REVIEW

Mechanisms and
management of normal
labour

ground substance. The smooth muscle is concentrated near the

internal os, but as yet no clear function for this has been demonstrated in humans. The concentration of elastin in the cervix decreases during pregnancy and it is deficient in the incompetent
cervix, but again little 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 undergoes hypertrophy and an
inflammatory-type reaction occurs, with a neutrophil polymorphnuclear 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
collagens is parallelled 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 the process and the final common pathway.

Tara Selman
Tracey Johnston

Abstract
It is essential that those providing antenatal and intrapartum care understand what constitutes normal labour. This allows complications that can
arise at any stage to be recognized early and can help prevent serious
sequelae. This review covers the physiology, mechanisms and evidence
based management of normal labour.

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

physiology of normal labour; second stage

Physiology of normal labour

Myometrium
The myometrium comprises bundle 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 contractions of the
myocytes. The myocytes contain actin and myosin filaments that
interact and form cross-bridges, resulting in contraction. The
actinemyosin interaction is regulated by myosin light chain kinase and is calcium dependent 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, hence the production of
cervical effacement, dilation, delivery and involution of the
uterus.

Term is the end of normal gestation in humans; the range for this
is 37e42 completed weeks. Although the estimated date of delivery (EDD) is 280 days from the first day of the last menstrual
period, only 3e5% of women deliver on their EDD. Labour is
defined as regular, painful uterine contractions leading to progressive effacement and dilation of the cervix from 4 cm dilatation. Towards the end of pregnancy, during what is described 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 parallelled during prelabour by an increase in the spontaneous contractility of the
myometrium. The BraxtoneHicks 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 are largely unknown.
What is clear is there that 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

Hormones
Maternal: progesterone is so called as it supports pregnancy. It is
made by the corpus luteum until approximately 7e8 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 systematic decrease in progesterone with
advancing gestation, there is a decrease in the number of

Tara Selman MRCOG PhD is a Consultant in Fetal Maternal Medicine at

Birmingham Womens Hospital NHS Foundation Trust, Birmingham, UK.
Conflicts of interest: none declared.
Tracey Johnston FRCOG MD is a Consultant in Fetal Maternal Medicine at
Birmingham Womens Hospital NHS Foundation Trust, Birmingham, UK.
Conflicts of interest: none declared.

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progesterone receptors and thus, most likely a decrease in local

progesterone concentration in the cervix and myometrium.
Oestrogen has an action opposing that of progesterone,
increasing prostaglandin production, oxytocin receptor concentration and uterine contractility. There is a gradual increase in the
oestrogen concentration (both oestriol and oestradiol) during the
third trimester of pregnancy. The progesterone/oestrogen ratio
decreases during the end of pregnancy, resulting in a positive
effect on uterine activity.
Oxytocin is an octapeptide hypothalamic hormone stored in the
posterior pituitary that induces uterine contractions and increases
the strength and frequency of existing contractions. It appears to
exert its effect by altering calcium influx and efflux in the myocytes.
There is no change in the systemic concentration of oxytocin until
the late first stage of labour; both the number of oxytocin receptors
in the myometrium and decidua increase during pregnancy,
reaching a peak during early labour. Oxytocin also stimulates
prostaglandin synthesis by the decidua and fetal membranes.
Placenta: the placental unit produces various hormones
important in the physiology of labour. The peptide hormone
relaxin, which promotes uterine quiescence during pregnancy, is
initially produced by the corpus luteum and later in the pregnancy by the placenta. The role of relaxin in pregnancy labour
and delivery is not clear and the literature is conflicting.
Human chorionic goandotrophin (hCG) is a glycoprotein
produced by the syncytiotrophoblast. It stimulates production of
relaxin and supports the corpus luteum to maintain production of
progesterone and oestrogen.
The level of corticotrophin-releasing hormone (CRH) increases
towards the end of pregnancy, with a peak in maternal plasma
level during labour. CRH potentiates the effects of prostaglandins
and oxytocin on uterine contractility and increases prostaglandin
production by the decidua and membranes. It has been suggested
that CRH may have an active role in the onset of labour.
Other placental hormones produced by the decidua and
placenta also have important roles in the onset of labour. These
include activin A and follistatin; the latter inhibits the effect of
activin, which is to stimulate hCG and progesterone production
by the placenta.
Fetal: the fetal pituitary gland secrets oxytocin, which also
may contribute to the initiation of labour. The fetal adrenal
glands produce cortisol, which stimulates the conversion of
progesterone to oestrogen. Fetal cortisol has other roles in preparing the fetus for birth. It promotes fetal lung maturation,
production of glycogen by the fetal liver and the production of
gut enzymes.
Prostaglandins are pivotal in both cervical ripening and myometrial contractility. The fetal membranes and the decidua produce
prostaglandins PGE2 and PGF2a respectively. PGE2 promotes cervical ripening and PGF2a increases intracellular calcium, which increases myometrial contractility. These properties have been
exploited pharmacologically in the use of exogenous prostaglandins
for cervical ripening and induction of labour. The role of prostacyclin
is unclear but it is known to inhibit uterine contractility.

