{
    "abstract": "Retained placenta is the most common second-trimester delivery complication. As the optimal third stage of labor duration remains undefined, complications associated with retained placentas are difficult to study.\nTo determine the optimal third stage of labor duration in second-trimester deliveries based on estimates of time-specific probabilities of placental delivery, placental intervention, and postpartum complication.\nWe retrospectively studied adult women with singleton second-trimester vaginal deliveries. We identified third stage of labor duration, placental delivery method (spontaneous vs. manual/operative intervention), and indication for intervention. Postpartum complication was examined as a composite outcome. Differences among groups defined by delivery method and postpartum complication were tested using parametric and nonparametric tests. Probability curves describing the time-specific probabilities of placental delivery were derived using lifetable methods with group differences tested using the log-rank test. Probability of placental intervention and complication by time to placental delivery were examined using logistic regression with adjustment for confounders and other predictors.\nWe identified 215 second-trimester placental deliveries (77% spontaneous, 23% intervention). Overall, 27% experienced postpartum complication, primarily hemorrhage (91%). Complication rates differed significantly between spontaneous placental deliveries (16%) and interventions (61%, P\u2009<\u20090.01). Both placental intervention and postpartum complication were strongly associated with longer time to placental delivery. Spontaneous placental deliveries occurred earlier than deliveries requiring intervention (P\u2009<\u20090.01). At 2\u2009h, placental delivery rates were 93% in spontaneous deliveries and 39% in those requiring intervention. The overall postpartum complication rate for spontaneous placental deliveries (16%) was used as the threshold of tolerable risk and the criterion for placental intervention. Adjusted probability curves for deliveries of average gestational age (21.6 weeks) suggested that most patients (63.9%) may not require intervention until approximately 2\u2009h following fetal delivery. Patients with PPROM would require intervention by 34\u2009min, and those with intrapartum fever or delivery EBL \u2265500\u2009mL would already exceed the risk threshold at fetal delivery.\nOur study suggests that an optimal third stage of labor duration of approximately 2\u2009h maximizes probability of spontaneous delivery and minimizes complication risk. Timing of intervention may be further individualized for patients based on maternal characteristics and intrapartum conditions.",
    "authors": [
        {
            "affiliation": "Aurora Health Care, Department of Obstetrics and Gynecology, Aurora Sinai Medical Center, Milwaukee, WI, United States. Electronic address: jessica.behrens@aurora.org.",
            "firstname": "Jessica A",
            "initials": "JA",
            "lastname": "Behrens"
        },
        {
            "affiliation": "Aurora Health Care, Aurora UW Medical Group and Center for Urban Population Health, Aurora Sinai Medical Center, Milwaukee, WI, United States.",
            "firstname": "Danielle M",
            "initials": "DM",
            "lastname": "Greer"
        },
        {
            "affiliation": "Aurora Health Care, Aurora UW Medical Group and Center for Urban Population Health, Aurora Sinai Medical Center, Milwaukee, WI, United States.",
            "firstname": "Jessica J F",
            "initials": "JJF",
            "lastname": "Kram"
        },
        {
            "affiliation": "Aurora Health Care, Department of Obstetrics and Gynecology, Aurora Sinai Medical Center, Milwaukee, WI, United States.",
            "firstname": "Eric",
            "initials": "E",
            "lastname": "Schmit"
        },
        {
            "affiliation": "Aurora Health Care, Department of Obstetrics and Gynecology, Aurora Sinai Medical Center, Milwaukee, WI, United States.",
            "firstname": "Marie M",
            "initials": "MM",
            "lastname": "Forgie"
        },
        {
            "affiliation": "Aurora Health Care, Department of Obstetrics and Gynecology, Aurora Sinai Medical Center, Milwaukee, WI, United States.",
            "firstname": "Nicole P",
            "initials": "NP",
            "lastname": "Salvo"
        }
    ],
    "conclusions": null,
    "copyrights": "Copyright \u00a9 2018 Elsevier B.V. All rights reserved.",
    "doi": "10.1016/j.ejogrb.2018.10.038",
    "journal": "European journal of obstetrics, gynecology, and reproductive biology",
    "keywords": [
        "Placental delivery",
        "Postpartum complication",
        "Retained placenta",
        "Second-trimester",
        "Third stage of labor"
    ],
    "methods": null,
    "publication_date": "2018-11-21",
    "pubmed_id": "30458426",
    "results": "We identified 215 second-trimester placental deliveries (77% spontaneous, 23% intervention). Overall, 27% experienced postpartum complication, primarily hemorrhage (91%). Complication rates differed significantly between spontaneous placental deliveries (16%) and interventions (61%, P\u2009<\u20090.01). Both placental intervention and postpartum complication were strongly associated with longer time to placental delivery. Spontaneous placental deliveries occurred earlier than deliveries requiring intervention (P\u2009<\u20090.01). At 2\u2009h, placental delivery rates were 93% in spontaneous deliveries and 39% in those requiring intervention. The overall postpartum complication rate for spontaneous placental deliveries (16%) was used as the threshold of tolerable risk and the criterion for placental intervention. Adjusted probability curves for deliveries of average gestational age (21.6 weeks) suggested that most patients (63.9%) may not require intervention until approximately 2\u2009h following fetal delivery. Patients with PPROM would require intervention by 34\u2009min, and those with intrapartum fever or delivery EBL \u2265500\u2009mL would already exceed the risk threshold at fetal delivery.",
    "title": "Management of the third stage of labor in second-trimester deliveries: How long is too long?",
    "xml": "<Element 'PubmedArticle' at 0x788506bd7880>"
}