Maternal and neonatal outcomes after a more interventional versus a more expectant management of the second stage of labor: A retrospective multicenter study

Background: The optimal duration of second stage of labor has been largely discussed in literature, but there are no uniformly accepted contemporary criteria for defining normal or abnormal length. Available evidence suggests that longer duration of second stage of labor is associated with a lower rate of spontaneous vaginal delivery and increased maternal morbidity. On the neonatal side, it seems that longer second stage doesn't affect new-born morbidity, in a context of very rare neonatal complications.

Objectives: To investigate the association between the second stage of labor management and maternal and neonatal outcomes.

Study design: This is a retrospective multicenter study involving all consecutive singleton term pregnancies who reached the second stage of labor between January and December 2022 at two third level maternity Hospitals. We compared an interventional management (considering operative vaginal delivery after 30 min of pushing) adopted at Robert Debre Hospital in France, and an expectant management (up to 1-2 h of pushing based on parity) adopted at AOUI Verona in Italy. Propensity score matched 1:1 analysis was implemented. The association between the second stage of labor management and maternal and neonatal outcomes was tested by conditional logistic regression, overall and stratified by parity.

Results: The propensity score matching (1:1) identified 1,168 matched couples of women. The interventional management was associated with a higher use of operative vaginal delivery (OR 2.3, 95 %CI 1.8-2.9) and episiotomy (OR 1.4, 95 % CI1.1-1.8), and a lower risk of severe postpartum hemorrhage (OR 0.1, 95 %CI 0.05-0.3) and cesarean section among nulliparous (OR 0.4, 95 % CI 0.2-0.9). No association with perineal lacerations, neonatal outcomes, and major maternal morbidity was observed.

Conclusions: The interventional management was associated with lower risk of postpartum hemorrhage in all patients and cesarean section among nulliparous women, but higher operative vaginal delivery and episiotomy use, without clinical advantages for the newborn. To support one approach over the other, additional factors should be considered, such as women's preferences and expectations, obstetricians' skills, and medicolegal context.