Preventing Primary

Cesarean Sections: Intrapartum Care

Tekoa L. King, CNM, MPH

Some intrapartum care practices promote vaginal birth, whereas others may increase the
risk for cesarean section. Electronic fetal monitoring and use of the Friedman graph to plot
and monitor labor progress are associated with increasing the cesarean section rate.
Continuous one-to-one support and midwifery management are associated with lower
cesarean section rates. This article reviews the evidence that links specific intrapartum
care practices to cesarean section. Strategies that can be implemented in the current social
and cultural setting of obstetrics today are recommended.
Semin Perinatol 36:357-364 © 2012 Elsevier Inc. All rights reserved.

KEYWORDS fetal heart rate monitoring, intrapartum care, midwifery, primary cesarean section

M ore than 4 million women give birth in the United

States each year and slightly more than one-third of
these women give birth by cesarean section.1 The rate of
cesarean section rose from 21% in 1996 to 32.9% in 2009,
and today, it is the most common surgical procedure per-
formed in the United States.1,2 Because cesarean births are
associated with short-term and long-term adverse health ef-
fects for the mother and infant, strategies that effectively
lower the incidence of this procedure are urgently needed.3-6
To lower the total cesarean section rate, which is the sum of
all repeat and primary procedures, decreasing the number of
primary cesarean sections is a critical first step. This article
reviews intrapartum management for nulliparous women at
term with a singleton fetus in vertex presentation (NTSV)
because this is the population in which the cesarean section
rate varies widely. Recommendations for care practices that
promote vaginal birth are presented.
Background: Indications for
Intrapartum Cesarean Section
Several labor management practices are associated with an
increased cesarean section rate, including, but not limited to,
early admission, diagnosis of the active phase of labor at 3-4
cm dilatation, and continuous electronic fetal monitoring. In
Department of Obstetrics, Gynecology and Reproductive Sciences, Univer-
sity of California San Francisco, San Francisco, CA.
Address reprint requests to Tekoa L. King, CNM, MPH, Department of
Obstetrics, Gynecology and Reproductive Sciences, University of Cali-
fornia San Francisco, San Francisco, CA. E-mail: tking@acnm.org
contrast, midwifery management and continuous support
during labor are associated with lower cesarean section rates
in both observational and randomized controlled trials
(RCTs).7-9 Labor support practices, such as encouraging oral
fluids, frequent ambulation, avoiding an epidural, and phys-
iological management of the second stage, have been pro-
moted as interventions that could lower the cesarean section
rate; however, studies evaluating some of these specific inter-
ventions have had conflicting results. Thus, there is a plethora of
intrapartum care practices that could influence the rate of cesar-
ean section either singly or in concert. Identification of the most
frequent indications for a primary cesarean section in low-risk
women sheds some light on where to look first.10,11
Barber et al11 analyzed the indications for 10,757 women
who had cesarean sections performed between 2003 and
2009 in one large academic hospital. They found that fetal
intolerance of labor (32%) and arrest of labor (18%) ac-
counted for 50% of the increase in the primary cesarean rate.
Similarly, Main et al10 analyzed the rates and indications for
cesarean sections in California, which is where 1 of every 8
infants born in the USA is born. These authors looked spe-
cifically at the NTSV cesarean section rate that was 28.1%
overall with regional variation that ranged from 21.5% to
33.5% and hospital variation that ranged from 10% to 50%.
Fetal intolerance of labor and arrest of labor accounted for
40%-50% of all cesarean sections, and they exhibited the
largest regional and interhospital variability.
Wide variability in practice is a well-known marker for
medical practices that are underused in some settings and
overused in others.12,13 In fact, the inverse relationship be-
tween quality health care and variation in practice has been

