This chapter should be cited as follows:

Harrington, L, Glob. libr. women's med.,

(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10127

Update due

Normal Labor and Delivery

AUTHORS
Lisa Harrington, CNM, MPH, MSN, MA
Nurse Midwife, Columbia Hospital for Women; Nurse Manager, Prenatal Diagnostic Center,
Perinatology Research Branch, NICHD, Georgetown University Medical Center; Adjunct Faculty,
Georgetown University School of Nursing, Washington, DC

INTRODUCTION
In the last 25 years there has been a steady increase in the rate of cesarean births, from 5.5%
in 1970, to approximately 25% in 1995.1 This increase has occurred as a result of changes in
the management of several factors, including malpresentation, fetal distress, prior cesarean
section, and dystocia. The increase in the cesarean section rate has not been a major
contributing factor in decreasing the perinatal mortality rate, which has occurred during the
same period of time. In view of this increase in the cesarean section rate, it is essential that all
medical personnel participating in the care of a laboring patient have a complete knowledge of
the principles of management of normal labor and delivery. This knowledge will help prevent
the necessity for cesarean sections by optimizing the care of laboring patients.
In this chapter we review the process of normal labor and delivery. The definition and etiology
of labor are presented, followed by a discussion of the course of normal labor. A discussion of
alternate approaches of labor management and controversial issues is also included.

DEFINITION OF LABOR
Labor is defined as the presence of regular uterine contractions with progressive cervical
dilation and effacement. During the last month of gestation, several physiologic changes
precede the onset of labor. Most patients report an increase in the incidence of Braxton Hicks
contractions. These usually are irregular in frequency and intensity. Many nulliparous patients
have difficulty distinguishing between the increased incidence of the Braxton Hicks
contractions and the onset of early labor. Besides the irregular nature of the Braxton Hicks
contractions, they are also characterized by their origination from diverse areas in the uterus.
This contrasts with true labor, in which the contractions usually originate from the uterine
fundus and extend downward toward the cervix. It is difficult, if not impossible, to determine
the exact moment of transition from Braxton Hicks contractions to the onset of true labor.
The clinician monitors major parameters, such as the presence of changes in cervical
effacement, dilation, position, consistency, and descent of the presenting part to determine
when this transition takes place.
Concomitant with the increased frequency of contractions, the patient may perceive descent of
the fetus into her pelvis. This is referred to as lightening. This process will happen as the lower
uterine segment expands due to the increase in frequency and intensity of contractions. As
the presenting part descends into the maternal pelvis, it can apply significant pressure onto
the sacrum and can exacerbate any chronic lumbosacral pain, or even originate such
problems. Some patients experience sciatic nerve pain secondary to this anatomic change of
pregnancy. In addition, lightening results in increased pressure on the maternal bladder, thus
increasing the symptoms of urinary frequency.
The cervical changes associated with early labor involve the process of effacement, in which the
cervix is incorporated into the lower uterine segment. This forces the cervical mucous plug out
of the cervix. This plug consists of a tenacious mucous produced by the hypertrophied
endocervical glands. It serves as both a mechanical and immunologic barrier to any ascending
pathogens from the vagina. During the process of cervical effacement and dilation, some
capillary blood vessels will rupture. This small amount of bleeding will give a bloody
appearance to the mucous plug. This is commonly referred to as the “bloody show.” In the
presence of regular contractions and effacement, the passage of the bloody show should be
considered an indication of the onset of labor.2

PHYSIOLOGY
There is no universal agreement about the series of events that triggers the onset of human
parturition. Although several mechanisms have been postulated, what follows is a recently
described theory that incorporates most of the factors that have been identified as possible
causes of the onset of labor.3,4,5
During the last trimester of pregnancy, the process of cervical growth and remodeling is
accelerated. This process is under the influence of the placental hormones and relaxin.
Prostaglandin E2 (PGE2) acts synergistically with these substances to promote cervical change.
At the end of gestation there is increased production of PGE2. Concomitantly, there is an
increase in the production and concentration of oxytocin receptors. The number of receptors
increases with uterine distention. This also causes an increase in the number of myometrial
gap junctions. As a result of these last two events, there is an increased response by the
myometrium to the oxytocin pulses secreted by the posterior pituitary, which then causes an
increase in the frequency and intensity of the contractions. This generates greater pressure
and tension on the cervix, which further increases the production of PGE2. This is followed by
an increasing frequency of oxytocin pulses that increases the frequency of contractions. The
decidua then responds to the oxytocin by releasing PGF2a, which increases the response to
oxytocin by the myometrium.
At this point, maturational changes in the placenta and fetus cause the release of a diverse
number of substances from several organs. This includes epidermal growth factor, platelet-
activating factor, adrenocorticotropic hormone, stress hormones, vasopressin, and increased
amounts of oxytocin. The release of some of these substances is caused by the stress of the
transient decrease in fetal oxygenation due to the increased frequency of uterine activity. As a
result of the release of these substances, additional mobilization of arachidonic acid from the
uterine phospholipids occurs. This causes an increase in the release of prostaglandins from
the placental membranes during the contractions. This, in turn, is a further stimulus for
increased uterine activity. In this way, this process creates a continuous cycle of activity that
results in the development of labor.

