Length of the First Stage of Labor and
Associated Perinatal Outcomes in
Nulliparous Women
Yvonne W. Cheng, MD, MPH, Brian L. Shaffer, MD,
and Aaron B. Caughey, MD, PhD
Downloaded from https://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3tjcLwhL8g9bPq7kcjNWDbqRaVBrJHlV2dmNH8rEPJLc= on 05/04/2020
OBJECTIVE: To estimate whether length of the first
stage of labor is associated with adverse maternal and
neonatal outcomes.
METHODS: This is a retrospective cohort study of
nulliparous women with term, singleton gestations deliv-
ered in one academic center between 1990 and 2008. The
length of the first stage was stratified into three sub-
groups: less than the 5th percentile, 5th to 95th percen-
tile, and greater than the 95th percentile. Maternal and
neonatal outcomes were compared using the ␹2 test.
Multivariable logistic regression models were used to
control for confounders.
RESULTS: Of the 10,661 nulliparous women meeting
study criteria, the median (50th percentile) length of the
first stage was 10.5 hours. Compared with women with a
first stage between 2.8 and 30 hours (5th to 95th percen-
tile thresholds), the risk of cesarean delivery was higher
(6.1% compared with 13.5%; adjusted odds ratio [OR],
2.28, 95% confidence interval [CI], 1.92–2.72) in women
with a first stage longer than 30 hours (greater than the
95th percentile). These women also had higher odds of
From the Division of Maternal–Fetal Medicine, Department of Obstetrics,
Gynecology and Reproductive Sciences, University of California, San Francisco,
San Francisco, California; and the Departments of Obstetrics and Gynecology,
Massachusetts General Hospital, Boston, Massachusetts, and Oregon Health &
Science University, Portland, Oregon.
Dr. Cheng is supported by the UCSF Women’s Reproductive Health Research
Career Development Award, NIH, the Eunice Kennedy Shriver National
Institute of Child Health and Human Development (K12 HD001262).
Dr. Caughey is supported by the Robert Wood Johnson Foundation as a
Physician Faculty Scholar. Dr. Bryant is supported by the Robert Wood Johnson
Foundation as an Amos Medical Faculty Development Scholar.
Corresponding author: Yvonne W. Cheng, MD, MPH, Division of Perinatal
Medicine and Genetics, Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California, San Francisco, 505 Parnassus Avenue, Box
0132, San Francisco, CA 94143-0132; e-mail: yvecheng@hotmail.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2010 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/10
VOL. 116, NO. 5, NOVEMBER 2010
Allison S. Bryant, MD, MPH,
chorioamnionitis (12.5% compared with 23.5%; adjusted
OR, 1.58; 95% CI, 1.25–1.98) and neonatal admission to
the neonatal intensive care unit (4.7% compared with
9.8%; adjusted OR, 1.53; 95% CI, 1.18 –1.97) but no other
associated adverse neonatal outcomes.
CONCLUSION: Women with a prolonged first stage of
labor have higher odds of cesarean delivery and chorio-
amnionitis, but their neonates are not at risk of increased
morbidity.
(Obstet Gynecol 2010;116:1127–35)
LEVEL OF EVIDENCE: II
I n 1955, Friedman1 described the characteristic first
stage of labor as sigmoid-shaped, consisting of a
latent phase and an active phase. This labor curve has
traditionally been accepted as the “normal” course of
labor and subsequent definitions of labor protraction
and arrest have been widely accepted.2,3 However,
the practice of obstetrics has changed over time.
Recent studies suggest that labor progression in con-
temporary obstetrics differs from Friedman’s labor
curve with a substantially slower rate of cervical
dilation,4,5 and less stringent criteria for normal labor
may be appropriate.6 –9
Although the American Congress of Obstetri-
cians and Gynecologists has defined labor as “the
presence of uterine contractions of sufficient intensity,
frequency, and duration to bring about demonstrable
effacement and dilation of the cervix,”10 uncertainty
exists regarding the definition of latent labor. Because
women present at different phases of labor, it is not
always possible to evaluate cervical effacement and
dilation corresponding to the onset of labor in the
latent phase. Thus, most studies of labor and labor
dystocia focus on progression of labor during the
active phase and the management thereof.7,9,11–13 Al-
though risk factors for a prolonged second stage of
OBSTETRICS & GYNECOLOGY 1127
labor and outcomes have been more extensively
investigated,14 –16 the association between the length of
the first stage of labor and perinatal outcome remains
largely unclear and can be methodologically chal-
lenging to evaluate17,18
Given such paucity of information on the length of
the first stage of labor and its associated perinatal
outcomes, we examined a cohort of nulliparous women
in spontaneous labor to investigate factors associated
with a prolonged first stage and whether the duration of
the first stage of labor is associated with maternal and
neonatal morbidity. Particularly, we examined the en-
tire length of the first stage rather than the active phase
of first stage. We hypothesized that in nulliparous
women, a prolonged first stage of labor might portend
labor dystocia, leading to a higher risk of maternal
complications but not neonatal morbidity.
MATERIALS AND METHODS
We designed a retrospective cohort study of all term,
cephalic, live singleton births to nulliparous women
who presented in spontaneous labor and delivered at
the University of California, San Francisco between
January 1990 and July 2008. Institutional review
board approval was obtained from the Committee on
Human Research at the University of California, San
Francisco. Term gestation was defined as gestational
age at delivery of 37 completed weeks or greater. The
exclusion criteria were multiple gestations, induction
of labor, cesarean delivery before onset of labor or
