What is the management approach for a healthy, pregnant woman at term with no underlying medical conditions undergoing normal labor?

Management of Normal Labor

For healthy, low-risk pregnant women at term undergoing normal labor, management should focus on minimizing unnecessary interventions while ensuring continuous support, appropriate pain management, and evidence-based monitoring—with spontaneous vaginal delivery being the preferred outcome.

First Stage of Labor Management

Admission and Initial Assessment

• Admit women in active labor (≥6 cm cervical dilation) rather than during latent phase to avoid unnecessary interventions, though admission during latent phase may be necessary for pain management or maternal fatigue 1
• Confirm gestational age is ≥39 weeks 0 days for any elective procedures, as early term neonates have increased respiratory morbidity risk 2
• Continuous one-to-one emotional support from personnel such as a doula is associated with improved outcomes 1

Monitoring and Position

• Continuous electronic fetal monitoring is not required for low-risk women with normally progressing labor and no evidence of fetal compromise 1
• Upright positions and ambulation are recommended for women without regional anesthesia 3
• Women with regional anesthesia can adopt whatever position they find most comfortable 3
• No single position needs to be mandated or proscribed 1

Fluid and Nutrition Management

• Oral restriction of fluid or solid food is not recommended for low-risk women 3
• If oral restriction is implemented, intravenous fluid containing dextrose at 250 mL/h is recommended 3
• Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids 1

Labor Progress and Interventions

• Routine amniotomy alone in normally progressing spontaneous labor cannot be recommended 3
• Routine use of partogram cannot be recommended as standard intervention 3
• There is no specific recommended frequency for cervical examinations 3
• Cesarean delivery for arrest should not be performed unless labor has arrested for minimum of 4 hours with adequate uterine activity or 6 hours with inadequate uterine activity in women with ruptured membranes, adequate oxytocin, and ≥6 cm cervical dilation 3

Management of Slow Progress

• Oxytocin augmentation is recommended to shorten time to delivery for women making slow progress in spontaneous labor 3
• Higher doses of oxytocin can be considered for augmentation 3
• Early intervention with oxytocin and amniotomy is recommended for prevention and treatment of dysfunctional or slow labor 3
• Slower labor patterns than traditionally described often result in vaginal delivery without unacceptable increases in maternal or neonatal morbidity 4

Pain Management

Neuraxial Analgesia

• Epidural analgesia is the preferred method during labor as it stabilizes cardiac output and provides effective pain relief 5
• Women should be encouraged to receive neuraxial labor analgesia (epidural or combined spinal-epidural) early in labor or as soon as contractions become uncomfortable 5

Alternative Pain Management

• Aromatherapy with essential oils through inhalation or back massage can be considered 3
• Immersion in water can be considered for low-risk pregnancies 3
• Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain 1

Medications to Avoid

• Opioid agonist/antagonists such as nalbuphine or butorphanol should be avoided as they can precipitate withdrawal in certain populations 5
• Inhaled nitrous oxide should be avoided in specific populations as it may be less effective and increase sedation risk 5

Second Stage of Labor Management

Delivery Approach

• Spontaneous vaginal birth is preferable for women whose condition is well controlled with an apparently healthy fetus 5
• The second stage involves increased exertion and strong contractions; prolonged bearing down efforts should be discouraged 5
• Where spontaneous delivery cannot be achieved rapidly, low forceps or vacuum-assisted delivery will reduce exertion and shorten the second stage 5

Positioning

• The left lateral position ensures adequate venous return from the inferior vena cava 5
• A sitting-up position may be needed for women in specific clinical situations 5

Third Stage of Labor Management

Active Management Components

• The term "active management of the third stage of labor" as a combined intervention should no longer be used; instead, "third stage care" should be adopted with evidence-based interventions 6
• The third stage can be managed actively using a single dose of intramuscular oxytocin 5
• Controlled cord traction at delivery is recommended when feasible 6

Medications

• Ergometrine is contraindicated in women with airways disease and those at risk for bronchospasm 5
• The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine, oxytocin plus misoprostol, or carbetocin 6
• Prostaglandin F2α used for postpartum hemorrhage may cause bronchoconstriction and is not recommended for women with asthma 5

Cord Management

• Delayed cord clamping is recommended based on current evidence 6
• Early skin-to-skin contact is recommended 6

Postpartum Immediate Care

Monitoring and Prevention

• After delivery, auto-transfusion of blood from lower limbs and contracted uterus may significantly increase preload 5
• A single intravenous dose of furosemide is commonly given at this stage in specific populations 5
• Early mobilization is important to reduce risk of venous thromboembolic disease 5

Pain Management

• Postpartum pain should be managed with a multimodal approach 5
• Optimal postpartum analgesia allows early mobilization with minimal side effects 5
• Additional systemic opioids may be necessary after delivery but should not be ordered routinely 5

Common Pitfalls to Avoid

• Do not perform elective deliveries before 39 0/7 weeks in low-risk pregnancies due to increased respiratory morbidity risk 2
• Avoid diagnosing arrest of labor prematurely—allow adequate time with appropriate interventions before considering cesarean delivery 3
• Do not routinely restrict oral intake in normally progressing labor 3, 1
• Avoid routine continuous electronic fetal monitoring in low-risk women, as it has not been shown to significantly affect outcomes like perinatal death and cerebral palsy 1
• Do not use routine amniotomy in normally progressing labor unless required to facilitate monitoring 1