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Active Labor Duration and Dilation Rates Among Low-Risk,

Nulliparous Women With Spontaneous Labor Onset: A


Systematic Review
Jeremy L. Neal, CNM, RNC, PhD, Nancy K. Lowe, CNM, PhD, Karen L. Ahijevych, RN, PhD,
Thelma E. Patrick, RN, PhD, Lori A. Cabbage, CNM, FNP, MSN, and Elizabeth J. Corwin, RN, PhD

Introduction: Laboring women are often admitted to labor units under criteria that are commonly associated
with the onset of active-phase labor (i.e., cervical dilatation of 35 cm in the presence of regular contractions).
Beginning with these criteria through complete dilatation, this systematic review describes labor duration and
cervical dilation rates among low-risk, nulliparous women with spontaneous labor onset.
Methods: Studies published in English (between 1990 and 2008) were identified via MEDLINE and CINAHL
searches. Data were abstracted and weighted active labor durations (i.e., from 35 cm through complete di-
latation) and linear dilation rates were calculated.
Results: Eighteen studies (n = 7009) reported mean active labor duration. The weighted mean duration was
6.0 hours, and the calculated dilation rate was 1.2 cm per hour. These findings closely parallel those found at the
median. At the statistical limits, the weighted active labor duration was 13.4 hours (mean + 2 standard de-
viations) and the dilation rate was 0.6 cm per hour (mean 2 standard deviations).
Discussion: These findings indicate that nulliparous women with spontaneous labor onset have longer ac-
tive labors and therefore slower dilation rates than are traditionally associated with active labor when com-
monly used criteria are applied as the starting point. Revision of existing active labor expectations and/or
criteria used to prospectively identify active phase onset is warranted.
J Midwifery Womens Health 2010;55:308318 2010 by the American College of Nurse-Midwives.
keywords: first stage of labor, labor onset, obstetric labor, parturition, pregnancy

INTRODUCTION hospital, women are closely monitored to ensure adequate


progress. Therefore, the purpose of this systematic review
Labor is the presence of uterine contractions of sufficient
was to describe the clinical parameters of active labor
frequency, duration, and intensity to cause demonstrable
duration and rates of cervical dilation beginning with clin-
effacement and dilation of the cervix.1 Attempts to define
ical criteria commonly used as prospective evidence of the
the norms and limits of labor duration have yielded vari-
onset of active-phase labor through complete cervical dila-
able results, undoubtedly because labor does not readily
tation. The focus is on nulliparous women without chronic
lend itself to measurement. Not only is prospectively de-
medical conditions or pregnancy complications who were
fining the onset of labor a significant challenge, but eval-
admitted for spontaneous labor onset.
uating its progression remains limited to rudimentary
cervical examinations performed episodically. Attempts
to divide the continuum of labor into stages and phases BACKGROUND
only add to the complexity. Moreover, multiple fixed fac- In contemporary practice, most providers aim to admit
tors such as parity, maternal weight, and fetal weight as women to the labor unit when cervical dilation is expected
well as commonly employed interventions (e.g., oxytocin to become more rapid (i.e., at the onset of the active phase
augmentation and epidural use) may significantly affect of labor). Authors of contemporary texts report that the ac-
the duration of labor. tive phase reliably begins between 3 and 5 cm dilatation in
In spite of measurement difficulties, a better understand- the presence of regular uterine contractions.2 Investigators
ing of the norms and slowest acceptable limits of labor du- have recently reported that cervical dilation follows a hy-
ration and rates of cervical dilation is important because perbolic pattern, increasing over time, without a distinct
this knowledge is the backbone of clinical decision-making point of dilation acceleration.3 This lack of a distinct point
in the intrapartum setting. Optimally defining these indices when dilation acceleration begins precludes the identifica-
from the point of typical spontaneous labor admission for- tion of a true, traditionally-defined active phase onset.
ward is especially pertinent because, once admitted to the Even when assuming that active-phase labor does exist
as a measurable entity, the variability between women in
its onset limits the prospective use of specific dilatations
in differentiating the active phase from the latent phase.
Address correspondence to Jeremy L. Neal, CNM, RNC, PhD, College of
Nursing, The Ohio State University, 1585 Neil Ave., Columbus, OH Peisner and Rosen4 found that roughly 75%, 50%,
43210-1289. E-mail: neal.167@osu.edu and 25% of regularly contracting, low-risk, nulliparous

