Management of Normal Labor and Delivery

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Management of normal labor and delivery

Authors: Edmund F Funai, MD, Errol R Norwitz, MD, PhD, MBA
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jun 2021. | This topic last updated: Apr 09, 2021.
INTRODUCTION
In 1997, the World Health Organization defined normal birth as

"spontaneous in onset, low-risk at the start of labor and remaining so
throughout labor and delivery. The infant is born spontaneously in the
vertex position between 37 and 42 completed weeks of pregnancy. After
birth, mother and infant are in good condition" [1].
This topic will present a paradigm for intrapartum management of women

who are expected to have a normal birth. Many of the options for caring for
these women have not been studied in clinical trials, or the data from
clinical trials are insufficient for making strong recommendations for a
specific approach [2]. Therefore, much of our approach is based upon our
clinical experience, data from observational studies, and expert opinion.
Intrapartum care of women with a complicated labor and delivery is

discussed in separate topic reviews (eg, malpresentation, protraction and
arrest disorders, preterm labor, operative vaginal delivery, maternal
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medical/obstetric disorders, hemorrhage; refer to individual topic reviews

on each subject).
COVID-19
Management of labor and delivery during the coronavirus disease 2019

(COVID-19) pandemic is reviewed separately. (See "COVID-19: Labor,
delivery, and postpartum issues and care", section on 'Management of
labor and delivery'.)
CREATING A SATISFACTORY CHILDBIRTH EXPERIENCE
Four factors important in determining a woman's satisfaction with her

childbirth experience are personal expectations, the amount of support she
receives, the quality of the caregiver-patient relationship (eg, respect,
communication, continuity of care), and her involvement in decision
making.
Childbirth preparation classes inform women and their partners about

what to expect during labor and birth and provide a foundation for
developing personal plans for the birth experience. (See "Preparation for
childbirth".)
One-on-one support by a doula during the birthing process may lower

intrapartum analgesia requirements, decrease the rate of operative
delivery, and increase satisfaction with the birth experience. (See
"Continuous labor support by a doula".)
WHEN SHOULD LABORING WOMEN BE ADMITTED TO THE

HOSPITAL

The appropriate time for hospital admission for women in labor with
uncomplicated pregnancies is unclear. There is consensus that women in
active labor should be admitted. The National Partnership for Maternal
Safety suggests assessing the presence of the following factors in making
the diagnosis of active labor: regular contractions that require the woman's
focus and attention, significant effacement (≥80 percent), and 4 to 5 cm
dilation with documented cervical change [3] since most women enter the
active phase of labor at 4 to 6 cm.
Given that women cannot check their cervical dilation or effacement, many
women will present for a labor check before cervical dilation reaches 4 cm.
If mother and fetus are well and transport to the hospital is not a concern,
should these patients be admitted to the Labor and Delivery Unit or sent
home? Both approaches are probably reasonable. Although women
admitted before 4 cm cervical dilation are at higher risk for iatrogenic
intervention, the maternal and perinatal consequences of sending these
patients home have not been studied adequately.
In Washington State, the Bree Collaborative Obstetrics Care Report

attempted to influence clinical practice by recommending admission for
spontaneously laboring women at term with uncomplicated pregnancies
only when cervical dilation was ≥4 cm [4]. The clinician determined whether
the pregnancy was low risk, as well as appropriate counseling and
reassessment of women not admitted. Adherence to the recommendation
was not mandatory. After publication of this report, a retrospective cohort
study of over 11,000 singleton, term deliveries in Washington State
observed a 10 to 15 percent increase in hospital admissions at cervical
dilation ≥4 cm [5]. Women admitted with cervical dilation <4 cm were more
likely to have epidural anesthesia, oxytocin augmentation, and a cesarean
delivery than women admitted with cervical dilation ≥4 cm. The authors
were unable to identify women evaluated for labor, sent home because of
cervical dilation <4 cm, and subsequently admitted; thus, the safety and
efficacy of the change in clinical practice could not be evaluated.

A large study from Texas reported that, after evaluation, discharging

patients with false labor at term was not associated with an increase in
adverse outcome [6]. Criteria for discharge were intact membranes,
cervical dilation <4 cm, no cervical change or contractions at the end of two
hours observation, and normal fetal heart rate tracing. Patients were
excluded from the study if they had pregnancy complications or a previous
cesarean delivery.
MANAGEMENT OF THE FIRST STAGE OF LABOR
Initial examination — The goals of the initial examination of the

parturient are to review her prenatal record for medical or obstetric
conditions that need to be addressed intrapartum, check for development
of new disorders since the last prenatal visit, establish baseline cervical
status so that subsequent progress can be determined, and evaluate fetal
status.
On admission to the labor unit, vital signs include the woman's blood
pressure; heart and respiratory rates; temperature; frequency, quality, and
duration of uterine contractions; and fetal heart rate (FHR).
Determining whether a woman is in labor is sometimes difficult as painful

uterine contractions alone are not sufficient to establish a diagnosis of
labor. Typically, the diagnosis is reserved for women with uterine
contractions that result in cervical dilation and effacement over time. A
recent history of membrane rupture or bloody show (vaginal discharge of a
small amount of blood and mucus [ie, mucus plug]) supports the diagnosis.
Physical examination is performed with particular emphasis on the cervical

examination. Digital examination is performed after placenta previa and
prelabor rupture of membranes (PROM) have been excluded (by history
and physical, laboratory, and ultrasound examinations, as appropriate).
The purpose of the initial examination is to determine:

● Whether fetal membranes are intact or ruptured – (See

"Management of prelabor rupture of the fetal membranes at term".)
If the membranes have ruptured, the presence of meconium is noted

because of the possibility of meconium aspiration. (See "Meconium
aspiration syndrome: Pathophysiology, clinical manifestations, and
diagnosis".)
● Whether uterine bleeding is present and excessive – Bleeding can

be due to placenta previa, vasa previa, and abruptio placentae, and
these disorders are potentially life-threatening to the mother and/or
fetus. (See "Placenta previa: Epidemiology, clinical features, diagnosis,
morbidity and mortality" and "Velamentous umbilical cord insertion
and vasa previa" and "Placental abruption: Pathophysiology, clinical
features, diagnosis, and consequences".)
● Cervical dilation and effacement – In women with contractions,

progressive cervical dilation and effacement on serial examinations or
advanced cervical dilation and effacement on an initial examination are
evidence of labor. The rate of cervical dilation becomes faster after the
cervix is completely effaced [7].
● Fetal station – Fetal station is expressed as the number of centimeters

of the leading bony edge of the presenting part above or below the
level of the ischial spines ( figure 1); the maximum denominator is 5
(eg, 1 cm beyond the ischial spines corresponds to +1/5 cm).
Effacement and station are shown in the figures ( figure 2A-B).
If a cervical examination is not performed because of ruptured

membranes or vaginal bleeding, engagement of the fetal head can be
described in terms of fifths of the fetal head palpable above the
symphysis pubis [8]. If the fetal head is not engaged (ie, three-fifths are
palpable above the pelvic inlet) in labor, this should raise concerns
about cephalopelvic disproportion.

● Fetal lie, presentation, and position – Document fetal lie,

presentation, and position. Lie refers to the long axis of the fetus
relative to the longitudinal axis of the uterus; it can be longitudinal,
transverse, or oblique.
Presentation refers to the fetal part that directly overlies the pelvic
inlet; it is usually vertex (cephalic) or breech but can be a shoulder,
compound (eg, head and hand), or funic (umbilical cord).
Fetal position is the relationship of a nominated site of the presenting

part to a denominating location on the maternal pelvis (eg, right
occiput anterior). The fontanelles and suture lines of the fetal skull and
their orientation according to fetal position are illustrated in the
figures ( figure 3 and figure 4A-C and figure 5 and figure 6).
Ultrasound examination can be useful if digital assessment is unclear,
particularly for occiput posterior [9-11]. The International Society of
Ultrasound in Obstetrics and Gynecology (ISUOG) has published
practice guidelines for intrapartum ultrasound. (See "Occiput posterior
position", section on 'Diagnosis'.)
Asynclitism refers to an oblique position of the fetal head where the

head is tilted toward the shoulder and the parietal bone is the point of
presentation.
● Fetal size and pelvic capacity – The clinician should make an attempt
to determine whether the fetus is macrosomic and may evaluate the
pelvic type ( figure 1); however, these assessments are poorly
predictive of the newborn weight and course of labor. (See "Shoulder
dystocia: Risk factors and planning delivery of high-risk pregnancies".)
Pelvimetry (ie, quantitative measurement of pelvic capacity) can be

performed clinically or via imaging studies (radiography, computed
tomography, magnetic resonance imaging ( figure 7A-B) [12-14]).
Average and critical limit values for the various parameters of the bony

pelvis have been established but do not accurately predict women at

risk for cephalopelvic disproportion [15]. Routine clinical pelvimetry is
not recommended [16]. Pelvimetry has been replaced, in large part, by
clinical trial of the pelvis ("trial of labor").
● Fetal and maternal well-being – Fetal status is assessed by the FHR

pattern (see "Intrapartum fetal heart rate monitoring: Overview").
Maternal assessment is primarily directed toward identifying
development of new pregnancy complications, such as preeclampsia,
infection, or abruption.
Laboratory tests — Results from the following laboratory tests should be

