 100 deliveries; the rate increased by about 3.7% per annum. CS rates were 7.1–89.9 times the IVD rates within the study period. The number of IVDs performed in the hospital declined by about 83.02%, from 53 cases in 2002 to nine cases in 2017. Forceps delivery declined at a faster rate than vacuum delivery between 2002 and 2017 (AAPC for forceps: −12.6% [−17.5 to −7.5], P < 0.001 vs AAPC for vacuum: −6.2% [−14.3 to 2.7], P = 0.200). The commonest indication for IVD was prolonged second stage of labor (47/162, 29.01%) and shortening of the second stage of labor for maternal conditions (47/162, 29.01%). Conclusion: IVD rates are low and declining at LUTH. There is need to train accoucheurs on the safe use of IVDs to potentially reduce the CS rate. Synopsis: The present study corroborates global reports of declining IVD rates and increasing CS rates. There is need to increase IVD use to potentially reduce CS rate. [ABSTRACT FROM AUTHOR]

Objective: Obesity and maternal age are increasing among pregnant patients. The understood effect of body mass index (BMI), advanced maternal age (AMA), and second stage of labor on obstetric anal sphincter injury (OASIS) at delivery is varied. The objective of this study was to assess whether incorporating BMI, second stage of labor length, and AMA into a model for predicting OASIS among forceps‐assisted vaginal deliveries (FAVD) had a higher predictivity value compared to models without these additions. Method: This was an IRB‐approved retrospective cohort study of singleton gestations who underwent a FAVD between 2017 and 2021. The primary outcome was prediction of OASIS via established models versus models including the addition of new predictive factors. Results: A total of 979 patients met inclusionary criteria and were included in the final analysis. 20.4% of patients had an OASIS laceration, 11.3% of neonates had NICU admissions, 23.7% had a composite all neonatal outcome, and 8% had a composite subgaleal/cephalohematoma outcome. Comparisons of known factors that predict OASIS (nulliparity, race, episiotomy status) to known factors with additional predictors (BMI, AMA, and length of second stage in labor) were explored. After comparing each model's AUC to one another (a total of 3 comparisons made), there was no statistically significant difference between the models (all P > 0.62). Conclusion: Including BMI, AMA, and second stage of labor length does not improve the predictivity of OASIS in patients with successful FAVD. These factors should not impact a provider's decision to perform a FAVD when solely considering increased odds of OASIS. Synopsis: We attempted to improve established models predicting OASIS in FAVDs. However, we did not find a significant difference in predictive ability when including additional factors. [ABSTRACT FROM AUTHOR]

• Deep learning is currently the leading artificial intelligence tool in medical image analysis. • The overall accuracy of the deep learning-based algorithm in the assessment of the fetal occiput position was 94.5 %. • The deep learning algorithm showed an accuracy of 98.3 % in identifying any subtype of fetal head malposition. To develop a deep learning (DL)-model using convolutional neural networks (CNN) to automatically identify the fetal head position at transperineal ultrasound in the second stage of labor. Prospective, multicenter study including singleton, term, cephalic pregnancies in the second stage of labor. We assessed the fetal head position using transabdominal ultrasound and subsequently, obtained an image of the fetal head on the axial plane using transperineal ultrasound and labeled it according to the transabdominal ultrasound findings. The ultrasound images were randomly allocated into the three datasets containing a similar proportion of images of each subtype of fetal head position (occiput anterior, posterior, right and left transverse): the training dataset included 70 %, the validation dataset 15 %, and the testing dataset 15 % of the acquired images. The pre-trained ResNet18 model was employed as a foundational framework for feature extraction and classification. CNN 1 was trained to differentiate between occiput anterior (OA) and non-OA positions, CNN 2 classified fetal head malpositions into occiput posterior (OP) or occiput transverse (OT) position, and CNN 3 classified the remaining images as right or left OT. The DL-model was constructed using three convolutional neural networks (CNN) working simultaneously for the classification of fetal head positions. The performance of the algorithm was evaluated in terms of accuracy, sensitivity, specificity, F1-score and Cohen's kappa. Between February 2018 and May 2023, 2154 transperineal images were included from eligible participants across 16 collaborating centers. The overall performance of the model for the classification of the fetal head position in the axial plane at transperineal ultrasound was excellent, with an of 94.5 % (95 % CI 92.0––97.0), a sensitivity of 95.6 % (95 % CI 96.8–100.0), a specificity of 91.2 % (95 % CI 87.3–95.1), a F1-score of 0.92 and a Cohen's kappa of 0.90. The best performance was achieved by the CNN 1 – OA position vs fetal head malpositions – with an accuracy of 98.3 % (95 % CI 96.9–99.7), followed by CNN 2 – OP vs OT positions – with an accuracy of 93.9 % (95 % CI 89.6–98.2), and finally, CNN 3 – right vs left OT position – with an accuracy of 91.3 % (95 % CI 83.5–99.1). We have developed a DL-model capable of assessing fetal head position using transperineal ultrasound during the second stage of labor with an excellent overall accuracy. Future studies should validate our DL model using larger datasets and real-time patients before introducing it into routine clinical practice. [ABSTRACT FROM AUTHOR]

Objective Maternal pushing can yield lactate levels that are above the normal range for nonpregnant individuals. Many hospitals require lactate levels as part of sepsis bundles, and this can confuse the clinicians when measured during labor. The objective of this study was to observe lactate levels in uncomplicated labor. Study Design This was a prospective study of patients presenting to Labor and Delivery in early labor. Patients met inclusion criteria if they presented at 37 weeks' gestation or greater and were either 3 to 4 cm dilated, in early labor with rupture of membranes less than 12 hours, or were being induced for oligohydramnios or postdates gestation. A baseline maternal lactate level was collected at enrollment. Further levels were collected at complete cervical dilation and every 30 minutes during the second stage of labor up to 3 hours or until delivery. Results From January 7, 2021, through December 30, 2021, a total of 148 screened patients met the inclusion criteria and 38 were enrolled. Eight (21%) patients withdrew after baseline lactate level was drawn. Twenty-three (61%) patients had a level drawn at complete dilation. Of the 12 (32%) patients with a lactate level drawn at complete and after 30 minutes of pushing, the mean change in lactate level was 2.0 ± 1.8 mmol/L or 0.07 ± 0.06 mmol/L/min (p < 0.01). This change is more pronounced in the second stage of labor for patients with chorioamnionitis (2.6 mmol/L), although this difference is not statistically significant (p = 0.41). Conclusion Lactate levels increase significantly once a patient reaches complete cervical dilation within 30 minutes of pushing. This increase is more pronounced, although significantly, in patients with chorioamnionitis. As sepsis is one of the leading causes of maternal morbidity and mortality, this pilot study is relevant for providers to see the natural course of lactate levels in labor. Key Points The change in lactate level during normal labor is unknown. We measured lactate levels in uncomplicated labor. Lactate levels can be elevated in uncomplicated labor. [ABSTRACT FROM AUTHOR]