308 Volume 55, No. 4, July/August 2010


2010 by the American College of Nurse-Midwives 1526-9523/$36.00  doi:10.1016/j.jmwh.2009.08.004
Issued by Elsevier Inc.
women admitted for spontaneous labor at 3, 4, and 5 cm, 21.8% and 30.9% of nulliparous women, respectively, di-
respectively, do not dilate at rates indicative of active la- late at rates averaging < 1 cm per hour at or after 3 cm of
bor, although these cervical dilatation measurements are dilatation. In addition, data from these studies and others
most often associated with active-phase onset. Such find- show that 10.3% to 11.7% of low-risk nulliparas in spon-
ings lead to one or both of the following conclusions: 1) taneous labor dilate at rates slower than 0.5 to 0.6 cm per
expected rates of cervical dilation during traditionally de- hour after 3 cm of dilatation.11-14 This suggests that inter-
fined active-phase labor are overly stringent, and/or 2) vention to accelerate labor should not be considered until
many women are admitted for labor before the onset of rates of cervical dilation fall below these limits.
the activephase of labor yet are managed as though they The aforementioned studies5-9,11-14 have informed
are in the active phase. worldwide obstetric practice over the past half-century, al-
Expectations of the duration of the active phase and though clinical practice expectations of labor duration and
rates of cervical dilation during the active phase largely rates of cervical dilation among nulliparous women con-
stem from research published by Friedman5-7 and Fried- tinue to be largely based on Friedmans research.5-9 Unfor-
man and Kroll8,9 beginning in the 1950s. Although these tunately, the onset of Friedmans traditionally defined
studies included some nulliparous women who did not active labor dilation and its differentiation from earlier
have a spontaneous labor onset and some who were not labor can only be discerned retrospectively.
low risk by contemporary standards, Friedman reported More recently, investigators such as Albers et al.,15 Alb-
that labor in nulliparas typically follows a near-identical ers,16 Zhang et al.,3 and Jones and Larson17 found that nor-
sigmoid curve varying only in slope. A womans active mal active phase labor in nulliparous women lasts
phase began with a retrospectively identifiable accelera- longer than previously thought, calling into question the
tion of cervical dilation and ended at complete dilatation standards that have been used since the work of Friedman.
that, for the aggregate, was the time from 2.5 cm to 10 Hence, the measures of central tendency that best define la-
cm. For nulliparous women, the active phase averaged bor length and cervical dilation rates after a diagnosis of ac-
4.6 to 4.9 hours,6,7,9 although the average time needed to tive-phase labor onset among low-risk nulliparae are in
dilate from 4 cm to 10 cm was only approximately 2.6 question, as are the statistical limits of these measures.
hours.6,7 At the mean + 2 standard deviation (SD), ac- Identifying the norms and limits of postadmission cervi-
tive-phase labor was 11.7 hours.6,7,9 Based on these stud- cal dilation rates remains critical to the assessment of labor
ies by Friedman,6,7 when dilation is between 4 and 9 cm progress and consideration of labor accelerative interven-
(termed the phase of maximum slope), nulliparous tion. Clinicians often use a cervical dilatation of 3 to 5 cm
women dilate at a mean rate of 3.0 cm per hour, whereas in the presence of regular uterine contractions as prospec-
the slowest acceptable rate is 1.2 cm per hour. Unfortu- tive evidence of active labor onset. Beginning with these
nately, these aggregate active-phase dilation rate estimates criteria through complete dilatation, the aim of this sys-
are of limited prospective use for individual women, be- tematic review was to describe labor duration and cervical
cause the dilatation at which active labor begins varies dilation rates among low-risk, nulliparous women with
widely among women. In 1996, Friedman himself wrote spontaneous labor onset.
.the majority of patients are in active-phase labor by
the time the cervix reaches 4 cm, but many are not.10
METHODS
Philpott and Castle11 and the World Health Organiza-
tion12 have contributed to this literature, finding that MEDLINE and CINAHL searches were performed with
each search limited to human research published in health
science journals between 1990 and 2008 in English and
with available abstracts. First, the keyword nulliparous
(searched in All Text) was cross-searched with each of the
Jeremy L. Neal, CNM, RNC, PhD, is an Assistant Professor in the College of
Nursing, The Ohio State University, Columbus, OH. following keywords (searched in Abstract): labor (labour)
Nancy K. Lowe, CNM, PhD, FACNM, FAAN, is Professor and Chair of the length, labor (labour) duration, active phase, and active la-
Division of Women, Children, and Family Health in the College of Nursing, bor (labour). Next, the keyword nulliparas (searched in
University of Colorado Denver, Aurora, CO. All Text) was cross-searched with each of the aforemen-
Karen L. Ahijevych, RN, PhD, FAAN, is a Professor and the Associate Dean tioned abstract keywords. Manual searches were not
for Academic Affairs in the College of Nursing, The Ohio State University,
Columbus, OH. used to avoid introducing selection bias. It was anticipated
Thelma E. Patrick, RN, PhD, is an Associate Professor in the College of that this search strategy would yield a representative cross-
Nursing, The Ohio State University, Columbus, OH. section of the practices and interventions that exist in mod-
Lori A. Cabbage, CNM, FNP, MSN, is a clinical faculty member in the Col- ern obstetric practice (e.g., those with or without oxytocin
lege of Nursing, The Ohio State University, Columbus, OH and is in clinical augmentation, artificial rupture of the amniotic mem-
midwifery practice at Dublin Methodist Hospital, Dublin, OH.
branes, epidurals, etc.).
Elizabeth J. Corwin, RN, PhD, is a Professor in the Division of Women, Chil-
dren, and Family Health, College of Nursing, University of Colorado Den- The MEDLINE and CINAHL searches yielded 375
ver, Aurora, CO. unique titles with abstracts. First-level screening of each

