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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Labour and Delivery Care Module: 8. Abnormal Presentations and Multiple Pregnancies

Study session 8  abnormal presentations and multiple pregnancies, introduction.

In previous study sessions of this module, you have been introduced to the definitions, signs, symptoms and stages of normal labour, and about the ‘normal’ vertex presentation of the fetus during delivery. In this study session, you will learn about the most common abnormal presentations (breech, shoulder, face or brow), their diagnostic criteria and the required actions you need to take to prevent complications developing during labour. Taking prompt action may save the life of the mother and her baby if the delivery becomes obstructed because the baby is in an abnormal presentation. We will also tell you about twin births and the complications that may result if the two babies become ‘locked’ together, preventing either of them from being born.

Learning Outcomes for Study Session 8

After studying this session, you should be able to:

8.1  Define and use correctly all of the key words printed in bold . (SAQs 8.1 and 8.2)

8.2  Describe how you would identify a fetus in the vertex presentation and distinguish this from common malpresentations and malpositions. (SAQs 8.1 and 8.2)

8.3  Describe the causes and complications for the fetus and the mother of fetal malpresentation during full term labour. (SAQ 8.3)

8.4  Describe how you would identify a multiple pregnancy and the complications that may arise. (SAQ 8.4)

8.5  Explain when and how you would refer a woman in labour due to abnormal fetal presentation or multiple pregnancy. (SAQ 8.4)

8.1  Normal and abnormal presentations

8.1.1  vertex presentation.

In about 95% of deliveries, the part of the fetus which arrives first at the mother’s pelvic brim is the highest part of the fetal head, which is called the vertex (Figure 8.1). This presentation is called the vertex presentation . Notice that the baby’s chin is tucked down towards its chest, so that the vertex is the leading part entering the mother’s pelvis. The baby’s head is said to be ‘well-flexed’ in this position.

During early pregnancy, the baby is the other way up — with its bottom pointing down towards the mother’s cervix — which is called the breech presentation . This is because during its early development, the head of the fetus is bigger than its buttocks; so in the majority of cases, the head occupies the widest cavity, i.e. the fundus (rounded top) of the uterus. As the fetus grows larger, the buttocks become bigger than the head and the baby spontaneously reverses its position, so its buttocks occupy the fundus. In short, in early pregnancy, the majority of fetuses are in the breech presentation and later in pregnancy most of them make a spontaneous transition to the vertex presentation.

8.1.2  Malpresentations

You will learn about obstructed labour in Study Session 9.

When the baby presents itself in the mother’s pelvis in any position other than the vertex presentation, this is termed an abnormal presentation, or m alpresentation . The reason for referring to this as ‘abnormal’ is because it is associated with a much higher risk of obstruction and other birth complications than the vertex presentation. The most common types of malpresentation are termed breech, shoulder, face or brow. We will discuss each of these in turn later. Notice that the baby can be ‘head-down’ but in an abnormal presentation, as in face or brow presentations, when the baby’s face or forehead (brow) is the presenting part.

8.1.3  Malposition

Although it may not be so easy for you to identify this, the baby can also be in an abnormal position even when it is in the vertex presentation. In a normal delivery, when the baby’s head has engaged in the mother’s pelvis, the back of the baby’s skull (the occiput ) points towards the front of the mother’s pelvis (the pubic symphysis ), where the two pubic bones are fused together. This orientation of the fetal skull is called the occipito-anterior position (Figure 8.2a). If the occiput (back) of the fetal skull is towards the mother’s back, this occipito-posterior position (Figure 8.2b) is a vertex malposition , because it is more difficult for the baby to be born in this orientation. The good thing is that more than 90% of babies in vertex malpositions undergo rotation to the occipito-anterior position and are delivered normally.

You learned the directional positions: anterior/in front of and posterior/behind or in the back of, in the Antenatal Care Module, Part 1, Study Session 3.

Note that the fetal skull can also be tilted to the left or to the right in either the occipito-anterior or occipito-posterior positions.

8.2  Causes and consequences of malpresentations and malpositions

In the majority of individual cases it may not be possible to identify what caused the baby to be in an abnormal presentation or position during delivery. However, the general conditions that are thought to increase the risk of malpresentation or malposition are listed below:

Multiple pregnancy is the subject of Section 8.7 of this study session. You learned about placenta previa in the Antenatal Care Module, Study Session 21.

• Abnormally increased or decreased amount of amniotic fluid
• A tumour (abnormal tissue growth) in the uterus preventing the spontaneous inversion of the fetus from breech to vertex presentation during late pregnancy
• Abnormal shape of the pelvis
• Laxity (slackness) of muscular layer in the walls of the uterus
• Multiple pregnancy (more than one baby in the uterus)
• Placenta previa (placenta partly or completely covering the cervical opening).

If the baby presents at the dilating cervix in an abnormal presentation or malposition, it will more difficult (and may be impossible) for it to complete the seven cardinal movements that you learned about in Study Sessions 3 and 5. As a result, birth is more difficult and there is an increased risk of complications, including:

You learned about PROM in Study Session 17 of the Antenatal Care Module, Part 2.

• Premature rupture of the fetal membranes (PROM)
• Premature labour
• Slow, erratic, short-lived contractions
• Uncoordinated and extremely painful contractions, with slow or no progress of labour
• Prolonged and obstructed labour, leading to a ruptured uterus (see Study Sessions 9 and 10 of this Module)
• Postpartum haemorrhage (see Study Session 11)
• Fetal and maternal distress, which may lead to the death of the baby and/or the mother.

With these complications in mind, we now turn your attention to the commonest types of malpresentation and how to recognise them.

