Labor Management: Original Research
Fetal Descent in Labor
Anna Graseck, MD, MSCI, Methodius Tuuli, MD, MPH, Kimberly Roehl,
George Macones, MD, MSCE, and Alison Cahill, MD, MSCI
OBJECTIVE: Studies using contemporary populations
and modern statistical methods have redefined our
understanding of cervical dilation in labor. However,
modern norms for fetal descent in labor have not been
developed. We sought to estimate norms for fetal
descent and estimate the expected fetal station for given
cervical dilations.
METHODS: A retrospective cohort study of consecutive-
term, vertex singletons who delivered vaginally. Detailed
history, labor, and delivery information, including cervi-
cal examinations, were collected. A repeated-measures
analysis was used to construct average descent curves.
Interval-censored regression was used to estimate dura-
tion of labor between levels of station and to estimate
the median station at a given dilation. Each analysis was
stratified by parity and labor type (spontaneous com-
pared with induced or augmented).
RESULTS: Of 4,618 consecutive-term spontaneous vag-
inal deliveries, 1,526 (33%) were nulliparous. Sixty-one
percent were augmented or induced. Multiparous
women had faster fetal descent at all stations except
from +2 to +3 station. The median time to descend
from one station point to another ranged from 0.1 to
1.6 hours, but the 95th percentiles encompassed over
12 hours at the same high-station among nulliparous
women who achieved vaginal delivery. Fetal descent
was more rapid in women who labored spontaneously
without augmentation. Multiparous women tended to
have a higher station than nulliparous women until late
in the first stage.
From the Division of Clinical Research, Department of Obstetrics and
Gynecology, Washington University in St. Louis School of Medicine, St. Louis,
Missouri.
Dr. Cahill is a Robert Wood Johnson Foundation Physician Faculty Scholar,
which partially supports this work.
Corresponding author: Anna Graseck, MD, MSCI, Campus Box 8064,
Washington University in St Louis School of Medicine, 4533 Clayton Avenue,
St Louis, MO 63110; e-mail: grasecka@wudosis.wustl.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2014 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/14
VOL. 123, NO. 3, MARCH 2014
MPH, Anthony Odibo, MD, MSCE,
CONCLUSION: Multiparous women and women who
are not augmented or induced have faster fetal descent.
There is wide variation in the expected station by
increments of dilation. However, 95% of women have
a fetal station of 0 or lower at complete cervical dilation.
(Obstet Gynecol 2014;123:521–6)
DOI: 10.1097/AOG.0000000000000131
LEVEL OF EVIDENCE: II
T he normal progress of labor has received increas-
ing attention in recent years. Modern statistical
methods have been used to evaluate the pattern of
cervical dilation in normal labor, creating a new par-
adigm to replace the Friedman curve.1–4 For instance,
the rapid cervical dilation that characterizes the active
phase occurs later in labor than described by Fried-
man. Also, the transition between the latent and active
stages is more gradual in nulliparous women. Cervical
dilation is essential to normal labor, but fetal descent
within the pelvis is also required to achieve vaginal
delivery. However, little attention has been paid to the
expected progression of fetal descent in labor.
Therefore, we aimed to describe expected norms
for fetal descent in labor and estimate the expected
station for a given cervical dilation during the first
stage.
MATERIALS AND METHODS
A retrospective cohort study was conducted at a single
academic teaching hospital including all consecutive-
term, vertex singletons who delivered vaginally from
2004 to 2008. Operative vaginal deliveries were
excluded. This study received approval from the
Washington University School of Medicine Human
Research Protection Office.
Term gestation was defined as greater than or
equal to 37 weeks 0 day of gestation. Diagnosis of
spontaneous labor was made by the admitting attend-
