Labor and Delivery Rounding: Essential Clinical Guidance

Active Labor Definition and Diagnosis

Active labor begins at 6 cm cervical dilation, not the traditional 4 cm threshold. 1, 2

The active phase is characterized by a linear cervical dilation rate with a minimum normal rate of 1.2 cm/hour in nulliparous women, not the 0.5-0.6 cm/hour suggested by some recent studies 1
Cervical dilation rates as slow as 0.5-0.6 cm/hour typically represent latent phase labor, not active phase, and mixing these populations has led to inappropriate lowering of intervention thresholds 1
Do not diagnose labor arrest until the cervix is ≥6 cm dilated with ruptured membranes and adequate oxytocin augmentation for at least 4 hours (with adequate contractions) or 6 hours (with inadequate contractions) 3

Continuous labor support by a doula improves outcomes and should be encouraged 4
Upright positioning and ambulation are recommended for women without regional anesthesia; women with epidurals may choose any comfortable position 3
Oral intake of fluids and solid food should NOT be restricted during labor 3
If oral restriction is necessary for clinical reasons, administer IV dextrose-containing fluids at 250 mL/hour 3

Early intervention with oxytocin and amniotomy is recommended for prevention and treatment of slow or dysfunctional labor 3
Higher-dose oxytocin protocols can be considered to shorten time to delivery in women with slow labor progress 3
Oxytocin augmentation is appropriate even in women attempting vaginal birth after cesarean (VBAC), with only 1 of 4 uterine ruptures occurring in oxytocin-augmented patients 5

Routine amniotomy alone in normally progressing spontaneous labor should NOT be performed 3
Routine episiotomy should be avoided as it causes complications without sufficient benefit 4
Fundal pressure during delivery should be avoided 4
Routine enema, perineal shaving, and vaginal irrigation are not beneficial and should be discontinued 4
Continuous bladder catheterization is not recommended 3
Routine use of partograms, peanut balls, or antispasmodic agents cannot be recommended 3

Structured intermittent auscultation should be considered for low-risk pregnancies, though continuous electronic fetal monitoring remains most common 2
Moderate fetal heart rate variability is the most reliable marker of fetal well-being 2

Epidural analgesia is NOT associated with increased cesarean delivery rates 2
Epidurals are associated with a longer second stage of labor but this does not necessitate intervention 2
For women attempting VBAC, epidural should only be placed after entering active phase (≥6 cm) 5

Cesarean for arrest of labor should NOT be performed unless labor has arrested for minimum 4 hours with adequate contractions or 6 hours with inadequate contractions, in a woman with ≥6 cm dilation, ruptured membranes, and adequate oxytocin 3
Manual rotation should be attempted for persistent occiput posterior presentations before proceeding to cesarean 2

Intrapartum antibiotic prophylaxis is mandatory for GBS-positive women 3
For term prelabor rupture of membranes with expected latency >12 hours, antibiotic therapy should be considered 3

Trial of labor should be encouraged in appropriate candidates, with success rates of 88% achievable using disciplined labor management 5
Older age, higher parity, and preterm delivery are associated with higher elective repeat cesarean rates 5
Oxytocin augmentation, epidural analgesia, and chorioamnionitis increase VBAC failure rates but should not preclude attempting trial of labor 5

For absent end-diastolic velocity (AEDV), deliver at 33-34 weeks; for reversed end-diastolic velocity (REDV), deliver at 30-32 weeks 6
Cesarean delivery should be strongly considered for FGR with AEDV/REDV based on the clinical scenario 6
Induction of labor is contraindicated when fetus already demonstrates severe compromise with ominous fetal heart tracing 6

Do not diagnose "failure to progress" before 6 cm dilation - this represents normal latent phase 1, 3
Do not rush to cesarean for "slow progress" if dilation rate is ≥1.0 cm/hour in active phase - this is normal 1
Do not withhold oxytocin in VBAC patients - uterine rupture risk is not significantly increased 5
Do not perform induction of labor for suspected macrosomia - this doubles cesarean risk without reducing shoulder dystocia 7