What is the step-by-step management of the first stage of labor?

From the Guidelines

The first stage of labor should be managed by closely monitoring cervical dilatation through serial vaginal examinations at least every 2 hours to identify the transition from the latent to the active phase, which is characterized by a more rapid rate of dilatation 1. To manage the first stage of labor effectively, several key steps should be taken:

• Assess maternal and fetal status upon admission, including vital signs, fetal heart rate monitoring, and cervical examination to determine dilation, effacement, and fetal position.
• Provide continuous support, encouraging the presence of a birth partner or doula, as this has been shown to improve outcomes.
• Offer non-pharmacological pain management methods first, such as breathing techniques, position changes, massage, hydrotherapy, and ambulation.
• If needed, pharmacological options can be considered, but the choice of medication and dosage should be tailored to the individual patient's needs and risk factors.
• Monitor maternal vital signs and fetal heart rate regularly, with the frequency depending on the presence of risk factors.
• Perform vaginal examinations approximately every 2-4 hours to assess progress, with the understanding that the active phase of labor is characterized by a more rapid rate of cervical dilatation, as identified through serial examinations 1.
• Encourage oral hydration and provide clear liquids as tolerated to support the patient's comfort and labor progress.
• If labor progress slows, consider interventions such as amniotomy or oxytocin augmentation, but these decisions should be made based on careful assessment of the patient's individual situation and the presence of any underlying factors that may be contributing to the slow progress, such as cephalopelvic disproportion or poor uterine contractility 1.

From the FDA Drug Label

Oxytocin Injection, USP (synthetic) is indicated for the initiation or improvement of uterine contractions, where this is desirable and considered suitable, in order to achieve early vaginal delivery for fetal or maternal reasons It is indicated for (1) induction of labor in patients with a medical indication for the initiation of labor, such as Rh problems, maternal diabetes, pre-eclampsia at or near term, when delivery is in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated;

The step-by-step management of the first stage of labor is not explicitly described in the provided drug label. However, based on the indications for oxytocin use, the management may involve:

• Induction of labor in patients with a medical indication for the initiation of labor
• Stimulation or reinforcement of labor in selected cases of uterine inertia The label does not provide a detailed, step-by-step guide for the management of the first stage of labor. 2

From the Research

Step-by-Step Management of the First Stage of Labor

The management of the first stage of labor involves several interventions that have been studied and recommended based on evidence. The following steps outline the management of the first stage of labor:

• Intrapartum antibiotic prophylaxis is recommended for group B streptococcus-positive women 3.
• Antibiotic therapy can be considered in women with term prelabor rupture of membranes whose latency is expected to be >12 hours 3.
• Aromatherapy with essential oils through inhalation or back massage can be considered 3.
• Immersion in water can be considered 3.
• Upright positions and ambulation are recommended in women without regional anesthesia, and women with regional anesthesia can adopt whatever position they find most comfortable and choose to ambulate or not ambulate 3.
• 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 3, 4.
• Early intervention with oxytocin and amniotomy for the prevention and treatment of dysfunctional or slow labor is recommended 3, 4.
• Cesarean delivery for arrest should not be performed unless labor has arrested for a minimum of 4 hours with adequate uterine activity or 6 hours with inadequate uterine activity in a woman with rupture of membranes, adequate oxytocin, and ≥6 cm cervical dilation 3.

Assessment of Labor Progress

The assessment of labor progress is crucial in the management of the first stage of labor. The following points highlight the importance of assessing labor progress:

• New labor curves have challenged the traditional understanding of the general pattern of dilation and descent in labor 5.
• The American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine first-stage arrest criteria are applicable only in late labor 5.
• Adaptive multifactorial models can improve precision by incorporating several factors that are related directly to labor progress 5.
• Percentile rankings of dilation or station based on adaptive multifactorial models can provide a quantitative assessment of labor progress 5.

Interventions to Support Physiologic Labor

The following interventions can support physiologic labor:

• Activity in labor is recommended 6.
• Intermittent auscultation is recommended 6.
• Nonpharmacologic methods of pain relief are recommended 6.
• Modifying intrapartum care to reflect current evidence can improve women's health 6.
• A multilevel approach and consistent midwifery demonstration of the model are required to implement evidence-based care practices 6.