STUDY OBJECTIVE:The objective of this study was to evaluate pain scores in patients with postmenopausal bleeding (PMB) and an atrophic cavity who underwent an endometrial biopsy compared to those who did not at office hysteroscopy. DESIGN:Single-center, single-blinded randomized control trial. The trial was registered prospectively (ClinicalTrials.gov ID NCT05378152). SETTING:The office hysteroscopy service in an academic and tertiary referral hospital in Dublin, Ireland. PATIENTS:Women with PMB who attended an office hysteroscopy and had an atrophic cavity on a hysteroscopic evaluation were included. A sample size of 76 was determined to show a 2-point difference in pain scores (Visual Analog Scale [VAS]), assuming 90% statistical power and a 5% level of significance. INTERVENTIONS:Women were randomized to either endometrial biopsy (group 1) or a sham procedure (group 2). The primary outcome was to compare pain scores after the intervention using a 100 mm VAS. Secondary outcomes included differences in follow-up patterns between groups. MEASUREMENTS AND MAIN RESULTS:A total of 169 women with PMB were recruited over an 18-month period; 87 were excluded on the basis of hysteroscopic findings during the procedure. There were 44 patients in group 1 (biopsy) and 38 patients in group 2 (sham). A significant difference in pain scores after the intervention was noted with a mean VAS score of 54 mm (±3 mm) in group 1 and 30 mm (±5 mm) in group 2 (p <.0001). There was no significant difference noted in follow-up patterns between either group. CONCLUSIONS:The performance of routine endometrial biopsy after a normal hysteroscopy with atrophic findings, in women referred with PMB, has been shown to result in higher pain scores. Further studies are needed to consider the role of endometrial biopsy in this context.

(Abstracted from Urogynecology (Phila) 2024) Overactive bladder (OAB) is associated with urgency urinary incontinence, urinary frequency, and nocturia and is defined by symptoms of urgency that cannot be postponed; it occurs in as many as 1 in 6 adults, with a higher prevalence in women and elderly individuals, and can significantly impact quality of life. Current guidelines surrounding treatment of OAB recommend behavioral therapy (BT) first, then pharmaceuticals, then invasive treatments in a tiered approach.

IMPORTANCE:The burden and high prevalence of overactive bladder (OAB) underline the urgent need for effective treatment. This study provides an initial look at an alternative approach to behavioral therapy for overactive bladder (OAB) that is delivered as an app on a smartphone. OBJECTIVE:This study aimed to investigate feasibility, acceptability, and preliminary efficacy of a digital therapeutic for OAB. STUDY DESIGN:This was a multicentered prospective pilot study. We used a convenience sample (N = 30) from waiting lists of women referred for incontinence, excluding urinary tract infections, urinary retention, bladder pain syndrome, pelvic cancer, current pregnancy, kidney disease, dementia, stroke, and prior neuromodulation. The intervention, a smartphone app, provided an 8-week program with weekly modules combining evidence-based knowledge videos and skill-building exercises that incorporated behavioral therapy, cognitive behavioral therapy, pelvic muscle training, and general health information. Combined scores on the International Consultation on Incontinence Questionnaire was the primary outcome measure. Secondary outcomes included improvement in quality of life, based on International Consultation on Incontinence Questionnaire, a 72-hour urinary diary, and Patient Global Impression of Improvement. We evaluated usability with the Mobile Application Rating Scale. Statistical tests included Shapiro-Wilk tests and paired-sample t tests. RESULTS:Overall, 100% of participants reported a reduction in their OAB symptoms and 82% reported an improvement in quality of life. There was a significant improvement in diary parameters, including frequency (10.19-6.71 a day: SD, 1.25; P = 0.017) and incontinence (10-3.57: SD, 4.58). Participants rated the app highly on functionality, and 70% would recommend it. Patient Global Impression of Improvement improved for 69% of participants. CONCLUSIONS:This study supports the application of a digital platform to over-come the real-world barriers for first-line treatment for OAB and offers information to inform further evaluation of the safety and efficacy of the NUIG OAB App.

