Urologia Pediatrica

13/9/2018 Normal and abnormal labor progression - UpToDate
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Normal and abnormal labor progression
Authors: Robert M Ehsanipoor, MD, Andrew J Satin, MD, FACOG

Section Editor: Vincenzo Berghella, MD
Deputy Editor: Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2018. | This topic last updated: Sep 07, 2018.
INTRODUCTION — During normal labor, regular and painful uterine contractions cause progressive dilation and effacement of the cervix,
accompanied by descent and eventual expulsion of the fetus. "Abnormal labor," "dystocia," and "failure to progress" are traditional but imprecise
terms that have been used to describe a labor pattern deviating from that observed in the majority of women who have a spontaneous vaginal
delivery. These labor abnormalities are best described as protraction disorders (ie, slower than normal progress) or arrest disorders (ie, complete
cessation of progress). By convention, an abnormally long active phase is usually described as protracted, whereas an abnormally long latent
phase or second stage is usually described as prolonged.
This topic will describe normal labor progress and discuss the diagnosis and management of protraction and arrest disorders. Management of
normal labor and delivery is reviewed separately. (See "Management of normal labor and delivery".)
NORMAL LABOR PROGRESSION — Although determining whether labor is progressing normally is a key component of intrapartum care,
determining the onset of labor, measuring its progress, and evaluating the factors (power, passenger, pelvis) that affect its course are an inexact
science.
Stages and phases — Interpretation of labor progress depends on the stage and phase. The three stages and their phases are:
● First stage – Time from onset of labor to complete cervical dilation. Clinically, women are simply asked the time when they believe labor
began (ie, when contractions started to occur regularly every 3 to 5 minutes for more than an hour) to document the onset of labor. The time
that complete dilation is first identified on physical examination documents the end of the first stage. The precise times of both the start of
labor and of complete dilatation are impossible to determine since the normal uterus contracts intermittently and irregularly throughout
gestation, the initial regular contractions at the onset of labor are mild and infrequent, initial cervical changes are subtle, and physical
examination to document cervical change is performed intermittently.
The first stage consists of a latent phase and an active phase. The latent phase is characterized by gradual cervical change and the
active phase is characterized by rapid cervical change. The labor curve of multiparas may show an inflection point between the latent and
active phases; this point occurs at about 5 cm dilation [1]. In nulliparas, the inflection point is often unclear and, if present, occurs at a more
advanced cervical dilation typically at approximately 6 cm or more. In any case, this inflection point is a retrospective finding.
● Second stage – Time from complete cervical dilation to fetal expulsion.
When pushing is delayed, some clinicians divide the second stage into a passive phase (from complete cervical dilation to onset of active
maternal expulsive efforts) and an active phase (from beginning of active maternal expulsive efforts to expulsion of the fetus) [2].
● Third stage – Time between fetal expulsion and placental expulsion.
Criteria for normal progress — Emanuel Friedman established criteria for the normal progress of labor in the 1950s, and these criteria were
used for assessment and management of labor for decades. As described below, he observed that normal labor should progress at a rate of at
least 1 cm cervical dilation per hour, starting at 3 to 4 cm of dilation.
However, data derived from women in labor in the 21st century (also described below) suggest that changes in obstetric and anesthesia practices
and in women themselves in recent decades have resulted in changes in the average progress of labor. Therefore, criteria for normal labor
progress have been revised, although this remains controversial. It is now believed that the active phase of the ﬁrst stage of labor may not start
until the cervix is 5 to 6 cm dilated, cervical dilation in normal labor can be slower than 1 cm per hour and still have a high chance of vaginal
delivery with normal perinatal outcomes, and the cervix does not dilate linearly (it is a hyperbolic pattern) [3,4].
Friedman (historic) criteria — Emanuel Friedman conducted his now classic studies defining the spectrum of normal labor by evaluating the
course of labor of 500 primigravidas admitted to the Sloane Hospital for Women in New York in the mid-1950s [5-7]. The norms established by his
data, depicted as the "Friedman curve" (figure 1), were widely accepted as the standard for assessment of normal labor progression for decades.
Based on these data, the transition from the latent phase to active phase appeared to occur at 3 to 4 cm cervical dilation, and the statistical
minimum rate (5th centile) of normal cervical dilation during the active phase was 1.2 cm/hour for nulliparous women and 1.5 cm/hour for
multiparous women.
A prolonged second stage for nulliparas and multiparas was defined as three hours and one hour, respectively.
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Contemporary criteria — The applicability of the Friedman curve and its established norms to contemporary obstetric practice was
challenged in the 21st century. Several studies evaluated labor curves in thousands of contemporary women to establish contemporary criteria for
normal labor progression [8-10]. These criteria are different from, and generally slower than, those cited by Friedman. This change has been
attributed to changes in patient characteristics (eg, higher mean body mass index), anesthesia practices (more use of neuraxial anesthesia), and
obstetric practices over the past half-century. In addition, a limitation of Friedman's findings is that his data were based on labors in only 500
women who were managed at a single institution. However, revision of the classic labor curve as described by Friedman has not been accepted
universally. For example, Friedman and Cohen argue that the shape of the curve may have been influenced by selection biases and confounders
[11,12]. The most appropriate statistical methods remain debated.
First stage
● Progress -- Zhang and colleagues obtained data on normal labor patterns by evaluating contemporary data from the Consortium on Safe
Labor, which included information on 62,415 singleton pregnancies with spontaneous onset of labor, cephalic vaginal delivery (≥88 percent
spontaneous), and normal neonatal outcome [8]. The data were collected retrospectively from the electronic medical records at 19 medical
centers in the United States. These data have been used to define normal labor progress, as shown in the table (table 1).
The shape of the normal labor curve generated from Zhang's data (figure 2) is different from the Friedman curve (figure 1). The Friedman
curve depicts a relatively slow rate of cervical dilation until approximately 4 cm (ie, latent phase), which is followed by an abrupt acceleration
in the rate of dilation (ie, active phase) until entering a deceleration phase at approximately 9 cm. Zhang's labor curves also demonstrate an
increase in the rate of cervical dilation as labor progresses, but the increase is more gradual than that described by Friedman: Over 50
percent of patients did not dilate >1 cm/hour until reaching 5 to 6 cm dilation, and a deceleration phase at the end of the first stage of labor
was not observed. Labor curves constructed from other contemporary data sets also generally differ from Friedman's curve [9,13].
Specifically, there is no abrupt change in the rate of cervical dilation indicating a clear transition from latent to active phase and there is no
deceleration phase at the end of the first stage of labor.
While the presence or absence of a deceleration phase at the end of the 1st stage of labor is not of major clinical significance, defining the
transition from latent to active phase (ie, transition from slower to more rapid cervical dilation) is clinically important for diagnosing labor
abnormalities. Contemporary data suggest that the normal rate of cervical change between 3 and 6 cm dilation is much slower than
described by Friedman, who reported minimum dilation should be at least 1 cm/hour [9,14]. Many contemporary women who go on to deliver
vaginally have rates of cervical dilation <1 cm/hour before reaching 6 cm dilation. Indeed, both nulliparas and multiparas who go on to deliver
vaginally can take more than six hours to dilate from 4 cm to 5 cm and more than three hours to dilate from 5 cm to 6 cm (table 1) [8]. Beyond
6 cm dilation, rates of cervical dilation are more rapid in both nulliparas and multiparas. This suggests that before 6 cm, slow cervical dilation
reflects the shallow slope of the latent phase portion of the contemporary normal labor curve, not a protracted active phase. At ≥6 cm
dilation, nearly all women should be in active labor, so slow cervical dilation beyond this point (ie, less than about 1 to 2 cm/hour) is a
deviation from the slope of the contemporary normal labor curve and is abnormal if it persists.
● Duration -- These contemporary observations about hourly labor progress translate into a longer normal duration of the first stage than
described by Friedman [13,15-18]. Zhang observed that the median (95th percentile) times for the cervix to dilate from 4 to 10 cm in
nulliparas and multiparas were 5.3 hours (16.4) and 3.8 hours (15.7), respectively [8]. In contrast, Friedman reported the corresponding
mean (95th percentile) durations in nulliparous and parous women were 4.6 hours (11.7) and 2.4 hours (5.2), respectively [7]. The
contemporary increase in first-stage duration persists after adjustments are made for maternal and pregnancy characteristics [15],
suggesting that changes in labor practice patterns may be the primary reason for the increase. Although epidural use has increased
dramatically since the 1960s, increased use of epidurals does not fully account for the difference. Further study is required to explain these
findings.
Second stage
● Descent -- At full cervical dilation, fetal station is typically ≥0. In nulliparous women in the second stage, Zhang found that the median (95th
percentile) time interval for fetal descent from station +1/3 to +2/3 was 16 minutes (three hours) [13]. The median (95th percentile) time
interval for fetal descent from station +2/2 to +3/3 was 7 minutes (38 minutes).
Fetal station at full cervical dilation tends to be higher in multiparous women than in nulliparous women, and descent tends to be faster
[19,20].
● Duration -- Zhang observed that the median (95th percentile) duration of the second stage in nulliparous and parous women with epidural
anesthesia was 1.1 hours (3.6) and 0.4 hours (2.0), respectively [8]. Without epidural anesthesia, the median (95th percentile) was 0.6 hours
(2.8) and 0.2 hours (1.3), respectively (table 1). Thus, epidural anesthesia increased the 95th percentile for the second stage by 0.8 hours in
nulliparous women and 0.7 hours in parous women compared with no epidural anesthesia. (See 'Neuraxial anesthesia' below.)
Diabetes, preeclampsia, fetal size, chorioamnionitis [21], duration of the first stage [22], maternal height, and station at complete dilation may
also play a role in predicting the duration of the second stage, but standards that account for these characteristics are not available [23].
The effect of induction is discussed below.
