Labor is divided into four distinct stages, each playing a crucial role in the birth process:

• First Stage: Begins with the onset of labor and continues until full cervical dilation (10 cm). This stage includes latent and active phases, with contractions becoming stronger and more frequent.
• Second Stage: Starts from full cervical dilation to the birth of the baby. The mother experiences the urge to push, leading to the expulsion of the fetus.
• Third Stage: Covers the period from birth of the baby to the delivery of the placenta and membranes. Proper management at this stage helps prevent postpartum hemorrhage (PPH).
• Fourth Stage: The first hour after placenta expulsion, a critical period for maternal monitoring, ensuring uterine contraction, stable vital signs, and early detection of complications.

The first stage of labor is a crucial period during which cervical dilatation and uterine contractions prepare the mother for delivery. To ensure labor progresses safely, healthcare providers rely on the Partograph, a World Health Organization (WHO)-recommended tool designed to monitor and assess labor patterns. Proper use of the partograph helps identify complications early and supports timely clinical decision-making, improving outcomes for both mother and baby.

The partograph provides a visual representation of key labor indicators, including cervical dilatation, fetal heart rate, uterine contractions, and maternal vital signs. This structured approach allows healthcare workers to determine whether labor is progressing normally or showing signs of deviation that may require intervention. A key feature of the partograph is its alert and action lines. The alert line represents the expected rate of cervical dilation – typically 1 cm per hour during active labor – while the action line, positioned four hours to the right, signals the need for clinical intervention if crossed. The use of the partograph begins once the cervix reaches 5 cm dilatation, marking the onset of active labor.

Regularly updating the partograph is essential in identifying prolonged or obstructed labor, ensuring timely referrals and appropriate medical interventions. By preventing unnecessary delays in care and guiding evidence-based clinical actions, the effective use of the partograph significantly improves maternal and neonatal outcomes during the first stage of labor.

More on the physiological changes during the first stage of labor.

Take a history of the pregnant mother, including:

• Demographic data.
• Gestational age.
• Duration elapsed since the onset of labor.
• Vaginal discharge.
• State of membranes.
• Past obstetric history.
• Medical history.
• Social/economic history.

• Position the Mother Comfortably: Place the mother in a supine position with head and knee support to ensure comfort and allow for relaxation of the abdominal wall musculature. Keep this position for no longer than 15 minutes to avoid discomfort. Ensure the mother’s arms are placed at her sides, not behind her head, for proper assessment.
• Conduct Abdominal Examination: Observe for key indicators, including:
  • Linea nigra (a dark line running down the abdomen).
  • Abdominal distension and fetal movements.
  • Striae (stretch marks) or previous surgical scars that may indicate past cesarean sections or surgeries.
  • Uterine contractions to assess labor progression.
• Check Maternal Vital Signs: Measure and record:
  • Temperature to detect fever or infection.
  • Heart rate to assess overall cardiovascular stability.
  • Blood pressure to monitor for hypertension or hypotension.
  • Pedal edema to check for swelling that may indicate pregnancy-related complications.
  • Jaundice, pallor, and alertness to assess maternal well-being and detect signs of anemia or liver dysfunction.

Follow these steps to conduct systematic abdominal palpation for assessing fetal position, lie, and presentation during the first stage of labor.

1. Position the Mother for Comfort

• Place the mother in a supine position with head and knee support to relax the abdominal wall musculature (do not exceed 15 minutes in this position).
• Ensure the mother’s arms are at her sides, not behind her head, to allow for proper abdominal examination.

Measure the fundal height using either:

• Finger breadths to approximate gestational age.
• A tape measure (in centimeters) from the pubic symphysis to the uterine fundus to assess fetal growth.

