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PROFESSIONAL / 
GYNECOLOGY AND OBSTETRICS / 
NORMAL LABOR AND DELIVERY / 
MANAGEMENT OF NORMAL LABOR

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IN THIS TOPIC

Beginning of labor

Stages of labor

Rupture of membranes

Birthing options

Admission

Preparation for delivery

Analgesia

General reference

Fetal Monitoring
OTHER TOPICS IN THIS CHAPTER

Management of Normal Labor

Management of Normal Delivery

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Management of Normal Labor

By 
 

Haywood L. Brown
, MD, Duke University Medical Center

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Overview of Stages of Labor

 
Labor consists of a series of rhythmic, involuntary, progressive contractions of the uterus that
cause effacement (thinning and shortening) and dilation of the uterine cervix. The stimulus
for labor is unknown, but digitally manipulating or mechanically stretching the cervix during
examination enhances uterine contractile activity, most likely by stimulating release
of oxytocin by the posterior pituitary gland.
Normal labor usually begins within 2 wk (before or after) the estimated delivery date. In a first
pregnancy, labor usually lasts 12 to 18 h on average; subsequent labors are often shorter,
averaging 6 to 8 h.

Management of complications during labor requires additional measures (eg, induction of

labor, forceps or a vacuum extractor ,cesarean delivery).
(See also Abnormalities and Complications of Labor and Delivery .)

Beginning of labor
Bloody show (a small amount of blood with mucous discharge from the cervix) may precede
onset of labor by as much as 72 h. Bloody show can be differentiated from abnormal 3rd-
trimester vaginal bleeding  because the amount is small, bloody show is typically mixed with
mucus, and the pain due to abruptio placentae  (premature separation) is absent. In most
pregnant women, previous ultrasonography has been done and ruled out placenta previa.
However, if ultrasonography has not ruled out placenta previa and vaginal bleeding occurs,
placenta previa is assumed to be present until it is ruled out. Digital vaginal examination is
contraindicated, and ultrasonography is done as soon as possible.
Labor begins with irregular uterine contractions of varying intensity; they apparently soften
(ripen) the cervix, which begins to efface and dilate. As labor progresses, contractions
increase in duration, intensity, and frequency.

Stages of labor
There are 3 stages of labor.

The 1st stage—from onset of labor to full dilation of the cervix (about 10 cm)—has 2 phases,
latent and active.
During the latent phase, irregular contractions become progressively better coordinated,
discomfort is minimal, and the cervix effaces and dilates to 4 cm. The latent phase is difficult
to time precisely, and duration varies, averaging 8 h in nulliparas and 5 h in multiparas;
duration is considered abnormal if it lasts > 20 h in nulliparas or > 12 h in multiparas.
During the active phase, the cervix becomes fully dilated, and the presenting part descends
well into the midpelvis. On average, the active phase lasts 5 to 7 h in nulliparas and 2 to 4 h in
multiparas. Traditionally, the cervix was expected to dilate about 1.2 cm/h in nulliparas and
1.5 cm/h in multiparas. However, recent data suggest that slower progression of cervical
dilation from 4 to 6 cm may be normal (1). Pelvic examinations are done every 2 to 3 h to
evaluate labor progress. Lack of progress in dilation and descent of the presenting part may
indicate dystocia (fetopelvic disproportion).
If the membranes have not spontaneously ruptured, some clinicians use amniotomy (artificial
rupture of membranes) routinely during the active phase. As a result, labor may progress
more rapidly, and meconium-stained amniotic fluid may be detected earlier. Amniotomy
during this stage may be necessary for specific indications, such as facilitating internal fetal
monitoring to confirm fetal well-being. Amniotomy should be avoided in women with HIV
infection or hepatitis B or C, so that the fetus is not exposed to these organisms.

