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Stephansson Et Al-2016-BJOG - An International Journal of Obstetrics & Gynaecology
Stephansson Et Al-2016-BJOG - An International Journal of Obstetrics & Gynaecology
Stephansson Et Al-2016-BJOG - An International Journal of Obstetrics & Gynaecology
13287
General obstetrics
www.bjog.org
Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Institutet, b Department of Womens and
Childrens Health, Division of Obstetrics and Gynaecology, Karolinska University Hospital and Institutet, Stockholm, c Department of
Womens and Childrens Health, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
Correspondence: O Stephansson, Clinical Epidemiology Unit, T2, Karolinska University Hospital, Solna, SE-17176 Stockholm, Sweden.
Email olof.stephansson@ki.se
Accepted 5 December 2014. Published Online 20 January 2015.
Please cite this paper as: Stephansson O, Sandstrom A, Petersson G, Wikstrom A-K, Cnattingius S. Prolonged second stage of labour, maternal infectious
disease, urinary retention and other complications in the early postpartum period. BJOG 2016;123:608616.
Introduction
Prolonged second stage of labour is usually defined as
23 hours for primiparous women and 12 hours for parous women, with the longer interval for women with epidural analgesia during labour.1,2 Prolonged second stage of
labour has been associated with increased risk of maternal
morbidity, including postpartum complications like infection or fever.39 Postpartum urinary retention is a serious
complication with both short-term and possible long-term
consequences for the mother.10 The bladder overdistension
608
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Methods
Data sources
Data on mother, delivery and infant characteristics were
obtained from the population-based Stockholm-Gotland
Obstetric Database. This database consists of automatically
retrieved information from the medical record system used
in the region for all maternity, delivery and postnatal care
units. The data are forwarded daily from the medical
records to the database and include information from 1
January 2008 and onwards. The database includes all prospectively collected information from antenatal care by
attending midwives or physicians and all information from
delivery (with partograph data) and the postpartum period
for both mother and child in a standardised manner.
Study population
The study population was defined as all vaginal deliveries
with a singleton, liveborn infant in cephalic presentation at
37 completed weeks of gestation or later, from 1 January
2008 through to 31 December 2012 (n = 91 893). Deliveries without any partograph data (n = 4180) and deliveries
without recorded time of retracted cervix (n = 15 120)
were excluded.
Statistical analyses
Crude odds ratios and adjusted odds ratios (aOR) with
95% confidence intervals (95% CI) were calculated by
unconditional logistic regression analysis. Logistic regression models were adjusted for maternal age, parity, height,
body mass index, smoking, gestational age, induction of
labour, epidural analgesia and oxytocin augmentation during delivery. Effect modification was tested by stratification
and insertion of an interaction variable in the regression
models. Variables with significant interaction results are
presented in stratified analyses. A P-value of <0.05 was
considered statistically significant. Women with missing
data were not included in the analysis.
Results
From 2008 through to 2012 there were 72 593 vaginal births
at 37 weeks of gestation or later of singleton infants in
cephalic presentation in the Stockholm-Gotland Obstetric
Database. Among deliveries with a partograph record for
time of retracted cervix the proportion of complications during maternity hospital care was 3.6% (n = 2629). Among
women who were excluded because of a missing partograph
record for time of retracted cervix (n = 15 120), the corresponding proportion was 1.5% (n = 222).
Rates of complications increased with time from
retracted cervix to birth. The rate of any complication
among parous women with previous caesarean section was
7.3%, in primiparous women 4.8%, and in parous women
with no previous caesarean section 1.7%. Induced deliveries, epidural analgesia and oxytocin augmentation during
labour were associated with increased rates of maternal
postpartum complications. Instrumental delivery and
advanced gestational age were associated with higher rates
of maternal complications in the early postpartum period.
Women with postpartum complications were more likely
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
609
Stephansson et al.
Table 1. Maternal and delivery characteristics, and rate of any maternal complication in the early postpartum period; women with singleton term
or post-term vaginal deliveries in the Stockholm-Gotland region, Sweden, 200812
Characteristics
Any complication*
610
P-value
No complication
n
2629
%
3.6
n
69 964
%
96.4
841
690
490
341
267
2.1
4.5
5.9
6.6
8.3
39 861
14 491
7851
4807
2954
97.9
95.5
94.1
93.4
91.7
<0.0001
333
709
993
591
3
3.9
3.7
3.7
3.3
8162
18 504
26 024
17 225
49
96.1
96.3
96.3
96.7
0.061
1853
240
521
15
4.8
7.3
1.7
36 561
3059
29 465
879
95.2
92.7
98.3
<0.0001
92
869
1327
310
31
4.4
3.6
3.6
3.8
2019
23 577
35 901
7838
629
95.6
96.4
96.4
96.2
0.19
306
1436
522
196
169
3.5
3.6
3.6
3.7
8548
38 314
13 864
5132
4106
96.5
96.4
96.4
96.3
0.88
2425
204
0
3.6
4.2
65 329
4622
13
96.4
95.8
0.020
2544
85
0
3.7
2.6
66 751
3184
29
96.3
97.4
0.0014
552
2077
4.8
3.4
10 937
59 027
95.2
96.6
<0.0001
1797
832
5.0
2.3
33 979
35 985
95.0
97.7
<0.0001
1958
671
5.0
2.0
36 869
33 095
95.0
98.0
<0.0001
1898
731
3.0
7.7
61 211
8753
97.0
92.3
<0.0001
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
Table 1. (Continued)
Characteristics
Episiotomy
Yes
No
Missing
Gestational age (weeks)
37
38
39
40
41
42
Any complication*
P-value
No complication
n
2629
%
3.6
n
69 964
%
96.4
151
2470
8
4.6
3.6
3104
66 602
258
95.4
96.4
0.0015
93
268
531
868
610
259
2.9
3.3
3.0
3.7
4.0
5.5
3065
7900
17 174
22 850
14 528
4447
97.1
96.7
97.0
96.3
96.0
94.5
<0.0001
*Complications include: maternal infectious disease, urinary retention, haematoma or ruptured sutures during postpartum hospital care.
