European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review article

Duration of spontaneous labour in ‘low-risk’ women with ‘normal’

perinatal outcomes: A systematic review
Edgardo Abalosa,* , Olufemi T. Oladapob , Mónica Chamillarda , Virginia Díaza ,
Julia Pasqualea , Mercedes Bonetb , Joao Paulo Souzab , A. Metin Gülmezoglub
a
Centro Rosarino de Estudios Perinatales, Moreno 878, P6. (2000), Rosario, Argentina
b
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of
Reproductive Health and Research (RHR), World Health Organization, Avenue Appia 20, Geneva 27 CH-1211, Switzerland

A R T I C L E I N F O A B S T R A C T

Article history: Background: Despite decades of research, the concept of normality in labour in terms of its progression
Received 15 January 2018 and duration is not universal or standardized. However, in clinical practice, it is important to define the
Received in revised form 25 February 2018 boundaries that distinguish what is normal from what is abnormal to enable women and care providers
Accepted 26 February 2018
have a shared understanding of what to expect and when labour interventions are justified.
Objectives: To synthesise available evidence on the duration of latent and active first stage and the second
Keywords: stage of spontaneous labour in women at low risk of complications with ‘normal’ perinatal outcomes.
Normal labour
Search strategy: PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible
First and second stage of labour
Labour onset
studies.
Labour duration Selection criteria: Observational studies and other study designs.
Systematic review Data collection and analysis: Four authors extracted data on: maternal characteristics; labour
interventions; duration of latent first stage, active first stage, and second stage of labour; and the
definitions of onset of latent and active first stage, and second stage where reported. Heterogeneity in the
included studies precluded meta-analysis and data were presented descriptively.
Main results: Thirty-seven studies reporting the duration of first and/or second stages of labour for
208,000 women met our inclusion criteria. Among nulliparous women, the median duration of active
first stage (when the starting reference point was 4 cm) ranged from 3.7–5.9 h (95th percentiles: 14.5–
16.7 h). With active phase starting from 5 cm, the median duration was from 3.8–4.3 h (95th percentiles:
11.3–12.7 h). The median duration of second stage ranged from 14 to 66 min (95th percentiles: 65–
138 min) and from 6 to 12 min (95th percentiles: 58–76 min) in nulliparous and parous women,
respectively. Sensitivity analyses excluding first and second stage interventions did not significantly
impact on these findings
Conclusions: The duration of spontaneous labour in women with good perinatal outcomes varies from one
woman to another. Some women may experience labour for longer than previously thought, and still
achieve a vaginal birth without adverse perinatal outcomes. Our findings question the rigid limits
currently applied in clinical practice for the assessment of prolonged first or second stage that warrant
obstetric intervention.
© 2018 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Characteristics of included studies and study populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Definition of phases and stages of labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

* Corresponding author.
E-mail addresses: edgardoabalos@crep.org.ar, crep@crep.org.ar (E. Abalos).

https://doi.org/10.1016/j.ejogrb.2018.02.026
0301-2115/© 2018 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
124 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132

Duration of labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Latent first stage (nulliparous and parous women) . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Active first stage (nulliparous and parous women) . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Second stage of labour (nulliparous and parous women) ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Main findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Strength and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Contribution to authorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Introduction population of interest. We included studies where the population

