presentation of normal labour

Management of Normal Labor

• Birthing Options |
• Beginning of Labor |
• Admission to Labor Unit |
• Cervical Examination |
• Rupture of Membranes |
• Stages of Labor |

Labor consists of a series of rhythmic, involuntary or medically induced contractions of the uterus that result in effacement (thinning and shortening) and dilation of the uterine cervix. In 1996, the World Health Organization (WHO) defined normal birth as follows ( 1 ):

The birth is spontaneous in onset and low risk at the start of labor and remains so throughout labor and delivery.

The infant is born spontaneously in the vertex position between 37 and 42 weeks of pregnancy.

After birth, mother and infant are in good condition.

The stimulus for labor is unknown, but digitally manipulating or stretching the cervix during examination enhances uterine contractile activity, most likely by stimulating release of oxytocin by the posterior pituitary gland.

In uncomplicated term pregnancies, labor usually begins within 2 weeks (before or after) of the estimated date of delivery. In a first pregnancy, labor lasts 12 to 18 hours on average; subsequent labors are often shorter, averaging 6 to 8 hours.

Management of labor protraction or arrest requires additional measures (eg, induction or augmentation of labor , forceps or vacuum extractor delivery , cesarean delivery ).

(See also Introduction to Intrapartum Complications .)

General reference

1. Care in normal birth: A practical guide . Technical Working Group, World Health Organization.  Birth 24(2):121-123, 1997.

Birthing Options

Settings for childbirth vary. Patients may have options of delivering at a hospital, birthing center, or at home. Hospital delivery has the advantage of having clinical staff and equipment immediately available if unexpected maternal and fetal complications occur during labor and delivery (eg, placental abruption , shoulder dystocia , need for emergency cesarean delivery , fetal or neonatal distress or abnormality) or postpartum (eg, postpartum hemorrhage ).

For many women, presence of their partner or another support person (eg, doula or perinatal support specialist) during labor is helpful and should be encouraged. Moral support and encouragement may decrease anxiety. Childbirth education classes can prepare parents for labor and delivery, including providing information about normal labor, monitoring equipment, and potential complications.

Beginning of Labor

Labor usually begins with irregular uterine contractions of varying intensity and the cervix begins to efface and dilate. As labor progresses, contractions increase in duration, intensity, and frequency. Sometimes the chorioamniotic membranes rupture before the onset of contractions.

Bloody show (a small amount of blood with mucous discharge from the cervix) may be an early sign the labor will soon begin. However, bloody show may also occur as a result of sexual intercourse. Bloody show may precede onset of labor by as much as 72 hours. Any vaginal bleeding in pregnancy should be assessed to exclude complications. With bloody show, the amount of blood is very small and mucus is typically present, which usually differentiates it from abnormal third-trimester vaginal bleeding .

Typically, pregnant women are advised to call their health care team or go to the hospital if they believe their membranes have ruptured or if they are experiencing contractions lasting at least 30 seconds and occurring regularly at intervals of about 6 minutes or less for an hour. Patients are evaluated, and if it is uncertain whether labor has begun, they are observed for a time and sent home if labor has not begun.

Symptoms that are not associated with normal labor, such as persistent (rather than intermittent) abdominal or back pain, heavy vaginal bleeding, or hemodynamic instability, that suggest placental abruption (premature separation of the placenta) require immediate evaluation and management. Placenta previa is typically ruled out with routine prenatal ultrasonography in the second trimester. However, if the location of the placenta is unknown or the placenta was low-lying on the most recent ultrasound, digital vaginal examination is contraindicated, and ultrasonography should be done as soon as possible.

Admission to Labor Unit

When a pregnant patient is admitted to the labor unit, vital signs are measured. Blood is drawn for a complete blood count (CBC), blood typing, and antibody screening. If routine laboratory tests were not done during prenatal visits, they should be done. These tests include screening for HIV, hepatitis B, and syphilis; testing rubella and varicella immunity; and group B streptococcal infection.

The presence and rate of fetal heart sounds are recorded. A physical examination is done. While examining the abdomen, the clinician estimates size, position, and presentation of the fetus, using the Leopold maneuver (see figure Leopold Maneuver ). If fetal presentation or lie is uncertain, ultrasonography may be done.

If labor is active, patients should receive little or nothing by mouth to prevent possible vomiting and aspiration during delivery or in case emergency delivery with general anesthesia is necessary. Some health facilities permit clear liquids in low-risk patients.

Shaving or clipping of vulvar and pubic hair is not indicated, and it increases the risk of wound infections.

An IV infusion of Ringer's lactate may be started, preferably using a large-bore indwelling catheter inserted into a vein in the hand or forearm. During a normal labor of 6 to 10 hours, women should be given 500 to 1000 mL of this solution. The infusion prevents dehydration during labor and subsequent hemoconcentration and maintains an adequate circulating blood volume. The catheter also provides immediate access for medications or blood products if needed. Fluid preloading is valuable if epidural or spinal anesthesia is planned.

Leopold Maneuver

If there are concerns about complications after the initial examination, fetal monitoring, and laboratory tests, additional testing or monitoring is done.

If the pregnancy is preterm ( < 37 weeks) and patients present with uterine contractions or leaking of fluid, they are assessed for preterm labor or preterm prelabor rupture of membranes and managed accordingly.

Cervical Examination

If the patient has regular, painful contractions, a cervical examination is done to assess cervical dilation.

In patients with placenta previa , cervical examination can cause severe hemorrhage and, therefore, is not done. If placental location has not been determined during prenatal care, ultrasonography should be done before a pelvic examination.

Cervical dilation is recorded in centimeters as the diameter of a circle; 10 cm is considered fully dilated.

Effacement is estimated in percentages, from zero to 100%. Because effacement involves cervical shortening as well as thinning, it may be recorded in centimeters using the normal, uneffaced average cervical length of 3.5 to 4.0 cm as a guide.

Station is expressed in centimeters above or below the level of the maternal ischial spines. Level with the ischial spines corresponds to 0 station. Levels below the ischial spines are documented as ( + ); levels higher in the pelvis above the ischial spines are documented as ( − ). Levels are recorded in centimeter increments.

Fetal lie, position, and presentation are noted.

Lie describes the relationship of the long axis of the fetus to that of the mother (longitudinal, oblique, transverse).

Position describes the relationship of the presenting part to the maternal pelvis (eg, occiput left anterior for cephalic, sacrum right posterior for breech).

Presentation describes the part of the fetus at the cervical opening (eg, breech, vertex, shoulder).

Abnormal fetal lie, position, or presentation may be associated with intrapartum complications.

Rupture of Membranes

Occasionally, the membranes (amniotic and chorionic sac) rupture before labor begins, and amniotic fluid leaks through the cervix. Rupture of membranes at any stage before the onset of labor is called prelabor rupture of membranes (PROM). Some women with PROM feel a gush of fluid from the vagina, followed by steady leaking ( 1 ).

If the patient presents with possible rupture of membranes, but does not have regular and painful contractions, a sterile speculum examination is done initially to confirm rupture of membranes. To decrease the risk of infection, digital cervical examinations are delayed until it appears that labor has begun or if there are other indications to assess cervical dilation (eg, planning labor induction).

Further confirmation is sometimes needed to differentiate amniotic fluid from other fluids (eg, urine, vaginal discharge, semen). Rupture of membranes can be confirmed on pelvic examination if fluid is seen leaking from the cervix, and there is pooling in the posterior vagina. Fetal meconium (producing greenish-brown discoloration) should be noted if present, because it may be a sign of fetal stress.

If pooling is not seen, confirmation may require testing. For example, the pH of vaginal fluid may be tested with nitrazine paper, which turns deep blue at a pH > 2 , 3 ).

If rupture is still unconfirmed, ultrasonography showing oligohydramnios (deficient amniotic fluid) provides further evidence suggesting rupture. Rarely, amniocentesis with instillation of dye is done to confirm rupture; dye detected in the vagina or on a tampon confirms rupture.

About 80 to 90% of women with PROM at term ( ≥ 37 weeks) and about 50% of women with preterm PROM ( > 90% of women with PROM go into labor within 2 weeks. If membranes rupture at term but labor does not start within several hours, labor is typically induced to lower risk of maternal and fetal infection. When preterm PROM occurs (at

Rupture of membranes references

1. Prelabor Rupture of Membranes : ACOG Practice Bulletin, Number 217.  Obstet Gynecol 135(3):e80-e97, 2020. doi:10.1097/AOG.0000000000003700

2. Ramsauer B, Vidaeff AC, Hösli I, et al : The diagnosis of rupture of fetal membranes (ROM): a meta-analysis.  J Perinat Med . 2013;41(3):233-240. doi:10.1515/jpm-2012-0247

3. Thomasino T, Levi C, Draper M, Neubert AG . Diagnosing rupture of membranes using combination monoclonal/polyclonal immunologic protein detection.  J Reprod Med . 2013;58(5-6):187-194.

Stages of Labor

There are 3 stages of labor.

First stage

The first stage—from onset of labor to full dilation of the cervix (about 10 cm)—has 2 phases, latent and active.

The latent phase is the interval from the onset of labor to the onset of the active phase ( 1 ). Irregular contractions become regular and more intense, discomfort is mild to moderate, and the cervix effaces and begins to dilate to 4 to 6 cm. The latent phase is difficult to define precisely and duration varies. For nulliparas, the mean is 7.3 to 8.6 hours (95th percentile, 17 to 21 hours) ( 2 ). For multiparas, the mean is 4.1 to 5.3 hours (95th percentile, 12 to 14 hours).

There is no standard definition of a protracted latent phase . A commonly used standard is > 20 hours in nulliparous patients or > 14 hours in multiparous patients, although some studies have reported shorter and longer durations ( 3 ).

The active phase is defined by accelerated cervical dilation. Regular contractions continue until the cervix becomes fully dilated.

Active-phase protraction is diagnosed when, after 6 cm dilation is reached, the cervix dilates 4 ). Active-phase arrest is typically defined as no change in cervical dilation for 2 to 4 hours.

Pelvic examinations are done as needed in the latent phase and typically every 2 to 3 hours in the active phase to evaluate labor progress.

Standing and walking shorten the first stage of labor by > 1 hour and reduce the rate of cesarean delivery ( 5 ).

If the membranes have not spontaneously ruptured, some clinicians use amniotomy (artificial rupture of membranes) routinely during the active phase. As a result, labor may progress more rapidly, and meconium-stained amniotic fluid may be detected earlier. Amniotomy during this stage may be necessary for specific indications, such as facilitating internal fetal monitoring to confirm fetal status. Amniotomy should be avoided in women with HIV infection or hepatitis B or C, so that the fetus is not exposed to these infections.

During the first stage of labor, maternal heart rate and blood pressure should be monitored frequently, and fetal heart rate should be checked continuously by electronic monitoring or intermittently by auscultation, usually with a portable Doppler ultrasound device (see fetal monitoring ). Women may begin to feel the urge to bear down as the presenting part descends into the pelvis. However, they should be discouraged from bearing down until the cervix is fully dilated so that they do not tear or cause swelling of the cervix.

Second stage

The second stage of labor is the time from full cervical dilation to delivery of the fetus. Mean duration is 36 to 57 minutes in nulliparous patients (95th percentile, 122 to 197 minutes) and 17 to 19 minutes in multiparous patients (95th percentile, 57 to 81 minutes) ( 2 ). For spontaneous delivery, women must supplement uterine contractions by expulsively bearing down. In the second stage, women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. Contractions may be monitored by palpation or electronically.

During the second stage of labor, perineal massage with lubricants and warm compresses may soften and stretch the perineum and thus reduce the rate of third- and fourth-degree perineal tears ( 6 ). These techniques are widely used by midwives and birth attendants.

During the second stage, the mother's position does not affect duration or mode of delivery or maternal or neonatal outcome in deliveries without epidural anesthesia ( 7 ). Also, the pushing technique (spontaneous versus directed and delayed versus immediate) does not affect the mode of delivery or maternal or neonatal outcome.

Second-stage arrest is typically defined as at least 3 hours of pushing in nulliparous women or at least 2 hours in multiparous women ( 8 ). Use of epidural anesthesia delays pushing and may lengthen the second stage by an hour ( 9 ). Duration of pushing may also be longer due to malposition (eg, occiput posterior).