0146-0005/12/$-see front matter © 2012 Elsevier Inc. All rights reserved. 357
http://dx.doi.org/10.1053/j.semperi.2012.04.020
358
well documented.14 Thus, the diagnosis of fetal intolerance of
labor and the management of dystocia are the 2 key areas
where application of evidence-based strategies may have the
most impact in lowering the rate of primary cesarean section.
The third variable that affects intrapartum cesarean section
rates is the influence of the provider.
Fetal Intolerance of Labor
Approximately 20%-30% of all NTSV cesareans are per-
formed for fetal intolerance of labor.10 Continuous electronic
fetal heart rate monitoring (EFM) is the norm for ⬎90% of
women who give birth in the United States.15 Nevertheless,
the efficacy of EFM has not been proven.
The Evidence for EFM
The story of EFM is well known.16 In brief, EFM was adopted
into clinical practice in the 1960s and 1970s before being
assessed in randomized trials. The beliefs that variant fetal
heart rate (FHR) patterns reflect fetal hypoxemia and that
EFM could identify the fetus with impending asphyxia early
enough to intervene were compelling, and this technology
was rapidly embraced. The first studies of EFM compared
outcomes in settings before and after the introduction of
intrapartum monitoring and found that women who had
continuous EFM during labor had fewer intrapartum still-
births.17 It is important to note that a reduction in intrapar-
tum stillbirth is still a true benefit of EFM.
The initial RCTs were conducted in the 1970s and 1980s.
They found that EFM was associated with higher rates of
cesarean section without a concomitant improvement in
newborn outcomes.18 A Cochrane meta-analysis, which was
last updated in 2006, compared 13 RCTs of continuous EFM
with intermittent auscultation (IA) and confirmed higher ce-
sarean section rates but no improvement in Apgar scores,
perinatal mortality or rates of cerebral palsy in infants born to
women in the continuous EFM.19 EFM is associated with a
50% reduction in the incidence of early neonatal seizures,
but there were no differences between the EFM and IA
groups in the rate of cerebral palsy when the infants with
newborn seizures were reexamined at 4 years of age.20
These results are frequently cited because the evidence that
shows EFM increases the cesarean section rate without a
concomitant improvement in newborn outcomes.21 On
closer examination, there are multiple study design differ-
ences and problems that should disallow generalizing the
results of these RCTs and meta-analysis to women in labor
today for either recommending its use or recommending that
it not be used. The RCTs included in the meta-analysis were
all conducted between 1976 and 1994, which makes them
⬎20 years old.19 The majority of these studies were con-
ducted before the importance of FHR variability because an
indicator of fetal hypoxemia was known; thus, the decision to
do a cesarean section for fetal distress was made on the basis
of decelerations with or without a diminution in baseline
variability. Many of the studies used fetal scalp sampling as an
auxiliary test, which is rarely used today in the United States.
T.L. King
There was no standard terminology shared by the different
study designs so even the definition of late decelerations was
different from 1 study to the next. In addition, the studies
differed in their inclusion criteria. Some included women at
term only and others included preterm gestations.
Recently Chen et al22 used US birth certificate data from
2004 to compare outcomes in women who had EFM in labor
vs those who were monitored via IA. The analysis included
women who were 24-44 weeks’ gestation. They excluded
stillbirths, infants with congenital anomalies, and women
who had repeat cesarean sections. A higher cesarean section
rate was found in the EFM group versus the IA group (2.8%
vs 1.5%, respectively; relative risk [RR] ⫽ 1.81, 95% confi-
dence interval [CI] ⫽ 1.74-1.88). However, early neonatal
mortality (infant death at ⬍6 days) for women who were
ⱖ37 weeks’ gestation was lower in the EFM group (0.2% for
EFM vs 0.3% for IA; RR ⫽ 0.65, 95% CI ⫽ 0.47-0.90).
Neonatal seizures were less common in women who had
obstetrical disorders, chronic medical conditions, or a pre-
term birth if monitored with EFM (0.7/1000 live births vs
1.1/1000 live births), but the incidence of neonatal seizures
in women who were low risk were not different when com-
pared by monitoring modality (0.5/1000 live births vs 0.5/
1000 live births).
Because 89% of the women in the Chen analysis experi-
enced EFM in labor, the numbers in the comparison groups
were markedly different. Additionally, much of the data re-
corded on birth certificates have been shown to be unreliable.
Thus, it is not clear if inherent bias in the data source benefits
one monitoring modality or neither. Perhaps most impor-
tantly, intrapartum hypoxia is only one of many etiologies of
early neonatal mortality. The results of this most recent study
do not inform the debate about using EFM versus IA for
low-risk women at term. In the end, the question of superi-
ority of EFM versus IA has not been solved, and a randomized
trial of sufficient power is unlikely to be completed given the
resources that would be needed to conduct this study.
Today, EFM is often used as the poster child for a medical
technology that was accepted in clinical practice despite hav-
ing no documented benefits,23,24 and the argument that EFM