during the first stage of labor for fetal indications (fetal
distress or fetal intolerance of labor), intrauterine fetal
death, or known lethal congenital anomalies. All
deliveries at this academic institution were performed
by resident clinicians with supervision by certified
nurse midwives or attending physicians.
Maternal characteristics and labor information
were collected by the managing physicians on Labor
and Delivery, and neonatal information was similarly
collected by pediatricians using a neonatal database.
The maternal and neonatal databases were then
linked using two unique maternal and neonatal iden-
tifiers and crosschecked with 100% linkage that was
performed by an externally contracted company. The
perinatal database was maintained with daily chart
review by trained abstractors to ensure proper infor-
mation gathering and to minimize missing data. The
database was additionally reviewed monthly by
trained physicians for quality assurance.
The duration of the first stage of labor was
defined as the time interval between onset of labor to
complete cervical dilation regardless of the timing of
rupture of the membranes. Onset of labor was char-
1128 Cheng et al First Stage of Labor and Perinatal Outcomes
acterized by the following: 1) regular, painful uterine
contractions with a frequency of at least every 5
minutes or three contractions in a 10-minute period as
reported by the parturient; and 2) cervical change
documented by the health care provider. For exam-
ple, if a woman presented for labor evaluation but did
not have regular contractions or documented cervical
change, then she was not in labor. If she then returned
the next day, reporting onset of painful, regular
contractions, which started 6 hours before the second
presentation, and subsequently had documented cer-
vical change, the time of labor onset in this case would
be recorded as 6 hours before admission. Although
the decision for admission and labor management
may be individualized, some (but not all) indications
for admission include active labor (cervix 3– 4 cm
dilated, effaced), rupture of the membranes, nonreas-
suring fetal heart tracing, and vaginal bleeding. Typ-
ically women were not admitted in latent labor for
augmentation without maternal or fetal indications.
Labor augmentation with oxytocin or artificial rup-
ture of the membranes was initiated usually only if
there was lack of labor progress. Active management
of labor was not a standard protocol during the study
period. Women may request pain control at any point
of labor, and regional analgesia is most often placed
during the active phase of labor. If cesarean delivery
was performed during the first stage, then the length
of the first stage was determined as the period be-
tween the onset of labor to time of cesarean delivery.
The length of the first stage of labor was stratified into
three time intervals: less than the 5th percentile, 5th to
95th percentile, and greater than the 95th percentile.
Maternal and labor characteristics were examined as
associated factors for length of the first stage.
Maternal outcomes evaluated included mode of
delivery (spontaneous vaginal delivery compared
with operative vaginal delivery compared with cesar-
ean delivery), third- or fourth-degree perineal lacera-
tions, postpartum hemorrhage (estimated blood loss
of greater than 500 mL for vaginal delivery and
greater than 1,000 mL for cesarean delivery during
the first 24 hours postdelivery), blood transfusion,
chorioamnionitis (defined as intrapartum maternal
temperature greater than or equal to 38.0°C and fetal
tachycardia or other clinical symptoms [greater than
160 beats per minute] on electronic fetal heart rate
monitoring), and endomyometritis (defined as post-
partum maternal temperature greater than 38.5°C in
the presence of uterine fundal tenderness). Neonatal
outcomes examined included 5-minute Apgar score
less than 7, cord umbilical arterial pH less than 7.0 or
base excess less than or equal to 12 (results of
OBSTETRICS & GYNECOLOGY
umbilical arterial blood gases were available for anal-
ysis in 76.2% of the births), meconium aspiration
syndrome, neonatal sepsis, birthweight greater than
4,000 g, shoulder dystocia, birth trauma (a composite
variable of skull fracture, clavicular fracture, brachial
plexus palsy, facial nerve palsy, and other nonspeci-
fied trauma), and admission to the neonatal intensive
care unit. The diagnosis of shoulder dystocia was
made by the delivering obstetric attending, whereas
neonatal diagnoses were made by the pediatricians
caring for the newborns. The diagnosis of neonatal
sepsis was based on either a positive blood culture or
based on clinical presentation or suspicion with addi-
tional support of abnormal laboratory results (such as
abnormal complete blood count or C-reactive pro-
tein) because neonatal blood cultures can be positive
if antibiotics were given intrapartum.
Statistical analysis was performed using STATA
9.0. Maternal and neonatal outcomes were analyzed
using the Pearson’s ␹2 test for categorical variables.
Potential confounders were controlled for using mul-
tivariable logistic analysis. The covariates in the mul-
tivariable regression models included maternal age,
race and ethnicity, gestational age at delivery, year of
delivery, epidural anesthesia, and the length of the
second stage of labor. Furthermore, we included
episiotomy and operative vaginal delivery as covari-
ates for the multivariable logistic models that exam-
ined the effect estimates of perineal lacerations and
shoulder dystocia; oxytocin augmentation was also
additionally included for the effect estimates of cho-
rioamnionitis; and mode of delivery as well as cho-
rioamnionitis were also included for the effect esti-
mates of postpartum hemorrhage and neonatal

