Normal labour

652,377 women gave birth in NHS hospitals in England and Wales in 2009-2010.1 This figure is fairly stable but there was a small dip from the preceding year (652,638 deliveries in 2008-2009). Most of these women are healthy and have a 'normal' labour.

The National Institute for Health and Clinical Excellence (NICE) guideline emphasises that birth is not a medical event but a 'normal' process.2Clinical intervention should not be offered or advised where labour is progressing normally.

First stage

  • The first stage begins with regular contractions (when the fetal presenting part has descended into the true pelvis), or on admission to hospital with obvious signs of labour.
  • The first stage ends when the cervix is fully dilated (10 cm).

First stage can be divided into:

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

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

Management2

  • Reassure and advise the patient on how her labour is progressing.
  • Measure 2-hourly pulse, temperature and blood pressure.
  • Monitor contractions and fetal heart rate (FHR); the FHR should be auscultated for a minimum of 1 minute immediately after a contraction. The maternal pulse should be palpated to differentiate between maternal and FHR. Then the FHR should be measured every 15 minutes (it should be 120-160 beats per minute (bpm)); <100 bpm may indicate fetal distress.3 There is no evidence that a cardiotocogram (CTG) on admission is superior to auscultation alone.4
  • Assess cervical dilatation and fetal head descent every 4 hours.
  • Discuss the patient's need and plan for pain relief in labour. There is no evidence of useful efficacy of transcutaneous electrical nerve stimulation (TENS) for labour pain.5 Acupuncture and hypnosis may be beneficial for the management of pain during labour.6
  • Assess the position of the fetal head with regard to the mother's pelvis.

The partogram

A pictorial record of labour (partogram) should be used once labour is established. Where the partogram includes an action line, the World Health Organization's recommendation of a 4-hour action line should be used. This means that, if the labour does not progress as predicted, some ACTION will be taken, e.g. amniotomy or augmentation.

NB: although it is advised in the NICE guideline, a Cochrane review did not find sufficient evidence to recommend universal partogram use.7

DUBLIN PARTOGRAM (OM214a.jpg)

Second stage

This starts when the cervix is fully dilated and ends with the birth of the baby:

  • Contractions are stronger, occur at 2- to 5-minute intervals and last 60-90 seconds.
  • The fetal head descends deeply into the pelvis and rotates anteriorly so that the back of the fetal head is behind the mother's symphysis pubis (98% of cases).
  • The woman also assists the contractions by pushing to force the fetus further into the pelvis.
  • The fetal head becomes more visible with each contraction until large part of the head can be seen.
  • The head is now born with first the forehead, then the nose, mouth and chin.
  • The head rotates to allow the shoulders to be born next, followed by the trunk and legs.
  • After this, the baby should start to breathe and to cry loudly.

Management2

  • Check for level of pain relief and supplement if required.
  • Ensure a midwife/doctor is present at all times to encourage pushing during contractions and relaxing in between.
  • Monitor contractions and FHR - measure every 5 minutes - this should be 120-160 bpm. If it is <100 bpm for >2 minutes then investigate possible causes.
  • If this stage is >2-3 hours then instrumental delivery should be considered.
  • There is debate about the optimal method to use during the second stage:
    • 'Hands on' - where pressure is placed on the baby's head and the perineum supported.
    • 'Hands poised' - where these manoeuvres are not carried out. The 'hands poised' method may reduce episiotomy rates but more trials are needed to decide the issue.8,9
  • Position during the second stage of labour:
    • As no good evidence currently exists to dictate optimal position for labour, women should be encouraged to adopt the position that they find most comfortable.10,11

Third stage

This stage starts with the birth of the baby and ends with the delivery of the placenta and membranes:

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

Management2

  • Expectant (traditional):
    • Once the placenta lies in the vagina, the uterus is 'rubbed up' to produce a contraction and the uterus is pushed towards the vagina to help with expulsion of the placenta and membranes.
    • These are held and twisted whilst pulling constantly so that membranes are kept intact.
  • Active:
    • Give intramuscular (IM) synthetic oxytocin at the appearance of the fetal head.
    • This takes approximately 2 minutes to be effective and so the baby is delivered slowly over the next minute.
    • The umbilical cord is clamped and cut soon after delivery.
    • Once the induced contraction is felt, controlled traction on the umbilical cord (with simultaneous suprapubic pressure by the other hand - to prevent uterine inversion) will facilitate expulsion of the placenta and membranes.
    • In a small proportion of cases, the placenta is not removed - repeat the attempt after 10 minutes and then remove manually.
    • In all cases the placenta and membranes are examined for completeness and any retained material removed under sterile conditions.
    • Ergometrine-oxytocin compared with oxytocin alone shows a small but statistically significant reduction of minor postpartum haemorrhage. However, vomiting, nausea and hypertension occur significantly more frequently with ergometrine-oxytocin compared with oxytocin alone.12

NB: active management of the third stage has been shown to be superior to expectant management with respect to blood loss, postpartum haemorrhage and other serious complications of the third stage.13
However, if ergometrine is used, there is an increased incidence of side-effects such as nausea, vomiting and hypertension. Active management should be used routinely for vaginal deliveries in a hospital setting.

Water births

Good-quality studies have shown that water births may significantly shorten the first stage of labour and reduce episiotomy rates and analgesic requirements.14
The technique appears to be safe if mothers are appropriately selected and correct hygiene procedures followed.15

Continuous support during labour

There is good evidence that women who receive continuous one-to-one support throughout their labour have better outcomes in terms of reduced analgesia requirements, decreased frequency of operative delivery and improved satisfaction with the experience.

This effect was most pronounced when the supporter was not a member of hospital staff, gave support from early in labour and where epidural analgesia was not routinely available.16,17


Document references

  1. NHS Maternity statistics. England and Wales - 2009-2010
  2. Intrapartum care, NICE Clinical Guideline (2007)
  3. Mires G, Williams F, Howie P; Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population. BMJ. 2001 Jun 16;322(7300):1457-60; discussion 1460-2. [abstract]
  4. Bix E, Reiner LM, Klovning A, et al; Prognostic value of the labour admission test and its effectiveness compared with auscultation only: a systematic review. BJOG. 2005 Dec;112(12):1595-604. [abstract]
  5. Transcutaneous electrical nerve stimulation (TENS) in labour pain, Bandolier, April 1997
  6. Smith CA, Collins CT, Cyna AM, et al; Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003521. [abstract]
  7. Lavender T, Hart A, Smyth RM; Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005461. [abstract]
  8. McCandlish R, Bowler U, van Asten H, et al; A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol. 1998 Dec;105(12):1262-72. [abstract]
  9. Mayerhofer K, Bodner-Adler B, Bodner K, et al; Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med. 2002 Jun;47(6):477-82. [abstract]
  10. Soong B, Barnes M; Maternal position at midwife-attended birth and perineal trauma: is there an association? Birth. 2005 Sep;32(3):164-9. [abstract]
  11. Hastings-Tolsma M, Vincent D, Emeis C, et al; Getting through birth in one piece: protecting the perineum. MCN Am J Matern Child Nurs. 2007 May-Jun;32(3):158-64. [abstract]
  12. McDonald SJ, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 1997, Issue 2. Art. No.: CD000201. DOI: 10.1002/14651858.CD000201.pub2
  13. Begley CM, Gyte GM, Murphy DJ, et al; Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD007412. [abstract]
  14. Cluett ER, Burns E; Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD000111. [abstract]
  15. Zanetti-Dallenbach R, Lapaire O, Maertens A, et al; Water birth, more than a trendy alternative: a prospective, observational study. Arch Gynecol Obstet. 2006 Oct;274(6):355-65. Epub 2006 Jul 26. [abstract]
  16. McGrath SK, Kennell JH; A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth. 2008 Jun;35(2):92-7. [abstract]
  17. Hodnett ED, Gates S, Hofmeyr GJ, et al; Continuous support for women during childbirth. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003766. [abstract]

Acknowledgements

EMIS is grateful to Dr Hayley Willacy for writing this article and to Dr Sean Kavanagh for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2010.
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