ing physician. Known fetal anomalies were excluded.
Obstetric history, labor progress, and delivery and
neonatal outcomes were collected from medical
records. Complete data on all cervical examinations
OBSTETRICS & GYNECOLOGY 521
were extracted, including the time of the examination,
the cervical dilation in centimeters, the effacement,
and the station (on a 23 to +3 scale). Resident physi-
cians provided the majority of labor and delivery serv-
ices, including performing cervical examinations at
regular intervals.
Baseline characteristics of the study sample were
tabulated, comparing parturients by parity and by
spontaneous compared with induced or augmented
(nonspontaneous) labor. Because prior published data
suggest similar labor progress in women with induced
and augmented labors, the two groups were combined
for the purpose of this analysis.5 The x2 test or Fisher’s
exact test was used for categorical variables, as appro-
priate. The Shapiro-Francia test was used to test nor-
mality of continuous variables, and the Student’s t test
and the Mann-Whitney U test were used to compare
these variables as appropriate.
A repeated-measures analysis with a ninth-degree
polynomial model was used to construct average
dilation and descent curves stratified by parity. A
repeated-measures analysis is required to account for
the correlation between cervical examinations in the
same woman. Labor progression (cervical dilation and
fetal descent) data are left-censored, because the
progression of labor before women present to the
hospital is unknown. For dilation curves, the starting
point was set as the time when dilation reached 10 cm,
known for all patients, and time was calculated
backward. For descent curves, the starting point was
chosen as the time the station was +3. The curves
were reversed after construction to resemble a tradi-
tional labor curve with time increasing from left to
right.1–4,6
Interval-censored regression was used to estimate
median time to descend from one level of station to
the next (traverse time). The median station at a given
cervical dilation was also estimated. The data were
further stratified by parity and whether labor was
spontaneous or nonspontaneous and compared with
the Mann-Whitney U test. Labor progression data are
also interval-censored, because cervical examinations
are performed at intervals rather than continuously.
Thus, one knows that the progression from 4 to 5 cm
dilation or 21 to 0 station occurred at some time
between two cervical examinations, but not exactly
when. The distribution of these time intervals was
right-skewed (as a result of some long labors, creating
a long right tail of the distribution) and was fitted to
a log-normal distribution. Potentially confounding
factors identified in univariable and stratified analyses
were considered using backward, stepwise regression.
The final models adjusted for maternal body mass
index (BMI, calculated as weight (kg)/[height (m)]2),
birth weight greater than 4,000 g, and induction of
labor. Other factors considered in the regression,
including age, gravidity, race, history of cesarean
delivery, regional anesthesia, and diabetes, were not
significant and were not included in the final model.
All analyses were performed using Stata 10.0
Special Edition and SAS 9.2.
RESULTS
Of 4,618 parturients, 1,526 (33%) were nulliparous.
Most women underwent induction or augmentation of
labor; only 39% of women had spontaneous labor
without augmentation.
Baseline characteristics were significantly differ-
ent between nulliparous and multiparous women
(Table 1). Multiparous women were older, more likely
to African American, have diabetes, and be obese.
Their neonates were more likely to be weigh more
than 4,000 g. In terms of their labor management,
multiparous women more often had spontaneous
labor without augmentation and were less likely to
receive regional anesthesia.
There were also significant baseline differences
between those undergoing spontaneous labor compared