Study Objective Pain and anxiety are common features of outpatient hysteroscopy (OPH). Endometrial biopsy is often insufficient when investigating post-menopausal bleeding (PMB) with a normal/atrophic hysteroscopic appearance, yet it is still commonly performed. The objective of this study was to evaluate outcomes in patients with PMB deemed eligible for endometrial biopsy with an atrophic-appearing cavity at OPH. Design A single-centre, single-blinded, randomized controlled trial. The trial was registered prospectively (ClinicalTrials.gov ID NCT05378152). Setting The outpatient hysteroscopy service in an academic and tertiary referral hospital in Dublin, Ireland. Patients or Participants Women with PMB who attended for an OPH and had an atrophic cavity on hysteroscopic evaluation. A sample size of 76 was determined to show a 2-point difference in pain scores (Visual Analogue Scale – VAS), assuming 90% statistical power and a 5% level of significance. Interventions Women were randomized to either endometrial biopsy (Group 1) or a sham procedure (Group 2) i.e. insertion of the speculum into the vagina. Measurements and Main Results A total of 169 women with PMB were recruited over an 18-month period, 87 were excluded based on hysteroscopic findings during the procedure. 44 patients in Group 1 (Biopsy) and 38 patients in the Group 2 (Sham). A significant difference in pain scores after the intervention was noted with a mean (SD) VAS score of 5.43 (0.33) in Group 1 and 2.97 (0.45) in Group 2 (p<0.001). Costs were 6.5 times higher in Group 1. There were no cases of emergency admissions or endometrial hyperplasia /cancer in either group at 3 months follow up. Conclusion Routine endometrial biopsy after a normal hysteroscopy in women referred with PMB should be considered unnecessary and could be stopped to help reduce pain for women and costs for healthcare organisations. A targeted endometrial biopsy approach should be considered but would need further studies.

OBJECTIVES:The rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates. STUDY DESIGN:This was a population-based study in a tertiary referral centre from 2008-2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p < .05. RESULTS:There were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90-1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01-1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07-1.27 p < .001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) CONCLUSION: This study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.

OBJECTIVE:In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery. STUDY DESIGN:The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated. RESULTS:A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%. CONCLUSION:In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

For expectant parents, a first birth is notable for its unpredictability, and the path to safe labour and delivery is commonly complicated by a requirement for unplanned caesarean delivery. The ability to anticipate an uncomplicated vaginal birth, or to predict the requirement for unplanned caesarean delivery, carries the potential to facilitate optimal birth choices. For example, elective caesarean delivery confers substantially less risk than unplanned caesarean delivery performed during the course of labour. Pre-delivery knowledge of a high predictive risk of requiring intrapartum caesarean delivery could lead to women opting to deliver by elective caesarean delivery, thereby lowering associated risks. Equally, pre-labour knowledge of a high prospect of achieving a successful and uncomplicated vaginal birth could result in enhanced motivation for women to deliver in a less medicalised environment. Predictive risk models have been utilised to good effect in other areas of medicine. The incorporation of a risk predictive tool for intrapartum caesarean delivery would enable women and their caregivers to choose the most appropriate management plan for each woman.

Maternal co-morbidity and Cesarean section (CS) rates are increasing globally. The nulliparous, term, singleton, vertex presentation (NTSV) spontaneously laboring woman, i.e. Robson Group 1(RG1),is considered to have the lowest risk for CS in nullips. However, there has been an escalating trend in CS rates for this group. The aim of this study was to identify any association between underlying maternal co-morbidities and the increase in the CS rate in this cohort. This was a population-based study carried out from 2008-2017, in a large tertiary institution where data from two hospital databases were amalgamated. The inclusion criteria for our study included; nulliparous, greater than 37 weeks', spontaneous labor, vertex presentation (NTSV). We collected details about maternal age, maternal co-morbidities (diabetes, hypertension, cardiovascular and thyroid disease, infertility treatment and obesity) and labor details. The trends of these were analyzed using SAS 9.3 software. There were 86,473 deliveries over the 10 years. The RG1 CS rate was 14.9% (n=2,579).The proportion of women in RG1 significantly reduced by 48% over this time frame but the CS rate increased from 14% to 16%, p< .001.The number of women who conceived with assisted reproduction in this cohort increased from 0.3-3.6% (p< .001).The incidence of diabetes (5%-7.3%, p=0.449) and thyroid disease (0.5%-1.7%, p=0.931) did not change. There was a decrease in incidence of cardiovascular disease from 4.5% to 0.5% (p< .012) and hypertension from 15%-4% (p< .001). Maternal age increased from 29.0 ± 5.7 to 30.5 ± 5.8 (p< .001). The rate of obesity did not change. The number of second stage CS decreased from 29%-18% (p< .001). This study shows a significant reduction in the number of nulliparous women entering spontaneous labor and a corresponding increase in RG1 CS rate. This study did not demonstrate an association between pre-existing maternal co-morbidity and CS rates. The decrease in second stage CS is an interesting finding and could indicate an overall change in the management of labor which needs to be further elucidated.

