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Normal Labour

First stage Begins with regular contractions, or on admission to hospital with obvious signs of labour. Ends with cervix fully dilated (10cm).

Starts with foetal presenting part (usually the head) descended into the true pelvis to some degree. First stage can be divided into:

• Latent or quiet phase – contractions are not particularly painful and at 5–10 min intervals. Contractions become stronger with shorter interval although the cervix is still dilating relatively slowly, with membranes possibly breaking later in this phase.
• Active phase – starts with cervix 3–4cm dilated and is associated with more rapid dilatation normally at 0.5–1.0cm/hour. Once cervix is dilated to 9cm, towards end of active phase, contractions may be painful and women may want to push. Pushing is undesirable at this stage: need to establish whether cervix is fully dilated by vaginal examination. During this time the foetal head descends into maternal pelvis and the foetal neck flexes.

When the first stage of labour lasts >9 hours in a multiparous women or >12 hours in a nulliparous women, need to determine the cause.

Management

• Reassure and advise the patient on how her labour is going
• Measure 2 hourly pulse, temperature and BP
• Monitor contractions and foetal heart rate (FHR) - measure FHR every 15 minutes (should be 120-160 bpm), <100 bpm may indicate foetal distress ²
• Assess cervical dilatation and foetal head descent every 4 hours
• Ascertain patient's need for pain relief. There is no evidence of useful efficacy of TENS for labour pain.⁴ Acupuncture and hypnosis may be beneficial for the management of pain during labour.⁷
• Assess position of the foetal head with regard to the mother's pelvis.

Second stage Starts when cervix is fully dilated and ends with birth of baby. Contractions are stronger, occur at 2–5 min intervals and last 60–90 seconds. Foetal head descends deeply into the pelvis and rotates anteriorly so that the back of the foetal head is behind the mother's symphysis pubis (98% cases).

Woman also assists contractions by pushing to force the foetus further into the pelvis. Foetal head becomes more visible with each contraction until large part of the head can be seen.

Head is now born with first the forehead then the nose, mouth and chin. Soon the head rotates to allow the shoulders to be born next followed by the trunk and legs. After which baby should start to breathe and cry loudly.

Management

• Check for level of pain relief and supplement if required
• Ensure midwife/doctor is present at all times to encourage pushing during contractions and relaxing in between
• Monitor contractions and FHR – measure every 5 minutes (should be 120-160 bpm), if <100 bpm for >2 min then investigate possible causes (prolapsed cord, alter mother's position)
• Typically, if this stage is >2–3 hours then instrumental delivery should be considered
• There is no evidence that perineal massage during labour improves outcome in terms of perineal damage or its sequelae⁹
• There is debate about the optimal method to use during the second stage. There are two possible methods – 'hands on', where pressure is placed on the baby's head and the perineum supported, and 'hands poised' where these manoeuvres are not carried out. The 'hands poised' method may reduce episiotomy rates but more trials are needed to decide the issue.¹²

Position during 2nd stage of labour A recent Cochrane review tentatively suggests that there may be several possible benefits for the upright posture during labour, with a downside of possible increased risk of blood loss >500ml. As there currently exists no good evidence to dictate optimal position for labour, women should be encouraged to adopt the position that they find most comfortable.⁸

Third stage This stage starts with birth of the baby and ends with delivery of the placenta and membranes. Separation of the placenta occurs immediately after birth due to forceful uterine contractions along with retraction of the uterus, thus greatly reducing the size of the placental bed. It normally takes up to 5 mins but can take longer. Haemorrhaging is prevented by contraction of uterine muscle fibres closing off the blood vessels supplying the placenta. Without active management, after 10–20 mins separation is shown by gush of blood, prominence of the fundus in the abdomen and apparent lengthening of the umbilical cord.

Management Expectant (traditional) - once placenta lies in the vagina, uterus is 'rubbed up' to produce a contraction and the uterus is pushed towards the vagina to help with expulsion of placenta and membranes. These are held and twisted whilst pulling constantly so that membranes are kept intact.