During the 1st stage of labor, maternal heart rate and BP and fetal heart rate should be
checked continuously by electronic monitoring or intermittently by auscultation, usually with
a portable Doppler ultrasound device (see Fetal Monitoring). Women may begin to feel the
urge to bear down as the presenting part descends into the pelvis. However, they should be
discouraged from bearing down until the cervix is fully dilated so that they do not tear the
cervix or waste energy.
The 2nd stage is the time from full cervical dilation to delivery of the fetus. On average, it
lasts 2 h in nulliparas (median 50 min) and 1 h in multiparas (median 20 min). It may last
another hour or more if conduction (epidural) analgesia or intense opioid sedation is used.
For spontaneous delivery, women must supplement uterine contractions by expulsively
bearing down. In the 2nd stage, women should be attended constantly, and fetal heart
sounds should be checked continuously or after every contraction. Contractions may be
monitored by palpation or electronically.
The 3rd stage of labor begins after delivery of the infant and ends with delivery of the
placenta. This stage usually lasts only a few minutes but may last up to 30 min.
Overview of Stages of Labor

THIS VIDEO IS CREATED AS A COLLABORATION BETWEEN THE MANUALS (KNOWN AS THE MERCK MANUAL IN THE
US AND CANADA AND AS THE MSD MANUAL IN THE REST OF THE WORLD) AND OSMOSIS
(HTTPS://OPEN.OSMOSIS.ORG/).
 VIDEO

Rupture of membranes
Occasionally, the membranes (amniotic and chorionic sac) rupture before labor begins, and
amniotic fluid leaks through the cervix and vagina. Rupture of membranes at any stage
before the onset of labor is called premature rupture of membranes  (PROM). Some women
with PROM feel a gush of fluid from the vagina, followed by steady leaking.
Further confirmation is not needed if, during examination, fluid is seen leaking from the
cervix. Confirmation of more subtle cases may require testing. For example, the pH of vaginal
fluid may be tested with Nitrazine paper, which turns deep blue at a pH> 6.5 (pH of amniotic
fluid: 7.0 to 7.6); false-positive results can occur if vaginal fluid contains blood or semen or if
certain infections are present. A sample of the secretions from the posterior vaginal fornix or
cervix may be obtained, placed on a slide, air dried, and viewed microscopically for ferning.
Ferning (crystallization of sodium chloride in a palm leaf pattern in amniotic fluid) usually
confirms rupture of membranes.
If rupture is still unconfirmed, ultrasonography showing oligohydramnios (deficient amniotic
fluid) provides further evidence suggesting rupture. Rarely, amniocentesis with instillation of
dye is done to confirm rupture; dye detected in the vagina or on a tampon confirms rupture.

When a woman’s membranes rupture, she should contact her physician immediately. About
80 to 90% of women with PROM at term and about 50% of women with PROM preterm go
into labor spontaneously within 24 h; > 90% of women with PROM go into labor within 2 wk.
The earlier the membranes rupture before 37 wk, the longer the delay between rupture and
labor onset. If membranes rupture at term but labor does not start within several hours,
labor is typically induced to lower risk of maternal and fetal infection.

Birthing options
Most women prefer hospital delivery, and most health care practitioners recommend it
because unexpected maternal and fetal complications may occur during labor and delivery or
postpartum, even in women without risk factors. About 30% of hospital deliveries involve
an obstetric complication  (eg, laceration, postpartum hemorrhage). Other complications
include abruptio placentae , abnormal fetal heart rate pattern, shoulder dystocia, need for
emergency cesarean delivery, and neonatal depression or abnormality.
Nonetheless, many women want a more homelike environment for delivery; in response,
some hospitals provide birthing facilities with fewer formalities and rigid regulations but with
emergency equipment and personnel available. Birthing centers may be freestanding or
located in hospitals; care at either site is similar or identical. In some hospitals, certified
nurse-midwives provide much of the care for low-risk pregnancies. Midwives work with a
physician, who is continuously available for consultation and operative deliveries (eg, by
forceps, vacuum extractor, or cesarean). All birthing options should be discussed.

For many women, presence of the their partner or another support person during labor is
helpful and should be encouraged. Moral support, encouragement, and expressions of
affection decrease anxiety and make labor less frightening and unpleasant. Childbirth
education classes can prepare parents for a normal or complicated labor and delivery.
Sharing the stresses of labor and the sight and sound of their own child tends to create
strong bonds between the parents and between parents and child. The parents should be
fully informed of any complications.

Admission
Typically, pregnant women are advised to go to the hospital if they believe their membranes
have ruptured or if they are experiencing contractions lasting at least 30 sec and occurring
regularly at intervals of about 6 min or less. Within an hour after presentation at a hospital,
whether a woman is in labor can usually be determined based on the following:

 Occurrence of regular and sustained painful uterine contractions

 Bloody show

 Membrane rupture

 Complete cervical effacement

If these criteria are not met, false labor may be tentatively diagnosed, and the pregnant
woman is typically observed for a time and, if labor does not begin within several hours, is
sent home.