Objective: Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care. Materials and Methods: This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score. Results: A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned. Conclusion: Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons. (C) 2020 Elsevier B.V. All rights reserved.

Background The RECIPE study aims to validate a risk prediction model for intrapartum caesarean delivery which has been developed by our group. The Genesis study was a prospective observational study carried out by the Perinatal Ireland Research Consortium across 7 clinical centres in Ireland between October 2012 and June 2015. Genesis investigated a range of maternal and fetal parameters in a prospective blinded study of 2336 singleton pregnancies between 39 + 0–41 + 0 weeks’ gestational age. This resulted in the development of a risk prediction model for Caesarean Delivery in nulliparous women at term. The RECIPE study now proposes to provide external validation of this risk prediction tool. Methods In order to externally validate the model, we aim to include a centre which was not involved in the original study. We propose a trial of risk-assignment for intrapartum caesarean amongst nulliparous women with a singleton pregnancy between 38 + 0 and 40 + 6 weeks’ gestational age who are planning a vaginal birth. Results of the risk prediction tool will be concealed from participants and from midwives and doctors providing labour care.. Participants will be invited for an ultrasound scan and delivery details will be collated postnatally. The principal aim of this study is to externally validate the risk prediction model. This prediction model holds the potential to accurately identify nulliparous women who are likely to achieve an uncomplicated vaginal birth and those at high prospect of requiring an unplanned caesarean delivery. Discussion Validation of the Genesis prediction model would enable more accurate counselling for women in the antenatal setting regarding their own likelihood of requiring an intrapartum Caesarean section. It would also provide valuable personalised information to women about the anticipated course of their own labour. We believe that this is an issue of national relevance that will impact positively on obstetric practice, and will positively empower women to make considered, personalised choices surrounding labour and delivery.

OBJECTIVE:The ability to predict the need for emergency Cesarean delivery holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean delivery and Improving the Primiparous Experience) was to externally validate a Cesarean delivery risk prediction model. This model, developed by the Genesis study, identified five key predictive factors for emergency Cesarean delivery: maternal age, maternal height, BMI, fetal head circumference (HC) and fetal abdominal circumference (AC). STUDY DESIGN:This prospective, observational study was conducted in two tertiary referral perinatal centers. Inclusion criteria were as follows: primiparous women with a singleton, cephalic presentation fetus in the absence of fetal growth restriction (FGR), oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned Cesarean delivery. Between 38 + 0 and 40 + 6 weeks' gestational age, participants attended for prenatal assessment that enabled the determination of an individualized risk calculation for emergency Cesarean delivery during labour based on maternal height, BMI, fetal HC and AC, with crucially both participants and care providers being blinded to the resultant risk prediction score. Labor, delivery and postnatal outcomes were ascertained. Calibration and receiver operator curves were generated to determine the predictive capacity for emergency Cesarean delivery of the Genesis risk prediction model in this cohort. RESULTS:559 primiparous participants were enrolled from May 2017 to April 2019, of whom 142 (25 %) had an emergency Cesarean delivery during labour. Participants with a low predicted risk score (<10 %) had a mean predicted rate of 8% (+/- standard deviation of 2%) and a similarly low actual observed rate of Cesarean delivery (8%). Participants with a high predicted risk (>50 %) had a mean predicted Cesarean delivery rate of 64 % (+/- standard deviation of 9%) and also had a high actual observed Cesarean delivery rate (62 %). The calibration curve and receiver operating characteristic curve demonstrated that this validation study had comparable discriminatory power for emergency Cesarean delivery to that described in the original Genesis study. The Area Under the Curve (AUC) in Genesis was 0.69, whereas the AUC in RECIPE was 0.72, which reflects good predictive capacity of the risk prediction model. CONCLUSION:The accuracy of the Genesis Cesarean delivery prediction tool is supported by this validation study.

