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CLINICAL PRACTICE GUIDELINE

NUMBER 8
JANUARY 2024

(REPLACES OBSTETRIC CARE CONSENSUS 1, MARCH 2014)

First and Second Stage Labor Management

Committee on Clinical Practice Guidelines—Obstetrics. This Clinical Practice Guideline was developed by the
ACOG Committee on Clinical Practice Guidelines–Obstetrics in collaboration with Alison G. Cahill, MD, MSCI; Nandini Ra-ghuraman,
MD, MSCI; and Manisha Gandhi, MD; with consultation from Anjali J. Kaimal, MD, MAS.
The Society for Maternal-Fetal Medicine (SMFM) supports this document.

PURPOSE: The purpose of this document is to define labor and labor arrest and provide recommendations for the
management of dystocia in the first and second stages of labor and labor arrest.

TARGET POPULATION: Pregnant individuals in the first or second stage of labor.

METHODS: This guideline was developed using an a priori protocol in conjunction with a writing team consisting of
one maternal–fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines–
Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature
search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE,
PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were evaluated by the writing team
based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified
GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework
was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS: This Clinical Practice Guideline includes definitions of labor and labor arrest, along with
recommendations for the management of dystocia in the first and second stages of labor and labor arrest.
Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to
provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

INTRODUCTION rate continues to rise, and reducing the number of Caesar-

In 2022, there were more than 3.66 million births in the ean deliveries is a priority in the United States (3). in
United States, the vast majority of which were a result of 2022, 32.2% of all births in the United States were cesar-ean
spontaneous or induced labor (1). The most common deliveries (1). Although cesarean delivery can be
indication for primary cesarean delivery is labor dystocia lifesaving for the fetus, the mother, or both in certain
(2). Worldwide, the projected average will cease delivery cases, the rapid increase in the rate of cesarean births

The American College of Obstetriciansand Gynecologists (ACOG) reviewsits publications regularly; however, its publications do not reflect the most may
recent evidence. A reaffirmation date is included in the online version of a document to indicate when it last reviewed. The current status and was any

Canyon
Updates of this document be found ACOG Clinical at acog.org/lot.

This information is designed voluntary. as an care,educational resource

use inclusive to aidtreatments
of all proper clinicians inmethods
providingofobstetric
statementand
of gynecologic
the standardand
of of this information is
This information should not be consideredas or care or as a It is not intended to substitute

care. mayfor
in the
the independent professional
reasonable judgment judgment
of the treating of the treating
clinician, suchclinician.
of actionVariations
is indicated
in by the condition
practice of the patient,
be warranted when, limitations of available resources,
course

advances in knowledge or or technology.

While ACOG makes efforts to present

everyaccurate and reliable
anything implied.information, this publication is provided “as is” without warranty of accuracy, reliability,
or otherwise, either express or ACOG does not guarantee, warrant, endorse the products services of firm, organization, or any person.

Neither ACOG officers, its nor including direct, or any

directors, members, employees, liable loss, damage, claim with
orrespect
anywill
agents information
to liabilities,
be presented. for

special, indirect, or consequential damages, incurred in connection with this publication reliance or on the

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since 1996, without evidence of concomitant decreases in maternal or

neonatal morbidity or mortality, raises significant concerns about STRENGTH OF RECOMMENDATION
contemporary cesarean delivery rates (4). Childbirth by its very nature STRONG
carries potential risks for the pregnant individual and the newborn, regard- ACOG recommends
less of the route of delivery. For certain clinical conditions—such as benefits clearly outweigh harms and burdens. Most patients
placenta previa or uterine rupture—cesarean delivery is firmly established should receive the intervention.
as the safest route of delivery. However, for most low-risk pregnancies,
cesarean delivery appears to pose greater risk of maternal morbidity ACOG recommends against Harms
and mortality than vaginal delivery, and labor dystocia is the predominant and burdens clearly outweigh the benefits. Most patients
driver for this intervention (5). This guideline provides definitions for should not receive the intervention.
labor arrest, along with recommendations for management of dystocia in CONDITIONAL
the first and second stages of labor that may help optimize labor ACOG suggests
management and assist with assessment of indication for cesarean The balance of benefits and risks will vary depending on
delivery for labor dystocia. patient characteristics and their values and preferences.
Individualized, shared decision making is recommended to help
patients decide on the best course of action for them.

SUMMARY OF RECOMMENDATIONS QUALITY OF EVIDENCE

HIGH
Labor and Labor Arrest
Randomized controlled trials, systematic reviews, and meta-
ACOG recommends that cervical dilation of 6 cm be considered the start
analyses without serious methodological flaws or limitations
of the active phase of labor. (STRONG
(eg, inconsistency, imprecision, confounding variables)
RECOMMENDATION, MODERATE-QUALITY EVIDENCE)

active
ACOG suggests that be defined phase
as no arrest
progression of labor
in cervical dilation in Very strong evidence from observational studies without
patients who are at least 6-cm dilated with rupture of membranes despite serious methodological flaws or limitations. There is high
4 hours of adequate uterine activity or 6 hours of inadequate uterine confidence in the accuracy of the findings and further research
activity with oxytocin augmentation. is unlikely to change this.

(CONDITIONAL RECOMMENDATION, LOW-QUALITY EVIDENCE) MODERATE YOURSELF

ACOG recommends that be Randomized controlled trials with some limitations

second of prolonged stage
work defined as more than 3 hours of pushing in nulliparous individuals Strong evidence from observational studies without serious

and 2 hours of pushing in multip-arous individuals. An individualized methodological flaws or limitations

approach should be used to diagnose second-stage arrest; incorporating LOW
information regarding progress, clinical factors that may affect the Randomized controlled trials with serious flaws Some evidence
likelihood of vaginal delivery, discussion of risks and benefits of available from observational studies
interventions, and individual patient preference is recommended when VERY LOW
time in the second stage is extended beyond these parameters.
Unsystematic clinical observations
Very indirect evidence from observational studies

(STRONG RECOMMENDATION, HIGH-QUALITY EVIDENCE)

GOOD PRACTICE POINTS
Arrest in the second stage can be identified earlier if there is lack of fetal
Ungraded Good Practice Points are incorporated when clinical guidance
rotation or descent despite adequate contractions, pushing efforts, and
is deemed necessary in the case of extremely limited or nonexistent
time. (GOOD PRACTICE POINT)
evidence. They are based on expert opinion as well as review of
ACOG recommends that neuraxial anesthesia be offered for pain relief the available evidence.
during any stage of labor. (STRONG RECOMM-
MENDATION, MODERATE-QUALITY EVIDENCE)

VOL. 143, NO. 1, JANUARY 2024 CPG First and Second Stage Labor 145

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Management of Dystocia in the First Stage Trials, EMBASE, PubMed, and MEDLINE. Parameters for
of Labor the search included human-only studies published in
English. The search was restricted to studies since 2000
ACOG recommends amniotomy for patients undergoing
to 2020. The MeSH terms and keywords used to guide
augmentation or induction of labor to reduce the duration of
the literature search can be found in Appendix A
work. (STRONG RECOMMENDATION, HIGH-QUALITY EVIDENCE)
(available online at http://links.lww.com/AOG/D485). An
ACOG recommends either low-dose or high-dose oxyto-cin strategies updated literature search was completed in November
as reasonable approaches to the active 2021 and was reviewed by the writing team using the
management of labor to reduce operative deliveries. same systematic process as the original literature
(STRONG RECOMMENDATION, HIGH-QUALITY EVIDENCE) search. A final supplemental literature search was per-formed in July
2023 to ensure that any newly published
ACOG recommends using intrauterine pressure catheters
high-level sources were addressed in the final
among patients with ruptured membranes to determine
manuscript.
adequacy of uterine contractions in those with protracted
active labor or when contractions cannot be accurately Study Selection
externally monitored. (STRONG RECOMMENDATION, LOW-QUALITY
A title and abstract screen of all studies was completed by
EVIDENCE)
ACOG research staff. Studies that moved forward to the full-text
Management of Dystocia in the Second screening stage were evaluated by the writing team
Stage of Labor based on standardized inclusion and exclusion criteria. To
be considered for inclusion, studies had to be conducted in
ACOG recommends that pushing begin when
countries ranked very high on the United Nations Human
complete cervical dilation is achieved. (STRONG RECOMM-
Development Index (7), published in English, and include
MENDATION, HIGH-QUALITY EVIDENCE)
participants identified as female or women. Although systematic
Management of Labor Arrest reviews, randomized controlled trials, and observational studies were
prioritized, case reports, case series,
ACOG recommends that cesarean delivery be performed in patients
and narrative reviews were considered for topics with limited evidence.
with active phase arrest of labor.
A PRISMA (Preferred Reporting Items for
(STRONG RECOMMENDATION, LOW-QUALITY EVIDENCE)
Systematic Reviews and Meta-Analyses) flow diagram of
ACOG suggests assessment for operative vaginal deliv-ery before the included and excluded studies can be found in Appen-dix B
performing cesarean delivery for second-stage arrest. (CONDITIONAL (available online at http://links.lww.com/AOG/D486).
RECOMMENDATION, LOW- All studies that underwent quality assessment had key
QUALITY EVIDENCE) details extracted (study design, sample size, details of inter-ventions,
outcomes) and descriptions included in the summary evidence tables
(Appendix C, available online at
METHODS http://links.lww.com/AOG/D487).

