ACOG Issues Evidence-Based Guidelines for Managing First and Second Stages of Labor

The Clinical Practice Guideline outlines definitions of labor and labor arrest and provides recommendations for managing dystocia during the first and second stages of labor. The recommendations are categorized based on their strength and the quality of supporting evidence. Additionally, Ungraded Good Practice Points offer guidance in areas where formal recommendations could not be made due to limited or insufficient evidence.

For the first stage of labor, ACOG emphasizes that active labor begins at 6 cm of cervical dilation. Active phase arrest is defined as no further cervical dilation despite 4 hours of adequate uterine activity or 6 hours with oxytocin augmentation. To manage prolonged labor, interventions such as amniotomy and oxytocin administration are strongly recommended to enhance uterine contractions and reduce labor duration.

In dystocia cases during the first stage, intrauterine pressure catheters may be used to accurately assess contraction adequacy, especially when external monitoring is inconclusive. These strategies aim to minimize the risk of operative deliveries, including cesarean sections, by promoting effective labor progress.

For the second stage of labor, prolonged pushing is defined as exceeding three hours for first-time mothers or two hours for those with prior vaginal deliveries. Decisions regarding second-stage arrest should incorporate clinical progress, the likelihood of vaginal delivery, and patient preferences. Neuraxial anesthesia is recommended to alleviate labor pain during any stage, enhancing patient comfort.

Management of dystocia in the second stage includes initiating pushing upon complete cervical dilation and considering operative vaginal delivery as an alternative to cesarean delivery for certain cases. Arrest in this stage may be identified earlier by observing a lack of fetal descent or rotation despite adequate contractions and maternal effort.

When labor arrest occurs, cesarean delivery is advised for active-phase arrest during the first stage. However, the second-stage arrest should be assessed for possible operative vaginal delivery before resorting to cesarean section, ensuring tailored care for each patient’s circumstances.

The guidelines emphasize the importance of individualized care and shared decision-making. Strong recommendations are supported by high-quality evidence, while conditional recommendations encourage consideration of patient values and preferences. ACOG’s recommendations aim to optimize maternal and fetal outcomes while addressing the complexities of labor management with a balanced, evidence-based approach.

“Both operative vaginal delivery, when performed by a qualified clinician for a suitable candidate, and cesarean delivery are evidence-supported options for managing second-stage labor arrest,” the guideline stated.

Reference: https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management