Normal and Abnormal Labor Progression - UpToDate

11.11.
2018 Normal and abnormal labor progress on - UpToDate
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Normal and abnormal labor progress on
Authors: Robert M Ehsan poor, MD, Andrew J Sat n, MD, FACOG

Sect on Ed tor: V ncenzo Berghella, MD
Deputy Ed tor: Vanessa A Barss, MD, FACOG
All top cs are updated as new ev dence becomes ava lable and our peer rev ew process s complete.
L terature rev ew current through: Oct 2018. | Th s top c last updated: Sep 07, 2018.
INTRODUCTION — Dur ng normal labor, regular and pa nful uter ne contract ons cause progress ve d lat on
and effacement of the cerv x, accompan ed by descent and eventual expuls on of the fetus. "Abnormal labor,"
"dystoc a," and "fa lure to progress" are trad t onal but mprec se terms that have been used to descr be a
labor pattern dev at ng from that observed n the major ty of women who have a spontaneous vag nal del very.
These labor abnormal t es are best descr bed as protract on d sorders ( e, slower than normal progress) or
arrest d sorders ( e, complete cessat on of progress). By convent on, an abnormally long act ve phase s
usually descr bed as protracted, whereas an abnormally long latent phase or second stage s usually
descr bed as prolonged.
Th s top c w ll descr be normal labor progress and d scuss the d agnos s and management of protract on and
arrest d sorders. Management of normal labor and del very s rev ewed separately. (See "Management of
normal labor and del very".)
NORMAL LABOR PROGRESSION — Although determ n ng whether labor s progress ng normally s a key
component of ntrapartum care, determ n ng the onset of labor, measur ng ts progress, and evaluat ng the
factors (power, passenger, pelv s) that affect ts course are an nexact sc ence.
Stages and phases — Interpretat on of labor progress depends on the stage and phase. The three stages
and the r phases are:
● F rst stage – T me from onset of labor to complete cerv cal d lat on. Cl n cally, women are s mply asked
the t me when they bel eve labor began ( e, when contract ons started to occur regularly every 3 to 5
m nutes for more than an hour) to document the onset of labor. The t me that complete d lat on s f rst
dent f ed on phys cal exam nat on documents the end of the f rst stage. The prec se t mes of both the
start of labor and of complete d latat on are mposs ble to determ ne s nce the normal uterus contracts
nterm ttently and rregularly throughout gestat on, the n t al regular contract ons at the onset of labor are
m ld and nfrequent, n t al cerv cal changes are subtle, and phys cal exam nat on to document cerv cal
change s performed nterm ttently.
The f rst stage cons sts of a latent phase and an act ve phase. The latent phase s character zed by
gradual cerv cal change and the act ve phase s character zed by rap d cerv cal change. The labor curve
of mult paras may show an nflect on po nt between the latent and act ve phases; th s po nt occurs at
about 5 cm d lat on [1]. In null paras, the nflect on po nt s often unclear and, f present, occurs at a more
advanced cerv cal d lat on typ cally at approx mately 6 cm or more. In any case, th s nflect on po nt s a
retrospect ve f nd ng.
● Second stage – T me from complete cerv cal d lat on to fetal expuls on.
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When push ng s delayed, some cl n c ans d v de the second stage nto a pass ve phase (from complete
cerv cal d lat on to onset of act ve maternal expuls ve efforts) and an act ve phase (from beg nn ng of
act ve maternal expuls ve efforts to expuls on of the fetus) [2].
● Th rd stage – T me between fetal expuls on and placental expuls on.
Cr ter a for normal progress — Emanuel Fr edman establ shed cr ter a for the normal progress of labor n
the 1950s, and these cr ter a were used for assessment and management of labor for decades. As descr bed
below, he observed that normal labor should progress at a rate of at least 1 cm cerv cal d lat on per hour,
start ng at 3 to 4 cm of d lat on.
However, data der ved from women n labor n the 21st century (also descr bed below) suggest that changes
n obstetr c and anesthes a pract ces and n women themselves n recent decades have resulted n changes
n the average progress of labor. Therefore, cr ter a for normal labor progress have been rev sed, although
th s rema ns controvers al. It s now bel eved that the act ve phase of the ﬁrst stage of labor may not start unt l
the cerv x s 5 to 6 cm d lated, cerv cal d lat on n normal labor can be slower than 1 cm per hour and st ll
have a h gh chance of vag nal del very w th normal per natal outcomes, and the cerv x does not d late l nearly
( t s a hyperbol c pattern) [3,4].
Fr edman (h stor c) cr ter a — Emanuel Fr edman conducted h s now class c stud es def n ng the
spectrum of normal labor by evaluat ng the course of labor of 500 pr m grav das adm tted to the Sloane
Hosp tal for Women n New York n the m d-1950s [5-7]. The norms establ shed by h s data, dep cted as the
"Fr edman curve" (f gure 1), were w dely accepted as the standard for assessment of normal labor
progress on for decades.
Based on these data, the trans t on from the latent phase to act ve phase appeared to occur at 3 to 4 cm
cerv cal d lat on, and the stat st cal m n mum rate (5th cent le) of normal cerv cal d lat on dur ng the act ve
phase was 1.2 cm/hour for null parous women and 1.5 cm/hour for mult parous women.
A prolonged second stage for null paras and mult paras was def ned as three hours and one hour,
respect vely.
Contemporary cr ter a — The appl cab l ty of the Fr edman curve and ts establ shed norms to
contemporary obstetr c pract ce was challenged n the 21st century. Several stud es evaluated labor curves n
thousands of contemporary women to establ sh contemporary cr ter a for normal labor progress on [8-10].
These cr ter a are d fferent from, and generally slower than, those c ted by Fr edman. Th s change has been
attr buted to changes n pat ent character st cs (eg, h gher mean body mass ndex), anesthes a pract ces
(more use of neurax al anesthes a), and obstetr c pract ces over the past half-century. In add t on, a l m tat on
of Fr edman's f nd ngs s that h s data were based on labors n only 500 women who were managed at a
s ngle nst tut on. However, rev s on of the class c labor curve as descr bed by Fr edman has not been
accepted un versally. For example, Fr edman and Cohen argue that the shape of the curve may have been
nfluenced by select on b ases and confounders [11,12]. The most appropr ate stat st cal methods rema n
debated.
F rst stage
● Progress -- Zhang and colleagues obta ned data on normal labor patterns by evaluat ng contemporary
data from the Consort um on Safe Labor, wh ch ncluded nformat on on 62,415 s ngleton pregnanc es
w th spontaneous onset of labor, cephal c vag nal del very (≥88 percent spontaneous), and normal
neonatal outcome [8]. The data were collected retrospect vely from the electron c med cal records at 19
med cal centers n the Un ted States. These data have been used to def ne normal labor progress, as
shown n the table (table 1).
The shape of the normal labor curve generated from Zhang's data (f gure 2) s d fferent from the
Fr edman curve (f gure 1). The Fr edman curve dep cts a relat vely slow rate of cerv cal d lat on unt l

