We appreciate Dr Jovanovski’s interest in our paper.

We performed the first randomized controlled trial of nulliparous women with singleton gestations who reached the American College of Obstetricians and Gynecologists definition of prolonged second stage of labor: 3 hours with epidural anesthesia.

Women were assigned to either extended labor (about 1 additional hour) or to usual labor (expedited delivery via cesarean or operative vaginal delivery). The incidence of cesarean delivery was 19.5% in the extended group and 43.2% in the usual group (relative risk, 0.45; 95% confidence interval, 0.22–0.93). Extending the length of labor decreased the incidence of cesarean delivery by 55%, compared with usual labor. Maternal and neonatal morbidity were not different; however, our study was underpowered to detect small differences.

First, in reply to Dr Jovanoski’s points, we also question whether this study indicates implementing policy change. The prevented risk (for every 1000 women with prolonged second stage, 237 cesarean deliveries would be prevented) and the preventative fraction (54.9% of expected cesarean deliveries in women with prolonged second stage were prevented) are powerful numbers. Additionally, the number needed to treat to prevent 1 primary cesarean delivery was 4.2. Whereas more randomized controlled trial data are needed, based also on prior publications, it seems proven that prolonging the second stage more than 3 hours if fetal and maternal conditions permit is associated with a higher chance of vaginal delivery.

Second, we agree with the recommendation for follow-up studies with larger sample sizes to address external validity and possible differences in maternal and neonatal outcomes. Although we confirmed that prolonging the second stage seems safe for neonates as long as the tracing is reassuring, maternal outcomes such as bleeding, infection, and perineal lacerations trended toward an increase. Moreover, perhaps our manuscript’s biggest shortcoming was the lack of long-term outcomes, including maternal (eg, urinary or fecal incontinence, uterine prolapse, etc) and infant (eg, neurodevelopmental outcomes). We have started a follow-up study assessing long-term outcomes on bladder, bowel, and pelvic floor dysfunction at 2 years after the delivery.

Third, we have started looking at changes to the standard of care at our own institution. We are collecting data regarding our institution’s cesarean delivery incidence in the poststudy period, with practice seemingly changing more toward “obstetrics;”, meaning, providers are “standing by” and allowing for longer second stages.