8.3  Breech presentation

In a b reech presentation , the fetus lies with its buttocks in the lower part of the uterus, and its buttocks and/or the feet are the presenting parts during delivery. Breech presentation occurs on average in 3–4% of deliveries after 34 weeks of pregnancy.

When is the breech position the normal position for the fetus?

During early pregnancy the baby’s bottom points down towards the mother’s cervix, and its head (the largest part of the fetus at this stage of development) occupies the fundus (rounded top) of the uterus, which is the widest part of the uterine cavity.

8.3.1  Causes of breech presentation

You can see a transverse lie in Figure 8.7 later in this study session.

In the majority of cases there is no obvious reason why the fetus should present by the breech at full term. In practice, what is commonly observed is the association of breech presentation at delivery with a transverse lie earlier in the pregnancy, i.e. the fetus lies sideways across the mother’s abdomen, facing a sideways implanted placenta. It is thought that when the placenta is in front of the baby’s face, it may obstruct the normal process of inversion, when the baby turns head-down as it gets bigger during the pregnancy. As a result, the fetus turns in the other direction and ends in the breech presentation. Some other circumstances that are thought to favour a breech presentation during labour include:

• Premature labour, beginning before the baby undergoes spontanous inversion from breech to vertex presentation
• Multiple pregnancy, preventing the normal inversion of one or both babies
• Polyhydramnios: excessive amount of amniotic fluid, which makes it more difficult for the fetal head to ‘engage’ with the mother’s cervix (polyhydramnios is pronounced ‘poll-ee-hy-dram-nee-oss’. Hydrocephaly is pronounced ‘hy-droh-keff-all-ee’)
• Hydrocephaly (‘water on the brain’) i.e. an abnormally large fetal head due to excessive accumulation of fluid around the brain
• Placenta praevia
• Breech delivery in the previous pregnancy
• Abnormal formation of the uterus.

8.3.2  Diagnosis of breech presentation

On abdominal palpation the fetal head is found above the mother’s umbilicus as a hard, smooth, rounded mass, which gently ‘ballots’ (can be rocked) between your hands.

Why do you think a mass that ‘ballots’ high up in the abdomen is a sign of breech presentation? (You learned about this in Study Session 11 of the Antenatal Care Module.)

The baby’s head can ‘rock’ a little bit because of the flexibility of the baby’s neck, so if there is a rounded, ballotable mass above the mother’s umbilicus it is very likely to be the baby’s head. If the baby was ‘bottom-up’ (vertex presentation) the whole of its back will move of you try to rock the fetal parts at the fundus (Figure 8.3).

Once the fetus has engaged and labour has begun, the breech baby’s buttocks can be felt as soft and irregular on vaginal examination. They feel very different to the relatively hard rounded mass of the fetal skull in a vertex presentation. When the fetal membranes rupture, the buttocks and/or feet can be felt more clearly. The baby’s anus may be felt and fresh thick, dark meconium may be seen on your examining finger. If the baby’s legs are extended, you may be able to feel the external genitalia and even tell the sex of the baby before it is born.

8.3.3  Types of breech presentation

There are three types of breech presentation, as illustrated in Figure 8.4. They are:

• Complete breech is characterised by flexion of the legs at both hips and knee joints, so the legs are bent underneath the baby.
• Frank breech is the commonest type of breech presentation, and is characterised by flexion at the hip joints and extension at the knee joints, so both the baby’s legs point straight upwards.
• Footling breech is when one or both legs are extended at the hip and knee joint and the baby presents ‘foot first’.

8.3.4  Risks of breech presentation

Regardless of the type of breech presentation, there are significant associated risks to the baby. They include:

• The fetal head gets stuck (arrested) before delivery
• Labour becomes obstructed when the fetus is disproportionately large for the size of the maternal pelvis
• Cord prolapse may occur, i.e. the umbilical cord is pushed out ahead of the baby and may get compressed against the wall of the cervix or vagina
• Premature separation of the placenta (placental abruption)
• Birth injury to the baby, e.g. fracture of the arms or legs, nerve damage, trauma to the internal organs, spinal cord damage, etc.

A breech birth may also result in trauma to the mother’s birth canal or external genitalia through being overstretched by the poorly fitting fetal parts.

Cord prolapse in a normal (vertex) presentation was illustrated in Study Session 17 of the Antenatal Care Module, and placental abruption was covered in Study Session 21.

What will be the effect on the baby if it gets stuck, the labour is obstructed, the cord prolapses, or placental abruption occurs?

The result will be hypoxia , i.e. it will be deprived of oxygen, and may suffer permanent brain damage or die.

You learned about the causes and consequences of hypoxia in the Antenatal Care Module.

8.4  Face presentation

Face presentation occurs when the baby’s neck is so completely extended (bent backwards) that the occiput at the back of the fetal skull touches the baby’s own spine (see Figure 8.5). In this position, the baby’s face will present to you during delivery.

Refer the mother if a baby in the chin posterior face presentation does not rotate and the labour is prolonged.

The incidence of face presentation is about 1 in 500 pregnancies in full term labours. In Figure 8.5, you can see how flexed the head is at the neck. Babies who present in the ‘chin posterior’ position (on the right in Figure 8.5) usually rotate spontaneously during labour, and assume the ‘chin anterior’ position, which makes it easier for them to be born. However, they are unlikely to be delivered vaginally if they fail to undergo spontaneous rotation to the chin anterior position, because the baby’s chin usually gets stuck against the mother’s sacrum (the bony prominence at the back of her pelvis). A baby in this position will have to be delivered by caesarean surgery.