Table 1. Baseline Characteristics of Study Parturients by Parity

Characteristic Nulliparous (n51,526) Multiparous (n53,092) P Relative Risk (95% CI)

Age (y) 20 (18–23) 25 (22–30) ,.001 —

Gravidity 1 3 (2–5) ,.001 —
African American race 1,087 (71) 231 (75) .007 0.95 (0.91–0.99)
Birth weight greater than 4,000 g 44 (3) 206 (7) ,.001 0.43 (0.31–0.60)
History of cesarean delivery 0 290 (9) — —
Spontaneous, nonaugmented labor 454 (30) 1,347 (44) ,.001 0.68 (0.63–0.74)
Regional anesthesia 1,364 (89) 241 (78) ,.001 1.14 (1.11–1.17)
Diabetes 29 (2) 113 (3) .003 0.55 (0.37–0.82)
BMI greater than 30 kg/m2 673 (44) 1,738 (56) ,.001 0.78 (0.74–0.84)
CI, confidence interval; BMI, body mass index.
Data are median (interquartile range) or n (%) unless otherwise specified.

522 Graseck et al Fetal Descent in Labor OBSTETRICS & GYNECOLOGY

Table 2. Baseline Characteristics of Study Parturients Stratified by Labor Type

Induced or Augmented Relative Risk

Spontaneous Labor (n51,801) Labor (n52,817) P (95% CI)

Age (y) 23 (20–27) 24 (20–28) .13 —

Gravidity 3 (2–4) 2 (1–4) ,.001 —
African American race 1,388 (77) 2,017 (72) ,.001 1.07 (1.04–1.11)
Birth weight greater than 4,000 g 72 (4) 178 (6) ,.001 0.63 (0.49–0.83)
History of cesarean delivery 119 (7) 171 (6) .46 1.1 (0.87–1.37)
Regional anesthesia 1,211 (67) 2,571 (91) ,.001 0.74 (0.71–0.76)
Diabetes 32 (2) 104 (4) ,.001 0.48 (0.33–0.71)
BMI greater than 30 kg/m2 788 (46) 1,623 (59) ,.001 0.78 (0.73–0.83)
CI, confidence interval; BMI, body mass index.
Data are median (interquartile range) or n (%) unless otherwise specified.

with those with augmentation or induction of labor
(Table 2). Women who labored spontaneously were
younger, of higher gravidity, and more likely to be
African American. These women were also less likely
to be obese or have diabetes and had fewer neonates
weighing more than 4,000 g. They also used regional
anesthesia less frequently. Multiparous women had fast-
er fetal descent than nulliparous women between all
stations except +2 to +3. This pattern was statistically
significant in both unadjusted (not shown) and adjusted
analyses (adjusted for nonspontaneous labor, maternal
BMI, and birth weight greater than 4,000 g; Table 3).
Similarly, women in spontaneous labor had quicker
fetal descent at all stations in both unadjusted (not
shown) and adjusted analyses (adjusted for parity,
maternal BMI, and birth weight greater than 4,000 g;
Table 4).
The median times to descend one level of station
were all less than 2 hours and less than 1 hour after
achieving 0 station. However, the 95% confidence
intervals (CIs) included up to 12.5 hours between
stations 22 and 21 in nulliparous women, all of
whom achieved spontaneous vaginal delivery.
The median stations at a given dilations were
stratified by parity (Table 5). Multiparous women
tended to have a higher station than nulliparous
women until late in the first stage. By 6 cm of dilation,
median station was 0 (95% CI 22 to 1) for nulliparous
and 21 (95% CI 23 to 0) for multiparous women. At
8 cm, 95% of nulliparous women were at 21 station
or lower. Both nulliparous and multiparous women
had a median station of 0 after active labor was estab-
lished (greater than 6 cm dilation) and 95% of all
women were 0 station or lower at complete cervical
dilation. When stratified by labor type (Table 6), those
in spontaneous labor had lower station at 1–3 cm of
dilation. However, between 7 and 9 cm of dilation,
these women had higher station than those being
induced or augmented.
Labor curves are presented in Figure 1 (stratified
by parity) and Figure 2 (stratified by induction type).
Nulliparous women and those with induced or aug-
mented labor had a gradual rate of descent, although
the rate increased later in labor. In comparison, there
was an inflection point in the descent curve for mul-
tiparous women and those in spontaneous labor with
rapid fetal descent occurring after 21 station.
DISCUSSION
For women in labor at term, the median time for
descent between station intervals was short, less than
2 hours in any group and less than 1 hour for most

Table 3. Median Hours to Descend From One Station to the Next Stratified by Parity

Fetal Station Nulliparous (n51,526) Multiparous (n53,092) P

22 to 21 1.6 (0.2–12.5) 1.2 (0.2–9.5) ,.01

21 to 0 1.3 (0.1–11.4) 0.6 (0.1–5.0) ,.01
0 to +1 0.9 (0.1–7.9) 0.3 (0.04–3.1) ,.01
+1 to +2 0.4 (0.1–3.1) 0.1 (0.02–1.1) ,.01
+2 to +3 0.2 (0.04–0.7) 0.1 (0.02–0.4) .12
Data are median hours (95% confidence interval) unless otherwise specified.
Median times adjusted for labor type, maternal body mass index, and birth weight greater than 4,000 g. No adjustment for maternal age,
diabetes, or regional anesthesia, which were not significant in the final model.