• First Maneuver: Fundal Palpation (Fundal Grip)
• Palpate the uppermost part of the abdomen (fundus) to determine which fetal part (head or buttocks) is occupying the fundus.
• Identifies fetal lie (longitudinal, oblique, or transverse).
• If neither the head nor buttocks is in the fundus, it may indicate an oblique or transverse lie.
• Second Maneuver: Lateral Palpation (Lateral Grip)
• Palpate both sides of the abdomen to locate the fetal back and limbs.
• Helps determine fetal position (e.g., if the back is on the left side and the head is presenting, the likely position is left occipito-anterior or LOA).
• Third Maneuver: Pawlick’s Palpation (Pawlick’s Grip)
• Assess fetal engagement by gently grasping the lower part of the uterus to determine if the fetal head has descended into the maternal pelvis.
• Fourth Maneuver: Pelvic Palpation (Pelvic Grip)
• Palpate the lower abdomen to confirm which fetal part (head or buttocks) is presenting.
• Determines engagement level, assessing whether the fetal head has entered the pelvis.

• Monitor uterine contractions every 30 minutes to assess labor progress.
• Assess contraction frequency – Count the number of contractions occurring within a 10-minute cycle.
• Determine contraction duration to classify intensity:

• <20 seconds → Mild contractions
• 20-40 seconds → Moderate contractions
• >40 seconds → Strong contractions
• >60 seconds → Hypertonic contractions (may require medical attention)

5. Conduct Abdominal Examination

• Locate the fetal back using Leopold’s maneuvers, as this is the optimal area for hearing the fetal heart sounds clearly.
• Use one of the following tools to listen to the fetal heart rate:
  • Pinard Fetoscope (non-electronic, requires skill in manual auscultation).
  • Electronic Fetal Doppler (provides clearer sound and digital heart rate reading).

• Rate: Normal range is 110-160 beats per minute (bpm).
• Rhythm: Determine if the heartbeat is regular or irregular.

• Monitor the fetal heart rate every 30 minutes (half-hourly) during active labor.
• If abnormalities are detected, repeat auscultation and take appropriate action based on guidelines.

• Ensure privacy and explain the procedure to the woman to ensure comfort and informed consent.
• Position the woman in a comfortable lithotomy or semi-recumbent position.
• Wash hands, wear sterile gloves, and use lubrication for a smooth examination.

• Examine for visible abnormalities, including:
  • Genital warts, scars from Female Genital Cutting (FGM), chancroid, sores, or Bartholin’s cysts.
• Assess vaginal discharge for:
  • Bleeding, mucus (show), amniotic fluid leakage, and unusual odor.

• Cleanse the vulva using the five-swab technique before starting the internal examination.
• Assess the vaginal walls for:
  • Temperature, elasticity, tenderness, or unusual findings.
• Locate the cervix and assess:
  • Position (central, anterior, or posterior).
  • Cervical effacement (thinning of the cervix).
  • Cervical dilatation (measured in cm).
  • Consistency (soft, firm, or intermediate).
• Use the Bishop Score (see table below) to determine the need for cervical ripening.

• If membranes are intact, check for:
  • Bulging forewaters (suggesting impending rupture).
  • Flat membranes (indicating less amniotic fluid in front of the fetal head).
• If membranes are ruptured, observe the color of the amniotic fluid:
  • Clear: Normal.
  • Blood-stained: May indicate complications.
  • Meconium-stained: Suggests fetal distress.

• Identify the presenting part (head, breech, or other).
• Determine:
  • Position of the presenting part in relation to the maternal pelvis.
  • Station (how far the fetal head has descended into the birth canal).
  • Moulding and caput (degree of skull bone overlap and swelling).
• Assess fetal head position by feeling the sagittal suture line and fontanelles.
• Identify the posterior fontanelle to determine the occiput position.

• Evaluate the bony landmarks of the pelvis, including:
  • Sacral promontory and curve.
  • Ischial spines and pubic arch.
  • Ischial tuberosities for space adequacy.

• Check gloves for the presence of show, liquor color, and smell.
• Inform the woman about the findings and discuss the next steps.
• Accurately document all findings in the patient’s record to guide labor management.

1. Choose the Appropriate Monitoring Method

• Use intermittent auscultation for low-risk pregnancies using:
  • Fetoscope.
  • Doppler device.
  • Pinard fetal stethoscope.
• Use continuous electronic fetal monitoring (EFM) or cardiotocography (CTG) in high-risk cases to provide real-time fetal heart rate assessment.

