Labor Progression Sys Rev March 2023

Expert Review ajog.
org
New insights on labor progression: a systematic

review
Xiaoqing He, MM; Xiaojing Zeng, MM; James Troendle, PhD; Maria Ahlberg, RNM, PhD; Ellen L. Tilden, PhD, CNM;
João Paulo Souza, PhD; Stine Bernitz, PhD; Tao Duan, MD, PhD; Olufemi T. Oladapo, MD; William Fraser, MD, MSC;
Jun Zhang, MD, PhD
Introduction
In 1955, Dr Emanuel Friedman pub- The past 20 years witnessed an invigoration of research on labor progression and a
lished a milestone article, illustrating a change of thinking regarding normal labor. New evidence is emerging, and more
normal labor pattern based on cervical advanced statistical methods are applied to labor progression analyses. Given the wide
dilation against time and subdivided into variations in the onset of active labor and the pattern of labor progression, there is an
first stage (including latent phase, accel- emerging consensus that the definition of abnormal labor may not be related to an
eration phase, maximum slope of cervi- idealized or average labor curve. Alternative approaches to guide labor management
cal dilation, deceleration phase), second have been proposed; for example, using an upper limit of a distribution of labor duration
stage (from full dilation to delivery of the to define abnormally slow labor. Nonetheless, the methods of labor assessment are still
infant), and third stage (from delivery of primitive and subject to error; more objective measures and more advanced instruments
the infant to delivery of the placenta).1 In are needed to identify the onset of active labor, monitor labor progression, and define
the following decades, a series of papers when labor duration is associated with maternal/child risk. Cervical dilation alone may be
was published by Dr Friedman based on insufficient to define active labor, and incorporating more physical and biochemical
data from his practice2e4 and the Na- measures may improve accuracy of diagnosing active labor onset and progression.
tional Collaborative Perinatal Project Because the association between duration of labor and perinatal outcomes is rather
(NCPP).5 The principal finding in these complex and influenced by various underlying and iatrogenic conditions, future research
articles was that in the active phase, cer- must carefully explore how to integrate statistical cut-points with clinical outcomes to
vical dilation progressed linearly, with reach a practical definition of labor abnormalities. Finally, research regarding the
cervical dilatation at a minimum of 1.2 complex labor process may benefit from new approaches, such as machine learning
cm per hour in nulliparous active labor.1 technologies and artificial intelligence to improve the predictability of successful vaginal
For over half a century, this idealized la- delivery with normal perinatal outcomes.
bor curve and the corresponding defini-
tions of abnormal labor were used to Key words: cervical dilatation, first and second stages of labor, labor duration, labor
guide labor management to a large progression, partogram
extent. Precise criteria and terminology
for the diagnosis of abnormal labor were
based primarily on the work of Fried- profoundly affected international intra- In 1972, Philpott8,9 developed a
man, which led to a definition that partum care practices.2,3,6,7 partogram for use in underresourced
From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (Ms He and Dr
Zhang); Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China (Ms He and Dr Zhang); Ministry of Education -Shanghai Key Laboratory
of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Ms He, Ms Zeng, and Dr
Zhang); Office of Biostatistics Research, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health,
Bethesda, MD (Dr Troendle); Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden (Dr Ahlberg);
Department of Obstetrics and Gynecology, School of Medicine, Department of Nurse-Midwifery, School of Nursing, Oregon Health & Science University,
Portland, OR (Dr Tilden); Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil (Dr Souza); Department
of Obstetrics and Gynaecology, Østfold Hospital Trust, Grålum, Norway (Dr Bernitz); Department of Health Promotion, Faculty of Health Sciences, Oslo
Metropolitan University, Oslo, Norway (Dr Bernitz); Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China (Dr
Duan); United Nations Development Programme/United Nations Population Fund/ United Nations Children’s Fund/World Health Organization/World
Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research,
World Health Organization, Geneva, Switzerland (Dr Oladapo); and Department of Obstetrics and Gynecology, Centre de Recherche du Centre
Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada (Dr Fraser).
Received Sept. 30, 2022; revised Nov. 26, 2022; accepted Nov. 28, 2022.
X.Q.H. and X.J.Z. share first authorship.
The authors of this study are also authors or coauthors of the systematic reviews summarized herein. There are no other commercial or financial conflicts
of interest to declare.
Corresponding author: Jun Zhang, MD, PhD. [email protected]
0002-9378/$36.00 ª 2022 Published by Elsevier Inc. https://doi.org/10.1016/j.ajog.2022.11.1299
MONTH 2022 American Journal of Obstetrics & Gynecology 1

Expert Review ajog.org
settings that proposed a dilatation rate of active phase at a wide range of cervical Materials and methods
1.0 cm per hour among labors 3 cm of dilations23 and finish with a spontaneous This systematic review was conducted ac-
cervical dilation. These normative labor vaginal birth and normal perinatal out- cording to the Preferred Reporting Items
progress assumptions were based on comes. This is contradictory to the popular for Systematic Reviews and Meta-Analyses
modification of the mean rate of cervical notion that the active phase starts at 3 or 4 (PRISMA) guidelines, and prospective
dilatation of the slowest 10% of primi- cm.1,4,24e31 To allow for these individual registration in the International Prospec-
gravid patients in the active phase and variations, it was proposed to adopt a new tive Register of Systematic Reviews
was slower than Friedman’s statistical approach for defining labor abnormality (PROSPERO; CRD42022363759), with
limit for “the phase of maximum slope” by using an upper limit of cervical dilation, out a prepared protocol.
of 1.2 cm per hour. The latter was pro- beyond which labor dystocia may be
posed as the threshold distinguishing diagnosed. Second, the 1 cm/h partogram Search strategy
normal from abnormal labor. With this alert line has been used to prompt labor A search of the relevant literature was
approach, all partograms were designed interventions in many settings around the conducted using the electronic databases
using 1 cm/h or faster as an acceptable world.32,33 However, labor is an extremely of PubMed, Embase, Web of Science,
rate of dilatation, which was designated variable phenomenon. The 1 cm/h alert and Cochrane Library, with publications
as the alert line on the partograph. The line is frequently crossed among parturi- up to August 18, 2022, using Medical
action line was drawn parallel to but 4 ents who proceed to have spontaneous Subject Headings (MeSH) or Emtree
hours to the right of the alert line. It is vaginal birth, and it also showed poor terms “labor, obstetric” and the term
suggested that if cervical dilatation rea- diagnostic accuracy in identifying women “progress*,” “curve*,” and “women.”
ches this action line, there should be a at risk of severe adverse birth out- Literature searches of bibliographies of
critical assessment of the cause of delay comes.34,35 For example, Souza et al35 related systematic reviews and eligible
and a decision about the appropriate assessed the accuracy of the alert line in studies complemented the search stra-
management to overcome this delay.8,9 the identification of women at risk of tegies. There were no date or language
The application of this knowledge to developing severe adverse birth outcomes restrictions. Details of the search strategy
the management of labor was reported (defined as the occurrence of any of the are presented in Fig S1.
by Studd in the United Kingdom,10 following: stillbirths, intrahospital early Original prospective or retrospective
O’Driscoll in Ireland,11 and other neonatal deaths, neonatal use of anticon- research studies were included in this
studies.12e18 The improved labor out- vulsants, neonatal cardiopulmonary analysis. We included publications that
comes noted in these mainly observa- resuscitation, 5-minute Apgar score <6, met the following criteria: (1) the study
tional studies suggested that the use of uterine rupture, and maternal death or population were nulliparous or multip-
Philpott’s partogram, with its alert and organ dysfunction with dystocia). The arous women or subgroups with a
action lines as a central monitoring tool, sensitivity and specificity were 56.7% and singleton fetus at 36 weeks’ gestation,
was of much help in identifying when 51.1%, respectively, indicating that the cephalic presentations, and spontaneous
intervention for diagnosis of labor alert line is not a good indicator for normal labor onset, or no evidence to the con-
dystocia was beneficial.11 labor progress.35 In contrast, because of the trary; (2) the participants were “low-
Philpott’s partogram played a key role continuous nature of labor, the upper risk” at study entry according to their
in translating Friedman’s work into US limits of labor duration at various stages description in the abstract (eg, without
clinical settings. This partogram was may be used to determine labor abnor- medical condition, pregnancy compli-
promoted worldwide by the World mality.36 These findings have been sup- cation, or diagnosed labor abnormality)
Health Organization (WHO) in 1994 ported by a number of studies published in or had no evidence to the contrary; and
following its landmark trial suggesting subsequent years34 and the reanalysis of the (3) the study presented identifiable
benefits.19e21 WHO’s research and sub- NCPP data.37 mean, median, or absolute cervical
sequent promotion played a key role in Over the past 2 decades, research on dilatation at study enrollment and
translating Philpott’s partogram into labor progression has been invigorated determinable labor duration from
worldwide use. with new hypotheses, analytical ap- enrollment to complete cervical
In 2002, Zhang et al22 used contempo- proaches, and biological samples dilatation or fetal delivery.
rary labor data and modern statistical permitting underlying mechanism to be We excluded studies focusing on
methods to reveal several points that explored. Numerous studies from across induction of labor, risk factors for first-
differed from the conclusion of previous the globe have been conducted to stage cesarean deliveries, or women with
publications on labor progress and explore various aspects of labor pro- comorbidities or complications (eg,
dystocia. First, this work further confirmed gression. We systematically searched for gestational diabetes mellitus, hypertensive
previous observations that labor patterns relevant literature and summarized the disorders, previous cesarean delivery), and
vary tremendously from person to person. findings on the labor milestones and those that applied “active management of
For example, a parturient may enter the length of labor. labor.” Publications that were not scientific
2 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org Expert Review
research or reviews, including reports, criteria. The selection procedure and et al55 demonstrated a deceleration
books, news articles, editorials, and letters screened studies are presented in a phase of 1.0 cm per hour between 8 and
were excluded because of limited detailed PRISMA flowchart (Figure 1). 10 cm of dilation based on 72 nulliparas
information. Two authors (X.Q.H. and with normal labor. Incerti et al39
X.J.Z.) independently screened the titles Findings regarding key elements and observed a deceleration phase pre-
and abstracts and assessed the full texts of milestones of labor progression sented toward the end of the active phase
potentially eligible studies. Disagreements Onset of active labor of labor (approximately 9 cm) based on
were resolved by a third author (J.Z.). Data Overall, 27 studies (71,559 women) 1119 nulliparas, but without details
on participants, dilatation (cm) at the provided a definition of onset of active concerning duration and dilation rate.
onset of “active labor,” labor duration, and labor for the first stage (Table 1). The Hopwood et al56 analyzed the data in
maternal and neonatal adverse outcomes definitions varied widely from study to women with shoulder dystocia: 58% of
were extracted. Adverse maternal study (eg, “regular uterine contractions women (38 cases, 28 primigravid and 10
outcomes evaluated included postpar with 10 min intervals”54; “at least two or multiparous women) experienced a
tum hemorrhage, infectious morbidity more spontaneous contractions per 10 prolonged deceleration phase of labor
(intrapartum fever, chorioamnionitis, minutes within the last hour or (8e10 cm) of over 2 hours (ranging
endometritis, and endomyometritis), longer”38; and “painful uterine contrac- from 60e360 minutes). No deceleration
third- and fourth-degree perineal lacerations powerful enough to cause descent phase in spontaneous labor was noted in
tion, operative vaginal delivery, cesarean of the presenting part and cervical dila- 5 studies (8825 primiparas and 5350
delivery, and women’s satisfaction with tion.”29 Others defined onset of active multiparas).22,27,43,51,53 Among these
their birthing experience. Adverse labor on the basis of cervical dilation, but studies, Zhang et al22 and Purwar et al53
neonatal outcomes assessed included cord including additional criteria, such as did not observe a deceleration phase in
pH acidemia at delivery (arterial cord pH regular contractions every 10 minutes, most of individual curves, but often
<7.10), 5-minute Apgar score <7, lasting >40 seconds, with cervical among women with protraction and ar-
neonatal intensive care unit (NICU) effacement >80%. Criteria concerning rest disorders, suggesting that decelera-
admission, sepsis, and neonatal trauma cervical dilation varied: 2 cm,39 2.5 cm,1 tion phase may be an indicator for
(including clavicular fracture, intracranial 3 cm with the cervix fully effaced,25 4 dystocia.
hemorrhage, brachial plexus palsy, and cm,24,26,28,30,31,34,40,41,43e45,47e49 4 cm
hypoxic-ischemic encephalopathy). with 90% effacement or 5-cm dilation Duration of the active phase of the first
Because the definitions of labor milestones regardless of effacement,50 5 cm,23 5-cm stage
varied so widely from study to study, data cervical dilation in multiparas and 6-cm Data on duration of the active phase of the
synthesis was very challenging, and no cervical dilation in primiparas,51 or 6 first stage were provided by 23 studies
quantitative synthesis or meta-analysis was cm.52,53 (139,638 nulliparas and 172,176 multi-
attempted. The percentile refers to the paras) (Table 3; S1). The duration of the
distribution of the data in each individual Acceleration and deceleration phases active phase was described as commencing
study. As shown in Table 2, only 8 studies at 2 to 6 cm, and ending at 10 cm, or at the
addressed acceleration and deceleration start of expulsive efforts. Two studies
Assessment of risk of bias phases. Friedman1 reported that the ac- defined the end of active phase at 9 cm.4,39
The NewcastleeOttawa Quality Assess- celeration phase was observed during Among studies of nulliparas reporting
ment Scale for cohort studies was used to cervical dilation from 2 to 4 cm, and was median/mean duration, 22 studies esti-
evaluate the quality of all included quite evanescent in most cases. Zhang mated that the median/mean duration of
studies. The scale was completed inde- et al22 observed an acceleration phase the active phase (when the onset point was
pendently by 2 of the study authors between 4 and 5 cm, after which the rate <4.5 cm) ranged from 2.4 to 8.4 hours
(X.Q.H. and X.J.Z.). of dilation doubled in an average labor (95th percentile [P95th]: 5.0e34.8
curve, whereas in the study by Nguyen hours).1,4,24,26e28,30,34,36,37,39e43,45 Four
Results et al,55 the fastest change was between 5 studies reported a median duration of 3.7
A total of 2162 citations were screened, and 6 cm, echoing the findings of Shindo to 4.3 hours (P95th: 9.7e13.8 hours) when
and 512 references were removed as et al.51 Purwar et al53 found no rapid the active phase was described as
duplicates. All 1650 abstracts were inflection at 4 to 5 cm, whereas the slope commencing at 5 to 5.5 cm.34,37,39,59 With
screened to identify labor progression of the labor curve changed after 6 cm. the reference point of the onset of active
publications; 152 publications were Friedman1,4 described the decelera- phase starting from 6 cm, 5 studies re-
selected for full review. In 74 studies, tion phase as starting at 9 cm and ter- ported a median duration of 2.2 to 2.9
either the study population or the out- minating at the first nonregressive 10- hours (P95th: 6e10.7 hours).34,39,53,59,60
comes did not meet the inclusion cm point, with a duration of 0.560.02 In multiparas, 14 studies reported that
criteria; hence, they were excluded. to 0.91.2 hours. Only 3 other studies the median/mean duration of active
Finally, 78 studies met our inclusion reported a deceleration phase. Nguyen phase starting at 4 cm ranged from 1.4 to