vertex position and ending with the mother and fetus in good
condition following a spontaneous delivery. In the UK almost
90% of women will give birth to a single baby after 37 weeks of
pregnancy with the baby presenting head first and two thirds go
into labour spontaneously. Labour is traditionally divided into
three stages of unequal length.
First stage
This stage is divided into the latent and active phase. The latent
phase in when there are painful contractions and cervical change
including effacement (shortening of the cervix to less that 0.5
cm); these changes may not necessarily be continuous. The
active phase is characterized by regular painful contractions and
progressive cervical dilation from 4 cm. The length of the active
phase varies between nulliparous and multiparous women. First
labours last an average of 8 h and are unlikely to last over 18 h
and subsequent labours last on average 5 h and are unlikely to
last over 12 h.
Second stage
The second stage of labour begins at full dilation and ends with
the delivery of the baby. This stage has two phases; an initial
passive phase which beings at full dilation prior to or in the
absence of involuntary expulsive efforts, and an active phase, the
onset of which is defined as the baby being visible, expulsive
contractions with a finding of full cervical dilation or active
maternal effort following confirmation of full cervical dilation in
the absence of expulsive contractions. The duration of second
stage is variable and again varies with parity. For nulliparous
women, birth should be expected to take place within 3 h of the
start of the active stage and for multiparous women 2 h. An
unduly prolonged second stage is associated with adverse
maternal and fetal outcome. The pH of the fetal blood decreases
during the second stage and therefore if the fetus is already
compromised when pushing commences, hypoxia can occur. An
excessively prolonged second stage can be associated with urinary tract damage and vesicovaginal fistula formation.
Third stage
The third stage of labour is the time from the birth of the baby to
the expulsion of the placenta and membranes. Signs of spontaneous separation of placenta include a gush of vaginal blood,
lengthening of the umbilical cord and a rise in the uterine fundus.
The commonest complication of the third stage is haemorrhage,
but this is significantly reduced by active management, which
has been shown to reduce the incidence of blood loss greater
than 500 ml from 15% to 5%. Active management of the third
stage involves three components; firstly the routine use of a
uterotonic drug, the most commonly used oxytocic agents either
Syntocinon 5 iu or Syntometrine (Syntocinon 5 iu and ergometrine 0.5 mg). Secondly, early clamping and cutting of the cord.
Thirdly, controlled cord traction; gentle cord traction is applied
while guarding the fundus to deliver the placenta and membranes once signs of separation have been seen. Even with active
management, studies indicate that there should be a delay in
clamping of the cord of over a minute to increase neonatal iron
stores at 4 months, this does not increase maternal complications. The third stage should be completed within 30 min of birth
of the baby with active management and within 90 min with

Normal labour
The WHO (World Health Organisation) defines normal labour as
low risk throughout, spontaneous in onset, with the fetus in

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Crowning of the head

This occurs when the fetal head no longer recedes from the
introitus between contractions and the biparital diameter is
delivered.

physiological management (there is no use of uterotonic drugs,

cord clamping is delayed until after the cord has ceased pulsating
and expulsion of the placenta is by maternal effort).