Despite the traditional division of labour into phases and stages
for clinical convenience, what constitutes normal labour in terms
of its progression and duration is not universal or standardized.
This is in part related to the complexity of the onset of labour and
the fact that transition between its phases and stages can only be
objectively determined in retrospect. Evidence on the duration of
the first stage of labour has largely been shaped by Friedman’s
observations in the 1950s and 1960s when he subdivided the first
stage of labour into an initial latent phase characterized by a slow
progression in cervical dilatation up to 2 or 3 cm, followed by an
active phase, when cervical dilatation rate significantly increases
[1–3]. The time limits proposed from these studies became the
benchmarks for assessment of normal labour progression [4–6]
and the need for interventions to accelerate or terminate labour
when it extends beyond these boundaries. However, over the past
two decades, the prescribed duration of latent and active first
stage, and second stage of labour, has increasingly been questioned
as a result of new evidence suggesting that the description of
labour progression that was proposed six decades ago may be
inappropriate [7–12].
The applicability of these safe time limits has become even
more problematic in contemporary practice because of the
variations in how onset of phases and stages of labour are defined.
For instance, active first stage has been redefined through a recent
professional consensus as starting from a cervical dilatation of
6 cm instead of 3 or 4 cm that has been traditionally applied [13].
Without a clear linkage between the definition and duration of
phases and stages of labour, interventions to correct deviations
from what is considered physiological progress of first and second
stages [13] to prevent adverse maternal or neonatal outcomes may
be unnecessary in some situations or even harmful [14].
The aim of this review was to synthesise available evidence on
the duration of first (latent and active) and second stages of
spontaneous labour in women without risk factors for complica-
tions and with good maternal and perinatal outcomes.
Methods
We conducted this review in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines, and followed a protocol (CRD42017054314)
[15]. Eligible studies included all published and unpublished
observational studies reporting on the duration of the first stage
(discriminating whenever possible its latent and active phases)
and the second stage of labour for women with low risk of
complications with ‘normal’ perinatal outcomes. We considered
other study designs (randomized trials and non-randomized
studies) where these observations were reported for our
was defined as ‘healthy women’, ‘women without risk factors for
complications’, women deemed to be ‘low-risk’, or with clearly
defined criteria including at the minimum singleton pregnancy,
near term or term pregnancy, and cephalic presentation. ‘Normal
perinatal outcomes’ were as defined by primary authors, but must
include at least the birth of a live baby with Apgar score 7 at
5 min. We excluded studies involving women with induction of
labour, morbidities or risk factors (e.g. gestational diabetes,
hypertensive disorders, previous caesarean section), and those
that applied ‘active management of labour’, or included first stage
caesarean sections. Reviews, commentaries and letters were also
excluded.
The outcomes of interest were the duration of the first stage
(total, latent phase, and active phase) and the second stage of
labour. We extracted information on the definitions of phases and
stages of labour in terms of the characteristic features and
reference points as reported by study authors, as well as baseline
information and interventions during labour.
We searched PubMed, EMBASE, CINAHL, POPLINE, and Global
Health Library using key concepts related to ‘spontaneous labour’,
‘labour onset’, ‘labour duration’, ‘cervical dilatation’, ‘labour
pattern’, ‘latent phase’, ‘active phase’, ‘first stage of labour’, and
‘second stage of labour’. Searches for grey literature and
bibliographies of related systematic reviews and eligible studies
complemented the search strategies. There were no date or
language restrictions. Details of the search strategy are presented
in Box S1. Four review authors (EA, MC, VD and JP) independently
screened the titles and abstracts, assessed the full texts of
potentially eligible studies, and extracted data. Disagreements
were resolved by discussion.
We extracted information on the duration of labour according
to parity groups: nulliparous (parity = 0) and parous women
(parity  1). For each parity group, we extracted the measure of
central tendency and corresponding dispersion as reported by the
authors according to latent first stage, active first stage, and second
stage of labour. Given the significant methodological heterogeneity
and variations in reporting format, data across studies were not
meta-analysed but descriptively presented for each study accord-
ing to the central measure of tendency (i.e. median and percentiles
or mean and standard deviations). We reported upper limits of
median as 95th percentiles (P95th) and upper limits of mean as
mean + 2 standard deviations (2SD, the so called “statistical limits”
or “statistical maximum”) as reported by the study authors. In
situations where statistical limit is not reported for the mean, we
deduced these values from the reported standard deviation.
The methodological quality of eligible studies was assessed to
investigate internal validity (the extent to which the information is
probably free of bias) and external validity (the extent to which the
study provides the correct basis for applicability to other
 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132
circumstances) with the following five attributes: intent of the
study research question, representativeness of the study popula-
tion, temporality of observations, adequacy of reference points and
use of a valid measure of central tendency to report data (Table S1).
Studies were graded as A, B or C if they were scored as low risk of
bias in at least four, three or two or less of the five domains pre-
specified above, respectively.
Results
