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Labor: Diagnosis and management of a prolonged second stage

AUTHORS: Robert M Ehsanipoor, MD, Andrew J Satin, MD, FACOG
SECTION EDITOR: Vincenzo Berghella, MD
DEPUTY EDITOR: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2023.

This topic last updated: Jul 21, 2023.

INTRODUCTION

The second stage of labor begins when the cervix becomes fully dilated and ends with expulsion of the neonate. Recognizing abnormal
labor progression in the second stage and initiating appropriate interventions are important because a prolonged second stage is
associated with increased risks for operative delivery and maternal and neonatal morbidity.

This topic will discuss the diagnosis and management of a prolonged second stage of labor. An overview of labor progress, risk factors for
protraction and arrest disorders, diagnosis and management of first stage labor abnormalities, and management of normal labor and
delivery are reviewed separately:

● (See "Labor: Overview of normal and abnormal progression".)

● (See "Labor: Diagnosis and management of the latent phase".)
● (See "Labor: Diagnosis and management of an abnormal first stage".)
● (See "Labor and delivery: Management of the normal first stage".)

BACKGROUND
The second stage of labor is typically much shorter than the first stage and characterized by considerable variation; it is often brief but
may extend for many hours. The identification and management of prolonged second stage are based on expert consensus and agreed-
upon definitions for what is normal and safe. Historically, analyses of second-stage duration have been descriptive, retrospective, and
influenced by both demographic and obstetric factors, which have varied across time and practice settings. For example, demographic
factors that may increase second-stage duration include nulliparity and high maternal body mass index. Obstetric factors include
increased birth weight, high fetal station at complete dilation, occiput posterior position, neuraxial analgesia, delayed pushing,
willingness to initiate oxytocin in the second stage, and the skill, judgment, and ability of the provider to safely perform a rotation or
operative vaginal delivery.

A major focus of efforts to reduce the rate of primary cesarean births performed in the second stage is to allow a longer maximum time in
the second stage before considering it prolonged. Reduction of the cesarean birth rate is an important goal, but must be balanced
against the rare but considerable perinatal morbidity reported in prolonged second stage [1-7]. The diagnosis of a prolonged second
stage per se does not imply delivery must occur, but should prompt reassessment of maternal and fetal status, labor progress, and the
chances of vaginal birth. (See 'Risks of prolonging the second stage' below.)

DIAGNOSIS

The appropriate duration and maximum length of time allowed for the second stage of labor is somewhat controversial. A specific
absolute maximum length of time spent in the second stage beyond which all patients should undergo operative delivery has not been
identified. One consideration is that the start of the second stage is not precise because it is diagnosed when the cervix is completely
dilated (usually defined as 10 cm), which might have occurred before the manual cervical examination that first detects complete dilation.

We diagnose a prolonged second stage based on an American College of Obstetricians and Gynecologists (ACOG) and Society for
Maternal-Fetal Medicine (SMFM) consensus group statement for prevention of the primary cesarean birth:

● In nulliparous patients, the second stage generally can be considered prolonged:

• After three hours of pushing [8]. However, a longer duration (commonly, up to four hours of pushing) may be appropriate for
patients with epidural anesthesia or with a fetal malposition as long as progress is documented.

● In parous patients, the second stage generally can be considered prolonged:

 • After two hours of pushing [8]. However, a longer duration (commonly, up to three hours of pushing) may be appropriate for
patients with epidural anesthesia or with a fetal malposition as long as progress is documented.

We acknowledge that some clinicians use total duration of the second stage instead of duration of pushing. These times are the same,
except in patients who delay pushing after complete cervical dilation and thus have 'active' and 'passive' phases of the second stage.

Concerning fetal or maternal status necessitates consideration of delivery prior to reaching the described time limits.

Clinical experience and judgment are of great importance in decision-making during the second stage of labor. Factors such as the fetal
station, estimated fetal weight, obstetric history, fetal status, pelvic size and shape, and adequacy of maternal pushing should be
considered. In select scenarios where the probability of a vaginal birth appears to be low, such as when a patient has been pushing
effectively without any descent or rotation, it is reasonable to make a diagnosis of a prolonged second stage and proceed with operative
birth prior to these times. On the other hand, a diagnosis of a prolonged second stage does not mandate prompt operative intervention
when the maternal and fetal status is reassuring. (See 'Timing of operative delivery' below.)

