Overview of normal labor and protraction and arrest disorders

Authors:
Robert M Ehsanipoor, MD
Andrew J Satin, MD, FACOG
Section Editor:
Charles J Lockwood, MD, MHCM
Deputy Editor:
Vanessa A Barss, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2017. | This topic last updated: Oct 26, 2016.

INTRODUCTION — During normal labor, regular and painful uterine contractions cause
progressive dilation and effacement of the cervix, accompanied by descent and eventual
expulsion of the fetus. "Abnormal labor," "dystocia," and "failure to progress" are traditional but
imprecise terms that have been used to describe a labor pattern deviating from that observed in
the majority of women who have a spontaneous vaginal delivery. These labor abnormalities are
best described as protraction disorders (ie, slower than normal progress) or arrest disorders (ie,
complete cessation of progress).

NORMAL LABOR — Although determining whether labor is progressing normally is a key

component of intrapartum care, determining the onset of labor, measuring its progress, and
evaluating the factors (power, passenger, pelvis) that affect its course are an inexact science.

Stages — There are three stages of labor:

●First stage – Time from onset of labor to complete cervical dilation. However, the
precise time of labor onset is nearly impossible to determine since the normal
uterus contracts intermittently and irregularly throughout gestation and the first
regular contractions of labor are mild and infrequent. Likewise, the time the cervix
first begins to change as a result of contractions is impossible to determine
precisely by intermittent physical examinations. For this reason, contemporary
research studies often define the first stage of labor as the time from hospital
admission to complete dilation or the time from 4 cm dilation to complete dilation.
The first stage consists of a latent phase and an active phase. The latent phase is
characterized by gradual cervical change and the active phase is characterized by
rapid cervical change. The labor curve of multiparas may show an inflection point
between the latent and active phases; this point occurs at about 5 cm dilation [1]. In
nulliparas, the inflection point is often unclear and, if present, occurs at a more
advanced cervical dilation. In any case, this inflection point is a retrospective
diagnosis.
●Second stage – Time from complete cervical dilation to fetal delivery.
 When pushing is delayed, some clinicians divide the second stage into a passive
phase (from complete cervical dilation to onset of active maternal expulsive efforts)
and an active phase (from beginning of active maternal expulsive efforts to
expulsion of the fetus) [2].
●Third stage – Time between fetal delivery and placental delivery.

Characterization of normal progress — Emanuel Friedman established criteria for the normal
progress of labor in the 1950s and these criteria were used for assessment and management of
labor for decades. However, data derived from contemporary women in labor suggest that
changes in obstetric and anesthesia practices and women themselves in recent decades have
resulted in changes in average progress of labor. Therefore, criteria for normal labor progress
have been revised.

Friedman (historic) data — In the mid-1950s, Emanuel Friedman conducted his now classic
studies defining the spectrum of normal labor by evaluating the course of labor of 500
primigravidas admitted to the Sloane Hospital for Women in New York [3,4]. The norms
established by his data, depicted as the "Friedman curve" (figure 1), were widely accepted as
the standard for assessment of normal labor progression.

Based on these data, the transition from the latent phase to active phase appeared to occur at 3
to 4 cm cervical dilation, and the statistical minimum rate of normal cervical dilation during the
active phase was 1.2 cm/hour for nulliparous women and 1.5 cm/hour for multiparous women
[5]. An abnormally long second stage for nulliparas and multiparas was defined as three hours
and one hour, respectively.

Contemporary data — The applicability of the Friedman curve and its established norms to
contemporary obstetric practice was challenged in the 21st century. Several studies evaluated
labor curves in contemporary women to establish contemporary thresholds for normal labor
progression [1,6-8]. These new thresholds are different from, and generally longer than, those
cited by Friedman. This change has been attributed to changes in patient characteristics (eg,
increases in mean body mass index), anesthesia practices, and obstetric practices over the past
half-century. In addition, a limitation of Friedman's findings is that his data were based on labors
in only 500 women who were managed at a single institution. However, revision of the classic
labor curve as described by Friedman has not been accepted universally [9,10].

First stage — Zhang and colleagues obtained data on normal labor patterns by evaluating
contemporary data from the Consortium on Safe Labor, which included information on 62,415
singleton cephalic vaginal deliveries with spontaneous onset of labor and normal neonatal
outcome [6]. The data were collected retrospectively from the electronic medical records at 19
medical centers in the United States.

The shape of the labor curve generated from Zhang's data (figure 2) is different from the
Friedman curve (figure 1). The Friedman curve depicts a relatively slow rate of cervical dilation
until approximately 4 cm (ie, latent labor), which is followed by an abrupt acceleration in the rate
of dilation (ie, active phase) until entering a deceleration phase at approximately 9 cm. Zhang's
labor curves also demonstrate an increase in the rate of cervical dilation as labor progresses,
but the increase is more gradual than that described by Friedman: Over 50 percent of patients
did not dilate >1 cm/hour until reaching 5 to 6 cm dilation, and a deceleration phase at the end
of the first stage of labor was not observed. Labor curves constructed from other contemporary
data sets also generally differ from Friedman's curve [1,7,11]. Specifically, there is no abrupt
change in the rate of cervical dilation indicating a clear transition from latent to active phase and
there is no deceleration phase at the end of the first stage of labor.

