Practice Essentials

Labor is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus.
*Stages of labor
Obstetricians have divided labor into 3 stages that delineate milestones in a continuous process.
First stage of labor
Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm
Divided into a latent phase and an active phase
The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix Contractions
become progressively more rhythmic and stronger
The active phase usually begins at about 6 cm of cervical dilation and is characterized by rapid cervical dilation and descent
of the presenting fetal part
Second stage of labor
Begins with complete cervical dilatation and ends with the delivery of the fetus
In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is
administered or 2 hours in the absence of regional anesthesia
In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1
hour without it [1] 
Third stage of labor
The period between the delivery of the fetus and the delivery of the placenta and fetal membranes
Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes
Expectant management involves spontaneous delivery of the placenta
The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered  [2] 
Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot
alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord

Mechanism of labor
The mechanisms of labor, also known as the cardinal movements, involve changes in the position of the fetus’s head during its
passage in labor. These are described in relation to a vertex presentation. Although labor and delivery occurs in a continuous
fashion, the cardinal movements are described as the following 7 discrete sequences  [2] :
1. Engagement 6. Restitution and External rotation
2. Descent 7. Expulsion
3. Flexion
4. Internal Rotation
5. Extension
History
The initial assessment of labor should include a review of the patient's prenatal care, including confirmation of the estimated
date of delivery. Focused history taking should elicit the following information:
A) Frequency and time of onset of contractions
B) Status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether
the amniotic fluid is clear or meconium stained)
C) Fetal movements
D) Presence or absence of vaginal bleeding.
Braxton-Hicks contractions must be differentiated from true contractions. Typical features of Braxton-Hicks contractions are as
follows:
Usually occur no more often than once or twice per hour, and often just a few times per day
Irregular and do not increase in frequency with increasing intensity
Resolve with ambulation or a change in activity

Contractions that lead to labor have the following characteristics:

 May start as infrequently as every 10-15 minutes, but usually accelerate over time, increasing to contractions that occur
every 2-3 minutes
Tend to last longer and are more intense than Braxton-Hicks contractions
Lead to cervical change

Physical examination
The physical examination should include documentation of the following:
Maternal vital signs Abdominal examination with Leopold maneuvers
Fetal presentation Pelvic examination with sterile gloves
Assessment of fetal well-being
Frequency, duration, and intensity of uterine contractions

Digital examination allows the clinician to determine the following aspects of the cervix:
Degree of dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated)
Effacement (assessment of the cervical length, which can be reported as a percentage of the normal 3- to 4-cm–long cervix
or described as the actual cervical length)
Position (ie, anterior or posterior)
Consistency (ie, soft or firm)
Palpation of the presenting part of the fetus allows the examiner to establish its station, by quantifying the distance of the
body (-5 to +5 cm) that is presenting relative to the maternal ischial spines, where 0 station is in line with the plane of the
maternal ischial spines. [2] 

Intrapartum management of labor

First stage of labor
On admission to the Labor and Delivery suite, a woman having normal labor should be encouraged to assume the position that
she finds most comfortable. Possibilities including the following:
Walking
Lying supine
Sitting
Resting in a left lateral decubitus position
Management includes the following:
Periodic assessment of the frequency and strength of uterine contractions and changes in cervix and in the fetus' station
and position
Monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions; in
most obstetric units, the fetal heart rate is assessed continuously  [3] 

Second stage of labor

With complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after
each contraction. [3] Prolonged duration of the second stage alone does not mandate operative delivery if progress is being made,
but management options for second-stage arrest include the following:
Continuing observation/expectant management
Operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean delivery.

Delivery of the fetus

Positioning of the mother for delivery can be any of the following  [2] :
Supine with her knees bent (ie, dorsal lithotomy position; the usual choice)
Lateral (Sims) position
Partial sitting or squatting position
On her hands and knees
Episiotomy used to be routinely performed at this time, but current recommendations restrict its use to maternal or fetal
indications

Delivery maneuvers are as follows:

The head is held in mid position until it is delivered, followed by suctioning of the oropharynx and nares
Check the fetus's neck for a wrapped umbilical cord, and promptly reduce it if possible
If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut
The fetus's anterior shoulder is delivered with gentle downward traction on its head and chin
Subsequent upward pressure in the opposite direction facilitates delivery of the posterior shoulder
The rest of the fetus should now be easily delivered with gentle traction away from the mother
If not done previously, the cord is clamped and cut
The baby is vigorously stimulated and dried and then transferred to the care of the waiting attendants or placed on the
mother's abdomen

