What are the stages of labor and how is it managed?

Stages of Labor and Management

Labor is divided into three distinct stages, each requiring specific management approaches to ensure optimal maternal and fetal outcomes. 1

First Stage of Labor

The first stage of labor consists of two phases:

Latent Phase

• Begins with the onset of regular uterine contractions and extends until the active phase begins 1, 2
• Characterized by gradual cervical remodeling, softening, thinning, and modest dilation 2
• Normal duration is approximately 20 hours for nulliparas and 14 hours for multiparas 2
• Management focuses on comfort measures and monitoring maternal and fetal status 2

Active Phase

• Begins when cervical dilation accelerates, regardless of the specific dilation measurement 1
• Identified by serial vaginal examinations (at least every 2 hours) to detect when dilation rate increases from the flat slope of latent phase 1
• Normal dilation rates:
  • Nulliparas: ≥1.2 cm/hour
  • Multiparas: ≥1.5 cm/hour 1
• Ends with a deceleration phase (slowing of dilation) as the cervix approaches full dilation 1
• Management includes:
  • Regular monitoring of cervical dilation using a partogram 1
  • Assessment of uterine contractions (though contraction patterns alone cannot reliably identify active phase) 1
  • Continuous fetal monitoring 1
  • Adequate pain management, with epidural analgesia being preferred as it stabilizes cardiac output 1

Second Stage of Labor

• Begins at complete cervical dilation (10 cm) and ends with delivery of the fetus 1
• Normal duration ranges from 30 minutes to 2 hours, with WHO guidelines recommending allowing 2-3 hours 1, 3
• Management includes:
  • Encouraging maternal pushing when she feels the urge, in her preferred position (avoiding supine) 3
  • Monitoring fetal heart rate after every second contraction 3
  • Considering assisted vaginal delivery (forceps or vacuum) if spontaneous delivery cannot be achieved rapidly 1
  • Using warm compresses and perineal massage to decrease risk of perineal trauma 4
  • Avoiding prolonged bearing down efforts 1

Third Stage of Labor

• Begins after delivery of the fetus and ends with delivery of the placenta 1, 5
• Normal duration is up to 1 hour if not actively managed 1
• Management focuses on preventing postpartum hemorrhage through:
  • Administration of a uterotonic agent (oxytocin is commonly used) 6, 5
  • Controlled cord traction when feasible 5
  • Delayed cord clamping 5
  • Early skin-to-skin contact 5
  • Avoiding ergometrine (contraindicated) 1
  • Monitoring for excessive blood loss 5

Special Considerations

Abnormal Labor Patterns

• Protracted active phase: slower than normal dilation rate but still progressing 1, 7
• Arrest of dilation: complete cessation of cervical dilation during active phase 1, 7
• Prolonged deceleration phase: deceleration phase lasting >2-3 hours in nulliparas or >1 hour in multiparas 1
• Management may include:
  • Oxytocin augmentation 6, 7
  • Amniotomy 7
  • Consideration of cesarean delivery if cephalopelvic disproportion is suspected 1

Risk Factors for Labor Abnormalities

• Cephalopelvic disproportion 1
• Excessive neuraxial block 1
• Poor uterine contractility 1
• Fetal malpositions or malpresentations 1
• Maternal obesity 7, 2
• Advanced maternal age 1
• Previous cesarean delivery 1

Medical Conditions

• Women with respiratory disease require:
  • Detailed birth plan developed early in pregnancy 1
  • Monitoring of oxygen saturation 1
  • Adequate pain relief to prevent respiratory compromise 1
  • Consideration of vaginal delivery when possible to minimize post-delivery complications 1

Common Pitfalls and Caveats

• Failing to recognize the transition from latent to active phase can lead to misdiagnosis of labor disorders 1, 2
• Relying solely on contraction patterns to identify active phase is unreliable; serial cervical examinations are necessary 1
• Extending labor beyond safe limits increases risks of postpartum hemorrhage, intraamniotic infection, and adverse neonatal outcomes 7
• The term "active management of the third stage of labor" as a combined intervention is no longer recommended; instead, evidence-based "third stage care" should be implemented 5
• Pain and anxiety during labor can lead to rapid shallow breathing and decreased alveolar gas exchange, potentially causing respiratory compromise in women with pulmonary disease 1