Risk of postpartum hemorrhage with increasing first stage labor duration

With increasing rates of postpartum hemorrhage (PPH) in high-income countries, an important clinical concern is the impact of labor duration on the risk of PPH. This study examined the relationship between increasing active first stage labor duration and PPH and explored the role of second stage labor duration and cesarean delivery (CD) in this association. Including 77,690 nulliparous women with spontaneous labor onset, first stage labor duration was defined as the time from 5 cm to 10 cm, second stage duration from 10 cm dilation to birth and PPH as estimated blood loss > 1000 ml. Using modified Poisson regression for risk ratios (RR) and confidence intervals (CI), we found a 1.5-fold (RR, 1.53; 95% CI, 1.41‒1.66) increased PPH risk when first stage of labor exceeded 12.1 h compared to the reference (< 7.7 h). Mediation analysis showed that 18.5% (95% CI, 9.7‒29.6) of the increased PPH risk with a prolonged first stage (≥ 7.7 h) was due to a prolonged second stage (> 3 h) or CD. These results suggest that including first stage duration in intrapartum assessments could improve PPH risk identification in first-time mothers with a singleton fetus in vertex presentation at full term with spontaneous labor onset.