Table 1. Maternal and Labor Characteristics of Nulliparous Women Stratified by Length of the First
Stage of Labor*
Greater Than the
Less Than the 5th 95th Percentile
Percentile 5th to 95th Percentile (More Than 30 h)
Length of the First Stage (0–2.8 h) (nⴝ525) (2.8–30 h) (nⴝ9,611) (nⴝ525) P

Maternal age (y)

Younger than 35 (n⫽9,006) 5.1 90.4 4.5 ⬍.001
35 or older (n⫽1,640) 4.0 88.9 7.1
Race/Ethnicity
White (n⫽4,714) 4.5 90.0 5.8
African American (n⫽1,196) 6.4 90.0 3.7 .04
Latina (n⫽1,056) 5.4 89.7 4.9
Asian (n⫽2,996) 4.6 90.6 4.8
Gestational age (wk)
Less than 41 (n⫽8,582) 5.4 90.2 4.4 ⬍.001
41 or more (n⫽2,072) 2.9 90.3 6.7
2
Maternal body mass index (kg/m )
Low (less than 19.5) (n⫽1,254) 6.1 91.6 2.4
Normal (19.5–25) (n⫽4,234) 4.6 91.2 4.3 ⬍.001
High (26–28) (n⫽684) 4.5 89.0 6.4
Obese (29 or greater) (n⫽628) 4.1 89.3 6.5
Marital status
Married (n⫽6,648) 4.5 90.3 5.2 .02
Not married (n⫽3,805) 5.4 90.3 4.3
Oxytocin augmentation of labor
No oxytocin (n⫽5,690) 6.1 91.0 2.9 ⬍.001
Had oxytocin (n⫽4,943) 3.5 89.4 7.1
Epidural use
No epidural use (n⫽3,397) 9.6 88.3 2.1 ⬍.001
Epidural use (n⫽7,211) 2.7 91.1 6.2
Fetal occiput position
OA position (n⫽9,088) 5.3 90.5 4.2 ⬍.001
OP position (n⫽911) 1.2 89.1 9.7
Birth weight (g)
4,000 or less (n⫽9,736) 5.1 90.2 4.7 ⬍.001
More than 4,000 (n⫽914) 2.9 90.0 7.0
OA, occiput anterior; OP, occiput posterior.
Data are % unless otherwise specified.
* The length of the first stage of labor was examined as a categorical variable using Pearson’s ␹2 test.

VOL. 116, NO. 5, NOVEMBER 2010 Cheng et al First Stage of Labor and Perinatal Outcomes 1129
Table 2. Maternal and Neonatal Outcomes by Length of the First Stage of Labor*
Less Than the 5th Greater Than the 95th
Percentile 5th to 95th Percentile Percentile (More Than
Length of the First Stage (0–2.8 h) (nⴝ525) (2.8–30 h) (nⴝ9,611) 30 h) (nⴝ525) P

Mode of delivery
Spontaneous VD 80.6 72.9 63.8
Operative VD 17.4 21.0 22.6 ⬍.001
Cesarean 2.0 6.1 13.5
Maternal outcomes
3rd- or 4th-degree perineal laceration† 10.0 11.5 9.4 .20
Postpartum hemorrhage 8.6 9.8 14.0 .004
Chorioamnionitis 2.9 12.5 23.5 ⬍.001
Endomyometritis 1.0 2.4 3.2 .04
Neonatal outcomes
5-min Apgar score less than 7 1.3 2.5 4.1 .02
UA pH less than 7.0 0.0 0.6 1.0 .23
Meconium aspiration 0.6 0.8 0.0 .38
Neonatal sepsis 0.0 0.1 0.2 .64
Shoulder dystocia† 1.4 1.5 0.7 .57
Birth trauma 0.6 0.7 0.0 .47
Neonatal intensive care unit admission 5.8 4.7 9.8 ⬍.001
VD, vaginal delivery; UA, cord umbilical artery.
Data are % unless otherwise specified.
* The length of the first stage of labor was examined as a categorical variable using Pearson’s ␹2 test.
†
For vaginal deliveries only.

intensive care unit admission. Additional models
were created excluding women with medical compli-
cations (diabetes, preeclampsia) as well as cesarean
deliveries and oxytocin augmentation or artificial
rupture of the membranes. As a result of the fact that
the study period spanned 19 years, we included year
of delivery as a potential confounding covariate in the
multivariable logistic models. Length of labor was
also examined by survival analyses using the log-rank
test to compare Kaplan-Meier survival curves. Statis-
tical significance was indicated by P⬍.05 and 95%
confidence intervals (CIs).
the first stage between 2.8 and 30 hours (5th to 95th
percentile), and 525 with a length of the first stage
lasting longer than 30 hours (greater than 95th
percentile).
Maternal characteristics associated with a
length of first stage longer than 30 hours (more than
95th percentile duration) included: maternal age,
gestational age at delivery greater than 41 weeks,
high prepregnancy maternal body mass index, and
being married (Table 1). Oxytocin augmentation of
labor was more frequent with longer first stage as
was epidural use, persistent occiput posterior posi-