Evidence and controversy — The contemporary criteria for diagnosis of a prolonged second stage were derived from an analysis of data
from the Consortium on Safe Labor by Zhang and co-investigators in 2010 [9], and then validated by a randomized trial [10] and large
observational study [11]. These data serve as a guide for describing the normal duration for the second stage of labor (median and 95th
percentile) in contemporary patients ( table 1) and are the foundation for ACOG and SMFM second-stage management guidelines.
However, this approach has been challenged by some experts, including Emanuel Friedman, MD, who believe that the safety of extending
the duration of the second stage to these lengths before making a diagnosis of arrest, particularly up to four hours in nulliparous patients
with neuraxial anesthesia, has not been established [6,12,13].

It is unclear whether a specific threshold exists for the duration of the second stage of labor beyond which operative delivery is absolutely
indicated. In our practice, we follow the criteria based on the data from the Consortium on Safe Labor by Zhang et al [9]. However, we
recommend increased vigilance when monitoring the fetal heart rate tracing and considering assisted-vaginal birth, in some cases prior
to reaching contemporary time criteria for diagnosis of a prolonged second stage. As discussed above (see 'Diagnosis' above), lack of
progress or concerning fetal or maternal status necessitates considering delivery prior to reaching the described time limits; however, a
reassuring assessment does not require prolonging the second stage indefinitely. In addition, the provider and patient will need to
engage in shared decision-making when weighing the likelihood of vaginal birth against the risk of serious maternal and neonatal
morbidity from expectant management when considering how long to continue the second stage.

Our approach is based on the following evidence:

 ● A meta-analysis that combined data from five retrospective cohort studies and two randomized trials performed worldwide found
similar rates of cesarean birth and adverse maternal and neonatal outcomes in nulliparous patients whether contemporary or
historic labor curves were used in the second stage [14]. A considerable degree of unexplained heterogeneity limited interpretation
of the findings. The authors concluded that it was not possible to establish a specific threshold for the duration of the second stage
beyond which all patients should undergo operative delivery.

● Another systematic review including 33 studies (>215,000 nulliparous individuals and >250,000 multiparous individuals) noted
considerable variation in the mean, median, and 95th percentile for duration of second stage among the included studies [15]. In 10
of the studies, increasing second-stage duration, with the exception of the first half hour, was associated with newborn morbidity.

● Patients with prolonged labor report a negative childbirth experience more often than those who had a labor of normal duration (34
versus 5 percent) [16].

INCIDENCE AND PROGNOSIS

In a retrospective study including over 15,000 nulliparous term cephalic singleton births from 1976 to 2001 in which 56 percent of the
entire cohort had epidural anesthesia, the frequency of patients giving birth during each hour of the second stage was as follows [3]:

● 0 to 1 hours – 46 percent
● 1 to 2 hours – 23 percent
● 2 to 3 hours – 14 percent
● 3 to 4 hours – 10 percent
● >4 hours – 7 percent

The route of birth among patients who gave birth during each hour was:

● 0 to 1 hours – nearly 100 percent vaginal (spontaneous or assisted)

● 1 to 2 hours – nearly 100 percent vaginal (spontaneous or assisted)
● 2 to 3 hours – nearly 95 percent vaginal (spontaneous or assisted)
● 3 to 4 hours – approximately 85 percent vaginal (spontaneous or assisted)
● >4 hours – 67 percent vaginal (spontaneous or assisted)
In a similar retrospective study of over 5000 multiparous patients, of whom 44 percent had epidural, the frequency of patients giving birth
during each hour of the second stage was as follows [4]:

● 0 to 1 hours – 80 percent
● 1 to 2 hours – 11 percent
● 2 to 3 hours – 5 percent
● >3 hours – 5 percent

The route of birth among patients who gave birth during each hour was:

● 0 to 1 hours – 96 percent vaginal (spontaneous or assisted)

● 1 to 2 hours – 99 percent vaginal (spontaneous or assisted)
● 2 to 3 hours – 93 percent vaginal (spontaneous or assisted)
● >3 hours – 73 percent vaginal (spontaneous or assisted)

MANAGEMENT

Approach to patients undelivered after pushing for 60 to 90 minutes — More than half of parturients who give birth vaginally will do
so within 60 to 90 minutes of beginning to push, regardless of parity or use of neuraxial anesthesia ( table 1). Reassessment is indicated
for the remainder of patients who remain undelivered at this point in the second stage.

Patients with adequate descent and/or rotation — If descent is adequate (>1 cm over 60 to 90 minutes) and/or rotation from a non-
occiput anterior (OA) position to OA occurred/is occurring, then we continue supportive care as long as the fetal heart rate pattern does
not necessitate expeditious delivery. Most patients with this labor pattern will achieve a vaginal birth before meeting criteria for a
prolonged second stage.

