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REVIEW

Mechanism and management of normal labour
Rita Arya Melissa Whitworth Tracey A Johnston

Abstract
It is important for providers of antenatal and intrapartum care to have an understanding of what constitutes normal labour. Complications may arise at any stage during labour, and early recognition and management may prevent serious sequelae. This review focuses on the physiology, mechanism and management of normal labour.

Keywords first stage; management of normal labour; normal labour;
physiology of normal labour; second stage

Physiology of normal labour
Term is the end of normal gestation in humans; the range for this is 37–42 weeks. Although the estimated date of delivery (EDD) is 280 days from the first day of the last menstrual period, only 3–5% of women deliver on their EDD. Labour is defined as regular uterine contractions that lead to progressive effacement and dilatation of the cervix. Towards the end of pregnancy, during the phase known as ‘pre-labour’, the tissues of the cervix undergo fundamental physiological and structural changes, resulting ­ in a marked reduction in tensile strength. It is this process of cervical ripening that converts the cervix into a soft, yielding structure that offers little resistance to the expulsive forces of the myometrium during labour. This process of cervical ripening is paralleled during pre-labour by an increase in the spontaneous contractility of the myometrium. The Braxton–Hicks contractions that are present throughout pregnancy increase exponentially in frequency and amplitude, reaching a peak during labour per se. The stimulus for the complex changes that result in labour is unknown. What is clear is that there is a complex interplay between maternal, fetal and placental factors. Cervix The main component of the cervix is collagen, along with some smooth muscle and elastin, all embedded in a connective tissue

ground substance. The smooth muscle is concentrated near the internal os, but as yet no clear function for it has been demonstrated in humans. The concentration of elastin in the cervix decreases during pregnancy, and it is deficient in the incompetent cervix, but little more is known about its role. The collagen fibrils are bound together in dense bundles and are embedded in the ground substance, which comprises proteoglycans and glycosaminoglycans (GAGs), including chondroitin sulphate and dermatan sulphate. The main cellular component of the cervix is fibroblasts, which produce the collagen and GAGs. At term, the cervix hypertrophies and an inflammatory-type reaction occurs, with a neutrophil polymorphonuclear leucocytosis that is believed to be partly mediated via interleukins. Cervical ripening is associated with a reduction in collagen concentration, an increase in water content and a change in the GAG composition. Fibroblast activation occurs and local prostaglandin production increases. Prostaglandins increase cervical ripening at term by altering the GAG content and structure, and by inducing collagen breakdown. The decrease in cervical collagen is paralleled by a concurrent increase in collagenase and neutrophil elastase. It is likely that cervical ripening is a result of a change in the balance between these various pro-inflammatory and anti-inflammatory agents, with prostaglandins involved in both the initiation of this process and the final common pathway. Myometrium The myometrium comprises bundles of smooth muscle cells, or myocytes, embedded in a connective tissue matrix abundant in collagen fibres that provides a framework to coordinate the transmission of the forces generated by contraction of the myocytes. The myocytes contain actin and myosin filaments that interact and form cross-bridges, resulting in contraction. The actin–myosin interaction is regulated by myosin light chain kinase and is calcium dependant via calmodulin. It is essential during labour that the activity of the myocytes is closely coordinated to ensure the generation of efficient uterine contractions. The myocytes coordinate their activity through intercellular connections called gap junctions that allow metabolic and electrophysiological communication between the cells, enabling them to act as a functional syncytium. In the myometrium, unlike other muscle tissues in the body, the actin filaments interact with the entire length of the myosin filaments, resulting in greater shortening at each contraction and hence the production of cervical effacement, dilatation, delivery and involution of the uterus. Hormones Maternal: progesterone is so called as it supports pregnancy. It is made by the corpus luteum until approximately 7–8 weeks gestation and subsequent to this is produced by the placenta. Progesterone is known to have potent anti-inflammatory properties, and antiprogestins have been demonstrated to effectively induce cervical ripening. Progesterone has an inhibitory effect on contractile proteins via its ability to block the formation of gap junctions. It also decreases prostaglandin production and inhibits oxytocin release and the formation of oxytocin receptors. Although there is no systemic decrease in progesterone with advancing gestation, there is a decrease in the number of progesterone receptors and thus, most likely, a decrease in local progesterone concentration in the cervix and myometrium.
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Rita Arya MRCOG Specialist Registrar in Obstetrics and Gynaecology, St Mary’s Hospital, Hathersage Road, Manchester M13 0JH, UK. Melissa Whitworth MD MRCOG Clinical Lecturer in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Liverpool Women’s Hospital, Crown Street, Liverpool L8 7SS, UK. Tracey A Johnston MD MRCOG Consultant in Fetal Maternal Medicine, St Mary’s Hospital, Hathersage Road, Manchester M13 0JH, UK.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8

© 2007 Elsevier Ltd. All rights reserved.

