Prolonged Labor (Failure to Progress)

The stages of labor and what counts as prolonged

These definitions, from ACOG and SMFM, are more patient than older ones. Many labors that once would have been called prolonged are now recognized as normal and allowed to continue safely.

Causes: the three Ps

Power

• contractions that are too weak, too infrequent or uncoordinated
• exhaustion and dehydration
• an epidural, which can lengthen labor, especially the second stage

Passenger

• position: the baby facing up (occiput posterior), tilted head, or breech
• size: a large baby (macrosomia), more likely with diabetes, including gestational diabetes
• rarely, abnormalities of the baby

Passage

• a small or unusually shaped pelvis
• a full bladder or bowel
• rarely, fibroids or other obstructions

Other factors

• first labor
• induction of labor
• maternal obesity
• older maternal age
• fear and anxiety, which can slow labor

Risks

For the mother:

• infection of the membranes and uterus (chorioamnionitis)
• heavy bleeding after birth (postpartum hemorrhage)
• perineal tears and pelvic floor injury
• exhaustion
• higher chance of assisted or cesarean birth
• in neglected obstructed labor, rare in settings with access to care: uterine rupture and fistula

For the baby:

• low oxygen and an abnormal heart rate pattern
• infection
• birth injuries
• shoulder dystocia with large babies

How it is managed

Care teams monitor cervical dilation, the baby's descent and position, contraction strength and frequency, and the baby's heart rate.

Supportive measures

• walking, upright positions and changing positions frequently
• emptying the bladder
• hydration and light food or fluids as allowed
• continuous labor support from a doula, partner or nurse, which is linked to shorter labor and fewer interventions
• pain relief, including epidural if desired; it may lengthen labor slightly but does not substantially increase cesarean rates

Medical measures

• Breaking the waters (amniotomy): can strengthen contractions.
• Oxytocin: an IV infusion to strengthen contractions.
• Manual rotation of a baby facing up.
• Assisted vaginal delivery: vacuum or forceps in the second stage when appropriate.
• Cesarean birth: when labor arrests despite these measures, or the baby shows signs of distress.

Preventing prolonged labor

• stay active during pregnancy and manage blood sugar if you have diabetes
• avoid going to the hospital too early in the latent phase if you and your baby are well, as advised by your provider
• consider continuous labor support
• discuss the pros and cons of induction with your provider

Outlook

Most people with a slow labor go on to have a vaginal birth, especially with patient management. If a cesarean is needed for failure to progress, many can try a vaginal birth in a future pregnancy (VBAC), depending on individual factors.

Frequently asked questions

How long is too long for labor?

It depends on the stage and whether it is a first birth. The latent phase can last a day in a first labor. In active labor, doctors become concerned when the cervix does not change for 4 to 6 hours despite good contractions. Pushing for 3 hours or more in a first birth is considered prolonged.

What causes failure to progress in labor?

Common causes are weak or irregular contractions, the baby being large or in a face-up position, a mismatch between the baby's head and the pelvis, exhaustion and sometimes an epidural. Often several factors combine.

What do doctors do if labor is not progressing?

They first check that mother and baby are well, then may encourage position changes, break the waters or start oxytocin to strengthen contractions. If labor still does not progress, they may use vacuum or forceps, or perform a cesarean.

Does an epidural cause prolonged labor?

An epidural may lengthen labor somewhat, especially the pushing stage, but large studies show it does not significantly increase the chance of cesarean birth. Guidelines allow a longer pushing stage for people with an epidural.