INTRODUCTION Spinning Babies® procedures and the Rebozo technique have been recently implemented as additional interventions in laboring women with a fetus in occiput posterior position (OPP) to favor the rotation to an anterior position, which improve birth experience and health outcomes. Our study aimed to compare the probability of occurrence of persistent OPP (POPP) of the fetal head at the second stage of labor between retrospective and prospective cohorts and to assess associated sociodemographic, obstetric and intrapartum factors. METHODS We conducted a combined prospective and retrospective cohort study including 1500 women giving birth in 2017 (retrospective cohort) and 779 between 15 May and 15 December 2023 (prospective cohort). Each cohort was divided into two sub-cohorts depending on presence of OPP. Primary outcomes were compared the probability of occurrence of POPP in the two OPP sub-cohorts by a log binomial regression and logistic regression. A p<0.05 was considered statistically significant. Data analysis was performed using Stata/MP18.0 RESULTS The proportion of OPP at the onset of labor was similar between the two cohorts (34.9% vs 35.1%). The probability of occurrence of POPP was significantly lower in the prospective OPP sub-cohort (27.7%, n=65/235) compared to the retrospective OPP sub-cohort (35.8%, n=154/430) (risk difference, RD= -0.081; 95% CI: -0.15 -0.008; p=0.031). In the retrospective OPP sub-cohort, maternal age ≥35 years (RD=0.096; 95% CI: 0.001-0.190, p=0.044) and nulliparity (RD= -0.100; 95% CI: -0.190 - -0.001, p=0.036) were significantly associated with the probability of POPP. CONCLUSIONS Our findings suggest a potential benefit of a set of interventions combining Spinning Babies® and the Rebozo technique in decreasing the probability of POPP [ABSTRACT FROM AUTHOR]

Background: Implementing research evidence into clinical practice is challenging. This study aim was to explore implementation of two intrapartum trials with compelling findings: BUMPES (position in second stage of labour in nulliparous women with epidural), and RESPITE (remifentanil intravenous patient-controlled analgesia). Methods: A qualitative interview study set in UK National Health Service Trusts and Universities. Purposively sampled investigators from RESPITE and BUMPES trials and clinicians providing intrapartum care: midwives, anaesthetists, and obstetricians, were recruited using existing networks and snowball sampling. Semi-structured virtual interviews were conducted. Thematic analysis was underpinned by Capability Opportunity Motivation Behaviour Change Framework. Results: Twenty-nine interview participants across 19 maternity units: 11 clinical academics, 10 midwives, 4 obstetricians, 4 anaesthetists. Most (25/29) were aware of one or both trials. BUMPES had been implemented in 4/19 units (one original trial site) and RESPITE in 3/19 units (two trial sites). Access to sufficient resources, training, exposure to interventions, support from leaders, and post-trial dissemination and implementation activities all facilitated uptake of interventions. Some clinicians were opposed to the intervention or disagreed with trial conclusions. However competing priorities in terms of staff time and a plethora of initiatives in maternity care, emerged as a key barrier to implementation. Conclusions: Compelling trial findings were not implemented widely, and numerous barriers and facilitators were identified. Large-scale improvement programmes and evidence-based national guidelines may mean single trials have limited potential to change practice. There is a need to examine how intervention implementation is prioritised to optimise safety outcomes in the context of workforce restrictions, limited resources and large arrays of competing priorities including statutory requirements, that have increased in maternity care. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Obstetric violence, or mistreatment of women in obstetric care, can have severe consequences such as fear of future childbirth, post‐traumatic stress disorder, and depression.The primary objective was to estimate the prevalence of obstetric violence in high‐income countries. The secondary objective was to extract the main domains of obstetric violence perceived by women from qualitative studies. Following prospective registration (PROSPERO CRD42023468570), PubMed, Web of Science, Scopus, CINAHL, Embase, and Cochrane Library were searched with no restrictions. Included studies were cross‐sectional, cohort, mixed methods, and qualitative studies based on populations from high‐income countries. The review was conducted by two independent reviewers. Risk of bias was assessed. Rates of obstetric violence were pooled using random effects model, computing 95% confidence intervals (CI) and assessing heterogeneity using I2 statistic. Funnel plots and Egger's test were used to detect potential reporting biases and small‐study effects.Of the 1821 records screened, 25 studies were included: 14 quantitative and 2 mixed methods studies, comprising 60 987 women, and 9 qualitative studies were included, comprising an additional 4356 women. 81.25% of quantitative studies, including the quantitative component of the mixed methods studies, were considered satisfactory or better regarding risk of bias. The prevalence of obstetric violence was overall 45.3% (95% CI 27.5–63.0; I2 = 100.0%). The prevalence of specific forms of mistreatment was also estimated. Lack of access to analgesia was 17.3% (95% CI 6.9–27.7; I2 = 99.7%). Ignored requests for help was 19.2% (95% CI 11.7–26.6; I2 = 99.0%). Shouting and scolding 19.7% (95% CI 13.0–26.4; I2 = 98.7%). The use of fundal pressure during the second stage of labor (Kristeller maneuver) was 30.3% (95% CI 22.1–38.5; I2 = 97.6%). There was no funnel asymmetry. Lack of information and/or consent were the most frequent domains extracted from the qualitative articles and the qualitative component of the mixed methods studies.The results demonstrate that obstetric violence is a prevalent problem that women in high‐income countries experience. Lack of information and/or consent were the domains most frequently described in the qualitative studies and the qualitative component of the mixed methods studies. [ABSTRACT FROM AUTHOR]

Objective: To explore the factors influencing lateral episiotomy in vaginal deliveries of suspected macrosomia. Methods: The clinical data of 149 pregnant women with suspected macrosomia who delivered at the Obstetrics Department of the First Affiliated Hospital of Nanjing Medical University from January to July 2022 were analyzed retrospectively. According to whether the perineum was cut laterally during vaginal delivery, the perineum was divided into two groups: the episiotomy group and the natural laceration group. Risk factors for vaginal delivery in pregnant women with suspected macrosomia were analyzed. Results: Among 149 pregnant women with suspected macrosomia, lateral episiotomy was performed in 40 cases (26.85%), while 109 cases (73.15%) had vaginal deliveries accompanied by natural laceration, including 93 cases of Grade I laceration and 16 cases of Grade II laceration. The proportion of primipara and midwives with less than 5 years of experience was higher in the episiotomy group compared to the laceration group (P < 0.001, P=0.021); the proportion of the second stage of labor less than 47 min in the episiotomy group was significantly higher than that in the natural laceration group (87.5% vs. 39.4%, P < 0.001). In addition, the proportion of amniotic fluid properties (clear + I degree)in the natural laceration group was significantly higher than that in the episiotomy group (87.2% vs. 72.5%, P=0.034), while the rate of postpartum hemorrhage was significantly lower than that in natural laceration group (P=0.010). Primipara and midwives with less than 5 years of experience were independent risk factors for episiotomy in suspected macrosomia (OR=2.708, P=0.021). Conclusion: The incidence of lateral episiotomy in vaginal delivery of suspected macrosomia increases in primipara and midwives with less than 5 years of experience, at the same time, the rate of postpartum hemorrhage in the lateral episiotomy group is significantly reduced. [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle–Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3. Results: In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17–2.51), primiparity (OR = 2.36, 95% CI = 1.64–3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00–8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62–32.72), vulvar edema (OR = 7.99, 95% CI = 5.50–11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11–131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28–57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79–18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32–7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70–7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84–5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50–6.96), forceps delivery (OR = 4.95, 95% CI = 2.88–8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30–4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96–6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12–3.19). Conclusions: Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified. [ABSTRACT FROM AUTHOR]