Third stage

The third stage of labor begins after delivery of the infant and ends with delivery of the placenta. This stage usually lasts only a few minutes but may last up to 30 minutes.

Stages of labor references

1. American College of Obstetricians and Gynecologists (ACOG) : Obstetrics Data Definitions

2. Kilpatrick SJ, Garrison E, Fairbrother E: Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux E, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Elsevier; 2021. eBook ISBN: 9780323613408

3. Tilden EL, Phillippi JC, Ahlberg M, et al : Describing latent phase duration and associated characteristics among 1281 low-risk women in spontaneous labor.  Birth 46(4):592-601, 2019. doi:10.1111/birt.12428

4. Friedman EA, Cohen WR . The active phase of labor.  Am J Obstet Gynecol . 2023;228(5S):S1037-S1049. doi:10.1016/j.ajog.2021.12.269

5. Lawrence A, Lewis L, Hofmeyr GJ, Styles C : Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev (8):CD003934, 2013. doi: 10.1002/14651858.CD003934.pub3

6. Aasheim V, et al : Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 6:CD006672, 2017. doi: 10.1002/14651858.CD006672.pub3

7. Gupta JK, Sood A, Hofmeyr GJ, et al : Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 5:CD002006, 2017. doi: 10.1002/14651858.CD002006.pub4

8. Obstetric care consensus no. 1 : safe prevention of the primary cesarean delivery.  Obstet Gynecol . 123(3):693-711, 2014. doi:10.1097/01.AOG.0000444441.04111.1d

9. Lemos A, Amorim MM, Dornelas de Andrade A, et al : Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev 3:CD009124, 2017. doi: 10.1002/14651858.CD009124.pub3

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

• Cookie Preferences

Mechanism of Labour – OSCE Guide

• 📖 Geeky Medics OSCE Book
• ⚡ Geeky Medics Bundles
• ✨ 1300+ OSCE Stations
• ✅ OSCE Checklist PDF Booklet
• 🧠 UKMLA AKT Question Bank
• 💊 PSA Question Bank
• 💉 Clinical Skills App
• 🗂️ Flashcard Collections | OSCE , Medicine , Surgery , Anatomy
• 💬 SCA Cases for MRCGP

To be the first to know about our latest videos subscribe to our YouTube channel 🙌

Table of Contents

Suggest an improvement

• Hidden Post Title
• Hidden Post URL
• Hidden Post ID
• Type of issue * N/A Fix spelling/grammar issue Add or fix a link Add or fix an image Add more detail Improve the quality of the writing Fix a factual error
• Please provide as much detail as possible * You don't need to tell us which article this feedback relates to, as we automatically capture that information for you.
• Your Email (optional) This allows us to get in touch for more details if required.
• Which organ is responsible for pumping blood around the body? * Enter a five letter word in lowercase
• Comments This field is for validation purposes and should be left unchanged.

Introduction

Describing the mechanism of labour is a common topic for OSCEs and MCQs. Although on the surface it can appear complicated, breaking the process down into individual steps makes it much easier to understand.

Normal labour involves the widest diameter of the fetus successfully negotiating the widest diameter of the bony pelvis of the mother via the most efficient route.

The mechanism of labour covers the passive movement the fetus undergoes in order to negotiate through the maternal bony pelvis. Labour can be broken down into several key steps.

Key stages of labour

• Neck flexion

Internal rotation

Extension of the presenting part.

• Restitution
• External rotation
• Lateral flexion

For the purposes of this guide, the fetal movements will be described in relation to a cephalic (vertex) presentation with a longitudinal lie . This is a common (low risk) presentation.

Pelvic anatomy

To understand the mechanism of labour, you need some basic understanding of pelvic anatomy .

Borders of the pelvic inlet

• Posteriorly : Sacral promontory
• Laterally : Iliopectineal line
• Anteriorly : Pubic symphysis

Borders of the pelvic outlet

• Posteriorly : Tip of the coccyx
• Laterally : Ischial tuberosity
• Anteriorly : Pubic arch

Pelvic dimensions

Since the transverse diameter is greater than the antero-posterior (AP) diameter in the pelvic inlet , the widest circumference of the fetal head descends in a transverse position . However, when it gets closer to the pelvic outlet , the nature of the pelvic floor muscles encourages the fetal head to rotate from a transverse position to an anterior-posterior position , as the AP diameter is greater than the transverse diameter .

Fetal head diameter varies depending upon the degree of neck flexion

It is also important to know how the circumference of the fetal head varies with different degrees of neck flexion:

• Suboccipitobregmatic (vertex, flexed) is 9.5cm
• Occipitofrontal (vertex, neutral flexion) is 11.0cm
• Submentobregmatic (face) is 9.5cm
• Verticomental (brow) is 13.5cm

Descent & engagement

It should be noted that descent and engagement occur together , rather than as completely separate/distinct stages, so consider them as 2 parts of the same process/stage.

The fetus descends into the pelvis.  

In the primigravida this is likely to occur from 38 weeks gestation onwards , in a multigravida woman , this may not occur until labour is established .

Descent is encouraged by :

• Increased abdominal muscle tone
• Braxton hicks in the late stages of pregnancy
• Fundal dominance of the uterine contractions during labour
• Increased frequency and strength of contractions during labour

As the head descends , it moves towards the pelvic brim in either the left or right occipito-transverse position (this means the occiput can be facing the left side or right side of the mother’s pelvis).

This is when the largest diameter of the fetal head descends into the maternal pelvis .

The term engagement is referring to the widest part of the fetal head successfully negotiating its way down deep into the maternal pelvis . Engagement is identified by abdominal palpation, where the fetal head is 3/5 th palpable or less .

As the fetus descends through the pelvis , fundal dominance of uterine contraction exerts pressure down the fetal spine towards the occiput, forcing the occiput to come into contact with the pelvic floor . When this occurs the fetal neck flexes (chin to chest) allowing the circumference of the fetal head to reduce to sub-occipitobregmatic (9.5cm).

In this position, the fetal skull has a smaller diameter which assists passage through the pelvis.

The pelvic floor has a gutter shape with a forward and downward slope , encouraging the fetal head to rotate from the left or right occipito-transverse position  a total of 90-degrees , to an occipital-anterior (occiput facing forward) position , to lie under the subpubic arch .

With each maternal contraction , the fetal head pushes down on the pelvic floor . Following each contraction, a rebound effect supports a small degree of rotation . Regular contractions eventually lead to the fetal head completing the 90-degree turn .

This rotation will occur during established labour and it is commonly completed by the start of the second stage . Further descent leads to the fetus moving into the vaginal canal and eventually, with each contraction, the vertex becomes increasingly visible at the vulva .

When the widest diameter of the fetal head successfully negotiates through the narrowest part of the maternal bony pelvis , the fetal head is considered to be ‘crowning’ .  This is clinically evident when the head , visible at the vulva , no longer retreats between contractions . Complete delivery of the head is now imminent and often the woman, who has been pushing, is encouraged to pant so that the head is born with control.

The occiput slips beneath the suprapubic arch allowing the head to extend . The fetal head is now born and will be facing the maternal back with its occiput anterior.

External rotation & restitution

Because the shoulders at the point of the head being delivered are only just reaching the pelvic floor they are often still negotiating the pelvic outlet and the fetus may naturally align its head with the shoulders. This is called restitution and visually you may see the head externally rotate to face the right or left medial thigh of the mother.

During the next contraction, the shoulders , having reached the pelvic floor , will complete their rotation from a transverse position to an anterior-posterior position . Evidence of this manoeuvre happening inside can be visualised by seeing the head externally rotating as the fetus keeps its spine aligned.

Delivery of the shoulders and body

Downward traction by the healthcare professional will assist the delivery of the anterior shoulder below the suprapubic arch.

This is followed by upward traction  assisting the delivery of the posterior shoulder.

The fetal body will be delivered by the contractions, the health professional’s role is only to assist safe negotiation of this last stage.

Faye Alabdulghafoor

Junior Doctor

Josh Chambers

Dr margaret bunting.

Midwife and Senior Lecturer in Medical Education

Other pages

• Product Bundles 🎉
• Join the Team 🙌
• Institutional Licence 📚
• OSCE Station Creator Tool 🩺
• Create and Share Flashcards 🗂️
• OSCE Group Chat 💬
• Newsletter 📰
• Advertise With Us

Join the community

Normal Labor and Delivery

• Author: Sarah Hagood Milton, MD; Chief Editor: Christine Isaacs, MD  more...
• Sections Normal Labor and Delivery
• Practice Essentials
• Stages of Labor and Epidemiology
• Mechanism of Labor
• Clinical History and Physical Examination
• Intrapartum Management of Labor
• Pain Control
• Questions & Answers

Labor is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus.

Stages of labor

Obstetricians have divided labor into 3 stages that delineate milestones in a continuous process.

First stage of labor

Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm

Divided into a latent phase and an active phase

The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix

Contractions become progressively more rhythmic and stronger

The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part

Second stage of labor

Begins with complete cervical dilatation and ends with the delivery of the fetus

In nulliparous persons, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia

In multiparous persons, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it [ 1 ]

Third stage of labor

The period between the delivery of the fetus and the delivery of the placenta and fetal membranes

Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes

Expectant management involves spontaneous delivery of the placenta

The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered [ 2 ]

Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord

Mechanism of labor

The mechanisms of labor, also known as the cardinal movements, involve changes in the position of the fetus’s head during its passage in labor. These are described in relation to a vertex presentation. Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as the following 7 discrete sequences [ 2 ] :

Internal rotation

Restitution and external rotation.

The initial assessment of labor should include a review of the patient's prenatal care, including confirmation of the estimated date of delivery. Focused history taking should elicit the following information:

Frequency and time of onset of contractions

Status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether the amniotic fluid is clear or meconium stained)

Fetal movements

Presence or absence of vaginal bleeding.

Braxton-Hicks contractions must be differentiated from true contractions. Typical features of Braxton-Hicks contractions are as follows:

Usually occur no more often than once or twice per hour, and often just a few times per day

Irregular and do not increase in frequency with increasing intensity

Resolve with ambulation or a change in activity

Contractions that lead to labor have the following characteristics:

May start as infrequently as every 10-15 minutes, but usually accelerate over time, increasing to contractions that occur every 2-3 minutes

Tend to last longer and are more intense than Braxton-Hicks contractions

Lead to cervical change

Physical examination

The physical examination should include documentation of the following:

Maternal vital signs

Fetal presentation

Assessment of fetal well-being

Frequency, duration, and intensity of uterine contractions

Abdominal examination with Leopold maneuvers

Pelvic examination with sterile gloves

Digital examination allows the clinician to determine the following aspects of the cervix:

Degree of dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated)

Effacement (assessment of the cervical length, which can be reported as a percentage of the normal 3- to 4-cm–long cervix or described as the actual cervical length)

Position (ie, anterior or posterior)

Consistency (ie, soft or firm)

Palpation of the presenting part of the fetus allows the examiner to establish its station, by quantifying the distance of the body (-5 to +5 cm) that is presenting relative to the maternal ischial spines, where 0 station is in line with the plane of the maternal ischial spines. [ 2 ]

Intrapartum management of labor

On admission to the labor and delivery suite, persons having normal labor should be encouraged to assume the position that they find most comfortable. Possibilities including the following:

Lying supine

Resting in a left lateral decubitus position

Management includes the following:

Periodic assessment of the frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position

Monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions; in most obstetric units, the fetal heart rate is assessed continuously [ 3 ]

With complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after each contraction. [ 3 ] Prolonged duration of the second stage alone does not mandate operative delivery if progress is being made, but management options for second-stage arrest include the following:

Continuing observation/expectant management

Operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean delivery.