While the presence or absence of a deceleration phase is not of major clinical significance,
defining the transition from latent to active phase (ie, transition from slower to more rapid
cervical dilation) is clinically important for diagnosing labor abnormalities. Contemporary data
suggest that the normal rate of cervical change between 3 and 6 cm dilation is much slower
than described by Friedman, who reported minimum dilation should be at least 1 cm/hour [7,12].
Contemporary women with rates of cervical dilation <1 cm/hour before reaching 6 cm dilation
often go on to have normal spontaneous vaginal births. Indeed, both nulliparas and multiparas
who take more than six hours to dilate from 4 cm to 5 cm and more than three hours to dilate
from 5 cm to 6 cm may still go on to have a normal spontaneous vaginal birth (table 1) [6].
Beyond 6 cm dilation, rates of cervical dilation are rapid in both nulliparas and multiparas. This
suggests that before 6 cm, slow cervical dilation reflects the shallow slope of the latent phase
portion of the contemporary normal labor curve, not a protracted active phase. At ≥6 cm dilation,
nearly all women should be in active labor, so slow cervical dilation beyond this point is a
deviation from the slope of the contemporary normal labor curve and is abnormal.

Most contemporary studies have found that the normal duration of the first stage takes longer
than described by Friedman [1,11,13-16]. Zhang observed that the median (95th percentile)
times for the cervix to dilate from 4 to 10 cm in nulliparas and multiparas were 5.3 hours (16.4)
and 3.8 hours (15.7), respectively [6]. In contrast, Friedman reported the corresponding mean
(95th percentile) durations in nulliparous and parous women were 4.6 hours (11.7) and 2.4 hours
(5.2), respectively [5]. In one contemporary study, the increase in first stage duration persisted
after adjustments were made for maternal and pregnancy characteristics, suggesting that
changes in practice patterns (eg, epidural use) may be the primary reason for the increase [13].
Although epidural use has increased dramatically since the 1960s, increased use of epidurals
did not fully account for the difference. Further study is required to explain these findings.

Second stage — Zhang observed that the median (95th percentile) duration of the second stage
in nulliparous and parous women (P1) with epidural anesthesia was 1.1 hours (3.6) and 0.4
hours (2.0), respectively [6]. Without epidural anesthesia, the median (95th percentile) was 0.6
hours (2.8) and 0.2 hours (1.3), respectively (table 1). Thus, epidural anesthesia increased the
95th percentile for the second stage by 0.8 hours in nulliparous women and 0.7 hours in parous
women compared with no epidural anesthesia. (See 'Neuraxial anesthesia' below.)

Induction of labor, diabetes, preeclampsia, fetal size, chorioamnionitis [17], duration of the first
stage [18], maternal height, and station at complete dilation may also play a role in predicting
the duration of the second stage, but standards that account for these characteristics are not
available [19].

Descent — The second stage can also be viewed in terms of fetal rather than maternal
changes, ie, changes in fetal station and descent. At full cervical dilation, fetal station is typically
≥0, and tends to be higher in multiparous women than in nulliparous women [20,21]. However,
descent during the second stage tends to be faster in multiparous women. In nulliparous women
in the second stage, Zhang found that the median (95th percentile) time interval for fetal descent
from station +1/3 to +2/3 was 16 minutes (three hours) [11]. The median (95thpercentile) time
interval for fetal descent from station +2/2 to +3/3 was seven minutes (38 minutes).

Normal progress in induced labors — The time to dilate 1 cm in latent phase (defined as
dilation <6 cm) is significantly longer in women undergoing induction than in those in
spontaneous labor, and can take many hours [22,23]. In a retrospective study, the median
(95thpercentile) time for nulliparous women to dilate from 3 to 4 cm in induced and spontaneous
labor was 1.4 hours (8.1 hours) versus 0.4 hours (2.3 hours), from 4 to 5 cm the time was 1.3
hours (6.8 hours) versus 0.5 hours (2.7 hours), and from 5 to 6 cm the time was 0.6 hours (4.3
hours) versus 0.4 hours (2.7 hours) [22]. In contrast, the time to dilate from 6 to 10 cm is more
rapid and similar in both induced and spontaneous labors [22,23].

Because the latent phase is longer in induced labors, the duration of the first stage (defined as
the time to dilate from 4 to 10 cm) is significantly longer in induced labor than in spontaneous
labor. For nulliparas, the median (95th percentile) for induced and spontaneous was 5.5 hours
(16.8 hours) versus 3.8 hours (11.8 hours); for multiparas, the median (95th percentile) was 4.4
hours (16.2 hours) versus 2.4 hours (8.8 hours) in one study [22].

There is no difference in length of the second stage between induced and spontaneous labor
[24].

ASSESSMENT OF LABOR PROGRESS — Assessment of labor includes several components:

a disciplined approach to the diagnosis of labor, assessment of maternal and fetal well-being,
and frequent monitoring of labor progress. (See "Management of normal labor and delivery",
section on 'Monitoring'.)

Serial cervical examinations are performed to determine whether progression is adequate [5].
Examinations are performed at two- to four-hour intervals when the active phase of labor
appears to be progressing normally, but more frequent examinations may be warranted if there
is a concern about labor progress or maternal or fetal well-being.