available at delivery, but intrapartum assessment is not always necessary.
● Hemoglobin/hematocrit – Although laboratory assessment of

hemoglobin/hematocrit is commonly performed upon admission,
there is no evidence that this practice is necessary in uncomplicated
pregnancies. Relying on a normal hemoglobin result obtained at 26 to
28 weeks (ie, at the time of screening for gestational diabetes) appears
to be a safe and acceptable approach [17,18].
● Blood type and screen – Approximately 1 to 2 percent of women

receive a blood transfusion in the peripartum period [19,20].
For women at low risk of postpartum hemorrhage, Rh typing with a

negative antibody screen at the first prenatal visit is probably adequate
[21-24], but obtaining and holding a clot is also reasonable. Some
clinicians obtain a type and screen on these women.
For women at moderate risk of needing a transfusion, a type and

screen should be performed, at a minimum. These women include
those with multiple gestation, trial of labor after cesarean,
preeclampsia/HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet
count) without coagulopathy, grand multiparity, intraamniotic
infection, or large fibroids.
For women at high risk of needing a transfusion, type and crossmatch

should be done [25]. These women include those with placenta previa
or accreta, preeclampsia/HELLP with coagulopathy, severe anemia,
congenital or acquired bleeding diathesis, previous postpartum
hemorrhage.
● Human immunodeficiency virus (HIV) – Women who have not had

HIV screening in pregnancy or whose HIV status is undocumented
should have rapid HIV testing in labor if possible or, otherwise, in the
immediate postpartum period, using an opt-out approach [26-30].
Some states require all women be screened at delivery. If the rapid test
is positive, then antiretroviral prophylaxis should be initiated while
waiting for the results of confirmatory testing. (See "Prenatal
evaluation of women with HIV in resource-rich settings" and
"Antiretroviral selection and management in pregnant women with HIV
in resource-rich settings".)
● Hepatitis B – Women who were not screened for hepatitis B surface

antigen prenatally, engage in behaviors that put them at high risk for
infection (eg, having had more than one sex partner in the previous six
months, evaluation or treatment for a sexually transmitted infection,
recent or current injection-drug use, a hepatitis B antigen-positive sex
partner), or have clinical hepatitis should be tested at hospital
admission for delivery [26]. Some states require screening of all
women at delivery. The infant should receive immunoprophylaxis if the
results are positive. (See "Hepatitis B virus immunization in infants,
children, and adolescents", section on 'HBsAg-positive mother or
mother with other evidence of HBV infection'.)
● Syphilis – Women who are at high risk for syphilis, live in areas of high
syphilis morbidity, or are previously untested should be screened at
delivery [26]. Some states require screening all women at delivery. (See
"Syphilis in pregnancy".)

● Group B streptococcus (GBS) – Women with unknown GBS status can

be tested with a nucleic acid amplification test (NAAT), such as
polymerase chain reaction for GBS, where available. However, such
testing is less reliable than routine GBS screening at 36+0 to 37+6
weeks. Chemoprophylaxis is indicated if NAAT is positive or if the GBS
carrier status is unknown but intrapartum risk factors for early-onset
GBS infection develop (delivery at <37 weeks gestation, temperature
≥100.4°F [≥38.0°C] or rupture of amniotic membranes ≥18 hours).
Some women with a history of GBS colonization in a previous
pregnancy may also receive chemoprophylaxis. (See "Neonatal group B
streptococcal disease: Prevention", section on 'Use of rapid diagnostic
tests'.)
Patient preparation — Meta-analyses of randomized trials support

avoidance of routine enemas and perineal shaving as these interventions
are not beneficial and have bothersome or harmful side effects [31,32].
Women can be encouraged to empty their bladder regularly; a urinary

catheter is unnecessary unless the woman is unable to void. Available data
suggest that bladder distention does not affect labor progress [33,34].
Activity — Women should be encouraged to move and ambulate freely

during early labor unless there is a specific contraindication [35].
Fluids and oral intake — Historically, oral intake has been restricted

during active labor because of the risk of aspiration pneumonitis, a major
cause of anesthetic-associated morbidity and mortality. However, this risk
is very low in the current era, and restriction of oral intake can lead to
hypovolemia (dehydration) and ketosis.
We allow clear liquids to women at low risk of cesarean delivery (eg,

uncomplicated pregnancy, nonobese, fetal weight appropriate for
gestational age, no previous cesarean, category 1 FHR tracing) and who
have an adequate airway, but restrict consumption of solid foods in

accordance with guidelines by the American Society of Anesthesiologists

Task Force on Obstetric Anesthesia that recommend avoidance of solid
foods in laboring women [36]. The volume of liquid consumed is less
important than the presence of particulate matter in the liquid.
If oral intake is inadequate or restricted because of increased risk for

cesarean delivery (eg, category 2 or 3 FHR tracing or other pregnancy
complications), we provide maintenance intravenous fluids with 5 percent
dextrose in 0.45 percent saline, normal saline, or Lactated Ringer solution
[37,38]. Glucose requirements in labor are analogous to the requirement
observed with sustained and vigorous exercise, and intrapartum
administration of glucose may be important for optimal myometrial
function [37,39].
Hypovolemia adversely affects exercise performance and may be a factor

contributing to longer duration of labor. Physiologists have shown that
fluid replacement improves skeletal muscle performance during prolonged
exercise; however, the effects of fluid replacement on smooth muscle are
less clear [40,41]. Among nulliparous women, a meta-analysis of seven
randomized trials found that the duration of labor may be shortened by
approximately one hour with administration of intravenous fluids at a rate
of 250 mL/hour rather than 125 mL/hour (mean difference -64.38 minutes,
95% CI -121.88 to -6.88) [42]. The risk of cesarean delivery overall and for
dystocia was also reduced (overall: 12.5 versus 18.1 percent, relative risk
[RR] 0.70, 95% CI 0.53-0.92; dystocia: 4.9 versus 7.7 percent, RR 0.60, 95% CI
0.38-0.97). Women had no or restricted oral intake in five of these trials and
unrestricted oral intake in two trials. The data did not allow a clear
conclusion as to whether the beneficial effects of intravenous fluids would
be mitigated or eliminated in women with unrestricted oral intake during
labor.
The effect of dextrose-containing intravenous fluids on length of labor has

not been studied extensively. In a meta-analysis of 16 trials (n = 2503 low
risk pregnancies ≥36 weeks) that evaluated the length of labor when
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patients received intravenous fluid with versus without dextrose, both

groups has a similar total length of labor, but dextrose appeared to shorten
the first stage (mean difference -76 minutes, 95% CI -121 to -31) [43].
Variations in oral intake and infusion rates in the trials limits interpretation
of these findings. In one of the only trials that compared length of labor in
women randomly assigned to 250 mL/hour of normal saline, 125 mL/hour
of 5 percent dextrose in normal saline, or 250 mL/hour of 2.5 percent
dextrose in normal saline with oral intake restricted to sips of water and ice
chips, length of labor was similar for all three groups [44]. Based on these
data, the type and rate of intravenous infusion does not appear to have a
significant impact on labor duration.
A 2017 systematic review of 10 randomized trials comparing less restrictive

food intake policies with more restrictive food intake policies during labor
in women with low-risk singleton pregnancies found that less restrictive
policies resulted in a slightly shorter duration of labor (-7 to -25 minutes)
[45]. No other benefits or harms were noted; however, a key outcome,
aspiration rate, could not be assessed because no events occurred.
Maternal satisfaction was also not assessed.
Antacids — We do not routinely administer sodium citrate to our laboring

patients, but give it to all patients before cesarean delivery. Some authors
have suggested administering a clear antacid (eg, 10 to 30 mL sodium
citrate) to all laboring women since aspiration pneumonitis results from the
acidity of the aspirated gastric contents; however, the utility of this
approach in laboring women has not been proven [46].
Medication management — Women can take their usual daily

medications orally during labor; however, gastric absorption is
unpredictable if labor is advanced. If this is a clinically important concern, a
nonoral route of administration is preferable.
Women who have been taking glucocorticoids in a dose equivalent to

prednisone 5 to 20 mg daily for more than three weeks may have

hypothalamic-pituitary-adrenal axis suppression and either should

undergo testing or receive empiric glucocorticoid coverage. Perioperative
management of specific medications, including glucocorticoid coverage, is
reviewed separately. (See "The management of the surgical patient taking
glucocorticoids".)
Infection prophylaxis
Systemic antibiotics — Intrapartum chemoprophylaxis to prevent

early-onset neonatal GBS infection is indicated for patients who meet
standard criteria; the agent of choice is penicillin G. A minimum of four
hours of intrapartum intravenous therapy has been recommended prior to
delivery; however, bactericidal levels in cord blood are achieved within 30
minutes of administration to the mother, so antibiotics should be
administered even if delivery seems imminent. Prevention of early-onset
neonatal GBS infection, including management of women with penicillin
allergy, is reviewed in detail separately. (See "Neonatal group B
streptococcal disease: Prevention".)
Vaginal delivery is not an indication for routine antibiotic prophylaxis, even

in women with cardiac lesions, since the rate of bacteremia is low (see
"Antimicrobial prophylaxis for the prevention of bacterial endocarditis",
section on 'Vaginal or cesarean delivery'). A Cochrane review concluded
that routine administration of antibiotics after a normal vaginal birth may
reduce the risk of endometritis but did not reduce the incidence of urinary
tract infections, wound infection, or the length of maternal hospital stay
[47]. Severe maternal infectious morbidity, antimicrobial resistance, and
women's satisfaction with care were not evaluated, and the overall quality
of evidence was low.
Vaginal antiseptic antibacterial agents — Available data provide no

convincing evidence to support the practice of intrapartum chlorhexidine
vaginal irrigation for reducing the risk of maternal and neonatal infection
[48].