MANAGEMENT OF LABOR

Admission to Labor and Delivery

A patient who presents to a labor and delivery unit with symptoms of labor should have a
thorough and systematic evaluation. The evaluating clinician should first make a rapid
assessment of the clinical situation. If there are no signs of an obstetric emergency (e.g.,
vaginal bleeding, severe hypertension, shock), the clinician should continue with a careful
history and physical examination. A complete history should be obtained, including past
obstetric, gynecologic, medical, and surgical problems. Allergies should be noted clearly. The
social history should be evaluated for the presence of toxic habits. The family history may
suggest hereditary or multifactorial problems that could have an impact on the present
pregnancy. Any current medications and their indications must be recorded. All of these
components of the history should be obtained, even if they already were obtained and
documented during the prenatal period. If the patient had prenatal care, careful attention
should be given to any complications that may have developed (e.g., gestational diabetes,
anemia). It is customary to document any prenatal laboratory results or testing. This provides
the clinician with additional tools to evaluate the patient at the moment of admission. Any
problems identified during the history should be evaluated for any possible impact on the
course of labor, the delivery, and the neonate.
The physical examination for a patient being admitted to a labor and delivery unit should be
as thorough as that for any patient being admitted to any other acute-care ward. After the
vital signs are obtained, a systematic examination is rendered, the pelvic examination being
reserved for last. During the abdominal examination, the clinician performs Leopold's
maneuvers. This, in conjunction with the pelvic examination, allows the clinician to assess the
fetal lie, presentation, and position. Careful attention should be given to the identification of
any abnormalities, such as uterine tenderness, fibroids, or possible malpresentations. During
the abdominal examination, the clinician should assess the fetal heart tones, using either a
DeLee fetoscope or a Doppler device. If there are any difficulties obtaining the fetal heart
tones, an ultrasound examination must be performed immediately. During the pelvic
examination, the clinician assesses the type of pelvis. The cervix is palpated for the presence
of dilation and effacement. During the pelvic examination, the station of the presenting part
can be determined. The cervical examination should be plotted on graph paper (i.e., a
partogram) for serial evaluation of the progress of labor. The cervical dilation is plotted on the
vertical axis. The longitudinal axis is used to record time in hours (Fig. 1). Some partograms
include a double vertical axis, so that dilation and fetal station can be plotted simultaneously
over time (Fig. 2). By the end of the examination, the clinician should be confident of his
assessment of the fetal presentation. If not, or if any other clinical indications are present, an
ultrasound examination should be performed.

Fig. 1. Composite of the average dilatation curve for nulliparous labor.(Friedman E: Labor: Clinical

Evaluation and Management, 2nd ed. New York, Appleton-Century-Crofts, 1978)

Fig. 2. Interrelationship between descent curve ( solid line) and concurrently developing dilatation

pattern ( broken line) in nulliparous patients.(Friedman E: Labor: Clinical Evaluation and Management,
2nd ed. New York, Appleton-Century-Crofts, 1978)

Occasionally, a patient presents in advanced labor. There might not be enough time to do a
complete history and physical examination before the delivery. The clinician must make
judgments based on the clinical situation and defer parts of the admission examination to
after the delivery. No patient should be permitted to leave the labor and delivery unit without
a complete examination.
Once the patient's history and physical are obtained and recorded, an assessment of the
patient's risk status and labor situation is made so that the care of the patient can be
individualized. Each institution should have a formal designation of what type of forms will be
used for this purpose. In the United States, it is customary to obtain intravenous access on
most laboring patients, although midwife nurses will frequently abstain from doing so. Some
patients may request a heparin lock for more comfortable ambulation during early labor. If
this is the case, intravenous solutions should be started at the earliest signs of dehydration or
the development of a complication. At the same time intravenous access is obtained, a blood
sample can be obtained for a complete blood count and for a type and screen. Besides the
blood sample, a urine specimen is obtained for protein and glucose determination. If the
laboring patient did not have prenatal care, the complete panel of routine maternal prenatal
laboratory tests should be ordered. This panel can vary among institutions and types of
patient populations.
During the course of labor, the fetus is monitored by either continuous or intermittent
auscultation. In the United States, the majority of hospital births attended by physicians are
monitored electronically. Further assessment of the fetus can be obtained from the quality of
the amniotic fluid. If it is meconium stained, careful attention should be given to any abnormal
fetal heart patterns. The presence of meconium suggests the possibility of a compromised
fetus. If circumstances were to allow it, an ultrasound assessment for estimated fetal weight
would provide the clinician with helpful information to assess the clinical situation.DeLee
suctioning of the fetus at birth is essential in cases of meconium stained amniotic fluid, as is
the presence of medical personnel trained to perform neonatal intubation.
Most of the discussion on the stages of labor that follows is based on the scholarly
contributions of Friedman, who for the last four decades has documented the normal and
abnormal patterns of human labor.