Normal progression in induced labors — The time to dilate 1 cm in latent phase (defined as dilation <6 cm) is significantly longer in women
undergoing induction than in those in spontaneous labor and can take many hours [24,25]. In a retrospective study, the median (95th percentile)
times for dilation in the latent phase for nulliparous women were [24]:
● From 3 to 4 cm: Induced labor 1.4 hours (8.1 hours), spontaneous labor 0.4 hours (2.3 hours)
● From 4 to 5 cm: Induced labor 1.3 hours (6.8 hours), spontaneous labor 0.5 hours (2.7 hours)
● From 5 to 6 cm: induced labor 0.6 hours (4.3 hours), spontaneous labor 0.4 hours (2.7 hours)
The time to dilate from 6 to 10 cm was more rapid and similar in both induced and spontaneous labors [24,25].
Because the latent phase is longer in induced labors, the duration of the first stage (defined as the time to dilate from 4 to 10 cm) is significantly
longer in induced labor than in spontaneous labor. For nulliparas, the median (95th percentile) duration of the first stage for induced and
spontaneous was 5.5 hours (16.8 hours) versus 3.8 hours (11.8 hours); for multiparas, the median (95th percentile) was 4.4 hours (16.2 hours)
versus 2.4 hours (8.8 hours), in one study [24].
There is no difference in length of the second stage between induced and spontaneous labor [26].
ASSESSMENT OF LABOR PROGRESS
Digital examination — Cervical examinations to document cervical dilation, effacement, and fetal station are usually routinely performed:
● On admission
● At two- to four-hour intervals in the first stage
● Prior to administering analgesia/anesthesia
● When the parturient feels the urge to push (to determine whether the cervix is fully dilated)
● At one- to two-hour intervals in the second stage
● If fetal heart rate abnormalities occur (to evaluate for complications such as cord prolapse or uterine rupture or fetal descent)
More frequent examinations are warranted when there is a concern about labor progress. A limitation of digital examination is that it is imprecise,
which is not a problem when monitoring most labors, but is a concern when the clinician is trying to determine whether cervical dilation and station
are advancing slowly or not at all. In a study that evaluated the accuracy of digital measurement of cervical dilation with a position-tracking
system, when cervical dilation was >8 cm, the mean error of digital examination was 0.75 +/- 0.73 cm; when cervical dilation was 6 to 8 cm, the
mean error was 1.25 +/- 0.87 cm [27]
Partogram — Results of cervical examinations can be documented on a partogram (or partograph), in addition to the medical record. The
partogram is a graphical representation of the patient's cervical dilation over time in comparison with the expected lower limit of normal progress.
The following partogram is based on cervical dilation at admission and shows the minimum rate of labor progress achieved by 95 percent of
nulliparous women with singleton term pregnancies and spontaneous onset of labor who had a vaginal delivery and normal neonatal outcomes
(figure 3) [8]. Right deviation from this curve suggests a protraction or arrest disorder. Although useful for visualizing labor progress, use of
partograms has not been proven to significantly improve obstetric outcome [28].
Ultrasound — Although not widely used clinically, intrapartum transperineal ultrasound examination can document fetal descent and rotation in
the second stage when performed serially, and assess the presence and extent of caput [29]. Ultrasound examination appears to be more
objective and reproducible than digital examination. One technique is to measure the angle between the symphysis pubis and the leading part of
the fetal skull (called the angle of progression) by transperineal ultrasound in the second stage (figure 4). Station can be determined from angle
of progression using a formula [30], and tables are available [31]. Head to perineum distance (HPD) can also be measured serially with
transperineal ultrasound. An advantage is that caput succedaneum can be measured, but station cannot be determined because the HPD
measurement does not account for the curvature of the birth canal [31].
OVERVIEW OF PROTRACTION AND ARREST DISORDERS
Prevalence — Protraction and arrest disorders are common. Reported incidences vary among studies due to differences in the definitions used
by authors as well as differences among study populations (eg, gestational age range, personal characteristics [eg, nulliparity parity and older
maternal age have been associated with longer labor]).
About 20 percent of all labors ending in a live birth involve a protraction and/or arrest disorder [32]. The risk is highest in nulliparous women with
term pregnancies. In a prospective Danish study, for example, 37 percent of healthy term nulliparas experienced dystocia during labor [33].
Protraction or arrest of labor is the most common reason for primary cesarean delivery. In one study including over 700 women who had
unplanned cesareans, 68 percent of the cesarean deliveries were due to lack of progress in labor [34].
When only the second stage is considered, 11.5 percent of nulliparous women with epidural anesthesia experienced a prolonged second stage in
a systematic review (two studies, n = 5350 women) [35].
Risk factors — Abnormal progress of spontaneously initiated labor may to related to uterine factors, fetal factors, the bony pelvis, or a
combination of these factors (table 2) [21]. A genetic component has been purported to account for 28 percent of the susceptibility to protracted
and difficult labor [36].
Selected risk factors for protraction and arrest are discussed below. Some risk factors are more prominent during the first stage of labor and
others primarily exert their effects in the second stage.
Hypocontractile uterine activity — Hypocontractile uterine activity is the most common risk factor for protraction and/or arrest disorders in
the first stage of labor. Uterine activity is either not sufficiently strong or not appropriately coordinated to dilate the cervix and expel the fetus.
Diagnosis — Uterine activity can be monitored qualitatively by palpation or external tocodynamometry. The diagnosis of hypocontractile
uterine activity in this setting is subjective, based on the perception that contractions are not strong on palpation and/or infrequent (<3 or 4
contractions/10 minutes) and/or of short duration (<50 seconds) [37,38].
Uterine activity can also be monitored quantitatively by measurement of Montevideo units (MVUs) using an internal pressure catheter (IUPC).
MVUs are calculated by subtracting the baseline uterine pressure from the peak contraction pressure of each contraction in a 10-minute window
and adding the pressures generated by each contraction (figure 5). Uterine activity less than 200 to 250 MVUs is considered inadequate (ie,
increased likelihood of not achieving expected normal rate of cervical change and fetal descent), based on the following seminal studies [39,40],
and other data [37,41,42]:
● In a retrospective report, 91 percent of women who had spontaneous vaginal deliveries after oxytocin induction achieved contractile activity
greater than 200 MVUs and 40 percent reached 300 MVUs; 77 percent of women who had spontaneous vaginal deliveries after
augmentation achieved contractile activity greater than 200 MVUs and 8 percent reached 300 MVUs [39].
● In a study of women with spontaneous initiation of labor, uterine activity averaged about 100 MVUs in the early first stage of labor, 175 MVUs
in the advanced first stage, and 250 MVUs in the second stage [40].
In most women, external and intrauterine devices for monitoring uterine activity perform equally well [43]; routine use of IUPCs does not improve
outcome [44-46]. However, selective use of an IUPC can be helpful for assessing uterine activity when it is difficult to monitor contractions
externally, such as in obese women. (See "Use of intrauterine pressure catheters".)
Maternal obesity — Increasing maternal body mass index (BMI) correlates with an increasing length of the first stage of labor. In one study,
for example, the median time to dilate from 4 to 10 cm in nulliparous women with BMI <25 kg/m2 and >40 kg/m2 was 5.4 and 7.7 hours,
respectively, even after controlling for multiple confounders [47]. The authors concluded more time should be allowed for labor progress in obese
patients. Maternal obesity is not independently correlated with the length of the second stage of labor [47,48]. (See "Obesity in pregnancy:
Complications and maternal management", section on 'Progress of labor'.)
Cephalopelvic disproportion — A disproportion in the size of the fetus relative to the maternal pelvis can result in failure to progress in the
second stage and has been termed cephalopelvic disproportion (CPD). This is usually due to fetal malposition (eg, extended or asynclitic fetal
head, occiput posterior or transverse position [discussed below]) or malpresentation (mentum posterior, brow) rather than a true disparity
between fetal size and maternal pelvic dimensions. However, true CPD may occur if the fetus has a large surface anomaly (eg, teratoma,
conjoined twin), the maternal pelvic bone is very small or deformed (eg, after pelvic trauma), or the fetus is extremely large (although vaginal
deliveries have been described in infants weighing 13 to 17 pounds and more).
Diagnosis — Cephalopelvic disproportion is a subjective clinical assessment based on physical examination and course of labor. In a
prospective study of nulliparous women in active labor, a persistently floating head at 7 cm dilation was predictive of eventual cesarean delivery in
100 percent of cases [49].
Antepartum, the clinician is generally unable to predict maternal pelvis-fetal size/position discordance leading to arrest of labor requiring cesarean
delivery. Clinical and radiologic assessments of the maternal pelvis and fetal size (ie, pelvimetry) are inexact and poorly predict the course and
outcome of labor [50,51]. Radiographic pelvimetry is not recommended [51]. Ultrasound evaluation of fetal position is accurate, but common
malpositions such as occiput posterior (OP) usually rotate intrapartum.
Non-occiput anterior position — The length of the second stage appears to correlate with the degree of rotation away from occiput anterior
(OA). Among nulliparous women under neuraxial anesthesia who began pushing at full dilation, the mean duration of the second stage for OA,
occiput transverse (OT), and OP positions was 2.2, 2.5, and 3.0 hours, respectively, and the cesarean delivery rates were 3.4, 6.9, and 15.2
percent, respectively [52]. Many fetuses actually enter labor in either OP or OT position and then undergo spontaneous rotation of the fetal head
during labor. Protraction and arrest disorders associated with malposition occur when rotation to OA does not occur or is slow to occur during
labor. (See "Occiput posterior position" and "Occiput transverse position".)
Bandl's ring — An hourglass constriction ring of the uterus, called Bandl's ring, has been estimated to occur in 1 in 5000 live births and is
associated with obstructed labor in the second stage [53-55]. The constriction forms between the upper contractile portion of the uterus and the
lower uterine segment. It is not clear if it is the cause or the result of the associated labor abnormality. It may also occur between delivery of the
first and second twin.
Diagnosis — Diagnosis is typically made at cesarean delivery. At the time of laparotomy, a transverse thickened muscular band can be
observed separating the upper and lower segment of the uterus. However, case reports have described predelivery diagnosis using ultrasound
[56,57]. Findings included thinning of the lower uterine segment, a thick upper uterine segment, and a prominent ring compressing the fetus