8.4.1  Causes of face presentation

The causes of face presentation are similar to those already described for breech births:

• Laxity (slackness) of the uterus after many previous full-term pregnancies
• Multiple pregnancy
• Polyhydramnios (excessive amniotic fluid)
• Congenital abnormality of the fetus (e.g. anencephaly, which means no or incomplete skull bones)
• Abnormal shape of the mother’s pelvis.

8.4.2  Diagnosis of face presentation

Face presentation may not be easily detected by abdominal palpation, especially if the chin is in the posterior position. On abdominal examination, you may feel irregular shapes, formed because the fetal spine is curved in an ‘S’ shape. However, on vaginal examination, you can detect face presentation because:

• The presenting part will be high, soft and irregular.
• When the cervix is sufficiently dilated, you may be able to feel parts of the face, such as the orbital ridges above the eyes, the nose or mouth, gums, or bony chin.
• If the membranes are ruptured, the baby may suck your examining finger!

But as labour progresses, the baby’s face becomes o edematous (swollen with fluid), making it more difficult to distinguish from the soft shape you will feel in a breech presentation.

8.4.3  Complications of face presentation

Complications for the fetus include:

• Obstructed labour and ruptured uterus
• Cord prolapse
• Facial bruising
• Cerebral haemorrhage (bleeding inside the fetal skull).

8.5  Brow presentation

In brow presentation , the baby’s head is only partially extended at the neck (compare this with face presentation), so its brow (forehead) is the presenting part (Figure 8.6). This presentation is rare, with an incidence of 1 in 1000 deliveries at full term.

8.5.1  Possible causes of brow presentation

You have seen all of these factors before, as causes of other malpresentations:

• Lax uterus due to repeated full term pregnancy
• Polyhydramnios

8.5.2  Diagnosis of brow presentation

Brow presentation is not usually detected before the onset of labour, except by very experienced birth attendants. On abdominal examination, the head is high in the mother’s abdomen, appears unduly large and does not descend into the pelvis, despite good uterine contractions. On vaginal examination, the presenting part is high and may be difficult to reach. You may be able to feel the root of the nose, eyes, but not the mouth, tip of the nose or chin. You may also feel the anterior fontanel, but a large caput (swelling) towards the front of the fetal skull may mask this landmark if the woman has been in labour for some hours.

Recall the appearance of a normal caput over the posterior fontanel shown in Figure 4.4 earlier in this Module.

8.5.3  Complications of brow presentation

The complications of brow presentation are much the same as for other malpresentations:

• Cerebral haemorrhage.

Which are you more likely to encounter — face or brow presentations?

Face presentation, which occurs in 1 in 500 full term labours. Brow presentation is more rare, at 1 in 1,000 full term labours.

8.6  Shoulder presentation

Shoulder presentation is rare at full term, but may occur when the fetus lies transversely across the uterus (Figure 8.7), if it stopped part-way through spontaneous inversion from breech to vertex, or it may lie transversely from early pregnancy. If the baby lies facing upwards, its back may be the presenting part; if facing downwards its hand may emerge through the cervix. A baby in the transverse position cannot be born through the vagina and the labour will be obstructed. Refer babies in shoulder presentation urgently.

8.6.1  Causes of shoulder presentation

Causes of shoulder presentation could be maternal or fetal factors.

Maternal factors include:

• Lax abdominal and uterine muscles: most often after several previous pregnancies
• Uterine abnormality
• Contracted (abnormally narrow) pelvis.

Fetal factors include:

• Preterm labour
• Placenta previa.

What do ‘placenta previa’ and ‘polyhydramnios’ indicate?

Placenta previa is when the placenta is partly or completely covering the cervical opening. Polyhydramnios is an excess of amniotic fluid. They are both potential causes of malpresentation.

8.6.2  Diagnosis of shoulder presentation

On abdominal palpation, the uterus appears broader and the height of the fundus is less than expected for the period of gestation, because the fundus is not occupied by either the baby’s head or buttocks. You can usually feel the head on one side of the mother’s abdomen. On vaginal examination, in early labour, the presenting part may not be felt, but when the labour is well progressed, you may feel the baby’s ribs. When the shoulder enters the pelvic brim, the baby’s arm may prolapse and become visible outside the vagina.

8.6.3  Complications of shoulder presentation

Complications include:

• Trauma to a prolapsed arm
• Fetal hypoxia and death.

Remember that a shoulder presentation means the baby cannot be born through the vagina; if you detect it in a woman who is already in labour, refer her urgently to a higher health facility.

8.7  Multiple pregnancy

In this section, we turn to the subject of multiple pregnancy , when there is more than one fetus in the uterus. More than 95% of multiple pregnancies are twins (two fetuses), but there can also be triplets (three fetuses), quadruplets (four fetuses), quintuplets (five fetuses), and other higher order multiples with a declining chance of occurrence. The spontaneous occurrence of twins varies by country : it is lowest in East Asia n countries like Japan and China (1 out of 1000 pregnancies are fraternal or non-identical twins), and highest in black Africans , particularly in Nigeria , where 1 in 20 pr egnancies are fraternal twins. In general, compared to single babies, multiple pregnancies are highly associated with early pregnancy loss and high perinatal mortality, mainly due to prematurity.

8.7.1  Types of twin pregnancy

Twins may be identical (monozygotic) or non-identical and fraternal (dizigotic). Monozygotic twins develop from a single fertilised ovum (the zygote), so they are always the same sex and they share the same placenta . By contrast, dizygotic twins develop from two different zygotes, so they can have the same or different sex, and they have separate placenta s . Figure 8.8 shows the types of twin pregnancy and the processes by which they are formed.