Journal of Midwifery & Womens Health  www.jmwh.org 309


Table 1. The 25 Studies Included in this Systematic Review
Trial, Location, Date N Trial Type Inclusion/Exclusion Criteriaa Qualifying Groups/Subgroups
Fraser et al., Canada 925 Prospective, Inclusion: Intact membranes; Routine early amniotomy vs.
and US, 199322 randomized normal fetal heart rate conservative membrane
Exclusion: Suspected IUGR; severe management after admission
preeclampsia; IDDM; $6 cm at at $3 cme
admission; maternal distress too
great to permit informed consent
Cammu et al., Belgium, 110 Prospective, Inclusion: Low-risk; 35 cm at Bathing vs. nonbathing with AML
199423 randomized admission; ruptured membranes
with clear fluid; no dystocia at
inclusion
Cammu et al., Belgium, 1000 Prospective, Inclusion: No contraindications for Unaugmented vs. augmented labor
199424 observational labor; maternal height $150 cm; with AML but without epidurale
$ 1 antenatal care visit(s)
Albers et al., US, 199615 347b Retrospective, Inclusion: Low-risk; non-Hispanic No treatment
record review white, Hispanic, or American Indian;
#4 cm at admission (for active
phase analyses)
Exclusion: Medical problems (e.g.,
hypertension, gestational diabetes,
asthma, or membranes ruptured >24 hrs);
oxytocin augmentation; epidural analgesia;
operative delivery
Cammu and Van Eeckhout, 306 Prospective, Inclusion: Normal cardiotocogram AML vs. selective intervention
Belgium, 199625 randomized and clear amniotic fluid at
admission; maternal height $150 cm;
$ 1 antenatal outpatient clinic
visit(s)
Bofill et al., US, 199726 100 Prospective, Inclusion: Healthy Epidural vs. narcotics for labor
randomized Exclusion: Medical problems pain relief
(e.g., IDDM, medicated chronic
hypertension, or PIH)
Dickinson et al., Australia, 497 Prospective, Inclusion: Low-risk Epidural vs. nonepidural with
199718 observational modified AML
Alexander et al., US, 199827 199 Retrospective Inclusion: Normal pregnancy; Epidural vs. IV meperidine for
analysis of augmented with oxytocin; labor pain relief
randomized trial nonoperative vaginal delivery
Exclusion: Pregnancy complication;
>5 cm at admission
Clark et al., US, 199828 318 Prospective, Exclusion: Contraindication to labor; Epidural vs. IV meperidine during
randomized thrombocytopenia or coagulation AML for labor pain relief
disorder precluding epidural placement
Thompson et al., US, 199829 641 Retrospective, Inclusion: Low-risk; 1835 yrs old; prenatal No epidural (no analgesia or parenteral
chart review care provided by study institution; black or opioids only) vs. low-dose epidural vs.
white high-dose epidural
Exclusion: Drug or alcohol abuse; smoking;
preeclampsia; hypertension; diabetes; $7
cm at admission; prepregnancy weight
>100 kg; chronic medical condition; history
of pelvic injury or major abdominal surgery;
hospitalization during pregnancy; uterine
myoma; active genital herpes; oligo- or
polyhydramnios; incomplete medical record
Albers, US, 199916 806b Prospective, Inclusion: Low-risk; #4 cm at admission; No treatment
observational membranes ruptured <24 hrs
Exclusion: Medical problems (hypertension,
gestational diabetes, asthma, or drug use);
oxytocin augmentation; epidural analgesia;
operative delivery (cesarean, forceps, or
vacuum)
(Continued)

310 Volume 55, No. 4, July/August 2010


Table 1 (Contd). The 25 Studies Included in this Systematic Review
Trial, Location, Date N Trial Type Inclusion/Exclusion Criteriaa Qualifying Groups/Subgroups
b
Fontaine and Adam, 100 Retrospective, Inclusion: < 6 cm at admission ITN vs. no ITN (IV narcotics or
US, 200030 chart review Exclusion: Epidural use; other undefined no analgesia)
reasons
Garite et al., US, 200031 195 Prospective, Inclusion: Uncomplicated pregnancy; 25 cm Isotonic IV fluids at 125 mL/hr vs.
randomized with or without ruptured membranes 250 mL/hr during labor
Exclusion: Preeclampsia; cardiac or renal
disease; chorioamnionitis, pyelonephritis,
or febrile illness before randomization
Sadler et al., New Zealand, 651 Prospective, Exclusion: Evidence of fetal distress at AML vs. routine labor management
200032 randomized admission; severe cardiac disease; uterine
scar; contracted pelvis; elective cesarean
Sharma et al., India, 200133 150 Prospective, Inclusion: Healthy; 1830 yrs old; intact IM drotaverine hydrochloride vs.
randomized membranes; dilatation of 4 cm with IM valethamate bromide vs.
partially effaced cervix; established unmedicated group
contractions
Exclusion: Medical, surgical, or obstetric
complications (e.g., preeclampsia or
antepartum hemorrhage); dilatation >5
cm
Zhang et al., US, 200134 1088 Retrospective, Inclusion: < 7 cm at admission; admission to Before vs. after on-demand
chart review delivery duration $3 hrs; 1834 yrs old; epidural analgesia
birth weight of 2.54 kg
Gurewitsch et al., US and 908b Retrospective, Inclusion: Uncomplicated pregnancy; $3 No treatment
Israel, 200235 comparative first-stage cervical examinations
Exclusion: Contraindication to labor; uterine
scars; hydramnios; fetal anomaly
Jones and Larson, US, 200317 120b Retrospective, Inclusion: Hispanic; 1544 yrs old; No treatment
comparative spontaneous vaginal birth
Exclusion: Cephalopelvic disproportion;
prolonged membrane rupture; social or
medical problems (substance abuse,
hypertension, diabetes, or asthma);
oxytocin augmentation; regional
anesthesia
Kaul et al., US, 200436 1671 Retrospective, Inclusion: Healthy; epidural during labor; Oxytocin augmentation groupe
comparative oxytocin augmentation during labor as
subgroup; elective IOL as subgroup
Exclusion: Previous medical problems;
complicated pregnancy; cesareans for fetal
distress
Somprasit et al., Thailand, 960 Prospective, Inclusion: Low-risk AML vs. conventional labor
200537 randomized Exclusion: Medical or surgical complications; management
contraindications to vaginal delivery or
oxytocin use; fetal distress at admission;
diabetes; PIH
Vahratian et al., US, 200538 2200 Retrospective, Inclusion: Low-risk; elective IOL as subgroup Spontaneous labor onset groupe
chart review Exclusion: Diabetes; hypertension; previous
infectious cardiovascular, pulmonary,
renal, mental, or thyroid disorders; IUGR;
uterine bleeding; oligohydramnios
Eslamian et al., Iran, 200619 300 Prospective, Inclusion: Uncomplicated pregnancy; 35 cm; Isotonic IV fluids at 125 mL/hr vs.
randomized intact membranes 250 mL/hr during labor
Exclusion: Chorioamnionitis; febrile illness or
pyelonephritis; preeclampsia; history of
cardiac or renal disease
Mikki et al., Israel, 200739 157b Prospective, Inclusion: Low-risk; intact membranes at Early amniotomy vs. intent to
randomized admission; normal fetal heart rate conserve membranes
Exclusion: Advanced labor; IUGR; suspected
macrosomia (>4.5 kg); preeclampsia;
IDDM; antepartum hemorrhage
(Continued)