2. Monitor the Fetal Heart Rate (FHR) at the Correct Intervals

• In the first stage of labor, assess FHR every 30 minutes.
• In the second stage of labor, assess FHR every 5–10 minutes or after each contraction.
• Ensure the normal fetal heart rate (FHR) remains between 110–160 beats per minute (bpm).

3. Recognize Signs of Fetal Distress

• Watch for abnormal FHR patterns, such as:
  • Tachycardia (FHR >160 bpm): May indicate maternal fever, infection, or fetal distress.
  • Bradycardia (FHR <110 bpm): May indicate cord compression, maternal hypotension, or fetal hypoxia.
  • Late decelerations: A gradual decrease in FHR after a contraction, suggesting placental insufficiency.

4. Take Immediate Action if Fetal Distress is Suspected

• Reposition the mother to improve placental blood flow (e.g., left lateral position).
• Administer oxygen to the mother if indicated.
• Provide IV fluid resuscitation if maternal hypotension is present.
• Prepare for expedited delivery (e.g., assisted vaginal delivery or emergency cesarean section) if distress persists despite corrective measures.

5. Ensure Timely Documentation and Communication

• Record fetal heart rate patterns, actions taken, and maternal response in the labor record.
• Communicate concerns immediately with the obstetric team for timely interventions.

The second stage of labor begins when the cervix is fully dilated (10 cm) and continues until the baby is delivered. This stage marks the culmination of labor, requiring effective maternal effort and close monitoring to ensure a safe birth. The duration of the second stage varies from woman to woman. For a first-time mother (primigravida), it typically lasts 2–3 hours, while for a woman who has given birth before (multigravida), it usually lasts around 1 hour. However, individual variations exist, and progress depends on factors such as maternal effort, fetal position, and uterine contractions.

Several key signs indicate the onset of the second stage of labor. These include complete cervical dilatation, allowing the baby to descend further into the birth canal. Anal gapping becomes noticeable as the pressure from the descending baby increases. The presenting part of the baby – usually the head – becomes visible at the vulva, a stage known as crowning. The mother experiences an intense urge to bear down, signaling that her body is ready for the pushing phase. Additionally, contractions become more frequent and intense, lasting more than 60 seconds with shorter intervals between them, helping to propel the baby downward.

During this stage, healthcare providers play a crucial role in guiding the mother, monitoring fetal well-being, and ensuring a safe delivery. Proper support and positioning help facilitate an effective pushing effort, reducing the risk of complications and ensuring a smooth transition to the third stage of labor.

More on physiological changes during the second stage of labor

• Ensure the birthing room is warm to provide comfort and prevent newborn hypothermia.
• Check that the resuscitaire or room warmers are functioning properly in case neonatal resuscitation is needed.

• Support the mother in adopting her preferred birthing position, whether semi-recumbent, squatting, side-lying, or upright.
• Provide continuous reassurance and emotional support to help her remain calm and focused.

• Monitor the fetal heart rate every 5 minutes to detect any signs of distress.
• Check maternal vital signs regularly, paying special attention to blood pressure and pulse.
• Perform vaginal examinations as needed to assess fetal descent, station, and progress.

• Encourage the mother to follow her natural urge to bear down rather than enforcing a coached pushing approach.
• Provide guidance on breathing techniques to optimize pushing efforts while minimizing exhaustion.

• Perform a controlled delivery of the fetal head to prevent perineal trauma and reduce the risk of excessive tearing.
• Support the perineum using warm compresses or perineal massage where appropriate.

• Routine or liberal episiotomy is not recommended, including for first-time mothers (primigravida).
• Only perform an episiotomy when absolutely necessary to prevent severe perineal tears, such as in cases of fetal distress or shoulder dystocia.

• Be prepared to recognize and manage obstetric emergencies, such as:
  • Shoulder dystocia (difficulty delivering the baby’s shoulders).
  • Arrested second stage (prolonged labor without progress).
• Act promptly to prevent complications for both mother and baby.