approx mately 4 cm ( e, latent phase), wh ch s followed by an abrupt accelerat on n the rate of d lat on
( e, act ve phase) unt l enter ng a decelerat on phase at approx mately 9 cm. Zhang's labor curves also
demonstrate an ncrease n the rate of cerv cal d lat on as labor progresses, but the ncrease s more
gradual than that descr bed by Fr edman: Over 50 percent of pat ents d d not d late >1 cm/hour unt l
reach ng 5 to 6 cm d lat on, and a decelerat on phase at the end of the f rst stage of labor was not
observed. Labor curves constructed from other contemporary data sets also generally d ffer from
Fr edman's curve [9,13]. Spec f cally, there s no abrupt change n the rate of cerv cal d lat on nd cat ng a
clear trans t on from latent to act ve phase and there s no decelerat on phase at the end of the f rst stage
of labor.
Wh le the presence or absence of a decelerat on phase at the end of the 1st stage of labor s not of major
cl n cal s gn f cance, def n ng the trans t on from latent to act ve phase ( e, trans t on from slower to more
rap d cerv cal d lat on) s cl n cally mportant for d agnos ng labor abnormal t es. Contemporary data
suggest that the normal rate of cerv cal change between 3 and 6 cm d lat on s much slower than
descr bed by Fr edman, who reported m n mum d lat on should be at least 1 cm/hour [9,14]. Many
contemporary women who go on to del ver vag nally have rates of cerv cal d lat on <1 cm/hour before
reach ng 6 cm d lat on. Indeed, both null paras and mult paras who go on to del ver vag nally can take
more than s x hours to d late from 4 cm to 5 cm and more than three hours to d late from 5 cm to 6 cm
(table 1) [8]. Beyond 6 cm d lat on, rates of cerv cal d lat on are more rap d n both null paras and
mult paras. Th s suggests that before 6 cm, slow cerv cal d lat on reflects the shallow slope of the latent
phase port on of the contemporary normal labor curve, not a protracted act ve phase. At ≥6 cm d lat on,
nearly all women should be n act ve labor, so slow cerv cal d lat on beyond th s po nt ( e, less than about
1 to 2 cm/hour) s a dev at on from the slope of the contemporary normal labor curve and s abnormal f t
pers sts.
● Durat on -- These contemporary observat ons about hourly labor progress translate nto a longer normal
durat on of the f rst stage than descr bed by Fr edman [13,15-18]. Zhang observed that the med an (95th
percent le) t mes for the cerv x to d late from 4 to 10 cm n null paras and mult paras were 5.3 hours
(16.4) and 3.8 hours (15.7), respect vely [8]. In contrast, Fr edman reported the correspond ng mean
(95th percent le) durat ons n null parous and parous women were 4.6 hours (11.7) and 2.4 hours (5.2),
respect vely [7]. The contemporary ncrease n f rst-stage durat on pers sts after adjustments are made
for maternal and pregnancy character st cs [15], suggest ng that changes n labor pract ce patterns may
be the pr mary reason for the ncrease. Although ep dural use has ncreased dramat cally s nce the
1960s, ncreased use of ep durals does not fully account for the d fference. Further study s requ red to
expla n these f nd ngs.
Second stage
● Descent -- At full cerv cal d lat on, fetal stat on s typ cally ≥0. In null parous women n the second stage,
Zhang found that the med an (95th percent le) t me nterval for fetal descent from stat on +1/3 to +2/3 was
16 m nutes (three hours) [13]. The med an (95th percent le) t me nterval for fetal descent from stat on
+2/2 to +3/3 was 7 m nutes (38 m nutes).
Fetal stat on at full cerv cal d lat on tends to be h gher n mult parous women than n null parous women,
and descent tends to be faster [19,20].
● Durat on -- Zhang observed that the med an (95th percent le) durat on of the second stage n null parous
and parous women w th ep dural anesthes a was 1.1 hours (3.6) and 0.4 hours (2.0), respect vely [8].
W thout ep dural anesthes a, the med an (95th percent le) was 0.6 hours (2.8) and 0.2 hours (1.3),
respect vely (table 1). Thus, ep dural anesthes a ncreased the 95th percent le for the second stage by
0.8 hours n null parous women and 0.7 hours n parous women compared w th no ep dural anesthes a.
(See 'Neurax al anesthes a' below.)

