REVIEW

Mechanism and management

of normal labour

ground substance. The smooth muscle is concentrated near the

internal os, but as yet no clear function for it has been dem
onstrated in humans. The concentration of elastin in the cervix
decreases during pregnancy, and it is deficient in the incompe
tent cervix, but little more is known about its role. The collagen
fibrils are bound together in dense bundles and are embedded
in the ground substance, which comprises proteoglycans and
glycosaminoglycans (GAGs), including chondroitin sulphate and
dermatan sulphate. The main cellular component of the cervix is
fibroblasts, which produce the collagen and GAGs.
At term, the cervix hypertrophies and an inflammatory-type
reaction occurs, with a neutrophil polymorphonuclear leucocyto
sis that is believed to be partly mediated via interleukins. Cervical
ripening is associated with a reduction in collagen concentration,
an increase in water content and a change in the GAG composi
tion. Fibroblast activation occurs and local prostaglandin produc
tion increases. Prostaglandins increase cervical ripening at term
by altering the GAG content and structure, and by inducing colla
gen breakdown. The decrease in cervical collagen is paralleled by
a concurrent increase in collagenase and neutrophil elastase. It is
likely that cervical ripening is a result of a change in the balance
between these various pro-inflammatory and anti-inflammatory
agents, with prostaglandins involved in both the initiation of this
process and the final common pathway.

Rita Arya
Melissa Whitworth
Tracey A Johnston

Abstract
It is important for providers of antenatal and intrapartum care to have
an understanding of what constitutes normal labour. Complications may
arise at any stage during labour, and early recognition and management
may prevent serious sequelae. This review focuses on the physiology,
mechanism and management of normal labour.

Keywords first stage; management of normal labour; normal labour;

physiology of normal labour; second stage

Physiology of normal labour

Term is the end of normal gestation in humans; the range for this
is 3742 weeks. Although the estimated date of delivery (EDD)
is 280 days from the first day of the last menstrual period, only
35% of women deliver on their EDD. Labour is defined as reg
ular uterine contractions that lead to progressive effacement and
dilatation of the cervix. Towards the end of pregnancy, during
the phase known as pre-labour, the tissues of the cervix under
go fundamental physiological and structural changes, resulting
in a marked reduction in tensile strength. It is this process of
cervical ripening that converts the cervix into a soft, yielding
structure that offers little resistance to the expulsive forces of the
myometrium during labour. This process of cervical ripening is
paralleled during pre-labour by an increase in the spontaneous
contractility of the myometrium. The BraxtonHicks contractions
that are present throughout pregnancy increase exponentially in
frequency and amplitude, reaching a peak during labour per se.
The stimulus for the complex changes that result in labour is
unknown. What is clear is that there is a complex interplay
between maternal, fetal and placental factors.

Myometrium
The myometrium comprises bundles of smooth muscle cells, or
myocytes, embedded in a connective tissue matrix abundant in
collagen fibres that provides a framework to coordinate the trans
mission of the forces generated by contraction of the myocytes.
The myocytes contain actin and myosin filaments that interact and
form cross-bridges, resulting in contraction. The actinmyosin
interaction is regulated by myosin light chain kinase and is cal
cium dependant via calmodulin. It is essential during labour that
the activity of the myocytes is closely coordinated to ensure the
generation of efficient uterine contractions. The myocytes coor
dinate their activity through intercellular connections called gap
junctions that allow metabolic and electrophysiological commu
nication between the cells, enabling them to act as a functional
syncytium. In the myometrium, unlike other muscle tissues in
the body, the actin filaments interact with the entire length of the
myosin filaments, resulting in greater shortening at each contrac
tion and hence the production of cervical effacement, dilatation,
delivery and involution of the uterus.

