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Managementofnormallaboranddelivery

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Managementofnormallaboranddelivery
Authors
EdmundFFunai,MD
ErrolRNorwitz,MD,PhD

SectionEditor
CharlesJLockwood,MD,MHCM

DeputyEditor
VanessaABarss,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Feb2015.|Thistopiclastupdated:Mar10,2015.
INTRODUCTIONLaboristhephysiologicalprocessbywhichafetusisexpelledfromtheuterustothe
outsideworld.Determiningwhetherawomanisinlaborissometimesdifficultaspainfuluterinecontractions
alonearenotsufficienttoestablishadiagnosisoflabor.Typically,thediagnosisisreservedforuterine
contractionswhichresultincervicaldilatationand/oreffacement.Bloodyshow(asmallamountofbloodwith
mucusdischarge[ie,mucusplug]fromthecervix)mayprecedetheonsetoflaborbyasmuchas72hours.
Occasionally,fetalmembranesrupturewithegressofamnioticfluidpriortotheonsetoflabor.
Thistopicwillpresentaparadigmforintrapartummanagementofwomeninlabor.Manyoftheoptionsfor
evaluatingandmanagingwomenduringlaborhavenotbeenstudiedinclinicaltrialsorthedatafromclinical
trialsisinsufficientforevidencebaseddecisionmaking[1]thus,manyofourrecommendationsarebased
uponclinicalexperience.
Managementofcomplicateddeliveriesisreviewedelsewhere.(See"Overviewofbreechpresentation"and
"Faceandbrowpresentationsinlabor"and"Operativevaginaldelivery".)
DEFINITIONTheWorldHealthOrganization(WHO)definesnormalbirthas:spontaneousinonset,low
riskatthestartoflaborandremainingsothroughoutlaboranddelivery.Theinfantisbornspontaneouslyinthe
vertexpositionbetween37and42completedweeksofpregnancy.Afterbirth,motherandinfantareingood
condition[2].
PSYCHOSOCIALISSUES
PreparationChildbirtheducationclasseshelptopreparewomen,andtheirpartners,forlaboranddelivery.
(See"Preparationforlaborandchildbirth".)
SupportEmotionalsupportofthepatientduringthebirthingprocessmaylowerintrapartumanalgesia
requirements,decreasetherateofoperativedelivery,andincreasepatientsatisfaction.(See"Continuouslabor
supportbyadoula".)
CommunicationThehealthcareteamshouldestablishgoodcommunicationwiththeparturientandthe
individualswhoaccompanyherduringlaboranddelivery.Goodcommunicationinvolvesidentifyingthe
clinicianswhowillparticipateinhercare(nurses,students,residents,attendingphysicians,anesthesiologists,
andpediatricians),explainingallprocedures,andkeepingtheparturientandherfamilyinformedaboutthe
maternalfetalstatus.Theteamshouldinvolvethewomanandhersupportpersoninmanagementdecisions,
suchastheuseofoxytocintoaugmentlabor,thetimingofamniotomy,intrapartumpainmanagement,orthe
needforoperativedelivery.
EVALUATIONThegoalsoftheinitialphysicalexaminationoftheparturientaretoestablishherbaseline
cervicalstatussothatsubsequentprogresscanbedetermined,toreviewherprenatalrecordformedicalor
obstetricalconditionswhichmayneedtobeaddressed(eg,pregestationaldiabetesmellitus,fetalabnormality,
groupBbetahemolyticstreptococcus[GBS]colonization),tocheckfordevelopmentofnewdisorders(eg,
bleeding,preeclampsia,chorioamnionitis),andtoevaluatethefetalstatus.
InitialexaminationOnadmissiontothelaborunit,thepatient'sbloodpressure,heartandrespiratoryrates,
temperature,weight,andfetalheartrate(FHR)arerecorded[3].Thequalityofuterinecontractionsandtheir
durationandfrequencyarealsorecorded(see'Uterinecontractions'below).
Asdiscussedabove,determiningwhetherawomanisinlaborissometimesdifficultaspainfuluterine
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contractionsalonearenotsufficienttoestablishadiagnosisoflabor.Typically,thediagnosisisreservedfor
uterinecontractionswhichresultincervicaldilatationand/oreffacement.Arecenthistoryofbloodyshow
(vaginaldischargeofasmallamountofbloodandmucus[ie,mucusplug])supportsthediagnosis.
Occasionally,fetalmembranesrupturepriortotheonsetoflabor.
Aphysicalexaminationisperformedwithparticularemphasisonthecervicalexamination.Thepurposeofthis
examinationistodetermine:
Whetherthefetalmembranesareintactorruptured.Vaginalexaminationsaredeferredifthe
membranesarerupturedandactivelaborhasnotensuedasterilespeculumexaminationisperformedin
womenwithsuspectedmembranerupturetoassessthecervixandconfirmthediagnosis.(See
"Managementofprematureruptureofthefetalmembranesatterm".)
Ifthemembraneshaveruptured,thepresenceorabsenceoffetalmeconiumshouldbenotedbecauseof
thepossibilityofmeconiumaspiration.(See"Clinicalfeaturesanddiagnosisofmeconiumaspiration
syndrome".)
Whetheruterinebleedingispresentandexcessive.(See"Overviewoftheetiologyandevaluationof
vaginalbleedinginpregnantwomen".)
Cervicalstatus:
(1)Dilation(0to10centimeters)
(2)Effacement,describedaszero(noeffacement,thecervixis3to4cmlong)to100percent(complete
thinningofthecervix)
(3)Fetalstation,whichshouldbeexpressedasthenumberofcentimetersoftheleadingbonyedgeofthe
presentingpartaboveorbelowtheleveloftheischialspinesthemaximumdenominatoris5(eg,one
centimeterbeyondtheischialspinescorrespondsto+1/5cm).Effacementandstationareshowninthe
figures(figure1AB).
Atthistime,cervicalstatusisbestevaluatedbydigitalexamination,recognizingthatinterand
intraobserverexaminationsaresubjectiveandnothighlyreproducible.Automateddevicesformore
objectiveandreproducibleassessmentareunderinvestigation,butnonehavebeenproventoperform
betterthanmanualexamination.
Anoldersystemdescribedfetaldescentbydividingthedistancefromtheischialspinestopelvicoutlet
intothirds.Usingthissystem,station+1/3roughlycorrespondsto+2/5cminthecentimetersystem.
Thisassessmenthaslargelybeenabandonedbecauseitisevenmoresubjectivethanthecentimeter
systemandmakesitdifficulttodocumentsmall,butclinicallysignificant,degreesofdescent.
Ifacervicalexaminationisnotperformed,fetaldescentcanalsobedescribedintermsoffifthsofthe
fetalheadpalpableabovethesymphysispubis[4].Thismethodisalsousefulifthereissignificant
molding(changeinshapeofthefetalskull)orcaput(edemaoftheportionofthefetalscalpoverlyingthe
cervicalopening).
Thepresentationandpositionofthefetus.Presentationreferstothepartofthefetusatthecervical
opening(eg,breech,vertex,shoulder,face,brow,orcompound)andpositiondescribestherelationshipof
thepresentingparttothepelvis(eg,leftocciputanterior,occiputposterior)(figure2andfigure3ACand
figure4andfigure5).Ifthereisuncertainty,ultrasoundexaminationcanbeuseful[57].
Theapproximatesizeofthematernalpelvis("clinicalpelvimetry").(See"Mechanismofnormallabor
anddelivery",sectionon'Passage(pelvis)'.)
LaboratorytestsAurinespecimenistestedforprotein(proteinuriaisonefeatureofpreeclampsia),and
bloodisdrawnforacompletebloodcountandABO/Rhbloodtyping.Althoughlaboratoryassessmentof
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hemoglobin/hematocritandbloodtyping/screeningarecommonlyperformeduponadmission,thereisno
evidencethatthispracticeisnecessaryinuncomplicatedpregnancies.Relyingonanormalhemoglobinresult
obtainedat26to28weeks(eg,atthetimeofscreeningforgestationaldiabetes)andRhesus(Rh)typingwith
anegativeantibodyscreenobtainedatthefirstprenatalvisitappearstobeasafeandacceptableapproach[8
13].Typingandscreeningpracticesvarywidely.Areasonableapproachistotypeandscreenpatientsat
moderateriskofneedingatransfusion(eg,multiplegestation,trialoflaboraftercesarean,
preeclampsia/HELLPwithoutcoagulopathy,priorpostpartumhemorrhage,grandmultiparity)andtypeand
crosspatientsathighriskofneedingatransfusion(eg,placentapreviaoraccreta,preeclampsia/HELLPwith
coagulopathy,severeanemia,congenitaloracquiredbleedingdiathesis)[14].
WomenwhohavenothadHIVscreeningshouldbeofferedrapidHIVtestinginlabor[1518].Iftherapidtestis
positive,thenantiretroviralprophylaxisshouldbeinitiatedwhileconfirmatorytestingisbeingperformed.(See
"PrenatalevaluationandintrapartummanagementoftheHIVinfectedpatientinresourcerichsettings"and
"UseofantiretroviralmedicationsinpregnantHIVinfectedpatientsandtheirinfantsinresourcerichsettings".)
WomenwhowerenotscreenedforhepatitisBsurfaceantigenprenatally,orengageinbehaviorsthatputthem
athighriskforinfection(eg,havinghadmorethanonesexpartnerintheprevioussixmonths,evaluationor
treatmentforanSTD,recentorcurrentinjectiondruguse,andanHBsAgpositivesexpartner),orwithclinical
hepatitisshouldberetestedatthetimeofhospitaladmissionfordelivery[18].Shortenedtestingprotocolscan