D abetes, preeclamps a, fetal s ze, chor oamn on t s [21], durat on of the f rst stage [22], maternal he ght,
and stat on at complete d lat on may also play a role n pred ct ng the durat on of the second stage, but
standards that account for these character st cs are not ava lable [23]. The effect of nduct on s
d scussed below.
Normal progress on n nduced labors — The t me to d late 1 cm n latent phase (def ned as d lat on <6
cm) s s gn f cantly longer n women undergo ng nduct on than n those n spontaneous labor and can take
many hours [24,25]. In a retrospect ve study, the med an (95th percent le) t mes for d lat on n the latent phase
for null parous 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: nduced labor 0.6 hours (4.3 hours), spontaneous labor 0.4 hours (2.7 hours)
The t me to d late from 6 to 10 cm was more rap d and s m lar n both nduced and spontaneous labors
[24,25].
Because the latent phase s longer n nduced labors, the durat on of the f rst stage (def ned as the t me to
d late from 4 to 10 cm) s s gn f cantly longer n nduced labor than n spontaneous labor. For null paras, the
med an (95th percent le) durat on of the f rst stage for nduced and spontaneous was 5.5 hours (16.8 hours)
versus 3.8 hours (11.8 hours); for mult paras, the med an (95th percent le) was 4.4 hours (16.2 hours) versus
2.4 hours (8.8 hours), n one study [24].
There s no d fference n length of the second stage between nduced and spontaneous labor [26].
ASSESSMENT OF LABOR PROGRESS
D g tal exam nat on — Cerv cal exam nat ons to document cerv cal d lat on, effacement, and fetal stat on are
usually rout nely performed:
● On adm ss on
● At two- to four-hour ntervals n the f rst stage
● Pr or to adm n ster ng analges a/anesthes a
● When the partur ent feels the urge to push (to determ ne whether the cerv x s fully d lated)
● At one- to two-hour ntervals n the second stage
● If fetal heart rate abnormal t es occur (to evaluate for compl cat ons such as cord prolapse or uter ne
rupture or fetal descent)
More frequent exam nat ons are warranted when there s a concern about labor progress. A l m tat on of
d g tal exam nat on s that t s mprec se, wh ch s not a problem when mon tor ng most labors, but s a
concern when the cl n c an s try ng to determ ne whether cerv cal d lat on and stat on are advanc ng slowly or
not at all. In a study that evaluated the accuracy of d g tal measurement of cerv cal d lat on w th a pos t on-
track ng system, when cerv cal d lat on was >8 cm, the mean error of d g tal exam nat on was 0.75 +/- 0.73
cm; when cerv cal d lat on was 6 to 8 cm, the mean error was 1.25 +/- 0.87 cm [27]
Partogram — Results of cerv cal exam nat ons can be documented on a partogram (or partograph), n
add t on to the med cal record. The partogram s a graph cal representat on of the pat ent's cerv cal d lat on
over t me n compar son w th the expected lower l m t of normal progress. The follow ng partogram s based
on cerv cal d lat on at adm ss on and shows the m n mum rate of labor progress ach eved by 95 percent of
null parous women w th s ngleton term pregnanc es and spontaneous onset of labor who had a vag nal
del very and normal neonatal outcomes (f gure 3) [8]. R ght dev at on from th s curve suggests a protract on
or arrest d sorder. Although useful for v sual z ng labor progress, use of partograms has not been proven to
s gn f cantly mprove obstetr c outcome [28].
Ultrasound — Although not w dely used cl n cally, ntrapartum transper neal ultrasound exam nat on can
document fetal descent and rotat on n the second stage when performed ser ally, and assess the presence
and extent of caput [29]. Ultrasound exam nat on appears to be more object ve and reproduc ble than d g tal
exam nat on. One techn que s to measure the angle between the symphys s pub s and the lead ng part of the
fetal skull (called the angle of progress on) by transper neal ultrasound n the second stage (f gure 4). Stat on
can be determ ned from angle of progress on us ng a formula [30], and tables are ava lable [31]. Head to
per neum d stance (HPD) can also be measured ser ally w th transper neal ultrasound. An advantage s that
caput succedaneum can be measured, but stat on cannot be determ ned because the HPD measurement
does not account for the curvature of the b rth canal [31].
OVERVIEW OF PROTRACTION AND ARREST DISORDERS
Prevalence — Protract on and arrest d sorders are common. Reported nc dences vary among stud es due to
d fferences n the def n t ons used by authors as well as d fferences among study populat ons (eg, gestat onal
age range, personal character st cs [eg, null par ty par ty and older maternal age have been assoc ated w th
longer labor]).
About 20 percent of all labors end ng n a l ve b rth nvolve a protract on and/or arrest d sorder [32]. The r sk s
h ghest n null parous women w th term pregnanc es. In a prospect ve Dan sh study, for example, 37 percent
of healthy term null paras exper enced dystoc a dur ng labor [33].
Protract on or arrest of labor s the most common reason for pr mary cesarean del very. In one study nclud ng
over 700 women who had unplanned cesareans, 68 percent of the cesarean del ver es were due to lack of
progress n labor [34].
When only the second stage s cons dered, 11.5 percent of null parous women w th ep dural anesthes a
exper enced a prolonged second stage n a systemat c rev ew (two stud es, n = 5350 women) [35].
R sk factors — Abnormal progress of spontaneously n t ated labor may to related to uter ne factors, fetal
factors, the bony pelv s, or a comb nat on of these factors (table 2) [21]. A genet c component has been
purported to account for 28 percent of the suscept b l ty to protracted and d ff cult labor [36].
Selected r sk factors for protract on and arrest are d scussed below. Some r sk factors are more prom nent
dur ng the f rst stage of labor and others pr mar ly exert the r effects n the second stage.
Hypocontract le uter ne act v ty — Hypocontract le uter ne act v ty s the most common r sk factor for
protract on and/or arrest d sorders n the f rst stage of labor. Uter ne act v ty s e ther not suff c ently strong or
not appropr ately coord nated to d late the cerv x and expel the fetus.
D agnos s — Uter ne act v ty can be mon tored qual tat vely by palpat on or external tocodynamometry.
The d agnos s of hypocontract le uter ne act v ty n th s sett ng s subject ve, based on the percept on that
contract ons are not strong on palpat on and/or nfrequent (<3 or 4 contract ons/10 m nutes) and/or of short
durat on (<50 seconds) [37,38].
Uter ne act v ty can also be mon tored quant tat vely by measurement of Montev deo un ts (MVUs) us ng an
nternal pressure catheter (IUPC). MVUs are calculated by subtract ng the basel ne uter ne pressure from the
peak contract on pressure of each contract on n a 10-m nute w ndow and add ng the pressures generated by
each contract on (f gure 5). Uter ne act v ty less than 200 to 250 MVUs s cons dered nadequate ( e,
ncreased l kel hood of not ach ev ng expected normal rate of cerv cal change and fetal descent), based on
the follow ng sem nal stud es [39,40], and other data [37,41,42]:
● In a retrospect ve report, 91 percent of women who had spontaneous vag nal del ver es after oxytoc n
nduct on ach eved contract le act v ty greater than 200 MVUs and 40 percent reached 300 MVUs; 77

percent of women who had spontaneous vag nal del ver es after augmentat on ach eved contract le
act v ty greater than 200 MVUs and 8 percent reached 300 MVUs [39].
● In a study of women w th spontaneous n t at on of labor, uter ne act v ty averaged about 100 MVUs n the
early f rst stage of labor, 175 MVUs n the advanced f rst stage, and 250 MVUs n the second stage [40].
In most women, external and ntrauter ne dev ces for mon tor ng uter ne act v ty perform equally well [43];
rout ne use of IUPCs does not mprove outcome [44-46]. However, select ve use of an IUPC can be helpful
for assess ng uter ne act v ty when t s d ff cult to mon tor contract ons externally, such as n obese women.
(See "Use of ntrauter ne pressure catheters".)
Maternal obes ty — Increas ng maternal body mass ndex (BMI) correlates w th an ncreas ng length of
the f rst stage of labor. In one study, for example, the med an t me to d late from 4 to 10 cm n null parous
women w th BMI <25 kg/m2 and >40 kg/m2 was 5.4 and 7.7 hours, respect vely, even after controll ng for
mult ple confounders [47]. The authors concluded more t me should be allowed for labor progress n obese
pat ents. Maternal obes ty s not ndependently correlated w th the length of the second stage of labor [47,48].
(See "Obes ty n pregnancy: Compl cat ons and maternal management", sect on on 'Progress of labor'.)
Cephalopelv c d sproport on — A d sproport on n the s ze of the fetus relat ve to the maternal pelv s can
result n fa lure to progress n the second stage and has been termed cephalopelv c d sproport on (CPD). Th s
s usually due to fetal malpos t on (eg, extended or asyncl t c fetal head, occ put poster or or transverse
pos t on [d scussed below]) or malpresentat on (mentum poster or, brow) rather than a true d spar ty between
fetal s ze and maternal pelv c d mens ons. However, true CPD may occur f the fetus has a large surface
anomaly (eg, teratoma, conjo ned tw n), the maternal pelv c bone s very small or deformed (eg, after pelv c
trauma), or the fetus s extremely large (although vag nal del ver es have been descr bed n nfants we gh ng
13 to 17 pounds and more).
D agnos s — Cephalopelv c d sproport on s a subject ve cl n cal assessment based on phys cal

exam nat on and course of labor. In a prospect ve study of null parous women n act ve labor, a pers stently
float ng head at 7 cm d lat on was pred ct ve of eventual cesarean del very n 100 percent of cases [49].
Antepartum, the cl n c an s generally unable to pred ct maternal pelv s-fetal s ze/pos t on d scordance lead ng
to arrest of labor requ r ng cesarean del very. Cl n cal and rad olog c assessments of the maternal pelv s and
fetal s ze ( e, pelv metry) are nexact and poorly pred ct the course and outcome of labor [50,51].
Rad ograph c pelv metry s not recommended [51]. Ultrasound evaluat on of fetal pos t on s accurate, but
common malpos t ons such as occ put poster or (OP) usually rotate ntrapartum.
Non-occ put anter or pos t on — The length of the second stage appears to correlate w th the degree of
rotat on away from occ put anter or (OA). Among null parous women under neurax al anesthes a who began
push ng at full d lat on, the mean durat on of the second stage for OA, occ put transverse (OT), and OP
pos t ons was 2.2, 2.5, and 3.0 hours, respect vely, and the cesarean del very rates were 3.4, 6.9, and 15.2
percent, respect vely [52]. Many fetuses actually enter labor n e ther OP or OT pos t on and then undergo
spontaneous rotat on of the fetal head dur ng labor. Protract on and arrest d sorders assoc ated w th
malpos t on occur when rotat on to OA does not occur or s slow to occur dur ng labor. (See "Occ put poster or
pos t on" and "Occ put transverse pos t on".)
Bandl's r ng — An hourglass constr ct on r ng of the uterus, called Bandl's r ng, has been est mated to
occur n 1 n 5000 l ve b rths and s assoc ated w th obstructed labor n the second stage [53-55]. The
constr ct on forms between the upper contract le port on of the uterus and the lower uter ne segment. It s not
clear f t s the cause or the result of the assoc ated labor abnormal ty. It may also occur between del very of
the f rst and second tw n.
D agnos s — D agnos s s typ cally made at cesarean del very. At the t me of laparotomy, a transverse
th ckened muscular band can be observed separat ng the upper and lower segment of the uterus. However,
case reports have descr bed predel very d agnos s us ng ultrasound [56,57]. F nd ngs ncluded th nn ng of the