Mechanisms of normal labour

Extension of the fetal neck
This allows the face to sweep the perineum and the chin to be
delivered.

Descent of the fetus

This is a prerequisite for vaginal delivery. The fetus has to undergo a series of important manoeuvres to negotiate its journey
through the maternal pelvis. The pelvic has three important diameters. The pelvic inlet has a wide transverse diameter of
approximately 13 cm. The midcavity of the pelvis is round, and
contraction of the mid pelvis is suspected if the ischial spines are
prominent or the pubic arch is narrow. The pelvic outlet has a
wide anterior-posterior diameter. The fetal manoeuvres that
occur during labour allow the fetus to traverse the pelvic diameters in the optimal position are described below. Not all fetuses follow this pattern as it is dependent on the presenting part.
The commonest situation is with the fetus in a longitudinal lie
with a cephalic presentation and well-flexed attitude. In these
circumstances, the vertex (the area bound by the anterior edge of
the posterior fontanelle, the two parietal eminences and the
posterior edge of the anterior fontanelle) hits the pelvic floor first
and rotates anteriorly, resulting in an occipitoanterior position
with the occiput as the denominator.

External rotation of the head

After delivery the head rotates to a transverse position, allowing
the head to come back into line with the shoulders. This is also
known as restitution. The shoulders rotate internally to an
anterior-posterior diameter to traverse the pelvic outlet.
Delivery is completed
This occurs with lateral flexion. Gentle downward traction of the
head allows delivery of the anterior shoulder and this is followed by
lateral flexion upwards of the baby to deliver the posterior shoulder.

Other mechanisms
Other mechanisms occur with malposition of the fetus. With right
or left occipitoposterior positions at the onset of labour, rotation to
an occipitoanterior position usually occurs before delivery. A
direct occipitoposterior position is associated with an occipitofrontal diameter of 11.5 cm and often a long dysfunctional labour.
Also, because this diameter is wider than the conventional suboccipitobregmatic diameter it is associated with relative cephalopelvic disproportion. If vaginal delivery occurs, the sinciput
emerges from under the symphysis pubis. Some occipitoposterior
positions arrest during internal rotation in an occipitotransverse
position, which can rarely be delivered spontaneously. A face
presentation results if extension rather than flexion occurs in early
labour. The face presentation continues to descend with increasing
extension when the chin reaches the pelvic floor. If rotation to a
mentoanterior position occurs, delivery can occur by flexion of the
neck. If the internal rotation results in a mentoposterior position,
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. If extension is incomplete, a brow presentation may occur,
which is associated with a mentovetical diameter of 13.5 cm. A
brow presentation is unstable; most convert to a deflexed vertex or,
occasionally a face presentation by full dilatation. If the brow
persists at full dilation, there is usually cephalopelvic disproportion and delivery should be undertaken by caesarean section unless the baby is small (e.g. preterm, second twin), in which case
successful vaginal delivery can be achieved.
The mechanism of labour for breech presentation involves
descent, internal rotation of the buttocks and descent of the
bitrochanteric diameter in the anteroposterior diameter. The hip
is delivered under the symphysis pubis by lateral flexion of the
body and restitution occurs once the posterior buttock is delivered. Internal rotation of the shoulders occurs as the sacrum
rotates anteriorly, and the head descends into the pelvis with the
sagittal suture in the transverse diameter. The head undergoes
internal rotation and is delivered with flexion of the neck.
Rotation to sacroposterior after delivery of the body leads to
difficulty in delivery of the head and should be prevented.