beusedtheinfantshouldreceiveimmunoprophylaxisiftheresultsarepositive.(See"Screeningforsexually
transmittedinfections",sectionon'HepatitisB'and"Hepatitisvirusesandthenewborn:Clinicalmanifestations
andtreatment",sectionon'Prevention:HBIGadministrationandearlyvaccination'.)
Insettingsinwhichnucleicacidamplificationtests(NAAT)suchasPCRforGBSareavailable,obstetric
providerscanchoosetoperformintrapartumtestingofvaginalrectalsamplesfromwomenwithunknownGBS
colonizationstatusandnointrapartumriskfactors(temperature100.4F[38.0C]orruptureofamniotic
membranes18hours)atthetimeoftestingandwhoaredeliveringatterm.EvenifNAATisnegative,
prophylaxisissuggestedifariskfactordevelopsintrapartum[19].(See"NeonatalgroupBstreptococcal
disease:Prevention",sectionon'Rapiddiagnostictests'.)
LABORMANAGEMENT
PatientpreparationThereisnoevidencethatroutineenemasorperinealshavingisbeneficial[20,21].A
urinarycatheterisnotnecessaryunlessthewomanisunabletovoid,butsheshouldbeencouragedtoempty
herbladderregularly.Althoughafullbladdersometimesappearstoimpedefetaldescent,thereisnoevidence
thatitaffectsthecourseoflabor[22,23].
FluidsandoralintakeThereisnoconsensusonacceptablematernaloralintakeorneedforintravenous
fluidsduringanuncomplicatedlabor.A2013systematicreviewoffivestudiesincludingover3000womenin
activelaborandatlowriskofpotentiallyrequiringageneralanestheticcomparedtheoutcomeofwomen
whoseintakeoffood/fluidswasrestrictedtotheoutcomeofwomenallowednourishment[24].Maternaland
neonataloutcomesweresimilarinbothgroupshowever,oneimportantoutcome,maternalsatisfaction,was
notassessed,andanotherimportantoutcome,aspirationrate,couldnotbeassessedbecausesofewevents
occurred.Theauthorsconcludedthatfood/fluidsduringlaborshouldnotberestrictedinwomenatlowriskof
complications.
Maternaloralintakeofsolidsisoftenlimitedduringactivelaborbecauseoftheriskofaspirationpneumonitis,a
majorcauseofanestheticassociatedmorbidityandmortality.Althoughthisriskisverylowinthecurrentera,
theAmericanCollegeofObstetriciansandGynecologistsandtheAmericanSocietyofAnesthesiologistsTask
ForceonObstetricAnesthesiarecommendavoidanceofsolidfoodsinlaboringwomen[25,26].
Someauthorshavesuggestedthatsinceaspirationpneumonitisresultsfromtheacidityoftheaspiratedgastric
contents,aclearantacid(eg,10to30mLsodiumcitrate)beadministeredtoallwomeninlaborhowever,this
hasnotbeenproventobepreventaspirationanditsconsequences[27].Wedonotroutinelyadministersodium
citratetoourlaboringpatients,butgiveittoallpatientsbeforecesareandelivery.Wedoallowclearliquidsto
womenatlowriskofcesareandeliverywhoareintheactivephaseoflabor.
Insertionofanintravenouscatheterprovidesimmediateaccessforadministrationofdrugsorbloodinan
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emergencyorforadministrationofdrugstoaugmentlabor,preventortreatinfection,andasprophylaxisor
treatmentofpostpartumhemorrhage(seebelow).Intravenousaccessisadvisableforfluidpreloadingif
epiduralorspinalanesthesiaistobeused.Wesuggestplacementofanintravenouslineoraheparinlockat
thetimeadmissionlaboratorytestsaredrawn.(See"Adverseeffectsofneuraxialanalgesiaandanesthesiafor
obstetrics".)
Inadequatehydrationinlabormaybeafactorcontributingtolongerdurationoflabor.Asystematicreview
foundthatifapolicyofnooralintakeisapplied,thenthedurationoflaborinnulliparouswomenmaybe
shortenedbytheadministrationofintravenousfluidsatarateof250mL/hourratherthan125mL/hour[28].
However,overhydrationcanbeharmful,particularlywithhypotonicliquids.Astudythatevaluatedthe
occurrenceofhyponatremiaamong287Swedishwomeninlaborfoundthat21developedplasmasodium130
mmol/L[29].Comparedtowomenwhosesodiumconcentrationremainednormal,womenwhodeveloped
hyponatremiaweresignificantlymorelikelytohavereceivedahighvolumeoffluid(totaloralandintravenous
fluidvolumeover2500mL)andahighmaximumoxytocindose(20to60mU/min).Twothirdsofthefluid
intakewasfromoralhypotonicbeverages.Theauthorsdidnotdocumentwhetherthesewomenhadsymptoms
ofhyponatremia(eg,headache,nausea).Inpatientsreceivingoxytocinathigherdoses(>20mU/min)orfor
prolongedperiods(greaterthan12to24hours),itisimportanttobealertforsignsofbothhyponatremiaaswell
asvolumeoverload.
Theoptimalcrystalloidsolutionhasnotbeendetermined,butsomebenefitshavebeenreportedfornormal
salinewith5percentdextroseratherthanwithoutdextrose[30,31].
MedicationmanagementWomencantaketheirusualdailymedicationsorallyduringlaborhowever,
gastricabsorptionisunpredictableiflaborisadvanced.Ifthisisaclinicallyimportantconcern,analternate
routeofadministrationispreferable.Womenwhohavebeentakingglucocorticoidsinadoseequivalentto
prednisone5to20mgdailyformorethanthreeweeksmayhavehypothalamicpituitaryadrenal(HPA)axis
suppressionandeithershouldundergotestingorreceiveempiricglucocorticoidcoverage.Perioperative
managementofspecificmedications,includingglucocorticoidcoverage,isreviewedseparately,(See
"Perioperativemedicationmanagement".)
Infectionprophylaxis
AntibioticsIntrapartumchemoprophylaxistopreventearlyonsetneonatalGBSinfectionisindicatedfor
appropriatepatientstheagentofchoiceisintravenouspenicillin.Aminimumoffourhoursofintrapartum
therapyhasbeenrecommendedpriortodeliveryhowever,bactericidallevelsincordbloodareachievedwithin
30minutesofadministrationtothemothersoantibioticsshouldbeadministeredevenifdeliveryseems
imminent[32].(See"NeonatalgroupBstreptococcaldisease:Prevention".)
Vaginalorcesareandeliveryisnotanindicationforroutineantibioticprophylaxissincetherateofbacteremia
withtheseproceduresislow.Itreasonabletoconsiderantibioticprophylaxisagainstinfectiveendocarditis
beforevaginaldeliveryatthetimeofmembraneruptureinselectpatientswiththehighestriskofadverse
outcomes(eg,prostheticcardiacvalveorprostheticmaterialusedforcardiacvalverepair,unrepairedor
palliatedcyanoticheartdisease).Theseissuesarediscussedindetailseparately.(See"Antimicrobial
prophylaxisforbacterialendocarditis",sectionon'Vaginalorcesareandelivery'.)
ChlorhexidineAvailabledataprovidenoconvincingevidencetosupportthepracticeofintrapartum
chlorhexidinevaginaldouchingforreducingtheriskofmaternalandneonatalinfection[33].
MaternalactivityandpositionLaboringwomenshouldassumepositionsthatarecomfortable[34,35],
unlessspecificpositionsareneededbecauseofmaternalfetalstatusandneedforclosemonitoring.Ina2013
metaanalysisincluding25trials(5218women),thedurationofthefirststagewasmorethanonehourshorter
inwomenrandomlyassignedtouprightpositions(standing,sitting,kneeling,walkingaround)thaninthose
randomlyassignedtorecumbentpositionsorbedcare(1.36hours,95%CI2.22to0.51hours)andwomenin
uprightpositionshadamodestreductionincesareandelivery(RR0.71,95%CI0.540.94),buttherewereno
statisticaldifferencesinuseofoxytocinaugmentation(RR0.89,95%CI0.761.05),maternalpainrequiring
analgesia(RR0.95,95%CI0.841.08),ordurationofthesecondstage(3.71minutes,95%CI9.371.94
minutes)[35].Forwomenwhohadepiduralanesthesia,therewerenodifferencesbetweenthoserandomized
touprightversusrecumbentpositionsforanyoftheoutcomesexamined.Somelimitationsofthesetrials
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includeriskofbiassinceblindingwasnotpossibleandwidevariationinthepatientspositionsandtimespent
invariouspositions.
A2013metaanalysisoffiverandomizedtrialsontheeffectofuprightversusrecumbentpositioninthesecond
stageoflaborinwomenwithepiduralanalgesiadidnotfindconclusiveevidencethatpositionaffectedtherate
ofoperativedelivery,durationofthesecondstage,oranyothermaternalorfetaloutcome[34].
PaincontrolManagementofpainduringlaboranddeliveryisreviewedseparately.(See"Pharmacologic
managementofpainduringlaboranddelivery".)
MonitoringanddocumentationAllpatientsinlaborshouldhaveanestimatedfetalweightdocumented,
eitherbyultrasoundorclinicalexamination.Allpregnantwomenrequiresurveillance(eg,monitoringofvital
signsandFHR)throughoutlaboranddeliveryasintrapartumcomplicationscanariserapidlyeveninlowrisk
women20to25percentofallperinatalmorbidityandmortalityoccursinpregnancieswithnounderlyingrisk
factorsforadverseoutcome[36].Assessmentoftheuterinecontractionsandcervicalexaminationsare
repeatedatappropriateintervalstofollowtheprogressoflabor.
FollowupexaminationsFewrandomizedtrialshaveevaluatedtheoptimumfrequencyandtimingof
intrapartumcervicalexamination[37].Ingeneral,vaginalexaminationsareperformed:

Onadmission
Atonetofourhourintervalsinthefirststageandatonehourintervalsinthesecondstage
Priortointrapartumadministrationofanalgesia
Whentheparturientfeelstheurgetopushtodeterminewhetherthecervixisfullydilated
IfFHRabnormalitiesoccurtoevaluateforconditionssuchascordprolapseoruterinerupture

Thenumberofexaminationsiskepttoaminimumtoavoidpromotingintraamnioticinfectionandforpatient
comfort.(See"Intraamnioticinfection(chorioamnionitis)",sectionon'Riskfactors'.)
FetalheartrateThelaboradmissiontestdoesnotappeartobeofvalueitisreviewedseparately.(See
"Intrapartumfetalheartrateassessment",sectionon'Laboradmissiontest'.)
Thevalueofroutinecontinuouselectronicfetalmonitoringduringlaboriscontroversial[3840].TheUnited
StatesPreventiveServicesTaskForce,theCanadianTaskForceonPreventiveHealthCare,andothershave
madethefollowingstatements[4143]:
Routineelectronicfetalmonitoringforlowriskwomeninlaborisnotmandatory.
Thereisinsufficientevidencetorecommendfororagainstintrapartumelectronicfetalmonitoringforhigh
riskpregnantwomen.
Nevertheless,someformoffetalheartrateassessmenthasbecomeastandardofcareforallwomeninthe
UnitedStatesandwillnotbeabandonedbecausepatientsandcliniciansarereassuredbynormalresultsand
believethereissomevalueindetectingabnormalpatterns.
Ingeneral,eithermanualauscultationorcontinuouselectronicfetalmonitoringisacceptableduringlabor.In
practiceintheUnitedStates,sincecurrentstandardsallowonenursetocarefortwolaboringuntilthesecond
stageoflabor,electronicfetalmonitoringismorepractical.(See"Intrapartumfetalheartrateassessment".)
Duringthefirststageoflabor,wesuggestthattheFHRbecheckedatleastevery15minutesandrecorded
duringandimmediatelyafteracontraction,whendecelerationsaremostlikelytooccur.Duringthesecond
stageoflabor,wesuggestthattheFHRbecheckedatleasteveryfiveminutes,andduringandimmediately
aftereachuterinecontraction.Ingeneral,continuousintrapartumFHRmonitoringissuggestedforhighrisk
patients[40]andwhenFHRbelow110orover160beatsperminutearedetected.
TheAmericanCollegeofObstetriciansandGynecologistssuggeststhatelectronicfetalmonitoringtracingsbe
reviewedevery30minutesinthefirststageoflaborandevery15minutesinthesecondstageinlowrisk
patients[40].Forhigherriskpatients,theysuggestreviewingthetracingevery15minutesinthefirststage
andeveryfiveminutesinthesecondstage.Wesuggestthatreviewandassessmentbedocumentedinthe
patient'smedicalrecord.
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Thisdocumentationshouldincludeadescriptionofuterinecontractions,baselineFHRrate,baselineFHR
variability,presenceorabsenceofaccelerations,presenceorabsenceofperiodic(ie,withcontractions)or
episodic(ie,unrelatedtocontractions)decelerations,andchangesintheFHRovertime.
UterinecontractionsUterinecontractionsaremonitoredtohelpinassessinglaborprogressionandfetal
heartratepatterns.Ninetyfivepercentofwomeninactivelaborwillhavethreetofivecontractionsper10
minutes.Excessiveuterineactivity(hyperstimulationortachysystole)isusuallycausedbyadministrationof
uterotonicdrugsnoniatrogenictachysystoleisusuallyrelatedtoabruptioplacentaorchorioamnionitis.
Hypocontractileuterineactivitymaybeduetodrugs(includinggeneralorregionalanesthesia),prolongedlabor,
fetopelvicdisproportion,uterinerupture,chorioamnionitis,dehydration,andexcessiveuterinedistention.
Uterineactivitycanbeassessedqualitativelybysimpleobservationofthemotherandpalpationofthefundus
oftheuterusthroughtheabdomenorbyexternaltocodynamometry.Bothmethodsprovidegoodinformationon
thefrequencyofcontractionsandanindicationoftheirduration.Neithermethodaccuratelyassesses
contractionstrength.(See"Mechanismofnormallaboranddelivery",sectionon'Powers(uterine
contractions)'.).
Maternalperceptionisinfluencedbywhetherthegravidahasreceivedanalgesia,aswellasthestrengthofthe
contraction,parity,andmaternalweight:nulliparousandobesewomenmaynotperceiveweakcontractions.
Contractionslessthan15mmHgarenotpainfulbecausetheydonotdistendtheloweruterinesegmentand
cervix,thustheymaynotbeperceivedbythemother[44,45].Theabilitytoassesscontractionsbypalpationis
influencedbythethicknessandtoneoftheabdominalwallandproviderexperience.Externaltocodynamometry
isaconvenientmeansforcontinuouslyrecordingcontractions,butisaffectedbymaternalmovement(eg,
breathing,coughing,vomiting,pushing,sitting,turning).Thetransducerhastobepositionedcorrectlyandthe
belttightenedappropriatelytodetectthechangeinshapeoftheuteruswhenitcontracts.Itworksbestwhen
themotheristhin,doesntmovearoundmuch,andispartiallysupine.However,confiningtheparturienttoher
bedandrestrictingpositionalchangestobetterevaluateuterinecontractionandfetalheartratepatternsis
undesirableandonlyindicatedwhenclinicallynecessary.
Uterineactivitycanalsobemeasuredquantitativelybydirectmeasurementofintrauterinepressureviainternal
tocodynamometrywithpressuretransducers.Alargerandomizedtrialthatcomparedpregnancyoutcomewith
internalversusexternaltocodynamometrydemonstratedthatbothmethodswereequivalentintermsof
operativedeliveryrates(cesarean,instrumentalvaginal)andneonataloutcomes[46].Giventhesedata,
externaltocodynamometryispreferredsinceitisnotassociatedwithseriousmaternalorfetalmorbidity.
Althoughcomplicationsareuncommon,useofinternaltocodynamometrycanbeassociatedwithseriousrisks,
includingtraumatotheplacenta,umbilicalcord,fetus,oruterusduringinsertionmaternaland/orfetalinfection
fromintroductionofaforeignbodyandpossiblyanaphylactoidsyndromeofpregnancy.(See"Insertionof
intrauterinepressurecatheters".)
AmniotomySomeprovidersartificiallyruptureintactfetalmembranesafterthediagnosisoflaborismade
toassessthequantityoffluidandthepresenceofmeconium.Anormalvolumeofclearamnioticfluidsuggests
thatfetalacidosisisunlikely,assumingthatdeliveryoccurswithinashortperiodoftimeandthereareno
suddenlaborcomplications(eg,placentalabruption,cordprolapse)[47].However,thepresenceofclear
amnioticfluiddoesnotdiminishtheneedtoevaluatefetuseswithnonreassuringFHRpatterns[48].
Routineruptureofthemembranesdoesnotacceleratespontaneouslabor.A2013systematicreviewof15
randomizedtrialsinvolving5583womencomparedtheoutcomeofwomenmanagedwithroutineamniotomy
versusthoseinwhompreservationofintactmembraneswasplanned[49].Comparedtothecontrolgroup:
Amniotomydidnotresultinasignificantreductioninthedurationofthefirststageoflabor(mean
difference20.4minutes,95%CI95.9to55.1minutes)orthesecondstage(meandifference1.33
minutes,95%CI2.92to0.26minutes).Thelackofsignificantreductionwasnotedinbothprimiparous
andmultiparouswomen.
Amniotomysignificantlyreducedtheriskofdysfunctionallabor(RR0.60,95%CI0.440.82)andoxytocin
augmentation(RR0.72,95%CI0.540.96).However,therewasatrendtowardanincreasedrateof
cesareandelivery(RR1.27,95%CI0.991.63).Thus,thestatisticalreductionsindysfunctionallaborand
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oxytocinusewerenotclinicallyadvantageous.
Amniotomydidnotincreasetheriskofmaternalinfectionoruseofnarcoticorepidural
analgesia/anesthesia.
Alimitationofthisanalysiswasthelackofconsistencyinthetimingofamniotomywithrespecttocervical
dilation.Inaddition,20to60percentofwomenassignedtothecontrolgroupreceivedanamniotomyatsome
stageintheirlabor.