Delivery of the fetus

Positioning of the patient for delivery can be any of the following [ 2 ] :

Supine with the knees bent (ie, dorsal lithotomy position; the usual choice)

Lateral (Sims) position

Partial sitting or squatting position

On the hands and knees

Episiotomy used to be routinely performed at this time, but current recommendations restrict its use to maternal or fetal indications

Delivery maneuvers are as follows:

The head is held in mid position until it is delivered, followed by suctioning of the oropharynx and nares

Check the fetus's neck for a wrapped umbilical cord, and promptly reduce it if possible

If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut

The fetus's anterior shoulder is delivered with gentle downward traction on its head and chin

Subsequent upward pressure in the opposite direction facilitates delivery of the posterior shoulder

The rest of the fetus should now be easily delivered with gentle traction away from the birthing parent

If not done previously, the cord is clamped and cut

The baby is vigorously stimulated and dried and then transferred to the care of the waiting attendants or placed on the birthing parent's abdomen

The following 3 classic signs indicate that the placenta has separated from the uterus [ 2 ] :

The uterus contracts and rises

The umbilical cord suddenly lengthens

A gush of blood occurs

Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus.

Pain control

Agents given in intermittent doses for systemic pain control include the following [ 4 ] :

Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours

Fentanyl, 50-100 mcg IV every hour

Nalbuphine, 10 mg IV or IM every 3 hours

Butorphanol, 1-2 mg IV or IM every 4 hours

Morphine, 2-5 mg IV or 10 mg IM every 4 hours

As an alternative, regional anesthesia may be given. Anesthesia options include the following:

Combined spinal-epidural

Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration. [ 1 , 2 ]

Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation. Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does not meet the definition of labor.

The first stage begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm. In Friedman’s landmark studies of 500 nulliparas, [ 5 ]  he subdivided the first stage into an early latent phase and an ensuing active phase. The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix. The contractions become progressively more rhythmic and stronger. This is followed by the active phase of labor, which usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part. The first stage of labor ends with complete cervical dilation at 10 cm. According to Friedman, the active phase is further divided into an acceleration phase, a phase of maximum slope, and a deceleration phase.

Characteristics of the average cervical dilatation curve is known as the Friedman labor curve, and a series of definitions of labor protraction and arrest were subsequently established. [ 6 , 7 ] However, subsequent data of modern obstetric population suggest that the rate of cervical dilatation is slower and the progression of labor may be significantly different from that suggested by the Friedman labor curve. [ 8 , 9 , 10 ]

The second stage begins with complete cervical dilatation and ends with the delivery of the fetus. The American College of Obstetricians and Gynecologists (ACOG) has suggested that a prolonged second stage of labor should be considered when the second stage of labor exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia for nulliparas. In multiparous persons, such a diagnosis can be made if the second stage of labor exceeds 2 hours with regional anesthesia or 1 hour without it. [ 1 ]

Studies performed to examine perinatal outcomes associated with a prolonged second stage of labor revealed increased risks of operative deliveries and maternal morbidities but no differences in neonatal outcomes. [ 11 , 12 , 13 , 14 ] Maternal risk factors associated with a prolonged second stage include nulliparity, increasing maternal weight and/or weight gain, use of regional anesthesia, induction of labor, fetal occiput in a posterior or transverse position, and increased birthweight. [ 13 , 14 , 15 , 16 ]

The third stage of labor is defined by the time period between the delivery of the fetus and the delivery of the placenta and fetal membranes. During this period, uterine contraction decreases basal blood flow, which results in thickening and reduction in the surface area of the myometrium underlying the placenta with subsequent detachment of the placenta. [ 17 ] Although delivery of the placenta often requires less than 10 minutes, the duration of the third stage of labor may last as long as 30 minutes.

Expectant management of the third stage of labor involves spontaneous delivery of the placenta. Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled cord traction of the umbilical cord. Andersson et al found that delayed cord clamping (≥180 seconds after delivery) improved iron status and reduced prevalence of iron deficiency at age 4 months and also reduced prevalence of neonatal anemia, without apparent adverse effects. [ 18 ]

A systematic review of the literature that included 5 randomized controlled trials comparing active and expectant management of the third stage reports that active management shortens the duration of the third stage and is superior to expectant management with respect to blood loss/risk of postpartum hemorrhage; however, active management is associated with an increased risk of unpleasant side effects. [ 19 ]

The third stage of labor is considered prolonged after 30 minutes, and active intervention, such as manual extraction of the placenta, is commonly considered. [ 2 ]

Epidemiology

As the childbearing population in the United States has changed, the clinical obstetric management of labor also has evolved since Friedman's studies. Data from number a studies have suggested that normal labor can progress at a rate much slower than that Friedman and Sachtleben [ 6 , 7 ] had described. Zhang et al examined the labor progression of 1162 nulliparas who presented in spontaneous labor and constructed a labor curve that was markedly different from Friedman's: The average interval to progress from 4-10 cm of cervical dilatation was 5.5 hours compared with 2.5 hours of Friedman's labor curve. [ 20 ] Kilpatrick et al [ 8 ] and Albers et al [ 9 ] also reported that the median lengths of first and second stages of labor were longer than those Friedman suggested.

A number of investigators have identified several maternal characteristics obstetric factors that are associated with the length of labor. One group reported that increasing maternal age was associated with a prolonged second stage but not first stage of labor. [ 21 ]

While nulliparity is associated with a longer labor compared to multiparas, increasing parity does not further shorten the duration of labor. [ 22 ] Some authors have observed that the length of labor differs among racial/ethnic groups. One group reported that Asian women have the longest first and second stages of labor compared with Caucasian or African American women [ 23 ] , and American Indian women had second stages shorter than those of non-Hispanic Caucasian women. [ 9 ] However, others report conflicting findings. [ 24 , 25 ] Differences in the results may have been due to variations in study designs, study populations, labor management, or statistical power.

In one large retrospective study of the length of labor, specifically with respect to race and/or ethnicity, the authors observed no significant differences in the length of the first stage of labor among different racial/ethnic groups. However, the second stage was shorter in African American women than in Caucasian women for both nulliparas (-22 min) and multiparas (-7.5 min). Hispanic nulliparas, compared with their Caucasian counterparts, also had a shortened second stage, whereas no differences were seen for multiparas. In contrast, Asian nulliparas had a significantly prolonged second stage compared with their Caucasian counterparts, and no differences were seen for multiparas. [ 26 ]

According to a systematic review of 13 trials involving 16,242 women, most women whose prenatal and childbirth care were led by a midwife had better outcomes compared with those whose care was led by a physician or shared among disciplines. Patients who received midwife-led pregnancy care were less likely to have regional analgesia, episiotomy, and instrumental birth and more likely to have no intrapartum analgesia or anesthesia, spontaneous vaginal birth, attendance at birth by a known midwife, and a longer mean length of labor. They were also less likely to have preterm birth and fetal loss before 24 weeks' gestation. However, the average risk ratio for caesarean births did not differ between groups, and there were no differences in fetal loss/neonatal death at 24 or more weeks' gestation or in overall fetal/neonatal death. [ 1 , 27 ]

Concerns associated with midwife-attended home births

However, concerns about the effect of midwife-attended home births on neonatal health were raised by an analysis of nearly 14 million singleton, full-term births, from 2007-2010, of infants of normal weight. The data, from the National Center for Health Statistics, indicated that delivering at home was associated with a greater than 10-fold increased risk for an Apgar score of 0 and a nearly 4-fold increased risk for neonatal seizure or serious neurologic dysfunction, as compared with hospital delivery. [ 28 , 29 ]

Compared with delivery by a hospital physician, midwife-attended home birth was associated with a relative risk (RR) of 10.55 for an Apgar score of 0. For midwife deliveries at freestanding birth centers, the RR was 3.56, and for hospital midwife deliveries, the RR was 0.55. [ 28 , 29 ]

In the same study, the RR for neonatal seizures or serious neurologic disorders for midwife-attended home births, compared with physician-attended hospital delivery, was 3.80. Compared with in-hospital physician delivery, the RR for midwife delivery at freestanding birth centers was 1.88, and for hospital midwife delivery, the RR was 0.74. [ 28 , 29 ]

The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies. Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as 7 discrete sequences, as discussed below. [ 2 ]

The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines.

The downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. The rate is greatest during the second stage of labor.

As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

As the head descends, the presenting part, usually in the transverse position, is rotated about 45° to anteroposterior (AP) position under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet.

With further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the pubic symphysis. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. This is followed by the delivery of the fetus' head.

When the fetus' head is free of resistance, it untwists about 45° left or right, returning to its original anatomic position in relation to the body.

After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus.

The initial assessment of labor should include a review of the patient's prenatal care, including confirmation of the estimated date of delivery. Focused history taking should be conducted to include information, such as the frequency and time of onset of contractions, the status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether the amniotic fluid is clear or meconium stained), the fetus' movements, and the presence or absence of vaginal bleeding.

Braxton-Hicks contractions, which are often irregular and do not increase in frequency with increasing intensity, must be differentiated from true contractions. Braxton-Hicks contractions often resolve with ambulation or a change in activity. However, contractions that lead to labor tend to last longer and are more intense, leading to cervical change. True labor is defined as uterine contractions leading to cervical changes. If contractions occur without cervical changes, it is not labor. Other causes for the cramping should be diagnosed. Gestational age is not a part of the definition of labor.

In addition, Braxton-Hicks contractions occur occasionally, usually no more than 1-2 per hour, and they often occur just a few times per day. Labor contractions are persistent, they may start as infrequently as every 10-15 minutes, but they usually accelerate over time, increasing to contractions that occur every 2-3 minutes.

Patients may also describe what has been called lightening, ie, physical changes felt because the fetus' head is advancing into the pelvis. The patient may feel that the baby has become light. As the presenting fetal part starts to drop, the shape of the patient's abdomen may change to reflect descent of the fetus. Breathing may be relieved because tension on the diaphragm is reduced, whereas urination may become more frequent due to the added pressure on the urinary bladder.

Physical examination should include documentation of the patient's vital signs, the fetus' presentation, and assessment of the fetal well-being. The frequency, duration, and intensity of uterine contractions should be assessed, particularly the abdominal and pelvic examinations in patients who present in possible labor.

Abdominal examination begins with the Leopold maneuvers described below [ 2 ] :

The initial maneuver involves the examiner placing both of his or her hands on each upper quadrant of the patient's abdomen and gently palpating the fundus with the tips of the fingers to define which fetal pole is present in the fundus. If it is the fetus' head, it should feel hard and round. In a breech presentation, a large, nodular body is felt.

The second maneuver involves palpation in the paraumbilical regions with both hands by applying gentle but deep pressure. The purpose is to differentiate the fetal spine (a hard, resistant structure) from its limbs (irregular, mobile small parts) to determinate the fetus' position.

The third maneuver is suprapubic palpation by using the thumb and fingers of the dominant hand. As with the first maneuver, the examiner ascertains the fetus' presentation and estimates its station. If the presenting part is not engaged, a movable body (usually the fetal occiput) can be felt. This maneuver also allows for an assessment of the fetal weight and of the volume of amniotic fluid.

The fourth maneuver involves palpation of bilateral lower quadrants with the aim of determining if the presenting part of the fetus is engaged in the patient's pelvis. The examiner stands facing the patient's feet. With the tips of the first 3 fingers of both hands, the examiner exerts deep pressure in the direction of the axis of the pelvic inlet. In a cephalic presentation, the fetus' head is considered engaged if the examiner's hands diverge as they trace the fetus' head into the pelvis.

Pelvic examination is often performed using sterile gloves to decrease the risk of infection. If membrane rupture is suspected, examination with a sterile speculum is performed to visually confirm pooling of amniotic fluid in the posterior fornix. The examiner also looks for fern on a dried sample of the vaginal fluid under a microscope and checks the pH of the fluid by using a nitrazine stick or litmus paper, which turns blue if the amniotic fluid is alkalotic. If frank bleeding is present, pelvic examination should be deferred until placenta previa is excluded with ultrasonography. Furthermore, the pattern of contraction and the patient's presenting history may provide clues about placental abruption.

Digital examination of the vagina allows the clinician to determine the following: (1) the degree of cervical dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated), (2) the effacement (assessment of the cervical length, which is can be reported as a percentage of the normal 3- to 4-cm-long cervix or described as the actual cervical length); actual reporting of cervical length may decrease potential ambiguity in percent-effacement reporting, (3) the position, ie, anterior or posterior, and (4) the consistency, ie, soft or firm. Palpation of the presenting part of the fetus allows the examiner to establish its station, by quantifying the distance of the body (-5 to +5 cm) that is presenting relative to the maternal ischial spines, where 0 station is in line with the plane of the maternal ischial spines). [ 2 ]

The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI). The pelvic planes include the following:

Pelvic inlet: The obstetrical conjugate is the distance between the sacral promontory and the inner pubic arch; it should measure 11.5 cm or more. The diagonal conjugate is the distance from the undersurface of the pubic arch to sacral promontory; it is 2 cm longer than the obstetrical conjugate. The transverse diameter of the pelvic inlet measures 13.5 cm.