Engagement of the fetal head

This occurs in the weeks prior to the onset of labour in nulliparous women and often not until the onset of labour in those that
are multiparous. It occurs secondary to the descent of the presenting part. 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. Once engaged, the
head is fixed in the pelvis and is no more than two to three fifths
palpable per abdomen.
Descent of the fetal head
This occurs progressively during labour secondary to contraction
and retraction of the myometrium.
Flexion of the fetal neck
This ensures the smaller diameter the fetal head presents so that
it can negotiate the pelvis more easily. With moderate flexion,
the suboccipitofrontal diameter leads (approximately 10 cm) and
with good flexion this converts to the suboccipitobregmatic
diameter (9.5 cm).
Internal rotation of the fetal head
This occurs during descent, when the vertex is pushed down on
the anterior slope of the pelvic floor by the uterine contractions.
With a well-flexed vertex presentation, the leading part of the
fetal head (the occiput) rotates anteriorly from a transverse position (appropriate for the pelvic inlet) into an anteroposterior
position, to pass the ischial spines (appropriate for the pelvic
outlet). The fetal shoulders remain in the transverse diameter at
this point so they can enter the pelvis through the widest pelvic
diameter, resulting in a degree of rotation of the fetal neck. The
occiput passes under the subpubic arch and distends the
perineum.

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Management of labour

heart rate is abnormal (greater than 160 bpm, less than 110 bpm or
declarations after a contraction), in the presence of a maternal
pyrexia, fresh vaginal bleeding, if oxytocin is to be used, or finally if
the mother requests it.

The aim of the management of labour is to achieve a good outcome

for mother and baby. In the UK, women are provided with appropriate choice of place to deliver. Low-risk women may choose to
deliver at home, in midwifery-led or in consultant-led units. The
Place of Birth Study has shown that the perinatal outcomes for lowrisk women delivering on a midwife led unit, or for multiparous
women delivering at home are no different to those in consultantled units, but that women face less intervention. At least 10% of low
risk labours become high risk and so facilities for transfer from one
unit to another should be available. The NICE guidelines for
intrapartum care highlight the importance of maternal preferences,
and women should have choice in terms of place of delivery,
posture during labour, pain relief options and birth partners.
An important role of the midwife is to accurately diagnose the
onset of labour. This can be difficult and errors can result in
either an inappropriate or a delayed diagnosis of slow progress,
both of which can result in increased interventions. The partogram was developed in 1972 by Hugh Philpott, and is a graphical
representation of the changes that occur in labour. Recordings
included maternal pulse, blood pressure, temperature, fetal heart
rate, cervical dilation, descent of the presenting part, colour of
liquor, strength of uterine contractions and drugs administered.
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. It should not,
however, be started during the latent phase of labour e it is a
tool to be used during established labour. When using a partogram, the World Health Organisation 4 h action line should be
used to determine inadequate progress.

Assessing progress of labour

Before the onset of labour and at the beginning of labour, the
modified Bishop score allows objective assessment of the vaginal
examination findings. When in active labour, progress is assessed
by the strength and frequency of the contractions and by the
changing cervical status and descent of the presenting part on
vaginal examination. Vaginal examination should be offered to
women every 4 h in active labour. The progress of labour during
this stage is influenced by three factors: the powers (uterine activity), the passenger (the fetus) and the passages (the pelvis).
Powers
Uterine activity should be frequent enough and strong enough to
ensure that progress occurs, in terms of cervical dilation and
descent of presenting part. In established labour, this usually
means around four contractions of good strength every 10 min;
however, delivery is achieved with less uterine activity in some
cases and more is required in others. Thus, progress in labour
must not be judged by contractions alone. Various factors influence uterine activity, including epidural anaesthesia, tocolytics and sedation, all of which decrease uterine activity and
oxytocics, which enhance uterine activity. Care must be taken
when tachysystole (more than five contractions in 10 min) occurs, as the uteroplacental circulation is compromised during
contractions and if there is insufficient rest time between contractions to allow the fetus to re-oxygenate, compromise will
occur resulting in hyperstimulation (abnormal fetal heart rate in
the presence of tachysystole).

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, abdominal or pelvic pain
A midwife performs the initial assessment of the women. Past
obstetric and medical history should be sought along with any
antenatal complications. During labour, maternal observation
including temperature and blood pressure should be recorded
every 4 h, maternal pulse hourly, frequency of contractions halfhourly and frequency of emptying the bladder should be documented. Urinalysis and abdominal palpation should be
performed as part of the initial assessment. There is no need for
H2-receptor antagonists or antacids to be given routinely.