FIRST STAGE.
The first stage of labor is the period of time from the onset of labor to complete cervical
dilation. This stage is divided into latent and active phases. The active phase is further
subdivided into the acceleration, maximum slope, and deceleration phases of dilation.

Latent Phase.
The latent phase is the longest of all the phases of the first stage (Table 1). It has been
determined that there is a negative correlation between the length of this phase and the
amount of cervical dilation at the moment of onset of labor.6,7 Although multiparous patients
appear to have shorter latent phases than nulliparous ones, this has not been a consistent
finding.7
TABLE 1 The Mean Duration of the Various Phases and Stages of Labor Along with Their
Distribution Characteristics

Latent Active Maximum Second

Phase Phase Dilatation Stage

(h) (h) (cm/h) (h)

Nulliparas

Mean 6.4 4.6 3 1.1

Limit* 20.1 11.7 1.2 2.9

 Latent Active Maximum Second

Phase Phase Dilatation Stage

(h) (h) (cm/h) (h)

Multiparas

Mean 4.8 2.4 5.7 0.39

Limit* 13.6 5.2 1.5 1.1

* 5th or 95th percentile.

(Modified from Friedman EA: Labor: Clinical Evaluation and Management, p23, 2nd ed. New
York, Appleton-Century-Crofts, 1978)

Active Phase.
The “transition” from the latent to the active phase is sometimes a very difficult one to
identify. Some patients have a transition of labor while manifesting increased levels of pain
and discomfort. Not infrequently, some have emesis as the cervix starts dilating at a faster
rate. This probably is due to the stimulation of vagal nerve endings present in the cervix. The
use of epidural anesthesia also makes this transition more clinically difficult to assess without
the performance of a cervical examination. Although the transition from latent to active phase
is difficult to identify, a dilation of 3 cm is accepted as the point beyond which the rate of
dilation should increase to the rate expected in the active phase7: 1.2 cm/hour in the
nulliparous patient and 1.5 cm/hour in the multiparous patient.8

Acceleration Phase.
The acceleration phase is clinically very difficult to document unless the clinician is performing
frequent serial vaginal examinations. It encompasses the period shortly before the phase of
maximum slope. In the nulliparous patient, this is compatible with a cervical dilation of 3 to 5
cm. In clinical practice, there will be a significant degree of variation in the length of this
phase.

Maximum Slope Phase.

This phase has the most rapid rate of cervical dilation during labor. It typically occurs during
dilation from 5 to 8 cm. According to Friedman,9 the plotting of the rate of dilation during this
phase reveals a linear relationship. Other authors have suggested that the labor curve during
this phase is hyperbolic.10,11 This is based on observations that reflected a constantly
increasing rate of dilation as dilation progressed. The rate of dilation during the active phase is
currently accepted to reflect a linear relationship. It is important for the clinician to be aware
that it is during this phase that the descent of the presenting part will begin.12

Deceleration Phase.
The existence of the deceleration phase has been questioned.11 The debate on its existence is
complicated by the short length of this phase, which is shorter than the length of the
acceleration phase and easily missed if the cervical examinations are done infrequently. This
phase rarely lasts more than 3 hours in a nullipara or 1 hour in a multipara. It usually extends
from 8 to 9 cm until cervical dilation is complete. The descent curve reaches its maximum slope
concomitant with the deceleration phase.13 The normal rate of descent of the presenting part
is at least 1 cm/hour in the nullipara or 2 cm/hour in the multipara.

SECOND STAGE.
The second stage of labor is the period of time from complete cervical effacement to the
delivery of the fetus. The presenting part is expected to descend at the same rate as during
the deceleration phase.