unaffected by contractions.
Neuraxial anesthesia — The potential impact of neuraxial anesthesia on uterine activity and fetal malposition has received a lot of attention
as a possible source of increasing rates of protracted labor, arrest, and cesarean delivery. Randomized trials have not shown a major impact on
the incidence of protraction and arrest disorders. In a 2011 systematic review of randomized trials, use of neuraxial labor anesthesia did not
increase the duration of the first stage of labor compared with non-neuraxial anesthesia or no analgesia (weighted mean difference [WMD] 18.5
minutes; 95% CI -12.9 to 49.9) or increase the risk of cesarean delivery (relative risk [RR] 1.10, 95% CI 0.97-1.25) [58]. There were small but
statistically significant increases in the duration of the second stage of labor (WMD 13.7 minutes; 95% CI 6.7-20.7) and use of oxytocin (RR 1.19,
95% CI 1.03-1.39). Women receiving neuraxial anesthesia were more likely to undergo operative vaginal delivery (RR 1.42, 95% CI 1.28-1.57).
(See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor'.)
FIRST STAGE PROTRACTION AND ARREST
Diagnosis — The diagnosis of protraction and arrest disorders is based on deviation from the contemporary norms described above and are
defined according to the phase of the first stage in which they occur.
Protraction — The diagnosis of a protracted active phase is made in women at ≥6 cm dilation who are dilating less than about 1 to 2 cm/hour,
which reflects the 95th centile in contemporary women (table 1).
Women with cervical dilation <6 cm are considered to be in latent phase. The same table (table 1) serves as a guide for diagnosing a prolonged
latent phase [8]. According to the table, it may take six to seven hours to progress from 4 to 5 cm and three to four hours to progress from 5 to 6
cm during a normal latent phase, regardless of parity.
Arrest — We agree with the criteria for arrest proposed by a workshop convened by the United States National Institute of Child Health and
Human Development (NICHD), Society for Maternal-Fetal Medicine (SMFM), and American College of Obstetricians and Gynecologists (ACOG)
and based on contemporary data [59]. Active phase arrest is diagnosed at cervical dilation ≥6 cm in a patient with ruptured membranes and [8]:
● No cervical change for ≥4 hours despite adequate contractions (usually defined as >200 Montevideo units [MVU])
● No cervical change for ≥6 hours with inadequate contractions
Given the slowness of the latent phase, latent phase arrest is not considered a clinical diagnosis.
Management
Prolonged latent phase — Management of labor abnormalities before 6 cm dilation (ie, latent phase) is reviewed separately. (See "Latent
phase of labor", section on 'Management of latent phase'.)
Dilation ≤1 cm over two hours in active phase — For patients (nulliparous or multiparous) in the active phase (cervix ≥6 cm) who dilate ≤1
cm over two hours, we administer oxytocin (if not already started) and proceed with amniotomy (if not already ruptured) if there has been
adequate fetal descent to a safe fetal station (eg, -2 or lower) for amniotomy. Oxytocin administration for women with slow progress is reasonable
even in the absence of documented hypocontractile uterine activity [60].
If the head is high and not well applied to the cervix, we begin oxytocin but delay performing amniotomy. If oxytocin alone for four to six hours does
not result in adequate progress, we consider performing an amniotomy at that time, regardless of fetal head position. A controlled amniotomy is
performed if the head is still high and not well applied to the cervix. (See "Umbilical cord prolapse", section on 'Minimizing risk from obstetric
maneuvers'.)
In a 2013 meta-analysis of randomized trials, our approach: early intervention with oxytocin and amniotomy, reduced the time to delivery by
approximately 1.5 hours [61]. Maternal satisfaction is also improved [62,63].
Alternatively, expectant management can be considered. Although meta-analyses have shown that the mean duration of labor can be shortened
by these interventions [61,64], cesarean delivery and instrumental delivery rates were not affected.
Oxytocin augmentation — Oxytocin is the only medication approved by the US Food and Drug Administration for labor stimulation in the
active phase. It is typically dosed to effect, as predicting a women's response to a particular dose is not possible [65]. We titrate the dose to
obtain an adequate uterine contraction pattern and do not generally exceed a dose of 30 milliunits/minute, but others have used cutoffs of 20 or
40 milliunits/minute.
After four hours of adequate uterine contractions (usually defined as >200 MVU if an internal pressure catheter is in place), or six hours without
adequate uterine contractions and no cervical change in the active phase of labor, we proceed with cesarean delivery. If labor is progressing,
either slowly or normally, we continue oxytocin at the dosage required to maintain an adequate uterine contraction pattern.
Dosing regimen — Numerous oxytocin dosing protocols that vary in initial dose, incremental dose increase, and time interval between
dose increases have been studied (table 3). (See "Induction of labor with oxytocin", section on 'Dose titration and maintenance'.)
The decision to use a high- versus a low-dose oxytocin regimen poses a risk-benefit dilemma: Higher-dose regimens are associated with shorter
labor and fewer cesareans but more tachysystole (>5 contractions in 10 minutes, averaged over a 30-minute window). The value placed on each
of these outcomes and the ability to respond to tachysystole may vary among labor and delivery units. Therefore, either a high- or low-dose
oxytocin regimen is acceptable and should depend on local factors. We use a high-dose regimen and do not alter our management based on
parity [44,66,67], with one important exception: We do not use a high-dose regimen in women who have had a previous cesarean delivery
because of risk of rupture [66].
Low-dose regimens were developed, in part, to avoid uterine tachysystole and are based upon the observation that it takes 40 to 60 minutes to
reach steady-state oxytocin levels in maternal serum [68]. A 2010 systematic review of randomized trials of high- versus low-dose oxytocin for
augmentation of women in spontaneous labor (10 trials, n = 5423 women) found that high-dose oxytocin [69]:
● Increased the frequency of tachysystole (relative risk [RR] 1.91, 95% CI 1.49-2.45)
● Decreased the cesarean delivery rate (RR 0.85, 95% CI 0.75-0.97) and increased the rate of spontaneous vaginal delivery (RR 1.07, 95% CI
1.02-1.12)
● Decreased the total duration of labor (mean difference -1.54 hours, 95% CI -2.44 to -0.64 hours)
● Resulted in similar maternal and neonatal morbidities
A 2013 systematic review had fewer trials because it excluded those involving augmentation as part of an active management of labor protocol,
but came to similar conclusions [70].
Ineffective and less well studied approaches
● Misoprostol – Oxytocin with or without amniotomy is the best approach for treatment of a protraction disorder, based on extensive experience
and data attesting to safety and efficacy. The body of evidence does not support using any alternative pharmacologic approach. Misoprostol
is typically used for cervical ripening and labor induction; there are limited data on its safety and efficacy for treatment of protraction
disorders [71,72]. However, low-dose titrated misoprostol may be a reasonable alternative in low-resource settings where safe oxytocin
infusion is not feasible.
● Ambulation may improve the comfort of the parturient and is not harmful, but there is no convincing evidence that this intervention prevents
or treats protraction or arrest disorders [73].
● Amniotomy alone – As discussed below, routine amniotomy alone did not clearly shorten the first or second stage in a meta-analysis of
randomized trials [74], whereas the combination of amniotomy and oxytocin had beneficial effects [61]. However, most of the trials did not
clearly distinguished between amniotomy for prevention versus treatment of dysfunctional labor. In the only trial that randomly assigned 60
women at term making slow progress in the first stage to amniotomy plus oxytocin, amniotomy alone, or expectant management, only the
combination of amniotomy plus oxytocin increased the rate of cervical dilation; the impact on the cesarean delivery rate was difficult to assess
because the trial was underpowered for this outcome [75]. (See 'Prevention of first stage labor abnormalities' below.)
Active phase arrest — Women with labor arrest in the active phase of the first stage are managed by cesarean delivery. The key issue is
using appropriate criteria for diagnosing labor arrest. Some unnecessary cesareans will be performed in arrest is diagnosed too soon, and
maternal complications (eg, uterine rupture) are likely to increase if arrest is diagnosed too late. We use the criteria described above, proposed
by a workshop convened by the NICHD, SMFM, and ACOG and based on contemporary data criteria. (See 'Arrest' above.)
These criteria were based on the following studies. These studies showed that oxytocin augmentation for at least four hours, rather than the
historical standard of two hours, before diagnosing arrest is safe for mother and fetus and increases the chances of achieving a vaginal delivery.
They also show that vaginal delivery is often possible despite levels of uterine activity and rates of cervical dilation below the range historically
considered necessary for success.
● A prospective study including 542 women in spontaneous labor at term with active phase labor arrest (defined as cervix ≥4 cm dilated and ≤1
cm of cervical progress in four hours) evaluated a protocol whereby oxytocin augmentation was initiated and cesarean delivery was not
performed for labor arrest until (1) the woman experienced at least four hours uterine contractions >200 MVUs or (2) the woman experienced
a minimum of six hours of oxytocin augmentation if this contraction pattern could not be achieved [44]. Only 12 percent of women did not
achieve the target 200 MVUs.
The authors found that 91 percent of multiparas and 74 percent of nulliparas who had not progressed (≤1 cm additional dilation) by the
traditional two hours of oxytocin administration and thus would have undergone cesarean delivery at that time went on to achieve a vaginal
delivery. Indeed, waiting at least four hours before performing a cesarean for labor arrest allowed 88 percent of multiparas and 56 percent of
nulliparas to achieve a vaginal delivery.
● The same investigators subsequently used a standardized protocol to manage 501 consecutive, term, spontaneously laboring women with
slow labor progress [45]. The protocol involved administration of oxytocin to achieve at least 200 MVUs for four hours before considering
cesarean delivery.
In this study, 80 percent of nulliparous women and 95 percent of multiparous women had a vaginal delivery, whether or not they were able to
achieve and/or maintain the MVU goal. Mean (5th percentile) rates of cervical dilation in nulliparas and multiparas were 1.4 cm/hour (0.5) and
1.8 cm/hour (0.5), respectively.
Prevention of first stage labor abnormalities — There is no strong evidence that any intervention will prevent first stage protraction and
arrest disorders.
● Amniotomy -- Amniotomy is the most common intervention that has been proposed for shortening the duration of labor. Routine amniotomy
alone versus intention to preserve the membranes (no amniotomy) did not clearly shorten the first or second stage in a meta-analysis of