Third stage of labor

The following 3 classic signs indicate that the placenta has separated from the uterus  [2] :
The uterus contracts and rises
The umbilical cord suddenly lengthens
A gush of blood occurs

Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30
minutes after delivery of the fetus.
Pain control
Agents given in intermittent doses for systemic pain control include the following  [4] :
Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours
Fentanyl, 50-100 mcg IV every hour
Nalbuphine, 10 mg IV or IM every 3 hours
Butorphanol, 1-2 mg IV or IM every 4 hours
Morphine, 2-5 mg IV or 10 mg IM every 4 hours

As an alternative, regional anesthesia may be given. Anesthesia options include the following:
Epidural
Spinal
Combined spinal-epidural

Definition
Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta)
are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual
effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and
duration. [1, 2] 
Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical
effacement and dilatation. Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas
uterine contraction without cervical change does not meet the definition of labor.

First stage of labor

The first stage begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm. In Friedman’s
landmark studies of 500 nulliparas [5] , he subdivided the first stage into an early latent phase and an ensuing active phase. The
latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix. The contractions become
progressively more rhythmic and stronger. This is followed by the active phase of labor, which usually begins at about 3-4 cm
(Zhang 6cm) of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part. The first
stage of labor ends with complete cervical dilation at 10 cm. According to Friedman, the active phase is further divided into an
acceleration phase, a phase of maximum slope, and a deceleration phase.
Characteristics of the average cervical dilatation curve is known as the Friedman labor curve, and a series of definitions of labor
protraction and arrest were subsequently established.  [6, 7] However, subsequent data of modern obstetric population suggest
that the rate of cervical dilatation is slower and the progression of labor may be significantly different from that suggested by
the Friedman labor curve.

Second stage of labor

The second stage begins with complete cervical dilatation and ends with the delivery of the fetus. The American College of
Obstetricians and Gynecologists (ACOG) has suggested that a prolonged second stage of labor should be considered when the
second stage of labor exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia for
nulliparas. In multiparous women, such a diagnosis can be made if the second stage of labor exceeds 2 hours with regional
anesthesia or 1 hour without it. 
Studies performed to examine perinatal outcomes associated with a prolonged second stage of labor revealed increased risks of
operative deliveries and maternal morbidities but no differences in neonatal outcomes.  Maternal risk factors associated with a
prolonged second stage include nulliparity, increasing maternal weight and/or weight gain, use of regional anesthesia, induction
of labor, fetal occiput in a posterior or transverse position, and increased birthweight.  

Third stage of labor

The third stage of labor is defined by the time period between the delivery of the fetus and the delivery of the placenta and fetal
membranes. During this period, uterine contraction decreases basal blood flow, which results in thickening and reduction in the
surface area of the myometrium underlying the placenta with subsequent detachment of the placenta.  Although delivery of the
placenta often requires less than 10 minutes, the duration of the third stage of labor may last as long as 30 minutes. Expectant
management of the third stage of labor involves spontaneous delivery of the placenta. Active management often involves
prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and
controlled cord traction of the umbilical cord. Andersson et al found that delayed cord clamping (≥180 seconds after delivery)
improved iron status and reduced prevalence of iron deficiency at age 4 months and also reduced prevalence of neonatal
anemia, without apparent adverse effects.  
A systematic review of the literature that included 5 randomized controlled trials comparing active and expectant management
of the third stage reports that active management shortens the duration of the third stage and is superior to expectant
management with respect to blood loss/risk of postpartum hemorrhage; however, active management is associated with an
increased risk of unpleasant side effects.
The third stage of labor is considered prolonged after 30 minutes, and active intervention, such as manual extraction of the
placenta, is commonly considered.

Mechanism of Labor
The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage
in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as
is the case in 95% of all pregnancies. Although labor and delivery occurs in a continuous fashion, the cardinal movements are
described as 7 discrete sequences, as discussed below.  
Engagement
The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is
the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the
presenting part is at 0 station, or at the level of the maternal ischial spines.

Descent

The downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. The rate is
greatest during the second stage of labor.

Flexion

As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor, resulting in
passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes
from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

Internal rotation

As the head descends, the presenting part, usually in the transverse position, is rotated about 45° to anteroposterior (AP)
position under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic
outlet.