8.7.2  Diagnosis of twin pregnancy

On abdominal examination you may notice that:

• The size of the uterus is larger than the expected for the period for gestation.
• The uterus looks round and broad, and fetal movement may be seen over a large area. (The shape of the uterus at term in a singleton pregnancy in the vertex presentation appears heart-shaped rounder at the top and narrower at the bottom.)
• Two heads can be felt.
• Two fetal heart beats may be heard if two people listen at the same time, and they can detect at least 10 beats different (Figure 8.6).
• Ultrasound examination can make an absolute diagnosis of twin pregnancy.

8.7.3  Consequences of twin pregnancy

Women who are pregnant with twins are more prone to suffer with the minor disorders of pregnancy, like morning sickness, nausea and heartburn. Twin pregnancy is one cause of hyperemesis gravidarum (persistent, severe nausea and vomiting). Mothers of twins are also more at risk of developing iron and folate-deficiency anaemia during pregnancy.

Can you suggest why anaemia is a greater risk in multiple pregnancies?

The mother has to supply the nutrients to feed two (or more) babies; if she is not getting enough iron and folate in her diet, or through supplements, she will become anaemic.

Other complications include the following:

• Pregnancy-related hypertensive disorders like pre-eclampsia and eclampsia are more common in twin pregnancies.
• Pressure symptoms may occur in late pregnancy due to the increased weight and size of the uterus.
• Labour often occurs spontaneously before term, with p remature delivery or premature rupture of membranes (PROM) .
• Respiratory deficit ( shortness of breath, because of fast growing uterus) is another common problem.

Twin babies may be small in comparison to their gestational age and more prone to the complications associated with low birth weight (increased vulnerability to infection, losing heat, difficulty breastfeeding).

You will learn about low birth weight babies in detail in the Postnatal Care Module.

• Malpresentation is more common in twin pregnancies, and they may also be ‘locked’ at the neck with one twin in the vertex presentation and the other in breech. The risks associated with malpresentations already described also apply: prolapsed cord, poor uterine contraction, prolonged or obstructed labour, postpartum haemorrhage, and fetal hypoxia and death.
• Conjoined twins (fused twins, joined at the head, chest, or abdomen, or through the back) may also rarely occur.

8.8  Management of women with malpresentation or multiple pregnancy

As you have seen in this study session, any presentation other than vertex has its own dangers for the mother and baby. For this reason, all women who develop abnormal presentation or multiple pregnancy should ideally have skilled care by senior health professionals in a health facility where there is a comprehensive emergency obstetric service. Early detection and referral of a woman in any of these situations can save her life and that of her baby.

What can you do to reduce the risks arising from malpresentation or multiple pregnancy in women in your care?

During focused antenatal care of the pregnant women in your community, at every visit after 36 weeks of gestation you should check for the presence of abnormal fetal presentation. If you detect abnormal presentation or multiple pregnancy, you should refer the woman before the onset of labour.

Summary of Study Session 8

In Study Session 8, you learned that:

• During early pregnancy, babies are naturally in the breech position, but in 95% of cases they spontaneously reverse into the vertex presentation before labour begins.
• Malpresentation or malposition of the fetus at full term increases the risk of obstructed labour and other birth complications.
• Common causes of malpresentations/malpositions include: excess amniotic fluid, abnormal shape and size of the pelvis; uterine tumour; placenta praevia; slackness of uterine muscles (after many previous pregnancies); or multiple pregnancy.
• Common complications include: premature rupture of membranes, premature labour, prolonged/obstructed labour; ruptured uterus; postpartum haemorrhage; fetal and maternal distress which may lead to death.
• Vertex malposition is when the fetal head is in the occipito-posterior position — i.e. the back of the fetal skull is towards the mother’s back instead of pointing towards the front of the mother’s pelvis. 90% of vertex malpositions rotate and deliver normally.
• Breech presentation (complete, frank or footling) is when the baby’s buttocks present during labour. It occurs in 3–4% of labours after 34 weeks of pregnancy and may lead to obstructed labour, cord prolapse, hypoxia, premature separation of the placenta, birth injury to the baby or to the birth canal.
• Face presentation is when the fetal head is bent so far backwards that the face presents during labour. It occurs in about 1 in 500 full term labours. ‘Chin posterior’ face presentations usually rotate spontaneously to the ‘chin anterior’ position and deliver normally. If rotation does not occur, a caesarean delivery is likely to be necessary.
• Brow presentation is when the baby’s forehead is the presenting part. It occurs in about 1 in 1000 full term labours and is difficult to detect before the onset of labour. Caesarean delivery is likely to be necessary.
• Shoulder presentation occurs when the fetal lie during labour is transverse. Once labour is well progressed, vaginal examination may feel the baby’s ribs, and an arm may sometimes prolapse. Caesarean delivery is always required unless a doctor or midwife can turn the baby head-down.
• Multiple pregnancies are always at high risk of malpresentation. Mothers need greater antenatal care, and twins are more prone to complications associated with low birth weight and prematurity.
• Any presentation other than vertex after 34 weeks of gestation is considered as high risk to the mother and to her baby. Do not attempt to turn a malpresenting or malpositioned baby! Refer the mother for emergency obstetric care.

Self-Assessment Questions (SAQs) for Study Session 8

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 8.1 (tests Learning Outcomes 8.1, 8.2 and 8.4)

Which of the following definitions are true and which are false? Write down the correct definition for any which you think are false.

A  Fundus — the ‘rounded top’ and widest cavity of the uterus.

B  Complete breech — where the legs are bent at both hips and knee joints and are folded underneath the baby.

C  Frank breech — where the breech is so difficult to treat that you have to be very frank and open with the mother about the difficulties she will face in the birth.

D  Footling breech — when one or both legs are extended so that the baby presents ‘foot first’.

E  Hypoxia — the baby gets too much oxygen.

F  Multiple pregnancy — when a mother has had many babies previously.