Journal of Midwifery & Womens Health  www.jmwh.org 311


Table 1 (Contd). The 25 Studies Included in this Systematic Review
Trial, Location, Date N Trial Type Inclusion/Exclusion Criteriaa Qualifying Groups/Subgroups
20 c
Miquelutti et al., Brazil, 2007 107 Prospective, Inclusion: Low-risk; 35 cm at Upright position vs. no particular
randomized admission; 1640 yrs old position encouraged (control group)
Exclusion: Elective cesarean;
contraindications to upright
positions
Svardby et al., Sweden, 200721 164 Prospective, Inclusion:d Uncomplicated No augmentation vs. active phase vs.
observational pregnancy second-stage augmentation

AML = Active management of labor; IDDM = insulin-dependent diabetes mellitus; IM = intramuscular; IOL = induction of labor; ITN = intrathecally-injected narcotics; IUGR = in-
trauterine growth restriction; IV = intravenous; PIH = pregnancy-induced hypertension.
a
All studies included nulliparae carrying live, singleton, cephalic presenting fetuses at a minimum of 36 weeks gestation with spontaneous labor onset. Mean, median, or absolute
dilatation between 3 and 5 cm at study enrollment or randomization must have been identified.
b
Value represents nulliparous women only, although this study also included primiparous and/or multiparous groups/subgroups.
c
Through contact with author, it was clarified that all labors had a spontaneous onset.
d
Through contact with author, it was clarified that primigravid rather than primiparous women were included in the study.
e
Study also included nulliparous subgroup(s) not qualifying for systematic review because dilatation at active phase onset was <3 cm, unknown, or labor was induced.

abstract was performed by the first author (J.L.N.) and the publication was included in these cases; n = 2). On a few
title was retained for second-level screening if the follow- occasions, publications could be neither excluded based
ing criteria were met: 1) the publication was an original on their full-text review nor immediately included because
prospective or retrospective research study; 2) strictly nul- not all potential exclusion criteria were addressed. In these
liparous groups or subgroups with a singleton fetus at $36 cases, authors were directly contacted for minor clarifica-
weeks gestation and spontaneous labor onset were in- tions, such as dilatation at active labor onset18-21 and
cluded or there was no evidence to the contrary; 3) study whether all women had a spontaneous labor onset.20
subjects were low-risk at study entry based on their de- Twenty-five publications remained after second-level
scription in the abstract (e.g., without medical condition, screening (Table 1).15-39 These studies were included
pregnancy complication, or diagnosed labor abnormality) without consideration of their results and, because inter-
or there was no evidence to the contrary. After first-level vention outcomes were not being compared, there was
screening, 212 publications remained, and all but one no need to exclude any based on threats to internal valid-
were successfully retrieved either electronically or manu- ity. Data from each publication including dilatation (cm) at
ally for second-level screening. the onset of active labor and active labor duration
Publications undergoing second-level screening (n = were abstracted and entered into an SPSS database (v
211) were evaluated in full-text against systematic review 17.0; SPSS, Chicago, IL). The difference between cervical
exclusion criteria that were established a priori. The first dilation at active labor onset and complete dilatation
identified exclusion criterion found within any given was divided by active labor duration to yield a linear
publication eliminated that study from the review. The cervical dilation rate (cm/hr) for each study group. This
second-level screening exclusion criteria and the number method was used because raw data were unavailable. Sub-
of publications eliminated by each are as follows: 1) no sequently, results from each study were aggregated to
strictly nulliparous study group or subgroup (n = 15); 2) yield weighted active labor durations and rates of dila-
documented inclusion of multiple gestations or nonce- tion. Weighting, based on the number of subjects (n) in
phalic presentations (n = 0); 3) documented inclusion of each study, was used to assure that the studies with smaller
women with chronic medical conditions (e.g., hyperten- sample sizes did not disproportionately affect the system-
sion, diabetes, asthma, HIV, American Society of Anes- atic review results. The results are irrespective of any treat-
thesiologist Physical Status Classification II or higher) or ment received; therefore, they provide composite data that
pregnancy complications (e.g., hypertensive disorders, are representative of the diverse care patterns in contempo-
gestational diabetes) (n = 20); 4) <36 weeks gestation (n rary practice.
= 4); 5) induction of labor including the use of prelabor cer- Active labor was defined as the onset of clinical cri-
vical ripening techniques (n = 42); 6) no identifiable mean, teria commonly used as prospective evidence of active
median, or absolute cervical dilatation between 3 and 5 cm phase onset through the diagnosis of complete cervical di-
at study enrollment or randomization (n = 78); 7) labor du- latation. Most investigators used between 3 and 5 cm dila-
ration from 3 to 5 cm through complete cervical dilatation tation in the presence of contractions as their definition of
indeterminable from study data (n = 25); and 8) study da- the onset of the active phase of labor. Importantly, the def-
tabase was previously used by another publication qualify- inition of active labor onset used in this systematic re-
ing for systematic review (note: only the earliest view, based on prospectively applied clinical criteria, is