ACOG Clinical Practice Guidelines provide clinical Recommendation and

management recommendations for a condition or
Manuscript Development
procedure by assessing the benefits and harms of
care options through a systematic review of the A modified GRADE (Grading of Recommendations
evidence. This guideline was developed using an a Assessment, Development, and Evaluation) evidence-to-decision
priori protocol in conjunction with a writing team framework was applied to interpret and translate
consisting of one maternal–fetal medicine sub-specialist appointed by the evidence into draft recommendation statements,
the ACOG Committee on Clin-ical Practice Guidelines–Obstetrics and which were classified by strength and evidence quality
two external (8, 9). Ungraded Good Practice Points were incorporated
subject matter experts. A full description of the Clinical to provide clinical guidance in the case of extremely
Practice Guideline methodology is published separately (6). The limited or nonexistent evidence. They are based on
following description is specific to this expert opinion as well as review of the available evidence
Clinical Practice Guideline. (10). The recommendations and supporting evidence
Literature Search tables then were reviewed, revised as appropriate, and
affirmed by the Committee on Clinical Practice
ACOG medical librarians completed a comprehensive Guidelines–Obstetrics at a meeting. The guideline man-uscript then
literature search for primary literature within the Cochrane was written and subsequently reviewed and
Library, Cochrane Collaboration Registry of Controlled approved by the Committee on Clinical Practice

146 CPG First and Second Stage Labor OBSTETRICS & GYNECOLOGY

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Guidelines–Obstetrics and other internal review bodies

Friedman Compared With Zhang Labor Curves
before continuing to publication. In the 1950s, Dr. Emanuel Friedman pioneered one of
the first objective and graphical descriptions of labor
Use of Language progression (13, 14). By creating cervical dilation time
ACOG recognizes and supports the gender diversity of graphs in at-term patients admitted in spontaneous
all patients who seek obstetric and gynecologic care. in labor, Friedman and colleagues described a sigmoid
original portions of this document, the authors seek to pattern to labor progression, with distinct divisions of
use gender-inclusive language or gender-neutral language. When the first stage, including latent, active, and deceleration
describing research findings, this document uses gender terminology phases. Using these data, the 95th percentile of latent
reported by the phase duration was 20 hours in nulliparous patients and
investigators. ACOG's policy on inclusive language can 14 hours in multiparous patients (13–15). The transition
be reviewed at https://www.acog.org/clinical-informa-tion/policy-and- from latent to active phase was thought to occur at
position-statements/statements-of-pol- icy/2022/inclusive-language. approximately 4 cm cervical dilation. Friedman
observed that the 95th percentile rate of active phase
cervical dilation ranged from 1.2 cm/hour in nulliparous
patients to 1.5 cm/hour in multiparous patients (13–15).
CLINICAL OVERVIEW The deceleration phase was thought to be a slower rate
Evidence-based labor management is a crucial step in of cervical change proximal to the end of the first stage
the efforts to achieve safe vaginal delivery, because labor of labor.
arrest is the most common indication for cesarean The 2010 data published by Zhang et al from the
delivery in the United States, accounting for approximately one-third of Consortium on Safe Labor have been used to refine the
all cesarean deliveries (11). Ideal definition of normal labor progress (16). In this retro-spective study
labor-management strategies should optimize the likeli-hood of vaginal conducted at 19 hospitals in the United
delivery and minimize both maternal and States, the duration of labor was analyzed in 62,415
neonatal morbidity while also addressing patient preferences and parturients, each of whom delivered a singleton vertex
values through a shared decision-making neonate vaginally and had a normal perinatal outcome.
process. In the Consortium on Safe Labor study, the latent phase
of labor had a wide range of duration that was dependent on cervical
examination at admission and parity,
CLINICAL RECOMMENDATIONS AND suggesting that a normal latent phase may have wide
EVIDENCE SUMMARY variation. Additionally, the 95th percentile rate of active-phase dilation
Labor and Labor Arrest Definitions was substantially slower than the standard rate derived from Friedman.
From 4cm to 6cm,
Normal Work
nulliparous and multiparous patients dilated at a similar
The onset labor
of is traditionally defined as the presence of
rate. Beyond 6 cm, multiparous individuals dilated more
regular and painful uterine contractions resulting in cervical dilation or
rapidly than nulliparous individuals. The transition to the
effacement or both. However,
active phase of labor was achieved at 6 cm compared
there is heterogeneity in how labor onset is defined in with the Friedman definition of 4 cm. The Consortium on
the literature; retrospective studies often use hospital
Safe Labor data did not show a deceleration phase at
admission or initial cervical examination as the starting
the end of the first stage of labor. Table 1 summarizes
point, which may underestimate the duration of early
differences between the Friedman and Zhang work
labor (12). curves.
The first of labor stage is defined as the interval
Since the publication of the Consortium on Safe Labor
between the onset of labor and complete or 10 cm cer-vical dilation.
data, additional studies have demonstrated that work
The first stage is further divided into two
curves may be affected by maternal obesity, maternal
phases: latent and active. The is latent phase of labor
hypertension, age, induction of labor, gestational age,
characterized by gradual and relatively slower cervical
multiple gestations, presence of fetal anomalies, fetal
dilation that starts on perception of regular uterine contractions and
size, and fetal sex (17–25).
ends when rapid cervical change initiates.
This phase of rapid cervical change is terminated and continues active Latent Labor
phase of labor until complete cervical The normal latent phase of labor varies widely among
second
dilation. The begins of labor stage
at 10 individuals, regardless of parity. Labor may take more
cm cervical dilation and ends on delivery of the neonate. than 6 hours to progress from 4 cm to 5 cm of dilation
The isthird of laborbetween
the period stage delivery of and more than 3 hours to progress from 5 cm to 6 cm
the neonate and delivery of the placenta. of dilation (26). Using Consortium on Safe Labor

VOL. 143, NO. 1, JANUARY 2024 CPG First and Second Stage Labor 147

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Table 1. Comparison of Friedman and Zhang Labor Curves

Friedman et al (1950s) 1,000 Zhang et al (2010)

Cohort parturients at term 62,415 parturients at term
Single center, United States Multicenter, United States

95th percentile of latent phase Nulliparous individuals: 20 h Nulliparous individuals: 4.5–15.7 h*