lower uter ne segment, a th ck upper uter ne segment, and a prom nent r ng compress ng the fetus unaffected
by contract ons.
Neurax al anesthes a — The potent al mpact of neurax al anesthes a on uter ne act v ty and fetal
malpos t on has rece ved a lot of attent on as a poss ble source of ncreas ng rates of protracted labor, arrest,
and cesarean del very. Random zed tr als have not shown a major mpact on the nc dence of protract on and
arrest d sorders. In a 2011 systemat c rev ew of random zed tr als, use of neurax al labor anesthes a d d not
ncrease the durat on of the f rst stage of labor compared w th non-neurax al anesthes a or no analges a
(we ghted mean d fference [WMD] 18.5 m nutes; 95% CI -12.9 to 49.9) or ncrease the r sk of cesarean
del very (relat ve r sk [RR] 1.10, 95% CI 0.97-1.25) [58]. There were small but stat st cally s gn f cant
ncreases n the durat on of the second stage of labor (WMD 13.7 m nutes; 95% CI 6.7-20.7) and use of
oxytoc n (RR 1.19, 95% CI 1.03-1.39). Women rece v ng neurax al anesthes a were more l kely to undergo
operat ve vag nal del very (RR 1.42, 95% CI 1.28-1.57). (See "Adverse effects of neurax al analges a and
anesthes a for obstetr cs", sect on on 'Effects on the progress and outcome of labor'.)
FIRST STAGE PROTRACTION AND ARREST
D agnos s — The d agnos s of protract on and arrest d sorders s based on dev at on from the contemporary
norms descr bed above and are def ned accord ng to the phase of the f rst stage n wh ch they occur.
Protract on — The d agnos s of a protracted act ve phase s made n women at ≥6 cm d lat on who are
d lat ng less than about 1 to 2 cm/hour, wh ch reflects the 95th cent le n contemporary women (table 1).
Women w th cerv cal d lat on <6 cm are cons dered to be n latent phase. The same table (table 1) serves as
a gu de for d agnos ng a prolonged latent phase [8]. Accord ng to the table, t may take s x to seven hours to
progress from 4 to 5 cm and three to four hours to progress from 5 to 6 cm dur ng a normal latent phase,
regardless of par ty.
Arrest — We agree w th the cr ter a for arrest proposed by a workshop convened by the Un ted States
Nat onal Inst tute of Ch ld Health and Human Development (NICHD), Soc ety for Maternal-Fetal Med c ne
(SMFM), and Amer can College of Obstetr c ans and Gynecolog sts (ACOG) and based on contemporary
data [59]. Act ve phase arrest s d agnosed at cerv cal d lat on ≥6 cm n a pat ent w th ruptured membranes
and [8]:
● No cerv cal change for ≥4 hours desp te adequate contract ons (usually def ned as >200 Montev deo
un ts [MVU])
● No cerv cal change for ≥6 hours w th nadequate contract ons
G ven the slowness of the latent phase, latent phase arrest s not cons dered a cl n cal d agnos s.
Management
Prolonged latent phase — Management of labor abnormal t es before 6 cm d lat on ( e, latent phase) s
rev ewed separately. (See "Latent phase of labor", sect on on 'Management of latent phase'.)
D lat on ≤1 cm over two hours n act ve phase — For pat ents (null parous or mult parous) n the act ve
phase (cerv x ≥6 cm) who d late ≤1 cm over two hours, we adm n ster oxytoc n ( f not already started) and
proceed w th amn otomy ( f not already ruptured) f there has been adequate fetal descent to a safe fetal
stat on (eg, -2 or lower) for amn otomy. Oxytoc n adm n strat on for women w th slow progress s reasonable
even n the absence of documented hypocontract le uter ne act v ty [60].
If the head s h gh and not well appl ed to the cerv x, we beg n oxytoc n but delay perform ng amn otomy. If
oxytoc n alone for four to s x hours does not result n adequate progress, we cons der perform ng an
amn otomy at that t me, regardless of fetal head pos t on. A controlled amn otomy s performed f the head s

st ll h gh and not well appl ed to the cerv x. (See "Umb l cal cord prolapse", sect on on 'M n m z ng r sk from
obstetr c maneuvers'.)
In a 2013 meta-analys s of random zed tr als, our approach: early ntervent on w th oxytoc n and amn otomy,
reduced the t me to del very by approx mately 1.5 hours [61]. Maternal sat sfact on s also mproved [62,63].
Alternat vely, expectant management can be cons dered. Although meta-analyses have shown that the mean
durat on of labor can be shortened by these ntervent ons [61,64], cesarean del very and nstrumental del very
rates were not affected.
Oxytoc n augmentat on — Oxytoc n s the only med cat on approved by the US Food and Drug
Adm n strat on for labor st mulat on n the act ve phase. It s typ cally dosed to effect, as pred ct ng a women's
response to a part cular dose s not poss ble [65]. We t trate the dose to obta n an adequate uter ne
contract on pattern and do not generally exceed a dose of 30 m ll un ts/m nute, but others have used cutoffs
of 20 or 40 m ll un ts/m nute.
After four hours of adequate uter ne contract ons (usually def ned as >200 MVU f an nternal pressure
catheter s n place), or s x hours w thout adequate uter ne contract ons and no cerv cal change n the act ve
phase of labor, we proceed w th cesarean del very. If labor s progress ng, e ther slowly or normally, we
cont nue oxytoc n at the dosage requ red to ma nta n an adequate uter ne contract on pattern.
Dos ng reg men — Numerous oxytoc n dos ng protocols that vary n n t al dose, ncremental dose
ncrease, and t me nterval between dose ncreases have been stud ed (table 3). (See "Induct on of labor w th
oxytoc n", sect on on 'Dose t trat on and ma ntenance'.)
The dec s on to use a h gh- versus a low-dose oxytoc n reg men poses a r sk-benef t d lemma: H gher-dose
reg mens are assoc ated w th shorter labor and fewer cesareans but more tachysystole (>5 contract ons n 10
m nutes, averaged over a 30-m nute w ndow). The value placed on each of these outcomes and the ab l ty to
respond to tachysystole may vary among labor and del very un ts. Therefore, e ther a h gh- or low-dose
oxytoc n reg men s acceptable and should depend on local factors. We use a h gh-dose reg men and do not
alter our management based on par ty [44,66,67], w th one mportant except on: We do not use a h gh-dose
reg men n women who have had a prev ous cesarean del very because of r sk of rupture [66].
Low-dose reg mens were developed, n part, to avo d uter ne tachysystole and are based upon the
observat on that t takes 40 to 60 m nutes to reach steady-state oxytoc n levels n maternal serum [68]. A
2010 systemat c rev ew of random zed tr als of h gh- versus low-dose oxytoc n for augmentat on of women n
spontaneous labor (10 tr als, n = 5423 women) found that h gh-dose oxytoc n [69]:
● Increased the frequency of tachysystole (relat ve r sk [RR] 1.91, 95% CI 1.49-2.45)
● Decreased the cesarean del very rate (RR 0.85, 95% CI 0.75-0.97) and ncreased the rate of
spontaneous vag nal del very (RR 1.07, 95% CI 1.02-1.12)
● Decreased the total durat on of labor (mean d fference -1.54 hours, 95% CI -2.44 to -0.64 hours)
● Resulted n s m lar maternal and neonatal morb d t es
A 2013 systemat c rev ew had fewer tr als because t excluded those nvolv ng augmentat on as part of an
act ve management of labor protocol, but came to s m lar conclus ons [70].
Ineffect ve and less well stud ed approaches
● M soprostol – Oxytoc n w th or w thout amn otomy s the best approach for treatment of a protract on
d sorder, based on extens ve exper ence and data attest ng to safety and eff cacy. The body of ev dence
does not support us ng any alternat ve pharmacolog c approach. M soprostol s typ cally used for cerv cal
r pen ng and labor nduct on; there are l m ted data on ts safety and eff cacy for treatment of protract on