Midpelvis: The midpelvis is the distance between the bony points of ischial spines, and it typically exceeds 12 cm.

Pelvic outlet: The pelvic outlet is the distance between the ischial tuberosities and the pubic arch. It usually exceeds 10 cm.

The shape of the patient's pelvis can also be assessed and classified into 4 broad categories based on the descriptions of Caldwell and Moloy: gynecoid, anthropoid, android, and platypelloid. [ 30 ] Although the gynecoid and anthropoid pelvic shapes are thought to be most favorable for vaginal delivery, many patients can be classified into 1 or more pelvic types, and such distinctions can be arbitrary. [ 2 ]

High-risk pregnancies can account for up to 80% of all perinatal morbidity and mortality. The remaining perinatal complications arise in pregnancies without identifiable risk factors for adverse outcomes. [ 31 ] Therefore, all pregnancies require a thorough evaluation of risks and close surveillance. As soon as the patient arrives at the labor and delivery suite, external tocometric monitoring for the onset and duration of uterine contractions and use of a Doppler device to detect fetal heart tones and rate should be started.

In the presence of labor progression, monitoring of uterine contractions by external tocodynamometry is often adequate. However, if a laboring person is confirmed to have rupture of the membranes and if the intensity/duration of the contractions cannot be adequately assessed, an intrauterine pressure catheter can be inserted into the uterine cavity past the fetus to determine the onset, duration, and intensity of the contractions. Because the external tocometer records only the timing of contractions, an intrauterine pressure catheter can be used to measure the intrauterine pressure generated during uterine contractions if their strength is a concern. While it is considered safe, placental abruption has been reported as a rare complication of an intrauterine pressure catheter placed extramembraneously. [ 32 , 33 ]

Bedside ultrasonography may be used to assess the risk of gastric content aspiration in pregnant persons during labor, by measuring the antral cross-sectional area (CSA), according to a study by Bataille et al. [ 34 , 35 ] In the report, which involved 60 women in labor who were under epidural analgesia, the investigators found that at epidural insertion, half of the women had an antral CSA of over 320 mm 2 , indicating that they were at increased risk of gastric content aspiration while under anesthesia. [ 34 , 35 ]

It was also found that the antral CSA was reduced during labor, falling from a median of 319 mm 2 at epidural insertion to 203 mm 2 at full cervical dilatation, with only 13% of the women at that time still considered at risk of aspiration. [ 34 , 35 ] This change, according to the investigators, suggested that even under epidural anesthesia, gastric motility is preserved.

Often, fetal monitoring is achieved using cardiotography, or electronic fetal monitoring. Cardiotography as a form of fetal assessment in labor was reviewed using randomized and quasirandomized controlled trials involving a comparison of continuous cardiotocography with no monitoring, intermittent auscultation, or intermittent cardiotocography. This review concluded that continuous cardiotocography during labor is associated with a reduction in neonatal seizures but not cerebral palsy or infant mortality; however, continuous monitoring is associated with increased cesarean and operative vaginal deliveries. [ 36 ]

If nonreassuring fetal heart rate tracings by cardiotography (eg, late decelerations) are noted, a fetal scalp electrode may be applied to generate sensitive readings of beat-to-beat variability. However, a fetal scalp electrode should be avoided if the birthing parent has HIV, hepatitis B or hepatitis C infections, or if fetal thrombocytopenia is suspected. A framework has been suggested to classify and standardize the interpretation of a fetal heart rate monitoring pattern according to the risk of fetal acidemia with the intention of minimizing neonatal acidemia without excessive obstetric intervention. [ 37 ]

The question of whether fetal pulse oximetry may be useful for fetal surveillance in labor was examined in a review of 5 published trials comparing fetal pulse oximetry and cardiotography with cardiotography alone. It concluded that existing data provide limited support for the use of fetal pulse oximetry when used in the presence of a nonreassuring fetal heart rate tracing to reduce caesarean delivery for nonreassuring fetal status. The addition of fetal pulse oximetry does not reduce overall caesarean deliveries. [ 38 ]

Further evaluation of a fetus at risk for labor intolerance or distress can be accomplished with blood sampling from fetal scalp capillaries. This procedure allows for a direct assessment of fetal oxygenation and blood pH. A pH of < 7.20 warrants further investigation for the fetus' well-being and for possible resuscitation or surgical intervention.

Routine laboratory studies of the parturient, such as complete blood cell (CBC) count, blood typing and screening, and urinalysis, are usually performed. Intravenous (IV) access is established.

Cervical change occurs at a slow, gradual pace during the latent phase of the first stage of labor. Latent phase of labor is complex and not well-studied since determination of onset is subjective and may be challenging as women present for assessment at different time duration and cervical dilation during labor. In a cohort of women undergoing induction of labor, the median duration of latent labor was 384 min with an interquartile range of 240-604 min. The authors report that cervical status at admission for labor induction, but not other risk factors typically associated with cesarean delivery , is associated with length of the latent phase. [ 39 ]

Most patients experience onset of labor without premature rupture of the membranes (PROM); however, approximately 8% of term pregnancies is complicated by PROM. Spontaneous onset of labor usually follows PROM such that 50% of women with PROM who were expectantly managed delivered within 5 hours, and 95% gave birth within 28 hours of PROM. [ 40 ]  The American College of Obstetricians and Gynecologists (ACOG) recommends that fetal heart rate monitoring should be used to assess fetal status and dating criteria reviewed, and group B streptococcal prophylaxis be given based on prior culture results or risk factors of cultures not available. Additionally, randomized controlled trials to date suggest that for women with PROM at term, labor induction, usually with oxytocin infusion, at time of presentation can reduce the risk of chorioamnionitis. [ 41 ]

According to Friedman and colleagues, [ 6 ] the rate of cervical dilation should be at least 1 cm/h in a nulliparous woman and 1.2 cm/h in a multiparous woman during the active phase of labor. However, labor management has changed substantially during the last quarter century. Particularly, obstetric interventions such as induction of labor, augmentation of labor with oxytocin administration, use of regional anesthesia for pain control, and continuous fetal heart rate monitoring are increasingly common practice in the management of labor in today’s obstetric population. [ 42 , 43 , 20 ] Vaginal breech and mid- or high- forceps deliveries are now rarely performed. [ 44 , 45 , 46 ] Therefore, subsequent authors have suggested normal labor may precede at a rate less rapid than those previously described. [ 8 , 9 , 20 ]

Data collected from the Consortium on Safe Labor suggests that allowing labor to continue longer before 6-cm dilation may reduce the rate of intrapartum and subsequent cesarean deliveries in the United States. [ 47 ] In the study, the authors noted that the 95 th percentile for advancing from 4-cm dilation to 5-cm dilation was longer than 6 hours; and the 95 th percentile for advancing from 5-cm dilation to 6-cm dilation was longer than 3 hours, regardless of the patient’s parity.

On admission to the labor and delivery suite, a person having normal labor should be encouraged to assume the position that is most comfortable. Possibilities including walking, lying supine, sitting, or resting in a left lateral decubitus position. Of note, ambulating during labor did not change the progression of labor in a large randomized controlled study of >1000 women in active labor. [ 48 ]

The patient and family or support team should be consulted regarding the risks and benefits of various interventions, such as the augmentation of labor using oxytocin, artificial rupture of the membranes, methods and pharmacologic agents for pain control, and operative vaginal delivery (including forceps or vacuum-assisted vaginal deliveries ) or cesarean delivery. They should be actively involved, and their preferences should be considered in the management decisions made during labor and delivery. [ 2 ]

The frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position should be assessed periodically to evaluate the progression of labor. Although progression must be monitored, vaginal examinations should be performed only when necessary to minimize the risk of chorioamnionitis, particularly in patients whose amniotic membrane has ruptured. During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions. In most labor and delivery units, the fetal heart rate is assessed continuously. [ 3 ]

Two methods of augmenting labor have been established. The traditional method involves the use of low doses of oxytocin with long intervals between dose increments. For example, low-dose infusion of oxytocin is started at 1 mili IU/min and increased by 1-2 mili IU/min every 20-30 minutes until adequate uterine contraction is obtained. [ 2 ]

The second method, or active management of labor, involves a protocol of clinical management that aims to optimize uterine contractions and shorten labor. This protocol includes strict criteria for admission to the labor and delivery unit, early amniotomy, hourly cervical examinations, early diagnosis of inefficient uterine activity (if the cervical dilation rate is < 1.0 cm/h), and high-dose oxytocin infusion if uterine activity is inefficient. Oxytocin infusion starts at 4 mili IU/min (or even 6 mili IU/min) and increases by 4 mili IU/min (or 6 mili IU/min) every 15 minutes until a rate of 7 contractions per 15 minutes is achieved or until the maximum infusion rate of 36 mili IU/min is reached. [ 49 , 2 ]

ACOG recommends amniotomy for patients undergoing augmentation or induction of labor to shorten the duration of labor. Additionally, either low- or high-dose oxytocin administration can be used for the active management of labor to reduce operative deliveries. [ 50 ]

Although active management of labor was originally intended to shorten the length of labor in nulliparous women, its application at the National Maternity Hospital in Dublin produced a primary cesarean delivery rate of 5-6% in nulliparas. [ 51 ] Data from randomized controlled trials confirmed that active management of labor shortens the first stage of labor and reduces the likelihood of maternal febrile morbidity, but it does not consistently decrease the probability of cesarean delivery. [ 52 , 53 , 54 ]

Although the active management protocol likely leads to early diagnosis and interventions for labor dystocia, a number of risk factors are associated with a failure of labor to progress during the first stage. These risk factors include premature rupture of the membranes (PROM), nulliparity, induction of labor, increasing maternal age, and or other complications (eg, previous perinatal death, pregestational or gestational diabetes mellitus, hypertension, infertility treatment). [ 55 , 56 ]

While the ACOG defines labor dystocia as abnormal labor that results form abnormalities of the power (uterine contractions or maternal expulsive forces), the passenger (position, size, or presentation of the fetus), or the passage (pelvis or soft tissues), labor dystocia can rarely be diagnosed with certainty. [ 1 , 50 ] Often, a "failure to progress" in the first stage is diagnosed if uterine contraction pattern exceeds 200 Montevideo units for 2 hours without cervical change during the active phase of labor is encountered. [ 1 ] Thus, the traditional criteria to diagnose active-phase arrest are cervical dilatation of at least 4 cm, cervical changes of < 1 cm in 2 hours, and a uterine contraction pattern of >200 Montevideo units. These findings are also a common indication for cesarean delivery.

Proceeding to cesarean delivery in this setting, or the "2-hour rule," was challenged in a clinical trial of 542 women with active phase arrest. [ 57 ] In this cohort of women diagnosed with active phase arrest, oxytocin was started, and cesarean delivery was not performed for labor arrest until adequate uterine contraction lasted at least 4 hours (>200 Montevideo units) or until oxytocin augmentation was given for 6 hours if this contraction pattern could not be achieved. This protocol achieved vaginal delivery rates of 56-61% in nulliparas and 88% in multiparas without severe adverse maternal or neonatal outcomes. Therefore, extending the criteria for active-phase labor arrest from 2 to at least 4 hours appears to be effective in achieving vaginal birth. [ 57 , 1 ]

When the patient enters the second stage of labor with complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after each contraction during the second stage. [ 3 ] Although the parturient may be encouraged to actively push in concordance with the contractions during the second stage, many persons with epidural anesthesia who do not feel the urge to push may allow the fetus to descend passively, with a period of rest before active pushing begins.

