There is no Evidence to Justify Cesarean or Vacuum for Prolonged Pushing

In the presence of a reassuring fetal heart, there is no reason to take any actions other than to keep pushing

There is no quality research showing adverse maternal or newborn outcomes as a result of being fully dilated and pushing even for 24 hours, unless the woman suffers from severe malnutrition, such as found in Africa. Evidence shows that If the fetal heart is reassuring, there are no time limits for delivering the baby. (1) The baby’s skull is designed to change shape to accommodate the shape of the pelvic diameters. In a well fed woman, the woman’s organs can withstand months of pressure from the fetus without becoming necrotic. Yet, delivering the woman by cesarean surgery after 2 hours of pushing or 3 hours if she has an epidural anesthesia is accepted practice and the justification for about 60% of ’emergency’ caesareans. Cesarean for Dystocia is harmful obstetric practice.

Prolonged labor is labeled with the word “DYSTOCIA”. Dystocia is a scary sounding word. What is really scary is that dystocia has no definition yet it is the justification for 50%(2) to 70% (3) of cesareans. World Health Organization protocols and American College of Obstetrics and Gynecology (ACOG) protocols for dystocia and prolonged second stage do not mention any time limits for second stage.(4,5) There is no Cochrane Review for the use of cesarean for prolonged second stage… because No RCT studies have ever been done. There are no studies comparing the outcomes of cesarean vs expectant management in prolonged second stage. A recent review about second stage of labor in JMWH (6) states that prolonged second stage is associated with adverse maternal outcomes such as increased rates of infection, severe lacerations, and postpartum hemorrhage. However, it also says that the infections, severe lacerations and hemorrhages are the result of the interventions used in hospitals to ‘treat’ long second stages: Pitocin augmentation, Episiotomy, Epidural, Forceps, Vacuum and Cesarean. “a causal relationship between prolonged second stage and morbidity is not clear. Most of these outcomes are strongly associated with the mode of birth.” In other words, the cause of the infections, lacerations and postpartum hemorrhage are the medical interventions, not the prolonged second stage.(6) Despite this, the JMWH authors make no recommendation to ignore the 2-3 hour time limits on second stage.(5) Even JMWH do not have the womans best interests as their top priority.

We all were trained to believe in the arbitrary 2 and 3 hour limits. Those of us with the privilege of practicing evidence based protocols are happily surprised the first time we experience a 6 or 8 hour second stage. The woman is always very happy with the perfect outcome.

In my practice, I did not come to this conclusion early in my practice. I have now been practicing for 30 years. First I had a birth with a 4 hour second stage, then a 6 hour one, and then an 8 hour second stage. Now I have had second stages of 15, 17 and 24 hours. The stories appear in Midwifery Today. ( It would be a shame for all midwives to have to attend 1000 births in order to realize that it is safe to allow women to push without time limits as long as the fetal heart is reassuring.

‘It seems reasonable’

No matter how many midwives hold on to the belief that there is medical evidence supporting limits on second stage, there is none. One should be alert to arguments such as ‘It seems reasonable’. Many midwives try to get around the 2 hour rule by delaying the start of pushing or by not checking if the woman is fully dilated. The JMWH article states: “It seems reasonable to delay pushing for up to 2 hours after complete dilatation, unless the woman has an urge to push or the fetal head is at the introitus, particularly for women who are using epidural analgesia.” (5) A statement that says something is reasonable, is not reasonable when it is not based on any reasons. Using the same logic, it is not reasonable to order a cesarean because someone has been pushing for 2 hours because it is not based on reason.

It is time to learn to manage prolonged second stage according to research evidence rather than ‘what seems reasonable’. Accepted practice teaches that cesarean surgery is justified where a woman pushes for longer than 2 hours without an epidural and 3 hours with an epidural. We have heard it so many times, we don’t even question how many contractions she had per hour. Since delivery is a direct result of the number and strength of contractions, it is illogical to ignore the number of contractions in favor of the number of hours that have passed. If contractions are every 10 minutes this translates to 12 contractions in 2 hours whereas if they are every 3 minutes, that translates into 40 contractions in 2 hours. The fact that the protocol measures second stage in time not contractions or pushes underlines the embarrassing lack of logic in addition to a total lack of evidence, behind second stage protocols.

Risk of obstetric fistula with prolonged labor due to malnutrition

“Obstetric fistulas result from untreated prolonged obstructed labor.” (6) This statement from the prestigious Current Opinion in Obstetrics and Gynecology, a journal which directs protocol, is presented with neither citation nor definition of the word: prolonged. The review only provides examples of obstetric fistulas resulting from untreated prolonged obstructed labor lasting an average of 4 days ….and sometimes for more than a week and 50% of cases occur among pre-teen girls in which the girl has not finished growing. (7) If obstructed labor is on average 4 days, obviously there is no justification for defining prolonged second stage as over 2 hours. Where there is inadequate space to deliver it without moulding, the fetal head presses against the pelvic outlet bones, causing the head to mould into a cone. Malnutrition is a necessary prerequisite to obstetric fistula (8). The connection between obstetric fistula to malnutrition points to a contracted pelvis, cephalopelvic disproportion (CPD) which combined with malnutrition allows vaginal tissue to more easily become necrotic. Grand multiparas in high income countries often experience a very low head for the last month of pregnancy pressing down against the pelvic bones, sometimes causing life changing symphysis pubis pain (SPD), but not necrosis. Obstetric fistulas associated with long labors are caused by malnutrition.

In high income countries, cesarean is the biggest cause of obstetric fistula: “In their review of 68 cases of genitourinary fistulas seen at University of California, Los Angeles, over a 25-year period, Goodwin and Scardino were able to locate only four women with fistulas due to obstetric complications, two of which were caused by direct injuries to the urinary tract sustained at the time of cesarean delivery rather than by labor itself.” (7)

I would be happy to participate in a discussion online with any group of practitioners interested in discussing this further.


1. Altman MRLydon-Rochelle MT. Prolonged second stage of labor and risk of adverse maternal and perinatal outcomes: a systematic review. Birth. 2006;33(4):315-22.

2. Shields SG, Ratcliffe SD, Fontaine P et al (2007). Dystocia in nulliparous women. American Family Physician 75(11):1671.

3. Gifford DS, Morton SC, Fiske M et al (2000). Lack of progress in labor as a reason for cesarean. Obstetrics and Gynecology 95(4):589-95.

4. American College of Obstetricians and Gynecologists (ACOG). Dystocia and augmentation of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2003 Dec. 10 p. (ACOG practice bulletin; no. 49). Reconfirmed as protocol in 2009

5. WHO guidelines: Managing Prolonged and obstructed labour. //

6. Kopas ML. A review of evidence-based practices for management of the second stage of labor. J Midwifery Womens Health. 2014;59(3):264-76.

7. Arrowsmith SDBarone MARuminjo J. Outcomes in obstetric fistula care: a literature review. Curr Opin Obstet Gynecol. 2013;25(5):399-403.

8. Wall LL. A framework for analyzing the determinants of obstetric fistula formation. Stud Fam Plann. 2012;43(4):255-72.

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