should be discarded frequently appears in the obstetrical lit-
erature.21,25 However, changing a practice that is currently
standard of care is very difficult.26 Therefore, using current
research findings to replace or alter the protocols used for
intrapartum fetal monitoring in monitored women who are
low risk for fetal acidemia at the onset of labor is more likely
to be successful than a whole-scale change in practice.
FHR Monitoring Modalities That
may Lower the Cesarean Section Rate
In the last decade, FHR research demonstrated that an um-
bilical artery pH value of ⬍7.0 reflects an increased risk for
hypoxic ischemic encephalopathy, and those FHR patterns
that are most associated with low umbilical artery pH values
were identified.27 Standardization in clinical practice also im-
proved. In 2005-2006, the relevant professional associations
all endorsed use of a standard terminology for FHR charac-
Preventing primary cesarean sections
Figure 1 Algorithm for interpreting fetal heart rate patterns. (Color version of figure is available online.) © Tekoa King.
teristics. In 2008, the workshop on FHR monitoring jointly
sponsored by the National Institute of Child Health and Hu-
man Development and the American College of Obstetricians
and Gynecologists recommended a 3-tier system for interpre-
tation of FHR patterns,28 and in 2010, American College of
Obstetricians and Gynecologists published a practice bulletin
that includes additional recommendations which results in a
four-tier system.29 In addition, there is a rapidly increasing
body of evidence about the relationship between specific
FHR patterns and fetal/newborn acidemia that if imple-
mented into practice, may help lower the primary cesarean
section rate.30,31
5-Tier System for FHR Interpretation
The practice change that is most likely to have a positive
impact on reducing the cesarean section rate is more refined
interpretation of FHR patterns and institutionally developed
protocols for management of abnormal FHR patterns. The
2008 National Institute of Child Health and Human Devel-
opment FHR workshop recommended that FHR patterns be
divided into 3 categories for interpretation on the basis of
their association with fetal acidemia: I, normal; II, indetermi-
nate; and III, abnormal.28 The FHR patterns in category I and
category III are well-established markers for a nonacademic
fetus and a fetus with a significant risk for acidemia, respec-
tively.32,33 Category II includes a heterogenous group of pat-
terns that vary with regard to their association with fetal
acidemia, which makes this category difficult to use in clini-
cal practice. However, there appears to be a dose-response
relationship between time spent in category II during the last
2 hours before birth and an increased risk for lower Apgar
scores and neonatal intensive care unit admission.33 Recent
studies of a 5-tier system that subdivides category II have
shown that the 5-tier system more accurately reflects fetal
acid– base status.34-36 A simplified graphic for FHR interpre-
tation adapted from the 5-tier system is presented in Figure 1.
Standardized management protocols must be considered
with caution. The response to a specific FHR pattern in an
out-of-hospital birthing center or level 1 hospital that does
not have in-house obstetrical or anesthesia coverage may
have to be more conservative than the response in a tertiary
359
academic center. Available institutional resources are a criti-
cal factor in making the decision about watching and waiting
versus intervention. Institutional protocols for managing
FHR patterns will work best if they are developed by a mul-
tidisciplinary team composed of all the key players, including
nursing, midwifery, obstetrics, anesthesia, and administra-
tion.37 Resultant cesarean section rates for nonreassuring fetal
status will always need to be risk adjusted for hospital level
characteristics.
IA Protocols
IA protocols could be established in settings that have the
resources to offer women this modality. Maternal and new-
born outcomes in women who give birth at home or in free-
standing birth centers are cared for with intermittent moni-
toring through labor. Large observational studies of these
settings have documented lower cesarean section rates and
similar or improved newborn outcomes when compared
with women with similar demographic characteristics who
give birth in hospitals and monitored with continuous
EFM.9,38 These cohort studies can at best detect an associa-
tion between the type of intrapartum care and newborn out-
comes. However, the results have been markedly consistent
across different populations and when the analysis controls
for possible confounders.39 It is important to note that posi-
tive newborn outcomes in settings that use IA only occur
when the staff understands how to use IA, the institution has
a workforce that allows the continuous presence of a nurse or
midwife for women in active labor, and there is a policy and
process in place for moving to EFM when abnormalities on IA
are detected.40
FHR Monitoring
in the Latent Phase of Labor
A brief FHR tracing is often obtained on admission to rule out
variant patterns that might require additional evaluation.
However, a meta-analysis of 4 RCTs that measured the out-
comes of low-risk women who had an admission test and
those who were evaluated via IA (n ⫽ 13,000) found no
difference in newborn outcomes and an increase in cesarean
sections in the women how had the admission test (RR ⫽
360 T.L. King

