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Objective : Second stage caesarean section is usually associated with the deeply engaged head, less liquor, and thinned out the lower uterine segment. This can lead to a high risk of maternal morbidities like an extension of the lower uterine segment incision, uterine atony, and injury to urinary bladder as well as neonatal morbidities such as birth asphyxia, NICU admission, and meconium aspiration syndrome. This study aims to observe the maternal and neonatal outcomes of caesarean delivery performed in the second stage of labor. Methods: This study was institution based Observational descriptive study And was conducted in Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal, India from March 2020- August 2021 including 90 women who had deliver by caesarean section at second stage of labour. Thorough history taking and clinical examination was done. Template was generated in MS excel sheet and analysis was done on SPSS software. Results: CPD was the most common indication of LSCS (53.3%). During the post-operative period, 24.4% had PPH, 15.6% had sepsis and 10% required hospitalizationformorethan5days. Among thebabiesborn52.2%ofthe baby required NICU admission. AmongthebabiesadmittedinNICU,29.8%hadBirthasphyxia,25.5%hadMeconiumaspirationsyndro me, Neonatal jaundice (23.4%)and Neonatalsepsis (10.6%)Conclusion: Caesarean sections during the second stage are increasing in prevalence. From the salient findings of the study, we may conclude that Caesarean section at full cervical dilatation is associated with higher likelihood of adverse outcome for both mother and fetus. [ABSTRACT FROM AUTHOR]

Introduction: During the second stage of labor, vacuum‐assisted delivery is an alternative to forceps delivery and emergency cesarean section. Extensive research concerning perinatal outcomes has indicated that the risk of complications, although rare, is higher than with a spontaneous vaginal delivery. An important factor related to perinatal outcomes is the traction force applied. Our research group previously developed a digital extraction handle, the Vacuum Intelligent Handle‐3 (VIH3), that measures and records traction force. The objective of this study was to compare traction force profiles in children with and without severe perinatal outcomes delivered with the digital handle. A secondary aim was to establish a safe force limit. Material and Methods: This was an observational case–control study at the delivery ward at Karolinska University Hospital, Sweden. In total, 573 children delivered with the digital handle between 2012 and 2018 were included. Cases were defined as a composite of severe perinatal outcomes, including subgaleal hematoma, intracranial hemorrhage, hypoxic ischemic encephalopathy 1–3, seizures or death. The cases in the cohort were matched 1:3 based on five matching variables. Traction profiles were analyzed using the MATLAB® software and conditional logistic regression. Results: The incidence of severe perinatal outcomes was 2.3%. The 13 cases were matched with three controls each (n = 39). A statistically significant increased odds for higher total traction forces was seen in the case group (odds ratio [OR] 1.004; 95% confidence interval [CI] 1.001–1.007) and for the peak force (OR 1.022; 95% CI 1.004–1.041). Several procedure‐related parameters were significantly increased in the case group. As expected, some neonatal characteristics also differed significantly. An upper force limit of 343 Newton minutes (Nmin) revealed an 86% reduction in severe perinatal outcomes (adjusted OR 0.14; 95% CI 0.04–0.5). Conclusions: Children with severe perinatal outcomes had traction force profiles with significantly higher forces. The odds for severe perinatal outcomes increased for every increase in Nmin and Newton used during the extraction procedure. A calculated total force level of 343 Nmin is suggested as an upper safety limit, but this must be tested prospectively to provide validity. [ABSTRACT FROM AUTHOR]

Women have anatomically different perineal sizes. Different perineal sizes in primiparous women may be related to episiotomy and its consequences. The aim of this study was to investigate the relationship between perineal size and episiotomy during delivery. 376 primiparous women referred to Fatemieh Hospital in Hamadan with single pregnancies, in the first stage of labor, and with a gestational age of 37 weeks and more, out of which 372 participated in this study. Before entering the first stage of labor, they underwent perineal measurements, such as perineal body (PB), genital hiatus (GH), and anogenital area (AGD), in a forced position. Then, they were followed up for episiotomy and vaginal wall rupture until the end of the second stage of labor. Our outcome in this study was an episiotomy during delivery. The mean gestational age was 39.10±1.21 weeks, and the neonatal weight was 3107.37±42.39 g. 86.3% of women had an episiotomy, and 5.4% experienced perineal tear (laceration). Mean perineal size was 3.99±0.77, genital hiatus was 3.040±0.74, GH+PB was 7.39±1.05, and AGD was 8.49±1.22 cm. There was a statistically significant relationship between perineal body size episiotomy (P=0.011), GH+PB (P=0.003), AGD (P=0.017), neonatal birth weight (P=0.021), as well as grade 1 and 2 rupture (P<0.001). The size of GH+PB at the cut-off point of 6.25 cm and AGD at the cut-off point of 9.25 cm significantly increased the chance of performing an episiotomy. In primiparous women with a gestational age of 37 to 42 weeks, vaginal delivery, shorter perineum, vaginal hiatus, and anogenital distance significantly increased the likelihood of an episiotomy. On the other hand, performing an episiotomy significantly reduced grade 1 and 2 perineal tear rates. [ABSTRACT FROM AUTHOR]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, explores the use of a combined clinical and sonographic algorithm triage model to predict difficult assisted vaginal delivery in women with prolonged second stage of labor. The study, conducted at Kwong Wah Hospital in Hong Kong, included 51 women who underwent vacuum extraction or forceps delivery. The results showed that the angle of progression with pushing may be the most sensitive predictor of difficult assisted vaginal delivery. However, further research with a larger sample size is needed to refine the algorithm model. [Extracted from the article]