FIGURE 1
Flowchart of the study selection process
The asterisk denotes additional records identified from checking through the reference list of relevant studies and personal communication with authors.
He. New insights on labor progression: a systematic review. Am J Obstet Gynecol 2022.
5.7 hours (P95th: 3.4e20.0 the cervix until the birth of the infant. It nulliparas, ranging from 20 to 66
hours).24,26e28,30,36,37,40,41,45,47,49,57,59 is not possible to accurately determine minutes1,4,27,28,30,40,64e66,68; 13 studies
Three studies with active-phase onset the time at which full dilation of the reported the median duration of the
marked at 5 cm reported a median/mean cervix was first reached. Two studies second stage in nulliparas, ranging from
duration of 1.5 to 3.4 hours (P95th: defined the starting reference points of 16 to 93 minutes (P95th:
7.7e15.5 hours)34,59,60 and 0.9 to 2.4 the second stage as 10 cm of cervical 40e330),22,24,38,41,49,57,58,60,71,73,74,77,78
hours (P95th: 5.9e8.9 hours) when dilation or the urge to bear down.61,62 without detailed information on
active-phase onset was set at 6 cm.34,59,60 However, in 3 studies, the definition epidural analgesia use. Five studies re-
Studies showed that multiparas had included the predicted or confirmed full ported the mean duration of the second
considerably faster labor progression dilation or the time of maternal spon- stage in nulliparas without epidural
compared with nulliparas; however, no taneous pushing, whichever occurred analgesia, ranging from 29 to 64
marked differences in duration of active first, until delivery of the infant.61e63 minutes10,61,65,67,69; 7 studies described
phase were noted among multiparas of A total of 33 studies (215,361 nullip- labor duration among women with or
varying parity (Figure 2; S2). arous and 258,355 multiparous women) without epidural analgesia use and re-
reported the duration of the second stage ported longer median durations when
Duration of the second stage (Table 4 and S2 show results for nulli- epidural analgesia was used (29e66 mi-
Most studies defined the second stage of paras). Ten studies reported the mean nutes; P95th: 156.6e246 vs 66e142 mi-
labor as the period from full dilation of duration of the second stage in nutes; P95th: 192e312).37,47,62,70,73,75,76

TABLE 1
Definition of onset of active labor
Study Population/Region N Definition
1
Friedman, 1955 United States 500 Point at which the rate of cervical dilation (slope)
begins to change (no specific definition)
Juntunen and Kirkinen,27 1994 Finland 42 Regular uterine contractions began occurring with 10-
min intervals
Johnson et al,29 1997 United Kingdom 1132 Regular contractions with cervical changes (undefined)
and effaced cervix or descent of the fetal head
Shi et al,38 2016 China 1091 At least 2 spontaneous contractions per 10.0 min
within the last h or longer with cervical changes or
spontaneous rupture of membranes regardless of
cervical dilation
Incerti et al,39 2011 Italy 1119 Regular contractions every 10 min, lasting >40 s,
with cervical effacement >80% and dilation of 2 cm
Friedman and Kroll,4 1969 United States 10,293 At a cervical dilation of 2.5 cm
25
Cowan et al, 1982 South Africa 29 At a cervical dilation of 3 cm with the cervix fully
effaced
Bergsjø et al,24 1979 Norway 2292 At a cervical dilation of 4.0 cm
26
Velasco et al, 1985 France 111 At a cervical dilation of 4.0 cm
28
Albers et al, 1996 United States 1513 At a cervical dilation of 4.0 cm
30
Schiff et al, 1998 Israel 163 At a cervical dilation of 4.0 cm
Albers,31 1999 United States 2511 At a cervical dilation of 4.0 cm
Jones and Larson,40 2003 Hispanic American 240 At a cervical dilation of 4.0 cm
41
Vahratian et al, 2006 United States 2645 At a cervical dilation of 4.0 cm
42
Ijaiya et al, 2009 Nigeria 238 At time of arrival in labor ward
43
Suzuki et al, 2010 Japan 2369 At a cervical dilation of 4.0 cm
Cahill et al,44 2012 United States 2373 At a cervical dilation of 4.0 cm
Tuuli et al,45 2015 United States 1775 At a cervical dilation of 4.0 cm
34,46
Oladapo et al, 2018 Nigeria, Uganda 715 At a cervical dilation of 4.0 cm
47
Lu et al, 2019 Asian American 993 At a cervical dilation of 4.0 cm
48
Bernitz et al, 2019 Norway 7277 At a cervical dilation of 4.0 cm
Tilden et al,49 2022 United States 15,331 At a cervical dilation of 4.0 cm
Rouse et al,50 2000 United States 509 At a cervical dilation of 4.0 cm with 90% effacement
or 5.0 cm dilation regardless of effacement
Peisner and Rosen,23 1986 United States 1699 At a cervical dilation of 5.0 cm
Shindo et al,51 2021 Japan 9481 At 6.0-cm cervical dilation in primiparous women and
5.0-cm cervical dilation in multiparas
Graseck et al,52 2014 United States 4618 At a cervical dilation of 6.0 cm
Purwar et al,53 2021 South Asia 500 At a cervical dilation of 6.0 cm
Median duration of the second stage of (Figure 3; S3). Eight studies reported a without detailed information on epidural
labor in nulliparas with epidural anal- mean duration of the second stage in anesthesia. Three studies reported the
gesia was almost twice as long as that of multiparas, ranging from 6 to 30 mean duration of the second stage in
nulliparas without epidural analgesia. minutes4,27,28,30,40,64,66,79; 10 studies re- nulliparas with epidural analgesia, ranging
A total of 27 studies reported the median ported a median duration of 8 to 51 mi- from 13 to 27 minutes.10,61,69 Seven studies
duration of the second stage in multiparas nutes (P95th: 22e73),24,41,49,57,60,71e74,77 indicated that the subgroup of multiparous

