Labor
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WHO intrapartum care labour stages recommendations
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- Definition and stages of labor
- Signs that labor has started
- Normal management and monitoring
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Do you mean labor in childbirth? If so, tell me whether you want:
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Definition and stages
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WHO intrapartum care definitions latent active first stage labour second third stages
Labor (labour) is the physiologic process in which regular, painful uterine contractions produce progressive effacement (thinning) and dilatation (opening) of the cervix, leading to delivery of the baby and then the placenta.
Stages of labor
1. First stage: cervical dilatation
From onset of true labor to full cervical dilatation, 10 cm.
It has two phases:
- Latent phase: contractions begin and the cervix effaces and dilates gradually. WHO defines this as cervical change up to 5 cm.
- Active phase: regular painful contractions with faster cervical dilatation from 5 cm to 10 cm. Older texts may use 4 cm as the start of active labor, so this cut-off can vary by guideline.
The WHO intrapartum guideline uses the 5 cm definition and emphasizes that normal progress differs substantially between individuals.
2. Second stage: expulsion of the fetus
From full dilatation, 10 cm, to birth of the baby.
- The presenting part descends through the birth canal.
- The mother develops an urge to bear down and pushes with contractions.
- It ends when the baby is delivered.
3. Third stage: delivery of the placenta
From birth of the baby to expulsion of the placenta and membranes.
- Uterine contraction and retraction cause placental separation.
- The placenta is delivered, and uterine contraction helps limit postpartum bleeding.
4. Fourth stage: immediate recovery period
This is commonly taught as the first 1 to 2 hours after placental delivery. It is not always counted as a formal stage.
During this period, clinicians monitor:
- Uterine tone and vaginal bleeding
- Maternal pulse and blood pressure
- Perineum or surgical wound
- Newborn adaptation, skin-to-skin contact, and initiation of feeding
In short:
1st stage: cervix dilates
2nd stage: baby is born
3rd stage: placenta is delivered
4th stage: immediate maternal and newborn observation
1st stage: cervix dilates
2nd stage: baby is born
3rd stage: placenta is delivered
4th stage: immediate maternal and newborn observation
Normal and abnormal
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labor dystocia management
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ACOG first and second stage labor management arrest of labor definition clinical practice guideline
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Normal labor
Normal labor is regular, painful uterine contractions that cause progressive cervical effacement and dilatation, followed by vaginal birth of the baby and delivery of the placenta.
Features of normal labor
- Contractions become regular, stronger, longer, and closer together.
- The cervix progressively effaces and dilates to 10 cm.
- The fetus descends and rotates through the pelvis.
- Mother and fetus remain clinically well, with reassuring fetal heart rate assessment.
- Delivery occurs spontaneously without major maternal or fetal complication.
Normal stages
| Stage | Normal event |
|---|---|
| First stage | Onset of true labor to full cervical dilatation (10 cm). Latent labor is early cervical change; active labor is faster dilatation. |
| Second stage | Full dilatation to birth of the baby, with descent and maternal pushing. |
| Third stage | Birth of baby to delivery of placenta and membranes. |
| Fourth stage | The immediate postpartum observation period, often the first 1 to 2 hours. |
Modern guidance considers 6 cm dilatation as the start of active labor, although older teaching commonly used 4 to 5 cm. ACOG guidance and the WHO intrapartum guideline support avoiding diagnosis of active-phase delay too early.
Abnormal labor
Abnormal labor, also called dysfunctional labor or labor dystocia, is labor that progresses unusually slowly or stops, or in which maternal or fetal problems make normal vaginal delivery unsafe.
It may involve abnormal power, passenger, or passage:
- Power: inadequate or uncoordinated uterine contractions; ineffective maternal pushing.
- Passenger: large fetus, malpresentation such as breech or transverse lie, malposition such as persistent occiput posterior, or shoulder dystocia.
- Passage: pelvic obstruction, cephalopelvic disproportion (CPD), a full bladder, or soft-tissue obstruction.
Common abnormal patterns
| Disorder | Meaning |
|---|---|
| Prolonged latent phase | Early labor is unusually long. It is often managed conservatively if mother and fetus are well and is not, by itself, a reason for cesarean birth. |
| Protracted active phase | Cervical dilatation is slower than expected during active labor. |
| Active-phase arrest | No further cervical dilatation after active labor is established. Current ACOG definition: at least 6 cm dilatation, ruptured membranes, and no cervical change after 4 hours of adequate contractions or 6 hours of inadequate contractions despite oxytocin augmentation. |
| Arrest of descent / second-stage arrest | Little or no fetal descent or rotation despite adequate contractions and pushing. |
| Precipitate labor | Unusually rapid labor and birth, potentially associated with trauma, postpartum hemorrhage, or fetal distress. |
| Obstructed labor | Mechanical obstruction prevents descent, often from CPD, malpresentation, or malposition. |
| Fetal distress during labor | Non-reassuring fetal heart rate pattern suggesting compromised fetal oxygenation, requiring prompt assessment and possibly expedited birth. |
Prolonged second stage
ACOG defines prolonged pushing as:
- More than 3 hours in a first birth (nulliparous person)
- More than 2 hours in someone who has previously delivered vaginally (multiparous person)
However, the decision to intervene is individualized. Ongoing descent or rotation, fetal status, maternal condition, and patient preference all matter. ACOG’s current recommendations also allow earlier identification of arrest when there is no descent or rotation despite adequate efforts.
Management principles
Management depends on the cause and condition of mother and fetus:
- Confirm labor progress, fetal position, presentation, descent, and contraction adequacy.
- Assess fetal well-being and maternal status.
- Correct reversible factors, such as dehydration, a distended bladder, ineffective contractions, or inadequate pain relief.
- Consider amniotomy or oxytocin only when clinically appropriate.
- Use operative vaginal birth or cesarean birth if vaginal delivery is unsafe or labor remains arrested.
A textbook describes dysfunctional labor as deviation from expected progress, including prolonged latent labor, protracted active-phase dilatation, secondary arrest of cervical dilatation, and arrest of descent. Textbook of Family Medicine, pp. 502-506.
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