This article, titled "EP19.15: Intrapartum assessment of head-perineum distance: a comparative study of measurements obtained with and without compression of perineal soft tissues," presents the findings of a study that aimed to evaluate and compare measurements of the head-perineum distance (HPD) obtained with and without compression of the perineal soft tissues. The study involved a series of singleton pregnancies and used transperineal sonography to evaluate the HPD. The results showed a good correlation and reproducibility between the HPD measured with and without compression, and it was also found that the body mass index at delivery may impact the difference in measurements. [Extracted from the article]

This article discusses a preliminary study on the feasibility of using an automatic algorithm to assess the likelihood of successful instrumental delivery in obstetrics. The algorithm analyzes ultrasound images to measure parameters such as the occiput position, head-perineum distance, and midline angle, and assigns a color code (green, yellow, or red) indicating the chances of success. The study found that the algorithm had a sensitivity of 0.80 and specificity of 0.82 for the green code, and a sensitivity of 0.64 and specificity of 0.80 for the yellow code. The authors conclude that these preliminary results are encouraging and suggest the potential for further improvements in clinical decision-making for delivery management. [Extracted from the article]

This article discusses the importance of standardizing terminology in ultrasound studies of the pelvic floor in pregnant women. The author commends a recent study for shedding light on the topic of maternal pushing and emphasizes the significance of maternal pelvic floor relaxation during vaginal delivery. The article highlights the use of different terminologies and cutoffs to describe the same phenomenon, which can lead to confusion and complicate the interpretation of studies. The author suggests adhering to the original definition of LAM co-activation to enhance consistency across studies and advocates for using the term "bearing down" instead of "Valsalva manoeuvre" to reflect the diversity in pushing techniques among pregnant women. [Extracted from the article]

Healthcare professionals working in labor wards worldwide regularly deal with the pressure of managing an emotionally charged and life-changing period for women, their families, and their friends. Furthermore, they frequently deal with long working hours, sleep deprivation, occasional scrutiny from the press, and legal dispute. The existing disagreements among leading scientific institutions on basic concepts of intrapartum care hinder the creation of a collective mental model in the labor ward, an aspect that is required for consistency in patient counseling and effective teamwork. Some of these disagreements are as follows: 1. When should laboring women be admitted to the hospital? 2. How long is the absence of labor progress acceptable before an intervention is proposed? 3. How long should women be allowed to push during the second stage of labor before an intervention is proposed? The international scientific community owes it to the vast number of healthcare professionals working in labor wards worldwide to agree on and provide clear definitions of these basic intrapartum concepts, thus making their work a little easier. International institutions, such as the International Federation of Gynecology and Obstetrics and the World Health Organization, have the highest authority to produce guidelines for the whole world, but the participation of leading national organizations, whose influence reaches well beyond the borders of their countries, is important for the wide dissemination of concepts. [ABSTRACT FROM AUTHOR]

Introduction: Occiput-posterior (OP) or occiput-transverse (OT) fetal malposition has a prevalence of 33–58% in the first-stage of labour with 12–22% persisting until delivery. Malposition is associated with significant maternal and neonatal morbidity. Most previous studies report the incidence and adverse maternal and fetal outcomes of persistent fetal malposition in the second stage of labour and do not include outcomes that may be present in the first stage of labour. Aims: To assess the incidence and health outcomes for women and their newborn infants of a fetal malposition in the first or second stage of labour. Materials and methods: A retrospective cohort study of 738 maternity records (randomly selected) from a tertiary hospital in New Zealand. Maternal and neonatal characteristics are described. Outcomes for women with a fetus in an OP or OT position in labour are compared to those for women with a fetus in an occiput-anterior position (OA). Results: 499 (68%) women had an OP/OT positioned fetus and 239 (32%) had an OA positioned fetus on vaginal examination in labour. Women had similar characteristics except a body mass index ≥30 kg/m2 was more common in the OP/OT group. Fetal malposition appears to be more likely in women with a right-sided fetal occiput. Three quarters of OP/OT fetuses rotated anteriorly by birth. Fetal malposition compared to no malposition was associated with oxytocin augmentation, epidural use, a longer first stage of labour, fewer normal vaginal births, and more caesarean sections. Fetal malposition during labour was not associated with adverse neonatal outcomes. Conclusion: Interventions such as maternal posture in the first and second stage of labour could potentially reduce the incidence of malposition and improve health outcomes for mothers. [ABSTRACT FROM AUTHOR]

