Comment on “Evaluating the Impact of the Second-stage and Pushing Duration on Maternal and Neonatal Outcomes: A Systematic Review and Meta-analysis”

The second stage of labor is defined as the duration between full cervical dilation and delivery. Guidelines from professional organizations define prolonged second stage as >3 hours of pushing in nulliparous individuals or >2 hours in multiparous individuals. These organizations also recommend individualized management for diagnosing second-stage labor. While previous research has found an association between second-stage labor and adverse pregnancy outcomes, the research has been inconsistent. Moreover, the threshold for adverse outcomes due to second-stage labor is unclear. Recently, the duration of active pushing has become a potentially new area of optimization in the second stage of labor. The aim of this study was to examine the association between maternal and neonatal morbidity and traditional second-stage labor and active pushing, by parity. This was a systematic review and meta-analysis based on a literature search of electronic databases from their establishment to October 2024. Included were studies that reported maternal and neonatal outcomes on second-stage labor and active pushing. Excluded were case reports and case series, as well as studies that did not stratify outcomes by parity or included multiple gestations, prior cesarean deliveries (CDs), or CDs performed before second stage. The primary outcome was CD. Secondary maternal outcomes included postpartum hemorrhage, need for blood transfusion, chorioamnionitis, laceration, and CD. Secondary neonatal outcomes included Apgar score at 5 minutes, fetal acidemia, sepsis, admission to the neonatal intensive care unit (NICU), and mechanical ventilation. A total of 26 studies were included in the analysis, including 18 retrospective cohort studies, 1 prospective cohort study, 6 secondary analyses, and 1 RCT. Meta-analysis of outcomes focused on prolonged second stage in nulliparous individuals found a higher risk of CD at ≥60 minutes vs <60 minutes [risk ratio (RR), 7.50; 95% CI, 2.02-27.83]. There was also a higher risk for transfusion (RR, 1.85; 95% CI, 1.04-3.29) and laceration (RR, 1.67; 95% CI, 1.24-2.24). Studies focusing on pushing duration in nulliparous individuals found an increased risk of postpartum hemorrhage (RR, 2.01; 95% CI, 1.76-2.30) and laceration (RR, 1.31; 95% CI, 0.65-2.64). Neonatal outcomes related to second-stage duration showed a greater risk of NICU admission (RR, 1.47; CI 95%, 1.36-1.59), while outcomes related to active pushing found a greater risk for low 5-minute Apgar score (RR, 1.89; 95% CI, 1.21-2.94) and NICU admission (RR, 1.43; 95% CI, 1.30-1.57). Meta-analysis of outcomes in multiparous individuals found similar trends, including increased risks of CD, chorioamnionitis, and laceration. Studies related to pushing duration found an increased risk of CD, postpartum hemorrhage, and laceration. Neonatal outcomes related to second-stage duration saw an increased risk of low Apgar score (RR, 3.54; 95% CI, 2.46-5.11). In conclusion, prolonged second stage of labor >60 minutes was associated with greater risk of adverse maternal and neonatal outcomes. Active pushing ≥60 minutes was also associated with a greater risk of maternal morbidity, but the association with neonatal outcomes is unclear. (Summarized from Aboukhater, D, Hayasaka, M, Furukawa, H, et al. Evaluating the impact of the second-stage and pushing duration on maternal and neonatal outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025;233(6):548–571.e9. doi:10.1016/j.ajog.2025.07.014).