RESULTS
0
During the study period, there were 23,646 women Spontaneous vaginal delivery
Operative vaginal delivery
with singleton, term, nonanomalous pregnancies Cesarean delivery
25
who had a trial of labor. We excluded 10,512
Delivered (%)

multiparous women, 2,256 nulliparous women who

50
had induction of labor, and 217 nulliparous women
who had cesarean delivery as a result of fetal
75
intolerance of labor or fetal distress, leaving 10,661
P<.001 by log-rank
women meeting study criteria and eligible for anal-
100
ysis. The median (50th percentile) length of the first
0 10 20 30 40 50
stage of labor was 10.5 hours with 2.8 hours as the
First stage of labor (hours)
5th percentile, 6.5 hours as the 25th percentile, 16.5
Fig. 1. Kaplan-Meier survival curves examining the length
hours as the 75th percentile, and 30.0 hours as the
of the first stage of labor and mode of delivery (P⬍.001 by
95th percentile thresholds. There were 525 women log-rank test).
with a length of the first stage less than 2.8 hours Cheng. First Stage of Labor and Perinatal Outcomes. Obstet
(less than the 5th percentile), 9,611 with a length of Gynecol 2010.

1130 Cheng et al First Stage of Labor and Perinatal Outcomes OBSTETRICS & GYNECOLOGY
tion at delivery, and birthweight greater than 4,000
g (Table 1).
The association between length of first stage and
mode of delivery was examined using univariable
comparison and survival analysis. In women with a
first stage more than the 95th percentile (30 hours),
75% still proceeded to have vaginal deliveries (Table
2). Conversely, in women who had a very short first
stage (less than the 5th percentile), less than 5%
required cesarean delivery (Table 2). Women who
had spontaneous vaginal delivery or operative vaginal
delivery had a shorter first stage compared with those
delivered by cesarean (P⬍.001 by log-rank test; Fig.
1). Of the women who had cesarean delivery, 72%
were performed for arrest of dilation or descent and
13% for failed attempts of forceps or vacuum-assisted
vaginal delivery; other indications (eg, cord prolapse,
active bleeding, malpresentation, chorioamnionitis,
and “others”) made up the remaining 14% of the
cesarean deliveries. Although women with a pro-
longed first stage (greater than the 95th percentile) did
not have a higher frequency of severe perineal lacer-
ations, they were more likely to have postpartum
hemorrhage, chorioamnionitis, and endomyometritis
(Table 2). Neonates born to women with a first stage
greater than the 95th percentile were more likely to
have 5-minute Apgar score less than 7 and admission
to the neonatal intensive care unit (Table 2). These
neonates were also more likely to weigh more than
4,000 g but they were not more likely to experience
shoulder dystocia (Table 2) or have birth trauma.
The association between length of the first stage
and mode of delivery as well as perinatal outcomes
were further examined using multivariable logistic
regressions models to adjust for potential confounding
bias on effect estimates. Compared with women with
a first stage duration between the 5th and 95th
percentiles, women with a short first stage (less than
the 5th percentile) had lower odds of cesarean deliv-
ery and chorioamnionitis (Table 3). On the other end
of the spectrum, women with a first stage duration
greater than the 95th percentile had higher odds of
cesarean delivery, both in the first and second stages
of labor, but lower odds of operative vaginal delivery
(Table 3). Furthermore, the length of first stage greater
than the 95th percentile was not associated with
higher odds of third- or fourth-degree perineal lacer-
ations, postpartum hemorrhage, or endomyometritis,

Table 3. Adjusted Odds Ratios of Perinatal Outcomes in Multivariate Logistic Regression Analyses*
Stratified by Length of the First Stage of Labor
Less Than the 5th Percentile Greater Than the 95th
(Less Than 2.8 h) Percentile (More Than 30 h)
Length of the First Stage aOR 95% CI aOR 95% CI