Results of cervical examinations can be documented on a partogram, in addition to the medical

record. The partogram is a graphical representation of the patient's labor in comparison with the
expected lower limit of normal progress. The following partogram shows the slowest
95th percentile of labor progress based on dilation at the time of admission (figure 3) [6]. Right
deviation from this curve suggests a protraction or arrest disorder. Although useful for
visualizing labor progress, use of partograms has not been proven to significantly improve
obstetric outcome [25].

Although not widely used clinically, intrapartum ultrasound examination can determine fetal
position and station, evaluate the presence and extent of caput, and document progress in the
second stage when performed serially [26]. In addition, measurement of the angle between the
symphysis pubis and the leading part of the fetal skull (called the angle of progression) is
predictive of vaginal delivery when ≥120 degrees [27,28].

PROTRACTION AND ARREST DISORDERS

Prevalence — Protraction and arrest disorders are common. Reported incidences vary among
studies due to differences in the definitions used by authors, as well as differences among study
populations (eg, gestational age range, personal characteristics). About 20 percent of all labors
ending in a live birth involve a protraction and/or arrest disorder [29]. The risk is highest in
nulliparous women with term pregnancies. In a prospective Danish study, for example, 37
percent of healthy term nulliparas experienced dystocia during labor [30].

Protraction or arrest of labor is the most common reason for primary cesarean delivery. In one
study including over 700 women who had unplanned cesareans, 68 percent of the cesarean
deliveries were due to lack of progress in labor [31].

Risk factors — Abnormal progress of spontaneously initiated labor may to related to uterine
factors, fetal factors, the bony pelvis, or a combination of these factors (table 2) [17]. A genetic
component has been purported to account for 28 percent of the susceptibility to prolonged and
difficult labor [32].

Selected risk factors for protraction and arrest are discussed below. Some risk factors are more
prominent during the first stage of labor and others primarily exert their effects in the second
stage.

Hypocontractile uterine activity — Hypocontractile uterine activity is the most common risk
factor for protraction and/or arrest disorders in the first stage of labor. Uterine activity is either
not sufficiently strong or not appropriately coordinated to dilate the cervix and expel the fetus.

Uterine activity can be monitored qualitatively by palpation or external tocodynamometry or

quantitatively by an internal uterine pressure catheter (IUPC). In most women, external and
intrauterine monitoring devices perform equally well [33]; routine use of IUPCs does not improve
outcome [34-36]. However, selective use of an IUPC can be helpful for assessing uterine
activity when it is difficult to monitor contractions externally, such as in obese women. (See "Use
of intrauterine pressure catheters".)

Montevideo units — Montevideo units (MVUs) can only be calculated using information
obtained by an IUPC. MVUs are calculated by subtracting the baseline uterine pressure from
the peak contraction pressure of each contraction in a 10-minute window and adding the
pressures generated by each contraction (figure 4). Uterine activity of 200 to 250 MVUs is
considered "adequate" (ie, expected to lead to a normal rate of cervical change and fetal
descent) based on the following seminal studies [37,38], and other data [39-41]:

●In a retrospective report, 91 percent of women with spontaneous vaginal deliveries

after oxytocin induction achieved contractile activity greater than 200 MVUs and 40
percent reached 300 MVUs; the corresponding figures for spontaneous vaginal
delivery after augmentation of spontaneous labor were 77 and 8 percent,
respectively [37].
●In a study of women with spontaneously beginning normal labor, uterine activity
averaged about 100 MVUs in the early first stage of labor, 175 MVUs in the
advanced first stage, and 250 MVUs in the second stage [38].

Maternal obesity — Increasing maternal body mass index (BMI) correlates with an increasing
length of the first stage of labor. In one study, for example, the median time to dilate from 4 to
10 cm in nulliparous women with BMI <25 kg/m2 and >40 kg/m2 was 5.4 and 7.7 hours,
respectively, even after controlling for multiple confounders [42]. The authors concluded more
time should be allowed for labor progress in these patients. Maternal obesity is not
independently correlated with the length of the second stage of labor [42,43]. (See "Obesity in
pregnancy: Complications and maternal management", section on 'Progress of labor'.)

Cephalopelvic disproportion — A disproportion in the size of the fetus relative to the maternal
pelvis can result in failure to progress in the second stage and has been termed cephalopelvic
disproportion (CPD). True CPD may occur if the fetus is very large, has a large surface
anomaly, or the maternal pelvic bone is small or deformed (eg, after pelvic trauma). More
commonly, it is due to fetal malposition (eg, extended or asynclitic fetal head, occiput posterior
or transverse position [discussed below]) or malpresentation (mentum posterior, brow) rather
than a true disparity between fetal size and maternal pelvic dimensions.

Antepartum, the clinician is generally unable to predict maternal pelvis-

fetal size/position discordance leading to arrest of labor requiring cesarean delivery. Clinical and
radiologic assessments of the maternal pelvis and fetal size (ie, pelvimetry) are inexact and
poorly predict the course and outcome of labor [44,45]. Radiographic pelvimetry is not
recommended [44]. Ultrasound evaluation of fetal position is accurate, but common
malpositions such as occiput posterior (OP) usually rotate intrapartum and do not affect labor
progress.