randomized trials [74]. However, in another meta-analysis, the combination of early amniotomy and early oxytocin administration versus
routine care for women in spontaneous labor shortened the first stage (mean difference -1.57 hours, 95% CI -2.15 to -1.00), and possibly
resulted in a small decrease in cesarean delivery (RR 0.87, 95% CI 0.77-0.99) [61]. The potential small benefits of the combined intervention
are not sufficiently compelling to warrant a recommendation for a change in routine management of spontaneous labor. (See "Management
of normal labor and delivery", section on 'Amniotomy'.)
● Neuraxial anesthesia -- Avoiding or delaying neuraxial anesthesia to potentially reduce the risk of labor abnormalities is not recommended.
ACOG has stated that the decision to place a neuraxial anesthetic should depend upon the patient's wishes with consideration of factors,
such as parity, also taken into account [76]. In particular, concern about future labor progress should not be a reason to require a woman to
reach an arbitrary cervical dilation, such as 4 to 5 cm, before fulfilling her request to receive neuraxial anesthesia.
PROLONGED SECOND STAGE
Diagnosis — The appropriate duration and maximum length of time allowed for the second stage of labor is not clearly defined. Parity, regional
anesthesia, and delayed pushing in addition to other clinical considerations all significantly impact the length of the second stage.
We follow the 2014 Obstetric Care Consensus statement of recommendations for safe prevention of primary cesarean delivery by the American
College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine [77]. These recommendations are used as a pragmatic
approach for diagnosis of a prolonged second stage and are supported by the data from Zhang et al (table 1), which we believe is the best guide
for establishing the normal duration for the second stage of labor (median and 95th centile). The following is a summary of the
statement/recommendations [77]:
● For nulliparous women, allow three hours of pushing, and for multiparous women, allow two hours of pushing prior to diagnosing arrest of
labor, when maternal and fetal conditions permit
● Longer durations may be appropriate on an individual basis (eg, epidural anesthesia, fetal malposition) as long as progress is being
documented
● A specific absolute maximum length of time that should be allowed in the second stage of labor has not been identified
Based on these recommendation and those of a 2012 workshop (National Institute of Child Health and Human Development workshop Preventing
the First Cesarean Delivery) [59], many obstetric providers allow an extra hour of pushing for women with an epidural, and good outcomes have
been reported [78].
Of note, this statement does not provide specific criteria for the upper limit of the second stage; it merely states that arrest should not be
diagnosed before passage of a specific minimum period of time. It should also be noted that the use of these criteria has been challenged by
some experts, who believe that the safety of extending the second stage to these lengths, particularly in nulliparous women with an epidural, has
not been established [11,79].
Assessing progressive, but small, degrees of descent and rotation by physical examination is challenging. Additional physical findings can support
the diagnosis of arrest due to cephalopelvic disproportion. The soft bones and open sutures of the fetal skull (figure 6) allow it to change in shape
(ie, molding) and thus adapt to the maternal pelvis during descent. Some overlap of the parietal and occipital bones at the lambdoid sutures and
overlap of the parietal and frontal bones at the coronal sutures is common in normal labor [50]. However, lack of descent with severe molding,
especially overlap of the parietal bones at the sagittal suture, is suggestive of cephalopelvic disproportion. Likewise, lack of descent with
malposition or malpresentation is suggestive of cephalopelvic disproportion.
Management
Candidates for oxytocin augmentation — After 60 to 90 minutes of pushing, we begin oxytocin augmentation if descent is minimal (ie, <1
cm) or absent and uterine contractions are less frequent than every 3 minutes. In the second stage, we are more concerned about a possible
physical issue (eg, malposition or malpresentation, macrosomia, small maternal pelvis) slowing descent than hypocontractile uterine activity, which
is the prominent concern in the first stage. (See 'Hypocontractile uterine activity' above and 'Oxytocin augmentation' above.)
Timing of operative delivery — In the absence of epidural anesthesia, we allow nulliparous women to push for at least three hours and
multiparous women to push for at least two hours prior to considering operative intervention. We avoid operative delivery (vacuum, forceps,
cesarean) in the second stage as long as the fetus continues to descend and/or rotate to a more favorable position for vaginal delivery, and the
fetal heart rate pattern is not concerning. Prompt operative intervention is indicated for fetuses with category III fetal heart rate tracings,
regardless of labor progress. (See "Management of intrapartum category I, II, and III fetal heart rate tracings".)
In women who have epidural anesthesia, we allow an additional hour of pushing on a case-by-case basis before considering operative
intervention for a prolonged second stage. Extending the duration of the second stage to four hours in nulliparous women and three hours in
multiparous women with epidural anesthesia may increase the chance of achieving a vaginal delivery, without significantly increasing maternal or
neonatal morbidity, but evidence is limited to retrospective data [80] and a small randomized trial [78]. In the randomized trial of 78 nulliparous
women with epidural anesthesia who had not delivered three hours after reaching full cervical dilation, intention to extend labor by at least one
hour resulted in a lower cesarean rate compared with expediting delivery by an operative method (19.5 versus 43.2 percent, relative risk [RR]
0.45, 95% CI 0.22-0.93) [78]. However, the trial was underpowered to detect small but clinically important differences in the frequency of adverse
outcomes between groups or provide a precise estimate of cesarean rate. Importantly, the durations of the second stage for each group were not
significantly different, in part because 14 percent of the cohort crossed-over from their assigned group.
Whether to extend the duration of the second stage beyond four hours in nulliparous women and beyond three hours in multiparous women with
epidural anesthesia (or beyond three hours in nulliparous women and beyond two hours in multiparous women without epidural anesthesia) is
controversial, as a prolonged second stage has potential clinical challenges and consequences [21,81,82]:
● If a cesarean delivery is necessary, a prolonged second stage may result in the fetal head trapped deep in the pelvis, which increases the
difficulty of delivering the fetus. Reverse breech extraction may reduce the risk of a difficult delivery or injury to the uterine vessels (see
"Management of deeply engaged and floating fetal presentations at cesarean delivery", section on 'Preferred approach: Reverse breech
extraction ("pull method")').
A prolonged second stage may also further thin the lower uterine segment, increasing the risk of extension of the hysterotomy into the
uterine vessels at cesarean.
● Prolonging the second stage appears to increase the risk for postpartum hemorrhage and maternal infection.
● Prolonging the second stage may worsen neonatal outcome. (See 'Maternal and newborn outcomes associated with abnormal labors' below.)
The importance of clinical experience and judgment regarding management of the second stage of labor must be emphasized, particularly when
the duration of the second stage approaches or exceeds two to three hours. This can be a challenging clinical scenario where the risks of both
maternal and neonatal morbidity are increased. We only allow labor to continue if our judgment suggests safe vaginal delivery is achievable.
Numerous clinical factors need to be considered. Examples of these factors and how they may favor expectant management is illustrated below:
● Obstetric history – A previous vaginal delivery
● Medical/surgical history – No comorbidities likely to impact labor
● Clinical pelvimetry – Pelvis deemed adequate for vaginal delivery based on physical examination
● Maternal height and weight – Gravida is not short and/or obese
● Fetal position – Occiput anterior, minimal caput and molding
● Maternal temperature – Absence of temperature ≥38.0°C (102.2°F) (presumptive chorioamnionitis)
● Estimated fetal weight – Appropriate for gestational age
● Effectiveness of maternal pushing – Effective pushing, mother is not exhausted
● Fetal heart tracing – Category I tracing
● Woman's desire to proceed with labor
If the woman has not been pushing or not effectively pushing, then we factor that into consideration and are more likely to have her continue to
push. If the fetal station is still high, the estimated fetal weight is >4000 to 4500 g, chorioamnionitis is suspected, or significant decelerations are
present, we generally proceed with cesarean delivery. When the fetal heart rate tracing is reassuring and maternal pushing is resulting in
progressive descent, we discuss with the patient the options of an operative vaginal (if she is an appropriate candidate (see "Operative vaginal
delivery", section on 'Prerequisites')) or cesarean delivery versus continued pushing. In our experience, unless delivery occurs or appears to be
imminent within the next 30 to 45 minutes, we proceed with an operative delivery.
Ineffective management interventions
● Turning down the epidural – A dense motor block may impair a woman's ability to push, but there is no strong evidence that turning down
the neuraxial anesthetic in women with a prolonged second stage is beneficial. In a meta-analysis including five trials in which patients with
epidurals were randomly assigned to discontinuation late in labor or continuation until birth, early discontinuation did not clearly reduce
instrumental delivery (23 versus 28 percent, RR 0.84, 95% CI 0.61-1.15) or other adverse delivery outcomes [83]. (See "Adverse effects of
neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor'.)
● Changing maternal position – There is no strong evidence that a change in maternal position (eg, upright posture, lateral, or hands and
knees position instead of supine) is useful for treatment of a prolonged second stage [84-86]. Women should be encouraged to labor and
give birth in the position they find most comfortable.
● Fundal pressure – Manual fundal pressure does not significantly shorten the duration of the second stage, although available data are low
quality [87].
Prevention of prolonged second stage — There is no strong evidence that any intervention will prevent a prolonged second stage of labor.
The following interventions have been studied.
● Delayed pushing – In a 2017 meta-analysis of trials of pushing/bearing methods in women with epidural anesthesia, delayed pushing
decreased the duration of pushing by a mean of 19 minutes but increased the duration of the second stage by a mean of 56 minutes
compared with immediate pushing [88]. Delayed pushing was also associated with a small increase in spontaneous vaginal delivery (for
nulliparas: 76 versus 71 percent, RR 1.07, 95% CI 1.02-1.11; 12 studies, 3114 women). Although the frequency of low umbilical cord blood
pH was increased (4.5 versus 2.0 percent, RR 2.24, 95% CI 1.37-3.68), no differences were observed in rates of admission to neonatal
intensive care or five-minute Apgar score less than 7.
● Maternal position and technique do not appear to affect the length of the second stage. (See "Management of normal labor and delivery",