The commonest complication of the third stage is haemorrhage. but the number of oxytocin receptors in the myometrium and decidua increases during pregnancy. PGE2 promotes cervical ripening and PGF2α increases intracellular calcium. which also may contribute to the initiation of labour. The pH of the fetal blood decreases during the second stage and therefore if the fetus is already compromised when pushing commences. Prostaglandins are produced from arachidonic acid by cyclo-oxygenase. is initially produced by the corpus luteum and later in the pregnancy by the placenta. Other placental hormones produced by the decidua and placenta also have important roles in the onset of labour. The second stage has two phases: an initial passive phase. Third stage The third stage commences at the time of delivery of the baby and ends with delivery of the placenta and membranes.5 cm and dilates from being closed to 3–4 cm. Oxytocin also stimulates prostaglandin synthesis by the decidua and fetal membranes. which stimulates the conversion of progesterone to oestrogen. and ending with the mother and fetus in a good condition following a spontaneous delivery. The second stage usually lasts 2 hours in primiparous women and 1 hour in multiparous women. Cervical ripening is associated with an increase in local prostaglandin production and administration of prostaglandin induces physiological cervical ripening in the absence of uterine contractility. and a second. Labour is traditionally divided into three stages. Active management of the third stage involves early clamping and cutting the umbilical cord and giving the mother an oxytocic agent before gentle cord traction is applied while guarding the fundus to deliver the placenta and membranes once signs of separation have been seen. Placental: the placental unit produces various hormones important in the physiology of labour. An unduly prolonged second stage is associated with adverse outcomes for the fetus and the mother. resulting in a positive effect on uterine activity. production of glycogen by the fetal liver and the production of gut enzymes. The progesterone/oestrogen ratio decreases during the end of pregnancy. Prostaglandins are pivotal in both cervical ripening and myometrial contractility. These include activin A and follistatin. The level of corticotrophin-releasing hormone (CRH) increases towards the end of pregnancy. Progress in labour varies between nulliparous and multiparous women and between spontaneous ­ and induced labour. Oxytocin is an octapeptide hypothalamic hormone stored in the posterior pituitary that induces uterine contractions and increases the strength and frequency of existing contractions. CRH potentiates the effects of prostaglandins and oxytocin on uterine contractility and increases prostaglandin production by the decidua and membranes. A deficiency of PGF2α has been demonstrated in dysfunctional labour. with cervical dilatation usually occurring at a minimum of 1 cm/h. The active phase is also variable in length. GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8 © 2007 Elsevier Ltd. Commonly administered oxytocic agents include Syntocinon 5 iu and Syntometrine (Syntocinon 5 iu and ergometrine 0. It has been suggested that CRH may have an active role in the onset of labour. Second stage The second stage of labour begins at full dilatation and ends with delivery of the baby. Human chorionic gonadotrophin (hCG) is a glycoprotein produced by the syncytiotrophoblast. with a peak in maternal plasma level during labour. labour and delivery is not clear and the literature is conflicting. It promotes fetal lung maturation. a 1 hour active phase and 1 hour to assess the woman and ensure delivery occurs. . All rights reserved. Normal labour The WHO defines normal labour as low risk throughout. which increases myometrial contractility. the latent phase can last 3–8 hours and is shorter for multiparous women. spontaneous in onset. The fetal adrenal gland produces cortisol. There is a gradual increase in the oestrogen concentration (both oestriol and oestradiol) during the third trimester of pregnancy. The peptide hormone relaxin. The third OBSTETRICS. with the fetus in a vertex presentation throughout. which has been shown to reduce the incidence of blood loss greater than 500 ml from 15% to 5%. The second phase of the first stage is the active phase. but it should be no longer than 3 hours (without an epidural). which is to stimulate hCG and progesterone production by the placenta. reaching a peak during early labour. the latter inhibits the effect of activin. oxytocin receptor concentration and uterine contractility. when regular uterine activity leads to full dilatation of the cervix. Fetal: the fetal pituitary gland secretes oxytocin. which promotes uterine quiescence during pregnancy. It appears to exert its effects by altering calcium influx and efflux in the myocytes. Signs of spontaneous separation of the placenta include a gush of vaginal blood. An excessively prolonged second stage may be associated with urinary tract damage and vesicovaginal fistula formation. The role of relaxin in pregnancy. Fetal cortisol has other roles in preparing the fetus for birth. the presenting part descends onto the pelvic floor and uterine activity may decrease. which begins with full dilatation and ends ­ when bearing down efforts begin. These properties have been exploited pharmacologically 228 in the use of exogenous prostaglandins for cervical ripening and induction of labour. lengthening of the umbilical cord and a rise in the uterine fundus. The fetal membranes and the decidua produce prostaglandins PGE2 and PGF2α respectively.REVIEW Oestrogen has an action opposing that of progesterone. During the passive phase. Labour is associated with significantly elevated prostaglandin concentrations in both the amniotic fluid and the systemic circulation. increasing prostaglandin production. The duration of these phases is variable. It stimulates production of ­ relaxin and supports the corpus luteum to maintain production of progesterone and oestrogen. hypoxia can occur. There is no change in the systemic concentration of oxytocin until the late first stage of labour. allowing for a 1 hour passive phase. The total duration is variable.5 mg). expulsive phase when active maternal pushing occurs. but this can be reduced by active management. First stage The first stage has an initial latent phase when the cervix shortens to less than 0. The role of prostacyclin is unclear but it is known to inhibit uterine contractility.

