When the Consensus Statement on Safe Prevention of the Primary Cesarean Delivery was published in 2014 by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM), guidelines for second-stage labor based on review of available evidence were offered. There was acknowledgment that a precise absolute maximum duration of second-stage labor beyond which all women should have an operative birth is unknown (ACOG & SMFM). A strong recommendation based on moderate quality evidence was before diagnosing a second-stage labor arrest, if appropriate based on maternal and fetal conditions, allow for at least 2 hours of pushing for multiparous women and at least 3 hours of pushing for nulliparous women (ACOG & SMFM). Duration was defined as active pushing rather than from timing of achieving 10 cm cervical dilation. A longer time frame may be appropriate in individualized clinical situations, for example, with epidural analgesia or fetal malposition as long as there is progress (ACOG & SMFM).

Over the past few months, several articles have been published about second-stage labor. Leveno, Nelson, and McIntire (2016) expressed concern about safety of allowing more than the traditional time for second-stage labor duration. They felt that evidence to support such a change was lacking. Grobman et al. (2016) in a review of 53,285 births in 25 hospitals found a vaginal birth occurred after 4 hours of pushing for 78% of nulliparous women and after 2 hours of pushing for 82% of multiparous women. In both groups more than 97% did not have an adverse neonatal outcome. They concluded that longer duration of pushing was associated with an increased relative risk but small absolute risk of neonatal complications. Earlier, in a review of 103,415 births in 19 hospitals, Laughon et al. (2014) found prolonged second stage was associated with a small but increased risk of maternal morbidity such as chorioamnionitis and 3rd- or 4th-degree lacerations and neonatal morbidity such as sepsis. They advised that benefits of an increased chance of vaginal birth should be weighed against potential small increases in maternal and neonatal risks (Laughon et al.). In a small randomized trial of 78 nulliparous women with epidural, women were randomized to one of two groups after 3 hours of second-stage labor: allowance of extending labor at least 1 more hour or expedited birth (Gimovsky & Berghella, 2016). Women in the extended labor group had a cesarean birth rate of 19.5%, whereas women in the expedited birth group had a 43.2% cesarean rate (Gimovsky & Berghella).

Evidence suggests that permitting more time than traditionally allowed for second-stage labor may be helpful in promoting vaginal birth (ACOG & SMFM, 2014); however, there may be small but significant risks to mother and baby. Periodic reassessment and collaboration among team members during active pushing may be beneficial to support safe care. Consider a brief huddle (nurse and birth attendant) at least every hour to collaboratively discuss the state of maternal and fetal well-being and chance of successful vaginal birth when the nulliparous woman has pushed for 2 hours, or the multiparous woman has pushed for 1 hour. Adopting this type of huddle as standard practice may accomplish both goals of promoting vaginal birth while keeping mother and baby safe.

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