Mode of delivery
Cesarean (first and second stages) 0.62 0.45–0.84 2.28 1.92–2.72
Cesarean (second stage only) 0.58 0.39–0.89 1.70 1.35–2.14
Operative vaginal† 1.12 0.94–1.34 0.80 0.68–0.96
Maternal outcomes
3rd- or 4th-degree perineal laceration† 1.08 0.86–1.35 1.10 0.86–1.39
Postpartum hemorrhage 0.95 0.74–1.22 1.18 0.95–1.45
Chorioamnionitis 0.31 0.17–0.56 1.58 1.25–1.98
Endomyometritis 0.72 0.39–1.32 0.94 0.62–1.43
Neonatal outcomes
5-min Apgar score less than 7 0.73 0.44–1.22 1.27 0.88–1.85
UA pH less than 7.0 0.87 0.29–2.51 0.73 0.22–2.42
Meconium aspiration 0.64 0.20–2.13 1.36 0.52–3.51
Neonatal sepsis — — 1.07 0.13–8.87
Shoulder dystocia 0.71 0.33–1.48 1.00 0.51–1.95
Birth trauma‡ 0.96 0.23–4.08 — —
Neonatal intensive care unit admission 0.91 0.67–1.25 1.53 1.18–1.97
aOR, adjusted odds ratio; CI, confidence interval; UA, cord umbilical artery.
Reference comparison group: white, length of first stage of labor in the 5th to 95th percentile.
* Adjusted for maternal age, gestational age at delivery, ethnicity, gestational diabetes, preeclampsia, placenta abruption, year of
delivery, delivery attendant, and epidural anesthesia (episiotomy and operative vaginal delivery additionally included for perineal
lacerations, and shoulder dystocia; oxytocin augmentation additionally included for chorioamnionitis; mode of delivery and
chorioamnionitis additionally adjusted for postpartum hemorrhage and neonatal intensive care unit admission).
†
For vaginal deliveries only.
‡
Birth trauma: composite variable of skull fracture, clavicle fracture, brachial plexus palsy, facial nerve palsy, and other nonspecified
trauma.

VOL. 116, NO. 5, NOVEMBER 2010 Cheng et al First Stage of Labor and Perinatal Outcomes 1131
but odds of chorioamnionitis were higher (Table 3).
There were no differences in neonatal outcomes,
except for higher odds of admission to the neonatal
intensive care unit in neonates born to women with a
first stage greater than the 95th percentile(adjusted
odds ratio, 1.53; 95% CI, 1.18 –1.97). However, infor-
mation regarding indications for neonatal intensive
care unit admission was not available.
To examine the association between length of the
first stage and perinatal outcomes, we repeated this
analysis in nulliparous women who delivered vagi-
nally (Table 4) and in women who did not receive
oxytocin augmentation of labor or artificial rupture of
the membranes (Table 5), and observed similar rela-
tionship between the duration of first stage of labor
and operative interventions and chorioamnionitis but
not worse neonatal outcomes.
To investigate whether risk of perinatal morbidity
increases before the 95th percentile threshold, we
stratified length of first stage into three subgroups: 5th
to 90th percentile, 90th to 95th percentile, and greater
than the 95th percentile. Univariable analyses using
Pearson’s ␹2 test were used to examine the association
between maternal and neonatal outcomes by these
first-stage thresholds (Table 6). We then performed
multivariable logistic regression analysis controlling
for the same covariates as the previous comparisons.
Compared with women with a first stage duration
between the 5th and 90th percentiles, the odds of
cesarean delivery and chorioamnionitis was higher in
both groups of women with a first stage duration
greater than the 90th percentile, but there were no
differences in perinatal outcomes except for increased
odds of neonatal intensive care nursery admission in
women whose first stage was greater than the 95th
percentile (Table 7).
DISCUSSION
In our large cohort of nulliparous women with a term,
singleton gestation experiencing spontaneous labor,
increasing length of the first stage of labor was
associated with increased risk of cesarean delivery
and chorioamnionitis but not adverse neonatal out-
comes. Among women who had a cesarean delivery,
their length of the first stage of labor was longer
compared with women who delivered vaginally. Yet,
it is important to note that although a prolonged first
stage is associated with a higher risk of cesarean
delivery, the majority of women still achieved vaginal
delivery, even in those with a first stage of labor
lasting beyond 30 hours (greater than the 95th per-
centile threshold).
The associated risk for chorioamnionitis was
greater when the first stage of labor was prolonged

Table 4. Adjusted Odds Ratios of Perinatal Outcomes in Multivariate Logistic Regression Analyses* in
Nulliparous Women Who Had Vaginal Deliveries
Less Than 5th Percentile Greater Than the 95th
(Less Than 2.8 h) Percentile (More Than 30 h)
Length of the First Stage aOR 95% CI aOR 95% CI

Maternal outcomes
Operative vaginal delivery† 1.25 0.97–1.62 1.16 0.91–1.48
3rd- or 4th-degree perineal laceration‡ 0.89 0.63–1.25 0.97 0.69–1.37
Postpartum hemorrhage 1.19 0.84–1.69 1.27 0.89–1.82
Chorioamnionitis 0.38 0.21–0.69 1.44 1.08–1.90
Endomyometritis 0.85 0.26–2.76 1.04 0.37–2.90
Neonatal outcomes
5-min Apgar score less than 7 0.63 0.28–1.44 0.98 0.52–1.88
UA pH less than 7.0 — — 1.53 0.36–6.55
Meconium aspiration 1.22 0.28–5.22 — —
Neonatal sepsis — — — —
Shoulder dystocia 1.06 0.40–2.67 0.46 0.11–1.90
Birth trauma 0.97 0.23–4.13 — —
Neonatal intensive care unit admission 1.15 0.76–1.74 1.45 0.98–2.17
aOR, adjusted odds ratio; CI, confidence interval; UA, cord umbilical artery.
Reference comparison group: white, length of first stage of labor in the 5th to 95th percentile.
* Adjusted for maternal age, gestational age at delivery, ethnicity, gestational diabetes, preeclampsia, placenta abruption, year of
delivery, delivery attendant, and epidural anesthesia (episiotomy and operative vaginal delivery additionally included for perineal
lacerations, and shoulder dystocia; oxytocin augmentation additionally included for chorioamnionitis; mode of delivery and
chorioamnionitis additionally adjusted for postpartum hemorrhage and neonatal intensive care unit admission).
†
For vaginal deliveries only.
‡
Birth trauma: composite variable of skull fracture, clavicle fracture, brachial plexus palsy, facial nerve palsy, and other nonspecified
trauma.