d sorders [71,72]. However, low-dose t trated m soprostol may be a reasonable alternat ve n low-
resource sett ngs where safe oxytoc n nfus on s not feas ble.
● Ambulat on may mprove the comfort of the partur ent and s not harmful, but there s no conv nc ng
ev dence that th s ntervent on prevents or treats protract on or arrest d sorders [73].
● Amn otomy alone – As d scussed below, rout ne amn otomy alone d d not clearly shorten the f rst or
second stage n a meta-analys s of random zed tr als [74], whereas the comb nat on of amn otomy and
oxytoc n had benef c al effects [61]. However, most of the tr als d d not clearly d st ngu shed between
amn otomy for prevent on versus treatment of dysfunct onal labor. In the only tr al that randomly ass gned
60 women at term mak ng slow progress n the f rst stage to amn otomy plus oxytoc n, amn otomy alone,
or expectant management, only the comb nat on of amn otomy plus oxytoc n ncreased the rate of
cerv cal d lat on; the mpact on the cesarean del very rate was d ff cult to assess because the tr al was
underpowered for th s outcome [75]. (See 'Prevent on of f rst stage labor abnormal t es' below.)
Act ve phase arrest — Women w th labor arrest n the act ve phase of the f rst stage are managed by
cesarean del very. The key ssue s us ng appropr ate cr ter a for d agnos ng labor arrest. Some unnecessary
cesareans w ll be performed n arrest s d agnosed too soon, and maternal compl cat ons (eg, uter ne rupture)
are l kely to ncrease f arrest s d agnosed too late. We use the cr ter a descr bed above, proposed by a
workshop convened by the NICHD, SMFM, and ACOG and based on contemporary data cr ter a. (See
'Arrest' above.)
These cr ter a were based on the follow ng stud es. These stud es showed that oxytoc n augmentat on for at
least four hours, rather than the h stor cal standard of two hours, before d agnos ng arrest s safe for mother
and fetus and ncreases the chances of ach ev ng a vag nal del very. They also show that vag nal del very s
often poss ble desp te levels of uter ne act v ty and rates of cerv cal d lat on below the range h stor cally
cons dered necessary for success.
● A prospect ve study nclud ng 542 women n spontaneous labor at term w th act ve phase labor arrest
(def ned as cerv x ≥4 cm d lated and ≤1 cm of cerv cal progress n four hours) evaluated a protocol
whereby oxytoc n augmentat on was n t ated and cesarean del very was not performed for labor arrest
unt l (1) the woman exper enced at least four hours uter ne contract ons >200 MVUs or (2) the woman
exper enced a m n mum of s x hours of oxytoc n augmentat on f th s contract on pattern could not be
ach eved [44]. Only 12 percent of women d d not ach eve the target 200 MVUs.
The authors found that 91 percent of mult paras and 74 percent of null paras who had not progressed
(≤1 cm add t onal d lat on) by the trad t onal two hours of oxytoc n adm n strat on and thus would have
undergone cesarean del very at that t me went on to ach eve a vag nal del very. Indeed, wa t ng at least
four hours before perform ng a cesarean for labor arrest allowed 88 percent of mult paras and 56 percent
of null paras to ach eve a vag nal del very.
● The same nvest gators subsequently used a standard zed protocol to manage 501 consecut ve, term,
spontaneously labor ng women w th slow labor progress [45]. The protocol nvolved adm n strat on of
oxytoc n to ach eve at least 200 MVUs for four hours before cons der ng cesarean del very.
In th s study, 80 percent of null parous women and 95 percent of mult parous women had a vag nal
del very, whether or not they were able to ach eve and/or ma nta n the MVU goal. Mean (5th percent le)
rates of cerv cal d lat on n null paras and mult paras were 1.4 cm/hour (0.5) and 1.8 cm/hour (0.5),
respect vely.
Prevent on of f rst stage labor abnormal t es — There s no strong ev dence that any ntervent on w ll
prevent f rst stage protract on and arrest d sorders.
● Amn otomy -- Amn otomy s the most common ntervent on that has been proposed for shorten ng the
durat on of labor. Rout ne amn otomy alone versus ntent on to preserve the membranes (no amn otomy)