THIRD STAGE.
The third stage of labor is the period of time from the delivery of the fetus to the delivery of
the placenta. There are several signs associated with the separation of the placenta from the
wall of the uterus. The uterus becomes globular, and there is a sudden gush of blood. This is
followed by the umbilical cord's extending more toward the vagina and introitus. During this
process, some clinicians massage the uterus using the Brandt-Andrews maneuver and
maintain a steady pull on the umbilical cord. Any excessive tension on the umbilical cord could
cause evulsion of the umbilical cord from its placental insertion, requiring manual removal of
the placenta. Uterine inversion is another complication derived from overaggressive uterine
massage and excessive tension on the umbilical cord. Placenta accreta also has been
associated with this problem. If uterine inversion occurs, rapid correction of the inversion is
essential. To decrease overall blood loss, the placenta should be removed after the uterus is
returned to the abdomen. Subsequent to the correction of the inversion, uterotonic agents
should be administered. The agents typically used are methylergonovine or prostaglandins. A
more rapid action of these agents is seen if they are administered directly intramyometrially
rather than intramuscularly. Many institutions routinely use a diluted intravenous oxytocin
solution after the delivery of the placenta. Oxytocin should not, however, be administered as a
direct intravenous bolus because it is associated with hypotension.14
The signs of separation of the placenta usually become evident within 5 to 10 minutes after
birth. Classically, failure to deliver the placenta after a period of 30 minutes or more is defined
as a retained placenta. This would justify a manual removal. If the patient is not having
excessive blood loss, it is advised that the clinician wait for adequate sedation before
performing the removal. This can be accomplished with a combination of narcotics and
benzodiazepines, or under regional anesthesia if it was used for pain control during labor and
delivery. In an emergency, however, the removal may have to be performed without analgesia.
During or after the delivery of the placenta, it is important that the patient be examined for
any lacerations or hematomas. A first degree laceration involves the vaginal mucosa and
perineal skin, leaving intact the muscle and fascia. In a second degree laceration, there is
involvement of the perineal muscles but not of the rectal sphincter. A fourth degree laceration
includes involvement of the rectal mucosa. Any patient with a significant laceration requires a
pelvic examination several hours after the repair to exclude the possibility of a hematoma. In
addition, all patients who had an episiotomy or laceration at the moment of delivery, should
have a gentle manual examination of the repair and visual examination of the perineum
before being discharged from the hospital. The patient should be instructed on the warning
signs of episiotomy breakdown or infection. Table 2 describes the advantages and
disadvantages of different types of episiotomies.
TABLE 2. Advantages and Disadvantages of Different Types of Episiotomy