Fig. 1 summarises the process for identification and selection of
eligible studies. From 5911 citations screened, 193 papers were
selected for full-text review. Thirty-seven studies evaluating the
duration of labour in 203,898 women met our inclusion criteria
[3,7–9,11,12,16–46]. Thirty-two (75,081 women) reported the
outcomes for nulliparous women and 29 (117,829 women) for
parous women. In three studies (10,988 women) [3,27,46] parity
was not reported separately, for that reason they were not included
in the analysis of labour duration.
Characteristics of included studies and study populations
Tables S1 and S2 show the maternal and neonatal character-
istics of nulliparous and parous women, respectively. Studies
included women from different ethnic origins and socio-demo-
graphic backgrounds in 17 countries (China, Columbia, Croatia,
Egypt, Finland, Germany, Israel, Japan, Korea, Myanmar, Nigeria,
Norway, Taiwan, UK, Uganda, USA, and Zambia). Most of them (20/
37) were relatively small, reporting data for a sample of 100 to 900
women, and only five were large (10,000 to more than 60,000
women). Seven studies were published in the 1960s and 1970s, 16
in the 1980s and 1990s, and 14 after year 2000.
Fig. 1. Detailed study selection process.
125
The overall quality of the studies was moderate to low. Ten
studies were graded as A, 14 studies as B, and the remaining 13 as C.
Fig. 2 shows the risk of bias for the five pre-specified domains
according to the number of studies and number of women
included in these studies.
Tables S3 and S4 show the baseline characteristics of women
at labour admission, and the interventions received during
labour according to parity. Many studies did not report the status
of amniotic membranes, cervical effacement or cervical dilata-
tion at labour admission. Although most studies reported the
inclusion of women with spontaneous and normally evolving
labours, some described the use of interventions such as
amniotomy, oxytocin augmentation, and epidural analgesia with
varying frequencies. Amniotomy varied from 0 to 60% (9 studies),
oxytocin augmentation from 0 to 60% (29 studies), epidural use
from 0 to 84% (30 studies), and instrumental vaginal birth from 0
to 73% (32 studies) in nulliparous women. In parous women,
amniotomy ranged from 0 to 71% (8 studies), oxytocin
augmentation from 0 to 45% (26 studies), epidural use from 0
to 77% (25 studies), and instrumental vaginal birth from 0 to 45%
(28 studies).
Definition of phases and stages of labour
Overall, 28 studies reporting data for 185,408 women did not
define labour or its onset. They only made a reference to ‘women in
labour’ or ‘established labour’. Nine studies (18,490 women)
provided a definition of spontaneous labour, such as cervical
dilatation of 3 cm [19] or 4 cm [12] and effacement, or regular
contractions within a 10-min period, [29,33,40] or regular
contractions every 5 min with cervical changes [7,30], or regular
contractions plus a cervical dilatation of 4 cm, [18] or regular
126 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132
Fig. 2. Risk of bias of included studies.
contractions with cervical changes (undefined) and effaced cervix
or descent of the fetal head [27].
First stage of labour was defined in five studies as the time
taken to reach full cervical dilatation from the initial examination
[22,23,26,30], or from the onset of regular contractions perceived
by the woman up to the start of expulsive efforts at full dilatation
[25]. Six studies defined the latent phase of first stage of labour.
Although there was no consistent description of when it starts, in
three studies, the authors confined its end to 2.5 cm [3], 3 cm
[16,23] or 4 cm [43] One study [26] defined the latent phase as the
“duration of labour before presentation to hospital,” and another
as the “length of time from the reported onset of regular
contractions until the time of the examination where the slope of
the cervical dilatation progress was greater than 1.2 cm per hour”
[36]. The onset of active phase of first stage of labour was
varyingly defined in 11 studies. In 10, it commenced at a cervical
dilatation of 1.5 cm, [40] 2.5 cm [3], 3 cm, [16] 4 cm [16–
18,28,29,38,43], or 5 cm [36] and ending at 10 cm (or full
dilatation). In one study, it was defined as the “time spent to
achieve full cervical dilatation from time of arrival in labour
ward” [26].
Nine studies provided definitions of second stage of labour, six
of them as the interval from full cervical dilatation to the expulsion
of the baby [12,17,18,20,30,38]. In the other three the definition
included the predicted or confirmed full dilatation or the time of
maternal spontaneous pushing, whichever occurred first, until
expulsion of the baby [22,24,35].
Duration of labour
Latent first stage (nulliparous and parous women)
In nulliparous, two studies reported the median duration of the
latent first stage lasting from 6.0–7.5 h but without reporting the
corresponding P95th (Table 1). Another two studies reported the
mean duration as 5.1–7.1 h with statistical limits of 10.3–11.5 h. For
parous women, the median duration reported by three studies
ranged from 4.5–5.5 h without recording P95th; and in three other
studies, mean duration was 2.2–5.7 h with statistical limits ranging
from 5.4–8.7 h.
Active first stage (nulliparous and parous women)
Among nulliparous, three studies suggest that the median
duration of active first stage (when the starting reference point was
less than 4.5 cm) ranged from 3.7–8.4 h (P95th: 14.5–20.0 h)
(Table 2). With reference point starting from 5 cm, two studies
reported the median duration of 3.8–4.3 h (P95th:11.3–12.7 h). The
only study recording 6 cm as the starting reference point showed a
median duration of 2.9 h (P95th: 9.5 h). From studies reporting
means, duration of active first stage starting from 2.5 to 4 cm was
3.1–7.7 h, with statistical limits of 6.1–19.4 h in 6 studies. In a small
study (18 women), mean duration of active first stage was 15.4 h
(statistical limit of 28.6 h) in women from the control group
admitted at 5.4 cm mean cervical dilatation. The remaining study
did not report cervical dilatation at admission nor the starting
points for active first stage.
 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132 127