When pregnant women are admitted, their blood pressure, heart and respiratory rates,
temperature, and weight are recorded, and presence or absence of edema is noted. A urine
specimen is collected for protein and glucose analysis, and blood is drawn for a CBC and
blood typing. A physical examination is done. While examining the abdomen, the clinician
estimates size, position, and presentation of the fetus, using Leopold maneuvers (see
Figure: Leopold maneuver). The clinician notes the presence and rate of fetal heart sounds, as
well as location for auscultation. Preliminary estimates of the strength, frequency, and
duration of contractions are also recorded.
A helpful mnemonic device for evaluation is the 3 Ps:

 Powers (contraction strength, frequency, and duration)

 Passage (pelvic measurements)

 Passenger (eg, fetal size, position, heart rate pattern)

Leopold maneuver
(A) The uterine fundus is palpated to determine which fetal part occupies the fundus. (B) Each side of the mat
palpated to determine which side is fetal spine and which is the extremities. (C) The area above the symphysi
to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetu
One hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the pre
confirm presentation and engagement.

If labor is active and the pregnancy is at term, a clinician examines the vagina with 2 fingers of
a gloved hand to evaluate progress of labor. If bleeding (particularly if heavy) is present, the
examination is delayed until placental location is confirmed by ultrasonography. If bleeding
results from placenta previa, vaginal examination can initiate severe hemorrhage.

If labor is not active but membranes are ruptured, a speculum examination is done initially to
document cervical dilation and effacement and to estimate station (location of the presenting
part); however, digital examinations are delayed until the active phase of labor or problems
(eg, decreased fetal heart sounds) occur. If the membranes have ruptured, any fetal
meconium (producing greenish-brown discoloration) should be noted because it may be a
sign of fetal stress. If labor is preterm (< 37 wk) or has not begun, only a sterile speculum
examination should be done, and a culture should be taken for gonococci, chlamydiae, and
group B streptococci.
Cervical dilation is recorded in centimeters as the diameter of a circle; 10 cm is considered
complete.
Effacement is estimated in percentages, from zero to 100%. Because effacement involves
cervical shortening as well as thinning, it may be recorded in centimeters using the normal,
uneffaced average cervical length of 3.5 to 4.0 cm as a guide.
Station is expressed in centimeters above or below the level of the maternal ischial spines.
Level with the ischial spines corresponds to 0 station; levels above (+) or below (−) the spines
are recorded in cm increments. Fetal lie, position, and presentation are noted.
 Lie describes the relationship of the long axis of the fetus to that of the mother
(longitudinal, oblique, transverse).
 Position describes the relationship of the presenting part to the maternal pelvis (eg,
occiput left anterior [OLA] for cephalic, sacrum right posterior [SRP] for breech).
 Presentation describes the part of the fetus at the cervical opening (eg, breech,
vertex, shoulder).

Preparation for delivery

Women are admitted to the labor suite for frequent observation until delivery. If labor is
active, they should receive little or nothing by mouth to prevent possible vomiting and
aspiration during delivery or in case emergency delivery with general anesthesia is necessary.
Shaving or clipping of vulvar and pubic hair is not indicated; it increases the risk of wound
infections.

An IV infusion of Ringer's lactate may be started, preferably using a large-bore indwelling

catheter inserted into a vein in the hand or forearm. During a normal labor of 6 to 10 h,
women should be given 500 to 1000 mL of this solution. The infusion prevents dehydration
during labor and subsequent hemoconcentration and maintains an adequate circulating
blood volume. The catheter also provides immediate access for drugs or blood if needed.
Fluid preloading is valuable if epidural or spinal anesthesia is planned.

Analgesia
Analgesics may be given during labor as needed, but only the minimum amount required for
maternal comfort should be given because analgesics cross the placenta and may depress
the neonate’s breathing. Neonatal toxicity can occur because after the umbilical cord is cut,
the neonate, whose metabolic and excretory processes are immature, clears the transferred
drug much more slowly by liver metabolism or by urinary excretion. Preparation for and
education about childbirth lessen anxiety.