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TABLE 2
Acceleration and deceleration phases
Cervical
dilation
range of Slope of the Cervical dilation Duration of Cervical dilation
Population/ acceleration maximum range of maximum deceleration range of deceleration
Study Region N Population selection phases (cm) phase (cm/h) slope (cm) phases (h)a phases (cm)
1
Friedman, 1955 United States 500 nulliparas 2.5e4.0 3.01.9 4.0e9.0 0.91.2 9.0e10.0
Friedman and United States 10,293 parturients with single births were — 6.00.1 3.0e6.0 to 6.5e9.0 0.560.02 9.0e10.0
Kroll,4 1969 included, except those with cesarean
delivery and those who delivered nonviable
infants
Juntunen and Finland 126 parturients with a term, singleton, vertex — 2.81.8 4.0e10.0 None None
Kirkinen,27 1994 fetus, and not complicated by any operative
procedures except for amniotomy at the
active phase of dilation
Zhang et al,22 United States 1699 nulliparas with a term, singleton, vertex 4.0e5.0 2.4 — None None
2002 fetus of normal birthweight after
spontaneous onset of labor
Nguyen et al,55 United States 72 nulliparas 4.0e5.0 1.5 5.0e8.0 2 8.0e10.0
2010
Suzuki et al,43 Japan 2369 nulliparas with a term, singleton, 5.0e6.0 — — None None
2010 vertex fetus of normal birthweight after
Incerti et al,39 Italy 1119 nulliparous women with spontaneous — — — — 9.0e10.0
2011 labor at term and singleton fetuses in
cephalic presentation, induction of labor,
or the presence of a uterine scar were
excluded
Purwar et al,53 South Asian 500 nulliparas with a term, singleton, — 1.6 — None None
2021 vertex fetus of normal birthweight after
spontaneous onset of labor with cervical
dilation <4 cm
Shindo et al,51 Japan 9481 nulliparas and multiparas with a term, 5.0e6.0 — 6.0e10.0 None None
2021 singleton, vertex fetus of normal
birthweight after spontaneous onset of
labor
a
Meanstandard deviation.
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TABLE 3
Duration of the active phase of the first stage in nulliparas
Duration of
Cervical Labor active phase
Population/ Definition of dilation on induced Oxytocin Epidural of the first
Study Region N Population selection active phase admission (cm) (%) (%) (%) stage (h)
Ijaiya Nigeria 163 Nulliparas with spontaneous onset, 37-wk gestation, from time of 5.4 — — — 4.8a
et al,42 live singleton pregnancy and who had spontaneous arrival in labor
2009 vertex delivery Prelabor rupture of membranes and ward to full
referred cases were excluded cervical dilation
Incerti Italy 54 Nulliparous women with spontaneous labor at term and cervical dilation 2 — — — 3.9 (6.3)
et al,39 singleton fetuses in cephalic presentation, induction of from 2e9 cm
2011 labor, or the presence of a uterine scar were excluded
Zhang United 4247 Nulliparas with a term, singleton, vertex fetus of normal cervical dilation 4 — 47 84 8.4 (20)
et al,36 States birthweight after spontaneous onset of labor from 2w2.5 to 10
2010 cm
Friedman,1 United 500 Nulliparas cervical dilation — — — — 4.93.4a
1955 States from 2.5 to 10 cm
Friedman United 500 Nulliparas with single births were included, except those cervical dilation — — — — 4.90.15a
and Kroll,4 States delivered by cesarean delivery and those with nonviable from 2.5e9.0 cm
1969 infants
Zhang United 6096 Nulliparas with a term, singleton, vertex fetus of normal cervical dilation 4 — 47 84 6.9 (17.4)
MONTH 2022 American Journal of Obstetrics & Gynecology
2010 cm
Bergsjø Norway 497 Nulliparas with spontaneous onset of labor cervical dilation — — — — 2.4 (5.0)b
et al,24 from 4e10 cm
1979
Velasco France 74 Nulliparas with single birth after spontaneous onset cervical dilation — 0 0 0 3.91.6a
et al,26 of labor from 4e10 cm
Expert Review
1985
Juntunen Finland 42 Nulliparas with a term, singleton, vertex fetus, and not cervical dilation — — — 43 3.1 1.5a
and complicated by any operative procedures except for from 4e10 cm
Kirkinen,27 amniotomy at the active phase of dilation
1994
He. New insights on labor progression: a systematic review. Am J Obstet Gynecol 2022. (continued)
7
Expert Review
TABLE 3
Duration of the active phase of the first stage in nulliparas (continued)
Duration of
Albers United 347 Nulliparas with a term, singleton, vertex fetus of cervical dilation — — — — 7.75.9a
et al,28 States normal birthweight after spontaneous onset of labor from 4e10 cm
1996
Schiff Israel 69 Nulliparas with a term, singleton, vertex fetus of cervical dilation — — — — 4.72.6a
et al,30 normal birthweight after spontaneous onset of labor from 4e10 cm
1998
Jones and Hispanic 120 Nulliparas with a term, singleton, vertex fetus after cervical dilation — — — — 6.23.6a
Larson,40 women spontaneous onset of labor from 4e10 cm
2003
Vahratian United 2645 Nulliparous low-risk women with a term, live-born cervical dilation 3 28.1 41 87.7 5.7
et al,41 States infant from 4e10 cm
2006
Suzuki Japan 2369 Nulliparas with a term, singleton, vertex fetus of cervical dilation 3 0 6.5 0 5
et al,43 normal birthweight after spontaneous onset of labor from 4e10 cm
2010
Zhang NCPP data, 8690 Nulliparas with a singleton term gestation, spontaneous onset cervical dilation 3 — 20 8 3.7 (16.7)
et al,37 1959 of labor, vertex presentation, and a normal perinatal outcome from 4e10 cm
2010 e1965
Tuuli United Black: 1391 Nulliparas with a term, singleton, vertex fetus and cervical dilation — — — — Black: 5.1
et al,45 States White: 384 had completed the first stage of labor from 4e10 cm (15.9)
2015 White: 4.9
(15.3)
Oladapo Nigeria, 715 Nulliparas with a term, singleton, vertex fetus of cervical dilation — — — — 5.9 (14.5)
et al,34,46 Uganda normal birthweight after spontaneous onset of labor from 4e10 cm
2018 with cervical dilation <6 cm
Lu et al,47 Asian 993 Nulliparas with a term, singleton, vertex fetus of normal cervical dilation 4 0 38 82 5.2 (14.4)
2019 American birthweight after spontaneous onset of labor from 4e10 cm
Boz et al,57 Turkey 200 Nulliparas with a term, singleton, vertex fetus of normal cervical dilation — — — — 5.8 (20)
2019 birthweight after spontaneous onset of labor with from 4e10 cm
cervical dilation between 3 and 5 cm at admission
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TABLE 3
Duration of
Dalbye Norway WHO Nulliparas with a term, singleton, vertex fetus after cervical dilation — WHO WHO WHO
et al,58 partograph: spontaneous onset of labor from 4e10 cm partograph: partograph: partograph:
2020 3305 47.2 50.0 4.5 (12.5)
Zhang’s Zhang’s Zhang’s Zhang’s
partograph: partograph: partograph: partograph:
3972 41.7 48.2 5.0 (15.0)
Lundborg Sweden 11,520 Nulliparas with a term, singleton, vertex fetus after cervical dilation — — — — 5.0 (14.1)
et al,59 spontaneous onset of labor with a live fetus from 4e10 cm
2020
Purwar South 250 Nulliparas with a term, singleton, vertex fetus of cervical dilation 3 — — — 5.0 (8.27)
et al,53 Asian normal birthweight after spontaneous onset of labor from 4e10 cm
2021
Tilden United 15,331 Nulliparas with a term, singleton, vertex fetus after cervical dilation — — — — 7.5 (34.8)
et al,49 States spontaneous onset of labor from 4e10 cm
2022 expulsive efforts
Zhang United 5550 Nulliparas with a term, singleton, vertex fetus of cervical dilation 4 — 47 84 5.3 (16.4)
et al,36 States normal birthweight after spontaneous onset of labor from 4 w4.5 to
2010 10 cm
et al,39 singleton fetuses in cephalic presentation, induction of labor, from 5e9 cm
2011 or the presence of a uterine scar were excluded

Oladapo Nigeria, 316 Nulliparas with a term, singleton, vertex fetus of normal cervical dilation — — — — 4.3 (11.3)
et al,34,46 Uganda birthweight after spontaneous onset of labor with from 5e10 cm
2018 cervical dilation <6 cm
Lundborg Sweden 8201 Nulliparas with a term, singleton, vertex fetus after cervical dilation — — — — 3.7 (12.3)
et al,59 spontaneous onset of labor with a live fetus from 5e10 cm
2020
Zhang United 2764 Nulliparas with a term, singleton, vertex fetus of normal cervical dilation 4 — 47 84 3.8 (13.8)
Expert Review
2010 cm
et al,39 singleton fetuses in cephalic presentation, induction of labor, from 6e9 cm
2011 or the presence of a uterine scar were excluded
9
women with 100% epidural analgesia had

active phase
longer median duration than multiparous
Duration of
of the first women without epidural analgesia (16e54
2.2 (10.0)
2.7 (10.7)
stage (h)
2.9 (9.3)
2.5 (6.0)
minutes; P95th: 96e135 vs 6e15 minutes;
P95th: 36e78),37,47,62,70,73,75,76 that is, the
median duration of the second stage of
labor in multiparas without epidural
Epidural
analgesia was nearly one-third of that of

(%)
—
60
multiparas with epidural analgesia.

induced Oxytocin
Labor duration and maternal and

perinatal outcomes
(%)
—
37
Maternal morbidity associated with

duration of active labor
Labor
Overall, 24 studies that examined the

(%)
—
association between duration of labor

and maternal morbidity were included
admission (cm)
in this review (Table 5). A total of 10

dilation on
studies estimated the association be-

Cervical
tween active phase duration and

maternal morbidity.80e89 Because of the
—
—
3
diverse definitions of the active phase

and prolonged first stage, it is chal-
cervical dilation
cervical dilation
cervical dilation
cervical dilation
from 6e10 cm
from 6e10 cm
from 6e10 cm
from 6e10 cm
active phase
lenging to extract and pool the data.

Definition of
Rouse et al96 suggested that extending

the minimum period of oxytocin
augmentation for active-phase labor ar-
rest from 2 to at least 4 hours did not
birthweight after spontaneous onset of labor with cervical
increase the risk for severe maternal or

Nulliparas with a term, singleton, vertex fetus of normal
neonatal complications. In a secondary

Nulliparas with a term, singleton, vertex fetus after
analysis of a cohort study with 5681

women, Dahlke et al84 found that

birthweight after spontaneous onset of labor
birthweight after spontaneous onset of labor

spontaneous onset of labor with a live fetus
maternal and neonatal outcomes after

cesarean delivery for labor arrest at 6
NCPP, National Collaborative Perinatal Project; SD, standard deviation WHO, World Health Organization.
cm dilation were comparable to those of

cesarean delivery performed at 4 to 5 cm,
with no difference in the composite

maternal outcome (adjusted odds ratio
Population selection
[OR], 1.19; 95% confidence interval

[CI], 0.94e1.52).
dilation <6 cm
Govindappagari et al87 indicated that

maternal composite morbidity was
Data are presented as meanSD or median (95th percentile).
greater in women with protracted active

labor than in women with a normal
active phase, defined as <4 hours in
duration (adjusted OR, 2.15; 95% CI,
43,576
1.62e2.8). Kawakita et al89 supported

5843
322
South Asian 250
MeanSD; b Median (90th percentile).
this conclusion on the basis of a retro-

N
Population/
spective cohort study of 31,505 term

singleton cephalic pregnancies. The
Sweden
Nigeria,
Uganda
Region
United
States
study showed that among women with

labor arrest at 6 or 7 cm of cervical
dilation, the arrest of dilation of <4
et al,34,46
Lundborg
TABLE 3
Laughon
Oladapo
Purwar
et al,60
et al,59
et al,53
hours compared with arrest of dilation

Study
2012
2018
2020
2021
of 4 to 5.9 hours was associated with

a
decreased risk for adverse maternal

1.40e1.83]), third- or fourth-degree

FIGURE 2
perineal laceration (adjusted OR, 1.44
Duration of active phase of the first stage in nulliparas [95% CI, 1.29e1.60]), and uterine
atony (adjusted OR, 1.31 [95% CI,
1.14e1.51]) in nulliparas.96 Mehta
et al90 found that when second stage is
>2 hours, compared with controls,
there is 7-fold greater risk for shoulder
dystocia (22% vs 3%; P<.005). Among
women with deliveries of infants with
birthweight >4000 g complicated by
shoulder dystocia, more had a second
stage of labor >2 hours (33% [6/18] vs
5.3% [1/19]; P¼.04).90
Simic et al99 found that women with a
second stage of >2 hours (vs 1 hour)
had an increased risk of perineal lacera-
tion (adjusted OR, 1.42; 95% CI,
1.28e1.58). The risk of perineal lacera-
tion increased with duration of second
stage of labor until 3 hours in both
instrumental (adjusted OR, 1.38e1.62)
and noninstrumental (adjusted OR,
1.21e1.34) vaginal deliveries, but this risk
did not continue to increase for second-
stage duration beyond 3 hours.
Compared with noninstrumental vaginal
Data are presented as mean2 SD or median (95th percentile).
deliveries, risk was elevated among
Single asterisk represents mean2 SD; double asterisks denote median (90th percentile).
SD, standard deviation.
instrumental vaginal deliveries (adjusted
OR, 2.24 [95% CI, 2.07e2.42]).99
Niemczyk et al103 showed that post-
partum transfers for multiparas increased
from 1.4% after second stage <15 mi-
outcomes. Moreover, increased rates Maternal morbidity associated with nutes to >4% after second stage
of maternal fever, chorioamnionitis, duration of second stage of labor exceeding 2 hours (P for trend, <.0001).
shoulder dystocia, third- or fourth- A total of 16 studies examined the as- The risk of postpartum hemorrhage
degree perineal laceration, instrumental sociation between second-stage dura- (adjusted OR, 2.5 [ 95% CI, 1.5e4.1])
deliveries, cesarean delivery, and post- tion and maternal morbidity.77,90e104 and intrapartum fever (adjusted OR, 2.7
partum transfusion and composite Women with second stages >30 mi- [95% CI, 1.3e5.5]) increased markedly
maternal morbidity were observed when nutes for primiparas or >15 minutes for after 2 hours of pushing in nulliparas.95
the mean duration of active phase multiparas had an increased risk of Laughon et al98 defined prolonged
increased. The risk of a prolonged sec- postpartum hemorrhage (primiparity: second stage by parity and epidural use
ond stage also increased with longer adjusted OR, 1.15e1.78; multiparity: (prolonged second stage in nulliparous
durations of first-stage active adjusted OR, 1.14e1.74), whereas women defined as >2 hours without
phase.82,83,85-87,89 Kempe and Vikström- women with prolonged first stage did epidural and >3 hours with epidural;
Bolin88 studied the influence of the not.77 In addition, rates of spontaneous prolonged second stage in multiparous
duration of active labor on women’s vaginal birth without serious morbidity women defined as >1 hour without
satisfaction with their birthing experi- steadily decreased with increasing epidural and >2 hours with epidural).
ence and suggested that prolonged labor second-stage duration except in the first They found that among nulliparous
is an independent and significant factor half-hour in nulliparas.100 Rouse et al96 women using epidurals, prolonged sec-
for women’s dissatisfaction, and mea- found that each additional hour of the ond stage increased the risk of endome-
sures for avoiding prolonged labor could second stage was associated with an tritis (adjusted OR, 3.52 [95% CI,
increase women’s satisfaction with their increased risk of chorioamnionitis 2.44e5.06]), postpartum hemorrhage
labor experience. (adjusted OR, 1.60 [95% CI, (adjusted OR, 1.50 [95% CI, 1.27e1.78]),