Cervix
The main component of the cervix is collagen, along with some
smooth muscle and elastin, all embedded in a connective tissue

Hormones
Maternal: progesterone is so called as it supports pregnancy. It
is made by the corpus luteum until approximately 78 weeks
gestation and subsequent to this is produced by the placenta.
Progesterone is known to have potent anti-inflammatory proper
ties, and antiprogestins have been demonstrated to effectively
induce cervical ripening. Progesterone has an inhibitory effect
on contractile proteins via its ability to block the formation of
gap junctions. It also decreases prostaglandin production and
inhibits oxytocin release and the formation of oxytocin recep
tors. Although there is no systemic decrease in progesterone with
advancing gestation, there is a decrease in the number of proges
terone receptors and thus, most likely, a decrease in local proges
terone concentration in the cervix and myometrium.

Rita Arya MRCOG Specialist Registrar in Obstetrics and Gynaecology,

St Marys Hospital, Hathersage Road, Manchester M13 0JH, UK.
Melissa Whitworth MD MRCOG Clinical Lecturer in Obstetrics and
Gynaecology, Department of Obstetrics and Gynaecology, Liverpool
Womens Hospital, Crown Street, Liverpool L8 7SS, UK.
Tracey A Johnston MD MRCOG Consultant in Fetal Maternal Medicine,
St Marys Hospital, Hathersage Road, Manchester M13 0JH, UK.

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Oestrogen has an action opposing that of progesterone,

increasing prostaglandin production, oxytocin receptor concen
tration and uterine contractility. There is a gradual increase in
the oestrogen concentration (both oestriol and oestradiol) dur
ing the third trimester of pregnancy. The progesterone/oestrogen
ratio decreases during the end of pregnancy, resulting in a posi
tive effect on uterine activity.
Oxytocin is an octapeptide hypothalamic hormone stored
in the posterior pituitary that induces uterine contractions and
increases the strength and frequency of existing contractions. It
appears to exert its effects by altering calcium influx and efflux in
the myocytes. There is no change in the systemic concentration
of oxytocin until the late first stage of labour, but the number
of oxytocin receptors in the myometrium and decidua increases
during pregnancy, reaching a peak during early labour. Oxytocin
also stimulates prostaglandin synthesis by the decidua and fetal
membranes.

in the use of exogenous prostaglandins for cervical ripening and

induction of labour. The role of prostacyclin is unclear but it is
known to inhibit uterine contractility.

Normal labour
The WHO defines normal labour as low risk throughout, sponta
neous in onset, with the fetus in a vertex presentation through
out, and ending with the mother and fetus in a good condition
following a spontaneous delivery. Labour is traditionally divided
into three stages.
First stage
The first stage has an initial latent phase when the cervix short
ens to less than 0.5 cm and dilates from being closed to 34 cm.
The second phase of the first stage is the active phase, when
regular uterine activity leads to full dilatation of the cervix. The
duration of these phases is variable; the latent phase can last 38
hours and is shorter for multiparous women. The active phase
is also variable in length, with cervical dilatation usually occur
ring at a minimum of 1 cm/h. Progress in labour varies between
nulliparous and multiparous women and between spontaneous
and induced labour.

Placental: the placental unit produces various hormones impor

tant in the physiology of labour. The peptide hormone relaxin,
which promotes uterine quiescence during pregnancy, is initially
produced by the corpus luteum and later in the pregnancy by the
placenta. The role of relaxin in pregnancy, labour and delivery is
not clear and the literature is conflicting.
Human chorionic gonadotrophin (hCG) is a glycoprotein
produced by the syncytiotrophoblast. It stimulates production of
relaxin and supports the corpus luteum to maintain production
of progesterone and oestrogen.
The level of corticotrophin-releasing hormone (CRH) increases
towards the end of pregnancy, with a peak in maternal plasma
level during labour. CRH potentiates the effects of prostaglandins
and oxytocin on uterine contractility and increases prostaglandin
production by the decidua and membranes. It has been suggested
that CRH may have an active role in the onset of labour.
Other placental hormones produced by the decidua and pla
centa also have important roles in the onset of labour. These
include activin A and follistatin; the latter inhibits the effect of
activin, which is to stimulate hCG and progesterone production
by the placenta.