Midline Mediolateral

Advantages Easy to repair Extension to rectum

Better healing  or sphincter uncommon

Less painful

Smaller amount of blood loss

Disadvantages Higher risk of extension to rectum Greater amount of blood loss

More painful

Difficult to repair

Active Management of Labor

The active management of labor (AMOL), was first described in 1969 by O'Driscoll and
colleagues.2 It was originally conceived as a technique for the prevention of prolonged labor,
originally defined by the authors as more than 24 hours of labor, and in later publications as
12 hours. More recently,AMOL has been found to be a highly successful method for the
prevention of labor dystocia and operative delivery.2,16,17,18 This technique was first
implemented at the National Maternity Hospital in Dublin, Ireland, in 1968. Within the past 27
years, their total cesarean section rate has remained less than 10%.
The basic principles of AMOL involve the education of patients, attention to the accurate
diagnosis of labor, close nursing or midwife support during labor, early amniotomy, early use
of relatively high doses of oxytocin for the correction of labor abnormalities, and rigorous peer
review.
In most of the published trials on AMOL, the criterion for patient enrollment has been as
follows: term pregnancy (a minimum of 37 weeks), singleton, vertex presentation, nullipara,
and spontaneous onset of labor.16,17,18 To our knowledge, there are no peer-review published
reports documenting the use of this technique on multiparas or for induction of labor.
A very concise and clear description of the labor and delivery process is given to the patient
during prenatal care visits. She is completely familiarized with all the principles of AMOL, and
all of her doubts or concerns will have been answered before she is admitted to the labor and
delivery unit. If there are no unexpected events, the patient is expected to have less anxiety
regarding her labor, thus allowing her to develop a more comfortable attitude toward her
labor process.
When patients are more aware of their labor process, unnecessary visits to labor and delivery
for evaluation of possible labor can be prevented. In AMOL protocol, labor is defined as
regular painful contractions in a frequency of at least one every 5 minutes. In addition to this,
the patient should have at least one of the following three criteria: spontaneous rupture of
membranes, complete cervical effacement, or the passage of bloody show. The evaluation of
labor is carried out within 1 hour of the arrival of the patient to the unit. Every attempt is
made to prevent having a patient walking for a prolonged period of time while still under
evaluation for labor. If the patient does not meet the above criteria, she is encouraged to go
home and to return when the labor symptoms are more intense.
One of the most important aspects of the AMOL protocol is the close support during labor.
AMOL does not imply a more aggressive or interventional attitude toward labor, but an active
involvement and awareness of the medical personnel with the events of a laboring patient. At
the National Maternity Hospital, the nursing personnel perform duties similar to a midwife.
This is done in close collaboration with the obstetrician-gynecologist. The nurse-to-patient ratio
is 1:1. Every attempt is made to have a nurse attend a patient at all times. The nurse should
be intimately aware of the progress and status of the patient. If there are any signs of an
abnormality, she assesses the situation and consults the attending physician. Along with this,
the constant presence of the nurse provides the patient with the so-called Dulla effect. “Dulla”
refers to a constant companion of a laboring patient. This companion provides psycho-social
support, with the goal of decreasing anxiety and stress during labor. The exact mechanism of
action of the “Dulla” effect is unknown. This effect by itself has been found to be associated
with a decreased incidence of cesarean section.19 The degree of participation of nurses is not
limited only to labor management: Nurses also are permitted to deliver low-risk patients under
the supervision of the attending obstetrician. These aspects of AMOL have made it difficult to
implement in US hospitals. Several US hospitals have adopted the AMOL protocol, but not with
the same degree of success as in Ireland. It is possible that if AMOL is implemented in US
hospitals in association with midwives, it could achieve even better success.
Once the diagnosis of labor is made, an amniotomy is performed within 1 hour. Obviously,
this should not be performed if the vertex is high and unengaged. With careful attention to
the station of the vertex, the likelihood of an umbilical cord prolapse is rare.17 There are
several reasons to perform early amniotomy. It allows the clinician to assess the quantity and
quality of the amniotic fluid. The clinician would have a higher level of suspicion for the
presence of a compromised fetus if scanty and thick, meconium-stained amniotic fluid was
identified; this would also lead to a different approach to the labor management of the
patient. Moreover, although it has been a source of debate in the literature, early amniotomy
is generally considered to accelerate the labor process. A recent review20 of the literature on
the effects of routine amniotomy on labor reached several important conclusions:
The length of labor is shortened by an amniotomy, without having a significant impact on the
route of delivery.
The reduction in the total length of labor consists mostly of a reduction in the length of the
first stage of labor.
The amniotomy will be more effective in reducing the length of labor if it is performed during
the active phase of the first stage.
Because of the shorter length of labor, there is a decreased utilization of oxytocin for the
treatment of protracted labors.
Without a comprehensive labor management plan, such as AMOL,21 the amniotomy may
indeed fall short of having the impact of decreasing the incidence of cesarean deliveries. The
amniotomy may increase the incidence of intrapartum abnormal fetal heart rate patterns,
specifically variable decelerations, but this has not resulted in an increased incidence of low
Apgar scores, neonatal acidosis, or morbidity.
After the amniotomy is performed, the patient is examined hourly for 3 hours, and then every
2 hours until delivery. This frequency of examinations has not resulted in an increased
incidence of chorioamnionitis or postpartum endometritis. The goal of this close monitoring of
the labor progress is to detect any dysfunctional pattern early. It is thought that with early
detection and an attempt to correct a dysfunctional pattern of labor, there would be a higher
likelihood of successfully correcting the abnormality, thus decreasing the need for operative
delivery.
The ideal rate of progress under the AMOL protocol is 1 cm/hour during the first stage. The
second stage is expected to last no more than 2 hours. A labor pattern associated with a rate
of progress slower than this would require careful evaluation for a cause of such an
abnormality. If the etiology is thought to originate from a dysfunctional pattern of uterine
contractions, then oxytocin augmentation would be indicated.
The AMOL oxytocin augmentation protocol uses relatively higher doses compared with other
protocols currently used in clinical practice.22 The protocol consists of an initial rate of 6
mU/minute, which is increased by increments of 6 mU/minute, to a maximum rate of 36
mU/minute. The optimal frequency of contractions with this augmentation protocol is seven in
15 minutes. The major goal of the use of higher dosages of oxytocin is to correct a
dysfunctional pattern of labor before an intractable uterine dystocia becomes established. The
oxytocin augmentation is limited to a period of 6 hours. Any patient that requires longer
augmentation is thoroughly evaluated for factors other than dysfunctional uterine contractions
that could account for the labor dystocia.
The major concerns regarding this augmentation protocol have centered on the issues of
possible morbidity and mortality to either the mother or the fetus. Maternal issues include
tachysystolic and tetanic uterine contractions, placental abruption, uterine rupture, postpartum
uterine atony, and the need for transfusion. Fetal/neonatal issues include intrapartum
meconium, fetal distress, acidosis, low Apgar scores, hyperbilirubin levels, admission to the
neonatal intensive-care unit, seizures, death, and length of hospitalization. Several investigators
have reported on the lack of association between AMOL augmentation and these factors.17,23,24
The use of relatively higher levels of oxytocin for augmentation of labor is not associated with
a higher incidence of morbidity when compared with protocols that use oxytocin in a more
conservative method. Of interest, the group at the National Maternity Hospital reported on
more than 30,000 nulliparous patients who had AMOL according to the outlined protocol.24
There were no cases of uterine rupture secondary to the higher levels of oxytocin.
The use of AMOL has not resulted in a higher utilization of analgesia or anesthesia during
labor.17 Patients can have intravenous sedation and regional blocks as judged clinically
necessary.
No method of labor management or augmentation can eliminate the problem of labor
dystocia. Even with AMOL, the clinician will have to determine when the augmentation is
considered unsuccessful and an operative delivery indicated. If there is minimal or no dilation
after 1 hour of optimal augmentation during the first stage, the clinician may consider
proceeding with a cesarean section. Lack of descent after 1 hour of optimal augmentation
during the second stage in the presence of optimal maternal pushing efforts is also an
indication to proceed with an operative delivery, either vaginally or abdominally. Obviously if
the patient has an arrest of dilation or descent disorder but an adequate pattern of
spontaneous uterine contractions, the above indications for operative intervention would still
apply. Whether and when to use an intrauterine pressure monitor for assessment of a
dysfunctional labor is a clinical decision. The AMOL protocol neither requires nor excludes the
use of this type of monitoring.
It has been demonstrated that the AMOL technique results in a shorter length of total labor.
As a consequence of this, there is a decrease in the incidence of infectious problems, such as
chorioamnionitis or endometritis.17 The incidence of labor dystocia also is diminished, resulting
in a lower rate of operative delivery. This is accomplished with no increase in maternal or
neonatal morbidity. These benefits also may translate into better utilization of the resources of
the labor and delivery unit, as well as potential savings to the patient and society.