Non-occiput anterior position — The length of the second stage appears to correlate with the
degree of rotation away from occiput anterior (OA). Among nulliparous women under neuraxial
anesthesia who began pushing at full dilation, the mean duration of the second stage for OA,
occiput transverse (OT), and OP positions was 2.2, 2.5, and 3.0 hours, respectively, and the
cesarean delivery rates were 3.4, 6.9, and 15.2 percent, respectively [46]. Many fetuses actually
enter labor in either OP or OT position and then undergo rotation of the fetal head during labor.
Protraction and arrest disorders associated with malposition occur when rotation to OA does not
occur or is slow to occur during labor. (See "Occiput posterior position" and "Occiput transverse
position".)

Bandl's ring — An hourglass constriction ring of the uterus, called Bandl's ring, is a rare
pregnancy complication associated with obstructed labor in the second stage [47-49]. The
constriction forms between the upper contractile portion of the uterus and the lower uterine
segment. It is not clear if it is the cause or the result of the associated labor abnormality. It may
also occur between delivery of the first and second twin. Diagnosis is typically made at
cesarean delivery. At the time of laparotomy, a transverse thickened muscular band can be
observed separating the upper and lower segment of the uterus.

Neuraxial anesthesia — The potential impact of neuraxial anesthesia on uterine activity and
fetal malposition has received a lot of attention as a possible source of increasing rates of
protracted labor, arrest, and cesarean delivery. Randomized trials have not shown a major
impact on the incidence of protraction and arrest disorders. In a 2011 systematic review of
randomized trials, use of neuraxial labor anesthesia compared with non-neuraxial anesthesia or
no analgesia was not associated with a significant increase in duration of the first stage of labor
(weighted mean difference [WMD] 18.5 minutes; 95% CI -12.9 to 49.9) or cesarean delivery
(relative risk [RR] 1.10, 95% CI 0.97-1.25) [50]. There were small but statistically significant
increases in the second stage of labor (WMD 13.7 minutes; 95% CI 6.7-20.7) and use
of oxytocin (RR 1.19, 95% CI 1.03-1.39), but these findings are of questionable clinical
significance. Women receiving neuraxial anesthesia were more likely to undergo operative
vaginal delivery (RR 1.42, 95% CI 1.28-1.57).

However, the impact of neuraxial anesthesia on labor progress continues to be debated. A large
retrospective cohort study reported use of epidural anesthesia increased the 95th percentile for
the second stage by about 2.3 hours in nulliparous women and by three hours in multiparous
women compared with no epidural anesthesia, which is significantly longer than in previous
studies [8]. The median (95thpercentile) duration of the second stage in nulliparous and parous
women with epidural anesthesia was two hours (5.6) and 0.6 hours (4.25), respectively. These
data were limited to women delivering at a single institution and it is possible that differences in
obstetric and anesthesia practices and selection bias in use of neuraxial anesthesia could
account for the significant difference compared with data from randomized trials (table 1).
(See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effect of
neuraxial analgesia on labor and delivery'.)

The American College of Obstetricians and Gynecologists (ACOG) has stated that the decision
to place a neuraxial anesthetic should depend upon the patient's wishes with consideration of
factors, such as parity, also taken into account [51]. In particular, concern about future labor
progress should not be a reason to require a woman to reach an arbitrary cervical dilation, such
as 4 to 5 cm, before fulfilling her request to receive neuraxial anesthesia.

Diagnosis — The diagnosis of protraction and arrest disorders is based on deviation from the
norms described above and are defined according to the stage of labor in which they occur.
First stage

Protraction — We consider the following table, based on contemporary data, the best guide for
determining whether labor progress is within the normal range or protracted (ie, beyond the
95th centile) (table 1) [6]. According to the table, it may take more than six hours to progress
from 4 to 5 cm and more than three hours to progress from 5 to 6 cm during a normal labor,
regardless of parity. The table also shows whether labor is progressing at the median rate,
faster or slower.

Women with cervical dilation <6 cm are considered to be in latent phase and those with cervical
dilation ≥6 cm are considered to be in the active phase as cervical dilation is normally more
rapid at this point.

Arrest — We agree with the criteria for arrest proposed by a workshop convened by the United
States National Institute of Child Health and Human Development (NICHD), Society of
Maternal-Fetal Medicine (SMFM), and ACOG and based on contemporary data [52]. Arrest of
labor is diagnosed at cervical dilation ≥6 cm in a patient with ruptured membranes and [6]:

●No cervical change for ≥4 hours despite adequate contractions (≥200 MVUs
(see 'Montevideo units' above))
●No cervical change for ≥6 hours with inadequate contractions

Prolonged second stage — The appropriate duration and maximum length of time allowed for
the second stage of labor is not clearly defined. Parity, regional anesthesia, and delayed
pushing in addition to other clinical considerations all significantly impact the length of the
second stage.