The commonest situation is with the fetus in a longitudinal lie with a cephalic presentation and a well-flexed attitude. the suboccipitofrontal diameter leads (approximately 10 cm). The pelvis has three important diameters. Extension of the fetal neck allows the fetal face to sweep the perineum and the chin to be delivered. Internal rotation of the shoulders occurs as the sacrum rotates anteriorly. OBSTETRICS. which is associated with a mentovertical dia­­meter of 13. but may last up to 1 hour under physiological conditions.5 cm and often a long. but often not until the onset of labour in multiparous women. and contraction of the mid-pelvis ­ is suspected if the ischial spines are prominent or the pubic arch is narrow. The occiput passes under the subpubic arch and distends the perineum. This is also known as restitution. With moderate flexion. as it is dependant on the presenting part. In the UK. Not all fetuses follow this pattern. Low-risk women may choose to delivery in a midwifery-led unit. Other mechanisms Other mechanisms occur with malposition of the fetus. dysfunctional labour. The fetal manoeuvres that occur during the mechanism of labour to allow the fetus to traverse the pelvic diameters in the optimal position are described below. Descent of the fetal head occurs progressively during labour secondary to contraction and retraction of the myometrium. second twin). It occurs secondary to the descent of the presenting part. Also. it is associated with relative cephalopelvic disproportion. The midcavity of the pelvis is round. A brow presentation is unstable. the leading part of the fetal head (the occiput) rotates anteriorly from a transverse position (appropriate for the pelvic inlet) into an anteroposterior position. The head is engaged when the widest diameter of the presenting part (the biparietal diameter in a cephalic presentation) has passed the pelvic brim or inlet. 229 Delivery is completed by lateral flexion. The shoulders rotate internally to an anterior–posterior diameter to traverse the pelvic outlet. If the brow persists at full dilatation. With a well-flexed vertex presentation. the two parietal eminences and the posterior edge of the anterior fontanelle) hits the pelvic floor first and rotates anteriorly. resulting in a degree of rotation of the fetal neck. If vaginal delivery occurs.g. the head is fixed in the pelvis and is no more than twoto three-fifths palpable per abdomen. All rights reserved. to pass the ischial spines (appropriate for the pelvic outlet). If rotation to a mentoanterior position occurs.5 cm).REVIEW stage lasts 5–15 minutes if actively managed. The fetal shoulders remain in the transverse diameter at this point so they can enter the pelvis through the widest pelvic diameter. In these circumstances. while consultant-led units serve women who have shared or total hospital antenatal care. rotation to an occipitoanterior position usually occurs before delivery. in which case successful vaginal delivery can be achieved. Crowning of the head occurs when the fetal head no ­longer recedes between contractions and the biparietal diameter is delivered. a brow presentation may occur. a face presentation by full dilatation. The hip is delivered under the symphysis pubis by lateral flexion of the body and restitution occurs once the posterior buttock is delivered.5 cm. A face presentation results if extension rather than flexion occurs in early labour. Once engaged. Flexion of the fetal neck ensures that smaller diameters of the fetal head present that can negotiate the pelvis more easily. and women should have choice in terms of place of delivery. Mechanism of normal labour Descent of the fetus through the pelvis is a prerequisite for vaginal delivery. posture during labour. most convert to a deflexed vertex or. The face presentation continues to descend with increasing extension when the chin reaches the pelvic floor. With right or left occipitoposterior positions at the onset of labour. because this diameter is wider than the conventional suboccipitobregmatic diameter. External rotation of the head after delivery to a transverse position allows the head to come back into line with the shoulders. the vertex (the area bounded by the anterior edge of the posterior fontanelle. The pelvic inlet has a wide transverse diameter of approximately 13 cm. A direct occipitoposterior position is associated with an occipitofrontal diameter of 11. GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8 © 2007 Elsevier Ltd. Some occipitoposterior positions arrest during internal rotation in an occipitotransverse position. The Changing Childbirth Initiative in the UK highlighted the importance of maternal preferences. Rotation to sacroposterior after delivery of the body leads to difficulty in delivery of the head and should be prevented. which can rarely be delivered spontaneously. there is usually cephalopelvic disproportion and delivery should be undertaken by caesarean section unless the baby is small (e. and the head descends into the pelvis with the sagittal suture in the transverse diameter. pain relief options and birth partners. delivery can occur by flexion of the neck. . and this is followed by lateral flexion upwards of the baby to deliver the posterior shoulder. Gentle downward traction of the head allows delivery of the anterior shoulder. when the vertex is pushed down onto the anterior slope of the pelvic floor by the uterine contractions. At least 10% of low-risk labours become high risk and so facilities for transfer from one unit to another should be available. The fetus has to undergo a series of important manoeuvres to negotiate its journey through the maternal pelvis. The mechanism of labour for breech presentation involves descent. If extension is incomplete. The pelvic outlet has a wide anterior–posterior diameter. women may choose to deliver at home or in hospital. preterm. The head undergoes internal rotation and is delivered with flexion of the neck. resulting in an occipitoanterior position with the occiput as the denominator. but with good flexion this converts to the suboccipitobregmatic diameter (9. Engagement of the fetal head occurs in the weeks before the onset of labour in nulliparous women. occasionally. internal rotation of the buttocks and descent of the bitrochanteric diameter in the anteroposterior diameter. Internal rotation of the fetal head occurs during descent. the sinciput emerges from under the symphysis pubis. the chin lies in the hollow of the sacrum and there is no mechanism for delivery of the baby vaginally as the fetal neck can extend no further. Management of labour The aim of management of labour is to achieve a good outcome for mother and baby. If the internal rotation results in a mentoposterior position.