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson's classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to develop a Practice Programme for Upright Positions in the Second Stage of Labour to provide a reference for midwifery professionals in the standardized implementation of upright positions in clinical practice. Background: The adoption of upright positions in the second stage of labour is recommended by many international organizations, but upright positions have not been widely used and their implementation varies greatly across studies. Methods: The Practice Programme for Upright Positions in the Second Stage of Labour was developed under the guidance of the Medical Research Council framework for developing and evaluating complex interventions and the World Health Organization handbook for guideline development. Four stages were conducted: (1) establishing the intervention development group, (2) identifying a theoretical basis and forming a content framework, (3) evidence retrieval and synthesis and (4) refining and modelling the practice programme. Results: The content framework of the Practice Programme for Upright Positions in the Second Stage of Labour was formed based on the literature review, semi‐structured interviews and expert consultation, including indications and contraindications, implementation methods, observations, potential risks and precautions. According to each item, we conducted a series of systematic reviews, and summarized the available best evidence from clinical guidelines, systematic reviews and original studies. Eventually, the Practice Programme for Upright Positions in the Second Stage of Labour was developed, integrating the findings of the iterative evidence reviews and revised by stakeholders. Conclusions: This study first reported the development process of the Practice Programme for Upright Positions in the Second Stage of Labour, characterized by evidence‐based, iteratively processed and highly rigorous. The implications may guide researchers to embed the intervention normatively into clinical practice for improving maternal and infant outcomes. Implications for Nursing Management: The Practice Programme for Upright Positions in the Second Stage of Labour could facilitatesystematic management of labour positions and guide midwives in the successful implementation of upright positions. [ABSTRACT FROM AUTHOR]

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Background: Epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Objectives: To assess effect of regional analgesia on labor pain, duration, outcome of delivery and neonates. Materials and Methods: Case control study included 400 pregnant woman 200 of them delivered by painless labour and other 200 whose delivered without analgesia who attended to the babylon maternity and pediatric hospital,Al sadiq hospital and private hospitals in al hilla city which included private Teiba, Al Fayhaa hospitals from first of february 2022 to June 2022. Results: The duration of first stage of labor was significantly prolonged at control mothers 26%(52) in compare to 10%(20) of mothers with epidural anesthesia had prolonged labor. While second stage shown no significant association with epidural anesthesia (P = 0.47). Fetal heart rate abnormalities shown no significant association with epidural analgesia (P = 0.96). While back pain and headache was significantly higher in mothers with epidural analgesia (P < 0.001). Conclusions: EA was not associated with a higher instrumental delivery rate and higher rate of c/s, EA not cause significant maternal or neonatal complications in primi- and multiparas. Importantly, EA associated with short first stage of labor and not higher rate effect on duration of second stage of labour. [ABSTRACT FROM AUTHOR]

Simple Summary: A fetal catheterization is an efficient tool allowing longitudinal in vivo studies on hormonal and metabolic changes, including fetal blood gases and acid-base changes. These surgical techniques made it possible to take blood samples daily under aseptic conditions to determine arterial and/or venous blood samples for acid-base variables (like pH, blood gas tensions: partial pressure of carbon dioxide and partial pressure of oxygen, oxygen saturation, bicarbonate concentration, total carbon dioxide, and base excess). All these examinations may contribute to a better understanding of the physiological changes that occur during calving, which may help reach a significant reduction in losses caused by perinatal mortality, which is still high today. The objective of the present study was to evaluate the changes in maternal and fetal arterial acid-base variables withdrawn from catheterized dams and fetuses during the last days before and during calving. The average gestation length in nine cows with chronically catheterized fetuses was 285 ± 10 (SD) days. The arterial acid-base variables of a catheterized dam and fetus were very stable during late gestation. Four newborn calves showed small differences between prenatal and postnatal pH values (−0.035). At the same time, pCO2 values started to increase significantly (p = 0.02), indicating a shift towards physiological respiratory acidosis during calving. The partial pressure of oxygen and oxygen saturation values showed some non-significant improvements immediately after birth, while the other acid-base parameters did not differ. The remaining five newborn calves showed a significant decrease in arterial blood pH (p < 0.01) and BE (p = 0.01), while pCO2 tended to be higher (p = 0.06), indicating a shift towards physiological respiratory and metabolic acidosis, while the other acid-base parameters hardly differed. It is essential to mention that physiological (n = 2) and mild metabolic acidosis (n = 2) developed gradually in four newborn calves during the second stage of calving, lasting about ≤ 2 h. In contrast, in the remaining newborn calf the physiological metabolic acidosis developed during the last 3 min of birth because immediately before birth, the BE value was 0.4 mmol/L. After birth, it was −5.4 mmol/L. The results indicate that the acid-base variables may start to move gradually in the direction of expressed respiratory and metabolic acidosis only after appearing the amniotic sac and fetal feet in the vulva during the second stage of labor; therefore, it is essential to complete obstetrical assistance in time. [ABSTRACT FROM AUTHOR]

Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases. We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes. In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae. Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate maternal outcomes with an extended second stage of labor and determine if an extended second stage is cost effective. This theoretical model evaluated expectant management to 4 h compared to delivery at 3 h in the setting of a prolonged second stage of labor in nulliparous women with epidural analgesia. In our theoretical cohort of 165,000 women, we found that an extended second stage resulted in 53,268 more spontaneous vaginal deliveries, 14,163 fewer operative vaginal deliveries, and 39,105 fewer cesarean deliveries. This approach also resulted in 1 fewer instance of maternal death. An extended second stage, however, led to 14,025 more cases of chorioamnionitis, 1699 more episodes of postpartum hemorrhage requiring transfusion, and 119 more severe perineal lacerations, suggesting that while an extended second stage of labor results in overall improved maternal outcomes, there are tradeoffs. Expectant management to 4 h was the dominant strategy in the model, as it saved over $114 million US dollars and resulted in 4000 additional QALYs over our theoretical cohort. Sensitivity analysis indicated that expectant management until 4 h was cost-effective as long as the probability of cesarean delivery at 4 h was below 41.8%, and was the dominant strategy below 38.2% (baseline input: 19.5%). Multivariable sensitivity analysis demonstrated that the model was robust over a wide range of assumptions. Expectant management of the second stage of labor until 4 h is a cost-effective strategy to prevent primary cesarean deliveries, decrease costs, and improve some maternal outcomes, despite tradeoffs. [ABSTRACT FROM AUTHOR]

Objectives: To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery. Design Retrospective cohort study. Setting: University hospital. Population Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded. Methods: Charts from 2007 to 2019 were reviewed. Main outcome measures: Rate of sPTB (<37 weeks of gestation) in the second delivery. Results: Of 13 958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180 min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96–1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second‐stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71–4.12; p < 0.001), with a more pronounced risk in those with second‐stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94–5.94; p < 0.001). Conclusion: Second‐stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second‐stage caesarean section, particularly if performed after a prolonged second stage. Second‐stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth. Second‐stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth. [ABSTRACT FROM AUTHOR]

Objective: To determine whether intrapartum transperineal ultrasound measurement of the angle of progression (AoP) during the second stage of labor can predict uncomplicated operative vaginal delivery (OVD) using vacuum or forceps extraction.Methods: A systematic search in PubMed, EMBASE, Scopus, Web of Science and Google Scholar was performed from inception to February 2021. Studies assessing the predictive accuracy of AoP, measured using intrapartum transperineal ultrasound, for uncomplicated OVD, defined as successful vaginal delivery within three pulls using forceps or no more than two detachments of the vacuum extractor cup, were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Summary receiver-operating-characteristics (ROC) curves, pooled sensitivity and specificity, area under the ROC curve (AUC) and summary likelihood ratios (LRs) were calculated.Results: Seven studies reporting on a total of 782 patients undergoing OVD were included in this systematic review and meta-analysis. Second-stage AoP measured during maternal rest had a pooled sensitivity of 80% (95% CI, 59-92%) and specificity of 89% (95% CI, 76-95%), with a LR+ of 7.3 (95% CI, 3.1-15.8) for uncomplicated OVD. AoP measured during active pushing had a sensitivity of 91% (95% CI, 85-94%) and specificity of 83% (95% CI, 69-92%), with a LR+ of 5.4 (95% CI, 2.7-10.6) for uncomplicated OVD. The performance of AoP measured at rest was particularly high in nulliparous women, with a sensitivity of 87% (95% CI, 75-94%) and specificity of 90% (95% CI, 82-94%) for uncomplicated OVD.Conclusion: AoP may be a reliable predictor for uncomplicated OVD when measured during the second stage of labor, especially in nulliparous women. © 2022 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

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The WHO (World Health Organization) recommends that the percentage of perineal incisions should not exceed 10%, indicating that this is a good goal to achieve, despite the fact that it is still a frequently used medical intervention in Poland. The risk factors for perineal incision that have been analyzed so far in the literature allow, among others, to limit the frequency of performing this procedure. Are they still valid? Have there been new risk factors that we should take into account? We have conducted this study to find the risk factors for performing perineal incision that would reduce the frequency of this procedure. The aim of the study was to check whether the risk factors that were analyzed in the literature are still valid, to find new risk factors for perineal incisions and to compare them among Polish women. This was a single-center retrospective case-control study. The electronic patient records of Saint Sophia's Hospital in Warsaw, Poland, a tertiary hospital was used to create an anonymous retrospective database of all deliveries from 2015 to 2020. The study included the analysis of two groups, the study group of patients who had had an episiotomy, and the control group-patients without an episiotomy in cases where an episiotomy was indicated. A logistic regression model was developed to assess the risk factors for perineal laceration. Independent risk factors for episiotomy in labor include oxytocin use in the second stage of labor (OR (Odds Ratio) = 6.00; 95% CI (Confidence Interval): 4.76–7.58), the supply of oxytocin in the first and the second stage of labor (OR = 3.18; 95% CI: 2.90–3.49), oxytocin use in the first stage of labor (OR = 2.72; 95% CI: 2.52–3.51), state after cesarean section (OR = 2.97; 95% CI: 2.52–3.51), epidural anesthesia use (OR = 1.77; 95% CI: 1.62–1.93), male gender (OR = 1.10; 95% CI: 1.02–1.19), and prolonged second stage of labor (OR = 1.01; 95% CI: 1.01–1.01). A protective factor against the use of an episiotomy was delivery in the Birth Centre (OR = 0.43; 95% CI: 0.37–0.51) and mulitpara (OR = 0.31; 95% CI: 0.27–0.35). To reduce the frequency of an episiotomy, it is necessary consider the risk factors of performing this procedure in everyday practice, e.g., limiting the use of oxytocin or promoting alternative places of delivery. [ABSTRACT FROM AUTHOR]