Extension

With further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the pubic
symphysis. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to
extend and rotate around the symphysis. This is followed by the delivery of the fetus' head.

Restitution and external rotation

When the fetus' head is free of resistance, it untwists about 45° left or right, returning to its original anatomic position in relation
to the body.

Expulsion

After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior
shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus.

Physical examination

Physical examination should include documentation of the patient's vital signs, the fetus' presentation, and assessment of the
fetal well-being. The frequency, duration, and intensity of uterine contractions should be assessed, particularly the abdominal
and pelvic examinations in patients who present in possible labor.
Abdominal examination begins with the Leopold maneuvers described below:
The initial maneuver involves the examiner placing both of his or her hands on each upper quadrant of the patient's
abdomen and gently palpating the fundus with the tips of the fingers to define which fetal pole is present in the fundus. If
it is the fetus' head, it should feel hard and round. In a breech presentation, a large, nodular body is felt.

The second maneuver involves palpation in the paraumbilical regions with both hands by applying gentle but deep
pressure. The purpose is to differentiate the fetal spine (a hard, resistant structure) from its limbs (irregular, mobile
small parts) to determinate the fetus' position.

The third maneuver is suprapubic palpation by using the thumb and fingers of the dominant hand. As with the first
maneuver, the examiner ascertains the fetus' presentation and estimates its station. If the presenting part is not
 engaged, a movable body (usually the fetal occiput) can be felt. This maneuver also allows for an assessment of the
fetal weight and of the volume of amniotic fluid.

The fourth maneuver involves palpation of bilateral lower quadrants with the aim of determining if the presenting part
of the fetus is engaged in the mother's pelvis. The examiner stands facing the mother's feet. With the tips of the first 3
fingers of both hands, the examiner exerts deep pressure in the direction of the axis of the pelvic inlet. In a cephalic
presentation, the fetus' head is considered engaged if the examiner's hands diverge as they trace the fetus' head into
the pelvis.

Pelvic examination is often performed using sterile gloves to decrease the risk of infection. If membrane rupture is suspected,
examination with a sterile speculum is performed to visually confirm pooling of amniotic fluid in the posterior fornix. The
examiner also looks for fern on a dried sample of the vaginal fluid under a microscope and checks the pH of the fluid by using a
nitrazine stick or litmus paper, which turns blue if the amniotic fluid is alkalotic. If frank bleeding is present, pelvic examination
should be deferred until placenta previa is excluded with ultrasonography. Furthermore, the pattern of contraction and the
patient's presenting history may provide clues about placental abruption.
Digital examination of the vagina allows the clinician to determine the following: (1) the degree of cervical dilatation, which
ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated), (2) the effacement (assessment of the cervical length,
which is can be reported as a percentage of the normal 3- to 4-cm-long cervix or described as the actual cervical length); actual
reporting of cervical length may decrease potential ambiguity in percent-effacement reporting, (3) the position, ie, anterior or
posterior, and (4) the consistency, ie, soft or firm. Palpation of the presenting part of the fetus allows the examiner to establish
its station, by quantifying the distance of the body (-5 to +5 cm) that is presenting relative to the maternal ischial spines, where 0
station is in line with the plane of the maternal ischial spines).

The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI). The pelvic
planes include the following:

Pelvic inlet: The obstetrical conjugate is the distance between the sacral promontory and the inner pubic arch; it should
measure 11.5 cm or more. The diagonal conjugate is the distance from the undersurface of the pubic arch to sacral
promontory; it is 2 cm longer than the obstetrical conjugate. The transverse diameter of the pelvic inlet measures 13.5
cm.

Midpelvis: The midpelvis is the distance between the bony points of ischial spines, and it typically exceeds 12 cm.

Pelvic outlet: The pelvic outlet is the distance between the ischial tuberosities and the pubic arch. It usually exceeds 10
cm.

The shape of the mother's pelvis can also be assessed and classified into 4 broad categories based on the descriptions of
Caldwell and Moloy: gynecoid, anthropoid, android, and platypelloid.   Although the gynecoid and anthropoid pelvic shapes are
thought to be most favorable for vaginal delivery, many women can be classified into 1 or more pelvic types, and such
distinctions can be arbitrary.