Physicians are increasingly offering epidural injection (providing regional anesthesia) as the
first choice for analgesia during labor. Typically, a local anesthetic (eg, 0.2% ropivacaine,
0.125% bupivacaine) is continuously infused, often with an opioid (eg, fentanyl, sufentanil),
into the lumbar epidural space. Initially, the anesthetic is given cautiously to avoid masking
 the awareness of pressure that helps stimulate pushing and to avoid motor block. Women
should be reassured that epidural analgesia does not increase the risk of cesarean delivery
(2).
If epidural injection is inadequate or if IV administration is preferred, fentanyl (100 mcg)
or morphine sulfate (up to 10 mg) given IV q 60 to 90 min is commonly used. These opioids
provide good analgesia with only a small total dose. If toxicity results, respiration is
supported, and naloxone 0.01 mg/kg can be given IM, IV, sc, or endotracheally to the neonate
as a specific antagonist. Naloxonemay be repeated in 1 to 2 min as needed based on the
neonate’s response. Clinicians should check the neonate 1 to 2 h after the initial dosing
with naloxone because the effects of the earlier dose abate.
If fentanyl or morphine provides insufficient analgesia, an additional dose of the opioid or
another analgesic method should be used rather than the so-called synergistic drugs
(eg, promethazine), which have no antidote. (These drugs are actually additive, not
synergistic.) Synergistic drugs are still sometimes used because they lessen nausea due to the
opioid; doses should be small.

General reference
 1. Zhang J, Landy HJ, Branch DW, et al : Contemporary patterns of spontaneous labor
with normal neonatal outcomes. Obstet Gynecol 116 (6): 1281–1287, 2010. doi:
10.1097/AOG.0b013e3181fdef6e.
 2. Practice Guidelines for Obstetric Anesthesia : An Updated Report by the American
Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric
Anesthesia and Perinatology*. Anesthesiology 124:270–300, 2016. doi:
10.1097/ALN.0000000000000935.

Fetal Monitoring
Fetal status must be monitored during labor. The main parameters are baseline fetal heart
rate (HR) and fetal HR variability, particularly how they change in response to uterine
contractions and fetal movement. Because interpretation of fetal HR can be subjective,
certain parameters have been defined (see Table: Fetal Monitoring Definitions ).
TABLE

Fetal Monitoring Definitions

Several patterns are recognized; they are classified into 3 tiers (categories [1]), which usually
correlate with the acid–base status of the fetus:
 Category I: Normal
  Category II: Indeterminate

 Category III: Abnormal

A normal pattern strongly predicts normal fetal acid-base status at the time of observation.
This pattern has all of the following characteristics:
 HR 110 to 160 beats/min at baseline

 Moderate HR variability (by 6 to 25 beats) at baseline and with movement or

contractions

 No late or variable decelerations during contractions

Early decelerations and age-appropriate accelerations may be present or absent in a normal

pattern.

An indeterminate pattern is any pattern not clearly categorized as normal or abnormal.

Many patterns qualify as indeterminate. Whether the fetus is acidotic cannot be determined
from the pattern. Indeterminate patterns require close fetal monitoring so that any
deterioration can be recognized as soon as possible.
An abnormal pattern usually indicates fetal metabolic acidosis at the time of observation.
This pattern is characterized by one of the following:
 Absent baseline HR variability plus recurrent late decelerations

 Absent baseline HR variability plus recurrent variable decelerations

 Absent baseline HR variability plus bradycardia (HR < 110 beats/min without variability
or < 100 beats/min)

 Sinusoidal pattern (fixed variability of about 5 to 40 beats/min at about 3 to 5

cycles/min, resembling a sine wave)

Abnormal patterns require prompt actions to correct them (eg, supplemental oxygen,
repositioning, treatment of maternal hypotension, discontinuation of oxytocin) or preparation
for an expedited delivery.
Patterns reflect fetal status at a particular point in time; patterns can and do change.

Monitoring can be manual and intermittent, using a fetoscope for auscultation of fetal HR.
However, in the US, electronic fetal HR monitoring (external or internal) has become standard
of care for high-risk pregnancies, and many clinicians use it for all pregnancies. The value of
routine use of electronic monitoring in low-risk deliveries is often debated. However,
electronic fetal monitoring has not been shown to reduce overall mortality rates in large
clinical trials and has been shown to increase rates of cesarean delivery, probably because
many apparent abnormalities are false positives. Rate of cesarean delivery is higher among
women monitored electronically than among those monitored by auscultation.