1132 Cheng et al First Stage of Labor and Perinatal Outcomes OBSTETRICS & GYNECOLOGY
Table 5. Adjusted Odds Ratios of Perinatal Outcomes in Multivariate Logistic Regression Analyses* in
Nulliparous Women Who Did Not Have Oxytocin Augmentation of Labor or Artificial Rupture
of the Membranes
Less Than the 5th Percentile Greater Than the 95th
(Less Than 2.8 h) Percentile (More Than 30 h)
Length of the First Stage aOR 95% CI aOR 95% CI
†
Mode of delivery
Cesarean (first and second stages) 1.38 0.79–2.41 3.05 1.90–4.90
Cesarean (second stage only) 1.01 0.40–2.55 2.93 1.62–5.31
Operative vaginal 1.25 0.86–1.80 0.78 0.48–1.25
Maternal outcomes
3rd- or 4th-degree perineal laceration 0.96 0.62–1.48 0.82 0.43–1.57
Postpartum hemorrhage 1.07 0.66–1.72 1.81 1.06–3.09
Chorioamnionitis 0.32 0.10–1.02 1.86 1.12–3.08
Endomyometritis 0.05 0.31–2.91 0.55 0.12–2.43
Neonatal outcomes
5-min Apgar score less than 7 1.13 0.44–2.88 1.00 0.31–3.27
UA pH less than 7.0 — — 2.16 0.27–17.3
Meconium aspiration 1.16 0.15–9.21 — —
Neonatal sepsis — — — —
Shoulder dystocia 1.35 0.46–3.91 0.95 0.13–7.18
Birth trauma 0.74 0.10–5.69 — —
Neonatal intensive care unit admission 1.55 0.87–2.73 1.72 0.85–3.49
aOR, adjusted odds ratio; CI, confidence interval; UA, cord umbilical artery.
Reference comparison group: white, length of first stage of labor in the 5th to 95th percentile (9.74 hours or less).
* Adjusted for maternal age, gestational age at delivery, ethnicity, gestational diabetes, preeclampsia, placenta abruption, year of
delivery, delivery attendant, epidural anesthesia, and length of the second stage of labor (episiotomy and operative vaginal delivery
additionally adjusted for perineal lacerations, and shoulder dystocia; mode of delivery and chorioamnionitis additionally adjusted
for postpartum hemorrhage, and intensive care unit admission).
†
Compared with spontaneous vaginal delivery.

(greater than the 95th percentile). Although longer
labor may have led to the greater risk of chorioam-
nionitis, alternatively, the presence of chorioamnioni-
tis may have caused dysfunctional contractions,
which led to longer labor. We did not observe an
association between length of labor and risk of en-
domyometritis. It could be that women who had
chorioamnionitis would have received antibiotics in
labor or postpartum, which may, in turn, reduce the
odds of endomyometritis.
We observed that epidural analgesia, fetal occiput
posterior position, and macrosomia were risk factors
for increased duration of first stage; however, neo-
nates born to women with a first stage greater than the
90th or 95th percentiles did not have higher odds of
adverse outcomes, except for neonatal intensive care
unit admission with first stage greater than the 95th
percentile. Although we did not have precise indica-
tions for neonatal intensive care unit admissions,
some may have been for sepsis workups in the
presence of chorioamnionitis, although the risk of
neonatal sepsis was not associated with a longer first
stage. Furthermore, the length of first stage was not
associated with other neonatal morbidity, which often
results in a neonatal intensive care unit admission,
including 5-minute Apgar score less than 7, neonatal
acidemia, birth trauma, or meconium aspiration syn-
drome.
As Zhang and colleagues recently pointed out,
“our inability to reduce cesarean delivery rate may be
contributed in part to the incomplete understanding
of a normal labor process, particularly in the first
stage.”9 This study provides information regarding the
association between length of first stage and mode of
delivery as well as associated perinatal outcomes that
is currently lacking.
Our study examined perinatal outcomes associ-
ated with the length of the first stage for nulliparous
women but has limitations. Because the first stage of
labor consists of both the latent and the active phases,
one challenge is the precise identification of the onset
of labor. In this study, the length of the first stage of
labor was determined based on self-report by the
parturient and by clinical examination, because
women do not always present for evaluation of labor
during the latent phase or at the exact onset of labor.
Self-reporting can be prone to recall error and cannot
be objectively verified. However, this is routinely how
women present to clinicians; thus, we believe our
findings have clinical validity.16 A recent study on the