Expert Review
TABLE 4
Duration of the second stage in nulliparas
Mean duration
of
Mean overall the second
Labor duration of the Mean duration of stage without
Population/ induced Oxytocin Epidural second stage the second stage with epidural
Study region N Population selection (%) (%) (%) (min) epidural (min) (min)
Friedman,1 United States 500 Nulliparas — — — 5748 — —
1955
Friedman and United States 500 Nulliparas with single births were included, — — — 572 — —
Kroll,4 1969 except those delivered by cesarean delivery
and those who had nonviable infants
Studd,10 United 176 Nulliparas with a term, singleton, vertex fetus, 0 0 0 — — 46
1973 Kingdom and not complicated by any operative
procedures
Studd et al,64 United 194 Nulliparas with a singleton, vertex fetus after — — — 40 — —
1975 Kingdom spontaneous onset of labor
Duignan United Asian: 77 Nulliparas with a term, singleton, vertex fetus 0 0 0 — — Asian: 36
et al,61 Kingdom of normal birthweight after spontaneous onset
1975 of labor
Black: 40 Black: 29
White: 320 White: 44
Chen and China 500 Nulliparas with a term, singleton, vertex fetus 0 0 0 — — 43
Chu,65 of normal birthweight after spontaneous onset
1986 of labor
Schorn United States 18 Nulliparas between 36- and 41-wk gestation, — — — 6654 — —
et al,66 in active labor, with intact membranes, and
1993 without major medical obstetrical complications
Juntunen and Finland 42 Nulliparas with a term, singleton, vertex fetus, — — 43 2020 — —
Kirkinen,27 and not complicated by any operative procedures
1994 except for amniotomy at the active phase of dilation
Albers et al,28 United States 556 Nulliparas with a term, singleton, vertex fetus — — — 53 47 — —
1996 of normal birthweight after spontaneous onset
of labor
Sills et al,67 Immigrated 1106 low-risk primigravidas delivering singleton, 0 0 0 — — 5242
1997 Chinese in vertex, term infants without conduction
France anesthesia or oxytocin
ajog.org
ajog.org
TABLE 4
Duration of the second stage in nulliparas (continued)
Mean duration
of
Schiff et al,30 Israel 69 Nulliparas with a term, singleton, vertex — — — 6636 — —
1998 fetus of normal birthweight after
Diegmann United States African Nulliparas with singleton gestations at — — — African Americans: — —
et al,68 Americans: 37e42 wk with vertex presentation 3223
2000 373
Puerto Puerto Ricans:
Ricans: 4433
157
Jones and Hispanic 120 nulliparas with a term, singleton, vertex fetus — — — 5444 — —
Larson,40 women after spontaneous onset of labor
2003
Cesario,69 North 97 Nulliparas with singleton gestations at 0 0 0 — — 6473
2004 America 37e42 wk with vertex presentation
Median overall Median duration of the Median duration
duration of the second second stage with of
stage (min) epidural (min) the second
stage
without epidural
(min)
Bergsjø Norway 946 Nulliparas with spontaneous onset of labor — — — 16 (40)a — —
et al,24
1979
Kilpatrick and United States — Nulliparas with singleton gestations at — — — — 79 (185) 54 (132)
Laros,70 37e42 wk with vertex presentation
1989
Paterson United 10,932 Nulliparas with a term, singleton, vertex fetus — — — — 82 (134)b 45 (76)b
Expert Review
et al,62 Kingdom of at least 37 wk gestation after spontaneous
1992 onset of labor
Sizer et al,71 United 774 Nulliparas who reached full dilation with a — — — 68 — —
2000 Kingdom singleton pregnancy at term and a cephalic
presentation
13
Expert Review
TABLE 4
Mean duration
of
Zhang et al,22 United States 1162 Nulliparas with a term, singleton, vertex fetus — 50 48 53 (138) — —
of labor
Gurewitsch United States 707 Nulliparas between 36 and 43 wk of 47 52 80 105 — —
et al,72 and gestation with an uncomplicated singleton
2003 Jerusalem pregnancy in cephalic presentation
Greenberg United States Black: Nulliparas with a term, singleton, vertex fetus — — — Black: 50 Black: 75 Black: 29
et al,73 1793
2006
Asian: 4383 Asian: 93 Asian: 142 Asian: 53
White: 7137 White: 92 White: 137 White: 54
Latino: Latino: 77 Latino: 116 Latino: 45
1406
Vahratian United States 2645 Nulliparous low-risk women with a term, 28 41 88 51 — —
et al,41 live-born infant
2006
Zhang et al,36 United States 25,624 Nulliparas with a term, singleton, vertex — 47 84 — 66 (216) 36 (168)
2010 c fetus of normal birthweight after
Laughon United States 43,576 Nulliparas with a term, singleton, vertex fetus — 37 60 54 (186) — —
et al,60 of normal birthweight after spontaneous onset
2012 of labor
Dior et al,74 Israel 12,631 Nulliparas with a singleton, term, cephalic, — — — 78 — —
2013 spontaneous vaginal deliveries
Zaki et al,75 United States 20w30 y Nulliparas with a term, singleton, vertex 20w30 20w30 y 20w30 y — 20w30 y old: 20w30 y old:
2013 old: 32,182 fetus of normal birth outcome y old: 43 old: 24 old: 63 72 (204) 48 (162)
30w40 y 30w40 y old: 54 30w40 30w40 y 30w40 y old: 30w40 y old:
old: 11,873 y old: 23 old: 69 90 (258) 60 (210)
>40 y old: >40 y old: >40 y >40 y old: >40 y old: 90 (312) >40 y old:
761 old: 18 66 (246)
ajog.org
64 72
ajog.org
TABLE 4
Mean duration
of
Shi et al,38 China 1091 Nulliparas with singleton gestations at 9 50 50 (116) — —
2016 37e42 wk with vertex presentation and
normal neonatal outcomes
Lu et al,47 Asian 993 Nulliparas with a term, singleton, vertex fetus 0 38 82 — 66 (192) 36 (168)
2019 American of normal birthweight after spontaneous onset
of labor
Boz et al,57 Turkey 200 Nulliparas with a term, singleton, vertex fetus — — — 30 — —
of labor with cervical dilation between 3 and
5 cm at admission
Ashwal Israel 15,948 Nulliparas with term, singleton, live-born infants — 23 84 — 103 (220) 34 (157)
et al,76
2020
Dalbye Norway WHO Nulliparas with a term, singleton, vertex fetus — WHO WHO WHO partograph: — —
et al,58 partograph: after spontaneous onset of labor partograph: partograph: 75 (204)
2020 3305 47 50
Zhang’s Zhang’s Zhang’s Zhang’s partograph:
partograph: partograph: partograph: 76 (242)

3972 42 48
Tilden et al,49 North 14,693 Nulliparas with a term, singleton, vertex fetus — — — 66 (330) — —
2022 America after spontaneous onset of labor
Ushida Japan 11,782 low- to moderate-risk nulliparas with term, — — — 38 (198)d — —
et al,77 2022 singleton, vertex births without previous
cesarean delivery
Data are presented as meanstandard deviation or median (95th percentile).
WHO, World Health Organization.
a
Median (90th percentile); b Median (75th percentile); c Obstet Gynecol 116(6): 1281e1287; d Median (97.5th percentile).
Expert Review
15
FIGURE 3
Duration of the second stage in nulliparas
Data are presented as mean2 SD or median (95th percentile).

Single asterisk represents mean2 SD; double asterisks represent median (90th percentile); triple asterisks represent median (97.5th percentile).
SD, standard deviation.
chorioamnionitis (adjusted OR, 3.01 successfully decreased primary cesarean >3 hours for multiparas without epidural
[95% CI, 2.65e3.43]), and third- or deliveries (relative risk [RR], 0.67; 95% analgesia) without a substantial increase
fourth-degree perineal laceration CI, 0.61e0.74), with a small rise in in maternal morbidities (OR for Fried-
(adjusted OR, 1.80 [95% CI, 1.58e2.05]). instrumental deliveries (19.2%, 732/ man’s criteria, 3.04; 95% CI, 2.26e4.09;
Among multiparous women using epi- 3515, vs 17.7%, 622/3796; P<.0001). The OR for Zhang’s criteria, 3.59; 95% CI,
durals with prolonged second stage, spontaneous vaginal delivery rate 2.68e4.80).104 However, Bernitz et al48
Laughon et al98 found increased risk of decreased progressively from 85%, 78%, conducted a multicenter cluster ran-
postpartum hemorrhage (adjusted OR, 59%, and 27% to 25% when the second domized trial with a total of 7277 women,
1.50 [95% CI, 1.07e2.10]), cho- stage lasted <1, 1 to 2, 2 to 3, 3 to 4, and 4 comparing cesarean delivery rates in
rioamnionitis (adjusted OR, 4.78 [95% to 5 hours, respectively. groups adopting the WHO partograph
CI, 3.46e6.61]), episiotomy (adjusted A more recent study showed that ce- (based on Friedman’s precepts) or
OR, 1.44 [95% CI, 1.21e1.70]), and sarean delivery rates, when compared Zhang’s curve. There were 196 (5.9%)
third- or fourth-degree perineal lacera- with those observed in normal labor intrapartum cesarean deliveries in women
tion (adjusted OR, 3.85 [95% CI, progress, may be reduced when changing in the WHO partograph group and 271
2.65e5.60]). Zipori et al101 indicated labor arrest criteria from Friedman’s to (6.8%) in the Zhang’s curve group, and
that allowing an additional 1 hour Zhang’s (second-stage arrest: >4 hours the frequency of intrapartum cesarean
before diagnosing second-stage arrest for nulliparas with epidural analgesia or delivery did not differ between the groups

