Practice Essentials

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 women, 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 women, the second stage should be

considered prolonged if it exceeds 2 hours with regional
anesthesia or 1 hour without it

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 fetuss 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] :
1. Engagement
2. Descent
3. Flexion
4. Internal rotation

5. Extension
6. Restitution and external rotation
7. Expulsion

History
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-cmlong 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
First stage of labor
On admission to the Labor and Delivery suite, a woman having
normal labor should be encouraged to assume the position that
she finds most comfortable. Possibilities including the following:

Walking
Lying supine
Sitting
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]

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.[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 mother for delivery can be any of the

following[2] :

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

Lateral (Sims) position

Partial sitting or squatting position

On her 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 mother
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
mother's abdomen
Third stage of labor

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:

Epidural
Spinal
Combined spinal-epidural
Definition

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.

Stages of Labor and Epidemiology

Stages of Labor
Obstetricians have divided labor into 3 stages that delineate
milestones in a continuous process.
First stage of labor
The first stage begins with regular uterine contractions and ends
with complete cervical dilatation at 10 cm. In Friedmans 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]
Second stage of labor
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 women, 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]
Third stage of labor
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 1,162 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]

Mechanism of Labor
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]

Engagement
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.
Descent
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.

Flexion
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.
Internal rotation
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.
Extension
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.
Restitution and external rotation
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.

Expulsion
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.

Clinical History and Physical Examination

History
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 mother may feel that her baby has become light.
As the presenting fetal part starts to drop, the shape of the
mother's abdomen may change to reflect descent of the fetus.
Her 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
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 mother's pelvis. The examiner stands
facing the mother'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 percenteffacement 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 mother'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 women can be classified into 1 or more pelvic types, and
such distinctions can be arbitrary.[2]

Workup
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 mother

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 mother 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]
Bedside ultrasonography may be used to assess the risk of
gastric content aspiration in pregnant women during labor, by
measuring the antral cross-sectional area (CSA), according to a
study by Bataille et al.[33, 34] 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 mm2, indicating that they were at increased risk
of gastric content aspiration while under anesthesia.[33, 34]
It was also found that the antral CSA was reduced during labor,
falling from a median of 319 mm2 at epidural insertion to 203

mm2 at full cervical dilatation, with only 13% of the women at that
time still considered at risk of aspiration.[33, 34] 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.[35]
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 mother
has HIV, hepatitis B or hepatitis C infections, or if fetal
thrombocytopenia is suspected. Recently, 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.[36]
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.
[37]

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.

Intrapartum Management of Labor

First stage of labor
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 384min 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.[38]
Most women 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.[39] Currently, 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 oxytocininfusion, at time of
presentation can reduce the risk of chorioamnionitis.[40]
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 todays obstetric
population.[41, 42, 20] Vaginal breech and mid- or high-forceps
deliveries are now rarely performed.[43, 44, 45] 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.[46] In the study, the authors noted that the
95th percentile for advancing from 4-cm dilation to 5-cm dilation
was longer than 6 hours; and the 95th percentile for advancing
from 5-cm dilation to 6-cm dilation was longer than 3 hours,
regardless of the patients parity.
On admission to the Labor and Delivery suite, a woman having
normal labor should be encouraged to assume the position that
she finds 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.[47]
The patient and her 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 vacuumassisted 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 women whose amniotic
membrane has ruptured. During the first stage of labor, fetal wellbeing 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 12 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.[48, 2]
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.[49] 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.[50, 51, 52]
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).[53, 54]
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] 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 activephase 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.[55] 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.[55, 1]
Second stage of labor
When the woman 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 women 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.[56, 57, 39] Furthermore, investigators who recently 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.[58]

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).[59, 60] 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.[61] 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 vacuumassisted vaginal delivery, or cesarean delivery) when secondstage 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.
Delivery of the fetus
When delivery is imminent, the mother is usually positioned
supine with her knees bent (ie, dorsal lithotomy position), though
delivery can occur with the mother 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.[62, 63]
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 mother. 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 mother'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.[64] Therefore, if the risks and benefits are balanced, active
management with oxytocin may be consideredapartofroutine
management of the third stage.

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 lidocaineprilocaine (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).[65]
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.[66]

Pain Control
Laboring women 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 mother's

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 duringlabor 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.[67, 44, 68] 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,[69, 70] 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[67, 68, 70] given during
early-stage or later in labor.[71] Although regional anesthesia is
effective as a method of pain control, common adverse effects
include maternal hypotension, maternal temperature >100.4F,
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 women may not wish to use
conventional pain medications during labor, opting instead for a
natural childbirth. Although these women 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.[72]
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.