Maternal activity and position — Maternal preferences can guide

maternal activity. In a randomized trial, walking during the first stage did
not enhance or impair active labor and had no harmful effects [49].
Laboring women should assume positions that are comfortable [50-52],

unless specific positions are needed because of maternal-fetal status and
need for close monitoring. Data from randomized trials provide no strong
evidence to discourage maternal preference for choosing position during
labor.
In a 2013 meta-analysis including 25 trials (5218 women), the duration of

the first stage was more than one hour shorter in women randomly
assigned to upright positions (standing, sitting, kneeling, walking around)
than in those randomly assigned to recumbent positions or bed care (-1.36
hours, 95% CI -2.22 to -0.51 hours) and women in upright positions had a
modest reduction in cesarean delivery (RR 0.71, 95% CI 0.54-0.94), but there
were no statistical differences in use of oxytocin augmentation (RR 0.89,
95% CI 0.76-1.05), maternal pain requiring analgesia (RR 0.95, 95% CI 0.84-
1.08), or duration of the second stage (-3.71 minutes, 95% CI -9.37 to 1.94
minutes) [50]. Some limitations of these trials include risk of bias since
blinding was not possible and wide variation in the patients' positions and
time spent in various positions.
Pain control and comfort measures — Multiple nonpharmacologic,

pharmacologic, and anesthetic options are available to help women
manage pain during labor. Use of nonpharmacologic measures can reduce
the use of drugs during labor and may have a modest favorable effect on
duration of labor. These options are reviewed in detail separately.
● (See "Nonpharmacologic approaches to management of labor pain".)

● (See "Pharmacologic management of pain during labor and delivery".)
● (See "Neuraxial analgesia for labor and delivery (including
instrumented delivery)".)

Amniotomy — We do not perform amniotomy routinely as there is no

convincing evidence of benefit in spontaneously laboring women. Rupture
of membranes increases the risk of ascending infection and cord prolapse.
In a 2013 systematic review and meta-analysis of randomized trials, routine
amniotomy did not shorten the first or second stage of labor or reduce the
rate of cesarean delivery compared with planned preservation of intact
membranes (15 randomized trials involving over 5500 women) [53]. A
limitation of this analysis was the lack of consistency in the timing of
amniotomy with respect to cervical dilation and substantial crossover: 20 to
60 percent of women assigned to the control group underwent amniotomy
at some stage in their labor.
Although amniotomy allows assessment of meconium passage, this

information alone has poor prognostic value and does not affect labor
management [54,55].
On the other hand, women undergoing augmentation or induction of labor

may benefit from the combination of oxytocin administration and
amniotomy [56,57]. In a randomized trial not included in the analysis
described above, early amniotomy within one hour of the diagnosis of
labor by strict criteria and oxytocin augmentation if cervical dilation was <1
cm per hour reduced the median duration of labor by 2.7 hours (from 8.9
to 6.2 hours) [56]. Amniotomy during induction is reviewed separately. (See
"Induction of labor with oxytocin", section on 'Amniotomy'.)
If amniotomy is performed in women with polyhydramnios or an

unengaged presenting part, we suggest using a small gauge needle (rather
than a hook) to puncture the fetal membranes in one or more places and
performing the procedure in an operating room. "Controlled amniotomy"
minimizes the risk of gushing amniotic fluid and permits emergency
cesarean delivery in the event of an umbilical cord prolapse. (See "Umbilical
cord prolapse".)

Amniotomy should be avoided, if possible, in women with active hepatitis

B, hepatitis C, or HIV infection to minimize exposing the fetus to ascending
infection. Positive GBS carrier status is not a contraindication to
amniotomy, if indicated.
Monitoring — Frequent maternal-fetal assessment is important as

intrapartum complications can arise rapidly even in low-risk women: 20 to
25 percent of all perinatal morbidity and mortality occurs in pregnancies
with no underlying risk factors for adverse outcome [58] and a study of 10
million birth certificates in the United States found that 29 percent of low-
risk pregnancies had at least one unexpected complication that would
require nonroutine obstetric or neonatal care [59]. The lowest risk for an
uncomplicated birth appears to be in multiparous women without a
previous cesarean delivery or other risk factors for complications; the risk
for a complicated birth in this group was 8 to 9 percent in one large English
study [60].
Fetal heart rate — Although controversial, intrapartum electronic FHR

monitoring has become the most common obstetric procedure for women
in the United States because patients and clinicians are reassured by
normal results and believe there is some value in detecting abnormal FHR
patterns. In women with pregnancies at increased risk of fetal compromise
during labor (eg, suspected fetal growth restriction, preeclampsia, abruptio
placentae, type 1 diabetes), we perform continuous electronic FHR
monitoring, in agreement with clinical management guidelines from the
American College of Obstetricians and Gynecologists (ACOG) [61]. We also
monitor low-risk pregnancies continuously because it is more practical than
intermittent monitoring in terms of nursing staff resources, but we are not
rigid about this if the patient understands the risks and benefits of
intermittent monitoring and has an uncomplicated pregnancy, normal FHR
tracing, and is not resting in bed. Intrapartum FHR monitoring is reviewed
in detail separately. (See "Intrapartum fetal heart rate monitoring:
Overview".)

Electronic FHR monitoring requires ongoing clinical assessment. At a

minimum, ACOG suggests review of FHR tracings in low-risk pregnancies
every 30 minutes in the first stage of labor and every 15 minutes in the
second stage [61]. For higher-risk pregnancies, they suggest reviewing the
tracing every 15 minutes in the first stage and every five minutes in the
second stage. Closer assessment and intervention may be indicated when
abnormalities are identified. (See "Intrapartum category I, II, and III fetal
heart rate tracings: Management".)
The health care provider's interpretation of the tracing should be

documented in the patient's medical record and should include a
description of the uterine contractions, baseline FHR rate, baseline FHR
variability, presence or absence of accelerations, presence or absence of
periodic decelerations (ie, with contractions) or episodic decelerations (ie,
unrelated to contractions), and changes in the FHR over time.
Uterine contractions — The frequency of contractions is documented

as the number of contractions over a 30-minute period divided by three to
give the number of contractions per 10 minutes. If this number is not a
whole number, it may be rounded.
External tocodynamometry is a noninvasive means for recording

contraction frequency and duration, and provides adequate information for
most labors. If the tracing is inadequate, an internal pressure transducer
can be placed to measure contraction frequency, duration, and strength.
(See "Use of intrauterine pressure catheters".)
Information about contraction frequency, duration, and strength can help

the clinician determine the cause of abnormal labor progression and
interpret abnormal FHR patterns. (See "Normal and abnormal labor
progression" and "Intrapartum category I, II, and III fetal heart rate
tracings: Management".)

Tachysystole is defined as >5 contractions over 10 minutes; any number

greater than 5 (eg, 5.2) should be interpreted as tachysystole. When
associated with administration of oxytocin, FHR abnormalities are the most
common potential consequence of tachysystole; uterine rupture is a rare
complication. Management is reviewed separately. (See "Induction of labor
with oxytocin", section on 'Tachysystole'.)
Labor progress — Few randomized trials have evaluated the optimum

frequency and timing of intrapartum vaginal examination of the cervix,
fetal position, and fetal descent [62]. In most women, we perform vaginal
examinations:
● On admission
● At four-hour intervals in the first stage
● Prior to administering analgesia/anesthesia
● When the parturient feels the urge to push (to determine whether the
cervix is fully dilated)
● At two-hour intervals in the second stage
● If FHR abnormalities occur (to evaluate for complications such as cord
prolapse or uterine rupture)
The number of examinations is kept to a minimum for patient comfort and

to minimize iatrogenically exposing the fetus to vaginal flora. (See
"Intraamniotic infection (clinical chorioamnionitis or triple I)", section on
'Risk factors'.)
Assessing whether labor is progressing normally is a key component of

intrapartum care; however, determining the onset of labor, measuring its
progress, and evaluating the factors (power, passenger, pelvis) that affect
its course is an inexact science. Criteria for normal and abnormal progress
and management of protracted labor are discussed in detail separately.
(See "Normal and abnormal labor progression".)