BACKGROUND : The recent advances in induction of labour has lead to decreased spontaneous labour and as a result increased complications. Thus a study is done to identify the progress of labour and fetomaternal outcomes in spontaneous versus induced labour patients as childbirth experience especially in primigravida have a major influence in family planning and subsequent pregnancies. AIM: To study the difference in progress, course and outcome between spontaneous and induced labours in a primigravida. MATERIALS AND METHODS: This is a prospective study undertaken on 100 Primigravidae of term gestation and uncomplicated pregnancy admitted in the labour room were studied and divided into 2 groups, those with induction of labor and those with spontaneous onset of labor. May 2022 to June 2023 was the time period in consideration. RESULTS: Among the study population, childbirth experience was poor in those with induced labour. The mean duration of second stage of labour was significantly more in induced labour (16.25 minutes) than in spontaneous labour (14.60 minutes)The caesarean section rates were higher in induced labour(33%) than in sponatenous labour(11%). The mean Apgar scores were comparable in two groups. CONCLUSION : The study shows that it is beneficial to wait for spontaneous onset of labor in a primigravida with no maternal or fetal complications since induction of labor is associated with higher caesarean rates, tears,prolonged labour,poor childbirth experience. It is essential to counsel the mother about the type of delivery. [ABSTRACT FROM AUTHOR]

Objective: Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation. Methods: This prospective cross‐sectional study, conducted in five different German level‐three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project. Results: A total of 514 women were included. On an 11‐point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor. Conclusion: This study highlights deficiencies in analgesic management in high‐level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient‐reported outcomes can guarantee qualitative tailored analgesic care in women. Synopsis: This study exposes relevant analgesic shortcomings for parturients in perinatal centers, highlighting the need for tools to monitor and improve the quality of obstetric analgesic care. [ABSTRACT FROM AUTHOR]

Background: We investigated possible parameters that could predict the need for obstetric maneuvers, the duration of the active second stage of labor (i.e., the duration of active pushing), and short‐term neonatal outcome in vaginal breech births. Materials and Methods: We performed a retrospective analysis of 268 successful singleton vaginal breech births in women without previous vaginal births from January 2015 to August 2022. Multivariable regression was used to investigate associations between maternal and fetal characteristics (including antepartum magnetic resonance (MR) pelvimetry) with obstetric maneuvers, the duration of active second stage of labor, pH values, and admission to the neonatal unit. Models for the prediction of obstetric maneuvers were built and internally validated. Results: Obstetric maneuvers were performed in a total of 130 women (48.5%). A total of 32 neonates (11.9%) had to be admitted to the neonatal unit. The intertuberous distance (ITD) (p < 0.001), epidural analgesia (p < 0.001), and birthweight (p = 0.026) were associated with the duration of active second stage of labor. ITD (p = 0.028) and birthweight (p = 0.011) were also independently associated with admission to the neonatal unit, while pH values below 7.10 dropped significantly (p = 0.0034) if ITD was ≥13 cm. Furthermore, ITD (p < 0.001) and biparietal diameter (p = 0.002) were independent predictors for obstetric maneuvers. Conclusions: ITD is independently associated with the duration of active second stage of labor. Thus, it can predict suboptimal birth mechanics in the last stage of birth, which may lead to the need for obstetric maneuvers, lower arterial pH values, and admission to the neonatal unit. Consequently, MR pelvimetry gives additional information for practitioners and birthing people preferring a vaginal breech birth. [ABSTRACT FROM AUTHOR]

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Objective: This comprehensive review aimed to assess perineal management strategies during labor and their effectiveness in preventing perineal tears while enhancing maternal well-being. Methods: A three-part review was conducted, covering labor pain causes and management, perineal tears and episiotomy, and preventive strategies with a focus on warm compresses. Existing literature and studies were synthesized to offer a holistic perspective on perineal management. Results: Understanding Labor Pain: Labor pain arises from uterine contractions, perineal and cervical stretching, and pelvic pressure. Management options, including pharmacological and nonpharmacological techniques, such as massage, hydrotherapy, and acupuncture, effectively alleviate pain. Perineal Tears and Episiotomy: Perineal tears, including Obstetric Anal Sphincter Injuries (OASIS), are frequently linked to instrumental delivery, prolonged labor, and fetal positioning. Episiotomy, while at times necessary, carries specific indications and potential complications. Preventive Strategies with Warm Compresses: Studies consistently demonstrate the effectiveness of warm compresses applied during the second stage of labor in reducing perineal tears and enhancing perineal integrity, thereby decreasing the need for sutures. Conclusion: Effective perineal management during labor is essential to ensure maternal well-being and reduce the risk of perineal trauma. Nonpharmacological pain management techniques provide viable options, while perineal tears and episiotomy complications emphasize the importance of preventive strategies. Warm compresses, thoughtfully applied during labor, consistently contribute to maintaining perineal integrity. Nurses play a pivotal role in implementing these strategies, offering holistic care, and ensuring safe and satisfying childbirth experiences. [ABSTRACT FROM AUTHOR]

Taking into account the growing increase in the political and social interest in childbirth, it is critical to identify and explore the instruments that allow and enhance its humanization today. The use of vocalization seems to be a powerful and empowering tool for a positive birthing experience when used by women in labour. A scoping review will be developed to map the evidence and knowledge about women's vocalization in the first and second stages of labour using the Joanna Briggs Institute methodology. The search will be carried out on the Web of Science, EBSCOhost Research Platform (selecting Academic Search Complete, MedicLatina, Cinahl plus with full text, Medline with full text), Willey Online Library, PubMed and Scopus. The National Register of Theses and Dissertations and the Open Scientific Repository of Portugal will also be taken into account. Three reviewers will conduct data analysis, extraction and synthesis independently. The outcomes pretend to be a source for identifying the use of vocalization by women in labour, in order to guide further research on the subject. This study was prospectively registered with the Open Science Framework on the 21 May 2024, with registration number DOI 10.17605/OSF.IO/Z58F4. [ABSTRACT FROM AUTHOR]

Background: The transition from first to second stage of labor is poorly understood. While the onset of second stage is defined by cervical measurement, dilation cannot be directly sensed or externally observed. Thus, uncertainty exists when women report pushing urges before dilation is confirmed. This study aimed to explore how sensations of pushing and uncertainty over progress are interactionally managed. Methods: We audio/video recorded the labors of 37 women in two midwife‐led units in England. Our analysis focused on a subset of 28 recordings that featured discussion of transition from first to second stage of labor. The interactions between midwives, laboring women and their birth partners were transcribed and analyzed using conversation analysis. Results: We identified a 'pushing until proven otherwise' rule granting temporary, contingent authority to bodily urges to push while tracking progress over time. Specifically, midwives supported reported pushing sensations without insisting on examinations. Caution was occasionally expressed in distinguishing between irresistible and forced pushing. Across multiple contractions, midwives watched and waited for alignment of sensations with signs of descent. Where signs of progress were absent over time, examinations were treated as clinically indicated. Discussion: Thus, a complex interplay of women's sensations and midwifery expertise produced care. Compared to past research, our analysis demonstrates increased validation of embodied experience in contemporary midwife‐led practice. However, uncertainty still requires navigation through collaborative work. We evidence how this navigation is accomplished in real‐time interactions. [ABSTRACT FROM AUTHOR]