Table 1
Duration of latent phase, nulliparous and parous women.

Nulliparous women

Study N Study Cervical dilatation Definition of starting and ending Median duration (h) 5th 95th
quality on admission (cm) reference points percentile (h) percentile (h)
Peisner 1983a36 1544 A 0.5** Reported onset of contractions until 7.5 – –
slope of labour record > 1.2 cm/h
Ijaiya 2009a26 75 B 5** Duration of labour before 6.0 – –
presentation
Mean duration (h) SD (h) +2SD (h)
Juntunen 1994a29 42 B NR Not defined 5.1 3.2 11.5
Velasco 1985a43 74 B NR From admission until 4 cm 7.1 1.6 10.3

Parous women
Peisner 1983b36 (P = 1) 720 A 4.5** Reported onset of contractions until 5.5 – –
slope of labour record > 1.5 cm/h
Peisner 1983c36 (P  1) 581 A 4.5** Reported onset of contractions until 4.5 – –
slope of labour record > 1.5 cm/h
Ijaiya 2009b26 163 B 6** Duration of labour before 5.0 – –
presentation
Mean duration (h) SD (h) +2SD (h)
Juntunen 1994b29 (P = 2/3) 42 B NR Not defined 3.2 2.3 7.8*
Juntunen 1994c29 (P > 3) 42 B NR Not defined 2.2 1.6 5.4*
Velasco 1985b43 37 B NR From admission until 4 cm 5.7 1.5 8.7*
*
Estimated by authors.
**
Median; P = Parity.

Table 2
Duration of active phase, nulliparous women.

Nulliparous women

Study N Study Cervical dilatation Amniotomy Oxytocin Epidural Definition of starting and Median 5th 95th
quality on admission (cm) (%) (%) (%) ending reference points duration (h) percentile percentile
(h) (h)
Zhang 2010 4247 B 2–2.5** NR 47* 8* From 2 (or 2.5) to 10 cm 8.4 – 20.0
(2)-19
** * *
Zhang 2010 6096 B 3–3.5 NR 47 8 From 3 (or 3.5) to 10 cm 6.9 – 17.4
(2)-29
Zhang 2010 8690 B 3** NR 20 8 From 4 to 10 cm 3.7 – 16.7
(1)11
Oladapo 715 A 4** NR 40* 0.0 From 4 to 10 cm 5.9 2.4 14.5
2018-134
** * *
Zhang 2010 5550 B 4–4.5 NR 47 8 From 4 (or 4.5) to 10 cm 5.3 – 16.4
(2)-39
** *
Oladapo 316 A 5 NR 40 0.0 From 5 to 10 cm 4.3 1.6 11.3
2018-234
Zhang 2010 2764 B 5–5.5** NR 47* 84* From 5 (or 5.5) to 10 cm 3.8 – 12.7
(2)-49
Oladapo 322 A 6** NR 40* 0.0 From 6 to 10 cm 2.9 0.9 9.3
2018-334
Mean SD (h) +2SD (h)
duration (h)
Schiff 69 B 3.5*** NR NR NR From 4 to 10 cm 4.7 2.6 9.9*
199838
Albers 806 A 4*** 0.0 0.0 NR From 4 to 10 cm 7.7 4.9 17.5
199917
***
Jones 120 B 4 NR 0.0 0.0 From 4 to 10 cm 6.2 3.6 13.4
200328
***
Albers 347 C 4 NR 0.0 NR From 4 to 10 cm 7.7 5.9 19.4
199618
Velasco 74 B NR 0.0 0.0 0.0 From 4 to 10 cm 3.9 1.6 7.1*
198543
Juntunen 42 B NR 57.1 0.0 42.9 From 4 to 10 cm 3.1 1.5 6.1*
199429
Lee 200731 66 C 2.5*** NR NR 0.0 NR 3.6 1.9 7.4*
Schorn 18 B 5.4*** NR 18 NR NR 15.4 6.6 28.6
199339
Kilpatrick 2032 C NR NR 0.0 0.0 NR 8.1 4.3 16.7*
198930

