REVIEW

The management of
normal labour

Sue Taylor Jim Thornton

MRCOG FRCOG

A
lthough many people hold strong opinions about recent years towards a 'physiological' third stage.
the management of normal labour. these are often In this review, we address the questions listed in Table I ,
based upon weak evidence. Many former standard using, where possible. evidence from randomised contrrol-
practices, such as the universal administration of enemas or led trials. The conclusions apply to low-risk labours only.
the routine use of episiotomy, have been modified or
abandoned. Changes of this kind may be in response to W.IIEKII SIIOI '1.1) K~OllI;hI.:\HOI K!
evidence from randomised trials, from re-evaluation of At present, fewer than 2% of births in the IJK take place
observational data, or simply as a result of a move to a less at h0me.l It is frequently assumed that labour in hospital
paternalistic style of practice. Patient pressure or campaigns must be safer than in the home. However, careful analysis
by groups such as the National Childblrth Trust also have a of the perinatal mortality figures for the various sites of
role - a notable example being the increased tendency in delivery do not support the view that hospital is safer for
low-risk pregnancies.
Table 1. Management decisions and type of evidence available Recent prospective studies in the Netherlands, where
31% of women give birth at home,2 and in the UK,3
Decision Evidence conclude that there is no increased risk. The IJK study
Home versus hospital delivery Prospective observational studies looked at 3466 home deliveries over a period of 14 years,
Continuous fetal monitoring Randomised controlled trials and from 1981 to 1994. It found that, although the overall
versus intermittent auscultation observational studies perinatal mortality was higher for home deliveries (38.7
Active management of labour Randomised controlled trial per 1000 against 9.7 per loPo>, this was due almost
versus non-intervention entirely to deliveries that had originally been booked for
Eating and drinking in labour Small randomised controlled trial, hospital (45 per 1000 for unplanned home deliveries
too small to assess clinical against 1.6 per 1000 for planned home deliveries). The
outcome perinatal mortality rate for planned home deliveries was
Position during labour Randomised controlled trial less than half that of the hackground population. The
Benefits and disadvantages of Randomised controlled trials for total number of perinatal deaths in the planned home
routine analgesia opiate and epidural anaesthesia delivery group was 14 and, of these, 11 actually delivered
Pharmacologicalcontraction Randomised controlled trial in hospital. One hundred and thirty-four deaths had
of the uterus versus actually occurred following home delivery but? of these,
physiologicalmanagement of
the third stage
131 were to women who had either planned hospital
delivery or who had received no antenatal care.