as these may be indicators of ­disproportion. Recordings include maternal pulse. this usually means around four contractions of good strength every 10 minutes. Pain relief In the antenatal period. Care must be taken when tachysystole (too-frequent contractions) 230 The modified Bishop score used to assess progress of labour Modified Bishop score Cervical length (cm) Cervical dilatation Cervical consistency (cm) Position of cervix Station Table 1 0 1 2 3 >4 <1 Firm Posterior Sp–3 2–4 1–2 Medium Mid/anterior Sp–2 1–2 2–4 Soft – <1 >4 – – Sp–1 to +1 >Sp+1 occurs. the passenger (the fetus) and the passages (the pelvis). and is a graphical representation of the changes that occur in labour. however. Once the woman is in active labour. Relative cephalopelvic disproportion can occur when a wider diameter of the fetal head is trying to negotiate the normal pelvic diameters. During labour. It should not. The colour of the liquor should also be recorded. ­ Assessing fetal well-being Currently in the UK. all of which decrease uterine activity. be started during the latent phase of labour – it is a tool to be used during established labour. Assessing maternal well-being Women should be advised to attend for evaluation of labour if they have any of the following symptoms: •  possible rupture of the membranes •  regular uterine contractions •  vaginal bleeding •  severe back. This can be difficult. All rights reserved. and by the changing cervical status and the descent of the presenting part on vaginal examination. fetal heart rate. Various factors influence uterine activity. Before the onset of labour and at the beginning of labour. . The heart rate should be recorded on the partogram. opiates such as pethidine and diamorphine. tocolytics and sedation. Assessing progress of labour Progress of labour is assessed by the strength and frequency of the contractions. Good psychological support is important and can be provided by birth partners. Passages: abnormality of the bony pelvis may cause a delay in the progress of labour. cervical dilatation. OBSTETRICS. Epidural analgesia may slow the second stage and is associated with an increased incidence of operative vaginal delivery. Cervical assessment also provides information about the station of the presenting part in relation to the ischial spines. as in malposition. the progress is influenced by three factors: the powers (uterine activity). Past obstetric and medical history should be sought along with any antenatal complications. Passenger: the progress of labour is influenced by fetal size and fetal position. maternal observations including pulse rate and blood pressure should be recorded every 2 hours and temperature every 4 hours. however. and diagnosis of labour at the wrong time can lead to misdiagnosis or missed diagnosis of slow progress. Analgesia can be provided in various forms including transcutaneous nerve stimulation. The development of caput and moulding are important. abdominal or pelvic pain. It is an important recording tool and its use has been shown to reduce operative intervention by allowing early recognition and therefore correction of poor progress in labour. Thus. A midwife performs the initial assessment of the woman. Cephalopelvic disproportion may occur between a macrosomic fetus and a pelvis of normal proportion. in a low-risk labour. but this have little or no effect on the active phase of labour. colour of liquor and drugs administered. and oxytocics.REVIEW An important role of the midwife is to accurately diagnose the onset of labour. blood pressure. progress of labour must not be judged by contractions alone. One-to-one support in labour is associated with reduced requirements for pain relief and less operative intervention. and regional analgesia. The partogram was developed in 1972 by Hugh Phillpott. both of which result in increased intervention. in terms of cervical dilatation and descent of the presenting part. the modified Bishop score (Table 1) allows objective assessment of the vaginal examination findings. The progress of labour in the latent phase may be slowed by opiate or epidural analgesia. descent of the presenting part. as the uteroplacental circulation is compromised during ­ contractions and there must be enough rest time between contractions to allow the fetus to reoxygenate or compromise will occur. and more is required in others. In established labour. as well as an improved birth experience for the mother. nitrous oxide. the woman should be advised about options available for pain relief during labour. the fetal heart is intermittently auscultated and the fetal heart rate recorded every 15 minutes in the first stage and after every contraction for 1 minute in the second stage. With improvements in maternal nutrition. Urinalysis should be performed initially and urine output should be recorded. such abnormalities are less common than in the past. temperature. midwives or doulas. Abdominal palpation should be performed to assess the descent of the presenting part. which enhance uterine activity. and this situation should be assessed by an experienced midwife regarding the need for episiotomy. delivery is achieved with less uterine activity in some cases. including epidural anaesthesia. GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8 © 2007 Elsevier Ltd. Powers: uterine activity should be frequent enough and strong enough to ensure that progress occurs. A rigid perineum can occasionally lead to delay in delivery.