VOL. 123, NO. 3, MARCH 2014 Graseck et al Fetal Descent in Labor 523
Table 4. Median Hours to Descend From One Station to the Next Stratified by Labor Type

Fetal Station Spontaneous Labor (n51,796) Induced or Augmented Labor (n52,822) P

22 to 21 0.3 (0.03–2.1) 1.2 (0.2–9.9) ,.01

21 to 0 0.2 (0.03–2.2) 0.6 (0.1–5.4) ,.01
0 to +1 0.2 (0.03–2.1) 0.4 (0.04–3.3) ,.01
+1 to +2 0.1 (0.02–0.8) 0.2 (0.02–1.1) ,.01
+2 to +3 0.05 (0.01–0.2) 0.1 (0.02–0.4) .03
Data are median hours (95% confidence interval) unless otherwise specified.
Median times adjusted for parity, maternal body mass index, and birth weight greater than 4,000 g. No adjustment for maternal age,
diabetes, or regional anesthesia, which were not significant in the final model.

intervals. Multiparous women and women in sponta-
neous labor had faster descent compared with nullip-
arous women or those with induced or augmented
labors. However, the 95% CIs were wide at higher
stations (over 12 hours at the same station in
nulliparous women or 10 hours in those who were
multiparous) in women who achieved vaginal deliv-
ery. Overall, obstetricians should expect wide varia-
tion in length of time spent at a higher station (above
0 station), particularly among nulliparous women and
those being induced or augmented.
Similarly, there is wide variation in the expected
station by increments of dilation among women
laboring spontaneously. However, 95% of nulliparous
women entering active labor (6-cm cervical dilation)
had a fetal station of 22 or lower. At complete cervi-
cal dilation, 95% of all women were 0 station or lower.
Few investigators have examined patterns of fetal
descent in labor. Friedman, well known for his classic
description of labor curves, also created descent
curves. In a 1965 series of articles, he created descent
curves using the same techniques he previously used
for dilation curves.7–9 He described an exponential
descent curve, in contrast to the sigmoidal cervical
dilation curve, and found that cervical dilation and
fetal descent were interrelated. The median station
at the active phase of labor was 0 regardless of parity.
Higher stations at the onset of each phase of labor
predicted dystocia. However, application of these re-
sults to a contemporary population is limited given
the high rate of midforceps deliveries altering the pro-
gression of the second stage in that era. Also, the
contemporary parturient is heavier and more likely
to undergo induction and augmentation of labor.
Gurewitsch et al10 used created descent curves
stratified by parity with emphasis on the descent pat-
terns in grandmultiparous women. The authors used
ordinal logistic regression models with generalized
estimating equations for robust variance estimation.
They observed that grandmultiparous women tended
to remain at a high station for a longer time before
delivery compared with nulliparous women. A similar
trend can be seen in Figure 1.
In an analysis of nulliparous labor, Zhang et al4
focused on cervical dilation curves but presented
descent data as well. The authors used interval

Table 5. Median Station at a Given Cervical Dilation, Stratified by Parity

Nulliparous Multiparous
Cervical
Dilation (cm) n Median Station (95% CI) (n51,526) n Median Station (95% CI) (n53,092) P

0 97 23 (23 to 22) 68 23 (23 to 23) .17

1 266 23 (23 to 21) 227 23 (23 to 21) ,.01
2 359 22 (23 to 0) 365 23 (23 to 21) ,.01
3 572 22 (23 to 0) 881 23 (23 to 21) ,.01
4 731 21 (23 to 0) 1,217 22 (23 to 0) ,.01
5 592 21 (23 to 1) 1,209 22 (23 to 0) ,.01
6 503 0 (22 to 1) 959 21 (23 to 0) ,.01
7 366 0 (22 to 1) 798 0 (23 to 1) ,.01
8 377 0 (21 to 1) 804 0 (22 to 1) ,.01
9 394 1 (21 to 2) 652 0 (22 to 2) ,.01
10 1,502 2 (0–3) 3,040 2 (0–3) .04
CI, confidence interval.
Data are n or median station (95% confidence interval) unless otherwise specified.
Median station adjusted for labor type, maternal body mass index, and birth weight greater than 4,000 g.