Second stage
The second stage of labour begins at full dilatation and ends
with delivery of the baby. The second stage has two phases: an
initial passive phase, which begins with full dilatation and ends
when bearing down efforts begin, and a second, expulsive phase
when active maternal pushing occurs. During the passive phase,
the presenting part descends onto the pelvic floor and uterine
activity may decrease. The second stage usually lasts 2 hours
in primiparous women and 1 hour in multiparous women. The
total duration is variable, but it should be no longer than 3 hours
(without an epidural), allowing for a 1 hour passive phase, a
1 hour active phase and 1 hour to assess the woman and ensure
delivery occurs. An unduly prolonged second stage is associated
with adverse outcomes for the fetus and the mother. The pH of
the fetal blood decreases during the second stage and therefore
if the fetus is already compromised when pushing commences,
hypoxia can occur. An excessively prolonged second stage may
be associated with urinary tract damage and vesicovaginal fistula
formation.

Fetal: the fetal pituitary gland secretes oxytocin, which also may
contribute to the initiation of labour. The fetal adrenal gland pro
duces cortisol, which stimulates the conversion of progesterone
to oestrogen. Fetal cortisol has other roles in preparing the fetus
for birth. It promotes fetal lung maturation, production of glyco
gen by the fetal liver and the production of gut enzymes.
Prostaglandins are pivotal in both cervical ripening and myo
metrial contractility. The fetal membranes and the decidua pro
duce prostaglandins PGE2 and PGF2 respectively. PGE2 promotes
cervical ripening and PGF2 increases intracellular calcium,
which increases myometrial contractility. A deficiency of PGF2
has been demonstrated in dysfunctional labour. Prostaglandins
are produced from arachidonic acid by cyclo-oxygenase. Cervi
cal ripening is associated with an increase in local prostaglandin
production and administration of prostaglandin induces physio
logical cervical ripening in the absence of uterine contractility.
Labour is associated with significantly elevated prostaglandin
concentrations in both the amniotic fluid and the systemic circu
lation. These properties have been exploited pharmacologically

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8

Third stage
The third stage commences at the time of delivery of the baby
and ends with delivery of the placenta and membranes. Signs of
spontaneous separation of the placenta include a gush of vaginal
blood, lengthening of the umbilical cord and a rise in the uterine
fundus. The commonest complication of the third stage is haem
orrhage, but this can be reduced by active management, which
has been shown to reduce the incidence of blood loss greater
than 500 ml from 15% to 5%. Active management of the third
stage involves early clamping and cutting the umbilical cord and
giving the mother an oxytocic agent before gentle cord traction
is applied while guarding the fundus to deliver the placenta and
membranes once signs of separation have been seen. Commonly
administered oxytocic agents include Syntocinon 5 iu and Syntometrine (Syntocinon 5 iu and ergometrine 0.5 mg). The third
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REVIEW

Delivery is completed by lateral flexion. Gentle downward

traction of the head allows delivery of the anterior shoulder, and
this is followed by lateral flexion upwards of the baby to deliver
the posterior shoulder.