d d not clearly shorten the f rst or second stage n a meta-analys s of random zed tr als [74]. However, n
another meta-analys s, the comb nat on of early amn otomy and early oxytoc n adm n strat on versus
rout ne care for women n spontaneous labor shortened the f rst stage (mean d fference -1.57 hours,
95% CI -2.15 to -1.00), and poss bly resulted n a small decrease n cesarean del very (RR 0.87, 95% CI
0.77-0.99) [61]. The potent al small benef ts of the comb ned ntervent on are not suff c ently compell ng
to warrant a recommendat on for a change n rout ne management of spontaneous labor. (See
"Management of normal labor and del very", sect on on 'Amn otomy'.)
● Neurax al anesthes a -- Avo d ng or delay ng neurax al anesthes a to potent ally reduce the r sk of labor
abnormal t es s not recommended. ACOG has stated that the dec s on to place a neurax al anesthet c
should depend upon the pat ent's w shes w th cons derat on of factors, such as par ty, also taken nto
account [76]. In part cular, concern about future labor progress should not be a reason to requ re a
woman to reach an arb trary cerv cal d lat on, such as 4 to 5 cm, before fulf ll ng her request to rece ve
neurax al anesthes a.
PROLONGED SECOND STAGE
D agnos s — The appropr ate durat on and max mum length of t me allowed for the second stage of labor s
not clearly def ned. Par ty, reg onal anesthes a, and delayed push ng n add t on to other cl n cal
cons derat ons all s gn f cantly mpact the length of the second stage.
We follow the 2014 Obstetr c Care Consensus statement of recommendat ons for safe prevent on of pr mary
cesarean del very by the Amer can College of Obstetr c ans and Gynecolog sts and the Soc ety for Maternal-
Fetal Med c ne [77]. These recommendat ons are used as a pragmat c approach for d agnos s of a prolonged
second stage and are supported by the data from Zhang et al (table 1), wh ch we bel eve s the best gu de for
establ sh ng the normal durat on for the second stage of labor (med an and 95th cent le). The follow ng s a
summary of the statement/recommendat ons [77]:
● For null parous women, allow three hours of push ng, and for mult parous women, allow two hours of
push ng pr or to d agnos ng arrest of labor, when maternal and fetal cond t ons perm t
● Longer durat ons may be appropr ate on an nd v dual bas s (eg, ep dural anesthes a, fetal malpos t on)
as long as progress s be ng documented
● A spec f c absolute max mum length of t me that should be allowed n the second stage of labor has not
been dent f ed
Based on these recommendat on and those of a 2012 workshop (Nat onal Inst tute of Ch ld Health and
Human Development workshop Prevent ng the F rst Cesarean Del very) [59], many obstetr c prov ders allow
an extra hour of push ng for women w th an ep dural, and good outcomes have been reported [78].
Of note, th s statement does not prov de spec f c cr ter a for the upper l m t of the second stage; t merely
states that arrest should not be d agnosed before passage of a spec f c m n mum per od of t me. It should
also be noted that the use of these cr ter a has been challenged by some experts, who bel eve that the safety
of extend ng the second stage to these lengths, part cularly n null parous women w th an ep dural, has not
been establ shed [11,79].
Assess ng progress ve, but small, degrees of descent and rotat on by phys cal exam nat on s challeng ng.
Add t onal phys cal f nd ngs can support the d agnos s of arrest due to cephalopelv c d sproport on. The soft
bones and open sutures of the fetal skull (f gure 6) allow t to change n shape ( e, mold ng) and thus adapt to
the maternal pelv s dur ng descent. Some overlap of the par etal and occ p tal bones at the lambdo d sutures
and overlap of the par etal and frontal bones at the coronal sutures s common n normal labor [50]. However,
lack of descent w th severe mold ng, espec ally overlap of the par etal bones at the sag ttal suture, s
suggest ve of cephalopelv c d sproport on. L kew se, lack of descent w th malpos t on or malpresentat on s
suggest ve of cephalopelv c d sproport on.
https://www.uptodate.com/contents/normal-and-abnormal-labor-progress on/pr nt?search=normal%20labor&source=search_result&selectedT tl… 10/30

Management
Cand dates for oxytoc n augmentat on — After 60 to 90 m nutes of push ng, we beg n oxytoc n
augmentat on f descent s m n mal ( e, <1 cm) or absent and uter ne contract ons are less frequent than
every 3 m nutes. In the second stage, we are more concerned about a poss ble phys cal ssue (eg,
malpos t on or malpresentat on, macrosom a, small maternal pelv s) slow ng descent than hypocontract le
uter ne act v ty, wh ch s the prom nent concern n the f rst stage. (See 'Hypocontract le uter ne act v ty' above
and 'Oxytoc n augmentat on' above.)
T m ng of operat ve del very — In the absence of ep dural anesthes a, we allow null parous women to
push for at least three hours and mult parous women to push for at least two hours pr or to cons der ng
operat ve ntervent on. We avo d operat ve del very (vacuum, forceps, cesarean) n the second stage as long
as the fetus cont nues to descend and/or rotate to a more favorable pos t on for vag nal del very, and the fetal
heart rate pattern s not concern ng. Prompt operat ve ntervent on s nd cated for fetuses w th category III
fetal heart rate trac ngs, regardless of labor progress. (See "Management of ntrapartum category I, II, and III
fetal heart rate trac ngs".)
In women who have ep dural anesthes a, we allow an add t onal hour of push ng on a case-by-case bas s
before cons der ng operat ve ntervent on for a prolonged second stage. Extend ng the durat on of the second
stage to four hours n null parous women and three hours n mult parous women w th ep dural anesthes a
may ncrease the chance of ach ev ng a vag nal del very, w thout s gn f cantly ncreas ng maternal or neonatal
morb d ty, but ev dence s l m ted to retrospect ve data [80] and a small random zed tr al [78]. In the
random zed tr al of 78 null parous women w th ep dural anesthes a who had not del vered three hours after
reach ng full cerv cal d lat on, ntent on to extend labor by at least one hour resulted n a lower cesarean rate
compared w th exped t ng del very by an operat ve method (19.5 versus 43.2 percent, relat ve r sk [RR] 0.45,
95% CI 0.22-0.93) [78]. However, the tr al was underpowered to detect small but cl n cally mportant
d fferences n the frequency of adverse outcomes between groups or prov de a prec se est mate of cesarean
rate. Importantly, the durat ons of the second stage for each group were not s gn f cantly d fferent, n part
because 14 percent of the cohort crossed-over from the r ass gned group.
Whether to extend the durat on of the second stage beyond four hours n null parous women and beyond
three hours n mult parous women w th ep dural anesthes a (or beyond three hours n null parous women and
beyond two hours n mult parous women w thout ep dural anesthes a) s controvers al, as a prolonged second
stage has potent al cl n cal challenges and consequences [21,81,82]:
● If a cesarean del very s necessary, a prolonged second stage may result n the fetal head trapped deep
n the pelv s, wh ch ncreases the d ff culty of del ver ng the fetus. Reverse breech extract on may reduce
the r sk of a d ff cult del very or njury to the uter ne vessels (see "Management of deeply engaged and
float ng fetal presentat ons at cesarean del very", sect on on 'Preferred approach: Reverse breech
extract on ("pull method")').
A prolonged second stage may also further th n the lower uter ne segment, ncreas ng the r sk of
extens on of the hysterotomy nto the uter ne vessels at cesarean.
● Prolong ng the second stage appears to ncrease the r sk for postpartum hemorrhage and maternal
nfect on.
● Prolong ng the second stage may worsen neonatal outcome. (See 'Maternal and newborn outcomes
assoc ated w th abnormal labors' below.)
The mportance of cl n cal exper ence and judgment regard ng management of the second stage of labor
must be emphas zed, part cularly when the durat on of the second stage approaches or exceeds two to three
hours. Th s can be a challeng ng cl n cal scenar o where the r sks of both maternal and neonatal morb d ty are
ncreased. We only allow labor to cont nue f our judgment suggests safe vag nal del very s ach evable.