Passenger
The progress of labour is influenced by fetal size and position.
Abdominal palpation should be performed to assess the descent
of the presenting part. Cervical assessment also provides information about the station of the presenting part in relation to the
ischial spines. The development of caput and moulding are
important, as these may be indicators of disproportion.
Passages
Abnormality of the bony pelvis may cause a delay in the progress
of labour. With improvements in maternal nutrition, such abnormalities are less common than in the past. Cephalopelvic
disproportion may occur between a macrosomic fetal head and a
pelvis of normal proportions. Relative cephalopelvic disproportion can occur when a wider diameter of the fetal head is trying
to negotiate the normal pelvic diameters, as in malposition. A
rigid perineum can occasionally lead to delay in delivery, and the
situation regarding the need for episiotomy should be assessed
by an experienced midwife.

Assessing fetal well-being

In the first stage of labour, the fetal heart should be intermittently
auscultated after a contraction for at least 1 min and at least every
15 min with the absolute rate recorded. The maternal pulse should
be palpated to differentiate the two heart rates. In the second stage,
intermittent auscultation of the fetal heart should occur after a
contraction for at least 1 min, at least every 5 min. The colour of the
liquor should be recorded. Continuous electronic fetal monitoring
should be performed if there is meconium stained liquor, if the fetal

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Management of suspected delay in normal labour

Diagnosis of delay in the first stage of labour
This should be aided by the use of a partogram and needs to take
in to consideration all aspects of progress in labour. The NICE

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intrapartum care guidelines recommend 4 areas that should be

included:
 cervical dilation of less that 2 cm in 4 h for first labours
 cervical dilation of less than 2 cm in 4 h or a slowing in
progress of labour for the second or subsequent labours
 descent and rotation of the head
 changes in the strength, duration and frequency of uterine
contractions.

in pain relief requirements, less operative intervention as well as

an improved birth experience for the mother.
There are various forms of analgesia available including; transcutaneous nerve stimulation (TENS e in the latent phase only),
water, nitrous oxide, opiates such as pethidine and diamorphine and
regional analgesia. NICE recommend that women are given the
opportunity to labour in water, with care taken to ensure a
comfortable temperature not above 37  C. The progress of labour in
the latent phase may be slowed by opiate or epidural analgesia, but
this has minimal or no effect in the active phase. Opiate analgesia
may also be associated with drowsiness, nausea and vomiting in the
woman and short term respiratory depression, drowsiness for
several days and interference with breast feeding for the baby.
Epidural analgesia may slow the second stage and is associated with
an increased incidence of operative vaginal delivery and this must be
explained to the women prior to choosing this option.

Interventions in the first stage

Women should be offered support, hydration and effective pain
relief as appropriate. When membranes are intact, an amniotomy
should be performed, followed by vaginal examination after a 2 h
interval. If the membranes have ruptured, a further examination
should take place 2 h later. Only if delay is confirmed after the 2 h
interval in nulliparous women should the use of oxytocin be
considered, as a significant number of women will make
adequate progress in this 2 h interval without the use of oxytocin.
This may also be appropriate for multiparous women, but full
examination is required by the obstetrician to exclude other
problems with the passenger or passages. The use of oxytocin
is an indication for transfer of a woman from low to high risk
care and for continuous electronic fetal monitoring.

Posture in labour
An environment helpful to the mother may include ample space
and the use of aids such as birth pool, mats on the floor, cushions, rocking chair and gym balls. Changes to position may help
labour progress. Women should be discouraged from lying supine or semi-supine in the second stage of labour as this is
associated with delay and an increased incidence of instrumental
delivery. They should be encouraged to adopt any other position
they find most comfortable as long as fetal well-being can be
confirmed. Squatting increases the pelvic diameter by 8 mm and
is similar to McRoberts manoeuvre employed in the management of shoulder dystocia.
A

Diagnosis of delay in the second stage of labour

Birth should be expected within 3 h of active pushing for
nulliparous women and within 2 h for parous women.
Interventions in the second stage
After an hour of active second stage delay should be suspected in
nulliparous women, and diagnosed in parous women. In the
presence of intact membranes, an amniotomy should be performed, and consideration should be made as to further analgesia. After 2 h in nulliparous women a diagnosis of delay should
be made. Once delay in second stage has been diagnosed, an
assessment should be carried out by the obstetrician. Review
should continue every 15e30 min to ensure delivery in the recommended time frame, with consideration as to the need for
instrumental delivery or caesarean section as appropriate. NICE
do not recommend the use of oxytocin at this stage.

