Normal labour and delivery

• Normal labour is the process that begins with regular, progressive contractions producing cervical change, continues with fetal descent and birth, and ends with delivery of the placenta, at term, in a singleton pregnancy with a cephalic, well-grown baby and no major complication. ^[1]
• The cardinal movements are the mechanical steps the fetal head and shoulders make to fit through the birth canal: engagement, descent, flexion, internal rotation, extension, external rotation and expulsion.
• Labour has three stages: first stage (cervix opens to 10 cm), second stage (baby is born) and third stage (placenta and membranes are delivered). ^[1]
• Long-standing guidance asks for companionship, mobility, hydration, analgesia and emotional support throughout, with one-to-one midwifery care whenever labour is established. ^[1][2]
• Monitoring is structured: observations of mother and baby are recorded on a partogram or, increasingly, the WHO Labour Care Guide, which FIGO endorsed in 2025 as the successor to the classical partograph. ^[1][5]
• Active management of the third stage lowers the risk of postpartum haemorrhage and is a package of care: uterotonic, controlled cord traction after the placenta has separated and cord clamping timed between about 1 and 5 minutes after birth. ^[1]
• Immediate care favours keeping mother and baby together, skin-to-skin, warm, with the baby offered the breast within the first hour and given vitamin K prophylaxis. ^[1]

By the end of this page you should be able to:

1. Define normal labour and name its three stages.
2. Describe the cardinal movements and why an occiput anterior position is favoured.
3. Explain the care and observations expected during each stage of labour.
4. Explain when and how to use a partogram or the WHO Labour Care Guide.
5. Manage the third stage actively and physiologically, including the timing of uterotonic, cord clamping and controlled cord traction.
6. Give immediate care to the baby and the mother after an uncomplicated vaginal birth.
7. State the key postpartum haemorrhage thresholds used by the RCOG and NICE.

Normal labour is a spectrum, not a fixed speed. What makes it normal is not a particular number of centimetres per hour but continued progress with normal observations and a well baby.

Labour only works because the fetal head and shoulders turn as they descend. These are the cardinal movements, taught in order of appearance:

1. Engagement. The widest part of the fetal head (usually the biparietal diameter) passes through the pelvic inlet.
2. Descent. The whole fetus moves downward through the canal, helped by uterine contractions and maternal pushing in the second stage.
3. Flexion. The chin tucks onto the chest as the head descends against the pelvic floor, reducing the presenting diameter.
4. Internal rotation. The occiput rotates from transverse or posterior to anterior under the pubic symphysis, bringing the longest diameter of the head into the widest diameter of the pelvis.
5. Extension. Once the occiput is under the symphysis, the head extends and the face, brow and vertex are born.
6. External rotation. The head turns back, realigning the shoulders so the anterior shoulder slips under the symphysis.
7. Expulsion. The posterior shoulder and then the rest of the body are born.

The occiput anterior position is favoured because it uses the widest pelvic diameters for the head and the narrowest presenting diameter for the shoulders. An occiput posterior position can still be normal, but it tends to produce a longer labour with more back pain; an ultrasound of the head position may clarify what is happening when examination is uncertain.

• First stage: from the onset of regular contractions producing cervical change to full dilatation (10 cm). It divides into the latent phase (cervical change up to 4 cm) and the established first stage (progressive dilatation from 4 cm). ^[1]
• Second stage: from full dilatation to the birth of the baby. It has a passive phase (no pushing while the head descends and rotates) and an active phase when the woman pushes or the baby is visible. ^[1]
• Third stage: from the birth of the baby to delivery of the placenta and membranes. ^[1]

Under NICE guidance the length of the established first stage varies between women: first labours last on average 8 hours and are unlikely to last over 18 hours, while second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours. ^[1]

Labour care is continuous. NICE recommends that all women be supported by the same principles, in whatever setting they give birth: ^[1]

• One-to-one care: established labour should not be left unattended except for short periods or at the woman's request. ^[1]
• Communication: clear, plain language, confirmation of understanding, use of interpreters when needed, and the woman placed at the centre of decisions. ^[1]
• Respect: a calm, confident, professional approach, personal space, privacy, dignity and permission to accept or decline care. ^[1]
• Position and mobilisation: encouragement to move and adopt any position found comfortable, except lying flat on the back. ^[1]
• Support: the presence of birth companions of her choice. ^[1]
• Hygiene: tap water may be used if cleansing is needed before vaginal examination and routine hand hygiene and single-use gloves are sufficient. ^[1]