Patients with inadequate descent and/or rotation — If descent is minimal (<1 cm over 60 to 90 minutes), then the probable cause
should be ascertained and treatment initiated. Possible causes include hypocontractility or a physical issue.

● Begin oxytocin augmentation in patients with hypocontractility – If uterine contractions are less frequent than every three
minutes (ie, hypocontractility), oxytocin augmentation is initiated or the oxytocin dose is increased as long as the fetal heart rate
pattern is reassuring. (See "Labor: Diagnosis and management of an abnormal first stage", section on 'Oxytocin dosing'.)
 We continue supportive care as long as the fetal heart rate pattern is reassuring and the fetus continues to descend and criteria for
a prolonged second stage have not been met. Absence of further descent with adequate contractions mandates clinical
reassessment and consideration of operative delivery. (See 'Timing of operative delivery' below.)

● Provide coaching and guidance to optimize maternal expulsive efforts – Data on coached versus uncoached maternal pushing
in uncomplicated labors during the second stage have failed to demonstrate significant benefits, although coaching is associated
with a slightly shorter second stage [17]. We have not identified any studies evaluating the impact of coaching in the setting of
inadequate descent. However, in our experience, the benefits of an experienced and engaged nurse or physician can be of
substantial benefit for patients who are experiencing inadequate descent due to suboptimal expulsive efforts.

● Assess the likelihood of a physical issue and consider manual rotation – If descent is minimal (<1 cm) and uterine contractions
and maternal expulsive efforts appear to be adequate, we consider the possibility of a physical issue (eg, malposition, macrosomia,
small maternal pelvis) as the cause for slow descent and do not begin oxytocin augmentation.

An experienced obstetrician can diagnose fetal position digitally. Sonography can confirm or increase accuracy of fetal position.
Manual rotation from the occiput posterior to OA position has a high success rate (especially if performed as soon as second stage
descent slows), can shorten the second stage, and increase the chances of vaginal birth. The procedure is described separately (see
"Occiput posterior position"). Similar considerations apply to occiput transverse position. (See "Occiput transverse position".)

We continue supportive care as long as the fetal heart rate pattern is reassuring and the fetus continues to descend and criteria for
a prolonged second stage have not been met. Absence of further descent with adequate contractions mandates clinical
reassessment and consideration of operative delivery for dystocia. (See 'Timing of operative delivery' below.)

Timing of operative delivery — Heightened clinical vigilance is warranted when approaching the diagnostic times for a prolonged
second stage of labor. The options of an operative delivery (assisted-vaginal, cesarean) versus continued pushing are considered and
discussed with the patient when approaching the times established for the upper limit of a normal second stage of labor (see 'Diagnosis'
above). At that time, if the station and position do not permit a safe assisted-vaginal delivery and further progress seems unlikely, we
advise cesarean birth. However, we will consider continuing the second stage beyond the time diagnostic of a prolonged second stage
when, in our judgment, a safe assisted-vaginal or spontaneous birth seems to be achievable within the next 30 to 45 minutes. This is a
shared decision; we discuss the options of continued pushing versus vacuum- or forceps-assisted vaginal delivery (if the patient is an
appropriate candidate) versus cesarean birth. (See "Assisted vaginal birth", section on 'Prerequisites'.)
Prompt operative intervention is required for fetuses with category III fetal heart rate tracings, regardless of labor progress. Category II
tracings are managed on a case-by-case basis, given the wide spectrum and significance of category II patterns. (See "Intrapartum
category I, II, and III fetal heart rate tracings: Management", section on 'Category II pattern (Indeterminate)'.)

Risks of prolonging the second stage — Whether to allow the duration of the second stage to extend beyond the times diagnostic of a
prolonged second stage before operative intervention is controversial, as a prolonged second stage has potential clinical challenges and
consequences [1-3,18]:

● If a cesarean birth becomes necessary, a prolonged second stage may result in the fetal head being trapped deep in the pelvis and
further thinning of the lower uterine segment, both of which increase the chances of extension of the hysterotomy into the uterine
vessels and surrounding tissues at cesarean. There are a variety of techniques to approach to reduce this risk, including changing
the location of the uterine incision, assistance with elevation of the fetal head manually or mechanically, or reverse breech
extraction. (See "Cesarean birth: Management of the deeply impacted head and the floating head", section on 'Reverse breech
extraction ("pull method")'.)

