Clinical overview
Labour is the physiological process by which the products of conception are expelled from the uterus after the age of viability. "Normal labour" is the benchmark against which every deviation is measured: spontaneous in onset at term (≥37 completed weeks), with a singleton fetus in a cephalic (vertex) presentation, progressing without intervention to a spontaneous vaginal birth of a healthy mother and baby. Most of obstetrics is, in effect, the discipline of recognising when a labour has stopped being normal — so a registrar must hold a precise mental model of what normal looks like, minute to minute, before they can safely call anything abnormal.
Managing normal labour well is deceptively demanding. The clinical imperative is to do less, watchfully — to support the woman, monitor mother and fetus, document progress objectively, and intervene only when there is a defined indication, while never missing the moment a labour tips into obstruction, fetal compromise, or haemorrhage. In South Africa, obstetric haemorrhage, hypertension and the hypoxic-ischaemic consequences of poorly monitored labour remain leading contributors to maternal and perinatal death (Saving Mothers/NCCEMD), and a large share of these deaths are judged avoidable. Disciplined, protocolised intrapartum care — the right level of care, an accurately completed partogram, structured fetal monitoring, and active management of the third stage — is therefore one of the highest-yield things you will ever do. This chapter describes that management; the abnormal labour patterns are covered under complicated-labour.
Core knowledge
Defining and dating labour onset
Labour is the coincidence of regular, painful uterine contractions with progressive cervical change (effacement and dilatation). Contractions alone, however strong, are not labour without cervical change; this distinction underpins the diagnosis of false labour and of the latent phase. A "show" (blood-stained mucus plug) and spontaneous rupture of membranes may herald labour but do not define it.
The stages of labour
Labour is divided into stages, and the first stage into phases. The exact numerical thresholds have shifted in modern guidance away from older Friedman-derived norms, so hedge the numbers and reason from the principle that labour is normal as long as it is progressing and mother and fetus are well.
- First stage — onset of labour to full dilatation (10 cm).
- Latent phase: slow cervical change, classically to around 4–5 cm, often irregular and prolonged. It can last many hours and is not an indication to intervene in a well woman; admitting and "actively managing" the latent phase causes a cascade of unnecessary interventions.
- Active phase: established labour with a faster, more predictable rate of dilatation. Contemporary partogram-based guidance (WHO Labour Care Guide, 2020; SA NDoH Integrated Maternal and Perinatal Care Guideline, NDoH, 2024) recognises that the active phase commonly begins around 5 cm and that the older fixed "1 cm/hour" expectation overdiagnosed dysfunctional labour. A slower-than-textbook but steadily progressing labour in a well mother and fetus is still normal.
- Second stage — full dilatation to delivery of the baby. Subdivided into a passive phase (full dilatation, no urge/involuntary pushing) and an active phase (maternal expulsive effort with the presenting part on the pelvic floor).
- Third stage — delivery of the baby to delivery of the placenta and membranes.
The mechanism of labour ("the seven cardinal movements")
The fetus negotiates the bony pelvis through a stereotyped sequence — engagement, descent, flexion, internal rotation, extension, restitution/external rotation, and expulsion. Understanding this is what lets you interpret abdominal and vaginal findings: a deflexed head presents a larger diameter; failure of internal rotation (e.g. persistent occipito-posterior) lengthens the second stage. The interaction of the three P's — Powers (contractions and maternal effort), Passage (bony pelvis and soft tissues) and Passenger (fetal size, presentation, position, attitude) — frames every assessment of progress. Adequate powers are classically described as 3–4 contractions in 10 minutes, each lasting >40 seconds. The physiology of contractions and fetal oxygen delivery is detailed in contractions-fetal-oxygenation.
Levels of care and where normal labour belongs (SA)
Under the SA system, an uncomplicated labour in a low-risk woman can be safely conducted at a midwife-obstetric unit (MOU)/district (level 1) facility. Risk factors identified at booking or in labour (high-risk-pregnancy-risks) mandate referral to regional (level 2) or tertiary (level 3) care. Knowing the referral criteria — and acting on them early, with the partogram as the trigger — is core SA practice.
Figure I13.1 — Normal-labour roadmap: the three stages, the seven cardinal movements, the three P's, and the principle that normal = progress continues AND mother and fetus are well.
Assessment
Assessment of the labouring woman is continuous and structured, not a single event. It begins with confirming the diagnosis of labour, establishing risk, and then monitoring mother and fetus on a defined schedule.
Admission assessment
- History: confirm gestation and dating (gestational-age-assessment); review the antenatal record and risk profile from antenatal-booking; ask about contraction frequency and onset, fluid loss (timing, colour — clear, meconium-stained, or blood), fetal movements, and any bleeding. Check HIV status and PMTCT regimen (hiv-in-pregnancy), antenatal screening results (antenatal-screening), blood group and rhesus status.
- Maternal examination: vital signs (pulse, blood pressure, temperature, respiratory rate); urinalysis (proteinuria, ketones, glucose); hydration. Abdominal palpation: symphysis–fundal height, lie, presentation, engagement (in fifths palpable abdominally), and assessment of contraction frequency, duration and strength by hand.