ALTERNATE OBSTETRIC MANAGEMENT MODELS: MIDWIFERY

Historically, midwives have managed and attended the majority of births and have had
primary responsibility for the care of mothers and infants through the perinatal period. Nearly
75% of all births in third-world countries are attended by women whom the World Health
Organization (WHO) has termed traditional birth attendants (TBA).25 The WHO has actively
promoted TBA training by professional midwives for the purpose of more efficient utilization
of health-care services to improve maternal and infant mortality rates. This model allows
obstetricians to focus on the care of complicated pregnancies.
Professional midwives (many of whom are nurse-midwives) attend up to 75% of all births in
European nations. In the past few years in the United States, midwives (predominantly nurse-
midwives) have attended a small, but growing, number of births (4%).26,27 All of the countries
with infant mortality rates that are lower than US rates utilize midwives as the principal birth
attendants. In addition, the majority of the 18 industrialized nations with cesarean rates that
are lower than US rates utilize midwives as primary caregivers for low-risk pregnant women.
Universal access to prenatal care, primarily provided by midwives, is also a shared
characteristic of the industrialized countries whose cesarean and infant mortality rates are
lower than those of the United States.
The salient characteristics common in midwifery models of care include the use of minimal
technology, time-intensive supportive care, the encouragement of maternal ambulation and
multiple positions for labor and delivery, the minimal use of routine episiotomies and routine
intravenous hydration, and the liberal use of comfort measures (massage, hydrotherapy,
position change) to reduce the need for obstetric analgesia or anesthesia. The literature
demonstrates that this model of management of normal labor and delivery is associated with
lower rates of cesarean section, decreased rates of episiotomies and third- or fourth-degree
lacerations, and infant morbidity and mortality rates comparable to or lower than those for
similar low-risk populations managed by physicians. A study comparing labor-and-delivery
management between nurse-midwives and family physicians showed that, despite similar
management styles, nurse-midwives were more likely to facilitate a vaginal delivery and to do
so without an episiotomy.28

Impact of Low Technology and Time-Intensive Supportive Care

The American College of Nurse-Midwives (ACNM), the national credentialing organization for
US nurse-midwives, developed the ACNM Position Statement on the Appropriate Use of
Technology in Childbirth,29 which describes the philosophy guiding the practice of most
midwives:

The practice of nurse-midwifery encourages continuity of care; emphasizes safe,

competent clinical management; advocates nonintervention in normal processes; and
promotes health education for women throughout the childbearing cycle.
In order to achieve the optimal outcome for the mother and/or infant at risk for
conditions that deviate from normal, the ACNM supports the use of appropriate
technological interventions where the benefits of such technology outweigh the risks.
When interventions are used, their benefits and risks should be thoroughly explained to
the woman, and an attempt should be made to adapt such interventions to her social
and cultural practices.
The ACNM recognizes the role of the certified nurse-midwife (CNM) within the health
care team and supports continuation of nurse-midwifery care within the team when
technology is indicated.

