Background Information

Stages of Labour

Stage		NICE definition
First stage	Latent	From: Presence of contraction, and Cervical dilation up to 4 cm (and some other cervical changes)
	Active (established labour)	From: 4cm cervical dilation, and Regular painful contractions To: full dilation (10 cm)
Second stage		From: full dilation (10 cm) with active / involuntary pushing To: delivery of the baby or starts when the baby is visible
Third stage		From: delivery of the baby To: delivery of the placenta

 

Place of Birth

Birth Settings

Common birth settings in the UK are:
 

Setting	Definition	Who provides care?	Access to obstetric care?
Home	Women give birth at home	Midwives only	No immediate access
Freestanding midwifery unit (FMU)	Separate birth centre, not on a hospital site
Alongside midwifery unit (AMU)	Birth centre on the same hospital site as the obstetric unit		Rapid access if needed
Obstetric unit	Hospital labour ward	Midwives and obstetricians

 

Low-Risk Women

Advise the following birth settings:

• Nulliparous women = midwifery unit (FMU / AMU)
• Multiparous women = home / midwifery unit (FMU / AMU)

 

High-Risk Women

If at increased risk → suggest planned birth at obstetric unit
 

Medical conditions that put women at high risk

Disease area	Medical condition
Cardiovascular	Confirmed cardiac disease Hypertensive disorders
Respiratory	Asthma requiring an increase in treatment or hospital treatment Cystic fibrosis
Haematological	Haemoglobinopathies, such as sickle-cell disease, beta-thalassaemia major History of thromboembolic disorders Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×109/litre Von Willebrand's disease Bleeding disorder in the woman or unborn baby Atypical antibodies which carry a risk of haemolytic disease of the newborn
Endocrine	Hyperthyroidism Diabetes needing medication
Infective	Hepatitis B or C with abnormal liver function tests Toxoplasmosis – women receiving treatment Current active infection of chicken pox, rubella or genital herpes in the woman or baby Tuberculosis under treatment
Immune	Systemic lupus erythematosus Scleroderma
Renal	Abnormal renal function Renal disease requiring supervision by a renal specialist
Neurological	Epilepsy Myasthenia gravis Previous cerebrovascular accident
Gastrointestinal	Liver disease associated with current abnormal liver function tests
Psychiatric	Psychiatric disorder requiring current inpatient care

 

Pregnancy-associated factors that put women at high risk

Factor	Additional information
Previous complications	Unexplained stillbirth or neonatal death, or previous death related to intrapartum difficulty Previous baby with neonatal encephalopathy Pre-eclampsia requiring preterm birth Placental abruption with adverse outcome Eclampsia Uterine rupture Primary postpartum haemorrhage requiring additional treatment or blood transfusion Caesarean birth Shoulder dystocia
Current pregnancy	Multiple birth Placenta praevia Pre-eclampsia or pregnancy-induced hypertension Preterm labour or preterm prelabour rupture of membranes Placental abruption Anaemia – haemoglobin less than 85 g/litre at onset of labour Confirmed intrauterine death Substance misuse Alcohol dependency requiring assessment or treatment Gestational diabetes needing medication Malpresentation – breech or transverse lie Recurrent antepartum haemorrhage Small for gestational age in this pregnancy (less than third centile or reduced growth velocity on ultrasound as defined in the NHS Saving babies lives version 3) Abnormal fetal heart rate, umbilical or fetal doppler studies Ultrasound diagnosis of oligo- or polyhydramnios
Previous gynaecological history	Myomectomy Hysterotomy

 

Pain Relief During Labour

Non-Pharmacological

Non-pharmacological options can be roughly categorised into 4 main categories.
 

Recommended by NICE

• Breathing exercises, having a shower or bath, massage may reduce pain during latent stage of labour

• Offer the women the choice to labour in water for pain relief 
  • Monitor temperature of the women and water hourly 
  • Water temperature should not exceed 37.5°C

Neutral Recommendation by NICE

NICE states NOT to offer the following, but support the woman's choice if they wishes to:

• Aromatherapy
• Yoga
• Acupressure
• Acupuncture
• Acupressure
• Hypnosis

NICE states to support the woman's choice if they chooses to use the following during labour:

• Breathing and relaxation techniques
• Massage techniques 

NICE recommendation on transcutaneous electrical nerve stimulation (TENS):

• Not provided by the NHS
• Supports the woman's choice if she wants to use TENS during labour
• Very little evidence of its effectiveness but no evidence of harm
• Other forms of pain relief can be used alongside TENS

Sterile Water Injections

NICE recommends considering intracutaneous / subcutaneous sterile water injections as a pain relief option for back pain in labour.