- Vaginal examination (VE): performed with consent and an explained reason, aseptically. Record cervical dilatation (cm), effacement, consistency and position; the presenting part and its position (e.g. occiput position by suture/fontanelle landmarks); station relative to the ischial spines; caput and moulding; and the state of the membranes (intact/ruptured, liquor colour). VEs are repeated approximately 4-hourly in established normal labour, or sooner if clinically indicated (e.g. urge to push, suspected delay, abnormal fetal heart). Avoid unnecessary repeated VEs — each carries infection risk, especially after membrane rupture.
Monitoring fetal wellbeing
For a low-risk labour, intermittent auscultation (IA) is the recommended method — there is no benefit, and a clear harm of increased intervention, from routine admission and continuous cardiotocography (CTG) in low-risk women (NICE NG235; NICE NG229). Standard teaching and SA practice:
- Auscultate the fetal heart (Pinard or hand-held Doppler) immediately after a contraction, for a full 60 seconds, at least every 15 minutes in the first stage and every 5 minutes (or after every contraction) in the second stage. Palpate the maternal pulse simultaneously at intervals to be sure you are counting the fetus, not the mother.
- A normal baseline is classically 110–160 bpm. Escalate to continuous CTG if IA detects an abnormality, or if intrapartum risk factors arise — meconium-stained liquor, maternal pyrexia ≥38°C, bleeding, oxytocin augmentation, or uterine tachysystole (>5 contractions in 10 minutes / contractions lasting >2 minutes) (NICE NG229).
The methods themselves are covered in fetal-monitoring-methods, and CTG pattern interpretation in ctg-interpretation.
Documenting progress — the partogram / Labour Care Guide
The single most important assessment tool in normal labour is the partogram (in SA, the modified WHO partogram, transitioning toward the WHO Labour Care Guide, 2020), described in detail in partogram-use. Graphically plotting cervical dilatation against time, alongside descent, contractions, fetal heart, liquor, moulding, and maternal observations, makes deviation visible before it becomes dangerous. The alert and action lines convert a subjective sense of "slow labour" into an objective trigger to reassess and, where appropriate, refer. Plot every VE; never backdate or estimate — the partogram is also a medicolegal document.
Management
The over-arching principle is supportive, expectant management with vigilant monitoring, escalating only on defined indication. Respectful, woman-centred care is itself an intervention with outcomes that matter — see respectful-care.
General first-stage care
- Continuous support: one-to-one labour support (a companion of the woman's choice plus the midwife) reduces operative delivery and improves satisfaction; encourage it (WHO; NICE NG235).
- Mobility and position: encourage the woman to be mobile and to adopt whatever upright or comfortable positions she chooses; do not confine her to bed without reason.
- Oral intake and hydration: isotonic fluids and light diet are appropriate in low-risk labour; routine "nil by mouth" is not required. Maintain hydration; monitor for ketosis.
- Bladder care: encourage regular voiding; a full bladder obstructs descent and can mask progress. Avoid routine catheterisation.
- Analgesia: offer a graded menu — non-pharmacological measures, then systemic options, then regional analgesia. Choices, contraindications and the SA EML picture (including the limited availability of epidural services outside higher-level units) are covered in labour-analgesia.
- Do not routinely: perform amniotomy or start oxytocin in a normally progressing labour. These are interventions for delay, not components of normal care.
Figure I13.2 — Watchful first-stage care: confirming labour, the admission snapshot, intermittent auscultation intervals, partogram alert/action lines, and the triggers to escalate to CTG.
Diagnosing and acting on delay
If the partogram shows the active-phase plot crossing the alert line, reassess the three P's, exclude a full bladder, ensure adequate hydration and analgesia, and arrange transfer to a facility able to manage delay if you are at an MOU. Crossing the action line mandates a senior obstetric assessment and a decision (e.g. amniotomy, augmentation, or caesarean). Augmentation and obstructed labour belong to complicated-labour — recognising the point of referral is the normal-labour skill.
Managing the second stage
- Confirm full dilatation before encouraging active pushing. Allow the passive phase (descent without pushing) in women without a strong urge, particularly with an epidural, rather than directing immediate pushing.
- Support spontaneous, woman-led pushing; avoid prolonged directed Valsalva. Encourage upright/lateral positions.
- Perineal management: use a "hands-on" or "hands-poised" technique per skill and unit policy, with warm compresses and controlled delivery of the head to slow crowning and reduce trauma — perineal protection technique and OASIS prevention are detailed in perineal-protection and oasis. Routine episiotomy is not recommended; reserve it for a defined indication (e.g. suspected fetal compromise needing expedited birth, rigid perineum, or instrumental delivery), using a mediolateral cut.
- Time limits (standard teaching, hedge exact figures): a prolonged second stage prompts reassessment and consideration of instrumental-delivery; nulliparous second stages are allowed longer than multiparous. Continuous progress (descent and rotation) matters more than a rigid clock.