Multiparous individuals: 2 p.m. Multiparous individuals: not defined Dilation
Transition from latent to active Dilation greater than 1 cm/h until 3–4 cm less than 1 cm/h until 6 cm
phase 95th
percentile for rate of cervical Nulliparous individuals: 1.2 cm/h Nulliparous individuals: 0.5–0.7 cm/h*
dilation in active phase 2nd Multiparous individuals: 1.5 cm/h Multiparous individuals: 0.5–1.3 cm/h*
stage
duration Nulliparous individuals: 0.9560.8 h Nulliparous individuals: 1.1 (3.6) h with epidural, 0.6 (2.8) h
without epidural without epidural Multiparous
Multiparous individuals: individuals: 0.3 (1.6)y to 0.4 (2.0)z h with epidural, 0.1 (1.1)y
0.2960.01 h without epidural to 0.2 (1.3)z h without epidural Data are mean6SD or
median
(95th percentile) unless otherwise specified.
*Depending on cervical examination on admission.
Parity 1.
and

z
Parity 2 or more.
Data from: Friedman E. The graphic analysis of labor. Am J Obstet Gynecol 1954;68:1568–75. doi: 10.1016/0002-9378(5490311-7);
and Friedman EA. Primimigravid labor; a graphicostatistical analysis. Obstet Gynecol 1955;6:567–89. doi: 10.1097/00006250-195512000-
00001; and Friedman EA, Sachtleben MR. Amniotomy and the course of labor. Obstet Gynecol 1963;22:755–70; and Friedman EA.
An objective approach to the diagnosis and management of abnormal labor. Bull NY Acad Med 1972;48:842–58 and Zhang J, Landy
HJ, Ware Branch D, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labor with normal neonatal
outcomes. Obstet Gynecol 2010;116:1281–7. doi:10.1097/AOG.0b013e3181fdef6e

norms, the median latent-phase duration in nulliparous patients ranges evidence-based definition for latent phase arrest.
anywhere from 0.6 to 6.0 hours based on the initial cervical examination Thus, cesarean delivery performed for a prolonged latent phase in the
findings. The most conservative estimate for the 95th percentile for setting of reassuring maternal and fetal status should be avoided. Among
duration between admission and active phase (ie, the latent phase) in patients undergoing induction of labor, “failed induction of labor” should
nulliparous patients is 16 hours. be the preferred terminology when there is no progression in latent phase
(see “Induced Labor” section).
Hence, a mayprolonged
be definedlatent
as longer
phasethan 16 hours. Although some have
suggested that abnormal phases of labor could be defined as lengths
associated with increased risk of morbidity rather than greater than the
90th–95th percentile in duration (27, 28), no suggested definitions have Active Labor
been published relative to the latent phase. Some data indicate that
ACOG recommends that cervical dilation of 6 cm be considered the
there may be differences by parity in the rate of dilation before 6 cm (29),
start of the active phase of labor. (STRONG RECOMMENDATION,
but generally, consider-ation of latent-phase length has not been
MODERATE-
stratified by parity. Although a prolonged first stage of labor is associated
QUALITY EVIDENCE)
with adverse maternal and neonatal out-
Based on the 2010 Zhang labor curve, the inflection point at which latent
labor transitions to active labor is at approximately 6 cm dilation (16, 26).
Although this reflects an average starting point, there may be a range of
comes (29–32), it is important to note that most pregnant individuals dilation between 4 cm and 6 cm at which the rate of cervical change
with prolonged latent phase will ultimately enter the active phase with rapidly increases. However, standards of active-phase management and
expectant management. With few exceptions, the remainder either will active-phase arrest should not be applied until at least 6 cm dilation.
cease contracting or, with amniotomy or oxytocin (or both), achieve the
active phase (33). There is no

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Active Phase Protraction and Arrest Disorder those who had not progressed despite 4 hours of oxyto-cin (and in whom
oxytocin was continued at the judgment of the health care professional),
ACOG suggests that active phase arrest of labor be defined as no the subsequent vaginal delivery rates were 88% in multiparous individuals
progression in cervical dilation in patients who are at least 6-cm dilated and 56% in nulliparous individuals. Other subsequent studies have validated
with rupture of membranes despite 4 hours of adequate uterine activity or these results (40, 41).
6 hours of inadequate uterine activity with oxytocin augmentation.
(CONDITIONAL RECOMMENDATION, LOW- These data led to ACOG's 2014 recommendations to
liberalize the duration required for which was active-phase arrest ,
defined as no progression in cervical dilation despite 4 hours of adequate
QUALITY EVIDENCE)
uterine activity (more than 200 Montevideo units [MVUs] by intrauterine
pressure catheter) or 6 hours of inadequate uterine activity with oxytocin
Labor protraction refers to labor progress that is slower than is defined augmentation in patients who are at at least 6-cm dilated with rupture of
normal, and labor arrest as cessation of labor membranes (42). It is important to note that the threshold of 200 MVUs for
progress despite best attempts at augmentation. Risk factors for protracted adequate uterine activity is primarily derived from an observational study of
or arrested labor include, but are not limited to, nulliparity, large for 109 patients performed in 1986, in which the majority (91%) of women with
gestational age fetus, maternal obesity, advanced maternal age, fetal spontaneous vaginal deliveries who underwent oxytocin induction or
cephalic position (ie, occiput posterior), and cephalopelvic disproportion (34– augmentation achieved greater than 200 MVUs (43).
37) .
Protraction and arrest disorders are associated with an increased risk of
adverse maternal and neonatal outcomes, including cesarean delivery,
chorioamnionitis, postpartum hemorrhage, fetal acidemia, and neonatal There are mixed data on whether changes to guide-lines and
intensive care unit (NICU) admission (27, 28, 32). recommendations based on this evidence improved cesarean delivery rates.
In a multicenter cluster randomized trial in Norway, labor management using
Contemporary data demonstrate that the rate of cervical dilation in the the World Health Organization partograph based on Fried-man data was
active phase of labor is slower than what was observed historically. The compared with management using Consortium on Safe Labor data (44).
95th percentile for active-phase dilation ranges from 0.5 cm/hour to 1.3 cm/ There was no difference in cesarean delivery rate or adverse outcomes
hour (16); Thus, may be conservatively defined as less than 1 cm dilation in between the two groups. However, the interpretation of these results is
to protracted active phase 2 hours. However, this range is affected limited by patient characteristics that are different from those of the US
by the patient's admission cervical examination and parity, and these factors population and pre-existing evidence that using a partograph may not affect
should be considered when protracted labor is suspected. outcomes (45). A cluster randomized trial to determine the effect of the
revised ACOG guidelines in 26 hospitals in Alberta, Canada, found no
difference in cesarean delivery rates. There was a statistically significant
Several studies have evaluated the optimal duration of oxytocin increase in spontaneous vaginal delivery rates among those in the arm
augmentation in the face of labor protraction or arrest. A prospective study adopting the new guidelines, but the clinical benefit was modest: 54.8% to
of 319 pregnant women with dysfunctional labor found that, with 4 additional 56.8% (baseline adjusted odds ratio [OR] 1.09; 95% CI, 1.01–1.18 ) (46).
hours of oxytocin, 50.7% of nulliparous individuals and 41.7% of multiparous
individuals delivered vaginally. In nulliparous patients, a period of 8 hours of
augmentation resulted in an 18% cesarean delivery rate. In contrast, if the
period of augmentation had been limited to 4 hours, the cesarean delivery
rate would have been almost twice as high at 35.5% (38). Thus, a slow but
progressive active phase of labor demonstrating cervical change at least Observational studies on the effect of the revised ACOG guidelines on
every 4 hours in the setting of reassuring maternal and fetal sta-tus should cesarean delivery rates have shown mixed results, some demonstrating
not be an indication for cesarean delivery. reduction and others dem-onstrating no effect (30, 47). These studies
performed in the United States were limited by their retrospective designs
and varied in the way cesarean delivery rates were assessed (primary
cesarean delivery rate vs global rate). Thus, regarding the true effect of the
A study of more than 500 pregnant women found that extending the 2014 changes in ACOG definitions and guidance for management of labor
minimum period of oxytocin augmentation for active-phase arrest from 2 arrest remains unclear, particularly maternal and neonatal morbidity.
hours to at least 4 hours allowed the majority of women who had not However, these suggestions provide a general framework for clinicians to
progressed at the 2-hour mark to give birth vaginally without adversely reasonably balance the risks of prolonged labor with the potential benefit of
affecting neonatal outcome (39). The vaginal delivery rate for patients who avoiding cesarean delivery, with room for individualization.
had not progressed despite 2 hours of oxytocin augmentation was 91% for
multipa-rous individuals and 74% for nulliparous individuals. For