We follow the 2014 Obstetric Care Consensus statement of recommendations for safe
prevention of primary cesarean delivery by ACOG and SMFM [53]. These recommendations are
supported by the data from Zhang et al (table 1), which we believe is the best guide for
establishing the normal duration for the second stage of labor (median and 95th centile). The
following is a summary of the statement/recommendations [53]:

●A specific absolute maximum length of time that should be allowed in the second
stage of labor has not been identified
●When maternal and fetal conditions permit, allow two hours of pushing in
multiparous women and three hours of pushing in nulliparous women prior to
diagnosing arrest of labor
●Longer durations may be appropriate on an individual basis (eg, epidural
anesthesia, fetal malposition) as long as progress is being documented

Of note, this statement does not provide specific criteria for second stage protraction or arrest; it
merely states that arrest should not be diagnosed before passage of a specific minimum period
of time.
Assessing progressive but small degrees of descent and rotation by physical examination is
challenging. Additional physical findings can support the diagnosis of arrest due to
cephalopelvic disproportion. The soft bones and open sutures of the fetal skull (figure 5) allow it
to change in shape (ie, molding) and thus adapt to the maternal pelvis during descent. Some
overlap of the parietal and occipital bones at the lambdoid sutures and overlap of the parietal
and frontal bones at the coronal sutures is common in normal labor [45]. However, lack of
descent with severe molding, especially overlap of the parietal bones at the sagittal suture, is
suggestive of cephalopelvic disproportion. Likewise, lack of descent with malposition or
malpresentation is suggestive of cephalopelvic disproportion.

Management — Management of protraction and arrest disorders depends on the cause

and stage/phase of labor.

First stage: protracted latent phase — Management of labor abnormalities before 6 cm

dilation (ie, latent phase) is reviewed separately. (See "Latent phase of labor", section on
'Management'.)

First stage: protracted active phase — For management of slow (ie, ≤1 cm) labor progression
over two hours, in the active phase (ie, cervix ≥6 cm), we administer oxytocin and proceed with
amniotomy if there is adequate fetal descent. Oxytocin administration to women with slow
progress is reasonable even in the absence of documented hypocontractile uterine activity [54].

We then wait an adequate period of time (four to six hours) for an effect, while monitoring the
mother and fetus. If there is inadequate progress with oxytocin alone, we proceed with
amniotomy even without the fetal vertex being well applied rather than proceeding with
cesarean delivery.

There are limited data comparing augmentation of labor with oxytocin versus amniotomy versus
combination of oxytocin with amniotomy. Based on data from two randomized trials, a
combination of oxytocin with amniotomy appears to reduce the time to delivery and maternal
satisfaction with no difference in the route of delivery or neonatal outcomes [55,56].

Alternatively, expectant management can be considered. In a 2013 meta-analysis of

randomized trials of women with slow progress in the first stage of spontaneous labor, early use
of oxytocin (intervention group) compared with other approaches (placebo, no treatment, or
delayed use of oxytocin) reduced the mean duration of labor by two hours [57]. Similarly,
another 2013 meta-analysis of randomized trials showed that early intervention with oxytocin
and amniotomy reduced the time to delivery by approximately 1.5 hours [58]. Although there
was significant heterogeneity among the trials in both meta-analyses, results were consistent.
Cesarean delivery and instrumental delivery rates were not affected by either intervention.

Oxytocin augmentation — Oxytocin is the only medication approved by the US Food and Drug
Administration for labor stimulation in the active phase. It is typically dosed to effect, as
predicting a women's response to a particular dose is not possible [59]. We titrate the dose to
obtain an adequate uterine contraction pattern and do not generally exceed a dose of
30 milliunits/minute. After four hours of adequate uterine contractions (or six hours without
adequate uterine contractions) and no cervical change in the active phase of labor, we proceed
with cesarean delivery. If labor is progressing, either slowly or normally, we continue oxytocin at
the dosage required to maintain an adequate uterine contraction pattern.

Dosing regimen — Numerous oxytocin protocols that vary in initial dose, incremental dose
increase, and time interval between dose increases have been studied (table 3). The decision to
use a high- versus a low-dose oxytocin regimen poses a risk benefit dilemma: Higher-dose
regimens are associated with shorter labor and fewer cesareans, but more tachysystole (>5
contractions in 10 minutes, averaged over a 30-minute window). The value placed on each of
these outcomes and the ability to respond to tachysystole may vary among labor and delivery
units. Therefore, either a high- or low-dose oxytocin regimen is acceptable and should depend
on local factors. We use a high-dose regimen and do not alter our management based on parity
[34,60,61], with one important exception: We do not use a high-dose regimen in women who
have had a previous cesarean delivery [60].

Low-dose regimens were developed, in part, to avoid uterine tachysystole and are based upon
the observation that it takes 40 to 60 minutes to reach steady-state oxytocin levels in maternal
serum [62]. A 2010 systematic review of randomized trials of high- versus low-dose oxytocin for
augmentation of women in spontaneous labor (10 trials, n = 5423 women) found that high-dose
oxytocin [63]:

●Increased the frequency of tachysystole (RR 1.91, 95% CI 1.49-2.45)

●Decreased the cesarean delivery rate (RR 0.85, 95% CI 0.75-0.97) and increased
the rate of spontaneous vaginal delivery (RR 1.07, 95% CI 1.02-1.12)
●Decreased the total duration of labor (mean difference -1.54 hours, 95% CI -2.44
to -0.64 hours)
●Resulted in similar maternal and neonatal morbidities

A 2013 systematic review had fewer trials because it excluded those involving augmentation as
part of an active management of labor protocol, but came to similar conclusions [64].