Risk of bias: A = at least four (out of five) domains scored as low risk; B = three domains scored as low risk; C = two domains or less scored as low risk.
SD = Standard deviation.
NR = Not reported.
h = h.
*
Estimated by authors.
**
Median.
***
Mean.
128 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132

For parous women, two studies suggest that the median
duration of active phase with onset defined as 3.5 or 4 cm ranged
from 2.2–4.7 h (P95th: 13.0–14.2 h) (Table 3). One study with
reference points starting from 5 cm reported median duration of
3.1–3.4 h (P95th 10.1–10.8 h), and 2.2–2.4 h (P95th:7.4–7.5 h)
when the starting reference point was 6 cm. For eight studies
presenting means, duration of active phase when defined from
4 cm was 2.1–5.7 h, with statistical limits from 4.9–13.8 h. One
study in this category did not report the starting points for active
first stage, nor the cervical dilatation at admission. In Schorn
et al.,[39] parous women also showed longer labours (mean
13.2 h, 2SD: 23.9 h).
Sensitivity analyses were conducted by excluding studies
reporting interventions aimed at shortening labour (augmenta-
tion, instrumental vaginal birth and intrapartum caesarean
section) (Table S5). Studies reporting amniotomy and epidural
analgesia remained in the analysis as they could have other
indications, such as internal fetal monitoring or pain relief.
Sensitivity analyses did not significantly impact on our observa-
tions in the entire dataset.
Second stage of labour (nulliparous and parous women)
Four studies reported the median duration of second stage in
nulliparous ranging from 14 to 66 min [0.2–1.1 h], P95th: 65–
138 min [1.1–2.3 h] (Table 4). Two of these studies with epidural
use at 48 and 100% reported a relatively longer median duration
(53–66 min [0.9–1.1 h], P95th: 138–216 min [2.3–3.6 h]). Seven-
teen studies reported means from 20 to 116 min [0.3–1.9 h], with
statistical limits of 78–216 min [1.3–3.6 h]. In one of these studies
42.9% of women received epidural and reported mean duration of
20 min [0.3 h] with statistical limits of 60 mins [1 h]. The other
with 4.1% epidural use reported mean duration of 40 min [0.7 h]
with no statistical limits reported.
For parous women, two studies reported the median duration
of second stage from 6 to 12 mins [0.1–0.2 h], P95th: 58–76 min
[1.0–1.3 h] (Table 5). The subpopulation of women with 100%

Table 3
Duration of active phase, parous (1) women.

Parous women

Study N Study Cervical dilatation Amniotomy Oxytocin Epidural Definition of starting and Median 5th 95th
quality on admission (cm) (%) (%) (%) ending reference points duration percentile percentile
(h) (h) (h)
Zhang 2010 6373 B 3.5** NR 20.0 11 From 4 to 10 cm 2.4 – 13.8
(1)11 (P = 1)
**
Zhang 2010 11765 B 3.5 NR 12.0 8 From 4 to 10 cm 2.2 – 14.2
(1)11 (P  2)
Oladapo 491 A 4** NR 29.8* 0.1 From 4 to 10 cm 4.6 1.7 13.0
2018-434
(P = 1)
Oladapo 626 A 4** NR 26.7* 0.0 From 4 to 10 cm 4.7 1.7 13.0
2018-534
(P  2)
Oladapo 292 A 5** NR 29.8* 0.1 From 5 to 10 cm 3.4 1.2 10.1
2018-634
(P = 1)
Oladapo 385 A 5** NR 26.7* 0.0 From 5 to 10 cm 3.1 0.9 10.8
2018-734
(P  2)
Oladapo 320 A 6** NR 29.8* 0.1 From 6 to 10 cm 2.2 0.6 7.5
2018-834
(P = 1)
Oladapo 414 A 6** NR 26.7* 0.0 From 6 to 10 cm 2.4 0.8 7.4
2018-934
(P  2)
Mean SD (h) +2SD (h)
duration
(h)
Schiff 199838 94 B 3.5*** NR NR NR From 4 to 10 cm 3.3 1.9 7.1*
Albers 199917 1705 A 4*** 0.0 0.0 0.0 From 4 to 10 cm 5.6 4.1 13.8
Jones 200328 120 B 4*** NR 0.0 0.0 From 4 to 10 cm 4.4 3.4 11.6
Albers 199617 602 C 4*** NR NR NR From 4 to 10 cm 5.7 4.0 13.7
Velasco 37 B NR 0.0 0.0 0.0 From 4 to 10 cm 2.1 1.4 4.9*
198543
Juntunen 42 B NR 69.0 0.0 2.4 From 4 to 10 cm 2.7 1.4 5.5*
199429
(P = 2/3)
Juntunen 42 B NR 71.4 0.0 9.5 From 4 to 10 cm 2.8 1.5 5.8*
199429 (GP)
Schorn 199328 30 B 5.3*** NR 18 NR NR 13.2 5.3 23.9
Kilpatrick 3767 C NR NR NR 0.0 NR 5.7 3.4 12.5
198930