stage lasts 515 minutes if actively managed, but may last up to

1 hour under physiological conditions.
Mechanism of normal labour
Descent of the fetus through the pelvis is a prerequisite for
vaginal delivery. The fetus has to undergo a series of important
manoeuvres to negotiate its journey through the maternal pelvis.
The pelvis has three important diameters. The pelvic inlet has
a wide transverse diameter of approximately 13 cm. The midcavity of the pelvis is round, and contraction of the mid-pelvis
is suspected if the ischial spines are prominent or the pubic arch
is narrow. The pelvic outlet has a wide anteriorposterior dia
meter. The fetal manoeuvres that occur during the mechanism of
labour to allow the fetus to traverse the pelvic diameters in the
optimal position are described below. Not all fetuses follow this
pattern, as it is dependant on the presenting part. The common
est situation is with the fetus in a longitudinal lie with a cephalic
presentation and a well-flexed attitude. In these circumstances,
the vertex (the area bounded by the anterior edge of the posterior
fontanelle, the two parietal eminences and the posterior edge of
the anterior fontanelle) hits the pelvic floor first and rotates ante
riorly, resulting in an occipitoanterior position with the occiput
as the denominator.
Engagement of the fetal head occurs in the weeks before the
onset of labour in nulliparous women, but often not until the
onset of labour in multiparous women. It occurs secondary to
the descent of the presenting part. The head is engaged when the
widest diameter of the presenting part (the biparietal diameter in
a cephalic presentation) has passed the pelvic brim or inlet. Once
engaged, the head is fixed in the pelvis and is no more than twoto three-fifths palpable per abdomen.
Descent of the fetal head occurs progressively during labour
secondary to contraction and retraction of the myometrium.
Flexion of the fetal neck ensures that smaller diameters of
the fetal head present that can negotiate the pelvis more eas
ily. With moderate flexion, the suboccipitofrontal diameter leads
(approximately 10 cm), but with good flexion this converts to the
suboccipitobregmatic diameter (9.5 cm).
Internal rotation of the fetal head occurs during descent,
when the vertex is pushed down onto the anterior slope of the
pelvic floor by the uterine contractions. With a well-flexed ver
tex presentation, the leading part of the fetal head (the occiput)
rotates anteriorly from a transverse position (appropriate for the
pelvic inlet) into an anteroposterior position, to pass the ischial
spines (appropriate for the pelvic outlet). The fetal shoulders
remain in the transverse diameter at this point so they can enter
the pelvis through the widest pelvic diameter, resulting in a
degree of rotation of the fetal neck. The occiput passes under the
subpubic arch and distends the perineum.
Crowning of the head occurs when the fetal head no longer
recedes between contractions and the biparietal diameter is
delivered.
Extension of the fetal neck allows the fetal face to sweep the
perineum and the chin to be delivered.
External rotation of the head after delivery to a transverse
position allows the head to come back into line with the shoul
ders. This is also known as restitution. The shoulders rotate
internally to an anteriorposterior diameter to traverse the pelvic
outlet.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8

Other mechanisms
Other mechanisms occur with malposition of the fetus. With
right or left occipitoposterior positions at the onset of labour,
rotation to an occipitoanterior position usually occurs before
delivery. A direct occipitoposterior position is associated with
an occipitofrontal diameter of 11.5 cm and often a long, dys
functional labour. Also, because this diameter is wider than
the conventional suboccipitobregmatic diameter, it is associ
ated with relative cephalopelvic disproportion. If vaginal deliv
ery occurs, the sinciput emerges from under the symphysis
pubis. Some occipitoposterior positions arrest during internal
rotation in an occipitotransverse position, which can rarely be
delivered spontaneously. A face presentation results if exten
sion rather than flexion occurs in early labour. The face pre
sentation continues to descend with increasing extension when
the chin reaches the pelvic floor. If rotation to a mentoanterior
position occurs, delivery can occur by flexion of the neck. If the
internal rotation results in a mentoposterior position, the chin
lies in the hollow of the sacrum and there is no mechanism
for delivery of the baby vaginally as the fetal neck can extend
no further. If extension is incomplete, a brow presentation
may occur, which is associated with a mentovertical diameter
of 13.5 cm. A brow presentation is unstable; most convert
to a deflexed vertex or, occasionally, a face presentation by
full dilatation. If the brow persists at full dilatation, there is
usually cephalopelvic disproportion and delivery should be
undertaken by caesarean section unless the baby is small
(e.g. preterm, second twin), in which case successful vaginal
delivery can be achieved.
The mechanism of labour for breech presentation involves
descent, internal rotation of the buttocks and descent of the
bitrochanteric diameter in the anteroposterior diameter. The hip
is delivered under the symphysis pubis by lateral flexion of the
body and restitution occurs once the posterior buttock is deliv
ered. Internal rotation of the shoulders occurs as the sacrum
rotates anteriorly, and the head descends into the pelvis with the
sagittal suture in the transverse diameter. The head undergoes
internal rotation and is delivered with flexion of the neck. Rota
tion to sacroposterior after delivery of the body leads to difficulty
in delivery of the head and should be prevented.