section on 'Pushing position and technique'.)
● Role of exercise:
• Pelvic floor muscle exercises – Training the muscles of the pelvic floor may prevent some cases of prolonged second stage. One trial
randomly assigned 301 healthy nulliparous women to an antepartum pelvic floor muscle training program or usual care from 20 to 36
weeks of gestation [89]. Women in the intervention group trained with a physiotherapist for one hour/week and were encouraged to
perform 8 to 12 intensive pelvic floor muscle contractions twice daily. Women in the exercise group were less likely to have a second
stage over 60 minutes than controls (21 versus 34 percent), but the overall duration of the second stage was similar for both groups (40
and 45 minutes, respectively), as was the rate of instrumental delivery (15 and 17 percent, respectively).
• Exercise – Exercise during pregnancy improves fitness, but does not affect the length of labor. In two trials, women randomly assigned to
participation in an aerobic exercise program during pregnancy had the same overall duration of labor as women who received standard
prenatal care [90,91]. Although the smaller trial (n = 91 women) observed a reduction in primary cesarean delivery in the exercise group
[90], the larger trial (n = 855 women) found no difference in labor outcomes [91].
In addition, it should be noted that women who are not able to push because of a spinal cord injury tend to have a normal, or even short,
second stage [92].
MATERNAL AND NEWBORN OUTCOMES ASSOCIATED WITH ABNORMAL LABORS — For the mother, first and second stage protraction
disorders have been associated with increased risks for operative vaginal delivery, third-/fourth-degree perineal lacerations, cesarean delivery,
urinary retention, postpartum hemorrhage, and chorioamnionitis in observational studies [2,33,93-100]. A prolonged second stage has also been
associated with pelvic floor injury, but this is likely related to instrumental intervention rather than the specific length of the second stage
[21,82,96,97,101,102].
For the neonate, a protracted first stage of labor has been associated with increased risks for admission to the neonatal intensive care unit and
five-minute Apgar score <7, but no increased risk for serious morbidity or mortality. In contrast, in many but not all studies, a prolonged second
stage has been associated with a small absolute increase in serious neonatal morbidity (seizures, hypoxic-ischemic encephalopathy, sepsis) and
mortality [12,79,95,97,99,103]. In one such study, the rate of birth asphyxia-related complications progressively increased with duration of second
stage: from 0.42 percent for second stage <1 hour to 1.29 percent when ≥4 hours (adjusted RR 2.46, 95% CI 1.66-3.66) [103].
However, a prolonged second stage itself may not be the causal factor for these adverse outcomes; factors such as persistent malposition or
macrosomia may both prolong the second stage and increase maternal and/or neonatal morbidity. It remains unclear whether performing a
cesarean delivery late in the second stage of labor would reduce the risk of adverse outcomes compared with continued labor. As discussed
above, a small randomized trial of nulliparous women with a prolonged second stage found no difference in the rates of maternal and neonatal
complications when labor was extended for at least one hour versus expedited operative delivery, but the trial was underpowered to detect small
differences in these outcomes [78].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Labor".)
SUMMARY AND RECOMMENDATIONS
● The Friedman curve (figure 1) and the norms established from Friedman's data historically had been widely accepted as the standard for
assessment of normal labor progression. However, Zhang and others have proposed a contemporary curve (figure 2) and norms (table 1)
that are different and slower from those cited by Friedman. (See 'Friedman (historic) criteria' above and 'Contemporary criteria' above.)
● Labor abnormalities may be related to hypocontractile uterine activity, neuraxial anesthesia, obesity, and/or absolute or relative obstruction
due to factors such as fetal size/position, Bandl’s ring, or a small maternal bony pelvis. (See 'Risk factors' above.)
● The normal duration of the latent phase tends to be longer in induced labors than spontaneous labors, but the active phase and second
stage have similar durations whether labor is spontaneous or induced. (See 'Normal progression in induced labors' above.)
First stage
● The diagnosis of a protracted active phase is made in women at ≥6 cm dilation who are dilating less than about 1 to 2 cm/hour, which reflects
the 95th centile. Slow cervical dilation before 6 cm reflects the shallow slope of the latent phase portion of the normal labor curve. (See 'First
stage' above and 'Protraction' above.)
● The diagnosis of active phase arrest is made in women at ≥6 cm cervical dilation with ruptured membranes and either no cervical change for
≥4 hours despite adequate contractions or no cervical change for ≥6 hours with inadequate contractions. (See 'Arrest' above.)
● For women (nulliparous or multiparous) in the active phase who dilate ≤1 cm over two hours, we administer oxytocin and proceed with
amniotomy if there has been adequate fetal descent, except when the head is high and not well applied to the cervix. In these cases, we
begin oxytocin but delay performing amniotomy. If oxytocin alone for four to six hours does not result in adequate progress, we consider
performing an amniotomy at that time. A controlled amniotomy is performed if the head is still high and not well applied to the cervix. (See
'Dilation ≤1 cm over two hours in active phase' above.)
● We use a high-dose oxytocin regimen (table 3) regardless of parity, except in women who have had a previous cesarean delivery. (See
'Dosing regimen' above.)
● In pregnancies with reassuring maternal and fetal status, if there has been no cervical change after four hours of adequate (>200
Montevideo units) uterine contractions or six hours without adequate uterine contractions in the active phase, we proceed with cesarean
delivery. If labor is progressing, either slowly or normally, we continue oxytocin at the dosage required to maintain an adequate uterine
contraction pattern. (See 'Oxytocin augmentation' above.)
Second stage
● Parity, regional anesthesia, delayed pushing, and other clinical factors significantly impact the length of the second stage. A pragmatic
approach is to diagnose a prolonged second stage when a nulliparous woman without epidural anesthesia has pushed for three hours or a
multiparous women without epidural anesthesia has pushed for two hours; an additional hour is added for women with epidural anesthesia.
(See 'Diagnosis' above.)
● For women in the second stage with minimal (ie, <1 cm) or absent descent after 60 to 90 minutes of pushing and uterine contractions less
frequent than every 3 minutes, we begin oxytocin augmentation. In the second stage, we are more concerned about a possible physical issue
(eg, malposition or malpresentation, macrosomia, small maternal pelvis) slowing descent than hypocontractile uterine activity. (See
'Candidates for oxytocin augmentation' above.)
● In the absence of epidural anesthesia, we allow nulliparous women to push for at least three hours and multiparous women to push for at
least two hours prior to considering operative intervention. We avoid operative delivery (vacuum, forceps, cesarean) in the second stage as
long as the fetus continues to descend and/or rotate to a more favorable position for vaginal delivery, and the fetal heart rate pattern is not
concerning. In women who have epidural anesthesia, we allow an additional hour of pushing on a case-by-case basis before considering
operative intervention for a prolonged second stage. Prompt operative intervention is indicated for fetuses with category III fetal heart rate
tracings, regardless of labor progress. (See 'Timing of operative delivery' above.)
● Whether to extend the duration of the second stage beyond four hours in nulliparous women and beyond three hours in multiparous women
with epidural anesthesia (or beyond three hours in nulliparous women and beyond two hours in multiparous women without epidural
anesthesia) is controversial as a prolonged second stage has potential clinical challenges and adverse consequences. We only allow labor
to continue if our judgement suggests safe vaginal delivery is achievable. (See 'Timing of operative delivery' above and 'Maternal and
newborn outcomes associated with abnormal labors' above.)
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72. Vogel JP, West HM, Dowswell T. Titrated oral misoprostol for augmenting labour to improve maternal and neonatal outcomes. Cochrane
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73. Bloom SL, McIntire DD, Kelly MA, et al. Lack of effect of walking on labor and delivery. N Engl J Med 1998; 339:76.
74. Smyth RM, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2013; :CD006167.
75. Blanch G, Lavender T, Walkinshaw S, Alfirevic Z. Dysfunctional labour: a randomised trial. Br J Obstet Gynaecol 1998; 105:117.
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77. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention
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78. Gimovsky AC, Berghella V. Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines. Am J Obstet
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79. Leveno KJ, Nelson DB, McIntire DD. Second-stage labor: how long is too long? Am J Obstet Gynecol 2016; 214:484.
80. Grantz KL, Sundaram R, Ma L, et al. Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal
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81. Sung JF, Daniels KI, Brodzinsky L, et al. Cesarean delivery outcomes after a prolonged second stage of labor. Am J Obstet Gynecol 2007;
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82. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal
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83. Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Discontinuation of epidural analgesia late in labour for reducing the adverse
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84. Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database Syst
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85. Roberts CL, Algert CS, Cameron CA, Torvaldsen S. A meta-analysis of upright positions in the second stage to reduce instrumental
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86. Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane
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87. Hofmeyr GJ, Vogel JP, Cuthbert A, Singata M. Fundal pressure during the second stage of labour. Cochrane Database Syst Rev 2017;
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88. Lemos A, Amorim MM, Dornelas de Andrade A, et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database
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91. Salvesen KÅ, Stafne SN, Eggebø TM, Mørkved S. Does regular exercise in pregnancy influence duration of labor? A secondary analysis of
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93. Stephansson O, Sandström A, Petersson G, et al. Prolonged second stage of labour, maternal infectious disease, urinary retention and
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94. Cheng YW, Shaffer BL, Bryant AS, Caughey AB. Length of the first stage of labor and associated perinatal outcomes in nulliparous women.
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Topic 4464 Version 84.0
GRAPHICS
Friedman labor curve
First stage = A + B + C + D, w here A = latent phase, B = acceleration phase, C =