• Provide appropriate pain relief based on the mother’s needs, whether through:
  • Breathing techniques and relaxation methods.
  • Pharmacological pain relief (if previously planned or requested).

• Use a clean, dry towel to gently but thoroughly dry the baby to prevent heat loss. This also stimulates the baby to cry.
• Remove wet towels and replace them with warm, dry ones to maintain body temperature.

• Check the newborn’s breathing and responsiveness immediately after birth.
• If the baby is not crying or has difficulty breathing, initiate neonatal resuscitation using the Helping Babies Breathe (HBB) protocol.

• Place the newborn on the mother’s chest for immediate skin-to-skin contact to:
  • Regulate body temperature, breathing, and heart rate.
  • Promote bonding and early breastfeeding initiation.
• Ensure the warm chain is maintained by covering both mother and baby with a warm cloth or blanket and keeping the room warm.

• Wait at least 1-3 minutes before clamping the umbilical cord to:
  • Allow additional blood transfer, providing the baby with iron stores to prevent anemia.
  • Enhance circulation and oxygenation, supporting a stable transition.

6. Initiate Early Breastfeeding

• Encourage breastfeeding within the first hour (this time period may vary based on your country guidelines) to:
  • Provide colostrum, which boosts the newborn’s immune system.
  • Stimulate oxytocin release, helping the uterus contract and reducing postpartum hemorrhage in the mother.

• Give Vitamin K to prevent hemorrhagic disease of the newborn (HDN).
• Apply Chlorhexidine Digluconate gel 7.1% to the umbilical cord stump (where recommended) to prevent infections.
• Apply Tetracycline eye ointment to prevent neonatal eye infections, particularly those caused by maternal infections.

• Place a drape under the woman’s buttocks to measure blood loss and monitor for excessive bleeding.
• Immediately after the baby is born, palpate the uterus to rule out the presence of additional babies.

• Explain to the woman the medications she will receive and their purpose in preventing excessive bleeding.
• Administer a uterotonic drug within the first minute after birth to promote uterine contractions and reduce postpartum hemorrhage:
  • Carbetocin 100 mcg IV/IM (heat stable) or Oxytocin 10 IU IM (first-line options).
  • If unavailable, administer Misoprostol 800 mcg sublingually or per rectum, or Syntometrine as alternatives.

• Wait 1-3 minutes before clamping the umbilical cord to allow for adequate blood transfer to the baby, improving iron stores and circulation.

• Perform controlled cord traction (CCT) while applying counterpressure to the uterus to aid in placental separation and delivery.
• Do not apply excessive force to prevent uterine inversion or trauma.

• Carefully inspect the placenta and membranes to ensure completeness and rule out retained placental tissue.
• Perform uterine massage immediately after placental delivery until uterine tone is achieved to prevent atony and excessive bleeding.

• Monitor and estimate blood loss to detect signs of postpartum hemorrhage early.
• Examine the birth canal thoroughly for any lacerations or perineal tears, and manage appropriately if found.

• Keep the mother in the labor ward for close observation to assess for potential complications.
• Examine the perineum, vagina, and cervix for any tears or lacerations and provide necessary treatment.
• Ensure uterus is contracted.

• Monitor the mother every 15 minutes for the first 2 hours after placenta delivery, checking:
  • Vital signs (blood pressure, heart rate, and temperature).
  • Vaginal bleeding to detect excessive blood loss.
  • Uterine tone to ensure the uterus remains firm and contracted.
  • Urinary bladder emptying to prevent uterine atony.
• After the initial 2 hours, continue observations every 30 minutes for the next 6 hours until uterine tone is well established.

• Cord stump for any signs of bleeding.
• Temperature to prevent hypothermia.
• Encourage and support breastfeeding within the first hour after birth to promote bonding, early nutrition, and oxytocin release.
• Keep the baby warm by maintaining skin-to-skin contact with the mother and ensuring a warm environment.

• Accurately record all assessments, interventions, and observations for both mother and baby in medical records.
• Ensure any abnormalities are reported promptly to prevent complications.