FURTHER READING
Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk
pregnancies: the Birthplace in England national prospective cohort
study. BMJ 2011; 343: d7400.
Intrapartum care. NICE clinical guidelines September 2007.
Philpot RH. Graphical records in labour. BMJ 1979; IV: 163e5.
Rogers D, Wood J, McCandish R, Ayres S, Truesdale A, Elsborne P. Active
management versus expectant management of the third stage of labour:
the Hinchingbrooke randomised control trial. Lancet 1998; 351: 693e9.
Steer P, Flint C. ABC of labour care. Physiology and management of
normal labour. BMJ 1999; 218: 793e6.
Weeks AD, Alia G, Vernon G, Namayanja A, et al. Umbilical vein oxytocin
for the treatment of retained placenta (release study): a double-blind,
randomised controlled trial. Lancet 2010; 375: 141e7.

Delay in the third stage

A diagnosis of delay is made when the placenta has not been
expelled within 30 min of active management and 60 min in a
physiological third stage. In the case of physiological third stage,
an active management protocol should be commenced. If after a
further 30 min the placenta is not delivered, or earlier if there is
bleeding, assessment should be made and appropriate analgesia
provided so that the placenta can be removed manually. The
Release Study, a double blind randomized control trial of umbilical vein oxytocin for the treatment of retained placenta shows
this treatment does not reduce the need for manual removal.

Practice points

Pain relief

Ideally pain relief should be discussed in the antenatal period.

Good psychological support is important and can be provided by
birth partners, midwives or doulas. Women in established labour
should not be left on their own except for short periods of time or
at their request. One to one support is associated with a reduction

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Term is 37e42 completed weeks. Around 90% of women in the

UK will go into labour with a single baby with cephalic presentation during this time. 47% of births are normal.
The physiology of labour is not fully understood, but is an
interaction of maternal, fetal and placental factors.

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REVIEW

Labour is divided into three stages of unequal length. The first

is from 4 cm dilation with regular painful contractions until full
dilation, the second from full dilation to delivery of the baby
and the third from delivery of baby to delivery of placenta.
Labour requires engagement of the fetal head, descent and
flexion of the neck, internal rotation, crowning, extension of
the neck and external rotation.
Management of normal labour requires maternal and fetal
observations and appropriate maternal support. Consideration
should be given to maternal preference for the place of birth
and pain relief used.
In the first stage, the fetal heart should be auscultated after a
contraction for at least 1 min and at least every 15 min and in
the second stage after a contraction for at least 1 min every 5
min.
Continuous electronic fetal monitoring is indicated if an abnormality in the fetal heart is detected (rate greater than 160
or less than 110 beats per minute, or decelerations after a

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213

contraction), if there is fresh vaginal bleeding, meconium

stained liquor, maternal pyrexia or if oxytocin is being used.
Diagnosis of delay in the first stage should take in to
consideration 4 areas; cervical dilation of less that 2 cm in 4 h
in first labour, a slowing in progress of labour in subsequent
labours, descent and rotation of the head, changes in strength,
duration and frequency of uterine contractions.
Intervention for delay in the first stage may include amniotomy
and the use of oxytocin.
The second stage of labour should be completed after 3 h of
active pushing for nulliparous and 2 h of active pushing for
multiparous women.
Delivery of the placenta should be achieved within 30 min with
active management of the third stage where there is a uterotonic drug administered, early clamping of the cord and delivery of the placenta by controlled cord traction. For a
physiological third stage the placenta should be delivered in
60 min.

2013 Elsevier Ltd. All rights reserved.