?he Obstetriciun G Gynuecolqyist April 2001 Vol.3 No. 2 69

Rwm Sue Taylor, Jim Thornton
A recent meta-analysis of six controlled observational
studies4 concluded likewise that there was no significant
difference in the risk of perinatal mortality for planned
home birth, when backed up by a modern hospital
system in the Western world.
Others have reached different conclusions. In one
Australian study5 the risk of intraparturn death at home in
normally formed term mfants was three times the national
average (2.7 per 1000 compared to 0.9 per 1000). However,
many were post-term, twins o r breech presentations, which
would usually be regarded as contraindications to home
delivery. Thus, as with the Dutch study, international com-
parisons must be made with caution. The applicabilityof data
from other countries is possibly limited by differences in the
population characteristics, supporting facilities and in the
distances involved.
It may be that any risks of home delivery in low--risk
women are too low to detect, or that they are balanced out
by other adverse factors operating in hospital (greater risk of
cross-infection, injudicious intervention). In the absence of
adequate randomised controlled trials, it is not surprising that
expert opinion differs. For low-risk pregnancies, it is reason-
able to follow the advice of the 1993 Changing Childbitfh
report," which stated that women should 'be able to choose
where they would like their baby to tx born' and that
'purchasers should ensure that home birth is a real option'.
An alternative arrangement is a midwife-led unit within or
adjacent to an obstetric unit. Low-risk women allocated to
such units have fewer interventions such as episiotomy or
analgesic use than those randomised to consultant-led care,'
without any countervailing increase in other adverse events.
I . Jl() \ I T ( ) H I \ ( J
FI~,'l'..l
Fetal monitoring during labour consists of either continuous
internal or external electronic fetal monitoring ( E M ) or
intermittent auscultation (IA) at 15-minute intervals. EFM is
preferable in high-risk pregnancies,*but there is controversy
over the best method of monitoring in low-risk pregnancies.
A Cochrane systematic review of 12 randomised controlled
trials of fetal monitoring in low-risk labours9 concluded that
their was no clear difference in either intrapartum deaths or
Cerebral palsy, when EFM was compared with LA, although
EFM increased the caesarean section rate. The authors noted
that this did not occur in settings where fetal blood sampling
was used as an adjunct to EFM. The numbers of perinatal
deaths and cerebral palsy cases was small, so the confidence
interval around the estimate of no effect on these end-points
was wide. The largest trial" clearly showed that EFM pre-
vented neonatal convulsions, which may predict cerebral
palsy. However, it was also noted in the same study that
there was no difference in the rate of cerebral palsy at the
age of one year. This was reinforced by a further study at
four years of age, in which there was likewise no difference
in the rates of cerebral palsy." The comparison of the two
methods was performed in a setting where TA by a midwife
in constant attendance was standard, so any differences in
70 The Obstetriciari G Gynaecologist April 2001
outcome may be more marked in units that are less well
staffed and where EFM has been in use for some time. In
less well-staffed units, a high standard of intermittent aus-
cultation might be more difficult to achieve. In addition. the
intraparturn stillbirth rate of this group was much lower than
that of most LJK units at the time (perinatal mortality rate of
2.2 per 1000). Against these arguments, the increasing avail-
ability of portable Doppler devices means that the level of
skill needed for successful recording of IA is lower.
Other mechanical methods of assessing fetal well-being
are in the early stages of development. Devices capable of
analysing the ST segment of the fetal ECG have also been
associated with a reduced intervention rate12 when used for
high-risk labours in conjunction with EFM. Analysis of this
kind is not generally available and experience in its use is at
present limited. Tts use in low-risk labour has not been
investigated. Other researchers have concentrated on the
development of fetal pulse oximetry, using a scalp probe.'j
To conclude, the benefit of EFM in low-risk pregnancy is
unproven and, if reliable blood sanipling is not available or
not possible, it increases caesarcan section rates. This is why
most reviews recommend IA, preferably with a portdde
Doppler device. However, uncertainty about the lack of
effect on intraparturn death and a belief in the reassurance
given hy a constant record probably explain why this advice
is often ignored. This belief that EFM prevents some intra-
partum deaths even in low-risk pregnancies is compatible
with trial results, if observational studies are given some
weight.14 If women regard this as worth an extra risk of
caesarean section, it is reasonable to use EFM. To minimise
the effect of an increased caesarean section rate, it should be
backed up with fetal blood sampling (ST segment waveform
monitoring is a possible future alternative).
:\(.'I'I\ 1.: . \ f . \ S . \ ( ; I ' \ l I , \ ' l ' 0 1 , 1 . \ 1 3 0 1 J<
During the 1960s, a protocol for the active management of
normal labour was established at the National Maternity
Hospital in Dublin.lj This comprised special antenatal
classes, rigorous criteria for the diagnosis of labour, early
amniotomy, early recourse to oxytocin, a designated mid-
wife in constant attendance and a guarantee that labour
would last no longer than 12 hours from diagnosis. Initial
results suggested that this policy prevented the dramatic
rise in caesarean section rates noted elsewhere during the
1970s, and it rapidly became popular, assisted by increased
use of the partogram.lb However, the effect on caesarean
section rates has not been confirmed by subsequent trials
of the individual components." The two largest trials of
early amniotomy in isolation show that it is associated with
a reduced duration of labour and no detrimental effect on
fetal outcome, but has no effect on caesarean section rate
or instrumental delivery rate.l8J9 Likewise, routine early
use of oxytocin is not associated with any benefits.20Only
one component - the provision of continuous S U P ~ O I Zby
a midwife - is associated with a reduced incidence o f
operative delivery and of other adverse events.ll The effect
Vol. 3 No. 2

