671,255 women gave birth in NHS hospitals in England in 2012-2013. This represents an increase of 2.9% over the preceding three years (652,377 deliveries in 2009-2010). Most of these women are healthy and have a 'normal' labour. There was a significant reduction in maternal deaths in the UK in the period 2009/12 compared with 2006/09 to 10.12 per 100,000 pregnant women. This was despite an increased number of births, as well as older maternal age, higher rates of obesity and a greater proportion of births to women born outside the UK, all factors associated with a higher risk of maternal death.
The National Institute for Health and Care Excellence (NICE) guideline emphasises that birth is not a medical event but a 'normal' process. Clinical intervention should not be offered or advised where labour is progressing normally.
- 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 more 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.
While the length of established first stage of labour varies between women, first labours last on average 8 hours (unlikely ≥18 hours). Second and subsequent labours last on average 5 hours (unlikely ≥12 hours). However if the first stage does not appear to be progressing, the cause needs to be determined.
- Reassure and advise the patient on how her labour is progressing.
- Measure pulse hourly and temperature and blood pressure 4-hourly.
- Monitor frequency of contractions half-hourly
- The fetal heart rate (FHR) should be auscultated for at least 1 minute immediately after a contraction. This should be carried out every 15 minutes. The maternal pulse should be palpated to differentiate between it and FHR. The FHR should be 100-160 beats per minute (bpm); <100 bpm or >180 is abnormal. There is no evidence that a cardiotocogram (CTG) on admission is superior to auscultation alone and it may be associated with an increase in the incidence of caesarean section without evidence of benefit.
- Offer a vaginal examination to assess cervical dilatation and fetal head descent every 4 hours and when the woman appears to be in established labour.
- Discuss the patient's need and plan for pain relief in labour. There is no evidence to support the use of transcutaneous electrical nerve stimulation (TENS) for labour pain. Acupuncture, relaxation and massage may be beneficial but the evidence for these and other non-pharmacological methods for relieving pain in labour is of poor quality.
- Assess the position of the fetal head with regard to the mother's pelvis.
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 four-hour action line should be used. This means that, if the labour does not progress as predicted, some ACTION will be taken - eg, amniotomy or augmentation.
NB: although it is advised in the NICE guideline and widely used and accepted, a Cochrane review did not find sufficient evidence to recommend universal partogram use.
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 second stage is said to be active once the baby is visible and the woman usually also wants to assist what have become expulsive contractions by pushing.
- The fetal head becomes more visible with each contraction until a 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.
- 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 100-160 bpm.
- If this stage is >2 hours for a nulliparous woman or >1 hour for a multiparous woman then instrumental delivery should be considered.
- There is debate about the optimal method to use during the second stage in order to reduce the frequency and severity or perineal trauma:
- 'Hands on' - where pressure is placed on the baby's head and the perineum supported. The application of a warm compress appears to reduce the severity of perineal trauma.
- '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.
- Position during the second stage of labour:
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 the contraction of uterine muscle fibres closing off the blood vessels that were 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.
- Expectant (traditional or physiological):
- 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.
- The cord is not clamped until pulsation has stopped and no uterotonic drugs are used.
- Should last <60 minutes.
- Give intramuscular (IM) synthetic oxytocin with the delivery of the anterior shoulder or as soon as the baby is born.
- The umbilical cord is clamped between 1-5 minutes after the birth and cut soon after delivery.
- After the cord has been cut and once there are signs of separation of the placenta, 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 anaesthetic.
- Should last <30 minutes.
NB: active management of the third stage has been shown to be superior to expectant management with respect to blood loss, blood transfusion, postpartum haemorrhage and other serious complications of the third stage. However, if ergometrine is used, there is an increased incidence of side-effects such as nausea, vomiting and hypertension; 10 IU of IM oxytocin are the preferred uterotonic. Active management should be offered routinely for vaginal deliveries in a hospital setting. However, a woman who is at low risk of postpartum haemorrhage and who requests physiological management, should have her request respected.
Good-quality studies have shown that water births may significantly shorten the first stage of labour and reduce episiotomy rates and analgesic requirements. The technique appears to be safe if mothers are appropriately selected and correct hygiene procedures followed. Also a small study showed that women who chose water immersion during labour had a lower rate of caesarean delivery and less stress urinary incontinence at 42 days.
Continuous support during labour
This effect was most pronounced when the supporter (or doula) was not a member of hospital staff, gave support from early in labour and where epidural analgesia was not routinely available.
Further reading and references
Intrapartum care for healthy women and babies; NICE Guideline (Dec 2014, updated Feb 2017)
Guideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period; Guideline Audit Implementation Network (Mar 2017)
NHS Maternity Statistics - England, 2012-2013; Health & Social Care Information Centre (HSCIC)
Saving Lives, Improving Mothers’ Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012; MBRRACE-UK, Dec 2014
Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014)
Devane D, Lalor JG, Daly S, et al; Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev. 2012 Feb 152:CD005122. doi: 10.1002/14651858.CD005122.pub4.
Dowswell T, Bedwell C, Lavender T, et al; Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev. 2009 Apr 15(2):CD007214.
Jones L, Othman M, Dowswell T, et al; Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012 Mar 143:CD009234. doi: 10.1002/14651858.CD009234.pub2.
Lavender T, Hart A, Smyth RM; Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database Syst Rev. 2013 Jul 107:CD005461. doi: 10.1002/14651858.CD005461.pub4.
Aasheim V, Nilsen AB, Lukasse M, et al; Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2011 Dec 7(12):CD006672. doi: 10.1002/14651858.CD006672.pub2.
Soong B, Barnes M; Maternal position at midwife-attended birth and perineal trauma: is there an association? Birth. 2005 Sep32(3):164-9.
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-Jun32(3):158-64.
Begley CM, Gyte GM, Devane D, et al; Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2011 Nov 9(11):CD007412. doi: 10.1002/14651858.CD007412.pub3.
Westhoff G, Cotter AM, Tolosa JE; Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev. 2013 Oct 3010:CD001808. doi: 10.1002/14651858.CD001808.pub2.
Cluett ER, Burns E; Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009 Apr 15(2):CD000111.
Zanetti-Dallenbach R, Lapaire O, Maertens A, et al; Water birth, more than a trendy alternative: a prospective, observational study. Arch Gynecol Obstet. 2006 Oct274(6):355-65. Epub 2006 Jul 26.
Liu Y, Liu Y, Huang X, et al; A comparison of maternal and neonatal outcomes between water immersion during labor and conventional labor and delivery. BMC Pregnancy Childbirth. 2014 May 614:160. doi: 10.1186/1471-2393-14-160.
Hodnett ED, Gates S, Hofmeyr GJ, et al; Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013 Jul 157:CD003766.