- At birth, note the time, and proceed to immediate newborn care and the third stage.
Active management of the third stage (AMTSL)
The third stage is where a normal labour most often turns lethal. Active management of the third stage of labour is recommended for all women to prevent postpartum haemorrhage — it roughly halves the risk of PPH compared with expectant management. The bundle:
- Uterotonic immediately after birth of the baby (and after excluding a second twin). In SA, the first-line agent is oxytocin 10 IU IM (NDoH; WHO). Carbetocin and misoprostol are alternatives where indicated/available.
- Controlled cord traction with counter-traction (guarding) above the symphysis to deliver the placenta, performed by a skilled attendant once signs of separation appear.
- Deferred (delayed) cord clamping for ≥1 minute in the vigorous newborn (improves neonatal iron stores) — this is part of modern AMTSL and is not in conflict with giving the uterotonic.
- Uterine tone assessment and uterine massage as needed after the placenta delivers; check the placenta and membranes for completeness.
After delivery: estimate blood loss objectively (a calibrated under-buttock drape improves early detection — the E-MOTIVE approach), inspect the genital tract for tears, and observe tone, lochia and vital signs. The full PPH drill is in postpartum-haemorrhage; immediate newborn transition and care follow in neonatal-transition and initiation-of-respiration, with feeding support per infant-feeding and recovery per normal-puerperium.
EMERGENCY DRILL — postpartum haemorrhage at delivery
PPH is the commonest way a normal labour kills. The moment estimated loss exceeds ~500 mL (vaginal) or the uterus is atonic, call for help and run the bundle in parallel — do not work serially:
- Call for senior help and a second pair of hands; alert theatre and blood bank.
- Massage the uterus / bimanual compression; ensure the bladder is empty.
- Oxytocics: repeat/escalate uterotonics per protocol.
- TXA: give tranexamic acid 1 g IV within 3 hours of onset (WOMAN trial).
- IV access (two large-bore cannulae), fluids, crossmatch, monitor.
- Examine and escalate: identify the cause — the 4 T's: Tone, Trauma, Tissue, Thrombin — and treat accordingly; transfer to definitive care.
SA / level-of-care specifics
Match the woman to the right facility: low-risk normal labour at an MOU/level 1 with clear, partogram-triggered referral pathways; any risk factor or deviation escalated promptly. Ensure HIV-positive women continue ART through labour and that the infant PMTCT plan is documented and actioned (hiv-in-pregnancy). Always have an emergency referral and transport plan agreed before it is needed.
Red flags / pitfalls
- Diagnosing labour too early and admitting/intervening in the latent phase — the single commonest start to an intervention cascade. A well woman in latent phase needs support and reassessment, not amniotomy and oxytocin.
- Applying a rigid "1 cm/hour" rule and over-diagnosing dysfunctional labour. Modern guidance is more permissive in the active phase; reassess the three P's rather than reflexively augmenting.
- Not plotting the partogram, or backdating it. An unfilled partogram is the hallmark finding in avoidable-death audits. Plot in real time.
- Confusing the maternal pulse for the fetal heart during IA — always palpate the maternal pulse simultaneously, especially with a maternal tachycardia.
- Missing the trigger to switch to continuous CTG — meconium, pyrexia ≥38°C, bleeding, oxytocin, tachysystole, or an abnormal IA.
- Routine episiotomy and aggressive directed pushing — both increase perineal trauma without benefit.
- Forgetting the second twin before giving the uterotonic; giving oxytocin with an undelivered twin in utero is dangerous.
- Under-estimating blood loss at the third stage — visual estimation systematically under-reads; use a calibrated drape and act early.
- Full bladder masquerading as poor progress or obstructing descent.
- Failure to escalate / refer in time from an MOU once the action line is crossed or the fetal heart is abnormal — the partogram exists to prevent exactly this.
Evidence anchors
- SA National Department of Health — National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024). The South African source of truth for intrapartum care, levels of care, referral criteria and uterotonic choice.
- WHO Labour Care Guide (2020) — supersedes the older partograph in many settings; redefines active-phase expectations and structures intrapartum monitoring.
- NICE NG235 — Intrapartum care (2023) — care of healthy women and babies in labour; continuous support, intermittent auscultation for low-risk women, restrictive episiotomy.
- NICE NG229 — Fetal monitoring in labour (2022) — continual risk assessment; triggers for continuous CTG (meconium, pyrexia ≥38°C, bleeding, oxytocin, tachysystole >5 in 10 / contractions >2 min).
- RCOG GTG 52 — Prevention and Management of Postpartum Haemorrhage — AMTSL and PPH management.
- WOMAN trial (Lancet 2017) — tranexamic acid 1 g IV within 3 hours of PPH onset reduces death from bleeding.
- E-MOTIVE bundle (NEJM 2023) — calibrated-drape early detection plus the MOTIVE response reduces severe PPH.
- Saving Mothers / NCCEMD (latest triennium) — obstetric haemorrhage and hypertension as leading, often avoidable, SA maternal deaths; the case for disciplined intrapartum care.