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Second Stage Several additional studies have demonstrated an association between

the duration of the second stage of labor and adverse maternal outcomes
ACOG recommends that prolonged second stage of labor be defined but conflicting results for neonatal outcomes. In a secondary analysis of
as more than 3 hours of pushing in nulliparous individuals and 2 hours a multicenter randomized study of 4,126 nulliparous women who reached
of pushing in multiparous individuals. the second stage of labor, longer duration of the second stage was
significantly associated with higher odds of chorioamnionitis, uterine
An individualized approach should be used to diagnose second-stage atony, and third-degree and fourth-degree perineal laceration, but there
arrest; incorporating information regarding progress, clinical factors was no association with adverse neonatal
that may affect the likelihood of vaginal delivery, discussion of risks
and benefits of available interventions, and individual patient preference
is recommended when time in the second stage is extended beyond
outcomes, including 5-minute Apgar score less than 4, umbilical artery
these parameters. (STRONG pH less than 7.0, intubation in the delivery room, need for admission to
the NICU, and neonatal sepsis (51). Similarly, in a secondary analysis of
1,862 women enrolled in an early compared with delayed pushing trial,
RECOMMENDATION, HIGH-QUALITY EVIDENCE) a longer duration of active pushing was not associated with adverse
neonatal out-comes, even in those who pushed for more than 3 hours
Arrest in the second stage can be identified earlier if there is lack of
(52) . A similar lack of association was found in a large, retrospective
fetal rotation or descent despite adequate contractions, pushing-ing
cohort study of 15,759 nulliparous women, even in a group whose
efforts, and time. (GOOD PRACTICE POINT)
second stage progressed beyond 4 hours (53). In one retrospective
study of 5,158 multiparous women, when the duration of the second
Parity, delayed pushing, use of epidural analgesia, maternal body mass stage of labor exceeded 3 hours, the risk of a 5-minute Apgar score less
index, birth weight, occiput posterior position, and fetal station at complete than 7, admission to the NICU, and a composite of neonatal morbidity
dilation have all been shown to affect the length of the second stage of were all significant. greatly increased (54). A population-based study of
labor (48). In the Consortium on Safe Labor study, the 95th percentile 58,113 multiparous women yielded similar results when the duration of
threshold was approximately 1 hour longer in patients who received the second stage was greater than 2 hours (55).
epidural analgesia than in those who did not receive epidural analgesia
(16).

In an observational study of 53,285 individuals with singleton

pregnancies who reached complete dilation, the probability of vaginal
delivery decreased as the duration of the second stage increased (49). It is important to consider maternal and neonatal risks of a prolonged
However, even at more than 4 hours of pushing, the chance of a vaginal second stage of labor in the context of the potential benefit of vaginal
delivery for a nulliparous individual was 78%; at more than 2 hours of delivery. To potentially optimize the chance of vaginal delivery while
pushing, the chance of a vaginal delivery for a multip-arous individual acknowledging the small absolute risk of maternal and neonatal
was 82%. A longer duration of pushing was statistically associated with morbidity, the 2014 ACOG guidelines recommended considering
a rise in composite neo-natal morbidity (including mechanical ventilation, extending the traditional definition of second stage limits by 1 hour—at
proven sepsis, brachial plexus palsy, clavicular fracture, skull frac-ture, least 2 hours of pushing in multiparous women and at least 3 hours of
other fracture, seizures, hypoxic-ischemic encephalopathy, and death). pushing in nulliparous women—while also allowing individualized
However, the absolute difference in neonatal risks was small, extension as long as progress in fetal descent is being observed and
approximately 1% or less. As the duration of pushing increased, the documented (42).
odds of postpartum hemorrhage, cesarean delivery, operative vaginal
delivery, and third-degree or fourth-degree lacerations also increased
(49). In a secondary analysis of the Consortium on Safe Labor study of In a randomized trial of 78 nulliparous patients with epidurals and a
43,810 nulliparous individuals and 59,605 multiparous individuals with prolonged second stage of labor longer than 3 hours, extension of labor
singleton pregnancies who reached complete dilation, the chance of by 1 hour was associated with a 50% decrease in the cesarean delivery
vaginal delivery after prolonged second stage was 79.9% for null-liparous rate. However, the study was not powered to assess differences in
women with epidurals and 88.7% for multiparous women with epidurals. neonatal outcomes (56). In a retrospective cohort study of more than
However, a prolonged second stage was associated with increased 19,000 patients comparing traditional definitions of second-stage arrest
chorioamnionitis, third-degree or fourth-degree lacerations, and neonatal (longer than 3 hours in nulliparous individuals with regional anesthesia
morbidity, including sepsis and asphyxia (50). or longer than 2 hours without it, and longer than 2 hours in multiparous
individuals with regional anesthesia and longer than 1 hour without it)
with contemporary standards that allow for the continuation of the second
stage

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for an additional 1 hour, the contemporary definition was risks associated with increasing length of the second
associated with a decreased rate of cesarean delivery stage and decreasing likelihood of vaginal delivery
but increased rates of neonatal acidemia, NICU admission, (Table 2). Ongoing management of the second stage
and third-degree and fourth-degree lacerations (57). of labor also assumes the demonstration of fetal
A systematic review and meta-analysis that included the descent. In a 2014 study of more than 4,500 vaginal
previous study and four other retrospective cohort studies as well as deliveries, 95% of all women were 0 station or lower at
two randomized controlled trials with complete cervical dilation (59). Thus, a fetal station that
20,165 nulliparous women compared the Zhang with remains at 0 despite pushing is unusual.
the Friedman labor curve for the second stage of labor
(10,861 with the Zhang labor curve vs 9,304 with the Induced Labor
Friedman labor curve) and showed similar cesarean The latent phase of labor is significantly longer in
delivery rates when either curve was used in the second induced labor compared with spontaneous labor; the
2
stage (pooled OR 0.86; 95% CI, 0.47–1.57; 593%), with
Yo
active phase of labor is similar between the two groups
Comparable rates of adverse maternal and neonatal out- (60). Several studies support that a substantial proportion
comes (58). Thus, shared decision making with the of patients undergoing induction who remain in the latent
patient regarding extending the second stage of labor phase of labor for 12–18 hours with oxytocin administration
should include a discussion of the maternal and neonatal and ruptured membranes will give birth vaginally if

Table 2. Odds of Adverse Outcomes and Proportion of Vaginal Deliveries by Duration of Second
Stage of Labor
Laughon et al.
(N5103,415)
Outcome [aOR (95% CI)] Grobman et al (N553,285) [OR (95% CI)]
Nulliparous patients More than 180 min* 180–239 minutes 240 min or morey

Vaginal delivery 79.9% 75.8% 77.6%

Chorioamnionitis 3.01; 2.65–3.43 — —

Postpartum hemorrhage 3rd- 1.50; 1.27–1.78 4.0; 2.7–6.0 3.8; 2.1–6.9

or 4th-degree laceration 1.80; 1.58–2.05 2.9; 2.4–3.6 3.5; 2.6–4.6
NICU admission 1.39; 1.20–1.60 — —

2.08; 1.60–2.70 — —
Neonatal sepsis
— 2.1; 1.4–3.3 2.2; 1.2–4.2
Neonatal composite adverse outcomez
Multiparous patients More than 120 min* 120–179 minutes

Vaginal delivery 88.7% 81.8%

Chorioamnionitis 4.78; 3.46–6.61 —

Postpartum hemorrhage 3rd- 1.50; 1.07–2.10 5.6; 3.2–9.6

or 4th-degree laceration 3.85; 2.65–5.60 5.5; 3.5–8.6
NICU admission 1.57; 1.22–2.03 —

1.73; 0.99–3.05 —
Neonatal sepsis
— 2.7; 1.5–4.8
Neonatal composite adverse outcomez
Abbreviations: aOR, adjusted odds ratio; OR, odds ratio; NICU, neonatal intensive care unit.
*With epidural, referent is 180 minutes or less in nulliparous individuals and 120 minutes or less in multiparous individuals.
and With and without epidural, referent is less than 60 minutes.
z Mechanical ventilation, proven sepsis, brachial plexus injury, clavicular fracture, skull fracture, other fracture, seizures, hypoxic-ischemic
encephalopathy, or death (within 120 days of delivery).
Data from: Laughon SK, Berghella V, Reddy UM, Sundaram R, Lu Z, Hoffman MK. Neonatal and maternal outcomes with prolonged
second stage of labor [published erratum appears in Obstet Gynecol 2014;124:842]. Obstet Gynecol 2014;124:57–67. doi:10.1097/
AOG.0000000000000278; and Grobman WA, Bailit J, Lai Y, Reddy UM, Wapner RJ, Varner MW, et al. Association of the duration of
active with pushing obstetric outcomes. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Maternal-Fetal Medicine Units (MFMU) Network. Obstet Gynecol 2016;127:667–73. doi: 10.1097/AOG.0000000000001354.