Intrapartum Management of Labor

First stage of labor

Cervical change occurs at a slow, gradual pace during the latent phase of the first stage of labor. Latent phase of labor is complex
and not well-studied since determination of onset is subjective and may be challenging as women present for assessment at
different time duration and cervical dilation during labor. In a cohort of women undergoing induction of labor, the median
duration of latent labor was 384min with an interquartile range of 240-604 min. The authors report that cervical status at
admission for labor induction, but not other risk factors typically associated with cesarean delivery, is associated with length of
the latent phase. 
Most women experience onset of labor without premature rupture of the membranes (PROM); however, approximately 8% of
term pregnancies is complicated by PROM. Spontaneous onset of labor usually follows PROM such that 50% of women with
PROM who were expectantly managed delivered within 5 hours, and 95% gave birth within 28 hours of PROM.  Currently, the
American College of Obstetricians and Gynecologists (ACOG) recommends that fetal heart rate monitoring should be used to
assess fetal status and dating criteria reviewed, and group B streptococcal prophylaxis be given based on prior culture results or
risk factors of cultures not available. Additionally, randomized controlled trials to date suggest that for women with PROM at
term, labor induction, usually with oxytocin infusion, at time of presentation can reduce the risk of chorioamnionitis.
According to Friedman and colleagues, [6] the rate of cervical dilation should be at least 1 cm/h in a nulliparous woman and 1.2
cm/h in a multiparous woman during the active phase of labor. However, labor management has changed substantially during
the last quarter century. Particularly, obstetric interventions such as induction of labor, augmentation of labor with oxytocin
administration, use of regional anesthesia for pain control, and continuous fetal heart rate monitoring are increasingly common
practice in the management of labor in today’s obstetric population.  Vaginal breech and mid- or high-forceps deliveries are now
rarely performed. Therefore, subsequent authors have suggested normal labor may precede at a rate less rapid than those
previously described. 
Data collected from the Consortium on Safe Labor suggests that allowing labor to continue longer before 6-cm dilation may
reduce the rate of intrapartum and subsequent cesarean deliveries in the United States.  In the study, the authors noted that the
95th percentile for advancing from 4-cm dilation to 5-cm dilation was longer than 6 hours; and the 95 th percentile for advancing
from 5-cm dilation to 6-cm dilation was longer than 3 hours, regardless of the patient’s parity.
On admission to the Labor and Delivery suite, a woman having normal labor should be encouraged to assume the position that
she finds most comfortable. Possibilities including walking, lying supine, sitting, or resting in a left lateral decubitus position. Of
note, ambulating during labor did not change the progression of labor in a large randomized controlled study of >1000 women in
active labor. 
The patient and her family or support team should be consulted regarding the risks and benefits of various interventions, such as
the augmentation of labor using oxytocin, artificial rupture of the membranes, methods and pharmacologic agents for pain
control, and operative vaginal delivery (including forceps or vacuum-assisted vaginal deliveries) or cesarean delivery. They
should be actively involved, and their preferences should be considered in the management decisions made during labor and
delivery.
The frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position should be
assessed periodically to evaluate the progression of labor. Although progression must be monitored, vaginal examinations
should be performed only when necessary to minimize the risk of chorioamnionitis, particularly in women whose amniotic
membrane has ruptured. During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at
least every 15 minutes, particularly during and immediately after uterine contractions. In most labor and delivery units, the fetal
heart rate is assessed continuously. 
Two methods of augmenting labor have been established. The traditional method involves the use of low doses of oxytocin with
long intervals between dose increments. For example, low-dose infusion of oxytocin is started at 1 mili IU/min and increased by
1-2 mili IU/min every 20-30 minutes until adequate uterine contraction is obtained.  
The second method, or active management of labor, involves a protocol of clinical management that aims to optimize uterine
contractions and shorten labor. This protocol includes strict criteria for admission to the labor and delivery unit, early
amniotomy, hourly cervical examinations, early diagnosis of inefficient uterine activity (if the cervical dilation rate is < 1.0 cm/h),
and high-dose oxytocin infusion if uterine activity is inefficient. Oxytocin infusion starts at 4 mili IU/min (or even 6 mili IU/min)
and increases by 4 mili IU/min (or 6 mili IU/min) every 15 minutes until a rate of 7 contractions per 15 minutes is achieved or
until the maximum infusion rate of 36 mili IU/min is reached.  
Although active management of labor was originally intended to shorten the length of labor in nulliparous women, its
application at the National Maternity Hospital in Dublin produced a primary cesarean delivery rate of 5-6% in nulliparas.   Data
from randomized controlled trials confirmed that active management of labor shortens the first stage of labor and reduces the
likelihood of maternal febrile morbidity, but it does not consistently decrease the probability of cesarean delivery.
Although the active management protocol likely leads to early diagnosis and interventions for labor dystocia, a number of risk
factors are associated with a failure of labor to progress during the first stage. These risk factors include premature rupture of
the membranes (PROM), nulliparity, induction of labor, increasing maternal age, and or other complications (eg, previous
perinatal death, pregestational or gestational diabetes mellitus, hypertension, infertility treatment).
While the ACOG defines labor dystocia as abnormal labor that results form abnormalities of the power (uterine contractions or
maternal expulsive forces), the passenger (position, size, or presentation of the fetus), or the passage (pelvis or soft tissues),
labor dystocia can rarely be diagnosed with certainty.  Often, a "failure to progress" in the first stage is diagnosed if uterine
contraction pattern exceeds 200 Montevideo units for 2 hours without cervical change during the active phase of labor is
encountered. [1] Thus, the traditional criteria to diagnose active-phase arrest are cervical dilatation of at least 4 cm, cervical
changes of < 1 cm in 2 hours, and a uterine contraction pattern of >200 Montevideo units. These findings are also a common
indication for cesarean delivery.
Proceeding to cesarean delivery in this setting, or the "2-hour rule," was challenged in a clinical trial of 542 women with active
phase arrest. In this cohort of women diagnosed with active phase arrest, oxytocin was started, and cesarean delivery was not
performed for labor arrest until adequate uterine contraction lasted at least 4 hours (>200 Montevideo units) or until oxytocin
augmentation was given for 6 hours if this contraction pattern could not be achieved. This protocol achieved vaginal delivery
rates of 56-61% in nulliparas and 88% in multiparas without severe adverse maternal or neonatal outcomes. Therefore,
extending the criteria for active-phase labor arrest from 2 to at least 4 hours appears to be effective in achieving vaginal birth.  