312 Volume 55, No. 4, July/August 2010


inherently different from Friedmans definition of active broadly associated with active phase onset (i.e., between
phase onset. According to Friedman, an individuals ac- 3 and 5 cm with regular uterine contractions), average ac-
tive labor begins at the point in time when the rate of dila- tive labor is longer than Friedman first suggested more
tion begins to become progressively more rapid.5-7 If than half a century ago. In Friedmans works, the active
discernible, such a point can only be identified retrospec- phase encompassed the time from 2.5 cm to 10 cm and av-
tively. eraged 4.6 to 4.9 hours.6,7,9 However, when starting at ap-
proximately 4 cm dilatation, Friedmans aggregate active
RESULTS phase data indicated that half of nulliparous women
reached full dilatation in 2.6 hours,6,7 whereas we found
The mean duration of active labor was reported in 18
that active labor is roughly 6 hours from this point for-
studies15-17,19,23-31,33,35-37,39 (Table 2). For nulliparous
ward. We found the SD of active labor duration for nul-
women in these studies (n = 7009), there was a weighted
liparous women to be 3.5 hours, which is consistent with
mean cervical dilatation of 3.7  0.4 cm at active labor
Friedmans findings, wherein the SD of active labor dura-
onset. The weighted mean duration of active labor was
tion ranged from 3.4 to 3.6 hours.6,7,9 Therefore, the differ-
6.0 hours, and the weighted mean rate of cervical dilation,
ence in active labor duration at mean + 2 SD between
based on linear calculations, was 1.2 cm per hour. For
Friedmans works6,7,9 and our systematic review (11.7
studies providing an active labor duration SD (n =
and 13.4 hours, respectively) stems from the discrepancy
4300),15-17,19,23-28,37,39 the calculated weighted active la-
in calculated mean active labor duration.
bor duration at the mean + 2 SD was 13.4 hours. In these
In studies by Albers et al.,15 Albers,16 and Jones and
same studies, the weighted cervical dilation rate at the
Larson,17 the investigators specifically aimed to identify
mean 2 SD was 0.6 cm per hour. Perhaps the finding
the duration of spontaneous active labor (i.e., no oxyto-
best indicating that the duration of normal active labor
cin, no epidurals, and no operative deliveries) among low-
varies widely is that the weighted mean of the SD was
risk nulliparous women delivering vaginally. Defining
3.5 hours.
active labor as the time necessary for the cervix to dilate
In eight studies included in this systematic review, the
from 4 to 10 cm, these investigators reported that sponta-
authors reported the median duration of active labor ei-
neous active labor lasts 6.2 to 7.7 hours on average,
ther in addition to a reported mean39 or exclusively (Table
with wide variability. The mean active labor duration
3).18,20-22,32,34,38 Among participants in these studies (n =
of 7.7 hours reported by Albers et al.15 and Albers16 was
4516), there was a weighted mean cervical dilatation of 4.0
longer than the active labor durations reported by
 0.2 cm at active labor onset. Based on provided me-
most of the other studies included in this systematic re-
dian values, the weighted median duration of active la-
view. This is possibly because there were no attempts to
bor was 5.4 hours and the average rate of cervical
accelerate cervical dilation in those studies. Although the
dilation in active labor was 1.2 cm per hour.
goal of this systematic review was to provide collective
Commonly used labor interventions, such as epidural
active labor data that are representative of the diverse
analgesia and amniotomy, were used in many of the in-
care patterns in contemporary practice, we recognize that
cluded studies, as were varying labor management strate-
nulliparous active labor progressing to vaginal birth
gies, such as the active management of labor (AML).
without oxytocin augmentation or epidural analgesia is
Based on the studies included in this systematic review,
increasingly less common. Therefore, we performed
a stratified post hoc analysis was used to compare active
a post hoc analysis and found that the overall findings of
labor between study groups receiving and not receiving
our systematic review remained stable even when the
epidurals. These groups were found to differ very little
data from Albers et al.,15 Albers,16 and Jones and Larson17
on active labor parameters. An additional stratified
were not included. Thus, these spontaneous active la-
post hoc analysis was used to compare AML with other
bor studies did not disproportionately affect the results
types of labor management. It was found that average ac-
of our systematic review.
tive labor duration was shorter in the AML group (4.87
We also found that rates of cervical dilation during ac-
versus 6.32 hours, respectively) while the average and
tive labor from 4 cm dilatation forward are much slower
slowest acceptable dilation rates were more rapid (1.6
than those reported by Friedman.6,7 Friedman determined
versus 1.1 cm per hour and 0.8 versus 0.4 cm per hour, re-
that nulliparous women dilate at a mean rate of 3.0 cm
spectively). An inability to isolate other interventions re-
per hour between 4 cm and 9 cm with a slowest acceptable
ceived and not received in an ample number of study
rate of 1.2 cm per hour.6,7 In comparison, when using crite-
groups (e.g., amniotomy versus membrane preservation)
ria broadly associated with active phase onset as the starting
precluded additional meaningful post hoc analyses.
point, we found that only half of nulliparous women dilate
at $1.2 cm per hour during active labor. Our slowest
DISCUSSION
acceptable rate (mean 2 SD) approximated 0.6 cm per
We found that when spontaneously laboring, low-risk nul- hour. The active labor dilation rate findings of our sys-
liparous women are admitted for labor under criteria tematic review closely align with those by Zhang et al.,3