Another2013metaanalysisincluded11trialsthatenrolledwomenwhowereinnormalspontaneouslaborat
randomizationandthenallocatedthemtoearlyamniotomyandoxytocinifslowprogressinlaborensuedorto
expectantmanagement[50].Thiscombinationofinterventionsresultedinamodestreductioninriskof
cesareandelivery(RR0.87,95%CI0.770.99,11trials,7753women)andshortenedlaborbyaboutonehour
(1.11,95%CI1.82to0.41,7trials,4675women).
Wedonotperformroutineamniotomyiflaborisprogressingwell.Wediscourageroutineamniotomy,even
whenprogressisslow,iftheheadisnotengaged.Amniotomyisindicatedtofurtherevaluatefetalstatus(eg,
placementofafetalscalpelectrode)oruterinecontractions(eg,placementofanintrauterinepressure
catheter).
Ifmembranesarerupturedwhenthereispolyhydramniosoranunengagedfetalpresentingpart,itisprudentto
useasmallgaugeneedle,ratherthanahook,topuncturethefetalmembranesinoneormoreplaces,andto
performtheprocedureintheoperatingroom.This"controlledamniotomy"minimizestheriskofgushing
amnioticfluidandpermitsemergencycesareandeliveryintheeventofanumbilicalcordprolapse.(See
"Umbilicalcordprolapse".)
Amniotomyshouldbeavoided,ifpossible,inwomenwithactivehepatitisB,hepatitisC,orHIVinfectionin
ordertominimizeexposureofthefetustoascendinginfection.PositiveGBScarrierstatus,ontheotherhand,
isnotacontraindicationtoamniotomy,ifindicated.
NormalprogressoflaborandlaborabnormalitiesAssessingwhetherlaborisprogressingnormallyisa
keycomponentofintrapartumcarehowever,determiningtheonsetoflabor,measuringitsprogress,and
evaluatingthefactorsthataffectitscourse(power,passenger,pelvis)isaninexactscience.Criteriafornormal
andabnormalprogressandmanagementofprotractedlaborarediscussedindetailseparately.(See"Overview
ofnormallaborandprotractionandarrestdisorders".)
PersistentanteriorcervicallipThefinalcentimeterofcervixanteriorlybetweenthepelvicbrimandthe
fetalheadusuallyrapidlydisappearsasthecervixfullydilatesandthefetalheaddescends.Ananteriorlipthat
persistsforgreaterthan30minutesmaybeavariationofnormalormayindicatealaborabnormalityor
malposition,suchasocciputposteriorpresentation.Anabnormalityormalpositionismorelikelyifthelip
becomesedematous.Someauthorssuggestrepositioningtheparturient,monitoringlaborprogress,and
exercisingpatiencetoseeifthelipresolvesovertime.Otherssuggestmanualreductiontoavoidprolonged
laborandtheriskofcervicallaceration,cervicalnecrosis,ordetachmentofthelip.Wedonotadviseroutine
manualreductionofananteriorlipbecauseoftheriskofcervicalinjuryandhemorrhage.Thisisespeciallytrue
iftheanteriorlipdoesnotreduceeasily.
Thefollowingprocedurehasbeensuggestedformanualreductionofananteriorcervicallip[51]:
Placeyourfingersontheanteriorlipwhereittouchesthefetalhead
Duringacontraction,useyourfingerstopushthecervicallipbackwardsuntilitslipsoverthefetalhead
andabovetheinteriorborderofthesymphysispubis
Holdthecervicallipinthispositionwhilewaitingforthenextcontraction.
Allowyourfingers,butnotthecervix,tobepusheddownwardsandoutasthefetalheaddescendswith
contractionsandmaternalpushing
Removeyourfingerswhenthecervixreducesoriftheprocedureisunsuccessfulorpoorlytolerated
DELIVERYSpontaneousvaginaldeliveryisdescribedbelow.Operativevaginalandabdominaldeliveryare
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discussedseparately.(See"Operativevaginaldelivery"and"Cesareandelivery:Technique".)
PerinealmassageAntepartumandintrapartumperinealmassagehavebeenproposedasameansof
softeningandstretchingtheperineumtoreduceperinealtraumaduringbirth.Althoughnotharmful,wedonot
routinelysuggestorperformperinealmassageaswefeelthereisinsufficienthighqualityevidence
demonstratingaclinicallysignificantbenefit.
Asystematicreviewreportedantepartumperinealmassageperformedatleastweeklyinthelastmonth
ofpregnancywasassociatedwithasmalloverallreductionintheincidenceoftraumarequiringsuturing
(RR0.91,95%CI0.860.96fourtrials,2480women)andfewerepisiotomies(RR0.84,95%CI0.74
0.95),butonlyinwomenwithnopreviousvaginaldeliveries[52].
Asystematicreviewoftrialsofintrapartumperinealinterventionsduringthesecondstagereporteduse
ofwarmcompressessignificantlyreducedtherateofthirdandfourthdegreetears(RR0.48,95%CI
0.280.84twotrials,1525women)[53].Perinealmassagewasalsoassociatedwithasignificant
reductionintherateofthirdandfourthdegreetears(RR0.52,95%CI0.290.94twotrials,2147
women).However,lackofblinding,differencesintheprovisionofusualcare,andinabilitytoaddressthe
importanceofotherfactorsrelatedanalsphincterinjurylimitinterpretationofthesefindings.
PushingObstetricpracticeintheUnitedStatesoftendictatesthattheparturientbeginpushingwhenthe
cervixattainsfulldilation(10cm).However,someclinicianshavequestionedthispracticeandsuggested
delayingpushinguntilthepresentingfetalparthasdescendedand/orthepatientfeelstheurgetopush.A
metaanalysisofpooleddatafrom12randomizedtrialsofimmediateversusdelayedpushingfoundthat
delayedpushingresultedinasmallbutstatisticalincreaseinawoman'schanceofhavingaspontaneous
vaginalbirth(61.5versus56.9percent,RR1.09,95%CI1.031.15),aswellasprolongationofthesecond
stage(meandifference57minutes,95%CI42to72minutes)andlesstimepushing(meandifference22
minutes,95%CI31to13minutes),butdidnotleadtoastatisticalreductionintherateofcesareanbirth(4.9
versus5.9percentRR0.85,95%CI0.631.14)orinstrumentaldelivery(33.7versus37.4percentRR0.89,
95%CI0.761.06)[54].Therewereinsufficientdataonwhichtobaseconclusionsaboutotherclinically
importantmaternalandneonataloutcomes.Inaddition,thesefindingsmaynotapplytosettingswithmuch
highercesareandeliveryrates(30percent)andmuchlowerinstrumentaldeliveryrates(5percent),whichare
commonintheUnitedStates.
Giventheavailabledata,thedecisiontodelaypushingcanbebasedonpatientspecificfactors,suchasthe
needtoexpeditedelivery(eg,inthepresenceofintraamnioticinfection),maternalfatigue,andmaternal
preference.IftheFHRtracingisreassuringandtheheadishigh,weoftendelaypushinguntilthewomanfeels
anurgetopush.
Theoptimummaternalpositionduringpushingisunclear[55].Physiologicbenefitspostulatedforanupright
ratherthanrecumbentpositionincludethepositiveeffectofgravityontheuterus,lessenedriskofaortocaval
compressionandimprovedacidbaseoutcomesinthenewborns,strongerandmoreefficientcontractions,
improvedalignmentofthefetusforpassagethroughthepelvis,andanincreaseinpelvicdimensions
(radiologicalevidenceoflargeranteriorposteriorandtransversepelvicoutletdiameters)[55].Forwomeninan
uprightposition,majoroutcomesappeartobesimilarwhetherkneelingorsitting[56].Wehavethepatientpush
inthepositionshefindsmostcomfortable,butadviseagainstthesupineposition.
Theoptimumpushingtechniqueisalsounclear.Womenaretypicallytoldtopullbacktheirknees,tuckintheir
chin,takeadeepbreath,beardownatthestartofacontraction,andpushwithaclosedglottis(Valsalva
pushing)for10secondswiththegoalofthreepushespercontraction.However,thereisnoevidencethat
coachingwomenintheirexpulsiveeffortshasanybenefitoverallowingthewomantobeardownandpush
accordingtoherownreflexneedsinresponsetothepainofcontractionsandthepressurefeltfromdescentof
thefetalhead[57].Wegenerallyfavorallowingthepatienttobeardownwhenshefeelstheneed
(spontaneouspushingorphysiologicalpushing),unlessepiduralanesthesiahasimpactedthebearingdown