TABLE 5
Duration of labor and maternal outcomes
Study Type N (y) Population selection Key findings
Duration of the active phase of first stage
Rouse et al,80 prospective 542 Term gravidas in spontaneous Extending the minimum period of oxytocin
1999 cohort study labor with active-phase labor
arrest (cervix at least 4 cm
dilated and 1 cm of cervical
progress in 2 h)
augmentation for active-phase labor arrest
from 2 to at least
4 h was effective and safe, without severe
maternal or neonatal complications
Cheng et al,81 retrospective 10,661 Nulliparas with term, singleton Women with a prolonged first stage (2.8 vs
2010 cohort study delivery 30 h, 5the95th percentile thresholds) of
(1990e2008)
labor have higher odds of cesarean delivery
(6.1% vs 13.5%; aOR, 2.28; 95% CI, 1.92
e2.72) and chorioamnionitis (12.5% vs
23.5%; aOR, 1.58; 95% CI, 1.25e1.98)
Lakshmidevi prospective 200 Primigravidae with spontaneous Increased rates of instrumental deliveries
et al,82 2012 observational onset of labor at term (97.7% vs 72.5% vs 18.5%; P<.001) were
study observed when mean duration of active
phase of labor increased (4.1 vs 6.9 vs 9.6
h)
Harper et al,83 retrospective 5030 Term gravidas reached the Longer first stage of labor was associated
2014 cohort study second stage of labor with an increased risk of a prolonged
(2004e2008)
second stage (aOR, 3.19; 95% CI, 1.94
e5.26), maternal fever (aOR, 3.01; 95% CI,
1.76e5.15), and shoulder dystocia (P<.01)
Dahlke et al,84 secondary 5681 Nulliparas with term, singleton, Maternal and neonatal outcomes after
2018 analysis of cohort vertex gestations who cesarean delivery for arrest of dilation 6
(1999e2002)
study underwent primary cesarean cm were comparable to those performed at
delivery for arrest of dilation 4 to 5 cm: no difference in composite
maternal outcome (aOR, 1.19; 95% CI, 0.94
e1.52) between the groups
Hoppe et al,85 retrospective 642 Nulliparas, aged 18 to 44 y, with Chorioamnionitis and cesarean delivery
2018 cohort study cephalic, singleton pregnancies, increased considerably as active labor
(2012e2015)
at >37 wk in spontaneous labor duration exceeded the median: the risk of
cesarean delivery was higher in the
median-95th percentile (aOR, 3.1; 95% CI,
1.8e5.5) and the >95th percentile (aOR,
6.8; 95% CI, 3.9e11.7) subgroups
Blankenship retrospective 6823 Nulliparas with term, cephalic, A prolonged first stage of labor duration
et al,86 2020 cohort study singleton delivery >90th percentile cutoff point was
(2010e2015)
associated with an increased risk of
composite maternal morbidity (OR, 2.2
[95% CI, 1.8e2.7]), maternal fever,
postpartum transfusion, prolonged second
stage of labor duration, third- or fourth-
degree perineal laceration, and cesarean or
operative vaginal delivery (P<.02)
Govindappagari retrospective 2559 Nulliparas with term, cephalic, Composite maternal morbidity was greater
et al,87 2020 study singleton delivery in women with protracted active labor
(2016e2017)
compared with cervical change in the
normal active phase (<4 h) group: aOR,
2.15; 95% CI, 1.62e2.86

TABLE 5
Duration of labor and maternal outcomes (continued)
Kempe and prospective 1380 Nulliparas with a term, singleton, Compared the durations of labor of <6, 6
Vikström-Bolin,88 cohort study vertex fetus after spontaneous e12, and >12 h; nullliparas with longer
(2013e2016)
2020 onset of labor labor reported lower mean satisfaction with
the birthing experience than women with
shorter labor (P<.001); multiple regression
analysis showed that duration of labor
(F¼12.292; P<.001) had independent
effects on the satisfaction with the birthing
experience
Kawakita et al,89 retrospective 31,505 Term singleton cephalic At cervical dilation of 6 or 7 cm, the arrest of
2021 cohort study pregnancies in spontaneous or dilation of <4 h compared with arrest of
induced active labor (6 cm) dilation of 4e5.9 h was associated with
decreased risks of adverse maternal outcomes
Duration of the second stage
Mehta et al,90 retrospective 130 Nulliparas whose delivery was The combination of fetal macrosomia,
2004 cohort study complicated by shoulder second stage of labor >2 h (22% vs 3%;
(1996e2001)
dystocia P<.05), and the use of operative vaginal
delivery (26% vs 1.5%; P<.001) were
associated with shoulder dystocia in
nulliparas
Cheng et al,91 retrospective 15,759 Nulliparas with term, cephalic, Nulliparas with >3 h of second stage
2004 cohort study singleton delivery compared with <3 h: increased risk of
(1976e1001)
postpartum hemorrhage (aOR, 1.48 [95%
CI, 1.24e1.78]), and choriamnionitis (aOR,
2.14 [95% CI, 1.80e2.57])
Nystedt et al,92 case referent 255 Women following a prolonged Women with prolonged labor had a negative
2005 study labor with assisted vaginal or childbirth experience more often than did
abdominal delivery women who had a normal labor (34% vs
4%; P<.05): “Pain relief during the delivery
saved me” (OR, 4.5 [95% CI, 1.9e11.1])
and “My difficulties during the delivery will
mark me for life” (OR, 12.4 [95% CI, 4.4
e35.9])
Cheng et al,93 retrospective 5158 All term, cephalic, singleton Compared with delivered between the 0-
2007 cohort study births delivered by multiparas and 2-h interval, multiparas with a second
(1991e2001)
stage >3 h had higher risks of operative
vaginal delivery (aOR, 13.27 [95% CI, 9.38
e18.8]), cesarean delivery (aOR, 6.00 [95%
CI, 4.06e8.86]), and maternal morbidity
including third- or fourth-degree perineal
lacerations, postpartum hemorrhage, and
chorioamnionitis
Allen et al,94 2009 population-based 121,517 Nulliparas and mulitiparas with Risks of adverse outcomes rise with
cohort study term, cephalic, singleton increased duration of the second stage,
(1988e2006)
delivery particularly for duration >3 h in nulliparas
and >2 h in multiparas：increase in risk of
obstetrical trauma (aOR, 1.84 [95% CI, 1.65
e2.06]), postpartum hemorrhage (aOR, 1.53
[95% CI, 1.37e1.72]), and puerperal febrile
morbidity (aOR, 1.63 [95% CI, 1.39e1.92])
Le Ray et al,95 secondary 1862 Nulliparas with epidural The risk of postpartum hemorrhage (aOR,
2009 analysis of analgesia in the second stage of 2.5 [95% CI, 1.5e4.1]) and intrapartum
(1994e1996)
multicentered labor fever (aOR, 2.7 [95% CI, 1.3e5.5])
randomized increased considerably after 2 h of pushing
controlled study in nulliparas

TABLE 5
96
Rouse et al, secondary 4126 Nulliparas reached second stage Each additional h of second stage in
2009 analysis of of labor nulliparas: increased risk of
multicentered chorioamnionitis (aOR, 1.60 [95% CI, 1.40
randomized e1.83]), third- or fourth-degree perineal
controlled study laceration (aOR, 1.44 [95% CI, 1.29e1.60]),
and uterine atony (aOR, 1.31 [95% CI, 1.14
e1.51])
Marsoosi et al,97 cross-sectional 100 75 primigravid women were The increase in genital hiatus occurring
2014 study recruited for assessment at 6 wk following natural delivery is related to the
postpartum compared with 25 prolapse of pelvic organs. Out of 19 patients
nulliparas with diameters higher than cutoffs (80th
percentile) at rest and during the Valsalva
maneuver, 8 patients had puborectalis
avulsion (P¼.025). The pelvic area during
contraction was 31.110.81 for the
nonprogressive labor group, which was
higher than those found for other groups,
and the difference was significant (P¼.014)
Laughon et al,98 retrospective 43,810 Women with singleton deliveries Prolonged second stage compared with no
2014 cohort study at 36 wk of gestation, vertex prolonged second stage (defined as: for
(2002e2008)
presentation, who reached the nulliparas, >3 h with epidural or >2 h
second stage of labor without; multiparas, >2 h with epidural or
>1 h without): increased risk of
endometritis (aOR, 3.52 [95% CI, 2.44
e5.06]), postpartum hemorrhage (aOR,
1.50 [95% CI, 1.27e1.78]),
chorioamnionitis (aOR, 3.01 [95% CI, 2.65
e3.43]), and third-/fourth-degree perineal
laceration (aOR, 1.80 [95% CI, 1.58e2.05])
for nulliparas with epidural; increased risk
of postpartum hemorrhage (aOR, 1.50 [95%
CI, 1.07e2.10]), chorioamnionitis (aOR,
4.78 [95% CI, 3.46e6.61]), episiotomy
(aOR, 1.44 [95% CI, 1.21e1.70]), and third-
/fourth-degree perineal laceration (aOR,
3.85 [95% CI, 2.65e5.60]) for multiparas
with epidural
Simic et al,99 population-based 52,211 Primiparas undergoing vaginal The risk of severe perineal laceration
2017 cohort study delivery with cephalic increases with duration until the third hour of
(2008e2014)
presentation at term second stage of labor. Risk of severe perineal
lacerations increased with duration of
second stage of labor. Compared with a
second stage of labor of 1 h, women with a
second stage of >2 h had an increased risk
(aOR, 1.42; 95% CI, 1.28e1.58). Compared
with noninstrumental vaginal deliveries, the
risk was elevated among instrumental
vaginal deliveries (aOR, 2.24; 95% CI, 2.07
e2.42). The risk of perineal laceration
increased with duration of second stage of
labor until <3 h in both instrumental and
noninstrumental vaginal deliveries, but after
3 h, the ORs did not further increase.
Grantz et al,100 retrospective 103,415 Singleton, vertex births at 36 Rates of spontaneous vaginal birth without
2018 cohort study wk of gestation without previous serious morbidity steadily decreased for
(2002e2008)
cesarean delivery increasing second-stage duration except for
the first 0.5 h for nulliparas

TABLE 5
Zipori et al, 101
Historical control 19,813 Singleton deliveries at 37-wk Second-stage arrest defined in multiparas
2019 cohort study gestation after 3 h with regional anesthesia or 2 h
(2011e2017)
without it; allowing an additional 1 h before
diagnosing second-stage arrest successfully
decreased primary cesarean deliveries (RR,
0.67; 95% CI, 0.61e0.74), with a small rise
in instrumental deliveries (19.2%, 732/3515,
vs 17.7%, 622/3796; P<.0001)
Naqvi et al,102 nested case 1197 term nulliparas with a singleton With each additional hour of the second
2022 econtrol study gestation who underwent a stage, the rate of obstetrical anal sphincter
(2014e2015)
vaginal delivery at a single injury increased; operative vaginal delivery
institution (aOR, 5.92; 95% CI, 17e11.07) and a
prolonged second stage (aOR, 1.92; 95% CI,
1.06e3.51) were independent predictors of
third- and fourth-degree lacerations
Niemczyk et al,103 retrospective 2196 Singleton, vertex live births Complications requiring hospitalization of
2022 analysis of without previous cesarean postpartum women and newborns become
(2007e2017)
deidentified delivery more common as the length of the second
client-level data stage increases. Postpartum transfers for
multiparas increased from 1.4% after
second stage <15 min to >4% for women
after second stage >2 h (P for trend,
<.0001.).
Ushida et al,77 multicenter 31,758 Low- to moderate-risk, Women with second stage of labor of >30 min
2022 retrospective singleton, vertex births at 37 (for primiparity) or >15 min (for multiparity)
study wk of gestation without previous showed an increased risk of postpartum
cesarean delivery hemorrhage (primiparity: aOR, 1.15e1.78;
multiparity: aOR, 1.14e1.74), whereas those
with prolonged first stage did not
Nunes et al,104 retrospective, 3665 Singleton deliveries at 37 wk Labor arrest was obviously associated with
2022 single-center were initially considered eligible higher total maternal morbidity (OR for
cohort study as long as women achieved 4 cm Friedman’s criteria, 3.04; 95% CI, 2.26
of dilation e4.09; OR for Zhang’s criteria, 3.59; 95%
CI, 2.68e4.80) and maternal hemorrhagic
(OR for Friedman’s criteria, 2.87; 95% CI,
1.81e4.55; OR for Zhang’s criteria, 2.80;
95% CI, 1.75e4.49) and infectious
morbidity (OR for Friedman’s criteria, 3.56;
95% CI, 2.44e5.18; OR for Zhang’s criteria,
4.77; 95% CI, 3.34e6.80). No differences
were found between Friedman’s and
Zhang’s groups in total maternal morbidity.
Changing labor arrest criteria from
Friedman’s to Zhang’s may reduce cesarean
delivery rates because of labor arrest.
(Friedman’s criteria: first-stage arrest:
without any change of dilation at least 2 h;
second-stage arrest: >3 h for nulliparas or
>2 h for multiparas; Zhang’s criteria: first-
stage arrest: achieved 6 cm of dilation and
exceeded 4 h without any cervical change;
second-stage arrest: >4 h for nulliparas
with epidural analgesia or >3 h for
multiparas with epidural analgesia)
The percentile refers to the distribution of the data in each individual study.
aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio; RR, relative risk.