One of the hallmarks of midwifery management is time-intensive supportive care, which has
been shown to be associated with lower rates of labor abnormalities, cesarean sections, and
fetal distress.30 This is consistent with earlier studies by Sosa and co-workers,31 which
demonstrated shortened labor and lower rates of intervention in patients who had a
supportive companion throughout labor. Midwifery management involves encouragement of
active involvement of birth companions chosen by the patient, as well as frequent supportive
midwifery interactions.
Several major studies involving birth center management (both in and out of hospitals) have
evaluated the characteristics and effects of the midwifery model of care. Fullerton and
Severino32 compared groups of women who were cared for principally by nurse-midwives in
hospital and freestanding birth-center settings; even when controlling for complications and
sociodemographic differences, they found that women in hospitals were more likely to receive
an interventive style of labor and delivery management. Both groups had similar low rates of
neonatal and maternal morbidity, but the incidences of sustained fetal distress, prolapsed
cord, and difficulty in establishing neonatal respirations were significantly greater in the
hospital sample. The National Birth Center Study33,34 involved 11,814 women admitted for
labor and delivery to 84 freestanding birth centers in the United States. CNMs provided care
during 78.6% of the labors and attended 80.6% of the births. Birth-center care deviated from
hospital-based medical management care in that women were much less likely to receive
narcotics, anesthesia, continuous electronic fetal monitoring, induction of labor, augmentation
of labor, intravenous infusions, amniotomies, and episiotomies. In addition, relatively few
vaginal examinations were performed, and the patients were more likely to be permitted to
use a variety of birthing positions, to eat solid or clear food, and to take showers or baths
during labor. The rate of cesarean section was 4.4%. There were no maternal deaths. The
overall intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of low
Apgar and infant mortality were comparable to those reported in large studies of low-risk
hospital births.
Greulich and colleagues35 reported on more than 30,000 nurse-midwife—attended births at
the Los Angeles County/University of Southern California Women's Hospital, in which expectant
midwifery management was the norm. Their findings are highlighted as follows:
  Intrapartum maternal or neonatal deaths: 0%
  Overall cesarean section rate: 1.8%
  Vaginal operative birth rate: 4%
  Unmedicated births: 93%
  Births resulting in an intact perineum: 57.2%
  Episiotomies: 5%
  Births resulting in third- or fourth-degree lacerations: 1.8%
  Neonates with a 5-minute Apgar score of less than 8: 0.4%.
The transfer rate to medical management from 1985 to 1992 was 13.1%, the most common
indication being failure to progress and the consequent requirement of oxytocin
augmentation. The patients who were transferred from a midwife to a physician's care service
at the same institution were not included in the statistics provided by Greulich and colleagues.
Midwifery management advocates the liberal use of intermittent external fetal monitoring
when one-to-one staffing permits. Several randomized clinical trials have not supported the
routine use of continuous electronic fetal monitoring in low-risk pregnancies. Often, an initial
20-minute fetal heart rate tracing is obtained at admission to evaluate whether there is any
evidence of fetal stress.

Maternal Ambulation and Position

Research has shown that maternal position effects the frequency and intensity of uterine
contractions during labor. Caldeyro-Barcia and colleagues36 demonstrated that lateral positions
were associated with more effective uterine contractions (i.e., stronger intensity and lower
frequency) than the supine position; this effect was more marked in spontaneous labor
compared with oxytocin-induced labor. The influence of position change on maternal
hemodynamic changes also has been studied. There is evidence that lateral positions are
associated with a higher cardiac output, decreased heart rate, and increased stroke volume
compared with the supine position.37 Several reports indicate that intrapartum ambulation
may improve labor. A randomized trial of ambulation versus oxytocin for labor enhancement38
indicated that, in relation to labor progress and initial effects on uterine activity, ambulation
can be as effective as oxytocin in stimulating labor. Squatting has been advocated to increase
the diameter of the pelvic outlet by as much as 2.0 cm, to increase the bearing-down urge, to
facilitate the delivery of the placenta, and to prevent supine hypotensive syndrome. In
addition, standing, kneeling, squatting, and lateral positions have been associated with
maintaining an intact perineum. This results from a more even application of the fetal head at
the introitus, which distributes pressure across the perineum, rather than concentrating the
pressure at a single point. In the absence of maternal or fetal contraindications, Roberts39
described a current consensus in the literature supporting the advantages of upright positions
in early labor; he advised that prolonged use of recumbent positions be minimized and that
lateral, Sims, hands and knees, and supported squatting positions be considered for labor and
delivery. Maternal comfort and preferences should be given priority when positions for labor
and delivery are recommended. Unfortunately, the use of regional anesthesia during labor
(epidural) can significantly limit the ambulation capabilities of the laboring patient. Similarly,
high-risk patients may not be able to ambulate because of the need for continuous fetal or
maternal monitoring.