524 Graseck et al Fetal Descent in Labor OBSTETRICS & GYNECOLOGY

Table 6. Median Station at a Given Cervical Dilation Stratified by Labor Type

Spontaneous Labor Induced or Augmented Labor

Cervical Dilation (cm) n Median Station (95% CI) (n51,796) n Median Station (95% CI) (n52,822) P

0 3 23 (23 to 23) 162 23 (23 to 22) .62

1 22 22.5 (23 to 0) 471 23 (23 to 21) ,.01
2 70 22 (23 to 0) 654 23 (23 to 21) .03
3 231 22 (23 to 0) 1,222 22 (23 to 21) ,.01
4 428 22 (23 to 0) 1,520 22 (23 to 0) .95
5 520 21 (23 to 0) 1,281 21 (23 to 0) .47
6 511 21 (23 to 1) 951 21 (23 to 1) .31
7 469 0 (23 to 1) 695 0 (22 to 1) .02
8 520 0 (22 to 1) 661 0 (22 to 1) .03
9 432 0 (22 to 2) 614 1 (21 to 2) .02
10 1,770 2 (0–2) 2,772 2 (0–3) .59
CI, confidence interval.
Median station adjusted for parity, maternal body mass index, and birth weight greater than 4,000 g.

censored regression and a repeated-measures analysis
for their analysis as we have presented here. Zhang
also found that nulliparous women can spend several
hours at a low station and still achieve vaginal deliv-
ery. For example, the 95% CIs included 3 hours from
stations +1 to +2 among women at 10 cm of dilation.
A limitation of our study is that it is retrospective,
limiting how cervical examinations were performed.
For instance, the frequency of cervical examinations
was not standardized, and examiners at our institution
typically record fetal station using the 23 to +3 scale
rather than the 5-cm scale.11 However, this represents
the typical management of labor at our institution and
can be generalized to similar institutions. There was
also a high rate of induction and augmentation of labor
(62%). Because we excluded women who underwent
cesarean or operative vaginal delivery, we cannot
comment on typical patterns of descent for these la-
bors. This exclusion was necessary to be able to show
the slowest rates of descent that still resulted in spon-
taneous vaginal delivery. Several other factors may
affect descent in labor that could not be assessed in
this study. These include interexaminer variability,
molding of the fetal head, head position, maternal
pushing effort, and the use of regional anesthesia.
Fetal descent is an essential component of labor
progression. There is wide variation in descent rates
and expected station early in labor, although at fetal
station above 0 is very unusual at complete cervical
dilation for both nulliparous and multiparous women.

Nulliparous dilation Spontaneous dilation

Nulliparous station Spontaneous station
Parous dilation Induced dilation
Parous station Induced station
10 10
–2
–2

–1
0 –1
Cervical dilation (cm)

Cervical dilation (cm)

8 8
Fetal station

Fetal station
0
+1

+1

6 6
+2

+2

4 4
+3

+3

0 2 4 6 8 0 2 4 6 8
Duration of labor (hours) Duration of labor (hours)
Fig. 1. Cervical dilation and descent curves by parity. Fig. 2. Cervical dilation and descent curves by labor type.
Graseck. Fetal Descent in Labor. Obstet Gynecol 2014. Graseck. Fetal Descent in Labor. Obstet Gynecol 2014.

VOL. 123, NO. 3, MARCH 2014 Graseck et al Fetal Descent in Labor 525
Multiparous women and women in spontaneous labor
should be expected to have faster fetal descent.
REFERENCES
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