NICE recommends explaining that the woman should drink during labour when thirsty, and that isotonic drinks may be more beneficial than water; there is no benefit to drinking more than normal, and overconsumption may be harmful. Ketonuria alone is not an indication for intravenous fluids in women without diabetes. ^[1] Bladder care is reviewed at least every 4 hours, including frequency of passing urine, bladder sensation and fluid balance monitoring when sensation is abnormal, when intravenous fluids or oxytocin are given, or when output is a concern; a positive fluid balance of 1500 ml or more, or clinical concern such as symptoms of hyponatraemia, should trigger an obstetric review and a sodium level, where hyponatraemia is a sodium level less than 130 mmol/L. ^[1] Emptying the bladder matters, because a full bladder can impede descent and prevent the uterus contracting well.

In the latent phase the emphasis is support: explanation of what to expect, pain relief, movement, oral intake, companionship and avoidance of unnecessary intervention while the cervix is under 4 cm. ^[1]

Once labour is established, assessment follows a set pattern. NICE recommends that a vaginal examination gathers the station and position of the presenting part, caput or moulding, effacement, dilatation and membranes, and that examinations are performed only when they add information, with the woman's consent and awareness that she may decline or stop at any time. ^[1]

Hourly risk assessments screen for transfer to obstetric-led care. Red flags include a raised maternal pulse on two readings, blood pressure 160 systolic or 110 diastolic on a single reading or 140 over 90 on two readings, respiratory rate under 9 or over 21, raised temperature on readings, fresh red bleeding, meconium, confirmed delay, request for regional analgesia, non-cephalic or high presenting part, suspected fetal growth problems and abnormal fetal heart rate patterns. ^[1]

The woman may eat a light diet in established labour if she wishes, unless opioids have been given or a risk of caesarean birth has developed. Food and drink decisions are made with the woman rather than being restricted routinely. ^[1]

If the waters break more than 24 hours before established labour begins, or if meconium is present, the woman is offered assessment and, where appropriate, transfer to obstetric-led care, with discussion of continuous cardiotocograph monitoring and the need for staff trained in advanced neonatal resuscitation. ^[1]

A partogram is the pictorial record NICE still asks for once labour is established: it plots cervical dilatation, descent of the fetal head and maternal and fetal observations over time. ^[1] Its original alert and action lines were built on the idea that the cervix should dilate about 1 cm an hour. That expectation has not stood up to modern data, where healthy women often take longer than an hour per centimetre early in the active phase, and a systematic review found the alert line did not reliably predict adverse birth outcomes. ^[1]

The WHO Labour Care Guide, published as a user's manual in 2021, is the successor tool. It records fetal heart rate, liquor colour, cervical dilatation, descent, contraction pattern, maternal pulse, blood pressure, temperature, urine protein and volume and supportive care, but frames progress as an individual assessment rather than a straight line on a graph. ^[3] In 2025 FIGO issued a position statement recommending universal adoption of the WHO Labour Care Guide, formally endorsing it as the replacement for the classical partograph. ^[5]

The second stage is defined in NICE guidance as the interval from full dilatation to birth. There is a passive second stage (full dilatation without pushing or before it) and an active second stage (pushing or the baby visible). When regional analgesia is in place and there is no urge to push and the head is not visible, pushing may be delayed by 1 hour for a multiparous woman and up to 2 hours for a nulliparous woman before active pushing is encouraged. ^[1]

Observations of mother and baby continue as in the first stage, with the frequency of fetal monitoring increased. Vaginal examination is offered hourly in the active second stage, or in response to the woman's wishes, and includes position and descent of the head, caput and moulding. The woman is encouraged to adopt any position she finds comfortable other than lying flat, because lying on her back can lower blood pressure and reduce placental blood flow; upright positions and keeping mobile may reduce fetal heart rate abnormalities and episiotomy rates and improve the experience of birth. ^[1]