Other approaches — Oxytocin with or without amniotomy is the best approach for treatment of
a protraction disorder. The body of evidence does not support using any alternative
pharmacologic approach.

●Misoprostol – Misoprostol is typically used for cervical ripening and labor

induction; there are limited data on its safety and efficacy for treatment of
protraction disorders [65,66]. We recommend oxytocin rather than misoprostol for
treatment of protraction disorders, based on extensive experience and data
attesting to its safety and efficacy. However, low-dose titrated misoprostol may be a
good alternative in low-resource settings where safe oxytocin infusion is not
feasible.
 ●Ambulation may improve the comfort of the parturient and is not harmful, but
there is no convincing evidence that this intervention prevents or treats protraction
or arrest disorders [67].

First stage: arrest — Women ≥6 cm dilatation with ruptured membranes and no further cervical
dilation after four hours of adequate uterine contractions or six hours of inadequate contractions
with oxytocin have labor arrest and are delivered by cesarean, in agreement with expert opinion
[35,52,68].

This approach is supported by the following evidence:

●A prospective study including 542 women in spontaneous labor at term with active
phase labor arrest (defined as cervix ≥4 cm dilated and ≤1 cm of cervical progress
in four hours) evaluated a protocol whereby oxytocin augmentation was initiated
and cesarean delivery was not performed for labor arrest until (1) the woman
experienced at least four hours uterine contractions greater than 200 MVUs or (2)
the woman experienced a minimum of six hours of oxytocin augmentation if this
contraction pattern could not be achieved [34]. Most women who had not
progressed (≤1 cm additional dilation) after two hours of oxytocin administration
went on to achieve vaginal delivery (91 percent of multiparas and 74 percent of
nulliparas). Similarly, many women who had not progressed after four hours of
oxytocin administration went on to achieve vaginal delivery (88 percent of
multiparas and 56 percent of nulliparas).
The same investigators subsequently used a standardized protocol to manage 501
consecutive, term, spontaneously laboring women with slow labor progress [35].
The protocol involved administration of oxytocin to achieve at least 200 MVUs for
four hours before considering cesarean delivery. Vaginal delivery occurred in about
80 percent of nulliparous women and 95 percent of multiparous women, whether or
not they were able to achieve and/or maintain the MVU goal. Mean (5th percentile)
rates of cervical dilation in nulliparas and multiparas were 1.4 cm/hour (0.5) and
1.8 cm/hour (0.5), respectively.
These studies suggest that oxytocin augmentation for at least four hours, rather
than the historical standard of two hours, is safe for mother and fetus and increases
the chances of achieving a vaginal delivery. They also suggest that vaginal delivery
is often possible despite levels of uterine activity and rates of cervical dilation below
the range historically considered necessary for success.

Prolonged second stage

Oxytocin — After 60 to 90 minutes of pushing, we begin oxytocin augmentation if descent is

minimal or absent and the uterus is hypocontractile. In the second stage we are more
concerned about a possible physical issue (eg, malposition or malpresentation, macrosomia,
small maternal pelvis) slowing labor progress than hypocontractile uterine activity, which is the
prominent concern in the first stage. (See 'Oxytocin augmentation' above.)
Operative delivery — We avoid operative delivery in the second stage as long as the fetus
continues to descend and/or rotate to a more favorable position for vaginal delivery, and the
fetal heart rate pattern is not concerning. Operative intervention is indicated for fetuses with
abnormal fetal heart rate tracings (table 4), regardless of labor progress. (See "Management of
intrapartum category I, II, and III fetal heart rate tracings".)

We manage second stage arrest with operative delivery (instrumental vaginal or cesarean, as
appropriate). In the absence of epidural anesthesia, we allow at least two hours of pushing in
multiparous women and at least three hours of pushing in nulliparous women prior to diagnosing
arrest of labor. In women who have epidural anesthesia, we allow an additional hour of pushing
before operative intervention on a case-by-case basis (see 'Prolonged second stage' above).
Extending the interval for the second stage to ≥4 hours may increase the chances of a vaginal
delivery, but has potential clinical challenges and consequences:

●If a cesarean delivery is necessary, a prolonged second stage may result in the
fetal head trapped deep in the pelvis, which increases the difficulty of delivering the
fetus. Reverse breech extraction may reduce the risk of a difficult delivery or injury
to the uterine vessels (see "Management of deeply engaged and floating fetal
presentations at cesarean delivery", section on 'Reverse breech extraction').
●A prolonged second stage may thin the lower uterine segment, increasing the risk
of surgical injury to the uterine vessels at the cesarean.
●Extending the second stage may also worsen neonatal outcome. (See 'Maternal
and newborn outcomes after protraction or arrest' below.)

Ineffective interventions

●Turning down the epidural – A dense motor block may impair a woman's ability
to push, but there is no strong evidence that turning down the neuraxial anesthetic
in women with a protracted second stage is beneficial. In a 2004 meta-analysis
including five trials in which patients with epidurals were randomly assigned to
discontinuation late in labor or continuation until birth, early discontinuation did not
clearly reduce instrumental delivery (23 versus 28 percent, RR 0.84, 95% CI 0.61-
1.15) or other adverse delivery outcomes [69]. (See "Adverse effects of neuraxial
analgesia and anesthesia for obstetrics", section on 'Effect of neuraxial analgesia
on labor and delivery'.)
●Changing maternal position – There is no strong evidence that a change in
maternal position (eg, upright posture, lateral, or hands and knees position instead
of supine) is useful for treatment of a prolonged second stage [70-72]. Women
should be encouraged to labor and give birth in the position they find most
comfortable.