Background: Pilates has captured interest due to its possible advantages during pregnancy and childbirth. Although research indicates that Pilates may reduce labor duration, alleviate pain, and improve satisfaction with the childbirth experience, consensus on these outcomes remains elusive, underscoring the necessity for additional studies. Aim: This systematic review and meta-analysis aimed to assess the impact of Pilates exercises on labor duration among pregnant women. Methods: The online database was searched to yield the literature using the terms of 'Pilates', 'childbirth', and 'labor duration', and similar terms including PubMed, Clinical Key, Scopus, Web of Science, Embase, and Cochrane Database of Systematic Reviews up to June 25, 2023. Studies were considered eligible if they were randomized or clinical controlled trials (RCTs/CCTs) published in English, focusing on healthy pregnant women without exercise contraindications. The studies needed to include interventions involving Pilates or exercise movement techniques, a comparison group with no exercise, and outcomes related to labor duration, the period of the active phase, and the second stage of delivery. Results: Eleven studies, totalling 1239 participants, were included in the analysis. These studies provided high-quality evidence from exercise only RCTs/CCTs. The findings indicated a significant reduction in the active phase of labor (8 RCTs, n = 1195; Mean Difference [MD] = -56.35, 95% Confidence Interval [CI] [-89.46 to -23.25]) and overall labor duration (8 RCTs, n = 898; MD = -93.93, 95% CI [-138.34 to -49.51]) in pregnant women who engaged in Pilates exercises compared to those who did not but doesn't affect on the duration of the second stage of labor (7 RCTs, n = 1135; MD = -0.11, 95% CI [-7.21 to 6.99]). Conclusions: While this review primarily addresses the effects of Pilates on healthy and low-risk pregnant women, the findings suggest a potential role for Pilates in shortening labor duration. Therefore, engaging in Pilates or similar physical activities is recommended for pregnant women to potentially facilitate a more efficient labor process. [ABSTRACT FROM AUTHOR]

Aim: To describe standardised iterative methods used by a multidisciplinary group to develop evidence‐based clinical intrapartum care algorithms for the management of uneventful and complicated labours. Population: Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility. Setting: Health facilities in low‐ and middle‐income countries. Search strategy: Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google. Case scenarios: Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes. Conclusions: Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence‐based, up to date, paper‐based or digital reminders and decision‐support tools. The algorithms need to be field tested and may need to be adapted to specific contexts. Evidence‐based intrapartum care clinical algorithms for a safe and positive childbirth experience. Evidence‐based intrapartum care clinical algorithms for a safe and positive childbirth experience. [ABSTRACT FROM AUTHOR]

Aim: To develop clinical algorithms for the assessment and management of slow progress of labour. Population: Low‐risk singleton, term, pregnant women in labour. Setting: Institutional births in low‐ and middle‐income countries. Search strategy: We systematically reviewed the literature on normal labour progression, and guidance on clinical management of abnormally slow progression from 1 December 2015 to 1 October 2020 from relevant international guidelines, Cochrane reviews and primary research studies in PubMed by searching for international and national guidance documents, electronic databases and published systematic reviews using relevant keywords. Case scenarios: We developed two clinical algorithms: one for abnormally slow labour progression and arrest during first stage and one for the second stage. The algorithms provide definitions of suspected and confirmed slow progress of labour or arrest, initial assessment and ongoing monitoring, differential diagnosis, and management of the abnormalities, as well as links to other algorithms for labour management. Conclusions: Identifying abnormal progress of labour is often challenging. These algorithms may help healthcare providers identify abnormal labour progress and institute prompt management or referral where needed but also reduce misdiagnosis and unnecessary use of interventions to accelerate labour. Evidence‐based clinical algorithms may help and standardize early identification and management of abnormally slow labour progress or arrest. Evidence‐based clinical algorithms may help and standardize early identification and management of abnormally slow labour progress or arrest. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of vacuum extraction (VE) or caesarean section (CS), compared with expectant management, on pelvic floor dysfunction (PFD) 1–2 years postpartum in primiparous women with a prolonged second stage of labour. Design: A population‐based questionnaire and cohort study. Setting: Stockholm, Sweden. Population: A cohort of 1302 primiparous women with a second stage duration of ≥3 h, delivering from December 2017 to November 2018. Methods: The 1‐year follow‐up questionnaire from the Swedish National Perineal Laceration Register was distributed 12–24 months postpartum. Exposure was VE or CS at 3–4 h or 4–5 h, compared with expectant management. Main outcome measures: Pelvic floor dysfunction was defined as at least weekly symptoms of urinary incontinence, pelvic organ prolapse or a Wexner score of ≥4. The risk of PFD was calculated using Poisson regression with robust variance estimation, presented as crude and adjusted relative risks (RRs and aRRs) with 95% confidence intervals (95% CIs). The implication of obstetric anal sphincter injury (OASI) on pelvic floor disorders was investigated through mediation analysis. Results: In total, 35.1% of women reported PFD. Compared with expectant management, the risk of PFD was increased after VE at 3–4 h (aRR 1.33, 95% CI 1.06–1.65) and 4–5 h (aRR 1.34, 95% CI 1.05–1.70), but remained unchanged after CS. The increased risk after VE was not mediated by OASI. Conclusions: Pelvic floor dysfunction was common in primiparous women after a prolonged second stage, and the risk of PFD increased after VE but was unaffected by CS, compared with expectant management. If a spontaneous vaginal delivery eventually occurred, allowing an extended duration of labour did not increase the risk of PFD. [ABSTRACT FROM AUTHOR]

Objective: To determine the cutoff of intertwin delivery intervals (IDIs) as a predictor for neonatal acidemia. Method: This retrospective cohort study was conducted at a single tertiary care center. Women attempting vaginal delivery of twins between 2010 and 2019 and who reached the second stage of labor were included. The cutoff point for prolonged IDI was established using a receiver operating characteristic (ROC) curve and Youden's J statistic. Maternal and neonatal outcomes were compared between short and prolonged IDI cohorts. Results: A total of 461 women were included in the study. A cutoff time of 10 min was found to be the best predictor for neonatal acidemia (arterial cord pH ≤ 7.1), with a sensitivity of 90% and a specificity of 59%. Second twins delivered more than 10 min after the first twin were more likely to be acidemic and to have a 5‐min Apgar score of 7 or less (13.5% vs 3.3%, P = 0.01, and 8.4% vs 3.2%, P = 0.02, respectively). An IDI of more than 10 min was also associated with increased rate of cesarean delivery and placental abruption (13.5% vs 0.8%, P < 0.001, and 3.4% vs 0.8%, P = 0.047, respectively). No other adverse maternal or neonatal outcomes were statistically significant between cohorts. Conclusion: An IDI of more than 10 min is associated with a higher risk for neonatal academia, with a low 5‐min Apgar score, and higher cesarean delivery and placental abruption rates. These findings provide insights that are valuable when counseling and managing twin pregnancies attempting vaginal delivery. Interventions aimed at shortening the IDI should be considered to prevent adverse neonatal outcomes. Synopsis: A 10‐min IDI cutoff is the best predictor for neonatal acidemia in twin deliveries, with implications for cesarean delivery and placental abruption risks. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To conduct an analysis using propensity score methods, exploring the association between a prolonged second stage (>3 h) and the risk of postpartum hemorrhage (PPH) in a diverse population.We conducted a prospective cohort study involving nullipara with epidural anesthesia and vaginal delivery, aged ≥18 years, presenting cephalically, and with a gestational age (GA) of ≥24 weeks at a tertiary maternity hospital in China (chictr.org.cn identifier: ChiCTR2200063094). Women undergoing emergency cesarean section in labor were excluded. The primary outcome was PPH, with secondary outcomes including severe postpartum hemorrhage and blood transfusion. We employed propensity score overlap weighting to analyze the association between prolonged second stage labor and PPH.The study included 3643 nullipara with epidural anesthesia, comprising 77 with a second stage of labor >3 h and 3566 with a second stage ≤3 h. Utilizing propensity score overlap weighting, there were no significant differences observed between the two groups regarding the risk of PPH (29.87% in >3 h group vs 17.64% in ≤3 h group; weighted odds ratio 1.01; 95% CI: 0.51–2.02). Subgroup interaction tests for PPH were not significant for assisted vaginal delivery, induction of labor, macrosomia, third‐/fourth‐degree perineal laceration, GA >41 weeks, twin pregnancies, episiotomy and GA >37 weeks. Sensitivity analysis did not reveal significant differences.This study did not find evidence supporting an increased risk of PPH associated with a second stage of labor lasting >3 h in our population, providing additional evidence for clinical practice. [ABSTRACT FROM AUTHOR]