(adjusted RR, 1.17; 95% CI, 0.98e1.40; decreased with increasing second-stage multiparas) to Zhang’s (second-stage
P¼.08; adjusted risk difference, 1.00%; duration, with the exception of the first arrest: >4 hours for nulliparas with
95% CI, 0.1 to 2.1). half-hour for nulliparous women.100 epidural analgesia or >3 hours for
Similar to findings regarding active Each additional hour of the second multiparas with epidural analgesia) was
phase duration, longer second-stage stage in nulliparous women increased not associated with worse neonatal
duration was associated with labor the risk for brachial plexus injury outcomes (Friedman’s criteria: OR, 1.39;
experience. Nystedt et al92 reported that (adjusted OR, 1.78 [1.08e2.78]).96 95% CI, 0.99e1.97; Zhang’s criteria: OR,
women with prolonged labor had a However, relative to the first hour of 1.18; 95% CI, 0.81e1.71).
negative childbirth experience more expulsive efforts, the chance of a spon-
often than women who had a labor of taneous vaginal delivery of a neonate Risk of bias of included studies
normal duration (34% vs 4%; P<.05), without signs of asphyxia decreased The quality of the studies was assessed
and that pain relief can ameliorate the considerably among nulliparas (for 1e2 with the NewcastleeOttawa Quality
negativity and difficulty associated with hours: adjusted OR, 0.4 [95% CI, Assessment Scale. Among the 78 studies,
the laboring woman’s experience of 0.3e0.6]; 2e3 hours: adjusted OR, 0.1 32 (41%) were rated as low- or
prolonged labor (OR, 4.5; 95% CI, [95% CI, 0.09e0.2]; 3 hours: adjusted moderate-quality (score of 0e6), and 46
1.9e11.1). OR, 0.03 [95% CI, 0.02e0.05]).95 (59%) were rated as high-quality (score
Complications requiring newborn hos- of 7e9) (Table S3).
Neonatal morbidity associated with pitalization became more common as
duration of active labor the length of the second stage increased. Methodological aspects in describing
Overall, 17 studies that examined the Newborn transfers increased when the and analyzing labor progression
association between duration of labor second stage was >2 hours vs <15 mi- Synthesis of this literature indicates that
and neonatal morbidity were included in nutes (for primiparas: 0.6%e6.33%; P analyzing labor progress data is complex.
this review (Table 6). Among these for trend,.0008; for multiparas: 1.4% Good-quality data and correct statistical
studies, 7 reported the association be- e10.6%; P for trend, <.0001).103 methods are essential to producing use-
tween duration of the active phase of first In multiple large cohort studies of ful results. For these reasons, we also
stage and neonatal morbidity.81-87 A nulliparas who reached the second stage conducted a comprehensive search of
large cohort study showed that women of labor, longer second stage was asso- statistical models recently used to study
with a prolonged first stage of labor (30 ciated with birth trauma, particularly for labor progress, outlined the strengths
vs <2.8 hours; 95th vs 5th percentiles) second-stage duration >3 hours. Using and weaknesses of each method and la-
had higher odds of chorioamnionitis the definition of prolonged second stage bor progress data, and reviewed the
(12.5% vs 23.5% vs 12.5%; adjusted OR, as >3 hours with epidural or >2 hours impact of labor data quality.
1.58; 95% CI, 1.25e1.98) and neonatal without epidural in nulliparas, or >2
admission to the NICU (9.8% vs 4.7%; hours with epidural or >1 hour without Models of dilation against time
adjusted OR, 1.53; 95% CI, 1.18e1.97), epidural in multiparas, Laughon et al98 Modern attempts to describe first-stage
but no other associated adverse neonatal indicated that when compared with de- labor progression began with Zhang
outcomes. Four other studies82,83,86,87 liveries within guidelines for “normal et al.22 Because data on vaginal dilation
also concluded that longer first stage of duration,” deliveries with prolonged are generally obtained only after the
labor was associated with an increased second stage increased the risk of laboring person is admitted to the birth
risk of the composite adverse neonatal neonatal sepsis in nulliparas (with setting, and subsequent to admission,
outcome. However, Dahlke et al84 found epidural: adjusted OR, 2.08 [95% CI, only for clinical care, Zhang et al36
that maternal and neonatal outcomes of 1.60e2.70]; without epidural: adjusted defined duration as time until reaching
cesarean delivery for arrest of dilation OR, 2.34 [1.28e4.27]), neonatal 10-cm dilation. This necessitates
6 cm were comparable to those of ce- asphyxia in nulliparas with epidural including only labors that reach a dila-
sarean delivery performed at 4 to 5 cm, (adjusted OR, 2.39 [95% CI, tion of 10 cm, thereby greatly limiting
with no difference in composite neonatal 1.22e4.66]), and perinatal mortality the relevance for managing labors when
morbidity (adjusted OR, 0.94; 95% CI, without epidural (nulliparas: adjusted the cervix is not yet fully dilated.
0.79e1.10) between the groups. OR, 5.92 [95% CI, 1.43e24.51]; multi- Nevertheless, data from vaginal dilation
paras: adjusted OR, 6.34 [95% CI, measurement have been used to produce
Neonatal morbidity associated with 1.32e30.34]). a labor curve of dilation against time,
duration of second stage of labor In contrast to the previously outlined representing a kind of standard for suc-
A total of 10 studies examined the studies, Nunes et al104 conducted a cessful labors, defined as vaginal delivery
duration of the second stage of labor and retrospective, single-center cohort study with normal perinatal outcomes. Zhang
its association with neonatal based on 3665 women, and indicated et alXX used repeated-measures regres-
morbidity.91,93-96,98,100,101,103,104 The that changing labor arrest criteria from sion with a polynomial time trend. This
rates of spontaneous vaginal birth Friedman’s (second-stage arrest: >3 model makes no assumptions about the
without serious morbidity steadily hours for nulliparas or >2 hours for velocity of dilation throughout the first

TABLE 6
Duration of labor and neonatal outcomes
Duration of the active phase of first stage
Cheng et al,81 2010 Retrospective 10,661 Nulliparas with term, Women with a prolonged first stage (2.8 vs
cohort study singleton delivery 30 h, 5the95th percentile thresholds) of
(1990e2008)
labor have higher odds of chorioamnionitis
(12.5% vs 23.5%; aOR, 1.58; 95% CI, 1.25
e1.98), and neonatal admission to the NICU
(4.7% vs 9.8%; aOR, 1.53; 95% CI, 1.18
e1.97), but no other associated adverse
neonatal outcomes
Lakshmidevi et al,82 2012 Prospective 200 primigravidae with Increased rates of infants with lower 5-min
observational spontaneous onset Apgar score and NICU admissions (0.8% vs
study of labor at term 10% vs 33.3%; P<.001) were observed
when mean duration of active phase of labor
increased (4.1 vs 6.9 vs 9.6 h)
Harper et al,83 2014 Retrospective 5030 Term gravidas Longer first stage of labor was associated
cohort study reached the second with an increased risk of the composite
(2004e2008)
stage of labor neonatal outcome (aOR, 1.9; 95% CI, 1.23
e1.93), admission to a level 2 or 3 nursery
(RR, 2.83; 95% CI, 1.82e4.38), and
shoulder dystocia (P<.01)
Dahlke et al,84 2018 Secondary 5681 (1999e2002) Nulliparas with term, Maternal and neonatal outcomes after
analysis of singleton, vertex cesarean delivery for arrest of dilation 6
cohort study gestations who cm were comparable to those of cesarean
underwent primary delivery performed at 4 to 5 cm: no
cesarean delivery for difference in composite neonatal morbidity
arrest of dilation (aOR, 0.94; 95% CI, 0.79e1.10) between
the groups
Hoppe et al,85 2018 Retrospective 642 Nulliparous, aged Chorioamnionitis and cesarean delivery
cohort study 18e44 y, with cephalic, increased considerably as active labor
(2012e2015)
singleton pregnancy, duration exceeded the median: the risk of
at >37 wk in cesarean delivery was higher in the
spontaneous labor median-95th percentile (aOR, 3.1; 95% CI,
1.8e5.5) and the >95th percentile (aOR,
6.8; 95% CI, 3.9e11.7) subgroups
Blankenship et al,86 2020 Retrospective 6823 Nulliparas with term, A prolonged first stage of labor duration
cohort study cephalic, singleton >90th percentile cutoff point was
(2010e2015)
gestations associated with an increased risk of
composite neonatal morbidity (OR, 2.6
[95% CI, 2.1e3.2]), respiratory distress
syndrome, need for mechanical ventilation,
and neonatal sepsis (P<.03)
Govindappagari et al,87 Retrospective 2559 Nulliparas with term, Composite neonatal morbidity was greater
2020 study cephalic, singleton in women with protracted active labor
(2016e2017)
deliveries compared with cervical change in the
normal active phase (<4 h) group: aOR,
1.38; 95% CI, 0.98e1.96
Duration of the second stage
Cheng et al,91 2004 Retrospective 15,759 Nulliparas with term, Nulliparas with >3 h of second stage
cohort study cephalic, singleton compared with <3 h: increased risk of 5-
(1976e1001)
deliveries min Apgar <7 (aOR, 0.73 [95% CI, 0.48
e1.11]), umbilical artery pH <7.0 (aOR,
1.21 [95% CI, 0.45e3.29]), base excess <
e12 (aOR, 0.61 [95% CI, 0.32e1.16]), NICU
admission (aOR, 1.07 [95% CI, 0.72e1.58])

TABLE 6
Duration of labor and neonatal outcomes (continued)
93
Cheng et al, 2007 Retrospective 5158 Multiparas with term, Multiparas with >3 h of second stage
cohort study cephalic, singleton compared with <3 h: increased risk of 5-
(1991e2001)
births min Apgar <7 (aOR, 3.63 [95% CI, 1.77
e7.43]), admission to the NICU (aOR, 2.08
[95% CI, 1.13e3.77]), composite neonatal
morbidity (5-min Apgar <7, umbilical
artery pH <7.0, umbilical artery base
excess < e12, shoulder dystocia, NICU
admission, and birth trauma; aOR, 1.85
[95% CI, 1.23e2.77]), and longer neonatal
hospital stay (aOR, 1.67 [95% CI, 1.11
e2.51])
Allen et al,94 2009 Population-based 121,517 Nulliparas and Increased duration of the second stage,
cohort study multiparas with term, particularly for duration >3 h in nulliparas
(1988e2006)
cephalic, singleton and >2 h in multiparas：increase in the
gestations risk of obstetrical trauma (aOR, 1.84 [95%
CI, 1.65e2.06])
Rouse et al,96 2009 Secondary 4126 Nulliparous laboring Each additional hour of second stage in
analysis of women reached the nulliparas: increased risk of brachial plexus
multicentered second stage of labor injury (aOR, 1.78 [1.08e2.78])
randomized
controlled study
Le Ray et al,95 2009 Secondary 1862 Nulliparas with epidural Relative to the first hour of expulsive efforts,
analysis of analgesia who were the chances of a spontaneous vaginal
(1994e1996)
multicentered in the second stage of delivery of a newborn without signs of
randomized labor asphyxia decreased considerably every hour
controlled study (1e2-h aOR, 0.4 [95% CI, 0.3e 0.6]; 2e3-h
aOR, 0.1 [95% CI, 0.09e0.2]; 3-h aOR, 0.03
[95% CI, 0.02e 0.05])
Laughon et al,98 2014 Retrospective 403,810 Women with singleton Prolonged second stage compared with
cohort study deliveries at 36-wk no prolonged second stage (defined as:
(2002e2008)
gestation, vertex for nulliparas, >3 h with epidural or >2
presentation, who h without; multiparas, >2 h with epidural
reached the second or >1 h without): increase in risk of
stage of labor neonatal sepsis in nulliparas (with
epidural: aOR, 2.08 [95% CI, 1.60
e2.70]; without epidural: aOR, 2.34
[95% CI, 1.28e4.27]), asphyxia in
nulliparas with epidural (aOR, 2.39 [95%
CI, 1.22e4.66]), and perinatal mortality
without epidural (nulliparas: aOR, 5.92
[95% CI, 1.43e24.51]; multiparas: aOR,
6.34 [95% CI, 1.32e30.34])
Grantz et al,100 2018 Retrospective 103,415 Singleton, vertex births Rates of spontaneous vaginal birth
cohort study at 36-wk gestation without serious morbidity steadily
(2002e2008)
without previous decreased with increasing second-stage
cesarean delivery duration except for the first 0.5 h for
nulliparas

