Prolonged second stage (of labor)

This code signifies a labor progression abnormality where the second stage of labor (from full cervical dilation to fetal expulsion) extends beyond the expected duration. This typically means more than 3 hours for nulliparous women or more than 2 hours for multiparous women, or longer with regional anesthesia. It indicates a failure of the fetus to descend and be delivered within the established timeframes.

Use this code when the physician's documentation explicitly states a prolonged second stage of labor, often accompanied by details of the duration and interventions attempted or performed. This diagnosis is supported by documentation of full cervical dilation followed by an extended period without delivery, despite adequate uterine contractions.

• Ensure the documentation clearly specifies "prolonged second stage" and not just "prolonged labor" without specifying the stage.
• Always sequence this code as a principal diagnosis when it is the reason for admission or the focus of care.
• Consider co-reporting with codes for any associated complications or interventions, such as instrumental delivery or cesarean section due to the prolonged second stage.