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induction is continued (61–63). In one study, 17% of pregnant women be tailored based on patient preference after discussion
were still in the latent phase of labor after 12 regarding the known risks.
hours, and 5% remained in the latent phase beyond 18
hours (62). In another study, of those pregnant people Amniotomy
who were in the latent phase for longer than 12 hours
and achieved the active phase of labor, approximately ACOG recommends amniotomy for patients

40% gave birth vaginally (63). In a cohort of 10,677 null-liparous undergoing augmentation or induction of labor
to reduce the duration of labor. (STRONG RECOMM-
women undergoing induction of labor, 96.4%
MENDATION, HIGH-QUALITY EVIDENCE)
reached the active phase for 15 hours. More than 40%
of people whose latent phase lasted 18 hours or more
Multiple studies have investigated the use of amniotomy
still had vaginal deliveries (64).
compared with no intervention, other interventions, or
Therefore, if the maternal and fetal status remain
adjunctive to other interventions during spontaneous
reassuring, cesarean deliveries for failed induction of
labor and induction of labor.
Labor in the latent phase can be avoided by recommending that
A 2020 systematic review published by the Agency for
oxytocin be administered for at least 12–18 hours
Healthcare Research and Quality (AHRQ) included five
after membrane rupture before deeming the induction to
randomized controlled trials from 2007 to 2010 investigating amniotomy
be unsuccessful. Depending on clinical characteristics,
in pregnant women undergoing spontaneous labor compared with
patient preference, and discussion of the risks and benefits, the
various control treatments
decision to continue past 18 hours may be
(65). The specific control treatment was under the obste-trician's
individualized (64).
discretion, without intentional amniotomy in the
Epidural Analgesia absence of other indications such as fetal scalp electrode or intrauterine
pressure catheter placement. The
ACOG recommends that neuraxial anesthesia review determined that amniotomy in spontaneous labor
be offered for pain relief during any stage of decreased the total duration of time in labor for nullipa-rous individuals
work. (STRONG RECOMMENDATION, MODERATE-QUALITY without increasing the risk for cesarean
EVIDENCE) delivery, maternal infection, hemorrhage, or trauma to the
pelvic floor. Neonatal outcomes were not routinely evaluated in all of
Regional anesthesia is a highly effective mode of pain
the included trials, but no significant differences were noted. None of
relief for individuals in labor. For pregnant women the randomized controlled
choosing regional pain management in labor, a systematic
trials demonstrated an increased risk of cord prolapse
review demonstrated that neither type of neuraxial
with amniotomy.
analgesia (epidural vs combined spinal epidural) nor
timing affected the risk of cesarean delivery (65). Early Compared With Late Amniotomy
Amniotomy has also been investigated in patients
Management of Dystocia in the First Stage undergoing induction of labor. Multiple studies have
of Labor shown shorter time intervals to delivery in those who
Various strategies to manage abnormal labor progression in the first had early amniotomy. A retrospective matched cohort
stage have been investigated. In the study of 546 nulliparous women with viable singleton
1960s, O'Driscoll et al (66) in Ireland proposed a com-prehensive gestations undergoing cervical ripening with Foley bal-loon catheter
approach to labor management, now completed compared (defined as early amniotomy
active management of labor, to reduce the duration of artificial rupture of membranes less than 1 hour after
work. This approach included standardized criteria for Foley removal) with no artificial rupture of membranes
the diagnosis of labor, early rupture of membranes, in the first hour after cervical ripening and demonstrated
administration of oxytocin for protracted labor, and one-to-one nursing. higher odds of vaginal delivery within 24 hours and a
In the largest randomized trial (n51,934) shorter duration of labor induction with early amniotomy
Comparing active with routine labor management, Frigoletto et al (68). A randomized controlled trial of 143 women admitted for induction
concluded that active management was associated with a shorter were randomized to early amniotomy
duration of labor and lower (concomitant with the beginning of oxytocin infusion) or
incidence of maternal fever, with no difference in the late amniotomy (4 hours after the beginning of oxytocin)
they will cease delivery rate. A subsequent meta-analysis of showed shorter labor time in nulliparous women (12
four trials demonstrated that active management is not hours vs 15 hours), with no effect on the risk of cesarean
associated with a significant reduction in the incidence of delivery in nulliparous and multiparous women (69). TO
cesarean delivery (67). Given the known risks of pro-longed labor (27, systematic review in 2020 of four trials from 2002 to
32), active management of labor is pre-ferred over expectant 2017 that included 1,273 patients undergoing induction
management; this approach may of labor after cervical ripening with either Foley catheter

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or prostaglandins at any dose demonstrated that early work (eight trials, n54,816 patients) (average MD –1.28
amniotomy compared with late amniotomy or spontaneous rupture of hours; 95% CI, –1.97 to –0.59). There were no meaning
membranes had a shorter interval from effects on maternal or neonatal morbidities. 2020
induction to delivery of approximately 5 hours (mean AHRQ systematic review similarly showed that early
difference [MD] –4.95 hours; 95% CI, –8.12 to –1.78), with administration of oxytocin is associated with a shorter
a similar risk for cesarean delivery (31.1% vs 30.9%; risk duration of labor but does not affect the overall cesarean
ratio [RR] 1.05; 95% CI, 0.71–1.56) (70). The largest study delivery rate compared with delayed administration of
in this systematic review randomized 585 pregnant oxytocin (65).
women undergoing induction to early amniotomy (artifi-cial rupture of A systematic review and meta-analysis including nine
membranes at less than 4 cm) compared randomized controlled trials (1,538 pregnant women)
with standard treatment and demonstrated that early am-niotomy evaluated the benefits and harms of discontinuation of
shortened the time to delivery by more than 2 oxytocin after the active phase of labor is reached (74).
hours (19.069.1 vs 21.3610.1 hours, 5.04) and Q Pregnant women who were randomized to have discontinuation of
increased the proportion of induced nulliparous individuals who oxytocin infusion after the active phase was
delivered within 24 hours (68% vs 56%; 95% CI, reached had a significantly lower risk of cesarean delivery (9.3% vs
Q without significant differences in
0.59–0.89; 5.002), 14.7%) (RR 0.64; 95% CI, 0.48–0.87) and of
cesarean delivery, amnioinfusion, chorioamnionitis, cord uterine tachysystole (6.2% vs 13.1%) (RR 0.53; 95% CI,
prolapse, abruption, or postpartum hemorrhage (71). 0.33–0.84) compared with those who were randomized to
There is high-quality evidence to recommend early have continuation of oxytocin infusion until delivery. Dis-continuation
amniotomy as adjunctive to the labor process to decrease of oxytocin infusion was associated with a
time to delivery without increasing the cesarean delivery modest increase in the duration of the active phase of
rate or other maternal or neonatal complications. labor (MD 27.65 minutes; 95% CI, 3.94–51.36). The
authors of the systematic review acknowledged the het-erogeneity of
Oxytocin the included trials from multiple different
countries, along with their small sample sizes. to similar
ACOG recommends either low-dose or high-dose oxytocin strategies
Cochrane database systematic review evaluated 10 ran-domized
as reasonable
controlled trials and showed similar findings of
approaches to the active management of labor
reduced cesarean delivery rates after discontinuation of
to reduce operational deliveries. (STRONG RECOMM-
intravenous oxytocin stimulation in the active phase of
MENDATION, HIGH-QUALITY EVIDENCE)
labor but determined the evidence to be of low certainty
When the first stage of labor is protracted or arrested, due to flawed study designs (RR 0.69; 95% CI, 0.56–0.86).
oxytocin is commonly recommended. Several studies When the analysis was restricted to trials that separately
have evaluated the optimal timing of initiation and reported participants who reached the active phase or
duration of oxytocin augmentation in the face of labor labor, no difference was noted between the groups (RR
protraction or arrest. 0.92; 95% CI, 0.65–1.29) (75). Further research is needed
Early augmentation , defined as oxytocin administration to determine whether oxytocin cessation after the active
When dystocia is identified, it has been examined in multiple phase of labor is reached decreases the cesarean delivery rate.
randomized controlled trials by meta-analysis (72).
Early oxytocin was associated with a modest increase
in the probability of spontaneous vaginal delivery (RR High-Dose Compared With Low-Dose Oxytocin
1.09; 95% CI, 1.03–1.17). The meta-analysis concluded Regimes
that, for every 20 patients treated with early oxytocin Multiple studies have reviewed dosing regimens for
augmentation, one additional spontaneous vaginal delivery would be oxytocin administration. These are typically referred to
expected. There was a decrease in antibiotic use (RR 0.45; 95% CI, as high-dose compared with low-dose regimens,
0.21–0.99) but also an although the actual dosing regimen frequently varies
increased risk of hyperstimulation (now termed tachysys-tole) (RR across studies.
2.90; 95% CI, 1.21–6.94), without evidence of A systematic review investigated an oxytocin protocol
neonatal adverse effects. In addition, patients in the early for induction of labor at term in which (defined high-dose oxytocin
oxytocin group reported higher levels of pain and dis-comfort in labor. as at least 100 milliunits oxytocin in the first
A follow-up systematic review of 14 trials 40 minutes, with increments delivering at least 600 milli-units in the
found that, in prevention trials, early augmentation was first 2 hours) was compared with low-dose
associated with a modest reduction in the number of oxytocin (defined as less than 100 milliunits oxytocin in
cesarean births (11 trials; n57,753) (RR 0.87; 95% CI, the first 40 minutes and increments delivering less than
0.77–0.99) (73). A policy of early oxytocin and early am-niotomy was 600 milliunits total in the first 2 hours) (76). Results of
associated with a shortened duration of primary outcomes revealed no significant differences in

