# Influence of the active second stage of labor in nulliparous women on umbilical cord blood pH and neonatal outcomes: a population-based, cohort study

## TL;DR

Prolonged labor in first-time mothers increases the risk of poor neonatal outcomes like low Apgar scores and CNS disease.

## Contribution

This study provides population-based evidence linking extended pushing time in labor to adverse neonatal outcomes in nulliparous women.

## Key findings

- Each 60-minute increase in pushing time raises odds of cord blood acidosis and low Apgar scores.
- Prolonged labor is associated with higher odds of suspected central nervous system disease in newborns.
- Time management during labor is crucial to reduce neonatal risks.

## Abstract

Prolonged second stage of labor increases the risk of insufficient gas exchange over the placenta to the fetus and risk of birth asphyxia. There are considerable variations in clinical guidelines regarding the recommended duration of pushing during the active second stage of labor. Thus, the aim of this study was to investigate the total duration of the second stage of labor and its association to changes in umbilical cord pH and adverse neonatal outcomes in nulliparous women.

This retrospective, multi-center cohort study was based on data from the Perinatal Revision South Register covering seven maternity units from 1995 to 2015. Nulliparous women with fetuses in cephalic position and complete and validated cord blood pH data were recruited to the study. Logistic regression was used to establish the relationship of duration of pushing, categorized in 60 min increments, with cord blood acidosis (umbilical cord arterial pH < 7.05) and adverse neonatal outcomes, including Apgar score at 5 min, risk for central nervous system (CNS) disease, utilization of continuous positive airway pressure (CPAP), neonatal intensive care unit (NICU) admission and hypoxic ischemic encephalopathy (HIE). The adjusted model adjusted for maternal BMI, gestational duration and birth weight.

A total of 37,008 women were included in the analysis. For every 60 min increase in pushing time, there was a significantly increased adjusted odds ratio (aOR) for umbilical arterial pH < 7.05, aOR = 1.639, (95% CI = 1.418–1.895, P = 0.02), Apgar score < 7 at 5-minutes, aOR = 1.408 (95% CI = 1.082–1.831, P = 0.01), and prevalence of suspected CNS disease, aOR = 1.417, (95% CI = 1.065–1.886, P = 0.02). The use of CPAP, (aOR = 1.215, 95% CI = 0.945–1.561, P = 0.13), NICU admission (aOR = 1.021, 95% CI = 0.890–1.171, P = 0.77), neonatal seizures (aOR = 0.000, P = 0.98) and HIE (aOR = 1.377, 95% CI = 0.416–4.109, P = 0.57) were not associated with increased pushing time.

Using a large, population-based cohort, we found that prolonged active second stage of labor was associated with an increased odds for cord blood acidosis at birth, low Apgar score at 5 min, and suspected CNS-disease in neonates. Efficient and evidence-based time management during the active second stage of labor is therefore crucial for reducing the risk of adverse neonatal outcomes.

The online version contains supplementary material available at 10.1186/s12884-025-07917-1.

Prolonged active second stage of labor increases the risk of cord blood acidosis at birth, low Apgar scores, and neonatal CNS disease. Effective, evidence-based time management is essential to minimize these risks and improve neonatal outcomes in clinical practice.

The online version contains supplementary material available at 10.1186/s12884-025-07917-1.