phase of maximum slope, and D = deceleration phase.
Second stage = E.
Data from: Friedman EA. Labor: Clinical evaluation and management, 2nd ed, Appleton-
Century-Crofts, New York 1978.
Graphic 53413 Version 4.0
Contemporary estimates of median and 95th percentile in hours by parity
Parity 0 Parity 1
Median number of hours Median number of hours
(95 th percentile) (95 th percentile)
Change in cervix
From 4 cm to 5 cm 1.3 (6.4) 1.4 (7.3)
From 5 cm to 6 cm 0.8 (3.2) 0.8 (3.4)
From 6 cm to 7 cm 0.6 (2.2) 0.5 (1.9)
From 7 cm to 8 cm 0.5 (1.6) 0.4 (1.3)
From 8 cm to 9 cm 0.5 (1.4) 0.3 (1.0)
From 9 cm to 10 cm 0.5 (1.8) 0.3 (0.9)
Duration of second stage
Second stage with epidural analgesia 1.1 (3.6) 0.4 (2.0)
Second stage without epidural analgesia 0.6 (2.8) 0.2 (1.3)
th
Note the 95 percentile for duration of time to dilate from 4 to 6 cm is almost 10 hours in nulliparous w omen.
Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010;
116:1281.
Contemporary labor curves by parity
Average labor curves by parity in singleton term pregnancies w ith spontaneous