Pushing choices follow the clinical picture: spontaneous pushing may shorten the active second stage compared with directed pushing, and if directed pushing is used, pushing while exhaling may shorten it for multiparous women. Continuous cardiotocograph monitoring is used during establishment of regional analgesia and after each bolus of 10 ml or more. ^[1]

Birthing pools are an analgesic option; the water temperature should not exceed 37.5 C and is monitored hourly along with the woman's temperature, and women who have received an opioid should not enter water within 2 hours or while drowsy. ^[1]

The third stage is the time from birth of the baby to expulsion of the placenta and membranes. ^[1]

• Active management is a package: routine uterotonic drug, clamping and cutting the cord after separation and controlled cord traction after signs of placental separation. ^[1]
• Physiological management uses no routine uterotonic, no clamping until pulsation stops or until after placental delivery, and delivery of the placenta by maternal effort or spontaneously. ^[1]

Both are offered to women after full discussion of benefits and risks. Active management is associated with fewer women having bleeding over 500 ml, less need for blood transfusion and less postpartum anaemia, while physiological management is associated with fewer drug side effects such as nausea and vomiting. ^[1]

For active management after vaginal birth, administer 10 units of oxytocin by intramuscular injection, or 5 units by slow intravenous injection over 3 to 5 minutes for women who have received oxytocin during labour, or 5 units of oxytocin plus 500 micrograms of ergometrine by intramuscular injection as a single injection (advised when risk factors for postpartum haemorrhage increase the risk). The uterotonic is given immediately after birth of the baby and before the cord is clamped and cut. ^[1]

Because oxytocin plus ergometrine causes more nausea and vomiting than oxytocin alone, offer an antiemetic such as cyclizine if it is used. Ergometrine is contraindicated in severe hypertension, pre-eclampsia, eclampsia and severe cardiac, hepatic or renal disease. ^[1]

For women who have had a caesarean birth, carbetocin by slow intravenous injection is offered for prevention of postpartum haemorrhage. ^[1]

After the uterotonic is given, clamp and cut the cord, but do not clamp earlier than 1 minute after birth unless there is concern about the cord or the baby has a heart rate below 60 beats a minute that is not getting faster, and clamp before 5 minutes so that controlled cord traction can be performed as part of active management. If the woman asks for the cord to be clamped later than 5 minutes, support her choice. Record the timing of cord clamping in both active and physiological management. ^[1]

Controlled cord traction is performed as part of active management only after oxytocin has been given and signs of placental separation have appeared. Do not use umbilical oxytocin infusion or prostaglandins routinely in the third stage. ^[1]

Diagnose a prolonged third stage if it is not completed within 30 minutes with active management or 60 minutes with physiological management. ^[1]

If the placenta is retained, secure intravenous access and explain why it is needed. Do not use umbilical vein agents, and do not use intravenous oxytocic agents routinely, although they should be given if the woman is bleeding excessively. A vaginal examination is offered to assess whether manual removal is needed, with adequate analgesia; manual removal is not carried out without anaesthesia, without the woman's consent or without appropriate expertise available. If the woman is not already in an obstetric unit when retention is diagnosed, arrange transfer. ^[1]

The RCOG defines primary postpartum haemorrhage as the loss of 500 ml or more of blood from the genital tract within 24 hours of birth. Blood loss of 500 to 1000 ml is minor; more than 1000 ml is major (1000 to 2000 ml moderate, more than 2000 ml severe). ^[4] In active management the uterotonic is the single most important step; the NICE evidence shows that about 120 women per 1000 fewer bleed over 500 ml when active rather than physiological management is used. ^[1]

Women with risk factors for postpartum haemorrhage (previous loss over 1000 ml, placenta accreta spectrum, pre-eclampsia, haemoglobin under 85 g/L at labour, BMI over 35, and others) should give birth in an obstetric unit, where more treatment options are available. ^[1]

The newborn is adapted to life outside the uterus through a series of simple, standard steps, timed from the moment of birth. ^[1]

Record the Apgar score at 1 minute and at 5 minutes for all births. When assessing colour, look at the mucous membranes and tongue for central oxygenation and the nail beds for peripheral oxygenation. Record the time from birth to the onset of regular respirations; these early assessments continue until the baby's condition is stable. ^[1]

If a baby is born in poor condition, follow neonatal resuscitation guidance appropriate to local accreditation and take paired cord blood samples for blood gas analysis after double clamping, continuing evaluation until the baby is improved. ^[1]