**Vacuum extraction or forceps delivery.
Discussion
Main findings
We found that risks of maternal early postpartum complications, including infectious disease and urinary retention,
increased with duration of second stage of labour: risks
were generally lowest if the second stage was <1 hour and
highest if second stage was 3 hours or more. Rates of
maternal postpartum complications were highest among
parous women with previous caesarean section followed by
primiparous women, whereas the lowest rates were
observed in parous women with no previous caesarean section.
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
611
DOI: 10.1111/1471-0528.13287
General obstetrics
www.bjog.org
Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Institutet, b Department of Womens and
Childrens Health, Division of Obstetrics and Gynaecology, Karolinska University Hospital and Institutet, Stockholm, c Department of
Womens and Childrens Health, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
Correspondence: O Stephansson, Clinical Epidemiology Unit, T2, Karolinska University Hospital, Solna, SE-17176 Stockholm, Sweden.
Email olof.stephansson@ki.se
Accepted 5 December 2014. Published Online 20 January 2015.
Please cite this paper as: Stephansson O, Sandstrom A, Petersson G, Wikstrom A-K, Cnattingius S. Prolonged second stage of labour, maternal infectious
disease, urinary retention and other complications in the early postpartum period. BJOG 2016;123:608616.
Introduction
Prolonged second stage of labour is usually defined as
23 hours for primiparous women and 12 hours for parous women, with the longer interval for women with epidural analgesia during labour.1,2 Prolonged second stage of
labour has been associated with increased risk of maternal
morbidity, including postpartum complications like infection or fever.39 Postpartum urinary retention is a serious
complication with both short-term and possible long-term
consequences for the mother.10 The bladder overdistension
608
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
n
%
aOR*
Primiparous
95% CI
Reference
0.881.70
0.921.76
1.001.91
1.242.35
aOR*
95% CI
1.00
1.47
1.32
2.33
3.48
Reference
0.962.25
0.752.31
1.284.25
1.567.76
10.2
14.3
11.6
13.7
10.1
1.00
1.84
1.60
2.01
1.06
Reference
0.883.88
0.703.65
0.864.69
0.382.95
4.6
7.0
6.0
10.8
16.1
16
20
11
11
4
aOR*
95% CI
1.00
2.19
2.80
2.74
2.60
Reference
1.692.84
1.894.15
1.425.30
0.808.42
3.5
7.8
7.5
10.2
6.6
1.00
1.71
2.21
3.30
2.03
Reference
0.793.71
0.915.39
1.308.37
0.606.90
1.3
3.2
4.3
4.5
4.2
*Adjusted for maternal age, height, body mass index, parental cohabitation, smoking, induction of labour, gestational age epidural analgesia and oxytocin augmentation.
1.00
1.22
1.27
1.38
1.71
15
26
16
16
8
5.2
6.9
7.6
7.9
9.7
<1
1 to <2
2 to <3
3 to <4
4
64
113
125
134
151
67
45
19
18
10
<1
348
3.0
1.00
Reference
1 to <2
393
4.1
1.27
1.091.48
2 to <3
283
5.4
1.56
1.311.85
3 to <4
151
5.3
1.54
1.241.89
4
91
6.5
1.80
1.402.33
Any maternal complication in instrumental vaginal deliveries
Primiparous (n = 7769)
Time from
retracted
cervix to
birth (hours)
Table 3. Time from retracted cervix to vaginal birth and risk of any maternal complication during the early postpartum period stratified by mode of delivery
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
613
Stephansson et al.
Interpretation
The association between prolonged second stage of labour
and risk of maternal infection is in agreement with previous studies on prolonged second stage and risk of chorioamnionitis among primiparous and multiparous women.4,6
Similar findings were also reported in a large cohort study
by Allen et al.7 However, due to a large amount of missing
data, maternal characteristics were not included in multivariate models whereas this was possible in the present
study. In a recent study by Laughon et al.,3 elevated risks
for maternal complications including chorioamnionitis
were reported; however this study compared prolonged
versus within-time limits for second stage of labour according to the US guidelines.1
As pointed out by Altman et al.13 in a systematic review
of prolonged second stage of labour, it is important to
address method of delivery as an effect modifier, which is
614
2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
Conclusion
Prolonged second stage of labour, more than 2 hours, is
associated with maternal infectious disease and urinary
retention in maternity care. A better control of voiding
during and after delivery and check-up for signs of maternal infection are warranted for these women. Future
research should study long-term consequences in women
with urinary retention during labour. Special attention has
to be given to parous women with previous caesarean section.
Disclosure of Interests
None to declare for the contributing authors.
Contribution to authorship
OS conceived and designed the study together with SC and
AKW. OS and GP performed the analyses. GP, AS and OS
contributed with materials. OS, KM, AS, AKW and SC
wrote the paper.
Funding
This study was supported by grants from the Swedish
Research Council (2013-2429, OS and 2008-5857, SC) and
by grants provided by the Stockholm County Council (ALF
project 20130156, OS and SC).
Acknowledgements
None to declare.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. ICD-10 codes for Maternal Complications. &
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2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
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2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.