Maternal and newborn outcomes after protraction or arrest

 ●Maternal – For the mother, protraction disorders have been associated with
increased risks for operative vaginal delivery, third/fourth-degree perineal
lacerations, cesarean delivery, urinary retention, postpartum hemorrhage, and
chorioamnionitis in observational studies [2,30,73-79].
●Newborn – For the neonate, a protracted first stage of labor has been associated
with increased risks for admission to the neonatal intensive care unit and five-
minute Apgar score <7, but no increased risk for serious morbidity or mortality.
In contrast, a protracted second stage has been associated with a small absolute
increase in serious neonatal morbidity (seizures, hypoxic-ischemic encephalopathy)
and mortality [10,75,79,80].

A protracted second stage itself may not be the causal factor for these adverse outcomes;
factors such as persistent malposition or macrosomia may both prolong the second stage and
increase maternal and/or neonatal morbidity.

It remains unclear whether performing a cesarean delivery late in the second stage of labor
would reduce the risk of adverse outcomes compared with continued labor. In a randomized trial
including 78 nulliparous women with a prolonged second stage (defined as three hours with an
epidural or two hours without an epidural), extending labor for at least one hour was compared
with expedited delivery (cesarean or operative vaginal delivery) [81]. Extended labor resulted in
a lower rate of cesarean delivery (19.5 versus 43.2 percent, RR 0.45, 95% CI 0.22-0.93); the
rate of maternal or neonatal complications was not significantly different for the two groups, but
the trial was underpowered to detect small differences in these outcomes.

POTENTIAL APPROACHES FOR PREVENTION OF LABOR ABNORMALITIES — There is

no strong evidence that any intervention will prevent protraction and arrest disorders, but some
of the following interventions appear to shorten the first stage. This evidence is described below.

Active management of labor — In a 2000 meta-analysis of randomized trials of the "active

management of labor" approach, active management reduced the duration of the first stage of
labor, but did not reduce the rate of cesarean delivery [82]. The components of this approach
that are most important (strict criteria for diagnosis of labor, early amniotomy,
early oxytocin initiation and dose, one-on-one labor support, etc) have not been studied
extensively. However, in a 2013 meta-analysis of randomized trials, the combination of early
amniotomy and early oxytocin administration versus routine care for women in spontaneous
labor shortened the first stage (mean difference -1.57 hours, 95% CI -2.15 to -1.00), and
possibly resulted in a small decrease in cesarean delivery (RR 0.97, 95% CI 0.77-0.99) [58].

Volume replacement and carbohydrate intake — Myometrial function may be suboptimal in

women who are not adequately hydrated. Physiologists have shown that hydration improves
skeletal muscle performance during prolonged exercise; however, the effects of hydration on
smooth muscle are less clear [83,84]. A 2013 meta-analysis of randomized trials of nulliparous
women in spontaneous labor demonstrated that when oral intake is restricted, an intravenous
fluid rate of 125 mL/hour compared with 250 mL/hour is associated with a longer mean duration
of labor (106 minutes, 95% CI 53-158 minutes) and higher rate of cesarean delivery (RR 1.56,
95% CI 1.10-2.21) [85]. When oral intake is not restricted, the benefit is less clear. The use of
fluid with dextrose has not been shown to significantly impact the rate of cesarean delivery or
duration of labor, although data are more limited [85,86].

In a systematic review and meta-analysis, small quantities of oral carbohydrate intake during
labor did not affect rates of oxytocin augmentation, cesarean or instrumental vaginal delivery,
vomiting, or length of labor, compared with placebo or standard care [87]. The effect of
significant oral carbohydrate intake on labor remains unclear as the mean difference between
the intervention and control groups was only 195 kcal and the overall quality of available data
was low. Further study is warranted since labor is a lengthy exertional state and carbohydrate
consumption before and during prolonged exercise appears to improve performance [88].

Delayed pushing — In a 2015 meta-analysis of trials of pushing/bearing methods in women

with epidural anesthesia, delayed pushing increased the duration of the second stage by a
mean of 54 minutes but decreased the duration of pushing by a mean of 20 minutes compared
with immediate pushing [89]. Delayed pushing was also associated with a slight increase in
spontaneous vaginal delivery (RR 1.07, 95% CI 1.03-1.11; 12 studies, 3114 women). Although
the frequency of low umbilical cord blood pH was increased (RR 2.24; 95% CI 1.37-3.68), no
differences were observed in rates of admission to neonatal intensive care or five-minute Apgar
score less than seven.

Maternal position and technique do not appear to affect the length of the second stage.
(See "Management of normal labor and delivery", section on 'Pushing'.)

