How is the first-stage of labor managed?

Updated: Jan 24, 2019
  • Author: Sarah Hagood Milton, MD; Chief Editor: Christine Isaacs, MD  more...
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Cervical change occurs at a slow, gradual pace during the latent phase of the first stage of labor. Latent phase of labor is complex and not well-studied since determination of onset is subjective and may be challenging as women present for assessment at different time duration and cervical dilation during labor. In a cohort of women undergoing induction of labor, the median duration of latent labor was 384min with an interquartile range of 240-604 min. The authors report that cervical status at admission for labor induction, but not other risk factors typically associated with cesarean delivery, is associated with length of the latent phase. [38]

Most women experience onset of labor without premature rupture of the membranes (PROM); however, approximately 8% of term pregnancies is complicated by PROM. Spontaneous onset of labor usually follows PROM such that 50% of women with PROM who were expectantly managed delivered within 5 hours, and 95% gave birth within 28 hours of PROM. [39] Currently, the American College of Obstetricians and Gynecologists (ACOG) recommends that fetal heart rate monitoring should be used to assess fetal status and dating criteria reviewed, and group B streptococcal prophylaxis be given based on prior culture results or risk factors of cultures not available. Additionally, randomized controlled trials to date suggest that for women with PROM at term, labor induction, usually with oxytocin infusion, at time of presentation can reduce the risk of chorioamnionitis. [40]

According to Friedman and colleagues, [6] the rate of cervical dilation should be at least 1 cm/h in a nulliparous woman and 1.2 cm/h in a multiparous woman during the active phase of labor. However, labor management has changed substantially during the last quarter century. Particularly, obstetric interventions such as induction of labor, augmentation of labor with oxytocin administration, use of regional anesthesia for pain control, and continuous fetal heart rate monitoring are increasingly common practice in the management of labor in today’s obstetric population. [41, 42, 20] Vaginal breech and mid- or high-forceps deliveries are now rarely performed. [43, 44, 45] Therefore, subsequent authors have suggested normal labor may precede at a rate less rapid than those previously described. [8, 9, 20]

Data collected from the Consortium on Safe Labor suggests that allowing labor to continue longer before 6-cm dilation may reduce the rate of intrapartum and subsequent cesarean deliveries in the United States. [46] In the study, the authors noted that the 95th percentile for advancing from 4-cm dilation to 5-cm dilation was longer than 6 hours; and the 95th percentile for advancing from 5-cm dilation to 6-cm dilation was longer than 3 hours, regardless of the patient’s parity.

On admission to the Labor and Delivery suite, a woman having normal labor should be encouraged to assume the position that she finds most comfortable. Possibilities including walking, lying supine, sitting, or resting in a left lateral decubitus position. Of note, ambulating during labor did not change the progression of labor in a large randomized controlled study of >1000 women in active labor. [47]

The patient and her family or support team should be consulted regarding the risks and benefits of various interventions, such as the augmentation of labor using oxytocin, artificial rupture of the membranes, methods and pharmacologic agents for pain control, and operative vaginal delivery (including forceps or vacuum-assisted vaginal deliveries) or cesarean delivery. They should be actively involved, and their preferences should be considered in the management decisions made during labor and delivery. [2]

The frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position should be assessed periodically to evaluate the progression of labor. Although progression must be monitored, vaginal examinations should be performed only when necessary to minimize the risk of chorioamnionitis, particularly in women whose amniotic membrane has ruptured. During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions. In most labor and delivery units, the fetal heart rate is assessed continuously. [3]

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