Risk of bias: A = at least four (out of five) domains scored as low risk; B = three domains scored as low risk; C = two domains or less scored as low risk.
SD = Standard deviation.
NR = Not reported.
P = Parity.
GP = Grand parity.
h = h.
*
Estimated by authors.
**
Median.
***
Mean.
 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132 129

Table 4
Duration of second stage, nulliparous women.

Nulliparous women

Study N Study Epidural Definition of starting Median duration (min) 5th percentile 95th percentile
quality analgesia (%) reference points (min) (min)
Oladapo 201834 2166 A 0 10 cm to birth 14 3.0 65
Zhang 2010(2)-19 4100 B 0 10 cm to birth 36 – 168
Zhang 200212 1162 A 48 10 cm to birth 53 18 138*
Zhang 2010(2)-29 21524 B 100 10 cm to birth 66 – 216
Paterson 199235 8270 C 0 10 cm or urge to bear down 45 – –
Mean duration (min) SD (min) +2SD (min)
Albers 199917 806 A 0.0 10 cm to birth 54 46 146
Diegmann 2000-120 373 C 0.0 10 cm to birth 32 23 78*
Diegmann 2000-220 157 C 0.0 10 cm to birth 44 33 110*
Kilpatrick 198930 2032 C 0.0 10 cm to birth 54 39 132*
Schiff 199838 69 B NR 10 cm to birth 66 36 138*
Albers 199618 347 C NR 10 cm to birth 53 47 147
Duignan 197522 437 B 0.0 10 cm or urge to bear down 42 – –
Abdel-Aleem 199116 175 A 0.0 Undefined 43 24 91*
Chen 198619 500 B 0.0 Undefined 43 – –
Jones 200328 120 B 0.0 Undefined 54 43 140*
Studd 197341 176 B 0.0 Undefined 46 – –
Lee 200731 66 C 0.0 Undefined 54 34 122*
Wusteman 200345 66 C 0.0 Undefined 36 5 46
Studd 197542 194 A 4.1 Undefined 40 – –
Juntunen 199429 42 B 42.9 Undefined 20 20 60*
Schorn 199339 18 B NR Undefined 66 54 174
Dior 201321 12631 C NR Undefined 78 – –
Shi 20167 1091 C NR Undefined 116 50 216

Risk of bias: A = at least four (out of five) domains scored as low risk; B = three domains scored as low risk; C = two domains or less scored as low risk
NR = Not reported.
SD = Standard deviation.
min = min.
*
Estimated by authors.

epidural in one of these studies had longer median duration of 18–
24 min [0.3–0.4 h], P95th: 96–120 min [1.6–2.0 h]. Fifteen studies
reporting data as mean show mean duration of second stage
ranging from 6 to 30 min [0.1–0.5 h] with statistical limits of 16–
78 min [0.3–1.3 h]. Only four of these studies clearly defined the
starting reference point for the second stage. Three studies
reported epidural use in 2.4%, 4.3% and 9.5% of women.
Sensitivity analysis excluding second stage interventions also
shows similar range of values (Table S6).
Discussion
Main findings
Our study provides an up-to-date overview of how the duration
of spontaneous labour in healthy women with good perinatal
outcomes was reported in the literature. Clear reference points for
the assessment of duration of labour were generally not provided
by primary study authors and where they were, there are
differences in the way the onset of phases and stages of labour
were defined. Nonetheless, some patterns emerged. When
beginning at 4 cm cervical dilatation (commonly associated with
active labour onset), the median duration of active first stage was
approximately 4–8 h in nulliparous with upper limits of up to 20 h,
and 4 h (up to 13 h) when active phase onset was defined by
cervical dilatation of 5 cm. In parous women, when beginning at
4 cm cervical dilatation, the median duration was approximately
2–5 h with an upper limit of up to 14 h, and 3 h (up to 11 h) when
starting point is defined at 5 cm. In nulliparous, the second stage
was often completed within 1 h but could take close to 4 h in
women with epidural analgesia. Likewise, the second stage in
parous women was usually completed in less than half an hour but
could take up to 2 h in women with epidural analgesia. Exclusion of
studies with accelerative labour interventions and second stage
interventions did not significantly impact on these findings.
Strength and limitations
All major datasets of women at low risk of labour complications
with normal perinatal outcomes, evaluating more than 200,000
women from different ethnic and demographic backgrounds
representing many regions and socio-economic settings were
included. However, the quality of the results and conclusions from
a systematic review are only as accurate and robust as the data
provided by the primary datasets. The main limitation of this
review relates to the considerable heterogeneity in the way
primary authors defined the reference points for labour phases and
stages, and how they measured and reported their duration. It is
possible that what some authors assessed as active phase had
included a variable period of time considered by others as part of
the latent phase. Other important limitation is the poor and
inconsistent reporting of other factors that could potentially affect
labour duration such as maternal characteristics at admission and
use of labour interventions.
Interpretation
When the onset of labour is determined differently, diverse
views are expected about the time needed to complete birth. Apart
from the fact that the duration and features of the latent phase was
reported in few studies, the point at which it truly commenced was
ambiguously reported, from self-perception of regular contrac-
tions by women at home to a given cervical dilatation confirmed by
a health professional at hospital admission. Despite the very low
certainty of the evidence, the reported data compares favourably
with the observations in Friedman’s pioneer work (1, 2) on ‘normal’
130 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132