Cesarean section (CS) rates are increasing globally. The nulliparous, term, singleton, spontaneously labouring woman, vertex presentation (NTSV) i.e Robson Group 1-RG1 is considered to have the lowest risk for CS.It has been hypothesised that more CSs occur at night-time or at weekends, due to obstetricians working patterns and senior support not being as readily available. The implementation of restricted physician working hours (EWTD) in our institution in 2012, was aimed at reducing physician fatigue.This study aimed to determine the effect of nocturnal hours, weekend call and implementation of working hours restrictions on CS rates in RG1. This was a population-based study over a 10 year period from 2008-2017, in a large tertiary institution where data from two separate hospital databases were used. Inclusion criteria were nulliparous women, >37 weeks', presenting in spontaneous labor and vertex presentation.Their mode of delivery was captured. Variation in RG1 CS rates were examined by time of day (day versus night) and day of the week (weekday versus weekend).The effect on CS rates in this cohort after implementation of working hour restrictions was also compared.Relative frequencies were compared using Chi-square test in GraphPad. There were 86,473 deliveries over the study period, with 18,925 in the RG1 cohort. Overall, the RG1 CS rate was 14.9% (n=2,835).Rates of CS in the RG1 group were not statistically different between those delivering on weekdays (15%, n=2,061) and weekends (14.4%, n=774, p=0.22).During daytime hours the CS rate in this cohort was 15% (n=7,669) and was similar at night (14.9%, n=1,157,p=0.72). Comparing the periods pre and post working hour restrictions, there was a significant increase in CS rates in the RG1 cohort (13% vs 15.7%, p< .001). In conclusion, working patterns do not appear to influence rates of CS in the RG1 cohort. The increase in the RG1 CS rate has continued despite the implementation of improved working hours for physicians.The cause of this increase is likely to be multi-factorial and requires further research.

The ability to predict the need for intrapartum Cesarean Delivery (CD) holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean and Improving Patient Experience) was to externally validate a CD risk prediction tool. This tool, produced by the Genesis study, identified 5 key predictors for intrapartum CD: maternal age, maternal height, maternal BMI, fetal head circumference and fetal abdominal circumference. We recruited from 2 large obstetric units for this prospective, observational study. Inclusion criteria included nulliparous women with a singleton, cephalic presentation fetus in the absence of IUGR, oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned CD. Participants attended for prenatal ultrasound and maternal data collection from 38+0 - 40+6 weeks' gestation. Labor, delivery and postnatal outcomes were collected. The Genesis model was applied to the RECIPE cohort and a calibration curve was determined (Figure 1a). 559 nulliparous women were enrolled from May 2017 to April 2019, of whom 142 (25%) had a CD. Predicted and actual CD rates are summarized in Table 1. Women with a low predicted risk score (< 10%) had a similarly low actual rate of CD (8%). Women with a high predicted risk (>50%) also had a high actual CD rate (62%). The overall CD rate was higher in RECIPE (25%) than in Genesis (21%). This validation study showed similar discriminatory power for intrapartum CD (AUC=0.72, Figure 1b) compared to the original Genesis study (AUC=0.69). 89% of the study participants stated they would be happy to know their risk score, 98% were satisfied with their care during labor and, of those who had a CD, 100% were satisfied that the need for CD was adequately explained. The accuracy of the CD prediction tool is supported by this validation study. Prelabor knowledge of a high prospect of achieving an uncomplicated vaginal birth reassures nulliparous women of their high probability of success and may help to stratify women into appropriate models of prenatal careView Large Image Figure ViewerDownload Hi-res image Download (PPT)