Amniotomy — In a 2013 systematic review of randomized trials of routine amniotomy alone

versus intention to preserve the membranes (no amniotomy) in women in spontaneous labor,
routine amniotomy did not clearly shorten the first stage of spontaneous labor (mean difference
-20.43 minutes, 95% CI -95.93 to 55.06 minutes; five trials, 1127 women) or the second stage (-
1.33 minutes, 95% CI -2.92 to 0.26 minutes), or decrease the rate of cesarean delivery (RR
1.27, 95% CI 0.99-1.63; nine trials, 5021 women) [90]. Heterogeneity in study designs precludes
making a definite conclusion about the lack of benefit of routine amniotomy.

Avoidance of occiput posterior — Pregnant women are often advised to perform exercises to
facilitate anterior rotation of the fetus, but there is no strong evidence that these maneuvers are
effective. The lack of benefit was best illustrated by a large, multicenter, randomized trial that
assigned 2547 women at 36 to 37 weeks of gestation to one of two exercise programs [91].
Group 1 was told to take a daily walk and Group 2 was asked to assume a hands and knees
position with slow pelvic rocking for 10 minutes twice a day until labor began. The incidence of
persistent occiput posterior position at birth or before instrumental rotation was similar in both
groups (about 8 percent).

Pelvic floor muscle exercises — Training the muscles of the pelvic floor may prevent some
cases of prolonged second stage. One trial randomly assigned 301 healthy nulliparous women
to an antepartum pelvic floor muscle training program or usual care from 20 to 36 weeks of
gestation [92]. Women in the intervention group trained with a physiotherapist for one hour per
week and were encouraged to perform 8 to 12 intensive pelvic floor muscle contractions twice
daily. Women in the exercise group were less likely to have a second stage over 60 minutes
than controls (21 versus 34 percent), but the overall duration of the second stage was similar for
both groups (40 and 45 minutes, respectively), as was the rate of instrumental delivery (15 and
17 percent, respectively).

Exercise — Exercise during pregnancy improves fitness, but does not affect the length of labor.
In two trials, women randomly assigned to participation in an aerobic exercise program during
pregnancy had the same overall duration of labor as women who received standard prenatal
care [93,94]. Although the smaller trial (n = 91 women) observed a reduction in primary
cesarean delivery in the exercise group [93], the larger trial (n = 855 women) found no
difference in labor outcomes [94].

SUMMARY AND RECOMMENDATIONS

●The Friedman curve (figure 1) and the norms established from Friedman's data
historically had been widely accepted as the standard for assessment of normal
labor progression. However, multiple studies have established that contemporary
norms are different from those cited by Friedman. (See 'Friedman (historic)
data' above.)
●Contemporary studies do not show an abrupt change in the rate of cervical dilation
indicating a clear transition from latent to active labor and normal labor progress
appears to be slower than that described by Friedman (figure 2); many women do
not dilate at a rate >1 cm/hour until 6 cm dilation. (See 'First stage' above.)
●In contemporary obstetric practice, women with cervical dilation <6 cm are
considered to be in latent phase and those with cervical dilation ≥6 cm are
considered to be in the active phase, as cervical dilation is normally more rapid at
this point. (See 'Protraction' above.)
●The following table (table 1) is a reasonable guide for determining when the
progress of labor is protracted, and can be used with a partogram (figure 3). These
data show that labor may take more than six hours to progress from 4 to 5 cm and
more than three hours to progress from 5 to 6 cm, regardless of parity. (See 'First
stage' above.)
●Arrest of labor in the first stage is diagnosed at cervical dilation ≥6 cm dilation in a
patient with ruptured membranes and no cervical change for ≥4 hours despite
adequate contractions or no cervical change for ≥6 hours with inadequate
contractions. (See 'Arrest' above.)
●For women with poor labor progression over two hours in the first stage after
reaching 6 cm dilation, we recommend administering oxytocin (Grade 1B). We
monitor progress for another four hours if contractions are adequate (>200
Montevideo units), or six hours if an adequate contraction pattern is not achieved. If
 there is no cervical change despite oxytocin administration, we proceed with
cesarean delivery. If labor is progressing, either slowly or normally, we continue
oxytocin. (See 'Oxytocin augmentation' above.)
●In the second stage of labor, we begin oxytocin augmentation if descent is minimal
or absent and the uterus is hypocontractile after 60 to 90 minutes of pushing.
(See 'Prolonged second stage' above.)
●We avoid operative delivery in the second stage as long as the fetus continues to
descend and/or rotate to a more favorable position for vaginal delivery and the fetal
heart rate pattern is not concerning. Operative intervention is indicated for fetuses
with abnormal fetal heart rate tracings, regardless of labor progress.
(See 'Prolonged second stage' above.)
●We diagnose second stage arrest if progressive fetal descent/rotation is not
observed after two hours of pushing in multiparous women and three hours of
pushing in nulliparous women. (See 'Prolonged second stage' above.)
We manage second stage arrest with an operative delivery (instrumental vaginal or
cesarean, as appropriate). In women who have epidural anesthesia, we allow an
additional hour of pushing before operative intervention on a case-by-case basis.
(See 'Prolonged second stage' above.)
●The time to dilate 1 cm in latent phase is significantly longer in women undergoing
induction than in those in spontaneous labor, and can take many hours. In contrast,
the time to dilate from 6 to 10 cm is more rapid and similar in both induced and
spontaneous labors. There is no difference in length of the second stage between
induced and spontaneous labor. (See 'Normal progress in induced labors' above.)
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