Table 5
Duration of second stage, parous (1) women.

Parous women

Study N Study Epidural analgesia Definition of starting reference Median duration 5th percentile 95th percentile
quality (%) points (min) (min) (min)
Oladapo 201834 1488 A 0.1 10 cm to birth 11 2 65
(P = 1)
Oladapo 201834 1952 A 0 10 cm to birth 11 2 58
(P  2)
Zhang 2010 (2)-19 4106 B 0 10 cm to birth 12 – 76
(P = 1)
Zhang 2010 (2)-19 4001 B 0 10 cm to birth 6 – 66
(P  2)
Zhang 2010 (2)-29 12649 B 100 10 cm to birth 24 – 120
(P = 1)
Zhang 2010 (2)-29 12218 B 100 10 cm to birth 18 – 96
(P  2)
Mean duration SD (min) +2SD (min)
(min)
17
Albers 1999 1705 A 0 10 cm to birth 18 23 64*
Kilpatrick 198930 3767 C 0 10 cm to birth 19 21 61*
Albers 199618 602 C NR 10 cm to birth 17 20 57*
Duignan 197522 869 B 0 10 cm or urge to bear down 17.4 – –
Abdel-Aleem 199116 372 A 0 Undefined 29 16 61*
Jones 200328 120 B 0 Undefined 22 28 78*
Studd 197341 264 B 0 Undefined 22 – –
Paterson 199235 13159 C 0 Undefined 19 21 61
Wusteman 200345 71 C 0 Undefined 16 21 58*
Juntunen 199429 42 B 2.4 Undefined 8.7 5.5
(P = 2/3)
Studd 197545 322 A 4.3 Undefined 19 – –
Juntunen 199429 (GP) 42 B 9.5 Undefined 6 5 16*
Schiff 199838 94 B NR Undefined 30 24 78*
Schorn 199339 30 B NR Undefined 24 24 72
Gibb 198223 749 C NR Undefined 17 – –
Dior 201321 (P = 2/5) 27252 C NR Undefined 21 – –
Dior 201321 (P  6) 4112 C NR Undefined 16 – –

Risk of bias: A = at least four (out of five) domains scored as low risk; B = three domains scored as low risk; C = two domains or less scored as low risk.
NR = Not reported.
SD = Standard deviation.
min = min.
P = Parity.
GP = Grand parity.
*
Estimated by authors.