Journal of Midwifery & Womens Health  www.jmwh.org 313


Table 2. Eighteen Studies With Mean Measures of Active Phase Duration in this Systematic Review
Active Phase Rate of Active Phase
Duration (hrs) Dilation (cm/hr)c
Dilatation at Active
Trial, Year Group/Subgroup n Phase Onset (cm)a Mean (SD) Mean + 2 SD Mean Limit
23
Cammu et al., 1994 Bathing group 54 3.8 (0.9) 4.07 (2.32) 8.71 1.5 0.7
Nonbathing group 56 4.0 (1.0) 4.4 (2.83) 10.06 1.4 0.6
Cammu et al., 199424 Unaugmented labor, no epidural 477 3.7 (1.6) 2.53 (1.3) 5.13 2.5 1.2
Augmented labor, no epidural 159 3.1 (1.2) 4.73 (1.75) 8.23 1.5 0.8
Albers et al., 199615 No treatment 347 4 7.7 (5.9) 19.4 0.8 0.3
Cammu and Van Eeckhout, 199625 AML group 152 3.2 (1.1) 4.23 (2.35) 8.93 1.6 0.8
Selective intervention group 154 3.2 (1.1) 4.72 (2.57) 9.86 1.4 0.7
Bofill et al., 199726 Epidural analgesia 49 4.2 (1.0) 6.25 (2.38) 11.01 0.9 0.5
Narcotics 51 4.2 (0.9) 5.95 (2.55) 11.05 1.0 0.5
Alexander et al., 199827 Epidural group 126 4 7.9 (3.0) 13.9 0.8 0.4
IV meperidine group 73 4 6.3 (3.0) 12.3 1.0 0.5
Clark et al., 199828 Epidural group 156 4 5.18 (2.7) 10.58 1.2 0.6
IV meperidine group 162 4 4.57 (2.35) 9.27 1.3 0.7
Thompson et al., 199829 No epidural (with labor curve) 142 4 5.25d 1.1
Low-dose epidural (with labor 172 4 6.0d 1.0
curve)
High-dose epidural (with labor 72 4 6.5d 0.9
curve)
Albers, 199916 No treatment 806 4 7.7 (4.9) 17.5 0.8 0.3
Fontaine and Adams, 200030 ITN 50 4 5.17 () 1.2
No ITN 50 4 4.43 () 1.4
Garite et al., 200031 IV fluids at 125 mL/hr (vaginal 78 3.6 () 8.05 () 0.8
delivery)
IV fluids at 250 mL/hr (vaginal 91 3.8 () 6.88 () 0.9
delivery)
Sharma et al., 200133 IM drotaverine HCL group 50 4 2.94e 2.0
IM valethamate bromide group 50 4 3.21e 1.9
Unmedicated group 50 4 5.94e 1.0
Gurewitsch et al., 200235 No treatment 908 3.1 (1.5) 4.5d 1.5
Jones et al., 200317 No treatment 120 4 6.2 (3.6) 13.4 1.0 0.5
Kaul et al., 200436 Oxytocin augmentation group 996 4 [3, 4] 5.3 1.1
Somprasit et al., 200537 AML group 320 3.1 (1.2) 8.97 (4.05) 17.07 0.8 0.4
Conventional labor management 640 3.1 (1.4) 9.82 (4.4) 18.62 0.7 0.4
group
Eslamian et al., 200619 IV fluids at 125 mL/hr (vaginal 118 4b 6.12 (1.75) 9.62 1.0 0.6
delivery)
IV fluids at 250 mL/hr (vaginal 123 4b 3.93 (1.43) 6.79 1.5 0.9
delivery)
Mikki et al., 200739 Early amniotomy 74 3 [3, 4] 3.85 (1.83) 7.51 1.8 0.9
Intent to conserve membranes 83 4 [3, 4] 5.28 (2.27) 9.82 1.1 0.6
Weighted values 7009 3.7 (0.4) 6.0 (2.0) 13.4 (5.0) 1.2 (0.5) 0.6 (0.3)

AML = Active management of labor; HCL = hydrochloride, IM = intramuscular; ITN = intrathecally-injected narcotics; IV = intravenous; IQR = interquartile range; SD = standard
deviation.
a
Group mean (SD), median [IQR], or absolute value shown when provided in study.
b
Through contact with author, it was clarified that median dilatation was 4 cm at active phase onset.
c
Calculated based on assumption that the cervical dilation phase ends at 10 cm, which approximates complete cervical dilatation.
d
Value derived from graphical labor curve presented in study publication.
e
Calculated based on mean rate of dilation provided in study publication.

who reported that it takes approximately 5.5 hours for nul- Hunter,14 who suggested that labors progressing at $0.5
liparas to dilate from 4 cm to 10 cm. This equates to 1.1 cm cm per hour, in the absence of other problems or symptoms,
per hour when viewed linearly. Our findings also align with be considered within normal limits. In their study, 10.3% of
those of Philpott and Castle11,13 and the World Health Or- term, nulliparous women with a spontaneous labor onset
ganization,12 wherein up to 31% of nulliparous women di- (n = 52 of 505) progressed at <0.5 cm per hour.
late slower than 1 cm per hour at or after 3 cm dilatation. There are two possible interpretations of our findings.
Furthermore, our findings confirm those of Perl and First, assuming that the clinical criteria commonly

314 Volume 55, No. 4, July/August 2010


Table 3. Eight Studies With Median Measures of Active Phase Duration in this Systematic Review
Dilatation at
Active Phase Median Rate of Active
Trial, Year Treatment n Onset (cm)a Duration (hrs) Phase Dilation (cm/hr)b
Fraser et al., 199322 Routine early amniotomy 390 3.8 (0.9) 4.33 1.4
Conservative membrane management 383 3.8 (0.8) 6.42 1.0
Dickinson et al., 199718 Epidural analgesia group 257 4c 4.6 1.3
Nonepidural group 240 4c 2.75 2.2
Sadler et al., 200032 AML group (vaginal delivery) 290 4.5 (1.8) 4.0 1.4
Routine management (vaginal delivery) 299 4.5 (2.1) 4.83 1.1
Zhang et al., 200134 Before on-demand epidural analgesia 507 4 6.0 1.0
After on-demand epidural analgesia 581 4 6.0 1.0
Vahratian et al., 200538 Spontaneous onset of labor group 1171 4 5.97 1.0
Mikki et al., 200739 Early amniotomy 74 3 [3,4] 3.5 2.0
Intent to conserve membranes 83 4 [3,4] 5.0 1.2
Miquelutti et al., 200720 Upright position group 35 4c 6.5 0.9
Control group 42 4c 5.42 1.1
Svardby et al., 200721 No augmentation 50 4c 5.08 1.2
Active phase augmentation 88 4c 7.32 0.8
Second stage augmentation 26 4c 7.33 0.8
Weighted values 4516 4.0 (0.2) 5.4 (1.0) 1.2 (0.3)