Aim: To reassess the normal duration of each stage of labor in a contemporary Japanese cohort, and to determine whether prolongation of each stage of labor increases the rate of postpartum hemorrhage (PPH) in vaginal deliveries. Methods: Clinical data of women who delivered at term at 12 facilities between 2012 and 2018 were retrospectively collected. A total of 31 758 women were subdivided into three or four subgroups according to the duration of each stage of labor and parity. Univariate and multivariate logistic regression analyses were performed to estimate crude and adjusted odds ratios (ORs) of PPH (blood loss ≥ 1000 mL) in each subgroup, with women with the shortest durations in each subgroup used as the reference group. Results: The reference range of each stage of labor was found to be shorter than that previously reported. Women with prolonged second (primiparity, adjusted OR: 1.15–1.78; multiparity, adjusted OR: 1.14–1.74) and third (primiparity, adjusted OR: 1.39–4.95; multiparity, adjusted OR: 1.46–3.80) stages of labor showed an increased risk of PPH, whereas those with prolonged first stage did not. A significantly increased risk of PPH was found both in primiparous and multiparous women with third stages of labor ≥ 5 min. Conclusions: The normal duration of each stage of labor in the Japanese population needs to be revised and well‐recognized by obstetric care providers. A prolonged third stage of labor was a more important contributing factor to PPH than prolonged first or second stages. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI. Study Design  This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations. Results  Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p  < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17–11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06–3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68–0.81). Conclusion  Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI. Key Points Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas. Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas. Improved models are needed for clinical risk-stratification. [ABSTRACT FROM AUTHOR]

Dystocia is an abnormal and difficult birth in which the first or the second stage of labour is markedly prolonged and subsequently found impossible for the dam to deliver without artificial aid. In cattle, it can be relieved by different obstetric methods, including the cesarean operation and fetotomy. Caesarean section is the extraction of the fetus or foeti from the dam, through a surgical opening in the abdominal wall and the uterus. This surgical method can be performed by about eight alternative surgical approaches in bovines with its advantages and disadvantages. However, the selection is dependent on many factors like the type of dystocia, the cows and environmental conditions, the availability of assistants, and the surgeon's preference. For cows, most surgeons use a standing left paralumbar celiotomy. However, the left oblique approach is also preferable under most circumstances because the uterus is readily exteriorized, limiting peritoneal cavity contamination. Besides, alternative approaches are also available that will further limit the potential for contamination but many junior surgeons perform the left paralumbar celiotomy using the same approach each time due to their comfort with one specific approach or lack of familiarity with other available options. Therefore, the objective of this review is to provide basic insights and highlight the cesarean section incision approaches with their relative advantages and disadvantages in cows. [ABSTRACT FROM AUTHOR]