TABLE 6
Duration of labor and neonatal outcomes (continued)
101
Zipori et al, 2019 Historical control 19,813 Singleton deliveries at Second-stage arrest defined in multiparas
cohort study 37-wk gestation after 3 h with regional anesthesia or 2 h
(2011e2017)
without it; allowing an additional 1 h before
diagnosing second-stage arrest
successfully decreased primary cesarean
deliveries (RR, 0.67; 95% CI, 0.61e0.74),
with a small rise in instrumental deliveries
(19.2%, 732/3515, vs 17.7%, 622/3796;
P<.0001). It also increased the other
immediate maternal and neonatal
complications: a higher rate of lower
umbilical artery cord pH was the most
marked finding, but the early neurologic
outcome did not change.
Niemczyk et al,103 2022 Retrospective 2196 Singleton, vertex live Complications requiring hospitalization of
analysis of births without previous postpartum women and newborns become
(2007e2017)
deidentified cesarean delivery more common as the length of the second
client-level data stage increases. Newborn transfers
increased as second-stage duration
increased from <15 min to >2 h
(primiparas: 0.6%e6.33%; P for
trend,.0008; multiparas: 1.4%e10.6%; P
for trend, <.0001)
Nunes et al,104 2022 Retrospective, 3665 Singleton deliveries at Compared with normal labor, labor arrest
single-center 37 wk were initially was markedly associated with higher total
cohort study considered eligible as maternal morbidity; changing labor arrest
long as women achieved criteria from Friedman’s (first-stage arrest:
4 cm of dilation without any change of dilation for at least 2
h; second-stage arrest: >3 h for nulliparas
or >2 h for multiparas) to Zhang’s (first-
stage arrest: achieved 6 cm of dilation and
exceeded 4 h without any cervical change;
second-stage arrest: >4 h for nulliparas
with epidural analgesia or >3 h for
multiparas with epidural analgesia) was not
associated with worse neonatal outcomes
(OR for Friedman’s criteria, 1.39; 95% CI,
0.99e1.97; OR for Zhang’s criteria, 1.18;
95% CI, 0.81e1.71)
The percentile refers to the distribution of the data in each individual study.
aOR, adjusted odds ratio; CI, confidence interval; NICU, neonatal intensive care unit; OR, odds ratio; RR, relative risk.
stage of labor; high-degree polynomials practice and is thus problematic when Zhang et al22 used interval-censored
are very flexible. analyzing observational data. regression to model the transit times
More recently, other authors34,105,106 from 1 cm of cervical dilation to any
have used nonlinear models that Models of dilation transit times other amount of cervical dilation. These
impose some assumption about the The average labor curve has limited times represent the time from first
shape of the curve, although they seem usefulness in guiding clinical manage- equaling or exceeding one integer centi-
fairly flexible. Elmi et al107 described ment. One limitation of an average labor meter of cervical dilation until first
using a branching curve to analyze the curve is that it is restricted to successful equaling or exceeding another integer
effects of interventions on dilation over labors. It depicts a general pattern of centimeter of cervical dilation. These
time. Although this idea is interesting, it normal labor progression but has limited transit times are never observed directly,
seems to assume that the time of inter- use in guiding clinical management but for any pair of integers, minimum
vention initiation is the same for all la- when a labor deviates from common and maximum (possibly infinite) transit
bors, which does not match clinical patterns, which occurs frequently.34 times can be obtained from the repeated

cervical dilation measures of a labor. in the values is reflected in the data exclusion of intrapartum cesarean
Parametric regression of the interval- used to fit the models. delivery.
censored intervals provides an approach
for modeling these transit times, but also Models of station Recent developments in better
requires an assumed distribution of the Zhang et al22 used repeated-measures measurement of labor progression
unobserved transit times. Zhang et alXX regression with a polynomial time In 2007, Sharf et al115 proposed an
used a log-normal distribution and also trend to model fetal station, similar to ultrasound-based computerized system
included covariates into the interval- their dilation labor curve methodology. for continuous monitoring of cervical
censored regression model that captures The same interval-censored regression dilation and fetal head station. However,
the relative overall progression of each used for dilation was also used to model it was invasive because the internal
labor on the basis of its entire set of transit times from first equaling or transducers were fixed at the cervix
measures. They further stratified their exceeding one integer station to first structure, and any invasive monitoring
analysis by cervical dilation at admission equaling or exceeding another integer creates risk for modifying labor pro-
to enhance the applicability of the model station. Haberman et al112 used a linear cesses.115,116 Subsequently, a noninva-
results because dilation at admission is mixed model with cubic splines for time sive ultrasound-based position tracking
potentially a key prognostic factor for to model the fetal station against time. system was developed, which combined
labor progression.36 magnetic position trackers, ultrasound,
However, de Vries et al108 criticized Quality of labor data and its impact and personal computer-based software,
the use of interval-censored regression Labor involves numerous transitions. At and required minimal skills.117 Unfor-
of transit times because this method different stages, specific problems may tunately, this system showed limited
used an assumption of log-normal dis- result in data quality issues and potential precision when tracking cervical
tribution for labor duration. They biases. Table 7 presents commonly changes.118,119 These recent innovations
showed that if the time intervals be- encountered challenges with analyzing in continuous cervical dilation moni-
tween consecutive cervical dilation retrospective data, their potential impact toring build on many years of previous,
measures are long, the assumed distri- on study results, and possible statistical and similarly clinically unsuccessful,
bution has an increasing impact on the solutions. efforts.120
results. Nonetheless, when vaginal ex- Retrospective labor data are often In recent years, intrapartum ultra-
aminations are performed every 1 to 3 subject to various random and system- sound techniques have been endorsed as
hours or more frequently, the average atic errors. Inaccurate digital measure- a useful auxiliary tool for labor progress
labor curve appears close to the un- ment of cervical dilation, for example, assessment.121,122 They can measure
derlying labor pattern. Oladapo et al34 can obscure certain labor patterns. Self- cervical dilation,119,123 identify fetal po-
used a multistate Markov model and reporting on the onset of painful con- sition and head station,124e126 and pre-
produced very similar results to those tractions and timing of hospital arrival dict mode of delivery.127,128 Compared
obtained with interval-censored regres- may be related to the degree of pain.113 with continuous cervical monitoring,
sion, suggesting that vaginal examina- Because pain is associated with dura- ultrasound is easy to use, objective, and
tions performed every 3 hours may tion of labor and risk of dystocia,114 early reproducible.129 In addition to tradi-
be adequate for retrospective data admission may not be a random event tional 2-dimensional ultrasound, 3-
analysis.109 and thus may have inherent selection dimensional techniques have also been
Mulatya et al110 used longitudinal bias. Recording the degree of pain at applied to assess the progress of labor
threshold models to estimate transit admission for future adjustment or and predict mode of delivery. Head-to-
times. As described, these models are ignoring early stage of labor may help to perineum distance, angle of progres-
too complex for easy interpretation, reduce such biases. However, pain and sion, and middle angle may play a role in
and thus seem to have limited applica- latent or early labor are also nearly uni- the prediction of mode of
bility. Oladapo et al34 applied a multi- versal aspects of labor experience and delivery.127,130e134 Three-dimensional
state Markov model to describe progression; therefore, ignoring either ultrasound can be helpful in standard-
transitions from one integer centimeter may also create bias. izing and simplifying measurements and
of cervical dilation to another. The Intrapartum cesarean deliveries post hoc analysis, but it requires more
model requires a Markov assumption, before full dilation may exclude more skills and more expensive devices.135
and moreover, it assumes instantaneous parturients with dystocia and bias the With the aim of reducing human error
transitions from one state to another. labor curve toward more rapid patterns. and providing rapid assessment, auto-
Some researchers have also attempted However, the incidence of intrapartum matic techniques and artificial intelli-
to model the time needed for cervical cesarean delivery, especially before full gence approaches that are incorporated
dilation to advance by 1 cm.106,111 dilation, is usually <15%.36 Thus, esti- into sonographic assessment have
However, this is not directly observed, mates of the average labor curve are recently been developed. These novel
and thus it is unclear how uncertainty unlikely to be seriously altered by the methods have shown potential for

TABLE 7
Quality of labor data, its impact, and possible statistical solutions
Impact on data quality or
Potential problem introducing potential bias Possible statistical solutions
Self-reporting on the onset of labor Subject to random errors; possibly Recording degree of pain at
or rupture of the membranes related to the degree of pain or pain admission may facilitate future
tolerance, which may be associated adjustment
with duration of labor and
intrapartum cesarean delivery
Variation in timing of hospital arrival Possible selection bias when Using 10-cm dilation as the starting
constructing the labor curve point and modeling the labor curve
backward; not using data points
before 3 or 4 cm
Waiting in triage vs sending home Waiting in triage may result in more No data solution
interventions, whereas sending
home may miss information on early
labor
Inaccurate digital measurements of Random and systematic errors by Data smoothing; delete
cervical dilation, effacement, and examiners; timing of the vaginal unreasonable data point
fetal station examination in relation to uterine
contraction
Varying time interval between Systematic bias owing to clinical Explained in the Discussion section
vaginal examinations indications
Delayed detection on full dilation Artificially long active labor but short No data solution
second stage
Timeliness of recording the Inaccurate recall of the No data solution
measurements or milestone events measurements
Routine use of interventions to Confounds labor progress data Analyses of data from populations in
hasten delivery in moderate- to moderate- to high-resource settings
high-resource settings with less frequent labor intervention
providing reliable measurements of maternal morbidity and neonatal 2019, ACOG recommendations changed
angle of progression and head-to- morbidity. again to deemphasize the focus on time
perineum distance136,137 and for recog- in labor, advising that expectant man-
nizing fetal head position.138 Further Onset of active labor agement is reasonable for women at 4 to
studies are warranted to validate the ac- The definition of onset of active phase of 6 cm of dilatation as long as maternal
curacy of these new tools and to provide the first stage is still ambiguous. In 1994, and fetal status are reassuring.141 In
evidence to support their routine use. the WHO suggested that the active phase 2018, the WHO suggested that the active
of labor commenced at 3 cm of cervical phase starts at 5-cm dilatation. Further-
Discussion dilatation, and the application of alert more, similar to the ACOG decision to
The process of labor occurs with the and action lines was also recommended shift recommendations away from time-
onset of regular contractions causing for labor management. In 1995, the based estimates, the WHO stopped rec-
progressive cervical effacement and American College of Obstetricians and ommending the use of the cervical dila-
dilation, leading to the descent of the Gynecologists (ACOG) defined the tation threshold of 1 cm per hour for
fetus in the pelvis and eventual birth. beginning of the active phase of labor by the assessment of normal labor
According to clinical diagnoses, Friedman’s criteria, with active-phase progression.46,142
approximately 20% of all labors ending onset signaled by an abrupt change in The onset of active labor, measured by
in a live birth involve either protraction the slope of the curve when cervical cervical dilation and/or by the start of
or an arrest in progression.139 Labor dilatation is plotted against time; this regular and painful contractions, varies
protraction or arrest are the most com- generally occurs when the cervix reaches widely by individual. Furthermore, cer-
mon reason for primary cesarean 3 to 4 cm of dilatation.7 However, in vical dilation alone may not be sufficient
delivery. In low-resource countries, 2017, ACOG suggested that the onset of to gauge the onset of active labor. Rouse
abnormal labor progression owing to active labor for many women may not et al50 proposed an active-phase onset
labor dystocia is associated with obvious occur until 5 to 6 cm of dilatation.140 In definition of 4-cm dilation and at least