Table 1 Normal Labor Progress in Nulliparous Women at Term in Spontaneous Labor

Active Phase
Author N Hours, Mean (2SD) Key Findings
Friedman46 500 2.5 (12) Frequent use of opioids, caudal
anesthesia, oxytocin, and
forceps different from today
Peisner and Rosen52 1060 <50% in active labor
by 4 cm, 74% in
active labor by 5 cm
Zhang et al50 26,838 4.4 (16.7) Active phase not entered until
5-6 cm. Speed of cervical
dilation progressively
accelerates
Kilpatrick and Laros53 2302 8.1 (16.6) no analgesia, Length of first and second
10.2 (19) conduction stages are longer in women
analgesia* with conduction anesthesia
Albers et al54 1513 7.7 (19.4) Length of active phase of labor
was longer in Hispanic and
American Indian women
when compared with non-
Hispanic white women
Albers55 2511 7.7 (17.5)* Midwifery-managed care.
43.7% used EFM, 61%
women were ambulatory in
labor. EFM and ambulation
were associated with longer
labors
Zhang et al49 1329 5.5 (13.7)† Marked interindividual
variability in cm at which
active phase starts (3-5 cm).
Time interval of no change
>2 hours not uncommon
before 7 cm
Jones and Larson56 120 6.2 (13.4) Hispanic population
Neal et al48 7009 6 (13.4) Systematic review included
studies of women with
analgesia and oxytocin
augmentation; slowest
normal rate of cervical
dilation approximates 0.5-0.6
cm/h
EFM, electronic fetal monitoring; IA, intermittent auscultation.
*First stage of labor as defined by patient history.
†90th percentile.
Clinical Implications
The Friedman curve should not
be used to monitor labor
progress
Do not make the diagnosis of
active labor until at least 5
cm
Do not make the diagnosis of
active labor until at least 5-6
cm
Cervical dilation in active phase
of labor in women with
conduction analgesia may
take 0.5-1 hour longer than
women who do not have
conduction analgesia
Racial differences in labor
length need to be explored in
more detail. Individual
institutions can determine
normal time frames for their
setting
Use of IA and ambulation
during active labor in women
without analgesia may
shorten length of the first
stage of labor
Allow at least 2 hours between
each increment of cervical
dilation before 7 cm
Allow at least 2 hours between
each increment of cervical
dilation in late active phase of
labor