onset of labor, vaginal delivery, and normal neonatal outcomes. Note that for
parous w omen the inflection point for acceleration of cervical dilation is at about 6
cm and that there is no clear inflection point for nulliparous w omen.
Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous
labor with normal neonatal outcomes. Obstet Gynecol 2010; 116:1281.
Contemporary estimates of labor duration by dilation at admission
The 95 th percentiles of cumulative duration of labor from admission among singleton

term nulliparous w omen w ith spontaneous onset of labor, vaginal delivery, and normal
neonatal outcomes. Colors represent cervical dilation w hen w omen w ere admitted to
the labor unit: green (5 cm), yellow (4 cm), blue (3 cm), red (2 cm).
Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor
with normal neonatal outcomes. Obstet Gynecol 2010; 116:1281.
Angle of progression
The angle of progression is the angle betw een a straight line draw n along the
longitudinal axis of the pubic bone and a line draw n from at the inferior edge of the
pubic bone to the leading edge of the fetal cranium.
Data from: Kalache KD, Dückelmann AM, Michaelis SA, et al. Transperineal ultrasound
imaging in prolonged second stage of labor with occipitoanterior presenting fetuses: how well
does the 'angle of progression' predict the mode of delivery? Ultrasound Obstet Gynecol
2009; 33:326.
Factors that have been associated with abnormal labor progress
Hypocontractile uterine activity
Older maternal age
Long cervical length at midpregnancy
Pregnancy complications
Nonreassuring fetal heart rate pattern
Bandl's ring
Neuraxial anesthesia
Macrosomia
Pelvic contraction
Non-occiput anterior position
Nulliparity
Short stature (less than 150 cm)
High station at full dilatation
C horioamnionitis
Postterm pregnancy
Obesity
Fetal anomaly resulting in cephalopelvic dystocia
Uterine abnormality
Data from: American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. Dystocia and augmentation of labor. ACOG Practice
Bulletin #49. Obstet Gynecol 2003; 102:1445.
Cardiotocography showing calculation of Montevideo units
Montevideo units are calculated by subtracting the baseline uterine pressure from the peak
contraction pressure of each contraction (arrow s) in a 10-minute w indow and adding the pressures
generated by each contraction.
FHR: fetal heart rate; bpm: beats per minute; mmHg: millimeters of mercury; kPa: kilopascals; UA: uterine
activity.
Examples of oxytocin infusion protocols
Starting dose, Dosage interval,

