Effect of Maternal Awareness of the Duration fo the Second Stage of Labor on the Length of the Second Stage

Effect of Maternal Awareness of the Duration fo the Second Stage of Labor on the Length of the Second Stage: A Randomized Controlled Trial

This study aims to understand whether informing laboring patients about how long they have been pushing during the second stage of labor affects the length of that stage and the overall childbirth experience.

The second stage of labor is the period from when the cervix is fully dilated until the baby is delivered. When this stage lasts longer than expected, it can increase the chance of complications such as assisted delivery with vacuum or forceps, cesarean delivery, heavy bleeding after delivery, and certain neonatal complications. Although healthcare providers routinely track the duration of the second stage, patients are not always told how long they have been pushing. Some providers believe that sharing this information may help motivate patients and improve their sense of control, while others worry that it could increase stress or pressure.

In this study, participants will be randomly assigned to one of two groups. In the intervention group, patients will receive regular updates about how long they have been pushing during the second stage of labor, and a visible timer will be used. In the comparison group, patients will receive standard care, which does not include structured time updates.

All participants will receive the same medical care otherwise. The study will measure the length of the second stage of labor as well as maternal and neonatal outcomes such as the type of delivery, postpartum complications, newborn health indicators, and admission to the neonatal intensive care unit. Participants will also be asked to complete a short questionnaire after delivery about their childbirth experience and sense of control during labor.

The risks of this study are minimal because the intervention involves only providing information about time during labor. There are no changes to medical treatment or standard care. The information gained from this research may help clinicians improve communication with patients during labor and may identify simple ways to enhance patient experience and potentially improve labor outcomes.

Participation in the study is voluntary, and patients may decline or withdraw at any time without affecting the care they receive.

Background and Rationale The second stage of labor, defined as the interval from complete cervical dilation to delivery of the fetus, is a critical phase of childbirth with important implications for maternal and neonatal outcomes. Prolonged second stage of labor has been associated with increased risks of operative vaginal delivery, cesarean delivery, postpartum hemorrhage, severe perineal lacerations, chorioamnionitis, and neonatal morbidity, including low Apgar scores and neonatal intensive care unit (NICU) admission. As a result, contemporary obstetric guidelines provide time-based thresholds to define prolonged second stage, often stratified by parity and use of neuraxial analgesia.

Despite the centrality of time thresholds in clinical decision-making, clinicians typically monitor second-stage and are recommended to continuously communicate with the parturient[a]. While some providers may offer general reassurance ("you're making progress"), others may avoid discussing time altogether, out of concern that emphasizing elapsed duration could increase anxiety, fatigue, or a sense of pressure. Consequently, the extent to which parturients are aware of the duration of the second stage varies widely and is largely unstructured.

Patient engagement and shared decision-making have increasingly been recognized as important components of high-quality obstetric care. In non-obstetric clinical settings, real-time feedback and awareness of performance metrics-such as elapsed time, distance, or workload-have been shown to influence behavior, motivation, and outcomes. In labor, behavioral factors such as maternal effort, positioning, coping strategies, perceived control, and coached pushing may plausibly affect the effectiveness of pushing and overall labor progress. However, the specific role of maternal awareness of elapsed time during the second stage of labor has not been systematically studied.

Existing literature on second-stage management has largely focused on physiologic versus directed pushing, delayed versus immediate pushing, maternal positioning, and clinician-led coaching strategies. While these studies provide important insights, they do not address whether informing the laboring person about the duration of the second stage-without altering clinical management-affects the second stage's length.

Importantly, maternal experience and satisfaction are increasingly recognized as meaningful outcomes in obstetric research. A sense of control, understanding of the labor process, and effective communication have been associated with greater satisfaction with childbirth and a reduced risk of negative birth experiences. Whether structured communication about second-stage duration enhances or detracts from these aspects of the birth experience remains unknown.

Given the lack of high-quality evidence on this topic, a randomized controlled trial is needed to evaluate the impact of structured maternal awareness of second-stage duration on second-stage labor duration and related maternal and neonatal outcomes. Such evidence would directly inform clinical communication practices during labor and could offer a low-cost, easily scalable intervention to optimize labor outcomes while supporting patient-centered care.

2. Objectives and Hypotheses Primary Objective To determine whether structured maternal awareness of the duration of the second stage of labor reduces the length of the second stage of labor compared with usual care.

Secondary Objectives

1. To assess the impact of the intervention on:

   • Mode of delivery (spontaneous vaginal vs operative vaginal vs cesarean delivery in the second stage).
   • Maternal outcomes: perineal laceration degree, postpartum hemorrhage, maternal exhaustion, need for operative assistance.
   • Neonatal outcomes: 5-minute Apgar score, umbilical artery pH (if available), NICU admission.
   • Maternal satisfaction with the birth experience and perceived sense of control.

2. To evaluate whether the effect of the intervention differs by parity and use of neuraxial analgesia.

   Hypotheses

   • Primary hypothesis: Women who receive structured feedback about the elapsed duration of the second stage will have a shorter median second stage of labor than women receiving usual care.

   • Secondary hypotheses:

     • The intervention will not worsen maternal or neonatal morbidity.
     • Maternal satisfaction and perceived control will be higher in the intervention group.

3. Study Design A single-center, parallel-group, randomized controlled trial with a 1:1 allocation ratio.

4. Setting The trial will be conducted on the Labor and Delivery unit of Bronxcare, a community hospital with approximately 1500 births per year.

Inclusion Criteria:

• Singleton, cephalic presentation
• Gestational age ≥ 37+0 weeks at delivery.
• Reached the second stage of labor (complete cervical dilation with intention to proceed with vaginal delivery).
• Ability to understand study information and provide informed consent.

Exclusion Criteria:

• Planned cesarean delivery.
• Intrauterine fetal demise.
• Critical maternal illness requiring intensive hemodynamic or respiratory support.
• Cognitive impairment or language barrier precluding consent and comprehension of instructions.
• Abnormal fetal heart tracing requiring operative vaginal delivery
• Shoulder dystocia requiring maneuvers other than McRoberts and suprapubic pressure