Dry the baby and cover with a warm blanket while maintaining skin-to-skin contact with the woman whenever possible. If the woman is not well, encourage the birth companion to hold the baby skin-to-skin instead. ^[1] The head must be supported so that the airway stays open during skin-to-skin contact, and parents should be shown how to maintain this. ^[1]

Encourage skin-to-skin contact as soon as possible, keep separation to a minimum during the first hour except for necessary immediate care or at the woman's request, and encourage initiation of breastfeeding as soon as possible, ideally within the first hour. ^[1]

Offer parents vitamin K prophylaxis to prevent vitamin K deficiency bleeding, explaining that this is a rare but serious and sometimes fatal disorder. It works best as an intramuscular injection; if parents decline injection, oral vitamin K may be given according to the manufacturer's instructions, which may require multiple doses including after discharge. ^[1]

Head circumference and birth weight are recorded and plotted on centile charts. Body temperature is checked and an initial examination looks for major physical abnormality. Babies born to mothers who took SSRI or SNRI antidepressants during pregnancy need additional monitoring, because of a small increased risk of persistent pulmonary hypertension of the newborn or neonatal withdrawal symptoms. ^[1]

A second clamp for double clamping should be available in all birth settings. ^[1] If a baby needs basic resuscitation, start with air, following nationally accredited guidelines. Staff caring for women in birth settings should attend neonatal resuscitation training annually. ^[1]

The minutes after birth are a time of bonding and recovery, and all care should minimise separation of mother and baby. ^[1]

In the third stage and immediately after, record the woman's general physical condition (colour, respiration, how she feels herself) and vaginal blood loss. Observations of mother and baby continue with the same red-flag screen used in labour. ^[1]

Good care includes:

• checking uterine tone and fundal height and rubbing up a contraction if the uterus is soft or bleeding increases;
• assessing blood loss and keeping any soaked pads visible;
• emptying the bladder and offering fluids;
• inspecting the perineum and carrying out any repair with adequate anaesthesia;
• gentle encouragement to eat, drink and mobilise as able;
• monitoring temperature, pulse and blood pressure.

If postpartum haemorrhage, a retained placenta or maternal collapse develops, observations become frequent and transfer to obstetric-led care is arranged, respecting that multiple risk factors increase urgency. ^[1]

• A printed partogram or the WHO Labour Care Guide, kept up to date by the skilled attendant, is the cheapest safety net and makes slow progress or deterioration visible before it becomes dangerous.
• Companionship, mobility, oral fluids when thirsty, pain relief offered respectfully, warmth for mother and baby, and an empty bladder should be routine. ^[2]
• Delayed cord clamping between 1 and 5 minutes is possible wherever there is a safe place for the baby; vitamin K should be given by injection as soon as supplies allow.
• A clean warm delivery area, and clarity in advance about when to transfer, matter more than sophisticated technology.
• Services should train all birth attendants annually in neonatal resuscitation, and ensure a second clamp is available in every setting. ^[1]

NICE, WHO and RCOG all aim for normal birth, but they illuminate different parts of the same care. NICE NG235, last updated June 2026, is a detailed, setting-specific guideline for term, healthy women, covering the whole continuum of intrapartum and immediate postnatal care with precise observations and timings. ^[1] WHO's 2018 recommendations bring together new and existing guidance into a single global package for good-quality, evidence-based care in any setting. ^[2] The WHO Labour Care Guide then translates the active-phase philosophy (start of the active phase at about 5 to 6 cm, individualised assessment, thresholds not treated as deadlines) into a monitoring tool; FIGO has now endorsed that tool in place of the old partograph. ^[3][5] The RCOG guide on postpartum haemorrhage supplies the standard definition and stratification of bleeding that every clinician uses when a third stage goes wrong. ^[4]

Where numbers differ between authorities it is usually because they define the same concept differently (the start of the active phase, for example) rather than because one is wrong. The plan for an individual labour should follow the guideline the service uses and the woman's preferences, documented and revisited.

Normal labour and delivery connects to labour stages and failure to progress, obstetric analgesia and anaesthesia, antepartum fetal surveillance, amniotic fluid disorders, shoulder dystocia and postpartum haemorrhage care on MedGrasp. '@