1.20, 95% CI ⫽ 1.00-1.44).41 Although this is a statistically
significant finding, it is difficult to justify not using EFM on
admission to screen for the rare FHR pattern that indicates an
increased risk for fetal acidemia given the current medicole-
gal climate in the United States. Nonetheless, women who are
admitted in latent labor are more likely to have a cesarean
section than women who are admitted in active labor,42 and
there are no professional guidelines that recommend EFM for
women who are in latent labor. Therefore, a shift from con-
tinuous EFM and bed rest to encouraging ambulation and
maintaining comfort for women who require hospital care
during the latent phase may help mitigate the cesarean sec-
tion rate in this population.
Labor Management Practices
That Improve Vaginal Birth Rates
Dystocia is the leading cause of primary cesarean sections
today, accounting for approximately half of those performed
during labor.43 Dystocia also accounts for the greatest varia-
tion in institutional cesarean rates.44,45 A brief review, the
Preventing primary cesarean sections
Figure 2 Partograph for low-risk, nulliparous women with spontaneous labor onset. Reprinted with permission from
Neal and Lowe.57 (Color version of figure is available online.)
indications for failure to progress and intrapartum care prac-
tices that are associated with lower rates of cesarean section,
informs recommendations for changes in intrapartum man-
agement.
Failure to Progress in Labor
Dystocia is vaguely defined as slow or abnormal progression
of labor. For decades, progress in labor has been measured to
determine the statistical limits of normal via use of a time
versus dilatation graph created by Emanual Friedman in
1955.46 Friedman followed the progress of 500 primigravid
women to determine the mean, median, range, and standard
deviation of the first stage of labor. He divided the resulting
sigmoid curve into the latent, active and transition phases
“for purposes of mathematical simplification . . . ”p569.46 Un-
fortunately, the intrapartum courses that informed the Fried-
man graph are not an accurate reflection of labor progress
today.47-50 Even more interesting is that they were probably
not an accurate depiction of labor in 1955.
Recent investigations have identified and corrected some
of the problems inherent in Friedman’s work.48,51 Zhang et
al50 repeated the analysis of labor progress using data from
the National Collaborative Perinatal Project. Using a repeated
measures analysis, they found that the latent phase of labor
lasted longer than Friedman detected and that a deceleration
phase did not occur. It is important to note that the data for
this analysis came from a large prospective study of women
who gave birth between 1955 and 1966, when intrapartum
management was similar to the management experienced by
the women in Friedman’s sample. Table 1 presents the results
of contemporary studies on labor progress in primigravid
women at term and summarizes the key findings.46,47-50,52-56
From a clinical perspective, it is clear that continued use of
the Friedman curve to determine the limits of normal is re-
sulting in iatrogenic intervention and overusage of cesarean
section.
A Labor Curve for the Future
Neal and Lowe57 recently developed a partogram (Fig. 2)
based on the following principles culled from an extensive
review of the current research on labor progress: (1) Active
labor must be accurately diagnosed before the rate of cervical
361
dilation is used to assess labor progression. (2) In nulliparous
women, 90% of women will have a linear dilation rate of at
least 0.5 cm/h. (3) Cervical dilation accelerates progressively
throughout active labor. (4) The time between each centime-
ter of dilatation is more variable in early active labor than it is
in late active labor. The partogram includes a dystocia line
that incorporates these 4 principles and additionally assumes
any ⬎4-hour delay in dilation after 5 cm is an indication for
intervention.57 The results of clinical research using the Neal
and Lowe partogram are anticipated. Until an improved labor
graph is clinically available, discarding the Friedman curve
and incorporating the key summary points listed in Table
242,45,58-66 are recommended when making clinical decisions
about labor progress.
Intrapartum Care Practices
That Lower the Cesarean Section Rate
Delayed admission until the onset of active labor, continuous
supportive care, avoiding epidural analgesia, supporting ad-
equate hydration, use of upright positions, and less use of
amniotomy and oxytocin during labor all have some biologic
plausibility for facilitating vaginal birth via support for phys-
iological labor. Although there is some evidence for use of
each of these practices, only continuous one-to-one support
during labor has been shown to confer a statistically signifi-
cant advantage.58 Table 2 summarizes the key findings from
studies of labor practices that may be associated with a lower
cesarean section rate.42,58-66 It is important to note that these
management strategies are most often studied individually,
which disallows assessment of any potentiating effect they
may have on each other when offered in aggregate. To date,
only studies of midwifery care have indirectly assessed intra-
partum management that includes all these care practices as a
comprehensive model of care.
The Role of the Provider
Many years of prospective and retrospective observational
studies have consistently found midwifery care associated
with a lower cesarean section rate when compared with phy-
sician-only management.9,38,67,68 There are 2 interrelated cri-
362 T.L. King

Table 2 Individual Intrapartum Care Practices that Promote Vaginal Birth in Women at Term in Spontaneous Labor
Management Practice
Admit in active labor
Ambulation and upright
positions
Continuous labor support
Epidural vs
nonpharmacologic
methods of pain control
Oral hydration and nutrition
OR, odds ratio; RCT, randomized controlled trial; RR, relative risk.
Key Findings Clinical Implications
Retrospective studies found admission after active labor Avoid admitting women in latent
is established results in less intervention and lower labor and/or avoid EFM and
cesarean sections.42,45 bed rest in women who are
One RCT of 209 women found a trend for fewer admitted in latent labor
cesareans (7.6% in delayed admission group vs 10.6%
in early admission group; OR ⴝ 0.70, 95% CI ⴝ 0.27-
0.81).58
Upright positions and freedom of movement are Ambulation in active labor may
associated with less perceived pain, shorter labor, shorten labor duration
improved uterine contractility, and increased patient
satisfaction.59,60
Trend toward lower cesarean section rates that is not
statistically significant
Continuous support provided by a nonmedical person Continuous one-to-one support
reduces cesarean section rate (16 trials, n ⴝ 13,391; during labor
RR ⴝ 0.91, 95% CI ⴝ 0.83-99)60,61
The association between epidural analgesia and cesarean Encourage nonpharmacologic
section is controversial, and most studies have methods of pain relief for
significant crossover or statistically significant results women who are interested in
that may not be clinically significant.62,63 avoiding epidural analgesia
RCTs that have found no association primarily use active
management of labor protocols. It is possible that
active management mitigates the effect of epidural
analgesia on cesarean section rates.64,65
125 cc/h vs 250 cc/h is associated with shorter labors, Encourage oral fluid and
less use of oxytocin, and a trend toward fewer nutrition in labor
cesarean sections.66