Active - give IM synthetic oxytocin at appearance of foetal head.⁶ This takes ~2 mins to be effective and so baby is delivered slowly over next minute. The umbilical cord is clamped and cut soon after delivery. Once induced contraction is felt, the umbilical cord is used to pull out the placenta and membranes as above. In small proportion of cases, the placenta is not removed - repeat attempt after 10 min and then remove manually. In all cases the placenta and membranes are examined for completeness and any retained material removed under sterile conditions. Ergometrine-oxytocin compared to oxytocin alone shows a small but statistically significant reduction of minor postpartum haemorrhage. However, vomiting, nausea and hypertension occur significantly more frequently with ergometrine-oxytocin compared to oxytocin alone.³

Active management has been shown to be superior to expectant management with respect to blood loss, post-partum haemorrhage and other serious complications of the third stage. However, if ergometrine is used there is an increased incidence of side effects such as nausea, vomiting and hypertension. Active management should be used routinely for vaginal deliveries in a hospital setting. The implications are less clear for domiciliary deliveries.⁵

Water births Good-quality studies have shown that water births may significantly shorten the first stage of labour and reduce episiotomy rates and analgesic requirements. The technique appears to be safe if mothers are appropriately selected and correct hygiene procedures followed.^10,11

Continuous support during labour There is good evidence that women who receive continuous one-to-one support throughout their labour have better outcomes in terms of reduced analgesia requirements, decreased frequency of operative delivery and improved satisfaction with the experience. This effect was most pronounced when the supporter was not a member of hospital staff, gave support from early in labour and where epidural analgesia was not routinely available.¹³

References Used

1. Fundamentals of Obstetrics and Gynaecology 7th Edition. Llewellyn-Jones D. Mosby 1999.
2. Mires G, Williams F, Howie P; Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population.;BMJ 2001 Jun 16;322(7300):1457-60; discussion 1460-2.[abstract]
3. McDonald S, Abbott JM and Higgins SP; Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour.;Cochrane Database Syst Rev 2005; (3):CD000201.[abstract]
4. Bandolier Evidence-based thinking about health care. Transcutaneous electrical nerve stimulation (TENS) in labour pain.
5. Prendiville WJ, Elbourne D and McDonald S Active versus expectant management in the third stage of labour.; 2005; (1):CD000007.[abstract]
6. Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S Prophylactic use of oxytocin in the third stage of labour.;Cochrane Database Syst Rev 2005; (3):CD001808.[abstract]
7. Smith CA, Collins CT, Cyna AM, Crowther CA Complementary and alternative therapies for pain management in labour.;Cochrane Database Syst Rev 2005 ;(2):CD003521
8. Gupta JK, Hofmeyr GJ Position in the second stage of labour for women without epidural anaesthesia.;Cochrane Database Syst Rev 2005 ;(2):CD002006
9. Stamp G, Kruzins G and Crowther C Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. BMJ 2001 26 May;322:1277-1280 [Full text]
10. Thoni A, Zech N, Moroder L; Water birth and neonatal infections. Experience with 1575 deliveries in water.;Minerva Ginecol 2005 Apr;57(2):199-206.[abstract]
11. Gilbert RE and Tookey PA Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999 21 August;319:483-487 [abstract]
12. Clinical Evidence Perineal care: 'Hands poised' versus 'hands on'
13. Hodnett ED, Gates S, Hofmeyr G J, Sakala C Continuous support for women during childbirth.;Cochrane Database Syst Rev 2005 ;(2):CD003766

Internet and further reading

• Steer P and Flint C ABC of labour care: Physiology and management of normal labour.;BMJ 1999 20 March;318:793-796 [Full text]
• Bandolier Evidence-based thinking about healthcare. The GP's guide to home birth.
• Bandolier Evidence-based thinking about health care. Epidural analgesia in labour pain.
• American Family Physician Nothnagle M and Scott Taylor J. Cochrane for Clinicians: Should Active Management of the Third Stage of Labor Be Routine?

Acknowledgements EMIS is grateful to Dr Sean Kavanagh for updating this article from an original by doctoronline.nhs.uk. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2005.

Last issued 30 Aug 2006