Second stage of labor

When the woman enters the second stage of labor with complete cervical dilatation, the fetal heart rate should be monitored or
auscultated at least every 5 minutes and after each contraction during the second stage.  [3] Although the parturient may be
encouraged to actively push in concordance with the contractions during the second stage, many women with epidural
anesthesia who do not feel the urge to push may allow the fetus to descend passively, with a period of rest before active
pushing begins.
A number of randomized controlled trials have shown that, in nulliparous women, delayed pushing, or passive descend, is not
associated with adverse perinatal outcomes or an increased risk for operative deliveries despite an often prolonged second
stage of labor. Furthermore, investigators who recently compared obstetric outcomes associated with coached versus
uncoached pushing during the second stage reported a slightly shortened second stage (13 min) in the coached group, with no
differences in the immediate maternal or neonatal outcomes.  [58] 
Le Ray et al reported that manual rotation of fetuses who were in occiput posterior or occiput transverse position at full
dilatation was associated with reduced rates of operative delivery (ie, cesarean or instrumental vaginal delivery).  [59, 60] In a study
involving 2 French hospitals, operative delivery rates were significantly lower at the institution whose policy favored manual
rotation than at the one that favored modification of maternal position (23.2% vs 38.7%), mainly because of lower rates of
instrumental deliveries (15.0% vs 28.8%).
When a prolonged second stage of labor is encountered, clinical assessment of the parturient, the fetus, and the expulsive
forces is warranted. A randomized controlled trial performed by Api et al determined that application of fundal pressure on the
uterus does not shorten the second stage of labor. Although the 2003 ACOG practice guidelines state that the duration of the
second stage alone does not mandate intervention by operative vaginal delivery or cesarean delivery if progress is being made,
the clinician has several management options (continuing observation/expectant management, operative vaginal delivery by
forceps or vacuum-assisted vaginal delivery, or cesarean delivery) when second-stage arrest is diagnosed.
The association between a prolonged second stage of labor and adverse maternal or neonatal outcome has been examined.
While a prolonged second stage is not associated with adverse neonatal outcomes in nulliparas, possibly because of close fetal
surveillance during labor, but it is associated with increased maternal morbidity, including higher likelihood of operative vaginal
delivery and cesarean delivery, postpartum hemorrhage, third- or fourth-degree perineal lacerations, and peripartum
infection. Therefore, it is crucial to weigh the risks of operative delivery against the potential benefits of continuing labor in
hopes to achieve vaginal delivery. The question of when to intervene should involve a thorough evaluation of the ongoing risks
of further expectant management versus the risks of intervention with vaginal or cesarean delivery, as well as the patients'
preferences.
Delivery of the fetus