on caesarean section rate was only demonstrated in
settings where partners were excluded from the labour
ward, which is not current UK practice. In response to
criticisms that these trials did not assess the whole package
of care, one group in Boston evaluated all components
together and randomised 2000 nulliparous women to either
active management in accordance with the O’Driscoll
criteria or to normal care.22The rate of caesarean section
did not alter. The only advantage was a reduction in the
apparent duration of labour from an average of nine hours
to six hours, but part of this was probably an artefact of the
stricter diagnostic criteria in the ‘activemanagement’group.
The policy for low-risk normal labour should be to follow
women’s preferences for the timing of amniotomy and the
use of oxytocin but not to leave them alone in labour.
EATING IN LABOUR
Oral intake is often restricted during labour to reduce the
risk of gastric aspiration should general anaesthesia be
required. Recommendations are difficult to make, as the last
but one Confidential Enquiry into Maternal Deaths in the
UKZ3only included two such cases, and the latest Enquiry24
had no deaths attributable to this cause. It may be that this
is partly due to a widespread policy of minimising oral
intake. Fasting does not guarantee an empty stomach, but
lowers the pH of the residual gastric fluid and contributes
to dehydration and ketosis, necessitating intravenous fluids.
In order to prevent ketosis, most units now allom7 low-risk
women in labour to have oral fluids and an increasing
number also permit low-residue solid food. In a 1999 trial25
involving 94 women randomised to receive either a light
solid diet (cereal, toast or biscuits) or water only for the
duration of labour, the light diet prevented ketosis but
increased the residual gastric volume. There were no
differences in the duration of first or second stage of labour,
oxytocin requirements, mode of delivery, Apgar scores or
umbilical artery and venous blood samples. Although
gastric pH was not measured, the increase in residual gastric
volume was associated with the presence of unabsorbed
solid food particles, and the authors suggested that isotonic
high-calorie drinks might maintain nutrition and hydration
while minimising gastric volume. An alternative suggestion
is the routine administration of H, receptor blockers to
reduce gastric acidity but, again, studies have been too
small to show any effect on gastric aspiration syndrome.
MOBILITY AND POSTURE IN LABOUR
An upright poshire may assist fetal descent and increase
the pelvic diameters, and avoids the risk of vena caval
compression.26Although many women like to have the
opportunity to be ambulatory early in labour, few remain
upright for long and most lie down as labour progresses;
no effect on mode of delivery or analgesia requirement is
apparent.,‘ In the second stage, women who adopt an
upright posture have less pain, a shorter second stage and
are less likely to have either a perineal tear or an episi-
isbe Obstetrician G Gynaecologist April 2001 Vol. 3 No. 2
The management of normal labour REVIM
otomy, although labial tears are more c o r n m o r ~ . ~ * , ~ ~
Blrth in water has become increasingly popular. In one
observational including over 2000 waterblrths,
women who delivered in water had lower rates of both
episiotomy and third- or fourthdegree tears, reduced blood
loss and lower levels of analgesia. Rates of perinatal infection
were not increased and no cases of water aspiration were
seen. However, there have been no randomised controlled
trial.. . A British survey of over 4000 waterblrths from April
1994 to March 19963l found no deaths attxibutable to birth in
water, but there were two admissions to the special care baby
unit for water aspiration. The RCOG issued a statement, Birth
in Watw, in January 2001, which stated that women ‘should
be cared for by attendants who have appropriate experience’.
PAIN RELJEF
The four most widely used forms of pain relief for labour in
the UK are transcutaneous electronic nerve stimulation
(TENS), nitrous oxide, intramuscular narcotics ( e g pethi-
dine) and epidural analgesia. Although the efficacy of TENS
has been disputed, neither it nor nitrous oxide has been
associated with any important adverse effects. Pethidine is
the most commonly used opiate and the only one that can
be prescribed by midwives. It is associated with maternal
nausea and drowsiness, causes reduced variability of the
fetal heart rate and, If given close to delivery, causes neo-
natal respiratory depression. Diamorphine is more effective
and causes less nausea.32Other opiates such as m e p t ~ i n o l ~ ~
have been tried, with no clear advantage over pethidine.
The largest and most recently published randomised
controlled trial showed a signifcant difference in the rate of
instrumental delivery, with the group who received epidurals
having a higher rate.34A Cochrane review of 11 randomised