● Prolonging the second stage increases the risk for occurrence of postpartum hemorrhage and maternal infection.

● Prolonging the second stage worsens neonatal outcome (eg, increased neonatal intensive care unit admission, neonatal sepsis).

Ultimately, the obstetrician's clinical experience and judgment, in concert with the patient's values and preferences, should guide
management. Clinical factors associated with increased chances of safe vaginal delivery include:

● Descent is occurring
● Previous vaginal birth
● Absence of comorbidities that are likely to impact labor
● Pelvis is deemed adequate for vaginal birth (based on physical examination)
● Patient is not short (height <160 cm [63 inches]) or obese (body mass index ≥30.0 mg/kg2)
● Fetus is OA, with minimal caput and molding.
● Station is at least +2/5 cm
● Absence of maternal fever, which is presumptive of chorioamnionitis
● Estimated fetal weight is appropriate for gestational age (<95th percentile)
● Pushing appears to be effective and the patient is not exhausted
● Category I fetal heart rate pattern
 ● Patient desire to proceed with labor

Ineffective management interventions

● Turning down the epidural – A dense motor block may impair a patient's ability to push, but there is no strong evidence that
turning down the neuraxial anesthetic in patients with a prolonged second stage is beneficial. In a meta-analysis including five trials
in which patients with epidurals were randomly assigned to anesthetic 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 [19]. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the
progress and outcome of labor'.)

● 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 [20-22]. Patients should be encouraged to
labor, push, and birth in the position they find most comfortable.

● Fundal pressure – Manual fundal pressure does not significantly shorten the duration of the second stage, although available data
are low quality [23].

PREVENTION

There is no strong evidence that any intervention will prevent a prolonged second stage of labor. The following interventions have been
studied.

● Delayed pushing – In a meta-analysis of 12 trials of pushing methods in over 5400 patients with epidural anesthesia, delayed
pushing increased the overall duration of the second stage by a mean of 46 minutes compared with immediate pushing (95% CI 33-
60 minutes) [24]. Delayed pushing also resulted in decreased overall duration of pushing by a mean of 28 minutes (95 % CI -43 to -12
minutes) and no significant difference in spontaneous vaginal birth (80.9 versus 78.3 percent, RR 1.05, 95% CI 1.00-1.10). Delayed
pushing increased the risk for chorioamnionitis (9.1 versus 6.6 percent, RR 1.37, 95% CI 1.04-1.81) and low umbilical cord pH (2.7
versus 1.3 percent, 95% RR 2.00, 95% CI 1.30-3.07).

● Maternal position and technique – Neither maternal pushing position nor technique (eg, physiologic versus coached) appears to
have a substantial effect on the length of the second stage, although an upright position for delivery may shorten the second stage
by 3 to 10 minutes [22]. (See "Labor and delivery: Management of the normal second stage", section on 'Pushing'.)
 ● Physical activity/exercise:

• Pelvic floor muscle exercises – Training the muscles of the pelvic floor may prevent some cases of prolonged second stage. In
the largest trial, 301 healthy nulliparous patients were randomly assigned to an antepartum pelvic floor muscle training program
or usual care from 20 to 36 weeks of gestation [25]. Patients in the intervention group trained with a physiotherapist for one
hour/week and were encouraged to perform 8 to 12 intensive pelvic floor muscle contractions twice daily.

The intervention group had fewer second stages over 60 minutes (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 assisted-vaginal delivery (15 and 17
percent, respectively).

• Exercise – Exercise during pregnancy improves fitness but does not affect the length of labor. In two trials, patients randomly
assigned to participation in an aerobic exercise program during pregnancy had the same overall duration of labor as those who
received standard prenatal care [26,27]. Although the smaller trial (91 participants) observed a reduction in primary cesarean
birth in the exercise group [26], the larger trial (855 participants) found no difference in labor outcomes [27].

In addition, it should be noted that patients who are not able to push because of a spinal cord injury tend to have a normal, or
even short, second stage [28].

• Continuous labor support – In a meta-analysis of randomized trials, continuous one-to-one intrapartum support by trained or
untrained individuals resulted in small but statistically significant improvements in pregnancy outcomes, such as shorter labor
and higher spontaneous vaginal birth rate, across a variety of health care settings and socioeconomic and ethnic groups,
although the length of the second stage was not specifically analyzed [29]. (See "Continuous labor support by a doula".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
(See "Society guideline links: Labor".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.
(You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Labor and childbirth (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Background – Normal human labor, particularly the second stage, is often brief, but characterized by considerable variation. The
identification and management of abnormalities of duration are based on expert consensus and agreed-upon definitions for what is
normal and safe. A major focus of efforts to reduce the rate of primary cesarean births performed in the second stage is to allow a
longer maximum time in the second stage before considering it prolonged. (See 'Background' above.)