A number of randomized controlled trials have shown that, in nulliparous women, delayed pushing, or passive descend, is not associated with adverse perinatal outcomes or an increased risk for operative deliveries despite an often prolonged second stage of labor. [ 58 , 59 , 40 ] Furthermore, investigators who compared obstetric outcomes associated with coached versus uncoached pushing during the second stage reported a slightly shortened second stage (13 min) in the coached group, with no differences in the immediate maternal or neonatal outcomes. [ 60 ]

Le Ray et al reported that manual rotation of fetuses who were in occiput posterior or occiput transverse position at full dilatation was associated with reduced rates of operative delivery (ie, cesarean or instrumental vaginal delivery). [ 61 , 62 ] In a study involving 2 French hospitals, operative delivery rates were significantly lower at the institution whose policy favored manual rotation than at the one that favored modification of maternal position (23.2% vs 38.7%), mainly because of lower rates of instrumental deliveries (15.0% vs 28.8%).

When a prolonged second stage of labor is encountered, clinical assessment of the parturient, the fetus, and the expulsive forces is warranted. A randomized controlled trial performed by Api et al determined that application of fundal pressure on the uterus does not shorten the second stage of labor. [ 63 ] Although the 2003 ACOG practice guidelines state that the duration of the second stage alone does not mandate intervention by operative vaginal delivery or cesarean delivery if progress is being made, the clinician has several management options (continuing observation/expectant management, operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean delivery) when second-stage arrest is diagnosed.

The association between a prolonged second stage of labor and adverse maternal or neonatal outcome has been examined. While a prolonged second stage is not associated with adverse neonatal outcomes in nulliparas, possibly because of close fetal surveillance during labor, but it is associated with increased maternal morbidity, including higher likelihood of operative vaginal delivery and cesarean delivery, postpartum hemorrhage, third- or fourth-degree perineal lacerations, and peripartum infection. [ 11 , 12 , 13 , 14 ] Therefore, it is crucial to weigh the risks of operative delivery against the potential benefits of continuing labor in hopes to achieve vaginal delivery. The question of when to intervene should involve a thorough evaluation of the ongoing risks of further expectant management versus the risks of intervention with vaginal or cesarean delivery, as well as the patients' preferences.

When delivery is imminent, the patient is usually positioned supine with her knees bent (ie, dorsal lithotomy position), though delivery can occur with the patient in any position, including the lateral (Sims) position, the partial sitting or squatting position, or on her hands and knees. [ 2 ] Although an episiotomy (an incision continuous with the vaginal introitus) used to be routinely performed at this time, the ACOG recommended in 2006 that its use be restricted to maternal or fetal indications. Studies have also shown that routine episiotomy does not decrease the risk of severe perineal lacerations during forceps or vacuum-assisted vaginal deliveries. [ 64 , 65 ]

Crowning is the word used to describe when the fetal head forcibly extends the vaginal outlet. A modified Ritgen maneuver can be performed to deliver the head. Draped with a sterile towel, the heel of the clinician's hand is placed over the posterior perineum overlying the fetal chin, and pressure is applied upward to extend the fetus' head. The other hand is placed over the fetus' occiput, with pressure applied downward to flex its head. Thus, the head is held in mid position until it is delivered, followed by suctioning of the oropharynx and nares. Check the fetus' neck for a wrapped umbilical cord, and promptly reduce it if possible. If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut. Of note, some providers, in an attempt to avoid shoulder dystocia, deliver the anterior shoulder prior to restitution of the fetal head.

Next, the fetus' anterior shoulder is delivered with gentle downward traction on its head and chin. Subsequent upward pressure in the opposite direction facilitates delivery of the posterior shoulder. The rest of the fetus should now be easily delivered with gentle traction away from the birthing parent. If not done previously, the cord is clamped and cut. The baby is vigorously stimulated and dried and then transferred to the care of the waiting attendants or placed on the birthing parent's abdomen.

Third stage of labor - Delivery of the placenta and the fetal membranes

The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs. [ 2 ]

Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding.

Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental separation and delivery are awaited.

A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used). However, given the reduced risk of complications, this review recommends that active management is superior to expectant management and should be the routine management of choice. [ 19 ]

A multicenter, randomized, controlled trial of the efficacy of misoprostol (prostaglandin E1 analog) compared with oxytocin showed that oxytocin 10 IU IV or given intramuscularly (IM) was preferable to oral misoprostol 600 mcg for active management of the third stage of labor in hospital settings. [ 66 ] Therefore, if the risks and benefits are balanced, active management with oxytocin may be considered a part of routine management of the third stage. A study by Adnan et al that included 1075 women to compare intravenous oxytocin and intramuscular oxytocin for the third stage of labor reported that although intravenous oxytocin did not lower the incidence of standard postpartum hemorrhage, it significantly lowered the incidence of severe postpartum hemorrhage as well as lowering the frequency of blood transfusion and admission to a high dependency unit. [ 67 ]

After the placenta is delivered, the labor and delivery period is complete. Palpate the patient's abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal/vaginal lacerations should be carried out.

Franchi et al found that topically applied lidocaine-prilocaine (EMLA) cream was an effective and satisfactory alternative to mepivacaine infiltration for pain relief during perineal repair. In a randomized trial of 61 women with either an episiotomy or a perineal laceration after vaginal delivery, women in the EMLA group had lower pain scores than those in the mepivacaine group (1.7 +/- 2.4 vs 3.9 +/- 2.4; P = .0002), and a significantly higher proportion of women expressed satisfaction with anesthesia method in the EMLA group than in the mepivacaine group (83.8% vs 53.3%; P = .01). [ 68 ]

In a Cochrane review, Aasheim et al suggest that evidence is sufficient to support the use of warm compresses to prevent perineal tears. They also found a reduction in third-degree and fourth-degree tears with massage of the perineum to reduce the rate of episiotomy. [ 69 ]

The World Health Organization developed a checklist to address the major causes of maternal death (hemorrhage, infection, obstructed labor and hypertensive disorders), intrapartum-related stillbirths (inadequate intrapartum care), and neonatal deaths (birth asphyxia, infection and complications related to prematurity). [ 70 , 71 ]

Laboring patients often experience intense pain. Uterine contractions result in visceral pain, which is innervated by T10-L1. While in descent, the fetus' head exerts pressure on the pelvic floor, vagina, and perineum, causing somatic pain transmitted by the pudendal nerve (innervated by S2-4). [ 4 ] Therefore, optimal pain control during labor should relieve both sources of pain.

A number of opioid agonists and opioid agonist-antagonists can be given in intermittent doses for systemic pain control. These include meperidine 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours, fentanyl 50-100 mcg IV every hour, nalbuphine 10 mg IV or IM every 3 hours, butorphanol 1-2 mg IV or IM every 4 hours, and morphine 2-5 mg IV or 10 mg IM every 4 hours. [ 4 ] As an alternative, regional anesthesia may be given. Options are epidural, spinal, or combined spinal epidural anesthesia. These provide partial to complete blockage of pain sensation below T8-10, with various degree of motor blockade. These blocks can be used during labor and for surgical deliveries.

Studies performed to compare the analgesic effect of regional anesthesia and parenteral agents showed that regional anesthesia provides superior pain relief. [ 72 , 45 , 73 ] Although some researchers reported that epidural anesthesia is associated with a slight increase in the duration of labor and in the rate of operative vaginal delivery, [ 74 , 75 ] large randomized controlled studies did not reveal a difference in frequency of cesarean delivery between women who received parenteral analgesics compared with women who received epidural anesthesia [ 72 , 73 , 75 , 76 , 77 ] given during early-stage or later in labor. [ 78 ]

Additionally, an analysis of studies published since 2005 in a Cochrane review showed epidural analgesia was not associated with an increase in the rate of assisted vaginal delivery. [ 76 , 77 ] Although regional anesthesia is effective as a method of pain control, common adverse effects include maternal hypotension, maternal temperature >100.4°F, postdural puncture headache, transient fetal heart deceleration, and pruritus (with added opioids). [ 4 ]

Despite the many methods available for analgesia and anesthesia to manage labor pain, some persons may not wish to use conventional pain medications during labor, opting instead for a natural childbirth. Although these patients may use breathing and mental exercises to help alleviate labor pain, they should be assured that pain relief can be administered at any time during labor.

A Cochrane review update concluded that relaxation techniques and yoga may offer some relief and improve management of pain. Studies in the review noted increased satisfaction with pain relief and lower assisted vaginal delivery rates with relaxation techniques. One trial involving yoga noted reduced pain, increased satisfaction with pain relief, increased satisfaction with the childbirth experience, and reduced length of labor. [ 79 ]

Of note, use of nonsteroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated in the third trimester of pregnancy. The repeated use of NSAIDs has been associated with early closure of the fetal ductus arteriosus in utero and with decreasing fetal renal function leading to oligohydramnios.

ACOG made the following recommendations concerning delivery of a newborn with meconium-stained amniotic fluid [ 80 ] :

• Infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning. However, a team with full resuscitation skills that include endotracheal intubation should be available.
• The same procedures for resuscitation for infants with clear fluid should be followed for infants with meconium-stained fluid. 

What is labor?

How many stages of labor are there?

How is the first stage of labor characterized?

How is the second stage of labor characterized?

How is the third stage of labor characterized?

How are the cardinal movements of labor characterized?

What is included in the initial assessment of labor?

What are Braxton-Hicks labor contractions?

What are the characteristics of contractions that lead to labor?

What is included in the physical exam for evaluation of normal labor?

What is the role of a digital exam in the evaluation of normal labor?

How should a woman be positioned during the first stage of labor?

What monitoring is performed during the first stage of labor?

What are the options for management of a prolonged second stage of labor?

How is the mother positioned for delivery?

What maneuvers are used in the delivery of a fetus?

What are the classic signs of placenta separation from the uterus during labor?

How is pain managed during labor?

What are the local anesthesia options for normal labor and delivery?

How is labor defined?

What do the stages of labor delineate?

What is the first stage of labor?

What is the second stage of labor?

Which factors increase the risk for a prolonged second stage of labor?

What is the third stage of labor?

What is the difference between expectant and active management of the third stage of labor?

What are the benefits of active management of the third stage of labor?

How is a prolonged third stage of labor managed?

What is the average interval of the first and second stages of labor?

Which factors are associated with longer labor?

What maternal outcomes have been reported for midwife led labor and delivery?

What fetal outcomes have been reported for midwife-attended home labor and delivery?

What are the mechanisms of labor?

How is engagement during labor defined?

How is descent during labor defined?

How is flexion during labor defined?

How is internal rotation during labor defined?

How is extension during labor defined?

How is external rotation during labor defined?

How is expulsion during labor defined?

Which clinical history findings are characteristic of labor?

How is abdominal exam performed to evaluate normal labor?

How is a pelvic exam performed to evaluate normal labor?

Why is a digital exam performed in the evaluation of normal labor?

What is the anatomy of the pelvis relevant to labor and delivery?

What is the initial monitoring performed when a woman is in labor?

When is an intrauterine pressure catheter indicated for monitoring of women in labor?

What is the role of bedside ultrasonography in the monitoring of women in labor?

How is fetal monitoring performed during labor?

How is the first-stage of labor managed?

How is labor augmented?

What are the reported outcomes for active management of the first stage of labor?

Which factors increase the risk of failure to progress during the first stage of labor?

What is labor dystocia and how is it diagnosed and managed?

How is second-stage of labor managed?

How is prolonged second-stage labor managed?

What are the steps in the delivery of a fetus?

How is the third-stage of labor managed?

What is included in maternal care following the delivery of the placenta?

What is the role of pain management during labor and delivery?

What are the ACOG recommendations for the delivery of a newborn with meconium-stained amniotic fluid?

ACOG. American College of Obstetricians and Gynecologists Practice Bulletin. Dystocia and augmentation of labor. Clinical management guidelines for obstetricians-gynecologists. No 49 . American College of Obstetricians and Gynecologists: Washington, DC; December 2003.

Norwitz ER, Robinson JN, Repke JT. Labor and delivery. Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: Normal and problem pregnancies . 3rd ed. New York: Churchill Livingstone; 2003.

ACOG. American College of Obstetricians and Gynecologists Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring. Clinical Management Guidelines for Obstetricians-Gynecologists. No 36 . American College of Obstetricians and Gynecologists;: Washington, DC; December 2005.

ACOG. American College of Obstetricians and Gynecologists Practice Bulletin. Obstetric Analgesia and Anesthesia. Clinical Management Guidelines for Obstetricians-Gynecologists. No 36 . American College of Obstetricians and Gynecologists;: Washington, DC; July 2002.

Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol . 1955 Dec. 6(6):567-89. [QxMD MEDLINE Link] .

Friedman EA, Sachtleben MR. Dysfunctional labor. I. Prolonged latent phase in the nullipara. Obstet Gynecol . 1961 Feb. 17:135-48. [QxMD MEDLINE Link] .

Friedman EA, Sachtleben MR. Dysfunctional labor. II. Protracted active-phase dilatation in the nullipara. Obstet Gynecol . 1961 May. 17:566-78. [QxMD MEDLINE Link] .

Kilpatrick SJ, Laros RK Jr. Characteristics of normal labor. Obstet Gynecol . 1989 Jul. 74(1):85-7. [QxMD MEDLINE Link] .

Albers LL, Schiff M, Gorwoda JG. The length of active labor in normal pregnancies. Obstet Gynecol . 1996 Mar. 87(3):355-9. [QxMD MEDLINE Link] .

Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol . 2002 Oct. 187(4):824-8. [QxMD MEDLINE Link] .

Menticoglou SM, Manning F, Harman C, et al. Perinatal outcome in relation to second-stage duration. Am J Obstet Gynecol . 1995 Sep. 173(3 Pt 1):906-12. [QxMD MEDLINE Link] .

Janni W, Schiessl B, Peschers U, et al. The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome. Acta Obstet Gynecol Scand . 2002 Mar. 81(3):214-21. [QxMD MEDLINE Link] .

Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?. Am J Obstet Gynecol . 2004 Sep. 191(3):933-8. [QxMD MEDLINE Link] .

Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with a prolonged second stage of labor. Obstet Gynecol . 2003 Jul. 102(1):52-8. [QxMD MEDLINE Link] .

O'Connell MP, Hussain J, Maclennan FA, et al. Factors associated with a prolonged second state of labour--a case-controlled study of 364 nulliparous labours. J Obstet Gynaecol . 2003 May. 23(3):255-7. [QxMD MEDLINE Link] .

Senecal J, Xiong X, Fraser WD. Effect of fetal position on second-stage duration and labor outcome. Obstet Gynecol . 2005 Apr. 105(4):763-72. [QxMD MEDLINE Link] .

Herman A, Zimerman A, Arieli S, et al. Down-up sequential separation of the placenta. Ultrasound Obstet Gynecol . 2002 Mar. 19(3):278-81. [QxMD MEDLINE Link] .

Andersson O, Hellstrom-Westas L, Andersson D, Domellof M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ . 2011 Nov 15. 343:d7157. [QxMD MEDLINE Link] . [Full Text] .

Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev . 2000. CD000007. [QxMD MEDLINE Link] .

Zhang J, Yancey MK, Klebanoff MA, et al. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol . 2001 Jul. 185(1):128-34. [QxMD MEDLINE Link] .

Rasmussen S, Bungum L, Hoie K. Maternal age and duration of labor. Acta Obstet Gynecol Scand . 1994 Mar. 73(3):231-4. [QxMD MEDLINE Link] .

Vahratian A, Hoffman MK, Troendle JF, Zhang J. The impact of parity on course of labor in a contemporary population. Birth . 2006 Mar. 33(1):12-7. [QxMD MEDLINE Link] .

Tuck SM, Cardozo LD, Studd JW, et al. Obstetric characteristics in different racial groups. Br J Obstet Gynaecol . 1983 Oct. 90(10):892-7. [QxMD MEDLINE Link] .

Duignan NM, Studd JW, Hughes AO. Characteristics of normal labour in different racial groups. Br J Obstet Gynaecol . 1975 Aug. 82(8):593-601. [QxMD MEDLINE Link] .

Sills ES, Baum JD, Ling X, et al. [Average length of spontaneous labor in Chinese primigravidas]. J Gynecol Obstet Biol Reprod (Paris) . 1997. 26(7):704-10. [QxMD MEDLINE Link] .

Greenberg MB, Cheng YW, Hopkins LM, et al. Are there ethnic differences in the length of labor?. Am J Obstet Gynecol . 2006 Sep. 195(3):743-8. [QxMD MEDLINE Link] .

Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev . 2013 Aug 21. 8:CD004667. [QxMD MEDLINE Link] .

Grunebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol . 2013 Oct. 209(4):323.e1-6. [QxMD MEDLINE Link] .

Laidman J. Home Birth 10 Times More Likely to Result in Apgar of 0. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/811222 . Accessed: September 24, 2013.

Caldwell WE, Moloy HC. Anatomical variations in the female pelvis and their effect in labor with a suggested classification. Am J Obstet Gynecol . 1933. 26:479.

Friedman EA. Labor. Clinical evaluation and management . New York, NY: Appleton-Century-Crofts; 1967. 34.

Sciscione AC, Manley JS, Pinizzotto ME, et al. Placental abruption following placement of disposable intrauterine pressure transducer system. Am J Perinatol . 1993 Jan. 10(1):21-3. [QxMD MEDLINE Link] .

Rosen H, Yogev Y. Assessment of uterine contractions in labor and delivery. Am J Obstet Gynecol . 2023 May. 228 (5S):S1209-21. [QxMD MEDLINE Link] .

Boggs W. Ultrasonography Assesses Gastric Aspiration Risk During Labor. Medscape . Feb 7 2014. [Full Text] .

Bataille A, Rousset J, Marret E, et al. Ultrasonographic evaluation of gastric content during labour under epidural analgesia: a prospective cohort study. Br J Anaesth . 2014 Jan 8. [QxMD MEDLINE Link] .

Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev . 2006. 3:CD006066. [QxMD MEDLINE Link] .

Parer JT, Ikeda T. A framework for standardized management of intrapartum fetal heart rate patterns. Am J Obstet Gynecol . 2007 Jul. 197(1):26.e1-6. [QxMD MEDLINE Link] .

East CE, Chan FY, Colditz PB, et al. Fetal pulse oximetry for fetal assessment in labour. Cochrane Database Syst Rev . 2007 Apr 18. CD004075. [QxMD MEDLINE Link] .

Grobman WA, Simon C. Factors associated with the length of the latent phase during labor induction. Eur J Obstet Gynecol Reprod Biol . 2007 Jun. 132(2):163-6. [QxMD MEDLINE Link] .

Hansen SL, Clark SL, Foster JC. Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Obstet Gynecol . 2002 Jan. 99(1):29-34. [QxMD MEDLINE Link] .

ACOG Practice Bulletin No. 80: premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol . 2007 Apr. 109(4):1007-19. [QxMD MEDLINE Link] .

Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2004. Natl Vital Stat Rep . 2006 Sep 29. 55(1):1-101. [QxMD MEDLINE Link] .

Roberts CL, Taylor L, Henderson-Smart D. Trends in births at and beyond term: evidence of a change?. Br J Obstet Gynaecol . 1999 Sep. 106(9):937-42. [QxMD MEDLINE Link] .

Chinnock M, Robson S. Obstetric trainees' experience in vaginal breech delivery: implications for future practice. Obstet Gynecol . 2007 Oct. 110(4):900-3. [QxMD MEDLINE Link] .

Bofill JA, Vincent RD, Ross EL, et al. Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia. Am J Obstet Gynecol . 1997 Dec. 177(6):1465-70. [QxMD MEDLINE Link] .

Powell J, Gilo N, Foote M, et al. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol . 2007 Jun. 27(6):343-6. [QxMD MEDLINE Link] .

Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol . 2010 Dec. 116(6):1281-7. [QxMD MEDLINE Link] .

Bloom SL, McIntire DD, Kelly MA, et al. Lack of effect of walking on labor and delivery. N Engl J Med . 1998 Jul 9. 339(2):76-9. [QxMD MEDLINE Link] .

O'Driscoll K, Meagher D. Introduction. O'Driscoll K, Meagher D, eds. Active Management of Labour . 2nd ed. Eastbourne, United Kingdom: Balliere Tindall; 1986.

[Guideline] First and Second Stage Labor Management: ACOG Clinical Practice Guideline No. 8. Obstet Gynecol . 2024 Jan 1. 143 (1):144-62. [QxMD MEDLINE Link] .

O'Driscoll K, Foley M, MacDonald D. Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol . 1984 Apr. 63(4):485-90. [QxMD MEDLINE Link] .

Lopez-Zeno JA, Peaceman AM, Adashek JA, et al. A controlled trial of a program for the active management of labor. N Engl J Med . 1992 Feb 13. 326(7):450-4. [QxMD MEDLINE Link] .

Frigoletto FD Jr, Lieberman E, Lang JM, et al. A clinical trial of active management of labor. N Engl J Med . 1995 Sep 21. 333(12):745-50. [QxMD MEDLINE Link] .

Sadler LC, Davison T, McCowan LM. A randomised controlled trial and meta-analysis of active management of labour. BJOG . 2000 Jul. 107(7):909-15. [QxMD MEDLINE Link] .

Sheiner E, Levy A, Feinstein U, et al. Risk factors and outcome of failure to progress during the first stage of labor: a population-based study. Acta Obstet Gynecol Scand . 2002 Mar. 81(3):222-6. [QxMD MEDLINE Link] .

Sheiner E, Levy A, Feinstein U, et al. Obstetric risk factors for failure to progress in the first versus the second stage of labor. J Matern Fetal Neonatal Med . 2002 Jun. 11(6):409-13. [QxMD MEDLINE Link] .

Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol . 1999 Mar. 93(3):323-8. [QxMD MEDLINE Link] .

Fraser WD, Marcoux S, Krauss I, et al. Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group. Am J Obstet Gynecol . 2000 May. 182(5):1165-72. [QxMD MEDLINE Link] .

Fitzpatrick M, Harkin R, McQuillan K, et al. A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence. BJOG . 2002 Dec. 109(12):1359-65. [QxMD MEDLINE Link] .

Bloom SL, Casey BM, Schaffer JI, et al. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol . 2006 Jan. 194(1):10-3. [QxMD MEDLINE Link] .

Boggs W. Manual Rotation of Fetuses in Posterior or Transverse Position Might Reduce Operative Delivery Rates. Available at http://www.medscape.com/viewarticle/809311 . Accessed: August 20, 2013.

Le Ray C, Deneux-Tharaux C, Khireddine I, Dreyfus M, Vardon D, Goffinet F. Manual Rotation to Decrease Operative Delivery in Posterior or Transverse Positions. Obstet Gynecol . 2013 Aug 5. [QxMD MEDLINE Link] .

Api O, Balcin ME, Ugurel V, Api M, Turan C, Unal O. The effect of uterine fundal pressure on the duration of the second stage of labor: a randomized controlled trial. Acta Obstet Gynecol Scand . 2009. 88(3):320-4. [QxMD MEDLINE Link] .

Kudish B, Blackwell S, Mcneeley SG, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol . 2006 Sep. 195(3):749-54. [QxMD MEDLINE Link] .

Christianson LM, Bovbjerg VE, McDavitt EC, et al. Risk factors for perineal injury during delivery. Am J Obstet Gynecol . 2003 Jul. 189(1):255-60. [QxMD MEDLINE Link] .

Gülmezoglu AM, Villar J, Ngoc NT, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet . 2001 Sep 1. 358(9283):689-95. [QxMD MEDLINE Link] .

Adnan N, Conlan-Trant R, McCormick C, Boland F, Murphy DJ. Intramuscular versus intravenous oxytocin to prevent postpartum haemorrhage at vaginal delivery: randomised controlled trial. BMJ . 2018 Sep 4. 362:k3546. [QxMD MEDLINE Link] .

Franchi M, Cromi A, Scarperi S, Gaudino F, Siesto G, Ghezzi F. Comparison between lidocaine-prilocaine cream (EMLA) and mepivacaine infiltration for pain relief during perineal repair after childbirth: a randomized trial. Am J Obstet Gynecol . 2009 Aug. 201(2):186.e1-5. [QxMD MEDLINE Link] .

Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev . 2011 Dec 7. 12:CD006672. [QxMD MEDLINE Link] .

WHO Safe Childbirth Checklist. World Health Organization. Available at http://www.who.int/patientsafety/implementation/checklists/childbirth/en/ . December 2015; Accessed: February 25, 2016.

