A Menu of Change

Assessing and Promoting
the Progress of First Stage Labor

Failure to progress is the primary cause of nearly half (47.1%) of all intrapartum cesarean deliveries.1 Despite widespread use of interventions to speed labor progress, including use of oxytocin and artificial rupture of membranes, the diagnosis of disorders of labor progress appears to account for a large proportion of the increase in cesarean rates over time2 and the variation in cesarean rates across geographic regions.3,4

Obstetric practice has been based on standards of labor progress that have proven to be too stringent and lead to unnecessary cesarean birth.5 Emerging evidence suggests the following changes to traditional standards that were based on Friedman criteria from the 1960s:

  • expecting longer mean times for cervical dilation,

  • anticipating slower labor progress in the earlier part of active labor (5-7cm),

  • observing greater variability in the progress of labor among women, and

  • awaiting the active phase of labor before diagnosing disorders of labor progress.7-10

Active management of labor, which includes routine amniotomy and treatment of slow labor progress with intravenous oxytocin, represents the prevailing approach to managing labor progress in the United States. The complete active management process includes prenatal education, strict criteria for diagnosing active labor, continuous one-to-one care in labor, use of a partograph to track labor progress, strict criteria for diagnosing disorders of labor progress, and peer review of assisted deliveries. Active management reduces the length of active labor but has had inconsistent effect on cesarean deliveries.11 Although researchers examining active management of labor have not found statistically significant differences in maternal or neonatal morbidity when active management is used, caution is warranted. Oxytocin is a high alert medication that requires continuous monitoring and one-to-one staffing to manage the potential for error or adverse effects. It is the drug most commonly associated with preventable adverse events during childbirth, and allegations of its misuse are the sources of approximately half of all paid obstetric claims.12 On the other hand, physiologic approaches appear to be more reliably effective for promoting spontaneous vaginal birth, have no or minimal risks, and are associated with other benefits, including increased comfort and maternal satisfaction.

Effective strategies to promote physiologic labor progress and spontaneous vaginal birth include the following:

  • use of physiologically appropriate standards for diagnosing onset and progress of labor,7,9

  • continuous labor support by a doula or other knowledgeable companion,13

  • upright positions and/or ambulation in labor,14

  • manual or digital rotation of the fetal head from occiput posterior (OP) or occiput transverse (OT) to occiput anterior (OA) near the end of the first stage of labor or at full dilation,15-17

  • labor and birth settings that encourage mobility and privacy,18 and

  • non-pharmacologic comfort and pain relief measures.19

Click to view additional resources available in the Promoting Progress in First Stage Labor Resource Toolbox, or search our resource library by clicking here.


  1. Zhang J, Troendle J, Reddy UM et al. Contemporary cesarean delivery practice in the United States.Am J Obstet Gynecol. 2010;203(4):326.e1-326.e10.doi: 10.1016/j.ajog.2010.06.058.

  2. Barber EL, Lundsberg LS, BelangerK, et al. Indications contributing to the increasing cesarean delivery rate.Obstet Gynecol. 2011;118(1):29-38. doi: 10.1097/AOG.0b013e31821e5f65.

  3. Baicker K, Buckles KS, Chandra A. Geographic variation in the appropriate use of cesarean delivery.Health Aff (Millwood). 2006;25(5):w355-w367.doi: 10.1377/hlthaff.25.w355.

  4. Main EK., Moore D, Farrell B. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement.Am J Obstet Gynecol. 2006;194(6):1644-1651.

  5. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists workshop.Obstet Gynecol.2012;120(5):1181-1193.

  6. Albers LL. The evidence for physiologic management of the active phase of the first stage of labor.J Midwifery Womens Health. 2007;52(3):207-215. doi:10.1016/j.jmwh.2006.12.009.

  7. Neal JL, Lowe NK. Physiologic partograph to improve birth safety and outcomes among low-risk, nulliparous women with spontaneous labor onset.Medical Hypotheses. 2012;78(2), 319-326. doi: 10.1016/j.mehy.2011.11.012; 10.1016/j.mehy.2011.11.012.

  8. Neal JL, Lowe NK, Ahijevych KL, et al. "Active labor" duration and dilation rates among low-risk, nulliparous women with spontaneous labor onset: a systematic review.J Midwifery Womens Health.2010;55(4):308-318. doi: 10.1016/j.jmwh.2009.08.004.

  9. Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281-1287. doi: 10.1097/AOG.0b013e3181fdef6e.

  10. Zhang J, Troendle J, Mikolajczyk R, et al. The natural history of the normal first stage of labor.Obstet Gynecol. 2010;115(4):705-710. doi: 10.1097/AOG.0b013e3181d55925.

  11. Brown JC, Paranjothy S, Dowswell T, Thomas J. Package of care for active management in labour for reducing caesarean section rates in low-risk women.Cochrane Database Syst Rev. 2013;9:CD004907. doi:10.1002/14651858.CD004907.pub3.

  12. Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug.Am J Obstet Gynecol.2009;200(1):35.e1-35.e6. doi: 10.1016/j.ajog.2008.06.010.

  13. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth.Cochrane Database Syst Rev. 2013;7:CD003766.

  14. Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2009;2:CD003934. doi: 10.1002/14651858.CD003934.pub2.

  15. Le Ray C, Serres P, Schmitz T, Cabrol D, Goffinet F. Manual rotation in occiput posterior or transverse positions: Risk factors and consequences on the cesarean delivery rate.Obstet Gynecol. 2007;110(4):873-879. doi: 10.1097/01.AOG.0000281666.04924.be.

  16. Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position.J Matern Fetal Neonatal Med. 2011;24(1):65-72. doi: 10.3109/14767051003710276

  17. Sen K, Sakamoto H, Nakabayashi Y, et al. Management of the occiput posterior presentation: a single institute experience.J Obstet Gynaecol Res. 2013;39(1):160-165. doi: 10.1111/j.1447-0756.2012.01935.x; 10.1111/j.1447-0756.2012.01935.x.

  18. Hodnett ED, Downe S, Walsh D. Alternative versus conventional institutional settings for birth.Cochrane Database Syst Rev. 2012;8:CD000012. doi: 10.1002/14651858.CD000012.pub4.

  19. Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour.Cochrane Database Syst Rev. 2011;12:CD000331. doi: 10.1002/14651858.CD000331.pub3.



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