Background and Objectives: This retrospective analysis investigated the impact of preparation of the pelvic floor for childbirth with stretching balloons and perineal massage on the risk of pelvic floor injuries. Materials and Methods: We analyzed 150 primiparous women who accessed private clinics in Padua (Italy) in the period 2019–2023 regarding the rate of perineal trauma and postpartum dysfunction across three groups: the balloon stretching group (BSG, N = 50, 33.3%), the perineal massage group (PMG, N = 39, 26.0%), and the control group (CG, 61, 40.7%). Results: Prenatal perineal training had a significant impact on reducing the rate of perineal injury and episiotomy (27.5% in BSG vs. 48.7% in PMG and 68.3% in CG, p = 0.008, respectively, 9.8% vs. 26% and 40%, p = 0.046) and the duration of the second stage of labor (BSG and PMG had a shorter duration compared to CG with a mean difference of −0.97892 h, p < 0.001, respectively, −0.63372 h, p = 0.002). Patients who carry out the preparation with the stretching balloon are less likely to develop urinary and anal incontinence and pain during intercourse. Specifically, the rate of urinary incontinence in BSG stands at around 23.5% compared to 43.6% in PMG (p = 0.345) and 55% in CG (p = 0.034). Dyspareunia in BSG was detected in 11.8% of cases compared to 35.5% in PMG (p = 0.035) and 61.7% in CG (p < 0.01). Symptomatology inherent to the posterior compartment was reported in 9.8% of cases in BSG vs. 23.11% in PMG (p = 0.085) and 33.3% in CG (p = 0.03%). Conclusions: Stretching balloons and perineal massage can be chosen as tools to prevent and reduce the rates of obstetric trauma during childbirth and to reduce the use of episiotomies as well as protect against the development of dysfunctions of the pelvic floor. [ABSTRACT FROM AUTHOR]

Background: Friedman's standards, developed almost 50 years ago, may no longer align with the needs of today's obstetric population and current pregnancy management practices. This study aims to analyze contemporary labor patterns and estimate labor duration in China, focusing on first-stage labor data from Chinese parturients with a spontaneous onset of labor. Methods: This retrospective observational study utilized data from electronic medical records of a tertiary hospital in Changsha, Hunan. Out of a total of 2,689 parturients, exclusions were made for multiple gestations, preterm, post-term, or stillbirth, cesarean delivery, non-vertex presentation, and neonatal intensive care unit admission. Average labor curves were constructed by parity using repeated-measure analysis, and labor duration was estimated through interval-censored regression, stratified by cervical dilation at admission. We performed an analysis to assess the impact of oxytocin augmentation and amniotomy on labor progression and conducted a sensitivity analysis using women with complicated outcomes. Results: Nulliparous women take over 180 minutes for cervical dilation from 3 to 4 cm, and the duration from 5 to 6 cm exceeds 145 minutes. Multiparous women experience shorter labor durations than nulliparous. Labor acceleration is observed after 5 cm in nulliparous, but no distinct inflection point is evident in the average labor curve. In the second stage of labor, the 95th percentile for nulliparous, with and without epidural analgesia, is 142 minutes and 127 minutes, respectively. Conclusions: These findings provide valuable insights for the reassessment of labor and delivery processes in contemporary obstetric populations, including current Chinese obstetric practice. [ABSTRACT FROM AUTHOR]

Purpose: Labor is shorter in multiparous women. However, there are no individualized data on differences in duration of labor for consecutive deliveries in the same parturient. Methods: We conducted a retrospective data analysis from 2004 to 2021 at the University Hospital of Zurich and included all women with 2 or more vaginal deliveries of a singleton child in cephalic position, between 22 and 42 weeks of gestation. Descriptive statistics were performed with SPSS version 25.0 (IBM, SPSS Inc., USA). The primary endpoint was the ratio between durations of labor stages in consecutive deliveries of the same parturient. Results: A total of 3344 women with 7066 births (2601 first [P0], 2987 s [P1], 1176 third [P2], and 302 fourth [P3]) were included. The ratio of duration of the active first stage of labor between P1 and P0 was 0.49 (95% CI 0.47–0.51, p < 0.001) meaning that the active first stage of labor was 51% shorter. The second stage of labor with a ratio of 0.26 (95% CI 0.24–0.27, p < 0.001) was 74% shorter in P1 compared to P0. Higher birthweight of the first child led to an even greater decrease in duration of the second stage of labor in P1 compared to P0 (p = 0.003). Neuraxial anesthesia was an independent risk factor for a longer duration of labor, irrespective of parity (p < 0.001). Birthweight and HC of the neonates did not significantly differ between the children born by the same women. However, higher birthweight in of the first child significantly augmented the rate of second stage of labor between P0 and P1 (p = 0.003). Discussion: Up to the third delivery, duration of labor decreased with each consecutive delivery of the same parturient. An individualized assessment of the expected duration of labor in multiparous women should be encouraged. [ABSTRACT FROM AUTHOR]

Objective: To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries. Methods: We performed a retrospective cohort study in a single, university‐affiliated medical center (2014–2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3–4 degree lacerations, and postpartum hemorrhage [PPH]). Results: We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2–3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant. Conclusion: Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h. Synopsis: Vacuum extraction delivery performed in the late second stage of labor, up to 3 h, is probably safe as VE performed in the early stages. [ABSTRACT FROM AUTHOR]

Objective: To determine intrapartum factors associated with perineal laceration at delivery. Methods: This was a planned secondary analysis of a multicenter randomized clinical trial of delayed versus immediate pushing among term nulliparous women in labor with neuraxial analgesia conducted in the United States. Intrapartum characteristics were extracted from the medical charts. The primary outcome was perineal laceration, defined as second degree or above, characterized at delivery in women participating in longer term pelvic floor assessments post-delivery. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, birth weight, and maternal age. Results: Among the 941 women participating in the pelvic floor follow-up, 40.6% experienced a perineal laceration. No first stage labor characteristics were associated with perineal laceration, including type of labor or length of first stage. Receiving an amnioinfusion appeared protective of perineal laceration (adjusted odds ratio, 0.48; 95% confidence interval 0.26–0.91; P = 0.01). Second stage labor characteristics associated with injury were length of stage (2.01 h vs. 1.50 h; adjusted odds ratio, 1.36; 95% confidence interval 1.18–1.57; P < 0.01) and a prolonged second stage (adjusted odds ratio, 1.64; 95% confidence interval 1.06–2.56; P < 0.01). Operative vaginal delivery was strongly associated with perineal laceration (adjusted odds ratio, 3.57; 95% confidence interval 1.85–6.90; P < 0.01). Conclusion: Operative vaginal delivery is a modifiable risk factor associated with an increased risk of perineal laceration. Amnioinfusion appeared protective against injury, which could reflect a spurious finding, but may also represent true risk reduction similar to the mechanism of warm perineal compress. Significance: The objective of this study was to examine intrapartum factors associated with an increased risk of perineal laceration at delivery among nulliparous women. Operative vaginal delivery and the length of second stage, particularly prolonged second stage, are modifiable risk factors associated with an increased risk of perineal laceration. Receiving an amnioinfusion appeared to be protective against perineal laceration. There are few intrapartum modifiable risk factors other than operative delivery for perineal laceration in nulliparous women. Length of the second stage is an important risk factor for perineal lacerations that is modifiable through active management. [ABSTRACT FROM AUTHOR]