Management of labour
The aim of management of labour is to achieve a good outcome
for mother and baby. In the UK, women may choose to deliver
at home or in hospital. Low-risk women may choose to delivery
in a midwifery-led unit, while consultant-led units serve women
who have shared or total hospital antenatal care. At least 10%
of low-risk labours become high risk and so facilities for trans
fer from one unit to another should be available. The Chang
ing Childbirth Initiative in the UK highlighted the importance of
maternal preferences, and women should have choice in terms of
place of delivery, posture during labour, pain relief options and
birth partners.
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An important role of the midwife is to accurately diagnose the

onset of labour. This can be difficult, and diagnosis of labour at
the wrong time can lead to misdiagnosis or missed diagnosis of
slow progress, both of which result in increased intervention.
The partogram was developed in 1972 by Hugh Phillpott, and is
a graphical representation of the changes that occur in labour.
Recordings include maternal pulse, blood pressure, temperature,
fetal heart rate, cervical dilatation, descent of the presenting
part, colour of liquor and drugs administered. It is an important
recording tool and its use has been shown to reduce operative
intervention by allowing early recognition and therefore correc
tion of poor progress in labour. It should not, however, be started
during the latent phase of labour it is a tool to be used during
established labour.

The modified Bishop score used to assess progress

of labour

Assessing maternal well-being

Women should be advised to attend for evaluation of labour if
they have any of the following symptoms:
possible rupture of the membranes
regular uterine contractions
vaginal bleeding
severe back, abdominal or pelvic pain.
A midwife performs the initial assessment of the woman. Past
obstetric and medical history should be sought along with any
antenatal complications. During labour, maternal observations
including pulse rate and blood pressure should be recorded every
2 hours and temperature every 4 hours. Urinalysis should be
performed initially and urine output should be recorded.

Cervical
length (cm)
Cervical
dilatation
Cervical
consistency (cm)
Position of
cervix
Station

>4

24

12

<1

<1

12

24

>4

Firm

Medium

Soft

Posterior

Mid/anterior

Sp3

Sp2

Sp1 to +1 >Sp+1

Table 1

occurs, as the uteroplacental circulation is compromised dur

ing contractions and there must be enough rest time between
contractions to allow the fetus to reoxygenate or compromise
will occur.
Passenger: the progress of labour is influenced by fetal size
and fetal position. Abdominal palpation should be performed
to assess the descent of the presenting part. Cervical assess
ment also provides information about the station of the present
ing part in relation to the ischial spines. The development of
caput and moulding are important, as these may be indicators
of disproportion.

Assessing fetal well-being

Currently in the UK, in a low-risk labour, the fetal heart is inter
mittently auscultated and the fetal heart rate recorded every
15 minutes in the first stage and after every contraction for
1 minute in the second stage. The heart rate should be recorded
on the partogram. The colour of the liquor should also be
recorded.

Passages: abnormality of the bony pelvis may cause a delay in

the progress of labour. With improvements in maternal nutrition,
such abnormalities are less common than in the past. Cephalo
pelvic disproportion may occur between a macrosomic fetus and
a pelvis of normal proportion. Relative cephalopelvic dispropor
tion can occur when a wider diameter of the fetal head is trying
to negotiate the normal pelvic diameters, as in malposition. A
rigid perineum can occasionally lead to delay in delivery, and
this situation should be assessed by an experienced midwife
regarding the need for episiotomy.