Precipitate or precipitous labor and delivery refers to a rapid labor and

delivery of the fetus, variously defined as expulsion of the fetus within two
to three hours of commencement of contractions [25,26]. It is rare and not
well-studied.
MANAGEMENT OF THE SECOND STAGE OF LABOR
Persistent anterior cervical lip — In most women, the final centimeter of

cervix anteriorly between the pelvic brim and the fetal head rapidly
disappears as the cervix fully dilates and the fetal head descends.
Occasionally an anterior lip persists for >30 minutes and may indicate
malposition or a labor abnormality, especially if the lip becomes
edematous.
We manage these patients expectantly and avoid manually reducing the

anterior lip because of the risk of lacerating the cervix and hemorrhage.
However, with prolonged expectant management, cervical laceration,
necrosis, or detachment of the lip may occur spontaneously. If manual
reduction is attempted, the cervical lip is pushed backwards during a
contraction until it slips over the fetal head and above the interior border of
the symphysis pubis [63]. The cervix is gently held in this position until the
fetal head descends with the next contraction and maternal pushing.
Perineal care — Application of warm compresses and perineal massage

with a lubricant have been proposed as means of softening and stretching
the perineum to reduce perineal trauma during birth.
In women who have not had a previous vaginal birth, a meta-analysis of

randomized trials found that antepartum perineal massage reduced
perineal trauma (mainly episiotomies) but did not reduce first- or second-
degree perineal tears or third-/fourth-degree perineal trauma [64].
In another meta-analysis of randomized trials, applying warm compresses

during the second stage of labor reduced third- and fourth-degree tears
compared with a hands off or no warm compress technique (risk ratio [RR]
0.46, 95% CI 0.27-0.79; four trials, n = 1799 women); performing massage
also reduced third- and fourth-degree tears compared with hands off/usual
care (RR 0.49, 95% CI 0.25-0.94; five trials, n = 2477 women) [65]. Rates of
minor trauma (eg, first- and second-degree tears) were similar for the
intervention and nonintervention groups.
Although not harmful and supported by some meta-analyses [64,65], we

do not routinely advise antenatal perineal massage, perform second stage
perineal massage, or apply warm compresses, as available trials
suggesting a benefit have major methodologic limitations due to lack of
blinding, differences in the provision of usual care, and inability to address
the importance of other factors related to perineal injury.
If used, warm compresses can be made from clean wash cloths or perineal
pads immersed in warm tap water (up to 110 degrees Fahrenheit [43
degrees Celsius]) and wrung to release excess water [66,67]. They are held
against the mother's perineum during and between pushes, and changed
as needed to maintain warmth and cleanliness. Perineal massage is
performed during and between pushes with two fingers of the lubricated
gloved hand moving from side to side just inside the patient's vagina and
exerting mild, downward pressure.
Manual perineal protection during delivery is discussed below. (See

'Delivery of the newborn' below.)
Pushing
Immediate versus delayed — The two most common approaches to

pushing in the second stage of labor are to initiate pushing as soon as
complete cervical dilation is identified (immediate pushing) or delay
pushing for as much as an hour until the presenting part has descended
further along the birth canal (ie, "laboring down" or delayed pushing).

We generally prefer that women begin pushing immediately to minimize

the duration of the second stage; however, if the fetal heart rate (FHR)
pattern is normal and the station is high, we often ask women to delay
pushing until the further descent has occurred to reduce the duration of
maximal maternal exertion. This decision is based on patient-specific
factors, such as whether there is a need to expedite delivery, maternal
fatigue, motor blockade from neuraxial anesthesia, and maternal
preference. There is no strong evidence that one approach is better than
another.
In a meta-analysis of term singleton pregnancies randomly assigned to

delayed or immediate pushing (12 trials, 5445 participants) [68]:
● Delayed pushing resulted in less time spent actively pushing (mean

difference -27.54 minutes, 95% CI -43.04 to -12.04) but at the expense
of a much longer second stage (mean difference 46.17 minutes, 95% CI
32.63-59.71).
● The longer second stage was associated with an increased risk for
chorioamnionitis (9.1 versus 6.6 percent, RR 1.37, 95% CI 1.04-1.81) and
low umbilical cord pH, as defined by individual trial authors (2.7 versus
1.3 percent, RR 2.00, 95% CI 1.30-3.07).
● Rates of spontaneous vaginal delivery, assisted vaginal delivery, and

cesarean delivery were similar for both approaches.
All of the participants had neuraxial analgesia. The overall quality of

evidence was considered low because of inconsistency and indirectness
due to the high heterogeneity of the included trials.
Position and technique — The optimum pushing position for labor and

delivery and the optimum breathing/pushing technique are unclear. We
have the patient push in the position she finds most comfortable. Upright
positions where the pelvis is in a vertical plane (eg, walking, standing,
sitting, supported kneeling) have several theoretical benefits, such as an
increase in pelvic dimensions and good fetal alignment with the birth
canal. The supine position should be avoided because of aortocaval
compression, but a left or right lateral position avoids this complication
and is acceptable. Data on outcomes with upright versus lying positions are
reviewed below. (See 'Maternal position for delivery' below.)
We favor allowing the woman to bear down when she feels the need (ie,
spontaneous pushing or physiologic pushing), unless neuraxial anesthesia
has inhibited the bearing down sensation. Although a common practice is
to tell women to pull back their knees, tuck in their chin, take a deep
breath, bear down at the start of a contraction, and push for 10 seconds
with the goal of three pushes per contraction, there is no clear evidence
that coaching women in this way has any benefit over allowing them to
bear down and push according to their own reflex needs in response to the
pain of contractions and the pressure felt from descent of the fetal head.
We advise against Valsalva pushing (pushing with a closed glottis) as there
is no clinically significant benefit to this technique.
In a meta-analysis of randomized trials of different breathing and pushing

techniques [69]:
● Women who followed their own instincts about breathing while

pushing (ie, spontaneous pushing) and those who were told to take a
deep breath at the beginning of a contraction and hold it as long as
possible while bearing down (ie, directed pushing with Valsalva
maneuver) had similar lengths of the second stage and duration of
pushing. All of the trials were limited by lack of blinding and by
crossover between groups.
Duration — As long as the FHR pattern is normal and some degree of

progress is observed, there is no strict upper limit to the duration of the
second stage (ie, time from full dilation to birth). There is no threshold at
which maternal or neonatal outcomes abruptly worsen, but a second stage
lasting longer than four hours (three hours of pushing) in nulliparas and

three hours (two hours of pushing) in multiparas appears to be associated

with a small increase in frequency of maternal and potentially serious
neonatal complications, and this is concerning. (See "Normal and abnormal
labor progression", section on 'Prolonged second stage' and "Normal and
abnormal labor progression", section on 'Maternal and newborn outcomes
associated with abnormal labors'.)
In a prospective study including over 53,000 women at term with singleton

cephalic gestations, 78 percent of nulliparas and 82 percent of multiparas
who continued to push longer these times achieved a vaginal delivery [70].
In nulliparas, the frequency of the neonatal composite adverse outcome at
<60 minutes and ≥240 minutes was 1.3 and 2.4 percent, respectively. In
parous women, the frequency of the neonatal composite adverse outcome
at <60 minutes and ≥120 minutes was 1.1 and 2.8 percent, respectively. Of
possible concern, seizures or hypoxia-ischemic encephalopathy accounted
for almost all adverse neonatal outcomes at ≥240 minutes (10 newborns or
2.2 percent of the population pushing ≥240 minutes versus 0.4 percent of
the population pushing <60 minutes). An increase in neonatal seizures and
hypoxia-ischemic encephalopathy at ≥120 minutes was also noted in
parous women (seven newborns or 1.5 percent of the population pushing
≥120 minutes versus 0.2 percent of the population pushing <60 minutes).
Maternal position for delivery — If no fetal manipulation or

complications are anticipated, delivery can be accomplished with the
mother in almost any position that she finds comfortable. Common
positions include the lateral (Sims) position and the partial sitting position.
Stirrups are not mandatory [71]. The lithotomy position is advantageous if
fetal manipulation or need for optimal surgical exposure is anticipated.
In two meta-analyses of randomized trials:
● Compared with lying positions (lateral, semirecumbent, lithotomy,

Trendelenburg), upright positions (sitting, squatting, kneeling) resulted
in a 3 to 10 minute reduction in the duration of the second stage of

labor, reduction in episiotomy rates (RR 0.75, 95% CI 0.61-0.92), and

reduction in assisted vaginal deliveries (RR 0.75, 95% CI 0.66-0.86) but
increased the risk for blood loss greater than 500 mL (RR 1.48, 95% CI
1.10-1.98) [51]. Cesarean delivery rates were similar for both positions.
Participants in these trials did not have neuraxial anesthesia. In trials in
which participants had neuraxial anesthesia, there was no clear
difference in risk for operative birth (assisted vaginal or cesarean)
between upright and lying positions [52].
● Maternal birth position did not appear to have a significant effect on

risk of third and fourth degree lacerations, regardless of type of labor
analgesia/anesthesia [51,52].
Episiotomy — Routine use of episiotomy is not beneficial and should be

avoided. Episiotomy is reserved for deliveries with a high risk of severe
perineal laceration, significant soft tissue dystocia, or need to facilitate
delivery of a possibly compromised fetus. The evidence for this
recommendation is discussed separately. (See "Approach to episiotomy".)
Delivery of the newborn — The procedure for spontaneous vaginal

delivery is described below. Operative vaginal and abdominal delivery are
reviewed separately (see "Operative vaginal delivery" and "Cesarean
delivery: Surgical technique"). Standard precautions for infection control
should be followed.
The responsibilities of the health care provider at delivery are to reduce the
risks of maternal perineal trauma and fetal injury during delivery and
provide initial support of the newborn. There is no consensus regarding the
best method for protecting the perineum at delivery [66,67,72-79], other
than avoiding both routine episiotomy and fundal pressure [80]. Options
include delivering the fetus between contractions versus during a
contraction, and various methods of using the accoucheur's hands to
control delivery of the fetal head. The latter may involve no touch ("hands-
off"), passive perineal support, support of the fetal crown, and using