Objectives: To study informed consent to midwifery practices and interventions during the second stage of labor and to investigate the association between informed consent and experiences of these practices and interventions and women's experiences of the second stage of labor. Methods: This study uses an observational design with data from a follow-up questionnaire sent to women one month after giving birth spontaneously in the Oneplus trial, a study aimed at evaluating collegial midwifery assistance to reduce severe perineal trauma. The trial was conducted between 2018–2020 at five Swedish maternity wards and trial registered at clinicaltrials.gov, no NCT03770962. The follow-up questionnaire contained questions about experiences of the second stage of labor, practices and interventions used and whether the women had provided informed consent. Evaluated practices and interventions were the use of warm compresses held at the perineum, manual perineal protection, vaginal examinations, perineal massage, levator pressure, intermittent catheterization of the bladder, fundal pressure, and episiotomy. Associations between informed consent and women's experiences were assessed by univariate and multivariable logistic regression. Findings: Of the 3049 women participating in the trial, 2849 consented to receive the questionnaire. Informed consent was reported by less than one in five women and was associated with feelings of being safe, strong, and in control. Informed consent was further associated with more positive experiences of clinical practices and interventions, and with less discomfort and pain from interventions involving physical penetration of the genital area. Conclusion: The findings indicate that informed consent during the second stage is associated with feelings of safety and of being in control. With less than one in five women reporting informed consent to all practices and interventions performed by midwives, the results emphasize the need for further action to enhance midwives' knowledge and motivation in obtaining informed consent prior to performance of interventions. [ABSTRACT FROM AUTHOR]

Background: Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia. Methods: We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013–2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated. Results: Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14–1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18–8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28–9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia. Conclusions: Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician. [ABSTRACT FROM AUTHOR]

Background: Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women. Methods: We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence. Results: This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80). Conclusions: Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage. Trial registration: CRD42023415996 (PROSPERO). [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: Obstetric anal sphincter injury (OASI) is a major complication associated with vacuum-assisted vaginal delivery (VAVD). The aim of this study was to evaluate risk factors related to vacuum extraction that are associated with OASI. Methods: This was a case–control study performed at a tertiary university teaching hospital. Included were patients aged 18–45 years who had a singleton pregnancy resulting in a live, term, VAVD. The study group consisted of women diagnosed with OASI following vacuum extraction. The control group included women following VAVD without OASI. Matching at a ratio of 1:2 was performed. Groups were compared regarding demographic, obstetric. and labor-related parameters, specifically focusing on variables related to the vacuum procedure itself. Results: One hundred and ten patients within the study group and 212 within the control group were included in the final analysis. Patients in the OASI group were more likely to undergo induction of labor, use of oxytocin during labor, increased second stage of labor, higher likelihood of the operator being a resident, increased number of pulls, procedure lasting under 10 min, occipito-posterior head position at vacuum initiation, episiotomy, increased neonatal head circumference, and birthweight. Multivariate logistic regression analysis revealed that increased week of gestation (OR 1.67, 95% CI 1.25–2.22, p < 0.001), unsupervised resident performing the procedure (OR 4.63, 95% CI 2.17–9.90), p < 0.001), indication of VAVD being fetal distress (OR 2.72, 95% CI 1.04–7.10, p = 0.041), and length of procedure under 10 min (OR 4.75, 95% CI 1.53–14.68, p = 0.007) were associated with OASI. Increased maternal age was associated with lower risk of OASI (OR 0.9, 95% CI 0.84–0.98, p = 0.012). Conclusions: When performing VAVD, increased week of gestation, unsupervised resident performing the procedure, fetal distress as vacuum indication, and vacuum procedure under 10 min were associated with OASI. In contrast, increased maternal age was shown to be a protective factor. [ABSTRACT FROM AUTHOR]

Introduction: To evaluate whether epidural analgesia is an independent risk factor for OASIS. Methods: A population-based cohort study including all women who delivered by spontaneous vaginal delivery or by instrumental delivery beyond 24 weeks gestation was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. Women with multiple gestations and those lacking prenatal care were excluded from the analysis. Results: During the study period, 252,542 women delivered at the Soroka University Medical Center and met the inclusion criteria. Of these, 583 (0.23%) were diagnosed with OASIS. Women with OASIS were more likely to be younger, nulliparous, with suspected fetal macrosomia, had higher rates of labor induction and vacuum extraction delivery, higher rates of conceiving after infertility treatments, more advanced gestational age at delivery, higher mean birth weight, higher rates of post-partum hemorrhage and need for blood transfusions. Use of epidural analgesia during pregnancy was significantly high among the OASIS group. Rates of episiotomy were not significantly different between the groups. Using a multimodal logistic regression model, after controlling for vacuum delivery, large for gestational age, nulliparity, gestational age, ethnicity, maternal age, induction of labor, fertility treatments, non-reassuring fetal heart rate and non-progressive second stage of labor, epidural analgesia was found to be significantly associated with OASIS. Conclusion: Epidural analgesia was found to be an independent risk factor for OASIS in our population. [ABSTRACT FROM AUTHOR]

Use of ultrasonography has been suggested as an accurate adjunct to clinical evaluation of fetal position and station during labor. There are no available reports concerning its actual use in delivery wards. The aim of this survey was to evaluate the current practice regarding the use of ultrasonography during labor. A questionnaire was sent to members of the Italian Society of Ultrasound in Obstetrics and Gynecology employed in delivery wards. The qFeuestionnaire was made up of 22 questions evaluating participant characteristics and the current use of ultrasound in labor in their hospital of employment. The answers were grouped according to participant characteristics. A total of 200 participants replied. Ultrasound was considered useful before an operative vaginal delivery by 59.6 % of respondents, while 51.8 and 52.5 % considered it useful in the management of prolonged first and second stages of labor, respectively. The major indication for ultrasound use during labor was the assessment of fetal occiput position. The major difficulties in its application were the perceived lack of training and the complexity of the ultrasound equipment use. Participants that reported fewer difficulties were those employed in hospitals with a higher number of deliveries or having delivery units with more years of experience using ultrasound in labor, or those who had attended specific training courses. The results indicate that, despite the reported evidence of a higher accuracy of ultrasound compared to clinical evaluation in assessing fetal position and station, its use is still limited, even amongst maternal-fetal medicine practitioners specialized in ultrasonography. [ABSTRACT FROM AUTHOR]