sensation.WedonotadvisewomentouseValsalvapushing,asthereisnoclinicallysignificantbenefittothis
technique[57].
InthepresenceofareassuringFHRandcontinuedprogress,itisdesirableforanulliparouspatientwithout
regionalanesthesiatopushforaslongastwohours(threehourswithregionalanesthesia)beforeresortingto
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interventionstofacilitatedelivery[58].However,ifthereiscontinuedprogressandnoevidenceofmaternalor
fetalcompromise,longertimesarenotassociatedwithincreasedmorbidity.(See"Overviewofnormallabor
andprotractionandarrestdisorders".)
DeliverysiteandmaternalpositionPreparationforspontaneousvaginaldeliveryshouldtakeintoaccount
thepatient'sparity,laborprogression,fetalpresentation,andcomplicationsofthelabor.Ifitisanticipatedthat
fetalmanipulationmaybenecessary,suchaswithtwinpregnanciesorshoulderdystocia(seeindividualtopic
reviewsonthesesubjects),wesuggesttransferringthepatienttoadeliveryroomequippedforemergency
surgery.Wealsosuggestencouragingdeliveryinthelithotomypositioninthesesettings.Stirrupsarenot
mandatory[59].
Ifnocomplicationsareanticipated,deliverycanbeaccomplishedinanappropriatelyequippedlaborroomwith
themotherinalmostanypositionthatshefindscomfortable[55].Commonpositionsincludethelateral(Sims)
positionandthepartialsittingposition.
EpisiotomyTheuseofepisiotomyinobstetricpracticeisdecreasing.Wesuggestlimitingthisprocedureto
deliverieswithahighriskofsevereperineallaceration,softtissuedystocia,orneedtofacilitatedeliveryofa
possiblycompromisedfetus.Thereisnobenefittoroutineepisiotomyatdelivery.(See"Approachto
episiotomy".)
DeliveryoftheinfantTheresponsibilitiesoftheaccoucheuraretoreducetheriskofmaternalperineal
trauma,preventfetalinjury,andprovideinitialsupportofthenewborn.Thereisnoconsensusregardingthe
bestmethodofprotectingtheperineumatdelivery[6069],otherthanavoidingroutineepisiotomy.Options
includeeffectingdeliverybetweencontractionsversusduringacontraction,andvariousmethodsofusingthe
accoucheur'shandstocontroldeliveryofthefetalhead.Thelattermayinvolvenotouch,passiveperineal
support,supportofthefetalcrown,andusingfingersplacedbetweentheanusandcoccyxtoactivelyliftthe
fetalchinanteriorly(ie,Ritgenmaneuver).Warmpadsandperinealmassage(see'Perinealmassage'above)
havealsobeentried,withinconsistentresults[66,68].
Althoughdatafromobservationalstudiesandrandomizedtrialsareinconsistent,weusethefollowingapproach
(calledthehandsontechnique)topreventprecipitousexpulsionoftheinfant,whichhasbeenassociatedwith
tearingoftheperineumandanalsphincter[60,69,70]:
Weaskthewomantopantormakeonlysmallexpulsiveeffortswhentheheadisfullycrowningand
deliveryisimminent.Thishelpskeeptheheadfromtearingthroughtheperineum.
Weplaceonehandonthevertextomaintaintheheadinaflexedpositionandcontrolthespeedof
crowning
Weusetheotherhandtoeasetheperineumoverthefetalhead.
Avoidingfundalpressure,midlineepisiotomy,anddeliveryinasquattingposition,andperformingdelivery
underepiduralanesthesiaalsoappeartoreducetheriskofanalsphincterlaceration[7174].(See"Effectof
pregnancyandchildbirthonanalsphincterfunctionandfecalincontinence"and"Operativevaginaldelivery"
and"Approachtoepisiotomy".)
Oncethefetalheadisdelivered,externalrotation(restitution)occursspontaneously.Ifthecordisaroundthe
neck(nuchalcord),slippingthecordovertheheadusuallysuccessfullyfreesthefetusfromthetether.Ifa
singlenuchalcordisnotreducible,wedoublyclampandtransectit.Otheroptionsthathavebeendescribedfor
acordthatisdifficulttoreducebutnottightincludeslippingitovertheshouldersanddeliveringthebaby's
bodythroughtheloop,anddeliveringthebodywithoutreducingthecord(somersaultmaneuver).
Mucusisgentlywipedfromthefetalnoseandmouth.Thereisnoevidencethatoronasopharyngealsuctioning
byabulborcatheterisbeneficialinhealthyterminfants[7579]and,insomestudies,suctioningslightly
loweredneonataloxygensaturationinthefirstfewminutesoflife[75,78,79].Suctioningimmediatelyafterbirth
isappropriateforbabieswithobviousobstructiontospontaneousbreathingduetosecretionsorwhoarelikely
torequirepositivepressureventilation.Themouthissuctionedfirstandthenthenarestodecreasetheriskfor
aspiration(newbornsareobligatenosebreathers).Suctioningoftheposteriorpharynxshouldbeavoided,asit
canstimulateavagalresponse,resultinginapneaand/orbradycardia.Inarandomizedequivalencytrial,wiping
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theface,mouth,andnosewithatowelwasequivalenttosuctionwithabulbsyringe[80].Thetrialsprimary
endpointwasmeanrespiratoryratewithinthefirst24hoursafterbirthinfantswhowerenonvigorousorborn
withmeconiumstainedamnioticfluidwereexcluded.(See"Overviewoftheroutinemanagementofthehealthy
newborninfant",sectionon'Deliveryroomcare'and"Neonatalresuscitationinthedeliveryroom",sectionon
'Airway'.)
Afterdeliveryofthehead,ahandisplacedoneachparietaleminenceandtheanteriorshoulderisdelivered
withthenextcontraction,usinggentledownwardtractiontowardsthemother'ssacruminconcertwith
maternalexpulsiveefforts.Inthisway,theanteriorshoulderisencouragedtoslipunderthesymphysispubis.
Theposteriorshoulderisthendeliveredbyupwardtraction.Thesemovementsshouldbeperformedwithas
littledownwardorupwardforceaspossibletoavoidperinealinjuryand/ortractioninjuriestothebrachial
plexus.Thedeliveryisthencompleted,eitherspontaneouslyorwithagentlematernalpush.
Theinfantiswipeddrywithatowel.Earlyinteractionbetweenthemotherandherinfantshouldbeencouraged
bysupportingskintoskincontactandearlyinitiationofbreastfeeding.(See"Overviewofpostpartumcare",
sectionon'Deliveryroom'.)
Thelocationofthenewborn(aboveorbelowtheleveloftheplacenta)beforecordclampingdidnotappearto
significantlyaffectvolumeofplacentaltonewborntransfusioninarandomizedtrial[81].Therefore,concerns
abouttransfusionvolumeshouldnotinfluencethedecisiontoplacethenewbornonthemothersabdomen.
MeconiumInthepresenceofmeconium,ithadbeencommonforobstetricalcareproviderstoaspiratethe
upperairwaysontheperineuminanattempttoreducetheriskofmeconiumaspirationsyndrome.However,
randomizedtrialsshownthatthisapproachdoesNOTdecreasemeconiumaspirationsyndromenorimprove
perinataloutcome[82].Basedonthesedata,theAmericanHeartAssociation,theAmericanAcademyof
Pediatrics,andtheAmericanCollegeofObstetriciansandGynecologistsrecommendedagainstroutine
intrapartumsuctioningofmeconiumstainedinfantswhoarevigorousatbirth[83,84].(See"Preventionand
managementofmeconiumaspirationsyndrome".)
CordclampingTraditionally,thetimingofcordclampingintheabsenceofamaternalorfetal/neonatal
medicalemergencywasdictatedbyconvenienceandwasusuallyperformedwithinoneminuteofdelivery[85].
Approximately75percentofthebloodavailableforplacentaltofetaltransfusionistransfusedinthefirstminute
afterbirth[86].Thepotentialvalueofdelayedcordclampingisadecreaseinneonatalandinfantanemia,but
potentiallyatacostofahigherrateofpolycythemiaandneonataljaundice,asillustratedinthefollowingmeta
analyses:
TerminfantsA2013metaanalysisof15randomizedtrialsincluding3911mothersandtheirinfants
evaluatedearlyversuslate(twotothreeminutesafterbirth)cordclampinginterminfants[87].Compared
toearlycordclamping,latecordclampingresultedinsignificantlyhigherneonatalhemoglobinlevelsat24
to48hoursafterbirth(meandifference1.49g/dL),butnotinsubsequentassessments,andsignificantly