Numerous cl n cal factors need to be cons dered. Examples of these factors and how they may favor
expectant management s llustrated below:
● Obstetr c h story – A prev ous vag nal del very
● Med cal/surg cal h story – No comorb d t es l kely to mpact labor
● Cl n cal pelv metry – Pelv s deemed adequate for vag nal del very based on phys cal exam nat on
● Maternal he ght and we ght – Grav da s not short and/or obese
● Fetal pos t on – Occ put anter or, m n mal caput and mold ng
● Maternal temperature – Absence of temperature ≥38.0°C (102.2°F) (presumpt ve chor oamn on t s)
● Est mated fetal we ght – Appropr ate for gestat onal age
● Effect veness of maternal push ng – Effect ve push ng, mother s not exhausted
● Fetal heart trac ng – Category I trac ng
● Woman's des re to proceed w th labor
If the woman has not been push ng or not effect vely push ng, then we factor that nto cons derat on and are
more l kely to have her cont nue to push. If the fetal stat on s st ll h gh, the est mated fetal we ght s >4000 to
4500 g, chor oamn on t s s suspected, or s gn f cant decelerat ons are present, we generally proceed w th
cesarean del very. When the fetal heart rate trac ng s reassur ng and maternal push ng s result ng n
progress ve descent, we d scuss w th the pat ent the opt ons of an operat ve vag nal ( f she s an appropr ate
cand date (see "Operat ve vag nal del very", sect on on 'Prerequ s tes')) or cesarean del very versus
cont nued push ng. In our exper ence, unless del very occurs or appears to be mm nent w th n the next 30 to
45 m nutes, we proceed w th an operat ve del very.
Ineffect ve management ntervent ons
● Turn ng down the ep dural – A dense motor block may mpa r a woman's ab l ty to push, but there s no
strong ev dence that turn ng down the neurax al anesthet c n women w th a prolonged second stage s
benef c al. In a meta-analys s nclud ng f ve tr als n wh ch pat ents w th ep durals were randomly
ass gned to d scont nuat on late n labor or cont nuat on unt l b rth, early d scont nuat on d d not clearly
reduce nstrumental del very (23 versus 28 percent, RR 0.84, 95% CI 0.61-1.15) or other adverse
del very outcomes [83]. (See "Adverse effects of neurax al analges a and anesthes a for obstetr cs",
sect on on 'Effects on the progress and outcome of labor'.)
● Chang ng maternal pos t on – There s no strong ev dence that a change n maternal pos t on (eg,
upr ght posture, lateral, or hands and knees pos t on nstead of sup ne) s useful for treatment of a
prolonged second stage [84-86]. Women should be encouraged to labor and g ve b rth n the pos t on
they f nd most comfortable.
● Fundal pressure – Manual fundal pressure does not s gn f cantly shorten the durat on of the second
stage, although ava lable data are low qual ty [87].
Prevent on of prolonged second stage — There s no strong ev dence that any ntervent on w ll prevent a
prolonged second stage of labor. The follow ng ntervent ons have been stud ed.
● Delayed push ng – In a 2017 meta-analys s of tr als of push ng/bear ng methods n women w th ep dural
anesthes a, delayed push ng decreased the durat on of push ng by a mean of 19 m nutes but ncreased
the durat on of the second stage by a mean of 56 m nutes compared w th mmed ate push ng [88].
Delayed push ng was also assoc ated w th a small ncrease n spontaneous vag nal del very (for
null paras: 76 versus 71 percent, RR 1.07, 95% CI 1.02-1.11; 12 stud es, 3114 women). Although the
frequency of low umb l cal cord blood pH was ncreased (4.5 versus 2.0 percent, RR 2.24, 95% CI 1.37-
3.68), no d fferences were observed n rates of adm ss on to neonatal ntens ve care or f ve-m nute Apgar
score less than 7.
● Maternal pos t on and techn que do not appear to affect the length of the second stage. (See
"Management of normal labor and del very", sect on on 'Push ng pos t on and techn que'.)
● Role of exerc se:
• Pelv c floor muscle exerc ses – Tra n ng the muscles of the pelv c floor may prevent some cases of
prolonged second stage. One tr al randomly ass gned 301 healthy null parous women to an
antepartum pelv c floor muscle tra n ng program or usual care from 20 to 36 weeks of gestat on [89].
Women n the ntervent on group tra ned w th a phys otherap st for one hour/week and were
encouraged to perform 8 to 12 ntens ve pelv c floor muscle contract ons tw ce da ly. Women n the
exerc se group were less l kely to have a second stage over 60 m nutes than controls (21 versus 34
percent), but the overall durat on of the second stage was s m lar for both groups (40 and 45
m nutes, respect vely), as was the rate of nstrumental del very (15 and 17 percent, respect vely).
• Exerc se – Exerc se dur ng pregnancy mproves f tness, but does not affect the length of labor. In
two tr als, women randomly ass gned to part c pat on n an aerob c exerc se program dur ng
pregnancy had the same overall durat on of labor as women who rece ved standard prenatal care
[90,91]. Although the smaller tr al (n = 91 women) observed a reduct on n pr mary cesarean del very
n the exerc se group [90], the larger tr al (n = 855 women) found no d fference n labor outcomes
[91].
In add t on, t should be noted that women who are not able to push because of a sp nal cord njury
tend to have a normal, or even short, second stage [92].
MATERNAL AND NEWBORN OUTCOMES ASSOCIATED WITH ABNORMAL LABORS — For the mother,
f rst and second stage protract on d sorders have been assoc ated w th ncreased r sks for operat ve vag nal
del very, th rd-/fourth-degree per neal lacerat ons, cesarean del very, ur nary retent on, postpartum
hemorrhage, and chor oamn on t s n observat onal stud es [2,33,93-100]. A prolonged second stage has also
been assoc ated w th pelv c floor njury, but th s s l kely related to nstrumental ntervent on rather than the
spec f c length of the second stage [21,82,96,97,101,102].
For the neonate, a protracted f rst stage of labor has been assoc ated w th ncreased r sks for adm ss on to
the neonatal ntens ve care un t and f ve-m nute Apgar score <7, but no ncreased r sk for ser ous morb d ty or
mortal ty. In contrast, n many but not all stud es, a prolonged second stage has been assoc ated w th a small
absolute ncrease n ser ous neonatal morb d ty (se zures, hypox c- schem c encephalopathy, seps s) and
mortal ty [12,79,95,97,99,103]. In one such study, the rate of b rth asphyx a-related compl cat ons
progress vely ncreased w th durat on 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 tself may not be the causal factor for these adverse outcomes; factors
such as pers stent malpos t on or macrosom a may both prolong the second stage and ncrease maternal
and/or neonatal morb d ty. It rema ns unclear whether perform ng a cesarean del very late n the second stage
of labor would reduce the r sk of adverse outcomes compared w th cont nued labor. As d scussed above, a
small random zed tr al of null parous women w th a prolonged second stage found no d fference n the rates
of maternal and neonatal compl cat ons when labor was extended for at least one hour versus exped ted
operat ve del very, but the tr al was underpowered to detect small d fferences n these outcomes [78].
SOCIETY GUIDELINE LINKS — L nks to soc ety and government-sponsored gu del nes from selected
countr es and reg ons around the world are prov ded separately. (See "Soc ety gu del ne l nks: Labor".)
SUMMARY AND RECOMMENDATIONS