duration of labour (which did not meet the inclusion criteria for
our review as Friedman’s studies also included women with twins,
breech presentations, and perinatal deaths – a set of risk factors
and outcomes that could complicate the interpretation and
applicability of our results to clinical practice). Similar to our
findings, Friedman reported the duration of latent phase in
nulliparous women as mean: 8.6 h; median: 7.5 h; and “statistical
maximum”: 20.6 h; and in parous women reported mean of 5.3 h;
median 4.5 h; and statistical maximum of 13.6 h. As stated by other
authors [47,48], there is little consensus on the degree of cervical
dilatation or the pattern of uterine contractions to define when the
latent phase ends and active phase begins. More recent studies
[7,9,11,12,34,49] did not find the inflection point defined by
Friedman at 2 to 3 cm dilatation, but rather a smoother transition
at later stages of cervical dilatation. Understanding when this
transition takes place is important as women who are managed
according to current standards of care for active first stage are
likely to receive more labour interventions, such as electronic fetal
monitoring, epidural analgesia, oxytocin, and caesarean section
[50–52]. The same uncertainties apply for determining when
second stage of labour truly begins. It was not possible in most
studies to precisely determine when a woman reached full cervical
dilatation, and it is probable that many were already in the second
stage for longer periods by the time they were assessed.
Diagnosis of progression and normality only can be made
retrospectively, so it is not possible to predict if a particular woman
in labour fits under specified parameters. On the other hand, the
majority of descriptions defined the phases and stages of labour by
cervical assessment over time, as defined by health professionals,
which may not reflect women’s own perceptions or expectations
on when and how labour starts and progresses [53].
The statistical methods used to report a central tendency and its
dispersion varied across studies, and were not consistently
reported. Most studies reported mean and standard deviations.
It has been shown, however, that labour duration may not hold to a
statistically normal curve, as there is a tendency for longer labours
to positively skew the statistical distribution [54]. Thus, median
labour duration is regarded as a superior measure of central
tendency than the means, which is more susceptible to these
slowest but yet normal labours [54]. For this reason, the data
presented as means and the corresponding statistical limits should
be interpreted with caution.
It is interesting to note that while the median times reported for
active first stage of labour in both nulliparous and parous women
reflect what one would expect if the cervix were dilating at least at
the rate of 1 cm/hour, the 95th percentile times suggest a much
longer duration. In nulliparous, active first stage extending beyond
12 h is often described as “prolonged labour” and interventions to
terminate labour process may be considered justified. In the light
of our results, it would be reasonable to take a more expectant and
supportive approach, when there is some evidence of labour
progression, provided maternal and fetal conditions are reassuring.
 E. Abalos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 123–132
The application of limits of labour duration as informed by the
respective 95th percentile thresholds as the benchmark for
identifying unduly prolonged labour might be cost-effective as it
has the potential to reduce the use of interventions to accelerate
labour and birth. However, it might increase costs associated with
the provision of supportive care such as pain relief, and labour
companionship required for women to tolerate slightly longer but
normal labours.
Conclusions
The duration of phases and stages of labour varies from one
woman to another, and is dependent on the reference point used to
signify onset. Given the limits within which women could still
achieve full cervical dilatation and give birth without adverse
perinatal outcomes, the decision to intervene whenever the first
stage of labour appears prolonged must not be taken on the basis of
duration alone. Health professional should aim to support
pregnant women to experience labour and childbirth according
to individual woman’s own natural reproductive processes
without interventions to shorten the duration, provided the
conditions of both mother and baby are reassuring, there is
evidence of progression, and the duration remains within the
upper limits presented in this review. Future studies on the
duration of first stage labour would benefit from an agreement on
reporting other elements, including the patterns of uterine
contractions, cervical effacement, fetal station, that should be
considered either alone or in combination in defining the onset of
phases and stages of labour.
Contribution to authorship
OTO, EA, MB and AMG conceived the general aims and objectives
of the review, and agreed on the analyses plan. EA drafted the
protocol with input from MB, OTO, JPS and AMG. EA, MC, VD, JP built
the search strategies, ran the searches, assessed the papers for
eligibility and extracted data. EA performed the data analyses with
inputs from all authors and wrote the first draft of the paper. All
authors contributed to revising the final version. EA is the guarantor.
All authors approved the manuscript for publication.
Funding
OTO, MB, JPS and AMG are staff of the UNDP/UNFPA/UNICEF/
WHO/World Bank Special Programme of Research, Development
and Research Training in Human Reproduction (HRP), Department
of Reproductive Health and Research (RHR), World Health
Organization, which commissioned the review. EA, MC, VD and
JP are staff of CREP, Rosario, Argentina, which received funds to
execute these systematic reviews from the World Health
Organization, as part of evidence base preparation towards the
WHO recommendations on intrapartum care for a positive
childbirth experience.
Conflicts of interest
OTO participated in a large unpublished study on labour
monitoring and action with a component that included cervical
dilatation patterns during labour in African women. Other
members of the review team have no conflicts of interest to
declare.
Acknowledgements
We would like to thank Dr Qian Long for her help in translating
papers from Chinese. We are grateful to Tomas Allen and José
131
Garnica, the Information Specialists at the World Health Organ-
izatiotablen, Geneva, Switzerland, for reviewing the search
strategies.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.ejogrb.2018.02.026.
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