lessirondeficiencyininfantsatthreetosixmonthsofage(14percentofinfantsintheearlyclamping
groupversus8percentinthelateclampinggroup).However,latecordclampingalsoresultedina40
percentincreaseinnewbornsneedingphototherapyforjaundice(2.74percentofinfantsintheearly
clampinggroupversus4.36percentinthelateclampinggroup).
PreterminfantsA2012metaanalysisof15randomizedtrialsevaluatedlateversusearlycord
clampingin738preterminfants[88].Comparedtoearlycordclamping,latecordclampingwas
associatedwithfewerinfantsrequiringtransfusionforanemia(24versus36percentRR0.61,95%CI
0.460.81seventrials,392infants),lowerriskofnecrotizingenterocolitis(21versus32percentRR
0.62,95%CI0.430.90fivetrials,241infants),andfewerinfantswithanygradeofintraventricular
hemorrhageonultrasound(14versus20percentRR0.59,95%CI0.410.8510trials,539infants).
Peakbilirubinlevelwassignificantlyhigherwithdelayedcordclamping,buttherewasnosignificant
increaseintheneedfortreatmentofjaundice.
A2014metaanalysisrestrictedtorandomizedtrialsofinterventionstopromoteplacentaltransfusion
(delayedcordclamping,cordmilking)inpregnancies<32weeksofgestationalsoreportedsignificant
neonatalbenefits(reducedmortality,reducedrateoftransfusion,reducedrateofintraventricular
hemorrhage)[89].Therewasalsoastrongtrendtowardhigherpeakbilirubinlevelswiththeintervention.
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Higherinfantironstoresmaybeparticularlyadvantageousforinfantsofmotherswithlowferritinlevels,
breastfedinfantsnotreceivingironsupplementsorfortifiedformula,andpreterminfants.Anadditionalbenefit
ofavoidingimmediatecordclampingisthatclampingbeforeinitiationofspontaneousrespirations(meanonset
1015secondsafterexpulsion[90])appearstoadverselyaffectcardiovascularhemodynamicsduringthe
fetaltoneonataltransition,likelyduetoremovalofthelowvascularresistanceplacentalcirculationbefore
dilatationofthepulmonaryvascularbed[9193].Thismaypartiallyaccountforsomeofthenonhematological
benefitsreportedintrialsofdelayedcordclamping.InanobservationalstudyperformedinaruralTanzanian
hospital,healthyselfbreathingneonatesweremorelikelytodieorbeadmittedtoaneonatalcareunitifcord
clampingoccurredbeforeorimmediatelyafteronsetofspontaneousrespirations,butnotwithdelayedcord
clamping[94].
Disadvantagesofdelayedcordclampingincludeanincreaseinhyperbilirubinemiaintheimmediatenewborn
periodresultinginmorephototherapyandanincreasedriskofpolycythemiaingrowthrestrictedneonates.
Delayingcordclampingalsoreducesthevolumeofumbilicalcordbloodavailableforharvestingstemcells,
thusthesizeandcelldoseofcollectedcordbloodunitsmaynotbeadequateforafuturehematopoieticcell
transplantifcordclampingisdelayed.Thisshouldbeconsideredwhencordbloodcollectionisplannedforthis
purpose.(See"Collectionandstorageofumbilicalcordbloodforhematopoieticcelltransplantation".)
Delayedcordclampingshouldnevercompromisethesafetyofthemotherorinfantduringchildbirth.Inthe
absenceofamaternalorfetal/neonatalmedicalemergency,whetherthereisaclinicalbenefitfromroutineuse
ofdelayedcordclampinginalltermdeliveriesisstillunprovenbyhighqualitydatatherefore,weagreewith
theAmericanCollegeofObstetriciansandGynecologists(ACOG)committeeopinionthatthedecisionto
performearlyordelayedcordclampingshouldbeindividualized[95].
Inpreterminfants,weagreewiththeACOGcommitteesopinionthatthesignificantreductionof
intraventricularhemorrhageassociatedwithdelayedcordclampingissufficientlycompellingtoadoptthis
intervention.
CordmilkingWedonotmilkorstriptheumbilicalcordhowever,thispracticeisanalternativeto
delayedclampingforenhancingbloodtransfusion.Arandomizedtrialinpreterminfantsfoundthatmilkingthe
accessiblelengthofthecordfourtimesataspeedof20cm/2secondswasequivalenttodelayingcord
clampingfor30seconds[96].
Cordmilkingmayhelptostabilizebloodpressureandincreaseurinaryoutputinprematureinfants[9799],but
atheoreticconcernisthatanonquantifiableamountofbloodwillbegiventoanimmatureinfantinan
uncontrolledfashion,whichcouldbeharmful.Ina2015metaanalysisofsevenrandomizedtrials(n=501
infants)ofumbilicalcordmilkingversususualcare,umbilicalcordmilkingsignificantlyincreasedhemoglobin
levelswithoutincreasingtheneedforphototherapyforhyperbilirubinemia[100].Inthe277infants<33weeks,
theneedforbloodtransfusionwasnotreducedandtheinterventiondidnotsignificantlyaffectmortality,
hypotensionrequiringvolumeexpandersorinotropesupport,severeintraventricularhemorrhage,ornecrotizing
enterocolitisrates.Thesedatadonotprovideconvincingevidencefororagainstumbilicalcordmilking.
Deliveryshouldnotbeunnecessarilydelayedtomilkthecordinsituationswhereimmediatepediatric
assistanceisneeded,suchasthickmeconiumorneonataldepression.Also,itshouldnotbedoneifcordblood
collectionisplanned.
CordbloodCordbloodcollectedfordiagnosticpurposesisusuallyobtainedbyallowingbloodtodrainfrom
thecutendintoaglasstubepriortodeliveryoftheplacenta,ifpossible.Cordbloodmaybetestedforblood
typeandRhortoscreenforavarietyofnewbornconditions,asindicated.BloodforpHtestingiscollected
fromtheumbilicalarterybyaneedleandsyringetominimizeexposuretoairandavoidmixingofarterialand
venousblood.(See"Umbilicalcordbloodacidbaseanalysisatdelivery".)
Collectionofcordbloodforbankingcanbeperformedwithasyringebeforeorafterdeliveryoftheplacenta,but
exuterocollectionispreferred.Theprocedureforcollectionofumbilicalcordbloodforbankingisreviewed
separately.(See"Collectionandstorageofumbilicalcordbloodforhematopoieticcelltransplantation".)
THIRDSTAGEOFLABORThethirdstageoflaboristheintervalfromthebirthofthebabytothe
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expulsionoftheplacenta.Thereisnouniversallyacceptedcriterionforthenormallengthofthethirdstage.
Twolargeseriesofconsecutivedeliveriesobservedthattheaveragelengthwasfivetosixminutes,andthat
90percentofplacentasweredeliveredwithin15minutesand97percentweredeliveredwithin30minutesof
birth[101,102].Thedurationofthethirdstageoflaborisimportantbecausetheprevalenceofpostpartum
hemorrhageincreasesasthedurationlengthens[101,103].
Gestationalageisthemajorfactorinfluencingthelengthofthethirdstage:pretermdeliveriesareassociated
withalongerthirdstageoflaborthantermdeliveries[101,102,104,105].Inonestudy,forexample,the
frequencyofretainedplacentawas20foldhigheringestations26weeksand3foldhigherinthoselessthan
37comparedwithtermpregnancies[101].
Themajorcomplicationsofthethirdstageoflaborare:
Hemorrhage(see"Overviewofpostpartumhemorrhage"and"Managementofpostpartumhemorrhageat
vaginaldelivery")
Retainedplacenta(see"Retainedplacentaaftervaginalbirth")
Uterineinversion(see"Puerperaluterineinversion")
NormalplacentalseparationMyometrialthickeningafterdeliveryoftheinfantleadstosubstantial
reductioninuterinesurfacearea,resultinginshearingforcesattheplacentalattachmentsiteandplacental
separation.Thisprocessgenerallybeginsatthelowerpoleoftheplacentalmarginandprogressesalong
adjacentsitesofplacentalattachment.A"waveofseparation"spreadsupwardssothattheuppermostpartof
theplacentadetacheslast[106,107].
Signsofplacentalseparationincludeagushofblood,lengtheningoftheumbilicalcord,andanteriorcephalad
movementoftheuterinefundus,whichbecomesfirmerandglobularaftertheplacentadetaches.Placental
