Release Date : March 06 2025
Labor Management: First and Second Stage Labor Management (2024)
About the Guideline
- An a priori protocol was used along with a three-person writing team consisting of a maternal-fetal medicine subspecialist and two external subject matter experts.
- An extensive literature search was performed with dates restricted to 2000-2020, and an additional literature search was conducted in July of 2023 to allow for the inclusion of any recently published high-level sources for the final guideline.
- This guideline replaces the 2014 consensus statement.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline, especially if you work in a labor and delivery setting.
Definitions
READ MORE...
- Onset of labor
- Regular and painful uterine contractions coupled with cervical changes and/or effacement
- First stage of labor
- Time frame between the onset of labor and complete cervical dilation (10 cm)
- Latent phase of labor
- Begins with gradual/slower cervical dilation and ends with rapid cervical changes
- Active phase of labor
- Rapid cervical changes taking place and ending with complete cervical dilation (10 cm)
- Second stage of labor
- Begins at complete cervical dilation and ends with neonate delivery
- Third stage of labor
- Occurs between the delivery of the neonate and the delivery of the placenta
- Labor protraction
- Slower than normal labor progress
- Labor arrest
- Cessation of labor even with augmentation practices
Active Phase Protraction and Arrest Disorder
READ MORE...
- Active phase arrest of labor:
- patients with ruptured membranes who have not progressed past 6 cm dilation with 4 hours of uterine activity OR
- patients who have experienced 6 hours of inadequate uterine activity with oxytocin augmentation
- Risk factors include nulliparity, obesity, large for gestational age (LGA) fetus, fetal cephalic position, cephalopelvic disproportion.
- To reduce unnecessary cesarean section intervention, consider extending the augmentation period to 8 hours as long as there are cervical changes every 4 hours and maternal and fetal status is stable.
Prolonged Second Stage
READ MORE...
- Prolonged second stage:
- more than 3 hours of pushing for nulliparous individuals, or
- more than 2 hours of pushing for multiparous individuals.
- Risk factors include obesity, use of an epidural, LGA fetus, occiput posterior position.
- Prolonged second stage can result in less-than-optimal outcomes including chorioamnionitis, third- or fourth-degree lacerations, and neonatal morbidity.
- Ensure that thorough clinical assessment of patient is conducted, including possible reasons for lack of progress, clinical factors, close monitoring of fetal descent, and an assessment of the risks and benefits of interventions.
Induction of Labor
READ MORE...
- The latent phase of labor is significantly longer with inductions.
- Consider extending oxytocin augmentation from 12 to 18 hours if membranes are ruptured, provided maternal and fetal status remains stable.
Epidural Anesthesia
READ MORE...
- Offer and use neuraxial anesthesia as pain relief at any point of labor.
Management of Dystocia in the First Stage of Labor
READ MORE...
- Rupturing membranes in individuals receiving augmentation or induction of labor aids in reducing the duration of labor without adding to maternal or fetal risk.
- Oxytocin is recommended to manage labor and to decrease cesarean section deliveries during protracted or arrested labor.
- Either low-dose or high-dose strategies may be used with no significant differences in maternal or neonatal outcomes.
- One-on-one continuous labor support showed an increase in vaginal births, less use of intrapartum analgesia, shorter labors, and a reduction in cesarean deliveries.
- Use of a peanut ball does not show significant differences in maternal outcomes but may provide comfort to the laboring patient.
- Promoting hydration is important (either oral or intravenous) and demonstrates a reduction in labor time.
- An intrauterine pressure catheter is recommended when external monitoring is hindered, or when active labor is protracted.
Management of Dystocia in the Second Stage of Labor
READ MORE...
- Initiate pushing once complete cervical dilation has occurred.
- Manual rotation from occiput posterior or occiput transverse to occiput anterior could decrease cesarean rate as well as other morbidities.
Management of Labor Arrest
READ MORE...
- For active phase arrest of labor, cesarean delivery is recommended.
- For second stage arrest of labor, operative vaginal delivery (forceps or vacuum) is recommended first before opting for a cesarean delivery.
Reference
READ MORE...
Download PDF Version