3 Labor and Delivery

How labor progresses

Labor and delivery involve coordinated changes in the cervix, uterus, and fetus. Care teams monitor the pregnant patient and fetus, support informed choices, and adjust the plan if complications arise. The duration of labor stages varies widely.

The stages of labor and birth

The first stage begins with regular contractions that cause cervical change and ends when the cervix is fully dilated to $10\text{ cm}$. The latent phase involves early cervical change; dilation is faster in the active phase. ACOG defines active labor as beginning at $6\text{ cm}$, so slow progress before that point does not by itself indicate arrested labor.

Active-phase arrest is diagnosed only when specific criteria are met. These include no cervical change at $6\text{ cm}$ or more with ruptured membranes, despite adequate time and contractions or oxytocin.

The second stage begins at full dilation and ends with delivery of the baby. The patient usually bears down with contractions. Position, coaching, and pushing style can be individualized, and progress and fetal descent matter alongside elapsed time.

The third stage follows the baby’s birth: the placenta separates from the uterine wall and is delivered. A uterotonic medication, commonly oxytocin, is used as part of active management to help the uterus contract and reduce bleeding.

Immediate recovery covers the first hours after birth. The team assesses the patient for bleeding and other complications and supports the newborn’s transition, warmth, and feeding.

Monitoring the patient and fetus

Monitoring is tailored to the patient’s risk factors, the course of labor, and preferences. Maternal assessment commonly includes vital signs, pain and coping, contraction pattern, cervical change when indicated, and signs of bleeding or infection. Contractions are assessed for frequency, duration, and relaxation between them.

Fetal heart rate may be checked intermittently with a Doppler or monitored continuously with electronic fetal monitoring (EFM). For low-risk labor, either approach may be appropriate; complications or emerging concerns may call for more frequent checks or continuous monitoring.

External EFM uses abdominal sensors to record fetal heart rate and contraction timing. Internal monitoring may be used in selected circumstances after the membranes have ruptured. An unusual tracing is interpreted in context: the team may change the patient’s position, address a suspected cause, and consider expedited birth if concern persists.

Pain relief during labor

Pain-relief options can be discussed before or during labor and may be combined. Nonmedication approaches include continuous support, breathing and relaxation techniques, movement or position changes, massage, and warm water where available.

Medication options include:

• Epidural or combined spinal–epidural: Regional analgesia reduces pain below the waist while the patient remains awake. Blood pressure and other effects are monitored.

• Spinal anesthesia: A regional injection commonly used when rapid, dense anesthesia is needed, such as for some cesarean births.

• Systemic opioids: Given by injection or through an IV. Effects on the newborn, including temporary drowsiness or breathing changes, are considered.

• Nitrous oxide: An inhaled medication available in some settings. It may reduce anxiety and make pain easier to cope with, but does not numb pain.

The appropriate method depends on the clinical situation and the patient’s preferences and health. Neuraxial analgesia can be offered during labor, including at any stage when suitable.

Birth procedures and interventions

Interventions are used when their expected benefits outweigh their risks. Explanations and shared decision-making are part of care whenever circumstances allow.

• Induction or augmentation: Labor may be started or strengthened with medications such as oxytocin. Amniotomy, the artificial rupture of membranes, may also be used in appropriate circumstances.

• Spontaneous vaginal birth: The baby is born through the vagina without instruments.

• Operative vaginal birth: Forceps or a vacuum device may assist birth when the baby needs to be delivered sooner or descent has stalled. Use depends on appropriate clinical conditions and the availability of a trained clinician. These procedures carry risks, including injury to the patient’s tissues or the baby.

• Cesarean birth: The baby is delivered through surgical incisions in the abdomen and uterus. It may be recommended for concerns such as labor arrest, fetal status, or a condition that makes vaginal birth unsafe.

• Episiotomy: A surgical incision in the perineum is not a routine step in vaginal birth; it is used selectively when clinically indicated.

Care immediately after birth

After birth, the team assesses whether the newborn is breathing and needs help. For a vigorous newborn, routine care includes drying, maintaining warmth, and skin-to-skin contact when appropriate. Delayed cord clamping for at least $30\text{–}60$ seconds is recommended for vigorous term and preterm infants; urgent maternal stabilization or newborn resuscitation may require a different approach.

The newborn’s transition is assessed, including with Apgar scores at $1$ and $5$ minutes. If breathing or heart rate is inadequate, trained staff provide resuscitation without delay. The team also supports early feeding when appropriate.

For the patient, immediate checks include uterine firmness and bleeding, vital signs, and assessment for birth-related injury. The placenta is examined for completeness, and tears are assessed and repaired as needed. Ongoing observation helps identify problems such as uterine atony or postpartum hemorrhage promptly.