Assessing progress of labour

Progress of labour is assessed by the strength and frequency of
the contractions, and by the changing cervical status and the
descent of the presenting part on vaginal examination. Before
the onset of labour and at the beginning of labour, the modified
Bishop score (Table 1) allows objective assessment of the vaginal
examination findings.
Once the woman is in active labour, the progress is influenced
by three factors: the powers (uterine activity), the passenger (the
fetus) and the passages (the pelvis).

Pain relief
In the antenatal period, the woman should be advised about
options available for pain relief during labour. Good psychologi
cal support is important and can be provided by birth partners,
midwives or doulas. One-to-one support in labour is associated
with reduced requirements for pain relief and less operative
intervention, as well as an improved birth experience for the
mother.
Analgesia can be provided in various forms including transcu
taneous nerve stimulation, nitrous oxide, opiates such as pethi
dine and diamorphine, and regional analgesia. The progress of
labour in the latent phase may be slowed by opiate or epidural
analgesia, but this have little or no effect on the active phase
of labour. Epidural analgesia may slow the second stage and
is associated with an increased incidence of operative vaginal
delivery.

Powers: uterine activity should be frequent enough and strong

enough to ensure that progress occurs, in terms of cervical dila
tation and descent of the presenting part. In established labour,
this usually means around four contractions of good strength
every 10 minutes; however, delivery is achieved with less uter
ine activity in some cases, and more is required in others. Thus,
progress of labour must not be judged by contractions alone.
Various factors influence uterine activity, including epidural
anaesthesia, tocolytics and sedation, all of which decrease uter
ine activity, and oxytocics, which enhance uterine activity. Care
must be taken when tachysystole (too-frequent contractions)

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 17:8

Modified
Bishop score

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Posture in labour
An environment helpful to the mother may include ample space
and the use of aids such as a birth pool, mats on the floor, cush
ions, a rocking chair and gym balls. Changes of position may help
the progress of labour and provide comfort to women who feel
that they wish to move round as much as possible. The woman
should be encouraged to deliver in whatever position she feels
comfortable with as long as fetal well-being can be confirmed. In
the late first stage of labour, many women elect to be in a semirecumbent position, despite this being associated with increased
intervention. Squatting increases the pelvic diameter by 8 mm
and is similar to the McRoberts position, which is used as a
manoeuvre to aid delivery in cases of shoulder dystocia. Other
women choose to deliver standing upright or on their hands and
knees.
The supine position should always be avoided as it results
in hypotension due to compression of the vena cava, leading to
fetal and maternal hypoxia.

The following exert a positive effect on uterine activity:

prostaglandins, CRH, oxytocin, decreased progesterone/
oestrogen ratio, influx of calcium into myocytes
The following exert a negative effect on uterine activity: hCG,
increased progesterone/oestrogen ratio
During labour, the fetal head engages and descends into the
maternal pelvis in the transverse diameter
Descent and internal rotation then occur to an
occipitoanterior position in the well-flexed fetus, dependant
on good uterine contractions
Following delivery, the fetal head restitutes to lie in line with
the shoulders
Management of labour involves regular assessment of fetal
and maternal condition and the progress of labour
A partogram is a useful tool to record maternal and fetal
well-being and assess the progress of labour, and has been
shown to reduce intervention
Maternal condition is monitored by regular observations of
pulse, blood pressure, temperature and urine output
Fetal condition is assessed by fetal heart rate monitoring and
the colour of the liquor
Progress of labour is monitored by assessing cervical
dilatation and the descent of the presenting part
It is also important to record the frequency and strength of
uterine contractions
One-to-one care in labour has been shown to reduce
intervention

Practice points
The mechanism of initiation of labour remains uncertain
Once the fetus is mature, various hormonal, neural and
mechanical factors interact, leading to the changes in cervical
ripening and uterine contractility that result in labour
Cervical ripening is promoted by prostaglandin E2

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