Objective: The primary objective of this systematic review was to assess the association between spontaneous vaginal delivery and manual rotation during labor for occiput posterior or transverse positions. Our secondary objective was to assess maternal and neonatal outcomes.Data Sources: An electronic search of PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Register of Controlled Trials covered the period from January 2000 to September 2021, without language restrictions.Study Eligibility Criteria: The eligibility criteria included all randomized trials with singleton pregnancies at ≥37 weeks of gestation comparing the manual rotation groups with the control groups. The primary outcome was the rate of spontaneous vaginal delivery. Additional secondary outcomes were rate of occiput posterior position at delivery, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, obstetrical anal sphincter injury, prolonged second stage of labor, shoulder dystocia, neonatal acidosis, and phototherapy. Subgroup analyses were performed according to types of position (occiput posterior or occiput transverse), techniques used (whole-hand or digital rotation), and parity (nulliparous or parous).Methods: The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials, known as RoB 2. The meta-analysis used random-effects models depending on their heterogeneity, and risks ratios were calculated for dichotomous outcomes.Results: Here, 7 of 384 studies met the inclusion criteria and were selected. They included 1402 women: 704 in the manual rotation groups and 698 in the control groups. Manual rotation was associated with a higher rate of spontaneous vaginal delivery: 64.9% vs 59.5% (risk ratio, 1.09; 95% confidence interval, 1.03-1.16; P=.005; 95% prediction interval, 0.90-1.32). This association was no longer significant after stratification by parity or technique used. Manual rotation was associated with spontaneous vaginal delivery only for the occiput posterior position (risk ratio, 1.08; 95% confidence interval, 1.01-1.15). Furthermore, it was associated with a reduction in occiput posterior or transverse positions at delivery (risk ratio, 0.64; 95% confidence interval, 0.48-0.87) and episiotomies (risk ratio, 0.84; 95% confidence interval, 0.71-0.98). The groups did not differ significantly for cesarean deliveries, operative vaginal deliveries, or neonatal outcomes.Conclusion: Manual rotation increased the rate of spontaneous vaginal delivery. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study is to investigate and analyze the techniques and ways of thinking that skilled midwives at independent birth centers in Japan use to ensure safe delivery, and thereupon to appraise the perineal management techniques introduced in two commonly used midwifery textbooks. Methods Participation in this study was requested from 25 managers of independent birthing centers in the Tokyo metropolitan and Kansai areas, eight of whom gave consent. Eight skilled midwives became the subjects of this study. With reference to the techniques used in the second stage of labor that was clarified by author's previous study, skillful midwives' techniques using a phantom and their ways of thinking were documented by a movie camera and IC recorders, and semi-structured interviews were conducted. The data collection period lasted from July to August 2017, and the data were analyzed qualitatively using the descriptive method. Results Eight midwives were considered for analysis. The midwives did not control or promote the third rotation, and during the delivery of the shoulders, they waited for the mother's contractions and delivered the fetus slowly by holding with both hands so as to optimize the fetus's rotation and the compact tucked-in position. Based on the belief that fetuses are to be delivered slowly through natural contraction and rotation, skilled midwives did not perform perineal management or actively intervene throughout the birthing process. Conclusion Fetal delivery techniques implemented by skilled midwives at birthing centers differ from the delivery assistance technique (perineal protection method) found in the two main textbooks of midwifery basics. Skillful midwives at independent birth centers used techniques to keep the fetuses in tucked-in position by optimizing their rotation. The midwives thought that slow delivery with natural contraction was not only important for preventing injury but also for the child's continued well-being. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: To evaluate the effect of the second stage of labor (SSL) lasting > 2 h on pelvic floor function. Methods: This single-center prospective cohort study included primiparous women with SSL > 2 h treated at Tongji Hospital between January 2018 and December 2019 (case group). A matched group of women with similar newborn weight and SSL < 2 h were recruited simultaneously (control group). Stress urinary incontinence (SUI) and pelvic floor muscle (PFM) characteristics were measured at 6 weeks, 6 months, and finally 1 year postpartum. Results: A total of 63 pairs of primiparous women completed 1-year follow-up. The incidence of SUI in the case group was significantly higher than that in the control group at 6 weeks postpartum (P = 0.020); however, the differences were not significant at 1 year postpartum (P=1.00). PFM endurance was significantly lower in the case group at 6 weeks (P = 0.000), 6 months (P = 0.000), and 1 year (P = 0.011) after childbirth. There was no difference in PFM strength between the two groups. The maximal voluntary contraction (MVC) of PFM was significantly lower in the case group at 6 weeks postpartum (P = 0.007), but the differences were not significant at 1 year postpartum (P = 0.197). PFM endurance and MVC were higher at 1 year than at 6 weeks postpartum in both groups. Conclusions: The SSL > 2 h increased the incidence of SUI at 6 weeks postpartum and decreased PFM endurance for 1 year. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Obstetrical anal sphincter injury (OASIS) is a common consequence of vaginal delivery in nulliparas and carries the risk of short- and long-term morbidity. The objective of this study was to estimate the association between the duration of the second stage of labour and OASIS risk. Methods: A population-based, retrospective cohort of nulliparas delivering singleton, vertex, non-anomalous fetuses at term in Nova Scotia, Canada, from 2005 to 2019, were identified using the Nova Scotia Atlee Perinatal Database. Poisson regression models were used to estimate risk ratios (RR) with robust 95% confidence intervals (CI) adjusting for confounding variables to investigate the association between the length of the second stage and OASIS in the entire cohort and in operative vaginal deliveries. Results: Of 36,662 participants, 7.6% sustained an OASIS (6.8% third-degree, 0.8% fourth-degree tear). The proportion of participants who sustained an OASIS increased over the study period. For each 30-min increase in the length of second stage, the OASIS risk increased by 11% (RR 1.11, 95% CI 1.10–1.12). When stratified by mode of delivery, second stage length ≥ 90 min was associated with an increased OASIS risk in spontaneous (RR 1.35, 95% CI 1.15–1.58) and vacuum-assisted vaginal deliveries (RR 1.42, 95% CI 1.11–1.81). In forceps-assisted vaginal deliveries, OASIS risk was increased, with shorter and longer durations of the second stage. Conclusion: Increasing length of the second stage of labour was associated with increasing risk of OASIS overall, but the association was heterogeneous between modes of delivery. Length of the second stage should be considered in counseling about OASIS risk. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Directed pushing while using the Valsalva maneuver is shown to lead to bladder neck descent, especially in women with urinary incontinence (UI). There is insufficient evidence about the benefits or adverse effects between the pushing technique during the second stage of labor and urinary incontinence postpartum. The objective of this study was to evaluate the effects of the pushing technique for women during labor on postpartum UI and birth outcomes. Methods: Scientific databases were searched for studies relating to postpartum urinary incontinence and birth outcomes when the pushing technique was used from 1986 until 2020. RCTs that assessed healthy primiparas who used the pushing technique in the second stage of labor were included. In accordance with Cochrane Handbook guidelines, risk of bias was assessed and meta-analyzed. Certainty of evidence was assessed using the GRADE approach. Results: Seventeen RCTs (4606 primiparas) were included. The change in UI scores from baseline to postpartum was significantly lower as a result of spontaneous pushing (two studies; 867 primiparas; standardized mean difference: SMD –0.18, 95% CI –0.31 to –0.04). Although women were in the recumbent position during the second stage, directed pushing group showed a significantly shorter labor by 21.39 min compared with the spontaneous pushing group: there was no significant difference in the duration of the second stage of labor between groups. Conclusions: Primiparas who were in the upright position and who experienced spontaneous pushing during the second stage of labor could reduce their UI score from baseline to postpartum. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: This study was aimed at exploring the mediating role of the prolonged second stage of labor (PSSL) in the association between delivery mode and urinary incontinence (UI) among postpartum women in Shandong, China. Methods: A cross-sectional study involving postnatal women from the Women's Pelvic Floor Functional Health Center in Shandong, China, was conducted. An electronic questionnaire was used to collect the data between June 2020 and February 2021. UI was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Logistic regression and multiple linear regression were employed to explore the association among delivery mode, PSSL, and UI, and the mediating role of PSSL. Results: Among the total of 5,586 postpartum women included in this study, the prevalence of UI was 13.3%. Among the 742 patients with UI, the prevalence of stress urinary incontinence (78.3%) was greater than urge urinary incontinence (8.6%), mixed urinary incontinence (9.3%), and others (3.8%). After adjusting for controlling variables, delivery mode was found to be significantly associated with PSSL, whereby women with vaginal delivery were more likely to be in PSSL, and women with PSSL had a higher probability of suffering from UI. PSSL played a partial mediating effect in delivery mode and UI. Conclusions: This study provided evidence that the effect of delivery mode on UI was partially mediated by PSSL among postpartum women in Shandong, China. Strategies to prevent PSSL should be actively adopted to reduce the risk of UI in women. [ABSTRACT FROM AUTHOR]