Regimen Incremental increase, milliunits/minute
milliunits/minute minutes
Low-dose 0.5 to 1 1 30 to 40
Alternative low-dose 1 to 2 1 to 2 15 to 30
High-dose 6 6 15 to 40
The incremental increase should be reduced to 3
milliunits/minute if hyperstimulation is present, and
reduced to 1 milliunit/minute if recurrent
hyperstimulation.
Some clinicians limit to a maximum cumulative dose of 10

units and a maximum duration of six hours.
Alternative high-dose 4 4 15
Oxytocin should be administered by trained personnel w ho are familiar w ith its effects. It should be administered using an infusion pump
that provides precise flow rate to ensure accurate minute to minute control. Most clinicians w ill not administer more than 40 milliunits/minute
as the maximum dose.
Sample oxytocin infusion protocols courtesy of author with additional information from ACOG Committee on Practice Bulletins -- Obstetrics, ACOG Practice
Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009; 114:386 (reaffirmed 2015).
Fetal head at term showing fontanelles, sutures, and biparietal

diameter
The anterior fontanelle is diamond shaped, at the intersection of four fetal skull
bones, and usually the larger fontanelle, w hereas the posterior fontanelle is
triangular, at the intersection of three fetal skull bones, and usually the smaller
fontanelle.
Contributor Disclosures
Robert M Ehsanipoor, MD Nothing to disclose Andrew J Satin, MD, FACOG Nothing to disclose Vincenzo Berghella, MD Nothing to
disclose Vanessa A Barss, MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-
level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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13/9/2018 Normal and abnormal labor progression - UpToDate

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Normal and abnormal labor progression

Authors: Robert M Ehsanipoor, MD, Andrew J Satin, MD, FACOG

● Second stage – Time from complete cervical dilation to fetal expulsion.

● Third stage – Time between fetal expulsion and placental expulsion.

ASSESSMENT OF LABOR PROGRESS

● At two- to four-hour intervals in the first stage

● Prior to administering analgesia/anesthesia

● At one- to two-hour intervals in the second stage

OVERVIEW OF PROTRACTION AND ARREST DISORDERS

FIRST STAGE PROTRACTION AND ARREST

● No cervical change for ≥6 hours with inadequate contractions

● Resulted in similar maternal and neonatal morbidities

Ineffective and less well studied approaches

PROLONGED SECOND STAGE

● Obstetric history – A previous vaginal delivery

● Medical/surgical history – No comorbidities likely to impact labor

● Maternal height and weight – Gravida is not short and/or obese

● Fetal position – Occiput anterior, minimal caput and molding

● Maternal temperature – Absence of temperature ≥38.0°C (102.2°F) (presumptive chorioamnionitis)

● Estimated fetal weight – Appropriate for gestational age

● Effectiveness of maternal pushing – Effective pushing, mother is not exhausted

● Fetal heart tracing – Category I tracing

● Woman's desire to proceed with labor

Ineffective management interventions

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 4464 Version 84.0

Friedman labor curve

First stage = A + B + C + D, w here A = latent phase, B = acceleration phase, C =

Graphic 53413 Version 4.0

Contemporary estimates of median and 95th percentile in hours by parity

From 4 cm to 5 cm 1.3 (6.4) 1.4 (7.3)

From 5 cm to 6 cm 0.8 (3.2) 0.8 (3.4)

From 6 cm to 7 cm 0.6 (2.2) 0.5 (1.9)

From 7 cm to 8 cm 0.5 (1.6) 0.4 (1.3)

From 8 cm to 9 cm 0.5 (1.4) 0.3 (1.0)

From 9 cm to 10 cm 0.5 (1.8) 0.3 (0.9)

Duration of second stage

Second stage with epidural analgesia 1.1 (3.6) 0.4 (2.0)

Second stage without epidural analgesia 0.6 (2.8) 0.2 (1.3)

Graphic 69170 Version 14.0

Contemporary labor curves by parity

Average labor curves by parity in singleton term pregnancies w ith spontaneous

Graphic 89190 Version 5.0

Contemporary estimates of labor duration by dilation at admission

The 95 th percentiles of cumulative duration of labor from admission among singleton

Graphic 89191 Version 4.0

Graphic 110927 Version 1.0

Factors that have been associated with abnormal labor progress

Hypocontractile uterine activity

Older maternal age

Long cervical length at midpregnancy

Nonreassuring fetal heart rate pattern

Non-occiput anterior position

Short stature (less than 150 cm)

High station at full dilatation

Fetal anomaly resulting in cephalopelvic dystocia

Graphic 66586 Version 5.0

Cardiotocography showing calculation of Montevideo units

Graphic 57354 Version 6.0

Examples of oxytocin infusion protocols