● The Fr edman curve (f gure 1) and the norms establ shed from Fr edman's data h stor cally had been
w dely accepted as the standard for assessment of normal labor progress on. However, Zhang and
others have proposed a contemporary curve (f gure 2) and norms (table 1) that are d fferent and slower
from those c ted by Fr edman. (See 'Fr edman (h stor c) cr ter a' above and 'Contemporary cr ter a'
above.)
● Labor abnormal t es may be related to hypocontract le uter ne act v ty, neurax al anesthes a, obes ty,
and/or absolute or relat ve obstruct on due to factors such as fetal s ze/pos t on, Bandl’s r ng, or a small
maternal bony pelv s. (See 'R sk factors' above.)
● The normal durat on of the latent phase tends to be longer n nduced labors than spontaneous labors,
but the act ve phase and second stage have s m lar durat ons whether labor s spontaneous or nduced.
(See 'Normal progress on n nduced labors' above.)
F rst stage
● The d agnos s of a protracted act ve phase s made n women at ≥6 cm d lat on who are d lat ng less than
about 1 to 2 cm/hour, wh ch reflects the 95th cent le. Slow cerv cal d lat on before 6 cm reflects the
shallow slope of the latent phase port on of the normal labor curve. (See 'F rst stage' above and
'Protract on' above.)
● The d agnos s of act ve phase arrest s made n women at ≥6 cm cerv cal d lat on w th ruptured
membranes and e ther no cerv cal change for ≥4 hours desp te adequate contract ons or no cerv cal
change for ≥6 hours w th nadequate contract ons. (See 'Arrest' above.)
● For women (null parous or mult parous) n the act ve phase who d late ≤1 cm over two hours, we
adm n ster oxytoc n and proceed w th amn otomy f there has been adequate fetal descent, except when
the head s h gh and not well appl ed to the cerv x. In these cases, we beg n oxytoc n but delay
perform ng amn otomy. If oxytoc n alone for four to s x hours does not result n adequate progress, we
cons der perform ng an amn otomy at that t me. A controlled amn otomy s performed f the head s st ll
h gh and not well appl ed to the cerv x. (See 'D lat on ≤1 cm over two hours n act ve phase' above.)
● We use a h gh-dose oxytoc n reg men (table 3) regardless of par ty, except n women who have had a
prev ous cesarean del very. (See 'Dos ng reg men' above.)
● In pregnanc es w th reassur ng maternal and fetal status, f there has been no cerv cal change after four
hours of adequate (>200 Montev deo un ts) uter ne contract ons or s x hours w thout adequate uter ne
contract ons n the act ve phase, we proceed w th cesarean del very. If labor s progress ng, e ther slowly
or normally, we cont nue oxytoc n at the dosage requ red to ma nta n an adequate uter ne contract on
pattern. (See 'Oxytoc n augmentat on' above.)
Second stage
● Par ty, reg onal anesthes a, delayed push ng, and other cl n cal factors s gn f cantly mpact the length of
the second stage. A pragmat c approach s to d agnose a prolonged second stage when a null parous
woman w thout ep dural anesthes a has pushed for three hours or a mult parous women w thout ep dural
anesthes a has pushed for two hours; an add t onal hour s added for women w th ep dural anesthes a.
(See 'D agnos s' above.)
● For women n the second stage w th m n mal ( e, <1 cm) or absent descent after 60 to 90 m nutes of
push ng and uter ne contract ons less frequent than every 3 m nutes, we beg n oxytoc n augmentat on. In
the second stage, we are more concerned about a poss ble phys cal ssue (eg, malpos t on or
malpresentat on, macrosom a, small maternal pelv s) slow ng descent than hypocontract le uter ne
act v ty. (See 'Cand dates for oxytoc n augmentat on' above.)

● In the absence of ep dural anesthes a, we allow null parous women to push for at least three hours and
mult parous women to push for at least two hours pr or to cons der ng operat ve ntervent on. We avo d
operat ve del very (vacuum, forceps, cesarean) n the second stage as long as the fetus cont nues to
descend and/or rotate to a more favorable pos t on for vag nal del very, and the fetal heart rate pattern s
not concern ng. In women who have ep dural anesthes a, we allow an add t onal hour of push ng on a
case-by-case bas s before cons der ng operat ve ntervent on for a prolonged second stage. Prompt
operat ve ntervent on s nd cated for fetuses w th category III fetal heart rate trac ngs, regardless of
labor progress. (See 'T m ng of operat ve del very' above.)
● Whether to extend the durat on of the second stage beyond four hours n null parous women and beyond
three hours n mult parous women w th ep dural anesthes a (or beyond three hours n null parous women
and beyond two hours n mult parous women w thout ep dural anesthes a) s controvers al as a
prolonged second stage has potent al cl n cal challenges and adverse consequences. We only allow
labor to cont nue f our judgement suggests safe vag nal del very s ach evable. (See 'T m ng of operat ve
del very' above and 'Maternal and newborn outcomes assoc ated w th abnormal labors' above.)
Use of UpToDate s subject to the Subscr pt on and L cense Agreement.
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Top c 4464 Vers on 84.0

GRAPHICS
Friedman labor curve
First stage = A + B + C + D, where 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 1
Parity 0
Median number of
Median number of hours
hours
(95 th percentile) th
(95 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)
Note the 95 th percentile for duration of time to dilate from 4 to 6 cm is almost 10 hours in nulliparous women.
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 with spontaneous onset of
labor, vaginal delivery, and normal neonatal outcomes. Note that for parous women the
inflection point for acceleration of cervical dilation is at about 6 cm and that there is no
clear inflection point for nulliparous women.
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 women with spontaneous onset of labor, vaginal delivery, and normal neonatal
outcomes. Colors represent cervical dilation when women were 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 between a straight line drawn along the longitudinal
axis of the pubic bone and a line drawn 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
Chorioamnionitis
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 (arrows) in a 10-minute window 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
Dosage
Starting dose, Incremental increase,
Regimen interval,
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- 4 4 15
dose
Oxytocin should be administered by trained personnel who are familiar with its effects. It should be administered
using an infusion pump that provides precise flow rate to ensure accurate minute to minute control. Most clinicians
will 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, whereas the posterior fontanelle is triangular, at the
intersection of three fetal skull bones, and usually the smaller fontanelle.

Contr butor D sclosures

Robert M Ehsan poor, MD Noth ng to d sclose Andrew J Sat n, MD, FACOG Noth ng to
d sclose V ncenzo Berghella, MD Noth ng to d sclose Vanessa A Barss, MD, FACOG Noth ng to d sclose
Contr butor d sclosures are rev ewed for confl cts of nterest by the ed tor al group. When found, these are
addressed by vett ng through a mult -level rev ew process, and through requ rements for references to be
prov ded to support the content. Appropr ately referenced content s requ red of all authors and must conform
to UpToDate standards of ev dence.
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Normal and abnormal labor progress on

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● Th rd stage – T me between fetal expuls on and placental expuls on.

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ASSESSMENT OF LABOR PROGRESS

● At two- to four-hour ntervals n the f rst stage

● Pr or to adm n ster ng analges a/anesthes a

● At one- to two-hour ntervals n the second stage

OVERVIEW OF PROTRACTION AND ARREST DISORDERS

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D agnos s — Cephalopelv c d sproport on s a subject ve cl n cal assessment based on phys cal

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FIRST STAGE PROTRACTION AND ARREST

● No cerv cal change for ≥6 hours w th nadequate contract ons

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● Increased the frequency of tachysystole (relat ve r sk [RR] 1.91, 95% CI 1.49-2.45)

● Resulted n s m lar maternal and neonatal morb d t es

Ineffect ve and less well stud ed approaches

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PROLONGED SECOND STAGE

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● Obstetr c h story – A prev ous vag nal del very

● Med cal/surg cal h story – No comorb d t es l kely to mpact labor

● Maternal he ght and we ght – Grav da s not short and/or obese

● Maternal temperature – Absence of temperature ≥38.0°C (102.2°F) (presumpt ve chor oamn on t s)

● Fetal heart trac ng – Category I trac ng

● Woman's des re to proceed w th labor

Ineffect ve management ntervent ons

● Role of exerc se:

SUMMARY AND RECOMMENDATIONS

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Top c 4464 Vers on 84.0

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Friedman labor curve

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

Graphic 53413 Version 4.0

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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

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Contemporary labor curves by parity

Graphic 89190 Version 5.0