This article examines a human effigy vessel found in Lee County, Florida, which is believed to depict a pregnant woman in a birthing position. The author suggests that the vessel was used for educational and shamanic purposes to teach about pregnancy and childbirth. The article also explores the symbolism of conical head coverings found on other female effigies, linking them to childbirth. The author emphasizes the importance of recognizing birth-related artifacts in archaeological studies and encourages inclusive interpretations that consider all sexual identities. Another article by Trevor Duke, George Luer, and Michael D. Glascock investigates the origins of Mississippian pottery along the Gulf Coast of Florida. The authors analyze the chemical composition of the pottery to trace its source and distribution patterns, providing insights into the cultural connections and trade networks of the Mississippian people in the region. [Extracted from the article]

Objective The objective of the study was to evaluate whether patients with oxytocin discontinued during the second stage of labor (≥30 minutes prior to delivery) had a lower rate of postpartum hemorrhage (PPH) compared with those with oxytocin continued until delivery or discontinued <30 minutes prior to delivery. Study Design Retrospective cohort study was performed from August 1, 2014 to July 31, 2019. Singleton pregnancies of 24 to 42 weeks gestation were included if they reached the second stage of labor and received oxytocin during labor. Patients on anticoagulants were excluded. Patients with oxytocin discontinued ≥30 minutes prior to delivery represented STOPPED and those with oxytocin continued until delivery or discontinued <30 minutes prior to delivery represented CONTINUED. Patient data were abstracted from the electronic medical record. The primary outcome was PPH (≥1,000 mL blood loss). Univariable analyses were performed to compare groups. Multi-variable logistic regression was performed to adjust for prespecified confounders. Planned sub-group analyses by the route of delivery were performed. Results Of 10,421 total patients, 1,288 had oxytocin STOPPED and 9,133 had oxytocin CONTINUED. There were no significant differences in age, race, or ethnicity, body mass index, public insurance, gestational diabetes, or pregnancy-induced hypertension between STOPPED and CONTINUED. The PPH rate was 15.2 and 5.7% in STOPPED and CONTINUED, respectively (p < 0.001). After adjusting for confounders, STOPPED remained at higher odds for PPH (adjusted odds ratio 2.859, 95% confidence interval 2.394, 3.414, p < 0.001). Among cesarean deliveries only, there was no significant difference in the rate of PPH between STOPPED and CONTINUED (38.0 vs. 36.4%, respectively, p = 0.730). However, among vaginal deliveries, the rate of PPH was actually lower in STOPPED than CONTINUED (3.4 vs. 5.2%, respectively, p = 0.024). Conclusion The rate of PPH was higher in patients with oxytocin STOPPED compared with CONTINUED. However, among vaginal deliveries, there was a significantly lower rate of PPH in STOPPED. These disparate findings may be explained by the variable impact of second-stage oxytocin on PPH as a function of delivery type. Key Points It is unclear if oxytocin use in the second stage of labor may independently increase the risk of hemorrhage. Patients with oxytocin discontinued during the second stage of labor had a higher rate of PPH. PPH was significantly lower among vaginal deliveries in patients with oxytocin discontinued. [ABSTRACT FROM AUTHOR]

Finite element models of the second-stage labor system have been commonly developed for providing objective and quantitative indicators as well as innovative therapeutic solutions for decision supports. However, the reliability of the simulation outcomes remains a challenging issue due to uncertainties in input data and model complexity as well as the lack of validation. The objective of this study was to perform uncertainty quantification (UQ) on the material properties of the pelvis soft tissue with a focus on the uterus tissue during the second labor simulation leading to explore more plausible outcome space for reliable decision support making. The developed modeling and simulation workflow includes an image-based finite element model of the fetal body and pelvis soft tissues (floor, vagina and uterus), an uncertainty modeling procedure using precise and imprecise probabilities and an uncertainty propagation process based on the Monte Carlo method with and without parameter dependency. Obtained results showed that hyperelastic properties of the uterus tissue are very sensitive during the second stage of labor simulation. Moreover, the use of imprecise probability and parameter dependency lead to a more consistent range of values for uterus tissue stress analysis. This study performed, for the first time, an UQ on the hyperelastic properties of the uterus tissue from the in silico simulation of the second-stage labor. This opens new avenues for providing reliable indicators for clinical decision support. As a perspective, the active uterus behavior will be integrated into a more realistic second-stage labor model and simulation. Then, UQ will be conducted for more reliable decision support. [ABSTRACT FROM AUTHOR]

The article offers information on the importance of optimum nutrition for mares during pregnancy. Topics include the ideal body condition score (BCS) for broodmares and its impact on fertility, the nutritional needs during the last trimester of pregnancy to support fetal development and prepare for lactation, and the National Research Council's recommendations for weight gain and the significance of providing the right nutrients to prevent health issues and abnormalities in foals.

Background and Objectives: Labor epidural analgesia can be maintained through programmed intermittent epidural bolus (PIEB), continuous epidural infusion (CEI), or patient-controlled epidural analgesia (PCEA). Our department changed from CEI+PCEA to PIEB+PCEA as the maintenance method. The higher hourly dose setting in the current regimen brought to our concern that side effects would increase with proportional staff workloads. This study aimed to investigate the validity of our proposal that PIEB+PCEA may function as a feasible tool in reducing the amount of work in the obstetrics anesthesia units. Materials and methods: This 2-year retrospective review included parturients with vaginal deliveries under epidural analgesia. We compared the staff burden before and after the switch from CEI (6 mL/h, PCEA 6 mL lockout 15 min, group A) to PIEB (8 mL/h, PCEA 8 mL lockout 10 min, group B). The primary outcome was the difference of proportion of parturients requiring unscheduled visits between groups. Side effects and labor and neonatal outcomes were compared. Results: Of the 694 parturients analyzed, the proportion of those requiring unscheduled visits were significantly reduced in group B (20.8% vs. 27.7%, chi-square test, p = 0.033). The multivariate logistic regression showed that PIEB was associated with fewer unscheduled visits than CEI (OR = 0.53, 95% CI [0.36–0.80], p < 0.01). Group B exhibited a significantly lower incidence of asymmetric blockade, as well as motor blockade. In nulliparous subjects, obstetric anal sphincter injury occurred less frequently when PIEB+PCEA was used. Significantly more multiparous women experienced vacuum extraction delivery in group B than in group A, and they had a longer second stage of labor. Conclusions: The PIEB+PCEA protocol in our study reduced workloads in labor epidural analgesia as compared to CEI+PCEA, despite that a higher dose of analgesics was administered. Future studies are warranted to investigate the effect of manipulating the PIEB settings on the labor outcomes. [ABSTRACT FROM AUTHOR]

Background: 60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities. Methods: Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities. Results: The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0–12 months after training: IRR 1.59, 95% CI: 1.04–2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37–4.41, p-value 0.003). There was no significant change in stillbirth or referral rates. Conclusions: Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted. [ABSTRACT FROM AUTHOR]

