What are the key management strategies for the first stage of labor?

From the Guidelines

The key management strategy for the first stage of labor is to accurately identify the onset of the active phase through serial vaginal examinations at least every 2 hours to determine when the rate of dilatation increases, and to monitor labor progress using the Friedman curve or similar methods 1. The first stage of labor management involves several crucial steps to support the mother and monitor maternal and fetal wellbeing.

• Establishing rapport and reviewing the birth plan is essential.
• Regular assessments, including vital signs every 1-4 hours, fetal heart rate monitoring, and cervical examinations approximately every 2-4 hours or as clinically indicated, are vital for monitoring progress and detecting any potential issues.
• Encouraging maternal position changes and ambulation as tolerated can help promote labor progression.
• Providing adequate hydration through oral fluids or IV if necessary is also important. For pain management, non-pharmacological methods should be offered first, followed by pharmacological options if requested.
• Monitoring labor progress using the Friedman curve or WHO partogram is critical, recognizing that normal active labor progression is approximately 0.5-1 cm/hour for nulliparous women and potentially faster for multiparous women, as noted in the study by 1.
• Continuous emotional support throughout labor reduces intervention rates and improves outcomes. If labor progress stalls, considering amniotomy or oxytocin augmentation can support physiologic labor while ensuring safety for both mother and baby.
• It is also important to be aware of potential underlying factors that may contribute to aberrant labor patterns, such as cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age, and previous cesarean delivery, as discussed in the study by 1.

From the FDA Drug Label

Accurate control of the rate of infusion flow is essential An infusion pump or other such device and frequent monitoring of strength of contractions and fetal heart rate are necessary for the safe administration of oxytocin for the induction or stimulation of labor. The initial dose should be no more than 1 to 2 mU/min The dose may be gradually increased in increments of no more than 1 to 2 mU/min, until a contraction pattern has been established which is similar to normal labor. The fetal heart rate, resting uterine tone, and the frequency, duration, and force of contractions should be monitored.

The key management strategies for the first stage of labor include:

• Accurate control of oxytocin infusion flow using an infusion pump or other device
• Frequent monitoring of:
  • Strength of contractions
  • Fetal heart rate
  • Resting uterine tone
  • Frequency, duration, and force of contractions
• Gradual increase in oxytocin dose, starting with no more than 1 to 2 mU/min and increasing in increments of no more than 1 to 2 mU/min until a normal labor contraction pattern is established 2

From the Research

Key Management Strategies for the First Stage of Labor

• The active phase of the first stage of labor is generally defined as the period between 3 cm to 4 cm to complete cervical dilatation, in the presence of regular uterine contractions 3.
• Care practices that support physiologic labor include activity in labor, intermittent auscultation, patience from caregivers, and nonpharmacologic methods of pain relief 3.
• The latent phase of labor is much slower than was previously thought and the transition from latent to active labor does not occur until about 6 cm of cervical dilatation, regardless of parity or whether labor was spontaneous or induced 4.
• Providers should have a low threshold to use safe and effective interventions to manage abnormal progression in the first stage of labor, including oxytocin, internal tocodynamometry, and amniotomy 4.

Fetal Heart Monitoring and Labor Management

• Continuous electronic fetal heart rate monitoring may not be necessary in the earliest phase of the first stage of labor, and starting it when the cervical dilatation is > 4 cm may be more beneficial for maternal comfort and labor supervision 5.
• Early amniotomy and/or active management of labour can reduce the duration of the first stage of labour, but may also increase the frequency of severe variable fetal heart rate decelerations 6.
• High doses of oxytocin and decreased oxytocin-dosing interval for augmentation of labour can induce uterine hyperstimulation, which is associated with a higher incidence of fetal heart rate abnormalities and neonatal acidosis 6.

Evidence-Based Labor Management

• Intrapartum antibiotic prophylaxis is recommended for group B streptococcus-positive women, and antibiotic therapy can be considered in women with term prelabor rupture of membranes whose latency is expected to be >12 hours 7.
• Aromatherapy with essential oils, immersion in water, and upright positions and ambulation are recommended as interventions during the first stage of labor 7.
• Oxytocin augmentation is recommended to shorten the time to delivery for women making slow progress in spontaneous labor, and higher doses of oxytocin can be considered 7.
• Routine use of certain interventions, such as vaginal disinfection with chlorhexidine, continuous bladder catheterization, and routine amniotomy, cannot be recommended 7.