Aim: To investigate how an extremely prolonged second stage of labor of 12 h or more affects maternal and neonatal outcomes. Material and methods: This retrospective cohort study included nulliparous, pregnant women with 37 + 0 to 41 + 6 weeks of gestation whom vaginal delivery was attempted at the Yokohama City University Medical Center between 2014 and 2018. Results: In 446 cases of the prolonged second stage of labor, there were 296 women (66%) in the 2‐ to 6‐h second stage of labor group, 112 women (25%) in the 6‐ to 12‐h group, and 38 women (8.5%) in the 12‐h or longer group. The longer the second stage of labor, the more significant was the increase in the rates of augmentation of the delivery, emergency cesarean delivery, and operative vaginal delivery. Even in the 12 h or longer group, 82% were able to have vaginal delivery. The 6‐ to 12‐h group had a significant increase in third‐ or fourth‐degree perineal lacerations compared to the 2‐ to 6‐h group (aOR 8.12 [95% CI 1.55–42.6]). Clinical chorioamnionitis was significantly increased in the 12 h or longer group (aOR 4.88 [95% CI 1.62–14.8]). In terms of neonatal outcomes, comparison between the three groups showed no significant difference. Conclusion: With an extremely prolonged second stage of labor, maternal complications involved a significant increase in severe perineal lacerations and chorioamnionitis; however, there was no increase in adverse outcomes for neonates. It was not possible to conclusively determine if the duration of the second stage is acceptable. [ABSTRACT FROM AUTHOR]

To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method. A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012–2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events. Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p =.013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69–46.40% in others, p <.001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12–15% in others, p <.001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44–6.56, p =.0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081–7.448, p =.0342). Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods. NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit. [ABSTRACT FROM AUTHOR]

Unintentional extension of uterine incision is a known complication during cesarean delivery estimated to occur in 4–8% of cesarean deliveries. The aim of this study was to examine risk factors associated with unintentional uterine incision extension and to assess which of them are independent risk factors for this condition. We conducted a retrospective cohort study at a large public university tertiary referral center between 2003 and 2017. Included were women who underwent cesarean delivery during this time period. Demographic, medical, obstetrical and surgical data were collected. The primary outcome was the presence of uterine incision extension during cesarean delivery. Secondary outcomes included detection of risk factors associated with uterine incision extension. A multivariate analysis was additionally performed to identify general and labor related risk factors for unintentional extension of uterine incision among patients that underwent cesarean delivery during second stage of labor During the study period, 25,879 cesarean deliveries performed in our medical center were assessed. Out of them, 731 (2.8%) cases of unintended uterine incision extension were identified. Women in this group had high rates of full cervical dilatation and increased maternal hemorrhage. Assessment of incision extension direction revealed that two-thirds of extensions were lateral, mostly unilateral. Median size of the extension was 2.7 ± 1.2 cm. Independent parameters associated with unintended uterine incision extension included nulliparity, vertex presentation, epidural anesthesia and cesarean section indication. Further analysis including cesarean deliveries performed during the second stage of labor revealed 397 (15.3%) cesarean deliveries in which incision extension was noted and 2205 (84.7%) cesarean deliveries without incision extension. Following multivariate analysis performed in women who underwent cesarean delivery during second stage of labor, two independent parameters associated with unintended uterine incision extension remained significant – past cesarean delivery and failed vacuum attempt. Vacuum extraction attempt and previous cesarean delivery are independent risk factors for uterine incision extension in women undergoing cesarean delivery during the second stage of labor. We also showed the majority of these extensions to be lateral. [ABSTRACT FROM AUTHOR]