fingers placed between the maternal anus and coccyx to actively lift the
fetal chin anteriorly (ie, Ritgen maneuver). Warm compresses and perineal
massage may be helpful to reduce perineal trauma. (See 'Perineal care'
above.)
We use the following approach (called the "hands-on" technique) to prevent

precipitous expulsion of the newborn, which can lacerate the perineum and
anal sphincter [72,79,81]. We ask the woman to pant or make only small
expulsive efforts when the head is fully crowning and delivery is imminent;
this prevents the head from being propelled through the perineum. We use
one hand to maintain the head in a flexed position and control the speed of
crowning and use the other hand to ease the perineum away from the path
of the emerging head ("manual perineal protection" [82]). Some providers
support the perineum with a sponge, applying medial pressure. Once the
fetal head delivers, external rotation (restitution) occurs spontaneously (
figure 8). A meta-analysis of three trials that evaluated manual perineal
support found that it did not significantly reduce obstetric anal sphincter
injuries (OASIS; RR 1.03, 95% CI 0.32-3.36), although three nonrandomized
studies suggested a benefit (RR 0.45, 95% CI 0.40-0.50). Since the
techniques for perineal support were not well described, it is difficult to
interpret these findings. The role of various obstetric factors on anal
sphincter injury and postpartum function are discussed separately. (See
"Fecal and anal incontinence associated with pregnancy and childbirth:
Counseling, evaluation, and management".)
If the cord is around the neck (nuchal cord), slipping the cord over the head
usually successfully frees the fetus from the tether. If a single nuchal cord is
not reducible, we doubly clamp and transect it. Other options for a cord
that is difficult to reduce but not tight include slipping it over the shoulders
and delivering the body through the loop and delivering the body without
reducing the cord (somersault maneuver). It is important to avoid avulsing
or tearing the cord while attempting to effect delivery. (See "Nuchal cord",
section on 'Delivery'.)

Mucus is gently wiped from the newborn's nose and mouth. Most
newborns do not need to be suctioned. (See 'Oropharyngeal care' below.)
After delivering the head, a hand is placed on each side of the head and the
anterior shoulder is delivered with the next contraction, using gentle
downward traction toward the mother's sacrum in concert with maternal
expulsive efforts. In this way, the anterior shoulder is guided under the
symphysis pubis. The posterior shoulder is then delivered by upward
traction. These movements should be performed with as little downward or
upward force as possible to avoid perineal injury and/or traction injuries to
the brachial plexus. The delivery is then completed, either spontaneously
or with a gentle maternal push.
Oropharyngeal care — There is no evidence that oro-nasopharyngeal

suctioning by a bulb or catheter is beneficial in healthy term newborns [83-
87] and, in some studies, suctioning slightly reduced neonatal oxygen
saturation in the first few minutes of life [83,86,87]. However, suctioning
immediately after birth is appropriate for newborns with obvious
obstruction to spontaneous breathing due to secretions or who are likely to
require positive-pressure ventilation. The mouth is suctioned first and then
the nares to decrease the risk for aspiration (newborns are obligate nose
breathers). Suctioning of the posterior pharynx should be avoided, as it can
stimulate a vagal response, resulting in apnea and/or bradycardia. In a
randomized equivalency trial, wiping the face, mouth, and nose with a
towel was equivalent to suction with a bulb syringe [88]. The trial's primary
endpoint was mean respiratory rate within the first 24 hours after birth;
neonates who were nonvigorous or born with meconium stained amniotic
fluid were excluded. (See "Overview of the routine management of the
healthy newborn infant", section on 'Delivery room care' and "Neonatal
resuscitation in the delivery room", section on 'Airway'.)
Meconium — The American Heart Association, the American Academy

of Pediatrics, and the American College of Obstetricians and Gynecologists
(ACOG) recommend against routine nasopharyngeal suctioning of
meconium-stained newborns [89,90]. Randomized trials have

demonstrated that this approach does not decrease meconium aspiration
syndrome or improve perinatal outcome [91]. (See "Meconium aspiration
syndrome: Prevention and management".)
MANAGEMENT OF THE THIRD STAGE OF LABOR
Cord clamping and other approaches to the cord
Early versus delayed cord clamping — Delayed cord clamping has

newborn benefits in both term and preterm births, but the optimum
duration of delay remains unclear [92]. Delayed cord clamping does not
appear to have maternal benefits or harms. Maternal blood loss was not
increased compared with immediate clamping in a randomized trial [93].
● Term infants – We agree with an American College of Obstetricians

and Gynecologists (ACOG) committee opinion that recommends
delaying umbilical cord clamping after birth in vigorous term infants
[94]. The American Academy of Pediatrics [95] and most other clinical
practice guidelines also endorse this approach [96]. Although the
optimal amount of time before cord clamping has not been studied
extensively, we agree with the ACOG recommendation of a delay of at
least 30 to 60 seconds; others have suggested a two- to five-minute
delay (or longer if the mother requests) [97].
Delaying cord clamping should not interfere with timely care of the
newborn and should never compromise the safety of the mother or
newborn. For example, it is not appropriate when the mother or
newborn is unstable or when the newborn-placental circulation is not
intact (eg, abruption, previa, cord avulsion). It may not be appropriate
in cases of fetal growth restriction with abnormal umbilical artery
Doppler studies, as these newborns may already have polycythemia
and hyperviscosity.

In term infants, the main advantage of delayed cord clamping is higher

infant iron stores at six months of age, which may be particularly
advantageous when the mother has a low ferritin level or plans to
breastfeed without supplementing with iron or fortified formula.
Preventing or reducing the occurrence of iron deficiency in infants may
have favorable long-term developmental effects, since iron deficiency
has been associated with impaired neurodevelopment. Disadvantages
of delayed cord clamping include an increase in hyperbilirubinemia in
the immediate newborn period resulting in more phototherapy and an
increased risk of polycythemia in growth-restricted neonates. Delaying
cord clamping also reduces the volume of umbilical cord blood
available for harvesting stem cells; thus, the size and cell dose of
collected cord blood units may not be adequate for a future
hematopoietic cell transplant if cord clamping is delayed. This should
be considered when cord blood collection is planned for this purpose.
(See "Collection and storage of umbilical cord blood for hematopoietic
cell transplantation".)
A 2013 meta-analysis of 15 randomized trials including 3911 mothers

and their infants evaluated early versus late (two to three minutes after
birth) cord clamping in term infants [98]. Compared with early cord
clamping, late cord clamping resulted in higher neonatal hemoglobin
levels at 24 to 48 hours after birth (mean difference 1.49 g/dL), but not
in subsequent assessments, and a lower proportion of infants with iron
deficiency at three to six months of age (14 percent of infants in the
early clamping group versus 8 percent in the late clamping group).
However, late cord clamping also resulted in a 40 percent increase in
newborns needing phototherapy for jaundice (2.74 percent of infants
in the early clamping group versus 4.36 percent in the late clamping
group).
In addition, the only randomized clinical trial that assessed the effects
of delayed cord clamping compared with early cord clamping at four

years of age reported a possible benefit in some neurodevelopmental

outcomes, particularly in boys, and no harmful effects [99].
● Preterm infants – We delay cord clamping for at least 30 seconds in

vigorous preterm infants [100], but available data (discussed below) do
not strongly support one approach over another; therefore, physicians
should use their judgment about whether and how long to delay cord
clamping in individual preterm infants until definitive data are
available. Although a benefit has not been demonstrated consistently,
delayed cord clamping is unlikely to be harmful. Differences among
populations and physician judgment as to whether it was safe to delay
cord clamping likely impacted the precision of the following data.
ACOG recommends delaying umbilical cord clamping for at least 30 to
60 seconds after birth in both vigorous term and preterm infants [94].
In preterm infants, providing more time for the physiologic transition

from fetal to newborn life is an advantage of delayed cord clamping
and possibly accounts for the significant reductions in intraventricular
hemorrhage (IVH) and necrotizing enterocolitis associated with this
intervention seen in some trials, but not meta-analyses. Approximately
75 percent of blood available for placenta-to-fetus transfusion is
transfused in the first minute after birth [101]. Delaying cord clamping
increases the volume of placental blood transfused to the fetus and
thereby increases neonatal blood volume, improves neonatal and
infant iron stores, and decreases neonatal and infant anemia. It also
facilitates the fetal to neonatal transition. Clamping the cord before
initiation of spontaneous respirations (mean onset of respiration is
10±15 seconds after expulsion [102]) appears to adversely affect
cardiovascular hemodynamics during the fetal to neonatal transition,
likely due to removal of umbilical venous return before dilation of the
pulmonary vascular bed [103-106]. Lung aeration triggers an increase
in pulmonary blood flow, which supplies most of the preload to the left
ventricle; if cord clamping precedes onset of respiration, ventricular

preload falls because the loss of umbilical venous return is not

balanced by an increase in pulmonary venous return [106]. This may
partially account for some of the nonhematologic benefits reported in
trials of delayed cord clamping [107].
• <37 weeks: In a 2018 meta-analysis of randomized trials of

delayed (typically ≥60 seconds) versus early (typically ≤10 seconds)
cord clamping in preterm deliveries (18 trials, n = 2834 infants),
delayed clamping, when safe to do so [108]:
- Reduced neonatal hospital mortality by approximately 30

percent (risk ratio 0.68, 95% CI 0.52-0.90; number needed to
benefit 33, 95% CI 20-100).
- Increased peak hematocrit by 2.73 percentage points (95% CI