expulsionfollowsseparationasaresultofacombinationofeventsincludingspontaneousuterinecontractions,
downwardpressurefromthedevelopingretroplacentalhematoma,andanincreaseinmaternalintraabdominal
pressure.(See"Overviewofpostpartumcare",sectionon'Uterineinvolution'.)
ActivemanagementActivemanagementisthepreferredapproachtomanagementofthethirdstageof
labor.Ina2011metaanalysiscomparingactiveversusexpectantmanagementofthethirdstageoflabor,
activemanagementresultedinreducedrisksofmaternalbloodloss>500mLand>1000mL,butdidnot
significantlyreducethelengthofthethirdstage[108].(See"Pharmacologicmanagementofthethirdstageof
labor",sectionon'Activemanagement'.)
Activemanagementgenerallyconsistsofprophylacticadministrationofanuterotonicagentbeforedeliveryof
theplacenta,typicallywithearlycordclamping/cuttingandcontrolledtractionoftheumbilicalcorduterine
massagealsomaybeperformed.Randomizedtrialshavedemonstratedthattheuterotonicagentisthemost
importantcomponentofthisregimen[109111].Wesuggestoxytocininfusionintoamaternalvein.(See
"Pharmacologicmanagementofthethirdstageoflabor",sectionon'Oxytocin'.)
DeliveryoftheplacentaWesuggestcontrolledcordtractiontofacilitateseparationanddeliveryofthe
placenta.Ina2014metaanalysisofrandomizedtrialscomparingcontrolledcordtractionwithahandsoff
approach,controlledcordtractionresultedinareducedneedformanualremovaloftheplacenta(RR0.70,95%
CI0.580.84),aswellassmallstatisticalreductionsinthedurationofthethirdstage(threeminutes),mean
bloodloss(10mL),andincidenceofpostpartumhemorrhage(11.8versus12.7percentRR0.93,95%CI0.87
0.99)theratesofseverepostpartumhemorrhage,needforadditionaluterotonics,andbloodtransfusionwere
notstatisticallydifferent[112].Othershavereportedsimilarfindings[113].Althoughthebenefitsofcontrolled
cordtractionaresmall,therearenosignificantharmsfromthemaneuverifperformedgentlywithoutexcessive
traction,whichcanresultincordavulsionoruterineinversion.
Twomaneuvershavebeendescribed:theBrandtAndrewsmaneuver(anabdominalhandsecurestheuterine
fundustopreventuterineinversionwhiletheotherhandexertssustaineddownwardtractionontheumbilical
cord)[114],andtheCrdemaneuver(thecordisfixedwiththelowerhandwhiletheuterinefundusissecured
andsustainedupwardtractionisappliedusingtheabdominalhand).WeprefertheBrandtAndrewsmaneuver.
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Ifthecordavulsesbeforedeliveryoftheplacenta,wewouldwaitupto30minutesforspontaneousplacental
separationandexpulsionwithmaternalpushing.Whilewaiting,preparationsareinitiatedincasemanual
removaloftheplacentaisneeded.Weintervenepromptlyifbleedingbecomesheavy.(See"Retainedplacenta
aftervaginalbirth",sectionon'Management'.)
Astheplacentaemergesfromthevagina,themembranesflowbehindit.Slowlyrotatingtheplacentaincircles
asitisdeliveredorgraspingthemembraneswithaclamphelpspreventthemfromtearingandpossiblybeing
retainedintheuterinecavity.
Theplacenta,umbilicalcord,andfetalmembranesshouldbesystematicallyexamined.Thefetalsideis
assessedforanyevidenceofvesselscoursingtotheedgeoftheplacentaandintothemembranes,
suggestiveofasuccenturiateplacentallobe.Thenumberofvesselsinthecordiscounted.(See"Gross
examinationoftheplacenta".)
BLOODLOSSAveragebloodlossatdeliveryisgenerallyestimatedtobe500mL.Theobstetriccare
providerandnursingstaffshouldbealerttoexcessivebloodlossandshouldbepreparedtointerveneas
required.(See"Overviewofpostpartumhemorrhage".)
REPAIROFLACERATIONSThecervix,vagina,andperineumshouldbecarefullyexaminedforevidence
ofbirthinjury.Themajorriskfactorsforthirdandfourthdegreeperineallacerationsarenulliparity,operative
delivery,episiotomy,anddeliveryofalargeforgestationalageinfant[115].
Ifalacerationisidentified,itslengthandpositionshouldbenotedandrepairinitiated.Adequateanalgesia
(eitherregionalorlocal)isessential,otherwiseexposureandoperativetechniquemaynotbeoptimal.Special
attentionshouldbepaidtorepairoftheperinealbody,theexternalanalsphincter,andtherectalmucosa.
Failuretorecognizeandrepairrectalinjurycanleadtoseriouslongtermmorbidity,mostnotablyurogenital
prolapsewithfecaland/orurinaryincontinence.(See"Urinaryincontinenceandpelvicorganprolapse
associatedwithpregnancyandchildbirth".)
POSTPARTUMISSUESANDCAREPostpartumissuesandcare,includingcareofthenewborn,are
reviewedseparately.(See"Overviewofpostpartumcare".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasics
andBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Laboranddelivery(childbirth)(TheBasics)"and"Patient
information:Howtotellwhenlaborstarts(TheBasics)"and"Patientinformation:Managingpainduring
laboranddelivery(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Keyelementsoflabormanagementincludegoodcommunicationwithandpreparationandsupportofthe
patient,attentiontohercomfort,andregularassessmentofbothmaternalandfetalstatus.(See
'Psychosocialissues'above.)
Thegoalsoftheinitialevaluationoftheparturientaretoestablishherbaselinecervicalstatus,reviewher
prenatalrecord,checkfordevelopmentofnewintrapartumcomplications,andevaluatethefetalstatus.
(See'Initialexamination'above.)
WomenwhohavenothadHIVscreeningshouldbeofferedrapidHIVtestinginlabor.(See'Laboratory
tests'above.)
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Eithermanualauscultationofthefetalheartrateorcontinuouselectronicfetalmonitoringisacceptable.
(See'Fetalheartrate'above.)
Werecommendnotperformingroutineenemas(Grade1A)andwesuggestnotroutinelyshavingthe
perineum(Grade2B).(See'Patientpreparation'above.)
Thereisnoconsensusonacceptablematernaloralintakeorneedforintravenousfluidsduringan
uncomplicatedlabor.Weallowourlowriskpatientstohaveclearliquids.Wesuggestplacementofan
intravenouslineorheparinlockforallwomeninlabor(Grade2C).(See'Fluidsandoralintake'above.)
Wesuggestthatallpregnantwomenwithcardiaclesionssusceptibletoinfectiveendocarditisreceive
antibioticprophylaxisfromtheonsetofactivelabor(Grade2C).TheAmericanHeartAssociation
recommendsantibioticprophylaxisforendocarditisinthepresenceofintraamnioticinfection.
Theoptimalpushingpositiontechnique,position,anddurationareunclear.Wesuggestthatthepatient
pushinthepositionshefindsmostcomfortableandwithanopenglottis(Grade2C).(See'Pushing'
above.)
Wedonotrecommendroutineepisiotomy(Grade1A).(See'Episiotomy'above.)
Routineintrapartumsuctioningofmeconiumstainedinfantsisunnecessary(Grade1A).(See'Meconium'
above.)
Werecommendactivemanagementofthethirdstageoflabor(Grade1A).(See'Activemanagement'
above.)
Inpretermbirths,werecommenddelayedcordclamping(Grade1B).Forterminfants,wesuggestthat
thedecisiontoperformearlyordelayedcordclampingorearlycordclampingandcordmilkingbe
individualized,basedonriskofanemia(Grade2B).(See'Cordclamping'above.)
Delayingcordclampingreducesthevolumeofumbilicalcordbloodavailableforharvestingstemcells
therefore,thesizeandcelldoseofcollectedcordbloodunitsmaynotbeadequateforafuture
hematopoieticcelltransplantifcordclampingisdelayed.(See'Cordclamping'above.)
Theplacentashouldbeexaminedtomakesureitisintact.(See'Activemanagement'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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GRAPHICS
Effacementanddilatationofthecervix

