Labor dystocia, a term used to describe slowly progressing labor, is the most common reason for cesarean delivery. Despite global efforts to establish improved practice guidelines over the past decade, there is significant debate in the literature about how to diagnose and manage labor dystocia when it occurs. The present study aims to illuminate 1) the decision-making processes surrounding labor dystocia, which previous literature suggests are complex and involve multiple stakeholders, and 2) the factors clinicians consider as part of these decisions that may contribute to whether a cesarean delivery is ultimately performed. These questions were approached qualitatively using informed constructivist grounded theory methodology. Our informants were obstetricians, family medicine physicians, midwives, and labor and delivery nurses in current practice in metropolitan North Carolina hospitals. We conducted semi-structured interviews that included a graphic elicitation diagramming exercise and collected sociodemographic data via an online survey. Several methodological strategies bolstered the study’s rigor and trustworthiness. Four common pathways emerged capturing the process through which decisions are made in the context of labor dystocia. A Social-Ecological Model of Intrapartum Decision-Making is proposed that represents influential factors at the level of the individual, patient-provider, social context, care team, maternity/hospital setting, and broader macrosystem. Findings advance our understanding of how decision-making processes unfold during a uniquely challenging medical experience and may lead to improvements in equitable, high-quality labor and delivery care.