1.94-3.52) and reduced the proportion of infants having blood
transfusion by 10 percent (95% CI 6-13 percent).
- Increased peak serum bilirubin by 4 micromol/L without

increasing morbidity (eg, partial exchange transfusions for
polycythemia, exchange transfusions for hyperbilirubinemia).
- Did not reduce the incidence of intubation for resuscitation,

admission temperature, mechanical ventilation, severe IVH,
brain injury, chronic lung disease, patent ductus arteriosus,
necrotizing enterocolitis, late onset sepsis or severe
retinopathy of prematurity, but also did not increase morbidity
from these entities (subgroup analysis).
• <34 weeks: A 2021 meta-analysis of trials limited to newborns <34

weeks did not find statistically significant differences in survival to
discharge when comparing early (<30 seconds) cord clamping,
delayed (≥30 seconds or based on physiologic parameters) cord
clamping, and cord milking [109]. Delayed cord clamping and cord
milking improved hematologic outcomes compared with early
cord clamping, but neither improved nor worsened major

neonatal morbidities.
• <28 weeks: When only extremely preterm infants (≤28 weeks) are
considered, a randomized trial found that placental transfusion
(delayed cord clamping or cord milking) did not significantly affect
the composite outcome of mortality or major morbidity by 36
weeks postmenstrual age (PMA; ie, the time period from the first
day of the mother's last menstrual period to the present, thus
including both prenatal and postnatal weeks; adjusted odds ratio
[aOR] 1.26, 95% CI 0.95-1.66), but decreased mortality by 36 weeks
PMA (aOR 0.71, 95% CI 0.55-0.92) and treatment for hypotension in
the first 24 postnatal hours (aOR 0.66, 95% CI 0.53-0.82) [110].
Given other evidence linking cord milking with IVH, until this
potential risk is better clarified, delayed clamping is advised over
cord milking. (See 'Cord milking' below.)
Cord milking — We do not milk or strip the umbilical cord; however,

some experts consider this practice an alternative to delayed clamping for
enhancing blood transfusion, especially when delayed clamping is not
feasible. Depending on technique, cord milking may be more efficient than
delayed cord clamping for improving neonatal blood volume. A
randomized trial in preterm infants found that milking the accessible
length of the cord four times at a speed of 20 cm/2 seconds was equivalent
to delaying cord clamping for 30 seconds [111].
Cord milking, like delayed cord clamping, may help stabilize blood pressure
and increase urinary output in preterm infants [112-114], but a concern is
that a nonquantifiable amount of blood will be given to an immature infant
in an uncontrolled fashion, which could be harmful.
● In a meta-analysis of 19 randomized trials of the efficacy and safety of

umbilical cord milking in preterm infants, compared with delayed cord

clamping, cord milking increased the risk for severe IVH in newborns
<34 weeks (relative risk [RR] 1.95, 95% CI 1.01-3.76) [115].
However, a subsequent network meta-analysis did not confirm this

finding in newborns <37 weeks: Delayed cord clamping and cord
milking resulted in similar odds of severe IVH (grade 3 or 4 IVH: OR
0.98, 95% CI 0.56-1.85) [116]. The mortality rate prior to discharge and
other neonatal outcomes (transfusion, bronchopulmonary dysplasia,
late onset sepsis, necrotizing enterocolitis, retinopathy of prematurity
requiring treatment, neurodevelopmental impairment) were also
similar, although data for some of these outcomes was sparse and
none of the data were high quality.
Interpretation of available data is limited by the heterogeneity of

milking techniques used in the trials, differences in gestational age,
and the lack of information about cord milking in extremely preterm
newborns (<28 weeks). However, there appears to be equipoise
between delayed cord clamping and cord milking in the overall
population of vigorous preterm newborns.
Delivery should not be unnecessarily delayed to milk the cord in situations

where immediate pediatric assistance is needed, such as thick meconium
or neonatal depression. Also, it should not be performed if cord blood
collection is planned.
Physiological cord clamping — Physiological cord clamping (PCC) is a

form of delayed cord clamping in which the time the cord is clamped is
based on physiological parameters such as onset of respirations and
cessation of cord pulsations rather than at a fixed time point. The cord
generally remains unclamped for a longer period of time with PCC
compared with nonphysiological delayed cord clamping (3 to 5 minutes
versus 30 to 60 seconds [117]). Because some newborns may need
intervention before their pulmonary and hemodynamic transitions to
extrauterine life have been completed, resuscitation tables have been

developed that enable a full standard of care for stabilization of newborns

with an intact umbilical cord [117].
In the first randomized trial of PCC versus delayed cord clamping in

preterm infants <32 weeks, the PCC group needed less time to reach
respiratory stability (mean time 5:54±2:27 versus 7:07±2:54 minutes; mean
difference -1:19 minutes, 95% CI -3.04 to 0.27) [118]. PCC was performed
when the infant had regular spontaneous breathing, heart rate ≥100 beats
per minute, and SpO2 >90 percent while using FiO2 <0.40. Although the
investigators used a specialized resuscitation table designed to provide full
standard care while the cord remained intact, 4 of 20 infants in the PCC
group had moderate hypothermia compared with 1 of 17 infants in the
delayed clamping group.
Umbilical nonseverance — In umbilical nonseverance (also called Lotus

birth), the umbilical cord is not clamped and cut [119-122]. The cord and
placenta remain attached to the newborn until the cord naturally detaches
from the umbilicus, which typically takes 3 to 10 days. Proponents of this
practice, which is uncommon and mostly done in home births, believe it is
less stressful for the newborn, leads to a more robust immune system, and
promotes maternal-infant bonding. There is no proven medical benefit and
no biological plausibility that would suggest medical benefit [123]. It is
neither natural nor physiologic since blood flow in the cord stops 5 to 10
minutes after birth. Some disadvantages include the odor associated with
placental necrosis, hygienic and infection issues, and inability to perform
histologic examination, if indicated. Data are limited to a few case reports,
with at least two describing serious neonatal infections that may have been
related to the practice [124,125]. We strongly discourage this practice.
Cord blood — Cord blood collected for diagnostic purposes is usually

obtained by allowing blood to drain from the cut end into a glass tube prior
to delivery of the placenta, if possible. Cord blood may be tested for blood
and Rh type or for a variety of newborn conditions, as indicated. Newborn
screening programs typically use blood from a heel stick obtained as close
to hospital discharge as possible to permit the maximum accumulation of

abnormal compounds in the infant's blood and the best chance of
obtaining a positive result if disease is present. (See "Newborn screening".)
When indicated (eg, neonatal depression), fetal blood for acid-base analysis
is collected from an umbilical artery using a needle and syringe to minimize
exposure to air and avoid mixing of arterial and venous blood. (See
"Umbilical cord blood acid-base analysis at delivery".)
Collection of cord blood for banking can be performed with a needle and
syringe before or after delivery of the placenta. Delayed cord clamping
significantly reduces the volume of cells available for cord blood donation
and may prevent adequate collection. The procedure for collection of
umbilical cord blood for banking is reviewed separately. (See "Collection
and storage of umbilical cord blood for hematopoietic cell
transplantation".)
Placental drainage — After the cord has been cut, there is no clinical

benefit to allowing the placenta to drain any residual blood, although small
differences in the length of the third stage and average blood loss were
described in randomized trials before the era of delayed cord clamping
[126]. Placental drainage does not reduce the incidence of postpartum
hemorrhage or retained placenta.
Draining the placenta passively or actively prior to extraction may result in

less fetomaternal bleeding; available data are sparse and discordant
[127,128]. The clinical significance (ie, frequency of alloimmunization) has
not been evaluated.
Maternal-newborn interaction — In the absence of maternal or neonatal

complications, a healthy term infant can be dried to minimize heat loss and
given to the mother. Skin-to-skin contact may benefit early mother-infant
attachment and breastfeeding outcomes [129,130].