G  Monozygotic twins — develop from a single fertilised ovum (the zygote). They can be different sexes but they share the same placenta.

H  Dizygotic twins — develop from two zygotes. They have separate placentas, and can be of the same sex or different sexes.

A is true.  The fundus is the ‘rounded top’ and widest cavity of the uterus.

B is true.  Complete breech is where the legs are bent at both hips and knee joints and are folded underneath the baby.

C is false . A frank breech is the most common type of breech presentation and is when the baby’s legs point straight upwards (see Figure 8.4).

D is true.   A footling breech is when one or both legs are extended so that the baby presents ‘foot first’.

E is false .  Hypoxia is when the baby is deprived of oxygen and risks permanent brain damage or death.

F is false.   Multiple pregnancy is when there is more than one fetus in the uterus.

G is false.   Monozygotic twins develop from a single fertilised ovum (the zygote), and they are always the same sex , as well as sharing the same placenta.

H is true.  Dizygotic twins develop from two zygotes, have separate placentas, and can be of the same or different sexes.

SAQ 8.2 (tests Learning Outcomes 8.1 and 8.2)

What are the main differences between normal and abnormal fetal presentations? Use the correct medical terms in bold in your explanation.

In a normal presentation, the vertex (the highest part of the fetal head) arrives first at the mother’s pelvic brim, with the occiput (the back of the baby’s skull) pointing towards the front of the mother’s pelvis (the pubic symphysis ).

Abnormal presentations are when there is either a vertex malposition (the occiput of the fetal skull points towards the mother’s back instead towards of the pubic symphysis), or a malpresentation (when anything other than the vertex is presenting): e.g. breech presentation (buttocks first); face presentation (face first); brow presentation (forehead first); and shoulder presentation (transverse fetal).

SAQ 8.3 (tests Learning Outcomes 8.3 and 8.5)

• a. List the common complications of malpresentations or malposition of the fetus at full term.
• b. What action should you take if you identify that the fetus is presenting abnormally and labour has not yet begun?
• c. What should you not attempt to do?
• a. The common complications of malpresentation or malposition of the fetus at full term include: premature rupture of membranes, premature labour, prolonged/obstructed labour; ruptured uterus; postpartum haemorrhage; fetal and maternal distress which may lead to death.
• b. You should refer the mother to a higher health facility – she may need emergency obstetric care.
• c. You should not attempt to turn the baby by hand. This should only be attempted by a specially trained doctor or midwife and should only be done at a health facility.

SAQ 8.4 (tests Learning Outcomes 8.4 and 8.5)

A pregnant woman moves into your village who is already at 37 weeks gestation. You haven’t seen her before. She tells you that she gave birth to twins three years ago and wants to know if she is having twins again this time.

• a. How would you check this?
• b. If you diagnose twins, what would you do to reduce the risks during labour and delivery?
• Is the uterus larger than expected for the period of gestation?
• What is its shape – is it round (indicative of twins) or heart-shaped (as in a singleton pregnancy)?
• Can you feel more than one head?
• Can you hear two fetal heartbeats (two people listening at the same time) with at least 10 beats difference?
• If there is access to a higher health facility, and you are still not sure, try and get the woman to it for an ultrasound scan.
• Be extra careful to check that the mother is not anaemic.
• Encourage her to rest and put her feet up to reduce the risk of increased blood pressure or swelling in her legs and feet.
• Be alert to the increased risk of pre-eclampsia.
• Expect her to go into labour before term, and be ready to get her to the health facility before she goes into labour, going with her if at all possible.
• Get in early touch with that health facility to warn them to expect a referral from you.
• Make sure that transport is ready to take her to a health facility when needed.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Abnormal labor (nursing).

Prabhcharan Gill ; Joshua M. Henning ; Karen Carlson ; James W. Van Hook ; Lisa M. Haddad .

Affiliations

Last Update: June 14, 2023 .

• Learning Outcome
• Recognize the stages of normal labor
• Distinguish between normal and abnormal labor progression
• Summarize basic medical and nursing therapy for abnormal labor
• Understand the role of amniotomy during labor
• Understand the role of oxytocin in the augmentation of labor
• Discuss the variability of maternal and fetal outcomes based on normal and abnormal labor
• Review the difference between protracted and arrested labor
• Introduction

Normal labor is characterized by regular and painful uterine contractions that conclude in progressive labor. A discussion on abnormal labor patterns is reviewed as abnormalities of the first stage (cervical dilation to complete cervical dilation) and the second stage (descent of the presenting part leading to delivery of the baby). The third stage of labor describes the expulsion of the placenta. An overview of labor abnormalities encompasses all the stages of labor. First and second-stage abnormalities are described either as protraction disorders (which means that delivery is progressing but is lower than normal) or as arrest disorders (complete cessation in progress).  Abnormal third-stage labor meriting intervention is placenta retention beyond 30 minutes, as most third stages are concluded within the first 10 to 20 minutes of delivery. [1]

Normal labor is characterized by regular and painful contractions plus cervical change.  Labor is divided into three stages as well as phases within the first stage:

• Latent phase
• Active phase (begins at 6 cm dilation and ends with complete cervical dilation)
• Maternal expulsive efforts and uterine contractions
• Begins with complete dilation and ends with the delivery of the fetus
• Placental delivery

Abnormal labor patterns in the first and second stages of labor are defined as either protraction or arrest disorders. Protracted labor stages indicate that labor is progressing but at a slower pace than expected. Arrest disorders indicate the complete cessation of the progress of cervical dilation and/or descent of the fetal presenting part.  Abnormal third-stage labor warrants intervention when the placenta is retained for > 30 minutes. 