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Table 3. Low-Dose and High-Dose Oxytocin Infusion Protocols Regimen Starting Dose (mU/min)

Incremental Increase (mU/min) 1–2 Dosage Interval (min) 15–40

Low-Dose 0.5–2

High-Dose 4 or higher Abbreviations: mU/min, 3–6 15–40

milliunits per minute; min, minutes.
Reprinted from: Myers ER, Sanders GD, Coeytaux RR, McElligott KA, Moorman PG, Hicklin K, et al. Labor dystocia. Comparative effectiveness review No.
226. AHRQ publication no. 29. Agency for Healthcare Research and Quality. 2020. doi: 10.23970/ AHRQEPCCER226.

Rates of vaginal delivery not achieved within 24 hours (two trials, n51,339 likely to have spontaneous vaginal births (RR 1.08; 95% CI, 1.04–1.12)
women) (RR 0.94; 95% CI, 0.78– 1.14) or cesarean delivery (eight trials, and less likely to report negative ratings of or feelings about their
n52,023 women) childbirth experiences (RR 0.69; 95% CI, 0.59–0.79) or to use any
(RR 0.96; 95% CI, 0.81–1.14). There was no difference in serious intrapartum analgesia (RR 0.90; 95% CI, 0.84–0.96) (78). In addition,
maternal morbidity or death (one trial, n5523 women) (RR 1.24; 95% CI, their labors were shorter (MD –0.69 hours; 95% CI, –1.04 to –0.34) and
0.55–2.82) and no difference in serious neonatal morbidity or perinatal they were less likely to have cesarean births (aver-age RR 0.75; 95% CI,
death (one trial, n5781 neonates) (RR 0.84; 95% CI, 0.23–3.12) (76). 0.64–0.88) or vaginal instruments births (RR 0.90; 95% CI, 0.85–0.96),
regional analgesia (average RR 0.93; 95% CI, 0.88–0.99), or to deliver
The AHRQ 2020 systematic review determined that, in nulliparous neo-nates with a low 5-minute Apgar scores (RR 0.62; 95% CI, 0.46–
women, high-dose oxytocin is associated with a lower cesarean delivery 0.85) (78). The subsequent 2020 AHRQ review also examined
rate compared with low-dose oxytocin protocols, with no difference in supportive adjunctive measures for labor dys-tocia (65). The review
maternal hem-orrhage (65). Table 3 outlines the typical high-dose and acknowledges that continuous emotional support did not show a benefit
low-dose oxytocin regimens identified in the AHRQ sys-thematic review. in reducing the duration of the first or second stage of labor, although
prior systematic reviews and meta-analyses, including the one discussed
above, showed a benefit in total labor duration. As with the previous
Current research suggests no significant differences in maternal or systematic review, the AHRQ review showed that emotional support
neonatal outcomes with different oxytocin dosing regimens; Therefore, interventions reduced cesarean deliveries and instrumental delivery.
either low-dose or high-dose oxytocin strategies are reasonable
approaches to the active management of labor to reduce operative
delivery-ies. A maximum dose of oxytocin has not been established.

series and remain one of the key interventions for adjunctive therapies.
Patients with continuous emotional support also appear to be less likely
Special Adjunctive Considerations Multiple to have negative birth experiences.
nonpharmacologic supportive care measures have been suggested to
have the potential to assist labor progression during labor dystocia. Given these benefits and the absence of demonstra-ble risks,
These include, but are not limited to, continuous emotional support, patients, obstetrician–gynecologists and other obstetric care clinicians,
peanut ball, hydration, perineal massage, water immersion, acupuncture, and health care organizations may want to develop programs and
ambulation, and positioning strategies. There is considerable policies to integrate trained support personnel into the intrapartum care
heterogeneity in the type and timing of interventions, which can make environment to provide continuous one-to-one -one emotional support to
them a challenge to study in a systematic fashion. individuals undergoing labor (77).

Continuous Support in Labor Published data Peanut Ball The

indicate that one of the most effective tools to improve labor and delivery peanut ball is a type of birthing ball shaped like a peanut shell with an
outcomes is the continuous presence of support personnel or the elongated shape that is placed between a patient's legs during labor,
continuous presence of a one-on-one person for support (77). Support while the patient is lying in the lateral recumbent position. Use of the
may include emotional support, information about labor progress, advice peanut ball is suggested to facilitate the widening of the pelvis and fetal
about coping techniques, comfort measures, and speaking up when descent by mimicking an upright position. A systematic review and meta-
needed on behalf of the pregnant individual. analysis of four randomized controlled trials with 648 nulliparous women
in spontaneous or induced labor that investigated the efficacy of the
peanut ball showed that there was no significance
One large systematic review demonstrated that pregnant women
allocated to continuous support were more

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difference in time in labor (MD 79.1 minutes; 95% CI, 2204.9 to 46.7) or cesarean delivery (RR 0.71; 95% CI, 0.54–0.94). The 2020 AHRQ review
incidence of vaginal delivery (RR 1.1; 95% CI, 1.0–1.2) or cesarean delivery found no differences in duration of labor or cesarean delivery rates for patients
(RR 0.8; 95% CI, 0.6–1.0) (79). Overall, the use of the peanut ball does not using differing positioning interventions, although those in kneeling positions
appear to show significant differences in maternal outcomes. were more likely than those in sitting positions to have reduced trauma to the
pelvic floor (65). Frequent position changes during labor to enhance maternal
comfort and promote optimal fetal positioning should be supported by adopting
positions to allow appropriate maternal and fetal monitoring and treatments.
Hydration
Ambula-tion was associated with a shorter duration of labor in the AHRQ 2020
Hydration modalities have also been investigated as adjunctive interventions
systematic review, although the strength of evidence was low (65).
during labor. Different rates of intravenous fluids and comparison of intravenous
fluid compared with oral hydration have been investigated.