In contemporary obstetric practice over 25% of women will undergo induction of labor. Although a medical intervention, induction is increasingly seen as a reasonable option for term, nulliparous women. Previously reported increases in cesarean delivery have been refuted, with clear evidence of reduced stillbirth rates. Oxytocin is the most commonly used agent; however, the optimum dosing regimen has yet to be reliably quantified. We aimed to establish the differences, if any, between low and high-dose oxytocin regimens for induction with regard to; duration of labor, mode of delivery and evidence of fetal compromise. This is a secondary analysis of a prospective, observational cohort – the Genesis study, where nulliparous women with a vertex presentation between 39+0 and 40+6 weeks' gestation were recruited at seven academic medical centers. All were suitable for a trial of labor at recruitment. This analysis focuses on the outcomes for women induced with oxytocin. Data in relation to oxytocin use were collected prospectively. Each study center was classified as low-dose (group 1. – 1 milliunit per minute increasing every 30 minutes) or high-dose (group 2. – 5 milliunits per minute increasing every 15 minutes). The analysis compares the outcomes for women and infants in the low and high-dose groups. Of the 2,336 women recruited, 563 had their labor induced with oxytocin. 277 (group 1.) were induced with a low- dose and 286 (group 2.) with a high-dose. Results for both primary and secondary outcomes are demonstrated in Table 1 . The duration of labor was similar in both groups. Operative vaginal delivery was significantly more likely in the low-dose group (p=0.019), as was malposition. Cesarean delivery rates were higher in group 2, although this did not reach statistical significance (p=0.108). There was no difference between the groups with regard to infant outcomes, however, a non-reassuring CTG was significantly more likely in group 2 (p=<0.001), and fever was more frequent (p=0.029). High-dose oxytocin did not shorten the duration of labor or increase the spontaneous vaginal delivery rate; it was associated with an increase in fever and non-reassuring CTG. The low-dose regimen saw an increase in malposition and operative vaginal delivery with its attendant potential morbidity. Neither dosing regimen can be deemed superior – an intermediate dosing regimen warrants investigation.

BACKGROUND:Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity. OBJECTIVE:In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome. STUDY DESIGN:The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH <7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture. RESULTS:Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P<.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at <1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at >3 hours (P<.001). Operative vaginal delivery increased from 35% at <1 hour to 65% at >3 hours (P<.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at <1 hour to 11% at >3 hours (P<.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P<.001). The composite neonatal birth injury rate increased from 1.8% at <1 hour to 3.4% at >3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P<.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration. CONCLUSION:In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor >3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.

ABSTRACTObjectiveIncreased fetal size is associated with shoulder dystocia during labor and subsequent need for assisted delivery. We sought to investigate if increased fetal adiposity diagnosed sonographically in late pregnancy is associated with increased risk of operative delivery.MethodsThis secondary analysis of the Genesis Study recruited 2392 nulliparous women with singleton pregnancy in cephalic presentation, in a prospective, multicenter study, to examine prenatal and intrapartum predictors of Cesarean delivery. Participants underwent ultrasound and clinical evaluation between 39 + 0 and 40 + 6 weeks' gestation. Data on fetal biometry were not revealed to patients or to their managing clinicians. A fetal adiposity composite of fetal thigh adiposity and fetal abdominal wall thickness was compiled for each infant in order to determine whether fetal adiposity > 90th centile was associated with an increased risk of Cesarean or operative vaginal delivery.ResultsAfter exclusions, data were available for 2330 patients. Patients with a fetal adiposity composite > 90th centile had a higher maternal body mass index (BMI) (25 ± 5 kg/m2 vs 24 ± 4 kg/m2; P = 0.005), birth weight (3872 ± 417 g vs 3585 ± 401 g; P < 0.0001) and rate of induction of labor (47% (108/232) vs 40% (834/2098); P = 0.048) than did those with an adiposity composite ≤ 90th centile. Fetuses with adiposity composite > 90th centile were more likely to require Cesarean delivery than were those with adiposity composite ≤ 90th centile (P < 0.0001). After adjusting for birth weight, maternal BMI and need for induction of labor, fetal adiposity > 90th centile remained a risk factor for Cesarean delivery (P < 0.0001). A fetal adiposity composite > 90th centile was more predictive of the need for unplanned Cesarean delivery than was an estimated fetal weight > 90th centile (odds ratio, 2.20 (95% CI, 1.65–2.94; P < 0.001) vs 1.74 (95% CI, 1.29–2.35; P < 0.001). Having an adiposity composite > 90th centile was not associated with an increased likelihood of operative vaginal delivery when compared with having an adiposity composite ≤ 90th centile (P = 0.37).ConclusionsFetuses with increased adipose deposition are more likely to require Cesarean delivery than are those without increased adiposity. Consideration should, therefore, be given to adding fetal thigh adiposity and abdominal wall thickness to fetal sonographic assessment in late pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.