• Nursing Diagnosis

The following criteria should be kept in mind when labeling the labor as abnormal:

First Stage Protraction and Arrest

• In nulliparas women:   greater than at least 20 hours
• In multiparas women:  greater than at least 14 hours
•   Due to its variable and slow progression, latent phase protraction alone should not be an indication for cesarean delivery.
• No cervical dilation after 4 hours of adequate contractions with ruptured membranes
• No cervical dilation after 6 hours of inadequate contractions, with ruptured membranes, despite oxytocin administration

Second Stage Protraction and Arrest

• For nulliparous women:  more than 3 hours without epidural or 4 hours with an epidural
• For multiparous women:  more than 2 hours without epidural or 3 hours with an epidural
• Longer durations may be appropriate with reassuring maternal and fetal status and the continued descent of the fetal presenting part

The normal progression of labor requires the inspection of  three  "Ps," representing power, passage, and passenger. The power comes from uterine contractions and maternal expulsive efforts. The passage is the maternal pelvis, and finally, the fetus is the passenger, who may or may not present itself in a favorable position and presentation. Abnormal progress of labor may be related to fetal factors, uterine factors, bony pelvis factors, or a combination of these. The size of the fetus and the capacity of the maternal pelvis are tested as uterine contractions provide propulsion. Asynclitism or extension of the fetal head as well as occiput posterior or transverse position or mentum or brow presentation may also be etiologies of abnormal progress of labor or labor dystocia. [2]  Labor abnormalities due to unfavorable fetal or maternal pelvic dynamics may lead to true dystocia requiring a cesarean delivery. [3]

• Risk Factors

Risk Factors Associated with Abnormal Labor

• Fetal macrosomia
• Maternal obesity
• Nonreassuring fetal heart rate patterns
• Non-gynecoid maternal pelvimetry
• Non-occiput anterior position
• Nulliparity
• Short stature
• High fetal station at full cervical dilation
• chorioamnionitis
• Post-term pregnancy
• Bandl's ring
• Gestational diabetes
• Hypertensive disorders
• Epidural analgesia

Labor begins with regular uterine contractions in addition to cervical dilation and/or effacement. An important aspect of the history to obtain from the patient is at what time the contractions began and how far apart they have been.  An abdominal examination is a key component of an obstetric exam as it provides an estimated fetal weight of the fetus and informs the provider of the fetal presentation. The continuous monitoring of uterine activity discerns how frequent contractions are occurring. Only with internal pressure catheter monitoring can the actual strength of contractions be measured. Digital vaginal exams to evaluate the maternal pelvimetry, bony pelvis shape and capacity, and cervical dilation and effacement occur at various intervals throughout labor. The fetal station is also assessed with these digital exams, and this provides information regarding the descent of the fetal presenting part, an integral piece of information when determining if labor is progressing normally or abnormally.

Determining the progress of labor is a key component of intrapartum care. Maternal uterine activity is assessed by either manual palpation, external tocodynamometry, or internal monitoring with a pressure catheter. With external tocodynamometry, target uterine activity is 3 to 5 contractions in a 10-minute window. The contractions should last 30 to 40 seconds to be effective. Internal intrauterine pressure assessment using a catheter may also be utilized when the amniotic sac is not intact, in which case the actual strength of contractions can be measured. The most common approach to quantitating uterine contractions is by measuring Montevideo units. Montevideo units are calculated by adding the sum of the net contraction pressures in 10 minutes.  Adequate uterine activity is targeted at 200 - 250 Montevideo units. [4]  Although this method of assessing uterine contractions has some limitations, no more useful and accurate system has been yet devised.

• Medical Management

Documentation of essential obstetric vital signs. 

Oxytocin may be given when indicated, during all stages of labor.

Most labor and delivery units will have an established protocol for the administration of oxytocin that entails the administration of the proper medication and dosage, as well as criteria for an incremental increase as clinically warranted. The protocols also include monitoring maternal and fetal status and avoiding tachysystole and abnormal fetal heart rate patterns. Such protocols allow collaborative care between the nursing staff and the obstetrician.

Therapeutic rest and analgesia may be provided during a prolonged latent phase of the first stage of labor.

In the case of maternal/fetal compromise, immediate preparation for delivery is indicated.

• Nursing Management
• Review the history of labor, including onset and duration
• Assess uterine contractile pattern and intensity
• Assess fetal heartbeat by auscultation or by continuous monitoring
• Evaluate the current level of maternal fatigue/emotional stress
• Observe for any signs of infection
• Monitor vitals
• Evaluate the degree of hydration. Note the quantity and type of oral intake
• Encourage change of position and ambulation, as tolerated
• Note signs of fetal distress, cessation of uterine contractions, and presence of vaginal bleeding
• Alert the midwife or physician of any warning signs
• Prepare the patient for cervical examinations and amniotomy, and assist with the exam, when indicated
• Administer pain medication as indicated
• Provide emotional support during labor
• When To Seek Help
• Maternal exhaustion
• A nonreassuring fetal heart tracing
• Absence of adequate uterine contractions
• Tachysystole
• Signs of hypovolemia/hypothermia
• Signs of maternal infection, including an elevated temperature
• Category 3 fetal heart rate tracing
• Maternal hypotension from epidural anesthesia
• Outcome Identification
• Maternal rest and readiness for delivery
• Reassuring fetal heart rate pattern
• Prevention of infections
• Healthy mother and baby

Monitor the fetus with fetal auscultation or continuous external or internal monitors

Monitor contractions

Check vitals per protocol

• Coordination of Care

The best management of labor requires a coordinated interprofessional effort between trained obstetric nurses, midwives, and physicians. Team management may lower the average cesarean section rates and improve overall outcomes. [Level V]

• Health Teaching and Health Promotion

Abnormal labor can be a daunting experience for women, especially during the first birth. However, patients must be aware that they can be managed both at home and at a maternity care clinic/hospital, depending on the stage and associated risk factors. Continued education and explanation of the progress of labor and recommended interventions will help promote positive healthcare outcomes and positive reflection of the labor experience.