AML = Active management of labor.


a
Group mean (SD), median [IQR], or absolute value shown when provided in study.
b
Calculated based on assumption that the cervical dilation phase ends at 10 cm, which approximates complete cervical dilatation.
c
Through contact with author, it was clarified that active phase onset was defined as 4 cm dilatation.

associated with active phase onset accurately define true ing to most repeat cesareans, it follows that the majority of
active phase onset, it can be concluded that current duration cesareans in the United States are related to the diagnosis
and dilation rate expectations of the active phase of labor of dystocia.2 At present, the total cesarean rate is higher
are overly stringent for low-risk nulliparous women. Under than ever before (31.8%).42 This is of concern because
this assumption, a revision of the existing active phase the best birth outcomes for mothers and babies reportedly
norms and limits is warranted. Alternatively, assuming occur with cesarean rates of 5% to 10%, while rates higher
that traditional expectations of retrospectively identified than 15% are associated with more harm than good.43,44
active labor are well defined, it can be concluded that In clinical practice, dystocia is generally defined as a de-
many women admitted to labor units in presumed active la- lay in cervical dilation progression beyond which acceler-
bor may not yet be actively dilating. For these women, ac- ative interventions such as oxytocin augmentation may be
tive labor will be perceived to be longer and rates of dilation justified. Multiple definitions of dystocia, based on cervi-
will seemingly be slower. Some combination of these two cal dilation rates, exist. Perhaps the most common defini-
interpretations may also exist. These scenarios may, in part, tion stems from the multifaceted labor management
explain the high rates of intrapartum interventions used to program AML that was pioneered by ODriscoll
accelerate labor in contemporary practice. No matter which et al.45,46 with the goal of shortening primigravid labor.
assumption bears more weight on the results of this review, Following the diagnosis of labor, AML accepts 1 cm per
nulliparous women admitted for labor under criteria gener- hour as the slowest acceptable rate of dilation; slower rates
ally associated with active-phase onset should be held to no receive prompt accelerative interventions to correct pre-
stricter cervical dilation expectation than those derived sumed inefficient uterine action.45 Clinical trials of AML
from extant research using these same criteria. have consistently shown that a majority of women dilate
Rates of cervical dilation during active labor are in- at <1 cm per hour at some point during labor, as indicated
timately linked to the topic of labor dystocia. Dystocia is by high oxytocin augmentation rates. A recent systematic
characterized by the slow, abnormal progression of la- review of randomized, controlled AML trials reported that
bor.1 Albeit a nebulous diagnosis, dystocia has been 62% of nulliparous women (n = 1393 of 2242) randomized
identified as the leading indication for primary cesarean to AML care received oxytocin augmentation.47 The rates
deliveries,1,2 accounting for as much as 50% of all cesar- of uterine stimulation with AML suggest that the clinical
eans performed in nulliparous women.40 Among term, expectations of cervical dilation for nulliparous cervical
low-risk women giving birth for the first time and with dilation have surpassed normalcy.
a vertex-presenting fetus, a cesarean rate of 25% was re- Cervical dilation during active labor is often concep-
ported by the Centers for Disease Control and Prevention tualized linearly, a conceptualization that likely contrib-
in 2005.41 Because dystocia is the original indication lead- utes to the high frequency of dystocia diagnoses and