(A)Cervixisuneffacedandminimallydilated.(B)Cervixisalmost
completelyeffacedanddilated.
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Assessingdescentofthefetalheadbyvaginal
examination

Thefetusisat2stationsignifyingthattheleadingbonyedgeofthe
presentingpartistwocentimetersabovetheischialspines.Thehead
isengagedat0station.
Sp:ischialspine.
Graphic67068Version2.0

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Fetalheadattermshowingfontanelles,sutures,and
biparietaldiameter

Graphic81518Version7.0

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Occiputanteriorpositions

A:Rightocciputanterior(ROA)B:Leftocciputanterior(LOA)C:Occiputanterior(OA).
*Posteriorfontanel.Thisisthesmallerofthetwofontanelsandisattheintersectionofthe
threesutures:thesagittalsutureandtwolambdoidsutures.
**Anteriorfontanel.Thislargefontanelisattheintersectionoffoursutures:thesagittal,
frontal,andtwocoronalsutures.
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Occiputposteriorposition

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Occiputtransversepositions

(A)Rightocciputtransverse(ROT),(B)Leftocciputtransverse(LOT).
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Occiputposteriorandocciputtransversepositions

(A)Rightocciputposterior(ROP).
(B)Rightocciputtransverse(ROT).
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Longitudinallie,cephalicpresentation

Differencesinattitudeofthefetalbodyin(A)vertex,(B)brow,and(C)face
presentations.Adeflexedfetalneckresultsinawiderpresentingcephalic
diameter.
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