VOL. 116, NO. 5, NOVEMBER 2010 Cheng et al First Stage of Labor and Perinatal Outcomes 1133
Table 6. Maternal and Neonatal Outcomes by Length of the First Stage of Labor*
5th to 90th
Percentile 90th to 95th Greater Than the 95th
(2.8–23.8 h) Percentile (23.8–30 h) Percentile (More Than 30 h)
Length of the First Stage (nⴝ9,069) (nⴝ542) (nⴝ525) P

Mode of delivery
Spontaneous VD 70.2 60.8 55.3
Operative VD 20.2 17.7 20.1 ⬍.001
Cesarean 9.6 21.6 24.6
Maternal outcomes
3rd- or 4th-degree perineal 11.5 10.7 9.4 .25
laceration†
Postpartum hemorrhage 9.6 11.9 14.1 .001
Chorioamnionitis 12.0 21.8 23.8 ⬍.001
Endomyometritis 2.4 3.1 3.2 .30
Neonatal outcomes
5-min Apgar score less than 7 2.5 3.0 4.2 .003
UA pH less than 7.0 0.7 0.0 1.0 .24
Meconium aspiration 0.8 1.8 0.0 .06
Neonatal sepsis 0.1 0.0 0.2 .64
Shoulder dystocia† 1.5 2.4 0.7 .22
Birth trauma 0.7 0.4 0.0 .38
Neonatal intensive care unit 4.7 6.3 9.9 ⬍.001
admission
VD, vaginal delivery; UA, cord umbilical artery.
Data are % unless otherwise specified.
* The length of the first stage of labor was examined as a categorical variable using Pearson’s ␹2 test.
†
For vaginal deliveries only.

latent phase of labor in women who had induction of
labor reports a mean duration of 384 minutes, or 6.4
hours19; it has been previously reported that the
median active phase of labor is approximately 4
hours.4,9 Our observation of a median duration of the
first stage of 10.5 hours is thus consistent with previ-
ous reports, although these study populations are
markedly different. The large number of patients in
our cohort also may overcome some of the limitations
of self-report. Most literature on the first stage of labor
examines only the active phase.4 –7 Our study provides
additional information regarding the progression of
the first stage of labor in its entirety; however, we do
not have detailed information on the transition be-
tween latent and active phases labor. Furthermore,
some of our outcomes involved multiple comparison
groups; thus, the potential pitfall of a type I error
(false-positive) exists. However, most of the outcomes
of interest were statistically significant with a P value
of ⬍.001, making the possibility of type I error less
likely and even with the Bonferroni correction that
accounts for multiple comparisons, these remained
statistically significant.
Another study limitation is that information on
labor augmentation, artificial rupture of the mem-
branes, or epidural placement were reported as pres-
ence or absence; thus, we could not explore how
these interventions may have influenced the course of
labor. Likely, as the quality of electronic medical
records improves, so will the data that become avail-
able. Future studies should endeavor to examine the
effects of these on length of labor and associated
perinatal outcomes. Another potential limitation is
that the diagnosis of chorioamnionitis was based on
clinical findings rather than placental pathology,
which may lead to an overestimation of the effect of
the first-stage length on chorioamnionitis. Also, we
excluded women who had a cesarean delivery for
fetal intolerance of labor or fetal distress from the
analysis; however, it is possible that some fetuses,
likely a small minority, with acute compromise may
remain in the cohort.
We observed that increasing lengths of the first
stage of labor are associated with maternal, but not
neonatal, morbidity; but even in women whose first
stage lasted beyond 24 hours, nearly three of four still
achieved vaginal delivery. In today’s obstetric climate
where successful vaginal birth after cesarean delivery
is less than 10%, achieving vaginal delivery in the first
pregnancy markedly decreases the risks of multiple
cesarean deliveries, and the associated morbidity, in
future pregnancies. Management of labor should in-
volve a thorough consideration of the ongoing risks of
continued expectant management compared with the