• Discharge Planning
• The patients should be discharged with appropriate analgesia and sedatives as desired, as well as specific instructions on when to return to labor and delivery if they plan to experience early labor at home.
• Patients should be encouraged to stay mobile, in the absence of any contraindications, as it may lead to better outcomes.
• Patients should be well-hydrated and given nourishment either orally or with dextrose IV solutions.
• The patient should have at least one support person during labor.
• Pearls and Other issues

With abnormal labor, cesarean delivery can be a life-saving procedure and may be medically necessary. Diligent management of labor aspires to minimize variation between providers as they resort to cesarean delivery for the management of abnormal labor. The new labor-management guidelines published in 2014 aim to decrease cesarean delivery rates and provide the best opportunity to improve outcomes and reduce costs as well as reduce future maternal obstetrical morbidity and mortality. [5]

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Disclosure: Prabhcharan Gill declares no relevant financial relationships with ineligible companies.

Disclosure: Joshua Henning declares no relevant financial relationships with ineligible companies.

Disclosure: Karen Carlson declares no relevant financial relationships with ineligible companies.

Disclosure: James Van Hook declares no relevant financial relationships with ineligible companies.

Disclosure: Lisa Haddad declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Gill P, Henning JM, Carlson K, et al. Abnormal Labor (Nursing) [Updated 2023 Jun 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Getting Pregnant
• First Trimester
• Second Trimester
• Third Trimester
• Labor and Delivery
• Pregnancy Complications
• View Full Guide

Understanding Labor and Delivery Complications

What Are Common Labor and Delivery Complications?

A pregnancy that has gone smoothly can still have problems when it's time to deliver the baby. Your doctor and hospital are prepared to handle them. Here are some of the most common concerns:

Preterm labor and premature delivery

One of the greatest dangers babies face is being born too early, before their body is mature enough to survive outside the womb. The lungs , for example, may not be able to breathe air, or the baby's body may not generate enough heat to keep warm.

A full-term pregnancy lasts about 40 weeks. Having labor contractions before 37 weeks of pregnancy is called preterm labor. Also, a baby born before 37 weeks is considered a premature baby who is at risk of complications of prematurity, such as immature lungs, respiratory distress, and digestive problems.

Drugs and other treatments can be used to stop preterm labor . If these treatments fail, intensive care can keep many premature babies alive.

The symptoms of preterm labor and birth include:

• Contractions before 37 weeks of pregnancy , with a tightening and hardening of the uterine muscle, 10 minutes apart or less (these may be painless)
• Cramps similar to menstrual cramps (not to be mistaken with Braxton Hicks contractions, which typically are not at regular intervals and do not open the cervix)
• Low backache
• A feeling of pelvic pressure
• Abdominal cramps, gas, or diarrhea ; in combination with contractions, may signal preterm labor
• Vaginal spotting or bleeding
• A change in quality or quantity of vaginal discharge , especially any gush or leak of fluid

Call your doctor if you notice or feel any of those symptoms.

Protracted labor

Protracted labor refers to cervical dilation that is abnormally slow or to abnormally slow fetal descent. This means the labor does not progress as fast as it should.

This could happen with a big baby, a baby in a breech position (buttocks down), or other abnormal presentation, or with a uterus that does not contract strongly enough. Often, there is no specific cause for protracted labor.

Both the mother and the baby are at risk for several complications, including infections, if the amniotic sac has been ruptured for a long time and the birth doesn't follow.

If labor goes on too long, the doctor may give IV fluids to prevent you from getting dehydrated. If the uterus does not contract enough, they may give you oxytocin, a drug that promotes stronger contractions . And if the cervix stops dilating despite strong contractions of the uterus, a C-section may be necessary.

Abnormal presentation

"Presentation" refers to the part of the baby that will appear first from the birth canal. In the weeks before your due date , the fetus usually drops lower in the uterus. Ideally, for labor, the baby is positioned head-down, facing the mother's back, with its chin tucked to its chest and the back of the head ready to enter the pelvis. That way, the smallest part of the baby's head leads the way through the cervix and into the birth canal. This normal presentation is called vertex (head down) occiput anterior.

Because the head is the largest and least flexible part of the baby, it's best for the head to lead the way into the birth canal. That way, there's little risk that the baby's body will make it through the birth canal, but the head will get caught.

Some babies present with their buttocks or feet pointed down toward the birth canal. This is called a breech presentation. Breech presentations are often seen during an ultrasound exam far before the due date, but most babies will turn to the normal head-down presentation as they get closer to the due date.

Types of breech presentation include:

• Frank breech. In a frank breech, the baby's buttocks lead the way into the pelvis; the hips are flexed, the knees extended.
• Complete breech. In a complete breech, both knees and hips are flexed, and the baby's buttocks or feet may enter the birth canal first.
• Incomplete breech. In an incomplete or footling breech, one or both feet lead the way.

Transverse lie is another type of presentation problem. A few babies lie horizontally in the uterus, called a transverse lie, which usually means the baby's shoulder will lead the way into the birth canal rather than the head.

In cephalopelvic disproportion, the baby's head is too large to fit through the mother's pelvis, either because of the size or because of the baby's poor positioning. Sometimes the baby is not facing the mother's back, but instead is turned toward their abdomen (occiput or cephalic posterior). This increases the chance of a lengthy, painful, childbirth , often called "back labor," or tearing of the birth canal.