● Diagnosis – We diagnose a prolonged second stage based on an American College of Obstetricians and Gynecologists (ACOG) and
Society for Maternal-Fetal Medicine (SMFM) consensus group statement for prevention of the primary cesarean birth (See 'Diagnosis'
above.):

• In nulliparous patients – The second stage generally can be considered prolonged:

- After three hours of pushing. However, a longer duration (commonly, up to four hours of pushing) may be appropriate for
patients with epidural anesthesia or with a fetal malposition as long as progress is documented.

• In parous patients – The second stage generally can be considered prolonged:

- After two hours of pushing. However, a longer duration (commonly, up to three hours of pushing) may be appropriate for
patients with epidural anesthesia or with a fetal malposition as long as progress is documented.

Concerning fetal or maternal status necessitates consideration of operative delivery prior to reaching the described time limits.
 ● Management

• For patients who have not met criteria for a prolonged second stage, we continue expectant management as long as the mother
is stable, the fetal heart rate pattern does not necessitate urgent delivery, and the fetus continues to descend and/or rotate to a
more favorable position. (See 'Approach to patients undelivered after pushing for 60 to 90 minutes' above.)

- If descent is <1 cm over the first 60 to 90 minutes of the second stage and contractions are less frequent than every three
minutes, oxytocin is initiated.

- If contractions are adequate, but maternal expulsive efforts are suboptimal, coaching from an experienced and engaged
nurse or physician can be helpful.

- If descent is minimal <1 cm over the first 60 to 90 minutes of the second stage and uterine contractions and maternal
expulsive efforts are adequate, the possibility of a physical issue (eg, malposition, macrosomia, small maternal pelvis) should
be considered. Fetal position can be diagnosed digitally, but with greater accuracy sonographically. Manual rotation from the
occiput posterior to occiput anterior position has a high success rate, can shorten the second stage, and increase the
chances of vaginal birth. Similar considerations apply to occiput transverse position.

• For patients approaching the times established for a prolonged second stage, if the station and position do not permit a safe
assisted-vaginal delivery and further progress seems unlikely, we generally advise the patient to undergo cesarean birth.
However, we will consider continuing the second stage beyond the time diagnostic of a prolonged second stage when, in our
judgment, a safe assisted-vaginal or spontaneous birth seems to be achievable within the next 30 to 45 minutes. This is a shared
decision; we discuss the options of continued pushing versus vacuum- or forceps-assisted vaginal delivery (if the patient is an
appropriate candidate) versus cesarean birth. (See 'Timing of operative delivery' above.)

● Risks of a prolonged second stage – A prolonged second stage of labor is associated with small increases in neonatal and maternal
complications. (See 'Risks of prolonging the second stage' above.)

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Topic 132063 Version 13.0
GRAPHICS

Contemporary estimates of median and 95 th percentile in hours by parity

Parity 0 Parity 1

Median number of hours Median number of hours

(95 th percentile) (95 th percentile)

Change in cervix

From 4 to 5 cm 1.3 (6.4) 1.4 (7.3)

From 5 to 6 cm 0.8 (3.2) 0.8 (3.4)

From 6 to 7 cm 0.6 (2.2) 0.5 (1.9)

From 7 to 8 cm 0.5 (1.6) 0.4 (1.3)

From 8 to 9 cm 0.5 (1.4) 0.3 (1.0)

From 9 to 10 cm 0.5 (1.8) 0.3 (0.9)

Duration of second stage

Second stage with epidural analgesia 1.1 (3.6) 0.4 (2.0)

Second stage without epidural analgesia 0.6 (2.8) 0.2 (1.3)

Note the 95 th percentile for duration of time to dilate from 4 to 6 cm is almost 10 hours in nulliparous women.

Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010; 116:1281.

Graphic 69170 Version 16.0

Contributor Disclosures
Robert M Ehsanipoor, MD No relevant financial relationship(s) with ineligible companies to disclose. Andrew J Satin, MD, FACOG No relevant financial
relationship(s) with ineligible companies to disclose. Vincenzo Berghella, MD Consultant/Advisory Boards: ProtocolNow [Clinical guidelines]. All of the
relevant financial relationships listed have been mitigated. Vanessa A Barss, MD, FACOG No relevant financial relationship(s) with ineligible companies
to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
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