Background: Evidence regarding the type and rate of intravenous (IV) fluid administration during labor is still inconclusive and the studies assessing the impact of IV fluids had mixed results. Objectives: To evaluate the effects of IV fluids at an infusion rate of 250 mL/h as compared with 125 mL/h on labor outcomes in nulliparous women. Search Strategy: We searched six databases for relevant studies through a search strategy containing the relevant keywords "IV hydration", "IV fluids", and "labor" from the inception of these databases to May 1, 2023, without any applied restrictions. Selection Criteria: Search results were imported to Covidence for screening of eligible articles for this review. Randomized controlled trials (RCTs) assessing the impact of IV fluids at 250 mL/h on the outcomes of labor in nulliparous women at term (>37 weeks) as compared with 125 mL/h were included only. Data Collection and Analysis: Data regarding the characteristics of included studies, participant's baseline characteristics, and concerned outcomes were collected in an Excel spreadsheet and all the concerned outcomes were pooled as risk ratios (RR) or mean difference (MD) with 95% confidence interval (CI) in the meta‐analysis models using RevMan 5.4. Main results: Pooled data from 11 RCTs with 1815 patients showed that 250 mL/h infusion rate had a significant reduction in cesarean section rate (RR 0.70, 95% CI 0.56–0.88, P = 0.002), the first stage of labor duration (MD –46.97, 95% CI –81.79 to −12.14, P = 0.008), the second stage of labor duration (MD –2.69, 95% CI –4.34 to −1.05, P = 0.001), prolonged labor incidence (RR 0.72, 95% CI 0.58–0.89, P = 0.003), as compared with 125 mL/h. Also, the vaginal delivery rate (RR 1.07, 95% CI 1.02–1.12, P = 0.009) was higher with a 250 mL/h infusion rate. Conclusion: IV fluids at an infusion rate of 250 mL/h during labor in nulliparous women decreased the cesarean delivery rate, increased the vaginal delivery rate, shortened the first and second‐stage labor duration, decreased the incidence of prolonged labor as compared with 125 mL/h. These findings suggest enhanced labor progression and a lower risk of labor complications with higher infusion rates. However, future research involving a more diverse population and exploring the potential benefits of combining IV infusion rates with other interventions, such as adding dextrose or less restrictive oral intake during labor, is needed. Synopsis: IV fluids at 250 mL/h reduce cesarean section rates and significantly affect the labor outcomes as compared with 125 mL/h. [ABSTRACT FROM AUTHOR]

BACKGROUND: Anal incontinence is defined as the involuntary loss of fecal material or flatus. The reported prevalence at 6 weeks postpartum varies from 4% to 39%. It is associated with reduced quality of life, negative psychogenic effects and social stigma. This study was done to assess its prevalence at 6 weeks after vaginal delivery and identify the associated factors. METHODS: This is a cross-sectional descriptive study. Data was collected using questionnaire adapted from International Consultation on Incontinence Questionnaire on Urinary Incontinence-Short Form. Data was analyzed using SPSS version 20.5. RESULT: The prevalence of anal incontinence at 6 weeks after vaginal delivery was 8.6%. The majority of the cases, 28 (84.8%), had only flatus incontinence. Participants of age group 20-35 years had significantly lower odds of having anal incontinence compared to those above age 35 (P < 0.05). The odds of having incontinence compared to spontaneous vaginal delivery was about 5 times higher for forceps (AOR= 4.93 (95%CI:1.48, 16.44)) and vacuum (AOR= 5.53 (95%CI:1.18, 25.96)) deliveries. Second stage of labor duration of >120 minutes had more than 4 times odds of developing incontinence compared to duration of <30 minutes (AOR= 4.79 (95%CI:1.01, 22.82)). Second degree perineal tear was the most significantly associated variable compared to those without tear (AOR= 12.31 (95%CI:3.89, 39.00)). CONCLUSION: The prevalence of anal incontinence at 6 weeks after vaginal delivery was 8.6%. Maternal age, mode of delivery, duration of second stage of labor and perineal tear were the significantly associated factors. [ABSTRACT FROM AUTHOR]

Objective We determine whether racial concordance between postpartum patients and obstetric providers (dyads) impacts the perception of quality of care among people undergoing intrapartum obstetrical procedures. Study Design This is a prospective cohort study of postpartum people who underwent operative vaginal or cesarean deliveries in the second stage of labor. Participants were asked to identify the race of their primary provider and complete the Interpersonal Processes of Care (IPC) survey, which assesses communication, patient-centered decision-making, and interpersonal style. The association of participant-identified patient–provider racial concordance with IPC scores was determined. The primary outcome was the IPC subdomain related to discrimination, and secondary outcomes included other IPC subdomains and IPC results by participant racial identity (Black, LatinX vs. White). Sociodemographic and biomedical data were extracted from the medical record. Bivariable analyses were performed. Results Of 168 patients who were approached, 107 (63.6%) agreed to participate and 87 (81.3%) completed the survey. The majority (n =49) identified a racially discordant provider. Participants in racially concordant dyads were more likely to be older, White, use English as a primary language, complete a higher degree of education, and have a higher household income when compared with racially discordant dyads. Intrapartum outcomes were not significantly different between groups. Median IPC subtest scores were not significantly different between groups or between racial/ethnic identities. Conclusion There were no significant differences in perceptions of IPC between racially concordant versus discordant dyads. However, there is an ongoing need to further clarify measures of quality of care in high-acuity obstetrical situations to remediate ongoing racial and ethnic disparities in adverse health outcomes. Key Points Racial concordance between patient and clinician has been associated with improved quality of care. There are limited data on racial concordance and perceptions of operative obstetrical care (e.g., operative vaginal delivery). Racial concordance was not associated with differences in patient-perceived quality of care associated with operative obstetrics. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to quantify patient satisfaction by hour of second stage of labor and subsequent delivery mode. Study Design Pilot cross-sectional study of nulliparous women delivered at George Washington University Hospital between April 2018 and March 2019. Patients completed three survey questionnaires in the immediate postpartum period: Patient Perception Score (PPS), Consumer Satisfaction Questionnaire (CSQ), and Six Simple Questions (SSQ). Length of second stage was divided into 2 groups (≤3 hours and >3 hours). Data on maternal characteristics, maternal outcomes, and neonatal outcomes were collected in REDCap and statistical analysis was performed using SAS version 9.4. Results Survey response rate was 100% (n = 100). Seventy-one patients had a normal second stage and 29 patients had a prolonged second stage. Prolonged second stage was significantly associated with a lower proportion of NSVD (65.5 vs. 90.1%; p <0.01) and a higher proportion of epidural (82.8 vs. 60.6%; p = 0.03) in comparison to a normal second stage. Length of second stage had a statistically significant negative correlation with overall PPS scores (ρ = − 0.25, p ≤0.01). Length of second stage was not correlated with the SSQ (ρ = 0.05, p = 0.25) or CSQ (ρ = − 0.18, p = 0.11) surveys. CSQ scores were statistically significantly lower in women who underwent second stage cesarean delivery. Conclusion Maternal satisfaction with childbirth and health care experience was high regardless of length of second stage. Only the PSS survey showed that shorter length of second stage was correlated with higher satisfaction. Cesarean delivery in the second stage was significantly associated with decreased maternal satisfaction. Future studies with larger cohorts are needed to confirm our findings. Key Points There is limited data on maternal satisfaction with childbirth. Mode of delivery may affect maternal satisfaction. Shared decision-making about delivery mode and timing is crucial. [ABSTRACT FROM AUTHOR]

Objective The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice. Study Design 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. Results 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%; p <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. Conclusion 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. Key Points 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. [ABSTRACT FROM AUTHOR]

Objective We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery. Study Design We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t -tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test. Results Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001). Conclusion Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings. Key Points Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean. Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups. There may be unmeasured provider level factors which contribute to disparities in cesarean rates. [ABSTRACT FROM AUTHOR]