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Introduction
In 2018 an estimated 731,213 births took place in the UK according to figures from the ONS.
In healthy women, with a singleton pregnancy, who have not suffered from complications during this or previous pregnancies, a normal labour can often be expected.
As NICE advise, women, if healthy and low risk, should be supported in having their birth at home, in a midwifery unit or an obstetric unit in line with their preference.
First stage
Regular contractions herald the arrival of the first stage of pregnancy and continues until the cervix is fully dilated.
Aspects of care
A partogram – graphic record of observations and events during labour – should be used. Monitor heart rate hourly, vital signs 4-hourly, urinary frequency and frequency of contractions every half hour.
Vaginal examination should be offered hourly. Additionally, offer if concern regarding the progress of labour or in response to the woman’s wishes.
Check pain and emotional wellbeing regularly. Offer appropriate analgesia as needed.
Length
The length of the first stage of labour varies widely:
- First labour: an average of around 8 hours may be expected, rarely would it last longer than 18 hours.
- Subsequent labour: may last around 5 hours on average and rarely longer than 12 hours.
Delay
Women with delay in the first stage of labour should be transferred to an obstetric unit and receive an assessment by an obstetrician. Options such as oxytocin and rupture of membranes can be considered
Second stage
The second stage of pregnancy runs from the point of complete cervical dilation to the birth of the baby.
Aspects of care
A partogram – graphic record of observations and events during labour should be used. Monitor BP hourly, temperature 4-hourly, urinary frequency and frequency of contractions every half hour.
Intermittent auscultation of the foetal heart rate should be conducted after a contraction for 1 minute and at least every 5 minutes. Palpate the women’s pulse every 15 minutes.
Vaginal examination should be offered 4-hourly. Additionally, offer if concern regarding the progress of labour or in response to the woman’s wishes.
Check pain and emotional wellbeing regularly. Offer appropriate analgesia as needed.
Length
The length of the second stage varies widely:
- Nulliparous (no previous births): normally will last less than 3 hours
- Multiparous (more than one previous birth): normally will last less than 2 hours
Delay
Women with delay in the second stage of labour should be transferred to an obstetric unit and receive an assessment by an obstetrician. Oxytocin and instrumental assistance can be considered.
Third stage
The third stage runs from the birth of the baby to the expulsion of the placenta and membranes.
Active management
Active management involves:
- Use of uterotonic drugs to encourage the expulsion of the placenta and membranes.
- Deferred cutting and clamping of the cord.
- Careful and controlled traction of the cord once signs of separation of the placenta.
Physiological management
Physiological management involves:
- Uterotonic drugs not routinely used.
- Cord not clamped until pulsation has stopped.
- Placenta delivered by maternal effort.
Delay and haemorrhage
The third stage is delayed if not complete within 30 minutes when receiving active management and 60 minutes when receiving physiological management.
Transfer patients to an obstetric unit and organise obstetrician review if there is any delay. If postpartum haemorrhage occurs or other concerns develop urgently transfer, consider major obstetric haemorrhage call or ambulance transfer depending on location.
