Letters to the Editors
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Assessing second-stage progress
TO THE EDITORS: In a recent editorial Caughey1 addressed
the optimal timing of intervention when the second stage of
labor is long. He stressed that the duration norms drawn from
Emanuel Friedman’s “notorious” research2 need reevaluation.
Friedman, however, never advocated such use of durations as
clinical norms. In fact, it was his enduring (and often corrob-
orated) contribution that the feasibility of safe vaginal delivery
is not determinable strictly from elapsed time in labor or con-
traction measurement, but is best realized by graphic analysis
of dilatation and descent patterns.2-4
Numerous factors, many elucidated by Friedman,2 affect
second-stage duration, including fetal station at full dilatation,
fetal position, uterine contractility, bearing-down efforts, pel-
vic architecture, epidural anesthesia, maternal body mass in-
dex, uterine infection, parity, and pushing style.
Most studies show the duration per se of the second stage has
little influence on neonatal outcome, if the pattern of descent is
normal and the fetus is properly monitored. This applies at
least until 3 hours have elapsed, and probably longer. Risks of
maternal hemorrhage and infection, and perhaps pelvic floor
damage, however, are increased in long second stages, reasons
to avoid its unnecessary prolongation.
Just as the pattern (slope) of dilatation of active labor best
defines normal progress in the first stage, so should the pattern
(slope) of descent and not its duration be the basis for decisions
about intervention in the second stage. The key to manage-
ment resides in determining whether and how the pattern of
descent deviates from normal. When it does, it can then be
determined what the cause of that divergence is, and whether it
can be safely overcome.
It is quite possible for the pattern of descent to be normal and
for the second stage to exceed 2 or even 3 hours. Consider a
nullipara’s second stage beginning at 0 station with steady de-
scent at 1.5 cm/h. The head would safely reach the pelvic floor
in 3 hours. By contrast, the likelihood of a safe vaginal delivery
would be much reduced if there were no descent after only 1
hour, especially with fetal macrosomia or pelvic contraction
present. In that situation additional counterproductive hours
of labor might increase the risk of harm to both mother and
fetus.
Defining the permissible duration of the second stage should
be individualized, based on the identification of graphically
definable disorders of descent combined with other clinical
observations to predict the probability of safe vaginal
delivery. f lem with generating new data in this arena is that labor norms
Wayne R. Cohen, MD
Albert Einstein College of Medicine
1400 Pelham Parkway South
Room 1S22
Bronx, NY 10461
waynercohen@me.com
e8 American Journal of Obstetrics & Gynecology SEPTEMBER 2010
www. AJOG.
Barry S. Schifrin, MD
Kaiser Permanente Los Angeles Medical Center
Los Angeles, California
bschifrinmd@aol.com
bschifrinmd@aol.com
REFERENCES
1. Caughey AB. Is there an upper time limit for the management of the
second stage? Am J Obstet Gynecol 2009;201:337-8.
2. Friedman EA. Labor: clinical evaluation and management, 2nd ed. New
York: Appleton Century Crofts; 1978.
3. Friedman EA, Sachtleben MR. Station of the fetal presenting part, I:
pattern of descent. Am J Obstet Gynecol 1965;93:522-9.
4. Cohen WR. Controversies in the assessment of labor. Prog Obstet
Gynecol 2006;17:231-44.
© 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.04.008
REPLY
I would like to thank Drs Cohen and Schifrin for their letter.
They underscore the importance of using clinical acumen and
ongoing assessment of the laboring woman as opposed to ar-
bitrary thresholds. I entirely agree, and this appears to hold true
in both the first and second stage.1-4 Further, they point out
that Dr Friedman had no intent of establishing norms to be
utilized as absolute thresholds. While this is true, as we all
know, his work has led to the establishment of thresholds that
are used by both obstetricians and malpractice attorneys and
has contributed to the current 32% cesarean delivery rate in the
United States.
As Drs Cohen and Schifrin note, much of the evidence re-
garding outcomes in the setting of prolonged second stage of
labor finds no difference in neonatal outcomes, and the pri-
mary maternal outcomes that are usually worse are related to
operative deliveries.5 In their discussion of the second stage,
the one thing I would add to ongoing assessment is to deter-
mine the strength of maternal expulsive efforts. One of the
biggest impacts of the epidural along with pain relief is to
weaken the strength of such efforts. This likely contributes to a
prolonged second stage of labor. In a recent presentation at the
Society for Maternal-Fetal Medicine, it was reported that the
epidural can prolong the 95th percentile of the second stage by
2-3 hours.6
Thus, it is time for new, thoughtful research in the area of
duration of labor. A great step in this area is reflected in the
work of Zhang et al,1 who just reported on the length of the first
stage of labor using data that are several decades old. The prob-
are dramatically affected by modern obstetric practice. Thus,
we may need to look to our midwifery colleagues or interna-
tional providers who are less likely to be interventional and
more likely to demonstrate patience during both the first and
second stage. Studying women in these settings may be better
suited to determining the characteristics of labor that will go on