controlled trials35 concluded that epidural analgesia was
associated with longer first and second stages of labour and
an increased incidence of fetal malposition. Despite increased
use of oxytocin there were more instrumentalvaginal deliver-
ies, especially if the block was maintained for the second
stage. There was no statistically si@icant effect upon caesar-
ean section rates. It is arguable that, owing to these effects of
epidural analgesb, mothers receiving it are no longer having
a ‘normal‘labour. In primigravidae with epidurals, the routine
use of oxytocin during the second stage minimises the
increase in operative de1ive1-y.~~ Delayed pushing in the
second stage” in order to allow the head to descend, so that
maternal effort may be more effective, is another option that
warrants further investigation.The development of combined
spinakpidural3 has led to a reduction in the associated
motor block and is enabling the development of ambulatory
epidurals. The effects of newer ambulatory techques on the
outcome of labour have not yet been quantified.
MANAGEMENT OF THE THIRD STAGE
The main debate is between active versus physiological
management. Active management involves three com-
ponents:
Yf
Rwm Sue Taylor, Jim Thornton
the use of pharmacological agents (oyvtocin 5 units
with ergometrine 500 pg) to contract the uterus
cutting the cord as soon as the baby is delivered
delivering the placenta by controlled cord traction.
Physiological management involves:
no routine use of drugs
not cutting the cord until it has stopped pulsating
awaiting spontaneous delivery of the placenta.
The first major randomised controlled trial39showed clearly
that active management prevented primary postpartum
liaemorrhage. A sample size of 3900 was planned, but the
study was terminated after interim analysis of the first 1500.
Since then, three other randoinised controlled trials have
confirmed this,4oTwo of the t1-iak.39,~~have shown no signif-
icant difference in admissions to the special care baby unit, in
the need for phototherapy, or in the proportion of women
breastfeeding at six weeks. There was a greater incidence of
nausea and vomiting in groups allocated to active manage-
ment - an adverse effect of ergometrine - and a greater
incidence of hypertension, although the latter did not reach
statistical significance. In one of these trials, the benefits of
active managcrnent were confinned in a unit where physie
logical management was the standard before the trial.41
-4sthe main draw-backto active management appears to be
ergometrine-associated nausea, some authors have suggested
the use of oxytocin alone. One randomised double-blind
study4' compared the use of Syntometrinea (Alliance,
Chippenham) with oxytocin in 1000 patients. The incidence
of primary postpartum haemorrhage w-as significantly dec-
reased by 40% in the Syntometrine group. The incidence of
retained placenta was higher in the Syntometrine group.
Interestingly,the incidence of nausea or vomiting was similar.
CONCLUSION
There is no strong evidence that low-risk women should be
delivered in hospital. The fetal heart rate should be mon-
itored. but this can be by IA or EFM. It is still argued that the
latter prevents intraparturn stillbirths, but there is no direct
evidence for this and, unless there are facilities for back-up
by fetal pH estimation, it increases the caesarean section
rate. Women prefer the opportunity to mobilise in the first
stage but rarely stay upright for long, and it makes little
difference to labour outcome. In the second stage, most
women in the UK find it difficult to maintain an upright
posture and again there is little clear benefit in terms of
mode of delivery, although perineal trauma is less likely.
There is no reason why women should not be given a light
diet in labour, although it may be wise also to administer an
H, antagonist. The only components of active management
of labour that reduce adverse outcome are the provision of
a trained attendant throughout the labour and early
amniotomy, which shortens labour slightly without any
discernible adverse effect. Nitrous oxide and TENS are safe
methods for pain relief but diamorphine is preferable to
72 The Ohsletv-iciuriC Gynaecologist April 2001
pethidine, providing more effective pain relief and less
nausea. Epidural anaesthesia is more effective than opiates
but probably prolongs labour and increases operative
delivery rates. It has been conclusively proven that active
management of the third stage significantly reduces the
incidence of postpartum haemorrhage and that
Syntometrine is more effective than oxytocin alone.
AUTHOR DETAILS
Sue Taylor MRCOG, Spciuht Registruq Obstetrics and
G y n u e c d o ~ Department
, of Obstetrics and Gynaecology,
Royal Hampshire County I Iospital, Romsey Koad,
Winchester SO22 SDG, UK (corresponding author)
Jim Thornton FRCOG, Consultant, Obstetrics and
Gynaecology,The General Infirmary at Leeds, Leeds, UK
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2