Brown T. WHO Releases Guidelines for Reducing Maternal, Newborn Deaths. Medscape Medical News. Available at http://www.medscape.com/viewarticle/855582 . December 08, 2015; Accessed: February 25, 2016.

Ramin SM, Gambling DR, Lucas MJ, et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol . 1995 Nov. 86(5):783-9. [QxMD MEDLINE Link] .

Sharma SK, Sidawi JE, Ramin SM, et al. Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor. Anesthesiology . 1997 Sep. 87(3):487-94. [QxMD MEDLINE Link] .

Alexander JM, Sharma SK, McIntire DD, et al. Epidural analgesia lengthens the Friedman active phase of labor. Obstet Gynecol . 2002 Jul. 100(1):46-50. [QxMD MEDLINE Link] .

Halpern SH, Muir H, Breen TW, et al. A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor. Anesth Analg . 2004 Nov. 99(5):1532-8; table of contents. [QxMD MEDLINE Link] .

Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev . 2018 May 21. 5 (5):CD000331. [QxMD MEDLINE Link] . [Full Text] .

Callahan EC, Lee W, Aleshi P, George RB. Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health. Am J Obstet Gynecol . 2023 May. 228 (5S):S1260-9. [QxMD MEDLINE Link] .

Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med . 2005 Feb 17. 352(7):655-65. [QxMD MEDLINE Link] .

Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev . 2011 Dec 7. 12:CD009514. [QxMD MEDLINE Link] .

Committee on Obstetric Practice. Committee Opinion No 689: Delivery of a Newborn With Meconium-Stained Amniotic Fluid. Obstet Gynecol . 2017 Mar. 129 (3):e33-e34. [QxMD MEDLINE Link] .

Contributor Information and Disclosures

Sarah Hagood Milton, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Health System Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT) A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute , American College of Obstetricians and Gynecologists , The Society of Federal Health Professionals (AMSUS) , American Medical Association , Utah Medical Association Disclosure: Nothing to disclose.

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists Disclosure: Nothing to disclose.

Bruce A Meyer, MD, MBA Executive Vice President for Health System Affairs, Executive Director, Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School Bruce A Meyer, MD, MBA is a member of the following medical societies: Medical Group Management Association , American College of Obstetricians and Gynecologists , American Association for Physician Leadership , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Massachusetts Medical Society , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Aaron B Caughey, MD, MPH, PhD Department Chair, Department of Obstetrics and Gynecology, Julie Newpert Stott Director of Center for Women's Health, Oregon Health and Science University School of Medicine Aaron B Caughey, MD, MPH, PhD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Society for Medical Decision Making , Society for Reproductive Investigation Disclosure: Nothing to disclose.

Yvonne Cheng, MD, MPH Adjunct Assistance Professor, Division of Maternal-Fetal Medicine, Departments of Obstetrics, Gynecology and Reproductive Science, University of California at San Francisco School of Medicine Yvonne Cheng, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Medical Association , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Faraaz Omar Khan, MD, and Mahpara Syed Razi, MD, to the development and writing of this article.

What would you like to print?

• Print this section
• Print the entire contents of
• Print the entire contents of article

• HIV in Pregnancy
• Cardiovascular Disease and Pregnancy
• Pulmonary Disease and Pregnancy
• Kidney Disease and Pregnancy
• Multifetal Pregnancy
• Vaccinations/Immunizations During Pregnancy
• Shock and Pregnancy
• Is immunotherapy for cancer safe in pregnancy?
• Are Nicotine Patches and E-Cigarettes Safe in Pregnancy?
• Prenatal Exercise Cuts Common Pregnancy Complications

• Drug Interaction Checker
• Pill Identifier
• Calculators

• 2020/viewarticle/immunotherapy-cancer-safe-pregnancy-2024a100083dnews news Is immunotherapy for cancer safe in pregnancy?
• 2003/viewarticle/993215Clinical Review Are Hypertensive Disorders of Pregnancy Associated With Heart Failure? 0.25 CME / CE / ABIM MOC Credits Clinical Review You are being redirected to Medscape Education Yes, take me there 0.25 CME / CE / ABIM MOC Are Hypertensive Disorders of Pregnancy Associated With Heart Failure?
• 2002261369-overviewDiseases & Conditions Diseases & Conditions Postterm Pregnancy
• 2002246123-overviewDiseases & Conditions Diseases & Conditions Kidney Disease and Pregnancy

Normal Labour

• First Online: 07 February 2022

Cite this chapter

• Priyanka Sara 4 ,
• Julie Whittington 5 &
• Nicola Lack 4  

1030 Accesses

The World Health Organisation (WHO) defines normal birth as one which is spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position [head down] between 37 and 42 completed weeks of pregnancy.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

World Health Organization, Maternal and Newborn Health/Safe Motherhood Unit. Care in normal birth: a practical guide. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/2413/2014/08/WHO_FRH_MSM_96.24.pdf . Accessed 24th August 2021.

National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies. Clinical Guideline 190. London: NICE; 2014. https://www.nice.org.uk/guidance/cg190/resources/intrapartum-care-for-healthy-women-and-babies-pdf-35109866447557 . Accessed 24th August 2021.

Moen V, Brudin L, Rundgren M, Irestedt L. Hyponatremia complicating labour – rare or unrecognised? A prospective observational study? BJOG. 2009;116:552–61.

Article   CAS   Google Scholar  

Zhang J, Klebanoff MA, DerSimonian R. Epidural analgesia in association with duration of labor and mode of delivery: a quantitative review. Am J Obstet Gynecol. 1999;180:970–7.

Download references

Author information

Authors and affiliations.

University College London Hospitals NHS Foundation Trust, London, UK

Priyanka Sara & Nicola Lack

Women’s Health Clinic, Naval Medical Center, Portsmouth, VA, USA

Julie Whittington

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Nicola Lack .

Editor information

Editors and affiliations.

Department of Anesthesiology, Intensive Care and Perioperative Medicine, Women’s Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar

Roshan Fernando

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA

Pervez Sultan

Department of Anaesthesia, Frimley Park Hospital, Frimley, UK

Sioned Phillips

Rights and permissions

Reprints and permissions

Copyright information

© 2022 Springer Nature Switzerland AG

About this chapter

Sara, P., Whittington, J., Lack, N. (2022). Normal Labour. In: Fernando, R., Sultan, P., Phillips, S. (eds) Quick Hits in Obstetric Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-030-72487-0_27

Download citation

DOI : https://doi.org/10.1007/978-3-030-72487-0_27

Published : 07 February 2022

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-72486-3

Online ISBN : 978-3-030-72487-0

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Online ordering is currently unavailable due to technical issues. We apologise for any delays responding to customers while we resolve this. For further updates please visit our website: https://www.cambridge.org/news-and-insights/technical-incident

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings .

Login Alert

• > The EBCOG Postgraduate Textbook of Obstetrics & Gynaecology
• > Normal Labour

Book contents

• The EBCOG Postgraduate Textbook of Obstetrics & Gynaecology
• Copyright page
• Contributors
• Section 1 Basic Sciences in Obstetrics
• Section 2 Early Pregnancy Problems
• Section 3 Fetal Medicine
• Section 4 Maternal Medicine
• Section 5 Intrapartum Care
• Chapter 43 Normal Labour
• Chapter 44 Issues during Labour for Migrant Populations
• Chapter 45 Prolonged Pregnancy
• Chapter 46 Induction of Labour
• Chapter 47 Intrapartum Fetal Monitoring
• Chapter 48 Augmentation of Labour
• Chapter 49 Analgesia and Anaesthesia during Labour
• Chapter 50 Preterm Labour
• Chapter 51 Management of Multiple Pregnancy during Labour
• Chapter 52 Abnormal Obstetric Presentation
• Chapter 53 Intrapartum Emergencies
• Chapter 54 Caesarean Section
• Chapter 55 Instrumental Operative Obstetrics
• Chapter 56 Maternal Collapse in Labour
• Chapter 57 Management of Postpartum Haemorrhage
• Chapter 58 Birth Injuries and Perineal Trauma
• Chapter 59 Management of Stillbirth
• Section 6 Neonatal Problems
• Section 7 Placenta
• Section 8 Public Health Issues in Obstetrics
• Section 9 Co-Morbidities during Pregnancy
• Plate Section (PDF Only)

Chapter 43 - Normal Labour

from Section 5 - Intrapartum Care

Published online by Cambridge University Press:  20 November 2021

Labour is defined as a series of physiological phenomena whereby the fetus, membranes and placenta are expelled from the uterus at a period in pregnancy where extrauterine survival is possible. The onset of labour implies the occurrence of rhythmic and effective uterine contractions that lead to progressive effacement and dilation of the cervix. This process is required before the fetus can progress through the birth canal.

Access options

Save book to kindle.

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle .

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service .

• Normal Labour
• By Silvia Serrano , Diogo Ayres-de-Campos
• Edited by Tahir Mahmood , Charles Savona Ventura , Ioannis Messinis , Sambit Mukhopadhyay
• Book: The EBCOG Postgraduate Textbook of Obstetrics & Gynaecology
• Online publication: 20 November 2021
• Chapter DOI: https://doi.org/10.1017/9781108863049.044

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox .

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive .

• Upload Ppt Presentation
• Upload Pdf Presentation
• Upload Infographics
• User Presentation
• Related Presentations

Brain Tumor

By: KhushbuSG Views: 481

Infectious Illnesses in Child

By: KhushbuSG Views: 367

Pharmacology of The Eye

By: KhushbuSG Views: 391

Neurology Diseases

By: KhushbuSG Views: 2840

The Human Genome And Human Evolution

By: KhushbuSG Views: 257

Cervical Cancer Awareness

By: KhushbuSG Views: 558

Fertilization Implantation And Early Development of The Embryo

By: KhushbuSG Views: 451

Hysterectomy

By: yourdoctors Views: 473

By: mochfids Views: 1440

Mechanisms and Management of Labor

By: JenniferDwayne Views: 1244

• About : Editor & Social Media Evangelist
• Occupation : Medical Professional
• Specialty : Other Health Professionals
• Country : India
• Website : http://blog.medicpresents.com/

HEALTH A TO Z

• Eye Disease
• Heart Attack
• Medications

• My presentations

Auth with social network:

Download presentation

We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!

Presentation is loading. Please wait.

MANAGEMENT OF NORMAL LABOUR

Published by Judith Morton Modified over 6 years ago

Similar presentations

Presentation on theme: "MANAGEMENT OF NORMAL LABOUR"— Presentation transcript:

Care of the Family in Childbirth

Out line Assess women during first stage Mechanism of labor.

Chapter 22: processes and stages of labor and birth

The course and conduct of normal labor and delivery

Length of Pregnancy A full term pregnancy is weeks. A full term pregnancy is weeks. Three trimesters of about 3 months each. Three trimesters.

Normal Labor and Delivery 正常分娩

Process and Stages of Labor and Birth Sarah Alkhaifi.

Labour “in labour” …..when uterine contractions reach sufficient strength, duration and frequency to cause effacement and dilatation of the cervix.

Presentation and prolapse of the umbilical cord

Childbirth Process.

How does it start? What are the stages? Are there signs?

Normal Labor and Delivery

Third stage of labour Dr.Roaa H. Gadeer MD.

Stages of Labor. The Beginning of Labor Lightening occurs pressure on upper abdomen is now reduced.

Emergency Medical Response You Are the Emergency Medical Responder You are the lifeguard at a local pool and are working as the emergency medical responder.

Breech presentation. Commonest malpresentation The lie is longitudinal The podalic pole presents at the pelvic brim.

What is labor? Labor is the chain of physiologic events that leads to the delivery of the fetus to the outside world. Labour may occur: Preterm (or prematuere)

Normal Birth The Mechanism of Normal labour

Notes Objective 3.03 Healthy Pregnancy & Delivery.

The Birth Process A baby is born Created by Mrs. Jane Ziemba

About project

© 2024 SlidePlayer.com Inc. All rights reserved.