Journal of Midwifery & Womens Health  www.jmwh.org 315


subsequent intervention. In reality, dilation patterns during with spontaneous labor onset irrespective of any interven-
labor are not linear. Some investigators have concluded tion. Because we did not have raw data from each study
that a sigmoid pattern develops,5-8 while data from other included in this review, our methodology was limited to
studies suggest that a hyperbolic pattern lacking a deceler- aggregate estimates. For example, we averaged the mean
ation phase predominates.3,12 In either scenario, cervical active labor durations provided in each study to obtain
dilation rates accelerate throughout the majority of labor. an overall estimate for the aggregate. While these aggre-
For example, Zhang et al.3 found that slopes of cervical di- gate estimates may introduce bias, knowledge that an in-
lation progressively steepen with each passing centimeter. verse relationship exists between cervical dilatation and
Median rates of dilation between 3 and 4, 4 and 5, 5 and 6, active labor duration minimizes the extent of this bias.
6 and 7, 7 and 8, 8 and 9, and 9 and 10 cm were 0.4, 0.6, Our findings also are meant to reflect the diverse care pat-
1.2, 1.7, 2.2, 2.4, and 2.4 cm per hour, respectively. At the terns in contemporary practice. Many of the studies in this
fifth percentile, which is used to define the slowest normal systematic review included women who received common
dilation rate, these dilation rates were 0.1, 0.2, 0.3, 0.5, 0.7, labor interventions, such as epidural analgesia, amniotomy,
0.8, and 0.7 cm per hour, respectively. Before 7 cm dilata- and oxytocin augmentation. Other studies included women
tion, it was not uncommon for there to be no change in di- whose labors were managed under AML protocols. Such in-
latation for >2 hours. When viewed linearly from 3 cm to terventions and labor management strategies may affect la-
10 cm dilatation, calculations based on the data reported bor duration. For example, several research teams have
by Zhang et al.3 found that the median and fifth percentile reported that epidural analgesia lengthens the first stage of la-
linear dilation rates were faster than the actual rates these bor among nulliparous women,27,28,48 although others have
investigators reported from one centimeter to the next not found such a relationship.26,34 We found that active la-
(e.g., from 4 cm to 5 cm) until some point after 5 cm dila- bor parameters differed very little between women with and
tation, at which point the linear rates become slower than without epidurals. AML also reportedly shortens first-stage
the actual rates. Therefore, when expected rates of dilation labor by 1.56 hours when compared to routine care (95%
during active labor are viewed linearlyas is common CI, 2.17- 0.96 hours).47 Our results comparing AML with
in contemporary practicethe likelihood of accelerative other types of labor management found this to be true; aver-
intervention is much greater in earlier active labor. age active labor duration was shorter in the AML group
The rates of cervical dilation found in this systematic re- while the average and slowest acceptable dilation rates
view are not exempt from this issue. While the cervical di- were more rapid. Because care patterns vary widely between
lation rate at the mean 2 SD was 0.6 cm per hour, providers, institutions, and regions, our findings are only
progression in the earlier part of active labor will typi- meant to broadly represent the active labor parameters
cally be slower than this average, while progression in the of low-risk nulliparous women with a spontaneous onset of
more advanced active labor will typically be more labor. They should not be strictly applied to any individual.
rapid. Although more complex, using a hyperbolic labor Discussions about where the maximum active phase of
curve in prospective clinical decision-making may lead labor duration should be drawn would be moot if there
to fewer diagnoses of dystocia and facilitate the more dis- were a clear point where incidences of perinatal morbid-
criminate use of labor accelerative interventions. ities sharply rise. Such a point has not yet been identified.
A matter of statistical and, perhaps, clinical relevance is Moreover, the extent to which the relationship between
that labor duration may not hold to a statistically normal prolonged labor and labor morbidity is causal is by no
curve. Specifically, there is a tendency for longer labors means certain. It remains unclear if the risks associated
to positively skew the statistical distribution.3 Therefore, with longer labors are more related to time in labor or to
it is possible that median labor duration may be a superior the interventions commonly applied to shorten labor.
measure of central tendency, with half of the population This issue is especially pertinent because a large number
falling above and half below this value compared to the of women are likely admitted to the hospital, often inad-
mean labor duration, which is more influenced by long la- vertently, before traditionally defined active labor onset.
bors. If active labor duration is positively skewed, me- Strategies are needed to aid clinicians in the prospective
dian duration will be shorter than the mean duration. This identification of active labor onset. Until such strategies
finding was borne out modestly in the present systematic are available, progress that is slower than is traditionally
review wherein the median and mean active-phase labor associated with active labor should be a reason for evalu-
durations were 5.4 and 6.0 hours, respectively. However, ation rather than for intervention. More outcome-based re-
it must be kept in mind that dilatation at active labor on- search in this area is needed.
set was also slightly more advanced in studies reporting
median durations compared to studies reporting mean du-
CONCLUSION
rations (4.0 versus 3.7 cm, respectively), which likely con-
tributed to the shorter median labor duration. Among healthy, low-risk nulliparous women at term with
Our goal was to describe active labor duration and a spontaneous labor onset, the active phase of labor
rates of cervical dilation for low-risk nulliparous women lasted an average of 6.0 hours, while the average linear

316 Volume 55, No. 4, July/August 2010


rate of cervical dilation during this period was 1.2 cm per 13. Philpott RH, Castle WM. Cervicographs in the management
hour. These findings closely parallel those found at the me- of labour in primigravidae. II. The action line and treatment of
dian. At the statistical limits, the weighted active labor abnormal labour. J Obstet Gynaecol Br Commonw 1972;
79:599602.
duration was 13.4 hours (mean + 2 SD) and the dilation
rate was 0.6 cm per hour (mean 2 SD). While these labor 14. Perl FM, Hunter DJ. What cervical dilatation rate during ac-
parameters are not intended to precisely define labor expec- tive labour should be considered abnormal? Eur J Obstet Gynecol
tations for nulliparous women, they do indicate that con- Reprod Biol 1992;45:8992.
temporary expectations of active labor are overly 15. Albers LL, Schiff M, Gorwoda JG. The length of active labor
stringent for this population when criteria traditionally asso- in normal pregnancies. Obstet Gynecol 1996;87:3559.
ciated with active labor onset are used as the starting point. 16. Albers LL. The duration of labor in healthy women. J Perina-
A revision of existing active labor expectations and/or a re- tol 1999;19:1149.
vision of criteria used to prospectively identify active phase 17. Jones M, Larson E. Length of normal labor in women of His-
onset is warranted, and efforts to do so must supersede panic origin. J Midwifery Womens Health 2003;48:29.
efforts to change labor to fit existing expectations.
18. Dickinson JE, Godfrey M, Evans SF, Newnham JP. Factors
influencing the selection of analgesia in spontaneously labouring
Supported by the Ruth L. Kirschstein National Research Service Fellowship nulliparous women at term. Aust N Z J Obstet Gynaecol 1997;
Award, National Institute of Nursing Research, National Institutes of Health 37:28993.
(to J.L.N; 1 F31 NR010054), the Sigma Theta Tau International Honor
Society of Nursing: Epsilon Chapter, and a Coca-Cola Critical Difference 19. Eslamian L, Marsoosi V, Pakneeyat Y. Increased intravenous
Grant for Research on Women, Gender, and Gender Equity. fluid intake and the course of labor in nulliparous women. Int J Gy-
naecol Obstet 2006;93:1025.
20. Miquelutti MA, Cecatti JG, Makuch MY. Upright position
during the first stage of labor: A randomised controlled trial. Acta
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318 Volume 55, No. 4, July/August 2010