The location of the newborn (above or below the level of the placenta)
before cord clamping did not appear to significantly affect the volume of
placenta-to-newborn transfusion in a randomized trial [131]. Therefore,
concerns about transfusion volume should not influence the decision to
place the newborn on the mother's abdomen.
Breastfeeding — Early initiation of breastfeeding (within one hour of

birth) and exclusive breastfeeding during the first month of life has
substantial benefits in reducing neonatal mortality and morbidity. Several
maternal benefits exist as well. (See "Initiation of breastfeeding" and
"Infant benefits of breastfeeding" and "Maternal and economic benefits of
breastfeeding".)
Normal placental separation — Myometrial thickening after delivery of

the infant leads to substantial reduction in uterine surface area, resulting in
shearing forces at the placental attachment site and placental separation.
This process generally begins at the lower pole of the placental margin and
progresses along adjacent sites of placental attachment. A "wave of
separation" spreads upward so that the uppermost part of the placenta
detaches last [132,133].
Signs of placental separation include a gush of blood, lengthening of the

umbilical cord, and anterior-cephalad movement of the uterine fundus,
which becomes firmer and globular after the placenta detaches. Placental
expulsion follows separation as a result of a combination of events
including spontaneous uterine contractions, downward pressure from the
developing retroplacental hematoma, and an increase in maternal
intraabdominal pressure.
There is no universally accepted criterion for the normal length of the third
stage. In two large series of consecutive deliveries, the average length was
five to six minutes, 90 percent of placentas were delivered within 15
minutes, and 97 percent were delivered within 30 minutes of birth
[134,135]. Gestational age is the major factor influencing the length of the

third stage: Preterm deliveries are associated with a longer third stage than
term deliveries [134-137]. (See "Retained placenta after vaginal birth".)
Active management and delivery of the placenta — We actively manage

the third stage because active management reduced the risk of severe
postpartum blood loss and blood transfusion compared with expectant
management in randomized trials. (See "Management of the third stage of
labor: Prophylactic drug therapy to minimize hemorrhage", section on
'Active management'.)
Active management generally consists of prophylactic administration of a

uterotonic agent before delivery of the placenta plus controlled traction of
the umbilical cord after cord clamping and transection; uterine massage
also may be performed. Randomized trials have demonstrated that the
uterotonic agent is the most important component of this regimen [138-
140]; we use oxytocin. (See "Management of the third stage of labor:
Prophylactic drug therapy to minimize hemorrhage", section on 'Oxytocin'.)
We use controlled cord traction to facilitate separation and delivery of the

placenta. In a 2014 meta-analysis of randomized trials comparing
controlled cord traction with a hands-off approach, controlled cord traction
resulted in a reduced need for manual removal of the placenta (RR 0.70,
95% CI 0.58-0.84), as well as small statistical reductions in the duration of
the third stage (three minutes), mean blood loss (10 mL), and incidence of
postpartum hemorrhage (11.8 versus 12.7 percent, RR 0.93, 95% CI 0.87-
0.99); the rates of severe postpartum hemorrhage, need for additional
uterotonics, and blood transfusion were not statistically different [141].
Others have reported similar findings [142]. Although the benefits of
controlled cord traction are small, there are no significant harms from the
maneuver if performed gently without excessive traction, which can result
in cord avulsion or uterine inversion.
Two maneuvers for applying cord traction have been described; we prefer
the Brandt-Andrews maneuver.

● In the Brandt-Andrews maneuver, an abdominal hand secures the

uterine fundus to hold it in a fixed position and prevent uterine
inversion while the other hand exerts sustained downward traction on
the clamped umbilical cord [143].
● In the Crede maneuver, the clamped umbilical cord is held at a fixed

position with one hand while the abdominal hand grasps the uterine
fundus and applies sustained cephalad traction). If the cord avulses
before delivery of the placenta, we wait up to 30 minutes for
spontaneous placental separation and expulsion with maternal
pushing. While waiting, preparations are initiated in case manual
removal of the placenta is needed. We intervene promptly if bleeding
becomes heavy. (See "Retained placenta after vaginal birth", section on
'Management'.)
As the placenta emerges from the vagina, the membranes flow behind it.
Slowly rotating the placenta in circles as it is delivered or grasping the
membranes with a clamp helps prevent them from tearing and possibly
being retained in the uterine cavity.
Compared with oxytocin alone, performing uterine massage along with

administering oxytocin provides no added benefit [140].
The placenta, umbilical cord, and fetal membranes should be

systematically examined. The fetal side is assessed for any evidence of
vessels coursing to the edge of the placenta and into the membranes,
suggestive of a succenturiate placental lobe. The number of vessels in the
cord is recorded. (See "Gross examination of the placenta".)
Of note, some women are requesting their placentas for consumption

postpartum (placentophagia or placentophagy) [144-146]. Various
commercial enterprises are available to desiccate and encapsulate
placental tissue, or it has been consumed raw or cooked. In one study,
most common reason for the practice was to prevent postpartum

depression [147]. There is a lack of scientific-evidence of any health

benefits in humans, but potential harms have been documented [148,149].
Bleeding — Average blood loss at vaginal delivery is estimated to be <500

mL. Excessive bleeding may be related to uterine atony, trauma,
coagulopathy, placental abnormalities, or uterine inversion. A visual aid
depicting known volumes of blood on common obstetric materials (eg, peri
pad, bed pan, kidney basin, bed pad) can improve obstetric provider
accuracy in estimating blood loss [150]. (See "Overview of postpartum
hemorrhage" and "Postpartum hemorrhage: Medical and minimally
invasive management" and "Puerperal uterine inversion".)
Repair of lacerations — The cervix, vagina, and perineum should be

examined for evidence of birth injury. The major risk factors for third and
fourth degree perineal lacerations are nulliparity, operative vaginal
delivery, midline episiotomy, and delivery of a macrosomic newborn
[151,152]. If a laceration is identified, its length and position should be
noted and repair initiated with adequate analgesia (see "Repair of perineal
and other lacerations associated with childbirth"). Failure to recognize and
repair a rectal injury can lead to serious long-term morbidity, most notably
fecal incontinence.
We perform a rectal examination after perineal repair to palpate sutures

inadvertently placed through the rectal mucosa into the rectal lumen. If
identified, the authors take down the repair and resuture, although this is
probably unnecessary since there is no evidence that transmucosal stitches
increase the risk of fistula formation. (See "Fecal and anal incontinence
associated with pregnancy and childbirth: Counseling, evaluation, and
management".)
Instrument and sponge counts — At the end of the delivery, it is

obviously important to ensure that no sponges or instruments are left in
the vagina. (See "Retained surgical sponge (gossypiboma) and other
retained surgical items: Prevention and management".)

POSTPARTUM ISSUES AND CARE
Postpartum issues and care, including care of the newborn, are reviewed
separately. If a pediatric provider does not attend the delivery, the obstetric
team may administer ophthalmic antibiotic agents, vitamin K, and the first
dose of the hepatitis B vaccine to the infant. (See "Overview of the
postpartum period: Normal physiology and routine maternal care" and
"Overview of the routine management of the healthy newborn infant".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected

countries and regions around the world are provided separately. (See
"Society guideline links: Labor" and "Society guideline links: Delivery".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in
plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are
written at the 10th to 12th grade reading level and are best for patients who
want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by searching
on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Labor and delivery (childbirth)

(The Basics)" and "Patient education: How to tell when labor starts (The
Basics)" and "Patient education: Managing pain during labor and
delivery (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Childbirth education classes inform women and their partners about

what to expect during labor and birth and provide a foundation for
developing personal plans for the birth experience. (See 'Creating a
satisfactory childbirth experience' above.)
● The goals of the initial examination of the parturient are to review her
prenatal record for medical or obstetric conditions that need to be
addressed intrapartum, check for development of new disorders since
the last prenatal visit, establish baseline cervical status so that
subsequent progress can be determined, and evaluate fetal status.
(See 'Initial examination' above.)
● Results from the following laboratory tests should be available at

delivery, but intrapartum assessment is not always necessary:
hemoglobin/hematocrit, blood type and screen, HIV, hepatitis B
antigen, syphilis, rectovaginal group B streptococcus. (See 'Laboratory
tests' above.)
Women who have not had HIV screening or whose HIV status is
undocumented should be offered rapid HIV testing in labor.
We recommend not performing routine enemas (Grade 1A) and we

suggest not routinely shaving the perineum (Grade 2B). (See 'Patient
preparation' above.)
● There is no consensus on acceptable maternal oral intake or need for

and type of intravenous fluids during an uncomplicated labor. We allow

patients at low risk of cesarean delivery to have clear liquids and we

place an intravenous line or heparin lock for all women in labor. We
administer a glucose containing solution to women receiving
intravenous fluids, and provide maintenance fluids when oral intake is
restricted or otherwise inadequate to avoid volume depletion and
ketosis. (See 'Fluids and oral intake' above.)
● Vaginal delivery is not an indication for routine antibiotic prophylaxis,

even in women with cardiac lesions, since the rate of bacteremia is low.
Intrapartum chemoprophylaxis to prevent early-onset neonatal GBS
infection is indicated for patients who meet standard criteria; the agent
of choice is penicillin G. (See 'Systemic antibiotics' above and "Neonatal
group B streptococcal disease: Prevention".)
● Maternal preferences can guide maternal activity. Walking during the

first stage does not appear to enhance or impair labor progress.
Laboring women should assume positions that are comfortable, unless
specific positions are needed because of maternal-fetal status and
need for close monitoring. (See 'Maternal activity and position' above.)
● Multiple nonpharmacologic, pharmacologic, and anesthetic options

are available to help women manage pain during labor. (See
"Nonpharmacologic approaches to management of labor pain" and
"Pharmacologic management of pain during labor and delivery" and
"Neuraxial analgesia for labor and delivery (including instrumented
delivery)".)
● We suggest not performing amniotomy routinely in patients in

spontaneous labor (Grade 2B). There is no convincing evidence of
benefit in spontaneously laboring women, and rupture of membranes
increases the risk of ascending infection and cord prolapse. (See
'Amniotomy' above.)