90% effacement, or 5-cm dilation uterine electromyography or amniotic These models focus on the time from
regardless of effacement, asserting that fluid lactate,145e148 may eventually prove first equaling or exceeding one integer
this definition would capture most useful for signaling active labor onset centimeter of cervical dilation until first
women who have entered the active and progression. More research is equaling or exceeding another integer
phase during labor induction. In required to find biomarkers that are centimeter of dilation. The simplest
contrast, Zhang et al36,37 suggested that clinically useful with sufficient sensitivity approach is to create interval-censored
because the onset of active phase is still and specificity. values for the unobserved true transit
ambiguous and varies widely by indi- It is still under debate whether the times from the observed dilation mea-
vidual, using a fixed dilation amount (eg, deceleration phase truly exists in normal sures and times. Then the transit times
3 or 4 cm) to define abnormal labor may labor. Given the low frequency of vaginal can be modeled with an assumed true
misclassify a substantial portion of labor examinations and short duration of distribution type. Without continuous
as dystocia. For example, Peisner and deceleration, it is easily missed in most monitoring, the true distribution of
Rosen23 found that among women who labors. Furthermore, oxytocin is transit times cannot be empirically
had no active-phase arrest, 50% were in commonly used in contemporary prac- studied. Zhang et al36 tried several dis-
active phase by 4 cm, 74% by 5 cm, and tice, which may hasten labor and obscure tributions, choosing log-normal as the
89% by 6 cm of dilation. These findings the deceleration phase. However, even best fitting for their large dataset from
highlight the importance of considering when labor was monitored continu- the United States (Consortium on Safe
variation in active-phase onset when ously,114 the deceleration phase was not Labor). This assumption is the main
diagnosing labor arrest. When deter- clearly observed. Instead, an obvious weakness of the interval-censored
mining if a woman is having labor pro- deceleration phase is usually diagnosed approach because the longer the
traction and arrest, the “average” starting as having prolonged labor or arrest of average time between consecutive dila-
point of active labor or “average” labor labor, suggesting that the deceleration tion measures, the more dependent the
duration may not be useful. For these may be a good indicator for potential resulting modeled distribution becomes
reasons, defining “normal labor” on the dystocia55 rather than a physiological on the assumed distribution type.
basis of the upper limit of cervical dila- process in normal labor. Nevertheless, interval-censored models
tation at the onset of active phase may be yield transit time distributions that can
a more sensible approach with promise Methods of analyzing labor progress be used to study the impact of in-
to decrease unnecessary intervention. It Description of the normal pattern of terventions and compare populations.
has been proposed that 6 cm is this upper labor progression, typically via a Approximately half of the intra-
limit.51-53 repeated-measures regression with a partum cesarean deliveries were owing
Will physical measurements aided by flexible time trend, yields a curve repre- to dystocia,36 and these parturients ten-
biomarkers improve the precision of the senting the average dilation and how it ded to have a long labor. Had these
diagnosis of active labor? Recent studies changes with time until 10 cm of cervical women been included in modeling labor
by Ding et al143 and Neal et al144 pro- dilation (for successful labors that do duration, the estimated duration would
vided a glimmer of hope. They found reach this threshold). A strength of this have been even longer, and the “normal”
that circulating concentrations of several methodology is that any flexible time curve would have appeared even slower.
inflammatory biomarkers were corre- trend should be able to accurately esti- The interval-censored regression used
lated with labor progression. Future in- mate the shape of physiological labor. the partial information from women
flammatory biomarker research must Statistical comparisons can be made who had intrapartum cesarean delivery,
contend with the complex relationship between populations via a labor curve which reduced the selection bias to some
between inflammation, labor onset, and approach if random effects are included degree.36 Although this acknowledges
labor progress. Specifically, there is evi- to account for correlation within a labor. the methodological deficiencies of labor
dence that inflammatory processes are However, the usefulness of this descrip- curve modeling, it further supports the
part of physiological spontaneous labor tion in managing labors is highly ques- notion that contemporary labor is
onset, but it is also clear that inflam- tionable. Another limitation of the labor slower than previously reported.
matory processes (eg, clinical cho- curve is the uncertainty in timing of Importantly, vaginal examinations are
rioamnionitis) are strongly correlated transition from early or latent labor to performed at different times in labor and
with longer labor and dystocia. Are in- active labor. Because it is unknown when may also be performed because of
flammatory processes involved in and how labors transition to the active maternal and/or fetal conditions. Vary-
normal labor onset vs labor progression phase, interpretations of curves that ing time intervals between vaginal ex-
different or are they the same processes represent population averages over time aminations could lead to informative
with different magnitudes? How does are limited. censoring in a model of interval-
labor inflammation affect both labor To avoid the problems associated with censored transit times and bias the
duration and adverse maternal/child developing labor curves and to better model results because the model as-
outcomes? Additional early research address management of ongoing labor, sumes noninformative censoring.108 A
suggests that other biomarkers, such as transit time models have been proposed. series of propensity models may be used

to compute corresponding propensity of physical assessment and/or biomarker contact with birthing people. What in-
scores for a labor longer than a certain measures, may improve the accuracy of sights can this close observation reveal
time duration. An inverse probability labor dystocia diagnosis. about what defines and supports normal
weight may be applied to reduce poten- Finally, assessing the association be- labor progress? How can scientists best
tial bias because of varying time intervals tween duration of labor and adverse partner with these team members to
between vaginal examinations. outcomes is vulnerable to at least 2 define and test promising hypotheses?
A study using continuous monitoring sources of bias. First, a normal fetus can Although there is longstanding belief
of cervical dilation (such as ultrasonic tolerate normal labor and be born un- that labor duration plays a key role in
methods or a wireless sensor system) eventfully, whereas a compromised fetus increasing maternal/child risk, confi-
with a sufficiently large sample size may not tolerate even normal labor dently demonstrating these associations
might be useful in providing empirical processes. In such cases, adverse peri- has proven challenging. Many with
evidence to support the distributional natal outcomes may not be driven by longer labors proceed to birth safely, and
assumption of the transit times, long labor. This effect modification, if many with shorter labors experience
although innovations in continuous not identified and stratified, may bias the poor outcomes. To better identify latent
cervical dilation monitoring must over- results toward the null. Second, clinical factors driving maternal/child risk, re-
come previous challenges noted with interventions after an early indication of searchers may find value in posing more
this approach.120 Other more complex fetal compromise, regardless of labor agnostic questions that do not assume
statistical models have also been used to duration, may prevent poor perinatal the centrality of labor duration and
estimate transit times. These approaches outcomes; this also reduces the associa- progress as key to elevating risk. Perhaps
have required additional assumptions, or tion between duration of labor and labor duration only contributes to
the complexity of interpretation has adverse perinatal outcomes. Thus, this elevated risk under certain conditions
limited their broad usefulness.34,108,110 association may depend on how closely and/or in certain populations? Gener-
Currently, with the available labor labor is monitored. Prompt intervention ating labor progress research questions
data, a feasible approach to establish may alleviate the impact of labor dura- informed by these considerations may be
criteria for identifying abnormal duration on perinatal outcome at a popula- helpful for differentiating those who can
tion of labor may be devised by exam- tion level. safely labor for extended periods from
ining a sufficiently high quantile (eg, the those who will benefit from assertive
95th) of the fitted log-normal distribu- Additional labor progress research efforts to hasten birth.
tion for transit time from 5 to 10 cm, considerations Finally, a successful vaginal delivery is
from an interval-censored regression of Future labor progress research may be likely to be determined by a number of
labors that were all admitted at the same strengthened through additional con- factors beyond the 4 Ps (power, passage,
amount of cervical dilation.36 This siderations. The most common passenger, and psyche). In addition, any
endeavor admittedly has some potential approach to labor science has been to maternity unit with a decent delivery
drawbacks. In addition to the log- divide labor duration into different volume has enormous amounts of
normal assumption, the choice of 5 cm phases and to describe the association accumulated labor and delivery infor-
to mark active-labor onset may not be between duration and poor outcomes in mation. As machine learning methods
universally applicable. Most impor- separate phases of labor; however, labor and artificial intelligence techniques
tantly, however, the quantile cutoff is duration is a continuous process. Given become more widespread, the applica-
arbitrary, and the clinical significance of the emerging evidence that the durations tion of these new advances may help the
exceeding any threshold still needs to be of phases of labor influence each other, study of labor. Hopefully, with the right
proven. Statistics alone cannot solve this what could be learned by studying labor information and methods, more accu-
problem, but can only quantify the wide progress as a continuous whole,149,150 rate prediction of successful vaginal de-
variation in labor durations. We propose from onset of the latent phase through livery can soon become a reality.
that the statistical definition of labor birth?
dystocia (ie, the 95th percentile) must be Direct observation is fundamental to Summary and perspectives
coupled with clear clinical implications the scientific endeavor, and the value of Subsequent to Dr Friedman starting the
to generate a reasonable, actionable directly observing labor progress has modern era of labor management in the
definition of labor dystocia. Ultimately, been emphasized by Dr Friedman.151 1950s, the past 20 years have witnessed a
clinicians must decide how to interpret What might we learn about normal vs change of thinking regarding labor pro-
labor duration findings and how to abnormal labor progress via science that gression. New evidence is emerging, and
define labor dystocia. Furthermore, includes information from those in the more advanced statistical methods are
given the intermittent nature of vaginal maternity care teams most often at the applied. Perhaps there remains a debate
examinations, cervical dilation alone bedside? Labor and delivery nurses, regarding how much new knowledge we
may not be the most sensitive and spe- midwives, and doulas are members of have gained and how much clinical
cific indicator. Incorporation of other maternity care teams whose training and practice has changed in the previous 2
parameters, including additional aspects roles place them in frequent, extended decades. We still cannot pinpoint the

onset of active labor, which is critical in 2. Friedman EA. Labor in multiparas; a graph- 21. World Health Organization. Maternal H, safe
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Labor Progression Sys Rev March 2023

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Expert Review ajog.

New insights on labor progression: a systematic

MONTH 2022 American Journal of Obstetrics & Gynecology 1

2 American Journal of Obstetrics & Gynecology MONTH 2022

MONTH 2022 American Journal of Obstetrics & Gynecology 3

4 American Journal of Obstetrics & Gynecology MONTH 2022

MONTH 2022 American Journal of Obstetrics & Gynecology 5

2011 or the presence of a uterine scar were excluded

women with 100% epidural analgesia had

of the first women without epidural analgesia (16e54

analgesia was nearly one-third of that of

multiparas with epidural analgesia.

Labor duration and maternal and

Maternal morbidity associated with

Overall, 24 studies that examined the

association between duration of labor

in this review (Table 5). A total of 10

studies estimated the association be-

tween active phase duration and

diverse deﬁnitions of the active phase

lenging to extract and pool the data.

Rouse et al96 suggested that extending

increase the risk for severe maternal or

Nulliparas with a term, singleton, vertex fetus of normal

Nulliparas with a term, singleton, vertex fetus of normal

neonatal complications. In a secondary

analysis of a cohort study with 5681

women, Dahlke et al84 found that

birthweight after spontaneous onset of labor

maternal and neonatal outcomes after

cm dilation were comparable to those of

with no difference in the composite

[OR], 1.19; 95% conﬁdence interval

Govindappagari et al87 indicated that

greater in women with protracted active

1.62e2.8). Kawakita et al89 supported

South Asian 250

MeanSD; b Median (90th percentile).

this conclusion on the basis of a retro-

spective cohort study of 31,505 term

study showed that among women with

hours compared with arrest of dilation

of 4 to 5.9 hours was associated with

decreased risk for adverse maternal

10 American Journal of Obstetrics & Gynecology MONTH 2022

1.40e1.83]), third- or fourth-degree

MONTH 2022 American Journal of Obstetrics & Gynecology 11

partograph: partograph: partograph: 76 (242)

Data are presented as mean2 SD or median (95th percentile).

16 American Journal of Obstetrics & Gynecology MONTH 2022

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18 American Journal of Obstetrics & Gynecology MONTH 2022

MONTH 2022 American Journal of Obstetrics & Gynecology 19

20 American Journal of Obstetrics & Gynecology MONTH 2022

MONTH 2022 American Journal of Obstetrics & Gynecology 21

22 American Journal of Obstetrics & Gynecology MONTH 2022

MONTH 2022 American Journal of Obstetrics & Gynecology 23

24 American Journal of Obstetrics & Gynecology MONTH 2022

MONTH 2022 American Journal of Obstetrics & Gynecology 25

26 American Journal of Obstetrics & Gynecology MONTH 2022

MeanSD; b Median (90th percentile).

Data are presented as mean2 SD or median (95th percentile).