PHYSIOLOGY OF NORMAL LABOUR

Oct 29, 2019

331 likes | 395 Views

PHYSIOLOGY OF NORMAL LABOUR. DEFINITION. Series of events that take place in the genital organs in an effort to expel the viable products of conception out of the womb through the vagina in to the outer world. Parturient is the patient in labour

Share Presentation

• normal labour
• true labour
• 3 cm dilatation
• fundal contraction cervical dilatation

Presentation Transcript

DEFINITION • Series of events that take place in the genital organs in an effort to expel the viable products of conception out of the womb through the vagina in to the outer world. • Parturient is the patient in labour • Parturition is the physiological process involved in birthing.

DEFINITION • EUTOCIA means normal labour. • DYSTOCIA means abnormal labour.

Criteria for Normal Labour • Spontaneous in onset and at term. • With vertex presentation. • Without undue prolongation. • Natural termination with minimal aids. • Without having any complication affecting the health of the mother and/or the baby. • 53% of women with singleton cephalic presentations at term had a spontaneous labour and delivery.

Causes for onset of Labour

STAGES OF LABOUR • FIRST STAGE- From the onset of true labour to complete dilatation of the cervix (6 to 18 hours in primigravida and 2 to 10 hours in a multipara). • SECOND STAGE- From complete dilatation of cervix to the birth of the baby (30 min to 3 hours in a primigravida, 5 to 30 min in multipara)

STAGES OF LABOUR • THIRD STAGE – From the birth of the baby to delivery of the placenta ( 5 to 30 min) • FOURTH STAGE – From the delivery of the placenta until the postpartum condition of the patient has become stabilized.

TRUE vs FALSE LABOUR • TRUE LABOUR • Contractions occur at regular intervals • Intervals gradually shorten • Intensity gradually increases • Discomfort is in the back and abdomen • Cervix dilates • Discomfort is not stopped by sedation • “Show” • Formation of “bag of waters”

TRUE vs FALSE LABOUR • FALSE LABOUR • Contractions occur at irregular intervals • Intervals remain long • Intensity remains unchanged • Discomfort is chiefly in the lower abdomen • Cervix does not dilate • Discomfort is relieved by sedation

EVENTS IN THE FIRST STAGE • UTERINE CONTRACTION AND RETRACTION • FORMATION OF DISTINCT LOWER AND UPPER SEGMENTS • CHANGE IN UTERINE SHAPE • CERVICAL DILATATION AND EFFACEMENT

Uterine contraction and retraction • Contraction is temporary reduction in length of the fibres, which attain full length on relaxation . • Retraction - permanent shortening of uterine muscle fibres • Initially come at varying intervals of 15-30 min for about 30 sec and in late first stage at intervals of 3-5 min lasting for 45 sec • Mechanical stretching of cervix enhances uterine activity FERGUSON REFLEX

CHARACTERISTICS OF UTERINE CONTRACTIONS • good synchronization of the contraction waves • Fundal dominance with gradual diminishing contraction wave through the mid zone to lower segment • Waves of contraction follow a regular pattern • Intra-amniotic pressure rises beyond 20mmHg with onset of true labour pains during contraction • Good relaxation occurs in between contractions

FORMATION OF DISTINCT LOWER AND UPPER SEGMENTS • Upper segment(active) - contracts, retracts & expels the fetus • Lower segment (passive) - thins & stretches • Physiological retraction ring is formed

CHANGES IN UTERINE SHAPE • With contractions produces elongation of uterine ovoid with decrease in horizontal diameter • Elongation of uterine ovoid causes the longitudinal muscles to taut and helps in cervical dilatation and formation of LUS • Decrease in horizontal diameter causes straightening of fetal vertebral column and exerts Fetal Axis Pressure.

CERVICAL DILATATION AND EFFACEMENT • Longitudinal muscle fibers of upper segment attached circular muscle fiber of lower segment & upper part of cervix in bucket holding fashion. • Polarity of Uterus- Co ordination between fundal contraction & cervical dilatation • Bag of membranes- Uterine contractions exert hydrostatic pressure through fetal membrane against cervix & lower uterine segment • Fetal axis pressure

Bag of membranes-

PHASES OF FIRST STAGE • The Latent Phase • Up to 3 cm dilatation • Dilatation averaging 0.39 cm/hour • Average latent phase lasts 8.6hrs in nulliparas and 5.3 hrs in multiparas • Upper limit is 20 hours in primigravidas and 14 hours in multiparas

PHASES OF FIRST STAGE • The Active Phase • Beyond 3cm dilatation • 1.2cm/hr for primigravida & 1.5cm/hr for multiparas • Average length of 5.8hrs in primigravida & 2.5 hrs in multiparas • Upper limit of 12 hrs for primigravida & 6hrs for multiparas

EVENTS IN THE SECOND STAGE • This stage is concerned with decent and delivery of the fetus • Contractions come at the intervals of 2-3min and last for about 1 to 1 ½ min • Expulsive forces of uterine contractions is added by voluntary contraction of abdominal muscles- Bearing Down Efforts

Evolution of dilatation and Decent curve

EVENTS IN THE THIRD STAGE • Comprises of placental separation, its decent and expulsion • Two ways of placental separation • Central (Schultze) • Marginal(Mathews-Duncan)

Two ways of placental separation

• More by User

MECHANISM OF LABOUR (NORMAL &amp; ABNORMAL)

MECHANISM OF LABOUR (NORMAL &amp; ABNORMAL). Presented By Dr. ZEINAB ABOTALIB MRCOG, DGO, Associate Professor &amp; Consultant Obs/Gyna Infertility &amp; IVF. Lie, presentation, attitude, &amp;position . FETAL LIE The relation of the long axis of the fetus to that of the mother

2.73k views • 27 slides

Bone: Normal Physiology and Response to Injury

Bone: Normal Physiology and Response to Injury. Wongworawat August 3, 2010. Structure. Cortical vs. Trabecular Woven vs. Lamellar Vascular supply Nutrient artery—intramedullary Periosteal Periarticular plexus. Extracellular Matrix. Mineral: 2/3 Hydroxyapatite Ca 10 (PO 4 ) 6 (OH) 2

657 views • 23 slides

Labor and Delivery : Physiology, Normal, Abnormal, and Preterm Labor

Labor and Delivery : Physiology, Normal, Abnormal, and Preterm Labor. William Goodnight, MD, MSCR Division of Maternal-Fetal Medicine. Images: googleimage.com; gabbeobstetrics.com. Objectives. Describe physiology of initiation of labor Define normal and abnormal labor

4.79k views • 55 slides

MECHANISM OF LABOUR NORMAL ABNORMAL

Lie, presentation, attitude,

1.85k views • 27 slides

NORMAL LABOUR INDUCTION OF LABOUR

LABOUR. Labour is a physiologic process during which the products of conception (i.e., the fetus, membranes, umbilical cord and placenta) are expelled outside the uterus.Labour is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine

2.1k views • 83 slides

Tutorial - Normal &amp; abnormal labour

Tutorial - Normal &amp; abnormal labour. Obstetric History. Age Gravidity Parity- (Preg&gt;24 wks)+(Preg&lt; 24wks) LMP; menst.cycle; conceived on pill; EDD

526 views • 24 slides

Normal Physiology of Motor Control

Normal Physiology of Motor Control. The intention to contract a skeletal muscle begins in the premotor area of the frontal lobes. This is where we plan our behaviour, the neurons compiling a program for the degree and sequence of muscle contractions required to perform an action. .

1.58k views • 9 slides

Normal Labour

Normal Labour. Lt Col Ambreen Anwer FRCOG. Labour. Onset of regular uterine contractions associated with effacement and cervical dilatation so that leads to expulsion of products of conception. Initiation of labour. Average human pregnancy lasts 280 days What triggers labour ?

1.15k views • 18 slides

Anatomy and physiology of the heart Embryology of normal heart and of the T4F

Anatomy and physiology of the heart Embryology of normal heart and of the T4F The congenital heart defects and the T4F. Anatomy and Physiology of the Heart. Fallot’ Project. http://www.nhlbi.nih.gov/health/dci/Diseases/hhw/hhw_anatomy.html

590 views • 22 slides

Department of Labour

ICT TRANSITION UPDATE. Department of Labour. 10 September 2013. BACKGROUND. The Department of Labour ( DoL ) entered into an Information Technology (IT) Public Private Partnership (PPP) with Siemens Business Services in 2002 for a period of ten years

365 views • 23 slides

DEPARTMENT OF LABOUR

DEPARTMENT OF LABOUR. RESPONSE ON THE EMPLOYMENT SERVICES BILL, 2012 PUBLIC COMMENTS. Response to concerns raised on the Employment Services Bill (Public hearings on 7-8/08/13). 1. Parliamentary hearings on amendments on EEA and PES Bills were held on 7-8/08/2013.

618 views • 47 slides

DEPARTMENT OF LABOUR LABOUR LAW AMENDMENTS

DEPARTMENT OF LABOUR LABOUR LAW AMENDMENTS. Briefing to the Select Committee on Labour and Public Enterprises. Background. Four bills published on 17 th December 2010: Labour Relations Amendment Bill, 2010 Basic Conditions of Employment Amendment Bill, 2010

408 views • 22 slides

Normal Skin Physiology

275 views • 7 slides

Normal Labour. Professor Razia Mustafa Abbasi. Labour. It is the process by which regular pain full uterine contraction bring about effacement and dilatation of cervix and decent of presenting part leading to explosion of the fetus and placenta from the mother. Term Labour. PTL.

2.21k views • 77 slides

Third stage of labour (Normal &amp; abnormal)

Third stage of labour (Normal &amp; abnormal). Dr. Abdalla H. Elsadig MD. Definition : 3 rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. Duration: - normally 5 to15 minutes.

834 views • 29 slides

Chapter 2 Normal Physiology: Hypoxia

Chapter 2 Normal Physiology: Hypoxia. Topics. Oxygen cascade from air-to-tissue Effects of reduced barometric pressure Alveolar ventilation equation Hyperventilation Acid-base changes Control of ventilation. Case Study #2: Bill. Mountain climber Hyperventilates on exposure to hypoxia

652 views • 27 slides

Physiology of Normal Labour and Childbirth

Physiology of Normal Labour and Childbirth. For you assessment you are required to revise those slides with white background. Slides with black ground would give you an idea about few practical aspects of childbirth and care of a woman in labour. http://www.youtube.com/watch?v=duPxBXN4qMg.

1.01k views • 24 slides

NORMAL LABOUR

NORMAL LABOUR. Prof. OSMAN DONIA. NORMAL LABOUR DEFINITIONS Labor &quot;Tocia&quot;: Labor is the process of expulsion of the fetus from the uterus after viability. Viability: Is a reasonable chance of the fetus for extrauterine survival (28 weeks in Egypt, 22 weeks in USA)

2.12k views • 63 slides

DEPARTMENT OF LABOUR Presentation to the Portfolio Committee on 2013/14 Annual Report Achievements and Challenges. OCTOBER 2014. 1. Table of contents. 1. Overview of DOL Programmes DOL Programmes 2013 / 2014 Annual Performance achievements, challenges and proposed interventions

431 views • 31 slides

699 views • 63 slides

PHYSIOLOGY OF NORMAL LABOUR . DR. POOJA RAJBHARA SENIOR RESIDENT. PARTURITION is defined as the process of bringing forth of young which comprises of multiple transformations in both uterine and cervical functions There are four phases : Quiescence, Activation phase, Stimulation phase,

787 views • 41 slides

DEPARTMENT OF LABOUR. EMPLOYMENT EQUITY AMENDMENT BILL, 2012. Objectives of the Amendments to the EEA. 1. To give effect to fundamental Constitutional rights, e.g. right to equality, fair labour practices and protection against unfair discrimination;

332 views • 31 slides

'Normal' Nigel Farage resonates with UK seaside voters

• Medium Text

ALL ABOUT NIGEL

Sign up here.

Editing by William James

Our Standards: The Thomson Reuters Trust Principles. New Tab , opens new tab

Thomson Reuters

Sarah reports on UK breaking news, with a focus on British companies. She has been a part of the UK bureau for 12 years covering everything from airlines to energy to the royals, politics and sport. She is a keen open water swimmer.

World Chevron

Putin, Kim agree to develop 'strategic fortress' relations, KCNA says

Russian President Vladimir Putin and North Korean leader Kim Jong Un agreed to develop their nations' relations, which have emerged a strategic fortress, during a meeting on the first day of Putin's visit to Pyongyang on Wednesday, North Korean state media.