Why a longer labor could cut cesarean delivery rates


A new study wonders if allowing a longer labor could help reduce rates of cesarean delivery. Plus: Does placing a cervical pessary prevent preterm birth? Also, a look at why teenaged LARC users aren't using condoms for STI prevention.

A small randomized controlled trial published in The American Journal of Obstetrics & Gynecology suggests that allowing women more time in the prolonged second stage of labor could drastically reduce the cesarean rate.

Researchers at the Sidney Kimmel College of Medicine at Thomas Jefferson University in Philadelphia, Pennsylvania assessed data on nulliparous women with singleton pregnancies at 36 0/7 to 41 6/7 weeks’ gestation. All of them reached the American College of Obstetricians and Gynecologists definition of prolonged second stage of labor: either 3 hours with epidural anesthesia or 2 hours without epidural anesthesia.

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Randomization was to either extension of labor by 1 additional hour or to the usual labor, defined as expedited delivery either via cesarean delivery or operative vaginal delivery. Exclusion criteria included intrauterine fetal death, age < 18 years, planned cesarean delivery, and suspected major fetal anomaly.

Overall 78 women were assigned randomly and all of the women had epidural anesthesia. The demographics of the women in the two study arms were not significantly different. In the extended labor group, the rate of cesarean delivery was 19.5% or 8 out of 41 births. In the usual labor group, the rate of cesarean delivery was 43.2% or 16 out of 17 births (relative risk, 0.45; 95% confidence interval, 0.22–0.93). The number needed-to-treat to prevent 1 cesarean delivery was 4.2. No statistically significant differences were seen in maternal or neonatal morbidity outcomes between the 2 groups.

The researchers concluded that extending labor in nulliparous women with a singleton pregnancy, under epidural anesthesia, and in a prolonged second stage seemed to decrease the rate of cesarean delivery by a little more than 50%. They pointed out that the study was underpowered in its ability to detect small differences, which could have some clinical importance.

NEXT: Can a cervical pessary help prevent preterm birth?


Can a cervical pessary help prevent preterm birth?

Research to date on use of a silicone pessary around the cervix to prevent preterm birth has produced contradictory results. Adding to those data are outcomes from a new randomized controlled trial, which cast doubt on the value of the devices. 

Published in The New England Journal of Medicine, the findings are from a multicenter comparison of pessary placement and expectant management by researchers from UK. The participants were 930 women aged ≥16 with singleton pregnancies and cervical lengths ≤25 mm at 20 weeks 0 days to 24 weeks 6 days gestation.

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Half the participants received cervical pessaries and half were followed expectantly. Vaginal progesterone was administered to 423 woman with a cervical length ≤15 mm at randomization or on a subsequent visit. Antibiotics were administered to 267 of the women who had positive vaginal cultures and cervical cerclages were placed in 7 women with very short cervixes.

The primary outcome of the study was spontaneous delivery before 34 weeks’ gestation, which occurred in 55 (12.0%) of the women who had pessaries and 50 (10.8%) of the women in the control group (odds ratio in the pessary group 1.12; 95% confidence interval [CI] 0.75 to 1.69; P=0.57). No significant difference was seen between the pessary and expectant management groups in percentage of women who did not give birth spontaneously before 34 weeks (hazard ratio in the pessary group 1.13; 95% CI 0.77 to 1.65; P=0.54). Adjustment for cervical length, progesterone use, and antibiotic treatment did not change the results.

Looking at adverse events, the investigators found that pessary placement did not affect rates of perinatal death, adverse neonatal outcomes, or need for neonatal special care. The women who received the devices did have more vaginal discharge than those in the control group (10.5% vs. 6.2%; P=0.02).

NEXT: Why do teen LARC users not use condoms?


Why do teen LARC users not use condoms?

A cross-sectional analysis recently published in JAMA Pediatrics shows that high school girls who use recommended long-acting reversible contraceptives (LARC) may be more likely to not use condoms during sexual intercourse than their peers who use oral contraceptives (OCs).

For the study, the researchers used data from the 2013 national Youth Risk Behavior Survey, a nationally representative sample of US students in grades 9 to 12. Descriptive analyses were performed with sexually active female students (n = 2288) while logistic regression analyses were limited to sexually active female users of LARC (intrauterine devices and implants) and moderately effective contraceptives (n = 619).

Among the 2288 participants (56.7% were white and 33.6% were in 12th grade), 1.8% used LARC; 5.7% used Depo-Provera, patch, or ring; 22.4% used OCs; 40.8% used condoms; 11.8% used withdrawal or some other method; 15.6 used no contraceptive method; and 1.9% were not sure about the method they used. Following an adjust analysis, LARC users were roughly 60% less likely to use condoms than were OC users (adjusted prevalence ratio [aPR], 0.42; 95% CI, 0.21-0.84). There was no significant difference in condom use between LARC users and those who used Depo-Provera, patch, or the ring (aPR, 0.57; 95% CI, 0.26-1.25). The study also raised the concern that LARC users had nearly double the chance of having 2 or more recent sexual partners in comparison to OC users (aPR, 2.61; 95% CI, 1.75-3.90) and Depo-Provera, patch, or ring users (aPR, 2.58; 95% CI, 1.17-5.67).

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Researchers were quick to point out that some limitations should be taken into account when interpreting the findings. The survey data used are based on self-report, allowing for misreported behaviors. In addition, the survey only asked about the primary contraceptive method used when a girl last engaged in sexual intercourse, which could mean that some teens polled used condoms in addition to their primary contraceptive choice, but only listed the primary method. Important information not included in the data involved duration of contraceptive use; whether the contraceptive was correctly and consistently; and information about the girls’ partners.

The researchers concluded that girls who use LARCs are far more likely to not use condoms while engaging in sexual intercourse than their peers who use OCs. They speculate that this could be because teens believe that condoms are for backup pregnancy prevention. Given the highly effective nature of LARCs, some girls may not perceive that they are at risk of sexually transmitted infections (STIs). This cognitive disconnect indicates a clear need to emphasize the STI prevention capabilities of condoms.

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