Background: Female genital mutilation (FGM) is defined as the partial or complete removal of the external female genitalia for non-medical reasons. There are some complications related to childbirth that concern both the mother and the baby. In this study, we aimed to evaluate the birth outcomes of FGM, which is widely applied in Somalia. Methods: The study included 268 women who gave birth at 37–42 weeks of gestation with a cephalic singleton, 134 with FGM and 134 without FGM. This study was designed a prospective cohort study and conducted between January 2019 and December 2020. Patients' ages, duration of delivery, FGM types, caesarean section requirements, before and after birth hemoglobin levels, birth weeks, baby birth weights and perineal tear data were recorded. In addition, we analyzed neonatal intensive care needs and APGAR scores for infants. Results: In patients with FGM, it was determined that the outlet obstruction increased 2.33 times, perineal tears increased 2.48 times, the need for caesarean section increased 2.11 times compared to the control group, and the APGAR score below 7 at the 5th minute in the children increased 2 times and the need for neonatal intensive care increased 1.87 times. Conclusions: FGM causes increased risk of perineal tear, prolongation in the second stage of labour, increased need for emergency caesarean section, and increased need for NICU for infants. Prevention of FGM will help reduce both obstetric and neonatal complications. [ABSTRACT FROM AUTHOR]

To determine if there is a difference in the maternal and perinatal characteristics and outcomes of women undergoing a medically indicated labor induction and delivering vaginally compared to women in spontaneous labor delivering vaginally. This is a planned secondary analysis of previously published data with additional data collected for a case-control design. Maternal and perinatal characteristics and outcomes of women undergoing a medically indicated labor induction of labor and delivering vaginally were compared with the next woman who went into labor spontaneously and delivered vaginally. There were 1097 women in the medically indicated labor group and 1096 women in the spontaneous labor group. The medically indicated induction group was younger (p <.0001), had less women of "other" race (p =.004), were of a lower gravidity and parity (p <.0001), had a lower Bishops' score on admission (p <.0001), had a greater proportion of umbilical arterial cord pH values <7.1 and <7.0 (p <.0001). Additionally, the induction group had longer first and second stages of labor (p <.0001). While the unadjusted rates of post-partum complications and NICU admission were higher in the medically indicated labor induction group, only cord gas pH <7.1 remained statistically significant after adjustment. Even with successful vaginal delivery of a medically indicated induction of labor, the risk for adverse outcomes remains elevated. [ABSTRACT FROM AUTHOR]

Background: Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied. Objectives: To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery. Methods: A population‐based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm‐Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second‐stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first‐stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios. Results: Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non‐linear trend is seen, demonstrated by a plateau in the second‐stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80). Conclusions: Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second‐stage duration, with applications in obstetric and perinatal epidemiology. [ABSTRACT FROM AUTHOR]

Aim: To examine the effect of fundal pressure applied in the second stage of labor on birth outcomes and neonatal O2 saturation. Methods: The study is of a descriptive and comparative type. Research data were collected in the obstetrics clinic of a Maternity Hospital between August 15, 2019 and February 15, 2020. The study sample consisted of 160 pregnant women who met the research criteria (80 pregnant women who received fundal pressure, 80 pregnant women who did not receive fundal pressure). Results: The duration of the second and third stages of labor was found to be shorter in the nonfundal pressure group (t = −3.422, p = 0.001; t = 2.195, p = 0.030). When the groups were compared, the formation of perineal trauma and second‐degree laceration, episiotomy requirement, elongation of the episiotomy incision and cervical laceration rate were found to be significantly higher in the fundal pressure group χ2 = 10.794 p = 0.001; χ2 = 8.403 p = 0.004; χ2 = 10.014, p = 0.002; χ2 = 16.579 p = 0.000; χ2 = 16.276 p = 0.000). The 1st and 5th min Apgar scores of the newborns were lower in the fundal pressure group (t = −6.377, p = 0.000; t = −3.581, p = 0.001). The 1st, 5th, 10th, and 15th min oxygen saturation of the newborns were determined to be significantly lower in the fundal pressure group (t = −4.753, p = 0.000; t = −2.427, p = 0.016; t = −2.604, p = 0.010; t = −2.492, p = 0.014). Conclusion: According to the study results, it was determined that the uterine fundal pressure has a negative effect on birth outcomes and neonatal oxygen saturation. Adverse effects of fundal pressure application should be revealed in different aspects. [ABSTRACT FROM AUTHOR]

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Genetic factors have been the leading risk factor for ASD based on the evidence of Folstein's twin study in 1977, which reported that the concordance ratio of ASD is higher in monozygotic twins than in dizygotic twins [[6]]. Keywords: Autism spectrum disorder; Risk factor; Labor neuraxial analgesia; Systematic literature search EN Autism spectrum disorder Risk factor Labor neuraxial analgesia Systematic literature search 327 329 3 03/29/23 20230401 NES 230401 Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00540-023-03162-y. Hanley et al. conducted a within-sibling and discordance in ASD status analysis, which restricted the population to women who were discordant for the ASD status of at least 2 of their children (i.e., at least 1 child was diagnosed with ASD and at least 1 other child was not diagnosed with ASD). However, LNA may be a risk factor for autism spectrum disorders (ASD) in offspring as the placental transfer of local anesthetics may produce neurotoxic effects and alter subsequent normal behavioral development [[3]]. [Extracted from the article]