Pregnant individuals in spontaneously progressing labor may not require

routine continuous infusion of intravenous fluids. Although safe, intravenous
hydration limits freedom of movement and may not be necessary. Oral Other Interventions The 2020

hydration can be encouraged to meet hydration and caloric needs (77). AHRQ systematic review and meta-analysis examined multiple supportive
adjunctive measures for labor dystocia. No significant differences were noted
in rates of cesarean delivery or duration of labor when investigated for perineal
A systematic review in 2017 examined different rates of intravenous fluids massage, water immersion, or acupuncture or acupressure (65); However,
and showed that individuals who received intravenous fluids at 250 mL/hour, there are few data to comment on potential for increased patient satisfaction
compared with those who received intravenous fluids at 125 mL/hour, had a with these interventions.
lower incidence of cesarean delivery for any indication (12.5 % vs 18.1%) (RR
0.70; 95% CI, 0.53–0.92) and for dystocia (4.9% vs 7.7%) (RR 0.60; 95% CI,
0.38– 0.97), shorter mean duration of labor of approximately 1 hour ( MD Propranolol has also been investigated as an agent in addition to oxytocin
264.38 minutes; 95% CI, 2121.88 to 26.88), and shorter mean length of the to assist with uterine contractility.
second stage of labor (MD 22.80 minutes; 95% CI, 24.49 to 21.10), without Propranolol, a beta-adrenergic receptor–blocking drug, has been shown to
increased maternal or neonatal morbidities and no increase in pulmonary reverse the inhibitory effect of the beta agonist isoproterenol on human uterine
edema ( 80). The review supported increased hydration for nulliparous women motility and has been shown to increase uterine activity (82, 83). A 2016 meta-
when oral intake is restricted but recommended further study regarding risks analysis evaluated six randomized controlled trials (n5609 parturients) involving
and benefits of increased hydration among women with unrestricted oral intake, the use of propranolol in the first stage of labor, in either the latent stage or the
those under-going induction of labor, and those with medical comorbidities active stage (84). Propranolol reduced the number of cesarean deliveries when
(80). The 2020 AHRQ systematic review and meta-analysis, which included it was administered for induction
the previous review, showed that administration of intravenous fluids combined
with oral intake alone demonstrated a reduction in the duration of labor,
although not increasing cesarean delivery rates, maternal hemorrhage, or tion of labor (OR 0.49; 95% CI, 0.27–0.89); However, this reduction was not
operative vaginal delivery rates (65). observed when it was administered

during the active phase of labor. No difference in adverse neonatal outcomes

was noted. The authors acknowledge

edged that the low number of participants and methodo-logic heterogeneity

precluded them from making conclusions. A 2023 randomized trial of 164
patients with prolonged labor found no difference in cesarean delivery rate (RR
0.99; 95% CI, 0.76–1.29) between those who received propranolol and those
who received placebo (85). Additional data are needed to provide guidance on
this intervention, and routine use is not recommended.
Position Changes and Ambulation Observational studies
of maternal position during labor have found that patients spontaneously
assume many different positions during labor (81). A meta-analysis that
compared upright positioning (including sitting, standing, and kneeling), Cervical Examinations Cervical

ambulation, or both with recumbent, lat-eral, or supine positions during the first examinations are indicated to determine labor progress, but there is insufficient

stage of labor found that upright positions shortened the duration of the first evidence to provide guidance on the frequency of cervical examinations in
stage of labor for approximately 1 hour and 22 minutes (MD 21.36; 95% CI, labor to assist with labor progress or dystocia (65). How-ever, there is evidence
22.22 to 20.51). Women in upright positions were also less likely to undergo through a retrospective cohort study of 2,395 pregnant women over 4 years
that showed no significant association between the number of

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cervical examinations in labor and intrapartum fever, Management of Dystocia in the Second
whether before or after amniotomy (86). It is reasonable Stage of Labor
to perform cervical examinations as often as needed
when clinically indicated.
Delayed or Immediate Pushing
Intrauterine Pressure Catheters ACOG recommends pushing commence when
complete cervical dilation is achieved. (STRONG
ACOG recommends using intrauterine pressure-sure catheters RECOMMENDATION, HIGH-QUALITY EVIDENCE)

among patients with ruptured

membranes to determine adequacy of uterine Among nulliparous patients with regional anesthesia, one
contractions in those with protracted active aspect of management of the second stage of labor
labor or when contractions cannot be accurately externally involves timing the initiation of pushing. The theoretical
monitored. (STRONG RECOMMENDS- advantage of delaying the initiation of pushing (some-times referred to
TION, LOW-QUALITY EVIDENCE) as “laboring down”) once complete dila-tion occurs would be to allow
the force of uterine
Intrauterine pressure catheters are frequently used after contractions to achieve fetal descent and reduction
amniotomy when there is evidence of protraction of labor the need for patient exertion. Immediate pushing once
or an inability to adequately monitor contractions. As of 2013 Complete dilation occurs more closely mimics the instinctive initiation
systematic review evaluated three randomized controlled of pushing when the second stage begins
trials including 1,945 pregnant women that showed no among individuals without regional anesthesia. A meta-analysis of 12
difference in maternal or neonatal outcomes with the use
trials comparing immediate with delayed
of intrauterine pressure catheters, although no trials pushing found that delayed pushing was associated with
specifically addressed the question of harms or benefits an increased rate of spontaneous vaginal delivery (61.5%
of use with labor dystocia (87). No significant differences vs 56.9%) (pooled RR 1.09; 95% CI, 1.03–1.15) (92). How-ever,
were noted in duration of labor, cesarean or instrumental among only high-quality studies, there was no difference in the rate of
vaginal delivery rates, hyperstimulation, or infection when spontaneous vaginal delivery
an intrauterine catheter was used. No serious complications, such as (59.0% vs 54.9%) (pooled RR 1.07; 95% CI, 0.98–1.26).
placenta or vessel perforation or placental Delayed pushing was associated with prolongation of
abruption, were reported. The 2020 AHRQ systematic the second stage of labor (weighted MD 56.92 minutes;
review included only this systematic review, with no additional 95% CI, 42.19–71.64) and shortened duration of active
randomized control trials, and concluded that there pushing (weighted MD 221.98 minutes; 95% CI,
were no statistically significant differences between intra-uterine 231.29 to 212.68), regardless of study quality. In 2018,
pressure catheters and external uterine monitor-ing for the outcomes a multicenter randomized controlled trial in the United
of mode of delivery, mean time to States of nulliparous individuals with neuraxial anesthesia comparing
delivery, neonatal acidemia, and admission to the NICU immediate with delayed pushing found no
(65). difference in rate of spontaneous delivery but noted an
Historically, 200 MVU of uterine contraction pressure increased length of the second stage of labor with delayed pushing
has been used as the cutoff to suggest adequacy of (31.8 minutes; 95% CI, 36.7–26.9; .001) Q
contraction efforts (43, 88). A secondary analysis of one (93). The study was stopped early due to an increased
of the randomized controlled trials in the 2013 systematic risk of postpartum hemorrhage, chorioamnionitis, and
review examined the amount of intrauterine pressure neonatal acidemia in the delayed pushing arm. estos
affecting labor outcomes and showed that the risk of data supports the recommendation to initiate pushing
cesarean delivery was higher in individuals who had once complete dilation is reached to avoid prolonging
low intrauterine pressure during labor (likelihood ratio the second stage of labor as well as the adverse out-comes associated
1.6 for intrauterine pressure less than 100 milliunits and with delayed pushing. Delayed push-ing has not been studied among
0.41 for intrauterine pressure greater than 300 milliunits), multiparous individuals
without effect on neonatal outcomes (89). or those without regional anesthesia; however, similar
Other observational studies have shown conflicting risks are anticipated, and, therefore, this approach
results regarding the effect of contractile patterns based should be avoided for these patients as well.
on intrauterine pressure catheter use on neonatal
outcomes (90, 91). Although there are insufficient data
Manual Rotation
to guide the use of intrauterine pressure catheters in the Compared with a fetal head position of occiput anterior,
setting of labor dystocia, it can be useful when there is an other fetal head positions have been associated with an
inability to monitor the frequency or strength of contractions externally increased risk of operative vaginal delivery and cesar-ean delivery
to allow for potential use of oxytocin Manual rotation
(36). the process by which ,
augmentation. a clinician assists in rotating the fetal head to