Alternatives to Analgesia/Anesthesia in Pain Management

Thorp and associates40 undertook a randomized, controlled prospective trial to determine the
effect of epidural anesthesia on nulliparous labor. Women were randomized to receive either
narcotic or epidural anesthesia in early spontaneous labor. The study demonstrated a
significant prolongation in the first and second stages of labor and a significant increase in the
frequency of cesarean delivery. A recent meta-analysis published by Morton and co-workers41
strongly supported previous findings that a significant increase in cesarean delivery is
associated with epidural anesthesia use. These results support the evidence that one factor
leading to the decreased incidence of cesarean section in midwifery-managed patients lies in
the lower rates of epidural use among midwifery patients. Petrie and colleagues42 presented
evidence of increased uterine activity over time in unmedicated labor; they also discussed the
depressant effect of narcotic administration on uterine activity. These studies support the
predominant style of midwifery management of normal labor, which optimizes uterine
effectiveness while minimizing risks through a minimal use of anesthesia and analgesia.
There has been a dearth of literature investigating the effect of alternative methods for pain
management in labor. Specific areas of interest involve the effects of acupuncture,
acupressure, and water immersion (hydrotherapy) on labor. Several investigators43,44 have
reported beneficial effects in pain management in labor afforded by hydrotherapy. Water
temperatures of less than 100°F are recommended. Conflicting evidence exists regarding the
effects of warm water immersion on labor progress. Most studies demonstrated no evidence
of increased maternal, neonatal, or infectious morbidity. There have been few case reports of
neonatal death in water immersion at delivery when the infant was not immediately brought
to the surface; however, no neonatal deaths have been reported in the literature when water
immersion was utilized in labor alone. Because of the lack of published randomized, controlled
clinical trials, caution is recommended when any of the above methods are attempted.

CONTROVERSIAL ISSUES
Fluids in Labor: Should Intravenous Hydration Be Used Routinely?
Fasting in labor has been an established practice throughout the United States since the
1940s. The major reason for this approach is the increased gastric emptying time that is
present during labor. A laboring patient with a full stomach is at risk of developing an
aspiration pneumonia secondary to vomiting during intubation for the administration of
general endotracheal anesthesia. The questioning of routine intravenous hydration has arisen,
in part, because of the decreased use of general anesthesia for deliveries and the increased
use of regional anesthesia.45 Nevertheless, aspiration pneumonia remains the main cause of
anesthesia-related deaths. It should be noted that fasting does not guarantee prevention of
emesis and aspiration.

Episiotomies: Should They Be Used Routinely to Reduce the Occurrence

of Perineal Lacerations?
Episiotomy is one of the most common surgical procedures in Western medicine. Thacker and
Banta46 published an extensive literature review describing the benefits and risks of
episiotomy as known up to 1983. The authors reported that there was no clearly defined
evidence supporting the efficacy of episiotomies, especially with respect to routine use. They
provided evidence that postpartum perineal pain and lacerations involving the anus may be
increased after episiotomy and that serious complications, such as maternal morbidity, can
result from the procedure. They did note, however, the need for randomized prospective trials
to determine the risks and benefits of episiotomy more conclusively.
Episiotomies are performed in more than 60% of vaginal deliveries in the United States.
Episiotomy rates associated with midwifery management are significantly decreased, ranging
from 5% to 26%.33,35 Goodlin47 described one technique utilized primarily by midwives to
maintain an intact perineum and to prevent injury to the fetal head:

In watching certified midwives assist many births, it was apparent that they did not
usually employ the modified Ritgen maneuver. Instead they kept the vertex flexed,
allowing extension of the fetal vertex only in the final stages of birth of the head.

Another technique is to provide supportive direction to the mother to facilitate controlled

deliveries. Recent studies have confirmed that midline episiotomies are associated with an
increased risk for anal sphincter damage, especially in the event of operative deliveries.48,49 In
response to studies advocating restrictive use of episiotomies (i.e., only to expedite the birth of
a distressed infant) over liberal use (i.e., in an attempt to prevent perineal tearing), there
appears to be evidence of declining overall rates of episiotomy use.34

CONCLUSIONS
There is no universal approach to the management of normal labor and delivery. Alternate
management protocols that address the problem of labor dystocia should be considered as
possible solutions to the high cesarean section rate. A common point of these alternate
protocols is a more stringent criterion for the diagnosis of labor and a strong emphasis on
providing supportive care. This minimizes the possibility of unnecessary interventions in early
labor that could be the origin of iatrogenic dystocia. Any labor management protocol must
maintain a reasonably low incidence of maternal and neonatal morbidity for it to be
acceptable.
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