tiques of this body of literature as a whole. First, most of the
research on midwifery has included nonrandomized com-
parison groups, which suggests selection bias may slant the
results in favor of midwifery care. To address this issue, many
of these studies applied logistic regression models and/or
specific selection criteria to comparison groups that ac-
counted for confounders. In clinical practice, midwives in the
United States care for a larger proportion of underserved
women when compared with the case mix of obstetricians.
This is a population that has been noted to have a higher a
priori risk for cesarean section.7,69,70
Secondly, women cared for by midwives who require a cesar-
ean section are referred to a collaborating physician, which may
result in the cesarean section being attributed to the physician
versus the midwife. Thus, only studies that include an intention-
to-treat analysis can address this problem. Hatem et al8 did con-
duct a meta-analysis of RCTs that evaluated outcomes by inten-
tion-to-treat and did not detect a difference in cesarean section
rates when midwifery care was compared with physician-only
care (11 trials, n ⫽ 11,897, RR ⫽ 0.96, 95%CI ⫽ 0.87-1.06).
The meta-analysis did find that midwifery care was associated
with improved outcomes in most other indices, including more
spontaneous vaginal births (9 trials, n ⫽ 10,926, RR ⫽ 1.04,
95% CI ⫽ 1.06-1.04). Despite the repute of the Cochrane meta-
analysis process, these RCT results and the subsequent meta-
analysis present an incomplete picture of midwifery care out-
comes. Several different models of midwifery care were included
in the RCTs, which were largely conducted in Europe. Intrapar-
tum management with regard to the indications for cesarean
section cannot be directly generalized to intrapartum care in the
United States.
The research methodology questions about midwifery care
may remain unsolved. It is not clear if women who chose
midwives are inherently at lower risk for having a cesarean
section in some intangible way that has not been measured,
or if the midwifery model of care lowers cesarean section
rates to a greater extent than has been measured given mid-
wives have a higher proportion of women in their caseload
who are at risk for cesarean section secondary to racial or
socioeconomic disadvantage. Of more importance is the
overall consistency of findings that midwifery care is associ-
ated with positive obstetrical outcomes that include higher
vaginal delivery rates. Increased use of midwives in the
United States is recommended.
Conclusions
The cesarean section rate for low-risk women at term is al-
most twice as high as it should be. Many of the medical
reasons for this crisis have been identified, including elective
induction, early admission, EFM, and a graphic standard for
labor progress that is outdated and inappropriate. A multi-
pronged reality-based approach is going to be necessary to
effect a positive change in the primary cesarean section rate.
Preventing primary cesarean sections
Specific changes in intrapartum management need to be part
of an overall program that includes education, opportunity,
and incentives that are made available to providers and pa-
tients alike.26,71
In settings that rely on continuous EFM, adoption of a
5-tier system for interpretation and management will im-
prove identification of the fetus who is at risk for significant
acidemia. Discarding the Friedman curve and revising how
labor progress is assessed can result in larger gains. Delayed
admission of women in latent labor, diagnosis of the active
phase after 5-6 cm, and extending the time frame for ex-
pected progress in the active phase of labor will result in
significantly fewer primary cesarean sections.
Any changes in labor management that result in longer
labors need to be counterbalanced with the addition of sup-
port measures that help women through this process. Prena-
tal education, policies that support women in latent labor
who are not yet admitted, and one-to-one support during
labor maybe essential. Expanded use of midwives, especially
as laborists, needs to be explored because the midwifery
model of care is the one model of intrapartum care that en-
compasses most of the individual components needed to pro-
vide better care to low-risk women during their labors.
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