Fetal pulse oximetry has been studied as a way to confirm abnormal or equivocal results of
electronic monitoring; status of fetal oxygenation may help determine whether cesarean
delivery is needed.
Fetal ST-segment and T-wave analysis in labor (STAN) can be used to check the fetal ECG
for ST-segment elevation or depression; either finding presumably indicates fetal hypoxemia
and has a high sensitivity and specificity for fetal acidosis. For STAN, an electrode must be
attached to the fetal scalp; then changes in the T wave and ST segment of the fetal ECG are
automatically identified and analyzed.
If manual auscultation of fetal HR is used, it must be done throughout labor according to
specific guidelines, and one-on-one nursing care is needed.

 For low-risk pregnancies with normal labor, fetal HR must be checked after each
contraction or at least every 30 min during the 1st stage of labor and every 15 min
during the 2nd stage.

 For high-risk pregnancies, fetal HR must be checked every 15 min during the 1st stage
and every 3 to 5 min during the 2nd stage.

Listening for at least 1 to 2 min beginning at a contraction’s peak is recommended to check

for late deceleration. Periodic auscultation has a lower false-positive rate for abnormalities
and incidence of intervention than continuous electronic monitoring, and it provides
opportunities for more personal contact with women during labor. However, following the
standard guidelines for auscultation is often difficult and may not be cost-effective. Also,
unless done accurately, auscultation may not detect abnormalities.

Electronic fetal HR monitoring may be

 External: Devices are applied to the maternal abdomen to record fetal heart sounds
and uterine contractions.

 Internal: Amniotic membranes must be ruptured. Then, leads are inserted through the
cervix; an electrode is attached to the fetal scalp to monitor HR, and a catheter is placed
in the uterine cavity to measure intrauterine pressure.

Usually, external and internal monitoring are similarly reliable. External devices are used for
women in normal labor; internal methods are used when external monitoring does not
 supply enough information about fetal well-being or uterine contraction intensity (eg, if the
external device is not functioning correctly).

External electronic fetal monitoring can be used during labor or electively to continuously
record fetal HR and correlate it with fetal movements (called a nonstress test). A nonstress
test is typically done for 20 min (occasionally for 40 min). Results are considered reactive
(reassuring) if there are 2 accelerations of 15 beats/min over 20 min. Absence of accelerations
is considered nonreactive (nonreassuring). Presence of late decelerations suggests
hypoxemia, potential for fetal acidosis, and the need for intervention.

A nonreassuring nonstress test is usually followed by a biophysical profile (adding

assessment of amniotic fluid volume and sometimes assessment of fetal movement, tone,
breathing, and heart rate, to the nonstress test). A nonstress test and biophysical profile are
frequently used to monitor complicated or high-risk pregnancies (eg, complicated by
maternal diabetes or hypertension or by stillbirth or fetal growth restriction in a previous
pregnancy).

External monitoring can be used with a contraction stress test as well as a nonstress test;
fetal movements and HR are monitored during contractions induced
by oxytocin ( oxytocin challenge test). However, contraction stress testing is now rarely done
and, when done, must be done in a hospital.
If a problem (eg, fetal HR decelerations, lack of normal HR variability) is detected during labor,
intrauterine fetal resuscitation is tried; women may be given oxygen by a tight nonrebreather
face mask or rapid IV fluid infusion or may be positioned laterally. If fetal heart pattern does
not improve in a reasonable period and delivery is not imminent, urgent delivery by cesarean
is needed.

Fetal monitoring reference

 1. Macones GA, Hankins GD, Spong CY, et al : The 2008 National Institute of Child
Health and Human Development workshop report on electronic fetal monitoring: Update on
definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs 37
(5):510–515, 2008. doi: 10.1111/j.1552-6909.2008.00284.x.
Last full review/revision February 2017 by Haywood L. Brown, MD
NOTE:  This
is the Professional Version. CONSUMERS:  Click here for the
Consumer Version

Risk Factors for Complications During Pregnancy

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 Management of Normal Delivery

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