156 CPG First and Second Stage Labor OBSTETRICS & GYNECOLOGY

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and Gynecologists. Published by Wolters Kluwer Health, Inc.
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Machine Translated by Google

accomplish a more favorable presentation and a Management of Labor Arrest

reduced fetal head diameter to move through the maternal pelvis, has Active Phase Arrest of Labor
been examined as an approach to treat
second-stage dystocia. In a US study of 3,258 women ACOG recommends that cesarean delivery be
with fetuses in the occiput posterior or occiput trans-verse position, performed in patients with active phase arrest
731 underwent an attempt of manual of labor. (STRONG RECOMMENDATION, LOW-QUALITY
rotation (94). Compared with expectant management, EVIDENCE)
individuals in the attempted manual rotation group
had lower rates of cesarean delivery, perineal laceration, hemorrhage, Arrest of the active phase of labor is the most common
and chorioamnionitis; the number of indication for primary cesarean delivery (2). One retrospective cohort
patients undergoing attempted manual rotation needed study of 1,014 women with defined as absence active phase arrest ,
to prevent one cesarean delivery was estimated to be of cervical change during the active
four. In another study of 2,522 deliveries in France, occi-put posterior phase of labor (4 cm or greater cervical dilation) for at least
fetal head position occurred in 233 individuals (9.2%) (95). Manual 2 hours in the presence of adequate uterine contractions
rotation was successful in (200 MVUs or greater per 10-minute period, as measured
71.7% of cases, and the rates of cesarean and operation by an intrauterine pressure catheter), demonstrated that
vaginal delivery were significantly lower after successful 33% went on to deliver vaginally and the rest delivered by
manual rotation. A meta-analysis of data from 1,402 Caesarean (41). Caesarean delivery was associated with an
women demonstrated a modest but statistically significant increase in increased risk of chorioamnionitis, endomyometritis, and
vaginal delivery rates when manual postpartum hemorrhage, and vaginal delivery was associated with an
rotations were performed in patients with occiput posterior fetuses increased risk for chorioamnionitis and shoul-der dystocia. Other
(96). In contrast, a randomized controlled studies have shown increased maternal
trial of 160 individuals with term pregnancies with occi-put transverse and neonatal morbidities with prolonged first stage of labor
fetal head position comparing manual duration above the 90th percentile (27, 28). Extended first
rotation with sham rotation did not find any difference stage of labor has been associated with an increased likelihood of
in the rate of need for operative vaginal delivery, but the composite maternal morbidity, maternal fever, post-partum transfusion,
study was not powered to evaluate for potential for harm prolonged second stage of labor
(97). Studies have demonstrated factors associated with duration, third-degree or fourth-degree perineal laceration,
successful manual rotation, which includes spontaneous and cesarean or operative vaginal delivery in the second
labor, fetal engagement, and attempt after completion Q and an increased likelihood of composite neonatal
stage of labor (#.02)
delay but before arrest is diagnosed (95, 98). morbidity, respiratory distress syndrome,
One small, randomized controlled parallel single-center trial of 58 need for mechanical ventilation, and confirmed or suspected neonatal
nulliparous individuals in the second Q etiology
sepsis (#.03) (27). The potential
stage of labor with fetuses in occiput posterior position for these associations is likely multifactorial in nature and
comparing clinical knowledge of fetal spine location not solely due to the length of the work.
before attempted manual rotation with lack of knowledge These data suggest that, although vaginal delivery can
suggested that knowing the fetal spine position was be achieved in some patients after prolonged first stage
associated with a significantly higher success rate (82.8% of labor, there is an increase in associated maternal and
Q and a higher rate of spontaneous
vs 41.4%; ,.001) neonatal comorbidities that can be seen after vaginal or
Q
vaginal delivery (69.0% vs 27.6%; 5.01) (99). they will cease delivery. In the absence of another maternal or
The timing of a manual rotation in the second stage of fetal indication for delivery, once a protracted active
labor has been debated, with some clinicians opting for phase of labor has been diagnosed, counseling regard-ing available
an earlier rotation and others opting to see whether interventions and potential outcomes while
rotation occurs with maternal pushing. In a systematic incorporating the patient's preferences and values
review of this question, earlier, prophylactic rotation was should inform decision making regarding continuing
associated with a shorter second stage but did not labor compared with proceeding to cesarean delivery.
demonstrate a change in the rate of vaginal delivery Once a diagnosis of arrest of labor in the active phase
(100). has been made, cesarean delivery is indicated.
These data suggest that manual rotation in the second
stage of labor from occiput posterior or occiput trans-verse position to
Second-Stage Arrest of Labor
occiput anterior may be associated with
ACOG suggests assessment for operative vaginal delivery before
decreased cesarean and operative vaginal delivery rates,
performing a cesarean
as well as the associated morbidities, without evidence of
delivery for second-stage arrest. (CONDITIONAL
increased maternal or neonatal risk.
RECOMMENDATION, LOW-QUALITY EVIDENCE)

VOL. 143, NO. 1, JANUARY 2024 CPG First and Second Stage Labor 157

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Labor arrest in the second stage should be managed mid-pelvic station (0 and +1 on the –5 to +5 scale) or
with operative vaginal delivery or cesarean delivery. The from an occiput transverse or occiput posterior position
decision to offer an operative vaginal delivery should be with rotation are reasonable in selected cases (101),
made by the clinician, taking into consideration clinician these procedures require a higher level of skill, are more
training and skill, hospital setting, available resources, likely to be unsuccessful than low (+2 or greater) or outlet
patient preferences, and candidacy for an operative (scalp visible at the introitus) operative vaginal deliveries,
vaginal delivery of the pregnant individual (101). In contrast to the and are infrequent in obstetric practice in the United
increasing rate of cesarean delivery, the rates States. In addition, the number of clinicians who are adequately
of operative vaginal delivery (by either vacuum or for-ceps) have trained to perform any forceps or vacuum delivery is decreasing. In a
decreased significantly during the past 15 survey of 507 obstetricians–
years (102). Yet, comparison of the outcomes of opera-tive vaginal gynecologist resident physicians in training, most (more
delivery and unplanned cesarean delivery
than 55%) did not feel competent to perform a forceps
shows reduced maternal morbidity after successful operative vaginal
delivery on completion of residency, although more than
delivery and no difference in serious neo-natal morbidity (eg,
90% felt competent to perform vacuum deliveries (110).
intracerebral hemorrhage or death).
Hence, prioritizing training in operative vaginal delivery,
In a large, retrospective cohort study, the rate of intracranial
particularly forces delivery, remains an important initiative. In summary,
hemorrhage associated with vacuum extraction did
operative vaginal delivery in the second
not differ significantly from that associated with either
stage of labor for labor arrest by experienced and well-trained
forceps delivery (OR 1.2; 95% CI, 0.7–2.2) or cesarean
physicians should be considered a safe, accept-able alternative to
delivery (OR 0.9; 95% CI, 0.6–1.4) (103). In a more recent
cesarean delivery.
study, forceps-assisted vaginal deliveries were associated with a
reduced risk of the combined outcome of Cesarean delivery is also a treatment for second-stage
labor arrest. Caesarean delivery in the second stage of
seizure, intraventricular hemorrhage, and subdural hem-orrhage as
labor is associated with increased maternal morbidity
compared with either vacuum-assisted vaginal delivery (OR 0.60; 95%
compared with cesarean delivery during the first stage. in
CI, 0.40–0.90) or cesarean
delivery (OR 0.68; 95% CI, 0.48–0.97), with no significance one retrospective cohort study comparing 400 women

difference between vacuum delivery or cesarean delivery undergoing cesarean delivery in the second stage with
(104). In a retrospective cohort study of 990 women 2,105 women undergoing cesarean delivery in the first
undergoing operative delivery in the second stage, com-paring those stage, endometritis occurred significantly more frequently
undergoing vacuum or forceps delivery with after second-stage cesarean delivery (4.25% vs 1.52%)
Those undergoing cesarean delivery, there was no difference in rates (adjusted OR 2.78; 95% CI, 1.51–5.09) (111). Another retrospective
of fetal acidemia between the groups (105). cohort study of 383 pregnant women comparing morbidity of cesarean
A 2023 systematic review comparing cesarean delivery delivery in the second stage of
and vacuum delivery in the second stage of labor that labor with cesarean delivery in the first stage found a
included this retrospective cohort study and 14 others significantly increased risk of hysterotomy extensions
studies from high-resource and lower-resource settings (112). These data can be used for operational planning
concluded that vacuum delivery is associated with lower and mobilization of necessary resources.
maternal and perinatal mortality (106). In summary, both operative vaginal delivery in the
Fewer than 3% of patients in whom vaginal operative appropriate candidate with an appropriately skilled
delivery has been attempted go on to deliver by clinician and cesarean delivery are evidence-based
Caesarean (107). Some have advocated using ultrasonography-raphy treatments for arrest of labor in the second stage of labor.
to assess fetal position to reduce maternal and
Neonatal morbidity associated with operative delivery.
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