Explain that:

• Sterile water injections can provide back pain relief from 10 minutes after the injection for up to 3 hours
• 4 injections to be given around the lower back

Pharmacological

Inhalational Analgesia

Entonox (50:50 mix of oxygen and nitrous oxide) can be used to reduce pain in labour

Possible side effects:

• Nausea
• Light-headed

Opioids

Pethidine, diamorphine (usually given IM) and other opioids can be used, but inform the woman that:

• They provide limited pain relief during labour
• May have significant side effects (both mother and baby)
  • Mother: drowsiness, nausea, vomiting
  • Baby: short-term respiratory depression, drowsiness, difficulty breastfeeding

Consider IV remifentanil PCA for those who want ongoing pain relief:

• Only use in obstetric units due to risk of respiratory depression and only under one-to-one care

Regional Analgesia

Only available in obstetric unit

• Epidural anaesthesia (allow continuous infusion) – most common
• Spinal anaesthesia (one-off)

Some important information about epidural anaesthesia:

• Prolongs second stage of labour 
• Increased chance of birth with forceps / ventouse
• Requires more intensive level of monitoring during labour

 Important side effects of spinal anaesthesia:

• Higher risk of hypotension
• Risk of post-dural puncture headache

 
 

Assessment During Labour

1st Stage Labour

The observations can be categorised by their frequency:
 

Frequency of observation	Observation
Every 15 min	Intermittent auscultation After a contraction (wait for a contraction to finish, then listen) Auscultate for at least 1 min
Every 30 min	Contraction frequency
Every 1 hour	Pulse (maternal)
Every 4 hours	Temperature
	Blood pressure
	Respiratory rate
	Vaginal examination – assess for: Bishop score components Presence or absence of caput / moulding Presence or absence of membranes

 

Red flags for Transfer

Red flags for transfer to obstetric-led care:

• Maternal observations
  • Pre-eclampsia concerns
    • 1 reading of BP >160/110 mmHg
    • 1 reading of BP >140/90 mmHg and 2+ protein on urinalysis
    • 2 consecutive readings of BP >140/90 mmHg
  • Pulse >120 bpm on 2 occasions 15-30 min apart
  • Respiratory rate <9 or >21 /min on 2 occasions 15-30 min apart
  • Pyrexia (single reading of ≥38°C or 2 consecutive readings of ≥37.5°C 1 hour apart)
  • New appearance of meconium
  • Fresh vaginal bleeding or blood-stained liquor
  • Pain differs from normal contraction pain
  • Woman requesting regional analgesia
  • Confirmed delay in 1st stage of labour
  • Obstetric emergency, including antepartum haemorrhage, cord prolapse, maternal seizure or collapse, or a need for advanced neonatal resuscitation

 

• Fetal observations
  • Non-cephalic presentation (including cord presentation)
  • High (4/5 to 5/5 palpable) or free-floating head in a nulliparous woman
  • Suspected fetal growth restriction or macrosomia
  • Suspected anhydramnios or polyhydramnios
  • Any changes in the fetal heart rate pattern

 

If none of these are observed, continue with midwifery-led care unless the woman requests transfer.

2nd Stage Labour

Similar to observations in 1st stage of labour but increased frequency of the following:

• Intermittent auscultation every 5 min
  • After a contraction (wait for a contraction to finish, then listen)
  • Auscultate for at least 1 min

 

• Vaginal examination every 1 hour to assess:
  • Head position
  • Descent
  • Caput and moulding

Otherwise, the same as 1st stage of labour, assess:

• Contraction (frequency, strength, duration) 
• Pulse every 1 hour
• Temperature, blood pressure, respiratory rate every 4 hours

Delayed 1st and 2nd Stage Labour Guidelines

Delayed 1st Stage Labour

Normal Duration

• Nulliparous: average 8 hours and mostly <18 hours
• Multiparous: average 5 hours and mostly <12 hours

Delayed Definition

Suspect delayed 1st stage labour if: cervical dilation of <2 cm over 4 hours with regular contractions.

Offer suspected cases a vaginal examination 2 hours later → diagnose delayed 1st stage labour

 

Delayed Management

Consider amniotomy (for artificial ROM) for women with intact membranes:

• Repeat vaginal examination 2 hours later

If no progress 2 hours later:

• Transfer the woman to obstetric-led care
• Consider oxytocin (after obstetric review) and offer epidural before starting 

 

Delayed 2nd Stage Labour

Normal Duration and Delayed Definition

Normal durations of 2nd stage labour depend on more factors, including parity and use of epidural:

• Nulliparous
  • No epidural:  within 3 hours
  • With epidural: within 3 hours (but may have a passive stage of up to 2 hours)

 

• Multiparous
  • No epidural: 2 hours
  • With epidural: 2 hours (but may have a passive stage of up to 1 hours)

 

Management

Consider amniotomy (for artificial ROM) for women with intact membranes:

If no progress after 1 hour (multiparous) / 2 hours (nulliparous) of pushing:

• Refer for senior review and decision on place and mdoe of birth
• Consider oxytocin (after obstetric review) 

 

Birth with Forceps / Ventouse

Offer birth with forceps / ventouse if:

• Concern about baby's well-being (e.g. abnormal cardiotography)
• Prolonged second stage labour
• Woman requests assistance 

 

Third Stage Labour Guidelines

Prolonged Third Stage Labour

Timing depends on whether active or physiological management:

• Active management: >30 min
• Physiological management: >60 min

Active vs Physiological Management

Active management:

• Routine use of uterotonic drugs (e.g. oxytocin)
• Cord clamping and cutting
• Controlled cord traction after signs of separation of the placenta

Physiological management:

• No routine use of uterotonic drugs
• No clamping of the cord until pulsation has stopped, or after delivery of the placenta
• Delivery of placenta spontaneously or by maternal effort 

References

Original Guideline