1134 Cheng et al First Stage of Labor and Perinatal Outcomes OBSTETRICS & GYNECOLOGY
Table 7. Adjusted Odds Ratios of Perinatal Outcomes in Multivariate Logistic Regression Analyses*
Stratified by Length of the First Stage of Labor
90th to 95th Percentile Greater Than the 95th
(23.8–30 h) Percentile (More Than 30 h)
Length of First Stage aOR 95% CI aOR 95% CI
Mode of delivery
Cesarean (first and second stages) 2.09 1.66–2.64 2.57 2.04–3.22
Cesarean (second stage only) 1.51 1.09–2.08 1.97 1.49–2.67
Operative vaginal† 0.73 0.58–0.93 0.88 0.70–1.11
Maternal outcomes
3rd- or 4th-degree perineal laceration† 1.09 0.80–1.49 0.89 0.63–1.24
Postpartum hemorrhage 1.09 0.81–1.46 1.31 0.99–1.74
Chorioamnionitis 1.61 1.28–2.02 1.79 1.42–2.24
Endomyometritis 0.89 0.50–1.54 1.01 0.58–1.76
Neonatal outcomes
5-min Apgar score less than 7 1.16 0.69–1.95 1.42 0.87–2.31
UA pH less than 7.0 — — 1.51 0.94–1.05
Meconium aspiration 2.39 0.92–6.20 — —
Neonatal sepsis — — 2.24 0.26–18.7
Shoulder dystocia 1.61 0.77–3.39 0.43 0.10–1.75
Birth trauma‡ 0.55 0.07–4.10 — —
Neonatal intensive care unit admission 1.24 0.85–1.79 1.88 1.37–2.58
aOR, adjusted odds ratio; CI, confidence interval; UA, cord umbilical artery.
Reference comparison group: white, length of first stage of labor in the 5th to 90th percentile.
* Adjusted for maternal age, gestational age at delivery, ethnicity, gestational diabetes, preeclampsia, placenta abruption, year of
delivery, delivery attendant, and epidural anesthesia (episiotomy and operative vaginal delivery additionally included for perineal
lacerations, and shoulder dystocia; oxytocin augmentation additionally included for chorioamnionitis; mode of delivery and
chorioamnionitis additionally adjusted for postpartum hemorrhage and neonatal intensive care unit admission).
†
For vaginal deliveries only.
‡
Birth trauma: composite variable of skull fracture, clavicle fracture, brachial plexus palsy, facial nerve palsy, and other nonspecified trauma.

risks of intervention on the current and future preg-
nancies as well as the incorporation of patient prefer-
ences into the decision-making process.
REFERENCES
1. Friedman EA. Primigravid labor: a graphicostatistical analysis.
Obstet Gynecol 1955;6:567– 89.
2. Friedman EA, Sachtleben MR. Dysfunction labor. I. Prolonged
latent phase in the nullipara. Obstet Gynecol 1961;17:135– 48.
3. Friedman EA, Sachtleben MR. Dysfunction labor. II. Pro-
tracted active-phase dilatation in the nullipara. Obstet Gynecol
1961;17:566 –78.
4. Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve
in nulliparous women. Am J Obstet Gynecol 2002;187:824 – 8.
5. Cesario SK. Reevaluation of Friedman’s Labor Curve: a pilot
study. J Obstet Gynecol Neonatal Nurs 2004;33:713–22.
6. Albers LL, Schiff M, Gorwoda JG. The length of active labor in
normal pregnancies. Obstet Gynecol 1996;87:355–9.
7. Rouse DJ, Owen J, Savage KG, Hauth JC. Active phase labor
arrest: revisiting the 2-hour minimum. Obstet Gynecol 2001;98:
550 – 4.
8. Kilpatrick SJ, Laros RK Jr. Characteristics of normal labor.
Obstet Gynecol 1989;74:85–7.
9. Zhang J, Troendle J, Mikolajczyk R, Sundaram R, Beaver J,
Fraser W. The natural history of the normal first stage of labor.
Obstet Gynecol 2010;115:705–10.
10. Dystocia and augmentation of labor. ACOG Practice Bulletin
No. 49. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2003;102:1445–54.
11. Sheiner E, Levy A, Feinstein U, Hallak M, Mazor M. Risk
factors and outcome of failure to progress during the first stage
of labor: a population-based study. Acta Obstet Gynecol Scand
2002;81:222– 6.
12. Sadler LC, Davison T, McCowan LM. A randomized con-
trolled trial and meta-analysis of active management of labour.
BJOG 2000;107:909 –15.
13. Impey L, Hobson J, O’herlihy C. Graphic analysis of actively
managed labor: prospective computation of labor progress in
500 consecutive nulliparous women in spontaneous labor at
term. Am J Obstet Gynecol 2000;183:438 – 43.
14. Myles TD, Santolaya J. Maternal and neonatal outcomes in
patients with a prolonged second stage of labor. Obstet
Gynecol 2003;102:52– 8.
15. Menticoglou SM, Manning F, Harman C, Morrison I. Perinatal
outcome in relation to second-stage duration. Am J Obstet
Gynecol 1995;173:906 –12.
16. Cheng YW, Hopkins LM, Caughey AB. How long is too long:
does a prolonged second stage of labor in nulliparous women
affect maternal and neonatal outcomes? Am J Obstet Gynecol
2004;191:933– 8.
17. Malone FD, Geary M, Chelmow D, Stronge J, Boylan P,
D’Alton ME. Prolonged labor in nulliparas: lessons from the
active management of labor. Obstet Gynecol 1996;88:211–5.
18. Vahratian A, Troendle JF, Siega-Riz AM, Zhang J. Method-
ological challenges in studying labour progression in contem-
porary practice. Paediatr Perinat Epidemiol 2006;20:72– 8.
19. Grobman WA, Simon C. Factors associated with the length of
the latent phase during labor induction. Eur J Obsetet Gynecol
Reprod Biol 2007;132:163– 6.

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