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Maternal and neonatal outcomes were evaluated by comparing second stage duration 3\u20134\u00a0h vs.\u2009&gt;\u20094\u00a0h.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 2,798 deliveries were included, with 2273 in the 3\u20134\u00a0h group (mean duration 3.42\u2009\u00b1\u20090.28\u00a0h) and 525 in the\u2009&gt;\u20094\u00a0h group (mean duration 4.38\u2009\u00b1\u20090.42\u00a0h). Compared to the 3\u20134\u00a0h group, the\u2009&gt;\u20094\u00a0h group had lower rate of vaginal deliveries (80.4% vs. 93%, p\u2009&lt;\u20090.001), relatively higher rate of vacuum extractions (VE) (56.0% vs. 42.4%, p\u2009&lt;\u20090.001) and higher rate of cesarean deliveries (CD) (19.6% vs. 7.0%, p\u2009&lt;\u20090.001). The\u2009&gt;\u20094\u00a0h group had higher rates of macrosomia and large for gestational age birthweights (7.0% vs. 4.0%, p\u2009&lt;\u20090.003 and 11.8% vs. 8.9%, p\u2009=\u20090.039, respectively). Shoulder dystocia, neonatal subgaleal hematoma and failed VE were more common in the\u2009&gt;\u20094\u00a0h group (2.7% vs. 1.1%, 9.0% vs. 3.3% and 4.4% vs. 1.0%, respectively, p\u2009&lt;\u20090.01 for all), as well as the composite neonatal trauma outcome (11.2% vs. 4.1%, p\u2009&lt;\u20090.001). Multivariable logistic regression adjusted for confounders including obesity, hypertensive disorders, diabetes, macrosomia and delivery mode, revealed that a duration of\u2009&gt;\u20094\u00a0h was associated with increased risks of shoulder dystocia, subgaleal hematoma and failed VE.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      Most patients achieve vaginal delivery even after a duration of\u2009&gt;\u20094\u00a0h. However, it is associated with increased risks of neonatal birth trauma and failed VE\n                      <jats:bold>.<\/jats:bold>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00404-025-08141-0","type":"journal-article","created":{"date-parts":[[2025,8,5]],"date-time":"2025-08-05T13:38:05Z","timestamp":1754401085000},"page":"1353-1363","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Second stage of labor beyond 4\u00a0h in nulliparous patients with epidural analgesia: implications and outcomes\u2014a retrospective cohort"],"prefix":"10.1007","volume":"312","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7944-0532","authenticated-orcid":false,"given":"Gal","family":"Cohen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michal","family":"Kovo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hila","family":"Shalev-Ram","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chen","family":"Key-Segal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gil","family":"Shechter-Maor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tal","family":"Biron-Shental","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanoch","family":"Schreiber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,8,5]]},"reference":[{"issue":"8","key":"8141_CR1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jogoh.2022.102447","volume":"51","author":"H Zhou","year":"2022","unstructured":"Zhou H et al (2022) Second-stage cesarean delivery and preterm birth in subsequent pregnancy: a large multi-institutional cohort study. 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