When delivery is imminent, the mother is usually positioned supine with her knees bent (ie, dorsal lithotomy position), though
delivery can occur with the mother in any position, including the lateral (Sims) position, the partial sitting or squatting position,
or on her hands and knees. [2] Although an episiotomy (an incision continuous with the vaginal introitus) used to be routinely
performed at this time, the ACOG recommended in 2006 that its use be restricted to maternal or fetal indications. Studies have
also shown that routine episiotomy.
Crowning is the word used to describe when the fetal head forcibly extends the vaginal outlet. A modified Ritgen maneuver can
be performed to deliver the head. Draped with a sterile towel, the heel of the clinician's hand is placed over the posterior
perineum overlying the fetal chin, and pressure is applied upward to extend the fetus' head. The other hand is placed over the
fetus' occiput, with pressure applied downward to flex its head. Thus, the head is held in mid position until it is delivered,
followed by suctioning of the oropharynx and nares. Check the fetus' neck for a wrapped umbilical cord, and promptly reduce it
if possible. If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut. Of note, some providers,
in an attempt to avoid shoulder dystocia, deliver the anterior shoulder prior to restitution of the fetal head.
Next, the fetus' anterior shoulder is delivered with gentle downward traction on its head and chin. Subsequent upward pressure
in the opposite direction facilitates delivery of the posterior shoulder. The rest of the fetus should now be easily delivered with
gentle traction away from the mother. If not done previously, the cord is clamped and cut. The baby is vigorously stimulated and
dried and then transferred to the care of the waiting attendants or placed on the mother's abdomen.

Third stage of labor - Delivery of the placenta and the fetal membranes

The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has
separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs.  
Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30
minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can
cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a
hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of
1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental
separation by inducing uterine contractions and to decrease bleeding.
Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management
involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is
delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental
separation and delivery are awaited.
A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active
management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third
stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used). However, given the
reduced risk of complications, this review recommends that active management is superior to expectant management and
should be the routine management of choice. A multicenter, randomized, controlled trial of the efficacy
of misoprostol (prostaglandin E1 analog) compared with oxytocin showed that oxytocin 10 IU IV or given intramuscularly (IM)
was preferable to oral misoprostol 600 mcg for active management of the third stage of labor in hospital settings.  [64] Therefore, if
the risks and benefits are balanced, active management with oxytocin may be considered a part of routine management of the
third stage. A study by Adnan et al that included 1075 women to compare intravenous oxytocin and intramuscular oxytocin for
the third stage of labor reported that although intravenous oxytocin did not lower the incidence of standard postpartum
hemorrhage, it significantly lowered the incidence of severe postpartum hemorrhage as well as lowering the frequency of blood
transfusion and admission to a high dependency unit.  [76] 
After the placenta is delivered, the labor and delivery period is complete. Palpate the patient's abdomen to confirm reduction in
the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of
the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy
or perineal/vaginal lacerations should be carried out.
Franchi et al found that topically applied lidocaine-prilocaine (EMLA) cream was an effective and satisfactory alternative
to mepivacaine infiltration for pain relief during perineal repair. In a randomized trial of 61 women with either an episiotomy or
a perineal laceration after vaginal delivery, women in the EMLA group had lower pain scores than those in the mepivacaine
group (1.7 +/- 2.4 vs 3.9 +/- 2.4; P = .0002), and a significantly higher proportion of women expressed satisfaction with
anesthesia method in the EMLA group than in the mepivacaine group (83.8% vs 53.3%; P = .01).  
In a Cochrane review, Aasheim et al suggest that evidence is sufficient to support the use of warm compresses to prevent
perineal tears. They also found a reduction in third-degree and fourth-degree tears with massage of the perineum to reduce the
rate of episiotomy. 
The World Health Organization developed a checklist to address the major causes of maternal death (hemorrhage, infection,
obstructed labor and hypertensive disorders), intrapartum-related stillbirths (inadequate intrapartum care), and neonatal deaths
(birth asphyxia, infection and complications related to prematurity).