● In women with pregnancies at increased risk of fetal compromise

during labor, we perform continuous electronic fetal heart rate (FHR)
monitoring, in agreement with clinical management guidelines from
the American College of Obstetricians and Gynecologists. We also
monitor low-risk pregnancies continuously because it is more practical
than intermittent monitoring, but we are not rigid about this if the
patient understands the risks and benefits of intermittent monitoring
and has an uncomplicated pregnancy, normal FHR tracing, and is not
resting in bed. Contractions and labor progress are also monitored.
(See 'Monitoring' above.)
● Either immediate or delayed pushing is reasonable for most patients,

and the choice is best made as a shared decision. We generally prefer
that women begin to push upon full dilation to shorten the second
stage, push in the position that they find most comfortable, and
maintain an open glottis. However, if the FHR tracing is normal and
station is high, we often ask women to delay pushing until further
descent has occurred to reduce the duration of time of maximal
maternal exertion.
● We recommend not performing episiotomy routinely (Grade 1A). (See

"Approach to episiotomy".)
● We suggest a "hands-on" technique (Grade 2C). Preventing precipitous

expulsion of the newborn can reduce the risk of obstetric and anal
sphincter injury. (See 'Delivery of the newborn' above.)
● Routine oro-nasopharyngeal suctioning of newborns by a bulb or

catheter is not beneficial, including those with meconium-stained
amniotic fluid. Suctioning is appropriate for newborns with obvious
obstruction to spontaneous breathing or who are likely to require
positive-pressure ventilation. (See 'Oropharyngeal care' above and
'Meconium' above.)

● In preterm births that do not require resuscitation, we suggest delayed

cord clamping (Grade 2C). Benefits may include reduced rates of
transfusion, intraventricular hemorrhage, necrotizing enterocolitis, and
hypotension, although a lack of benefit has also been reported. For
term infants who do not require resuscitation, we suggest delayed
cord clamping (Grade 2C). However, not routinely delaying cord
clamping is also reasonable as the improvement in iron stores needs to
be balanced with the disadvantage of an increased risk for
hyperbilirubinemia and more need for phototherapy. We delay
clamping for at least 30 seconds. (See 'Early versus delayed cord
clamping' above.)
● Delaying cord clamping reduces the volume of umbilical cord blood

available for harvesting stem cells; therefore, the size and cell dose of
collected cord blood units may not be adequate for a future
hematopoietic cell transplant if cord clamping is delayed. (See 'Early
versus delayed cord clamping' above.)
● Active management of the third stage reduces maternal blood loss and
risk of postpartum hemorrhage compared with expectant
management. We administer oxytocin and apply controlled traction of
the umbilical cord. The placenta should be examined to make sure it is
intact. (See 'Active management and delivery of the placenta' above.)
● Average blood loss at vaginal delivery is estimated to be <500 mL.

Excessive bleeding may be related to atony, trauma, coagulopathy,
placental abnormalities, or uterine inversion. (See 'Bleeding' above.)
● Failure to recognize and repair a rectal injury can lead to serious long-
term morbidity, most notably fecal incontinence. (See 'Repair of
lacerations' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 4445 Version 195.0

GRAPHICS
Superior view of female pelvis
Graphic 60078 Version 3.0

Effacement and dilatation of the cervix
(A) Cervix is uneffaced and minimally dilated.
(B) Cervix is almost completely effaced and dilated.

Assessing descent of the fetal head by vaginal examination
The fetus is at -2 station signifying that the leading bony edge of the presenting part is 2
centimeters above the ischial spines. The head is engaged at 0 station.
Sp: ischial spine.

Fetal head at term showing fontanelles, sutures, and biparietal

diameter
The anterior fontanelle is diamond shaped, at the intersection of four fetal skull bones, and
usually the larger fontanelle, whereas the posterior fontanelle is triangular, at the intersection of
three fetal skull bones, and usually the smaller fontanelle.

Occiput anterior positions
(A) Right occiput anterior (ROA).
(B) Left occiput anterior (LOA)
(C) Occiput anterior (OA).
* Posterior fontanel. This is the smaller of the two fontanels and is at the intersection of the three sutures: the
sagittal suture and two lambdoid sutures.
** Anterior fontanel. This large fontanel is at the intersection of four sutures: the sagittal, frontal, and two
coronal sutures.

Occiput posterior position

Occiput transverse positions
(A) Right occiput transverse (ROT).
(B) Left occiput transverse (LOT).

Occiput posterior and occiput transverse positions
(A) Right occiput posterior (ROP).
(B) Right occiput transverse (ROT).

Longitudinal lie, cephalic presentation
Differences in attitude of the fetal body in (A) vertex, (B) brow, and (C) face presentations.
A deflexed fetal neck results in a wider presenting cephalic diameter.

Vaginal examination to determine the diagonal conjugate
P: sacral promontory; S: symphysis pubis.
Reproduced with permission from: Pritchard JA, MacDonald PC. Williams Obstetrics, 16th Edition,
Appleton-Century-Crofts, New York 1980. Copyright ©1980 McGraw Hill. p.280.

Obstetric diameters of the pelvic inlet
The three anteroposterior diameters of the pelvic inlet are the true conjugate (average diameter 11.0
cm), obstetric conjugate (average diameter 10.5 cm), and diagonal conjugate (average diameter 12.5
cm). Also shown is the anteroposterior diameter of the mid-pelvis.
P: sacral promontory; Sym: symphysis pubis.
Reproduced with permission from: Pritchard JA, MacDonald PC. Williams Obstetrics, 16th Edition, Appleton-Century-
Crofts, New York 1980. Copyright ©1980 McGraw Hill. p. 278.

Cardinal movements of birth process
The cardinal movements (or mechanisms) of delivery.
Reproduced with permission from: Wolters Kluwer. Copyright © 2009.

Contributor Disclosures
Edmund F Funai, MD Nothing to disclose Errol R Norwitz, MD, PhD,
MBA Consultant/Advisory Boards: Illumina [Minimally invasive genetic testing for
fetal and pregnancy-related disorders]. Patent Holder: Bayer [Prediction test for
preeclampsia]. Other financial interests: Board of Scientific Counselors,
NICHD. Charles J Lockwood, MD, MHCM Nothing to disclose Vanessa A Barss,
MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group.
When found, these are addressed by vetting through a multi-level review process,
and through requirements for references to be provided to support the content.
Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

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5/7/2021 Management of normal labor and delivery - UpToDate

Official reprint from UpToDate®

In 1997, the World Health Organization defined normal birth as

This topic will present a paradigm for intrapartum management of women

Intrapartum care of women with a complicated labor and delivery is

medical/obstetric disorders, hemorrhage; refer to individual topic reviews

Management of labor and delivery during the coronavirus disease 2019

CREATING A SATISFACTORY CHILDBIRTH EXPERIENCE

Four factors important in determining a woman's satisfaction with her

Childbirth preparation classes inform women and their partners about

One-on-one support by a doula during the birthing process may lower

WHEN SHOULD LABORING WOMEN BE ADMITTED TO THE

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In Washington State, the Bree Collaborative Obstetrics Care Report

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A large study from Texas reported that, after evaluation, discharging

MANAGEMENT OF THE FIRST STAGE OF LABOR

Initial examination — The goals of the initial examination of the

Determining whether a woman is in labor is sometimes difficult as painful

Physical examination is performed with particular emphasis on the cervical

The purpose of the initial examination is to determine:

● Whether fetal membranes are intact or ruptured – (See

If the membranes have ruptured, the presence of meconium is noted

● Whether uterine bleeding is present and excessive – Bleeding can

● Cervical dilation and effacement – In women with contractions,

● Fetal station – Fetal station is expressed as the number of centimeters

If a cervical examination is not performed because of ruptured

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● Fetal lie, presentation, and position – Document fetal lie,

Fetal position is the relationship of a nominated site of the presenting

Asynclitism refers to an oblique position of the fetal head where the

Pelvimetry (ie, quantitative measurement of pelvic capacity) can be

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pelvis have been established but do not accurately predict women at

● Fetal and maternal well-being – Fetal status is assessed by the FHR

Laboratory tests — Results from the following laboratory tests should be

● Hemoglobin/hematocrit – Although laboratory assessment of

● Blood type and screen – Approximately 1 to 2 percent of women

For women at low risk of postpartum hemorrhage, Rh typing with a

For women at moderate risk of needing a transfusion, a type and

For women at high risk of needing a transfusion, type and crossmatch

● Human immunodeficiency virus (HIV) – Women who have not had

● Hepatitis B – Women who were not screened for hepatitis B surface

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● Group B streptococcus (GBS) – Women with unknown GBS status can

Patient preparation — Meta-analyses of randomized trials support

Women can be encouraged to empty their bladder regularly; a urinary

Activity — Women should be encouraged to move and ambulate freely

Fluids and oral intake — Historically, oral intake has been restricted

We allow clear liquids to women at low risk of cesarean delivery (eg,

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accordance with guidelines by the American Society of Anesthesiologists

If oral intake is inadequate or restricted because of increased risk for

Hypovolemia adversely affects exercise performance and may be a factor

The effect of dextrose-containing intravenous fluids on length of labor has

patients received intravenous fluid with versus without dextrose, both

A 2017 systematic review of 10 randomized trials comparing less restrictive