decreased progesterone/ oestrogen ratio. Squatting increases the pelvic diameter by 8 mm and is similar to the McRoberts’ position. leading to fetal and maternal hypoxia. All rights reserved. Changes of position may help the progress of labour and provide comfort to women who feel that they wish to move round as much as possible. leading to the changes in cervical ripening and uterine contractility that result in labour •  Cervical ripening is promoted by prostaglandin E2 •  The following exert a positive effect on uterine activity: prostaglandins. CRH. despite this being associated with increased intervention. oxytocin. ◆ Practice points •  The mechanism of initiation of labour remains uncertain •  Once the fetus is mature. The woman should be encouraged to deliver in whatever position she feels comfortable with as long as fetal well-being can be confirmed. GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8 231 © 2007 Elsevier Ltd. . many women elect to be in a semirecumbent position. cushions. neural and mechanical factors interact. and has been shown to reduce intervention •  Maternal condition is monitored by regular observations of pulse. Other women choose to deliver standing upright or on their hands and knees. a rocking chair and gym balls. increased progesterone/oestrogen ratio •  During labour. blood pressure. mats on the floor. temperature and urine output •  Fetal condition is assessed by fetal heart rate monitoring and the colour of the liquor •  Progress of labour is monitored by assessing cervical dilatation and the descent of the presenting part •  It is also important to record the frequency and strength of uterine contractions •  One-to-one care in labour has been shown to reduce intervention OBSTETRICS. The supine position should always be avoided as it results in hypotension due to compression of the vena cava. which is used as a manoeuvre to aid delivery in cases of shoulder dystocia. various hormonal. the fetal head engages and descends into the maternal pelvis in the transverse diameter •  Descent and internal rotation then occur to an occipitoanterior position in the well-flexed fetus.REVIEW Posture in labour An environment helpful to the mother may include ample space and the use of aids such as a birth pool. influx of calcium into myocytes •  The following exert a negative effect on uterine activity: hCG. dependant on good uterine contractions •  Following delivery. the fetal head restitutes to lie in line with the shoulders •  Management of labour involves regular assessment of fetal and maternal condition and the progress of labour •  A partogram is a useful tool to record maternal and fetal well-being and assess the progress of labour. In the late first stage of labour.