In malpresentation, the baby is not "presenting" or positioned in the normal way. In malpresentation of the head, the baby's head is positioned wrong, with the forehead, top of the head, or face entering the birth canal, instead of the back of its head. Sometimes a placenta previa (when the placenta blocks the cervix) may cause an abnormal presentation. But many times the cause is not known.

Abnormal presentations increase a woman's risk for uterine or birth canal injuries and abnormal labor. Breech babies are at an increased risk of injury and a prolapsed umbilical cord, which cuts off the baby's blood supply. A transverse lie is the most serious abnormal presentation, and it can lead to injury of the uterus, as well as injury to the fetus .

Toward the end of your third trimester , your doctor will check the baby's presentation and position by feeling your belly or with an ultrasound . If the fetus remains in breech presentation several weeks before the due date , your doctor may attempt to "turn" the baby into the correct position in a procedure called an "external version."

One way to try to turn the baby after 36 weeks is an external cephalic version, which involves a doctor manually rotating the baby by placing their hands on the mother's belly and turning the baby. These manipulations work about 50% to 60% of the time and are usually more successful on women who have given birth previously because their uteruses stretch more easily. The procedure typically takes place in the hospital, in case an emergency C-section becomes necessary. To make the procedure easier to perform, safer for the baby, and more tolerable for the mother-to-be, doctors sometimes give a uterine muscle relaxant and then use an ultrasound and electronic fetal monitor as guides.

If the first attempt is unsuccessful, turning the baby may be tried again with an epidural pain medication to help relax the uterine muscles. Since not all doctors have been trained to do versions, you may be referred to another obstetrician .

There is a very small risk that the maneuver could cause the baby's umbilical cord to become entangled or the placenta to separate from the uterus. There's also a chance (about 4%) that the baby might flip back into a breech position before delivery, so some doctors induce labor immediately. The closer you are to your due date, the lower the risk of reverting back to a breech position. But the bigger the baby, the harder it is to turn.

The procedure can be uncomfortable for the mother, but if successful, may avoid a C-section, which is more likely if the baby can't be moved into the proper position.

Premature rupture of membranes (PROM)

Normally, the membranes surrounding the baby in the uterus break and release amniotic fluid (known as the "water breaking") either right before or during labor. Premature rupture of membranes means that these membranes have ruptured too early in pregnancy, meaning prior to the onset of labor. This exposes the baby to a high risk of infection.

If the baby is mature enough to be born, your doctor will induce labor or do a C-section if necessary. If the baby isn't mature enough, you may be given antibiotics to prevent infection as well as other medications to try to prevent or slow preterm PROM.

Umbilical cord prolapse

The umbilical cord is your baby's lifeline. You pass oxygen and other nutrients from your body to your baby through the umbilical cord and placenta.

Sometimes, before or during labor, the umbilical cord can slip through the cervix after your water breaks, preceding the baby into the birth canal. The cord may even protrude from the vagina -- a dangerous situation because the blood flow through the umbilical cord can become blocked or stopped. You may feel the cord in the birth canal if it prolapses, and may see the cord if it protrudes from your vagina .

Umbilical cord prolapse happens more often when a baby is small, preterm, in breech presentation, or if its head hasn't entered the mother's pelvis yet. Cord prolapse can also occur if the amniotic sac breaks before the baby has moved into position in the pelvis. Umbilical cord prolapse is an emergency. If you aren't at the hospital when it happens, call an ambulance to take you there. Until help arrives, get on your hands and knees , with your chest on the floor and your buttocks raised. In this position, gravity will help keep the baby from pressing against the cord and cutting off their blood and oxygen supply. Once you get to the hospital, a C-section will be performed.

Umbilical cord compression

Because the fetus moves and kicks inside the uterus, the umbilical cord can wrap and unwrap itself around the baby many times throughout pregnancy. While there are "cord accidents" in which the cord gets twisted around and blocks the blood supply to the baby, this is extremely rare and can't be prevented.

Sometimes the umbilical cord gets stretched and compressed during labor, leading to a brief decrease in blood flow to the fetus. This can cause sudden, short drops in fetal heart rate, called variable decelerations, which are usually picked up by monitors during labor. Cord compression happens in about one in 10 deliveries. In most cases, these heart rate changes are of no major concern, and the birth proceeds normally. But a C-section may be necessary if the baby's heart rate worsens or the baby shows other signs of distress.

Umbilical cord compression can occur if the cord becomes wrapped around the baby's neck or a limb or gets pressed between the baby's head and the mother's pelvic bone. You may be given oxygen to increase the oxygen available to your baby. Your doctor may hurry along the delivery by using forceps or vacuum assistance, or, in some cases, delivering the baby by C-section.

Amniotic fluid embolism

This is one of the most serious complications of labor and delivery . Very rarely, a small amount of amniotic fluid -- the fluid that surrounds the fetus in the uterus -- enters the mother's bloodstream, usually during a particularly difficult labor or a C-section. The fluid travels to the woman's lungs and may cause the arteries in the lungs to constrict. For the mother, this constriction can result in a rapid heart rate, irregular heart rhythm, collapse, shock, or even cardiac arrest and death. Widespread blood clotting is a common complication, requiring emergency care.

Preeclampsia

Preeclampsia is a complication of pregnancy involving high blood pressure that develops after 20 weeks of pregnancy or shortly after delivery. Preeclampsia may lead to premature detachment of the placenta from the uterus, maternal seizure, or stroke .

Uterine bleeding (Postpartum hemorrhage)

After a baby is delivered, excessive bleeding from the uterus, cervix, or vagina, called postpartum hemorrhage, can be a major concern. Excessive bleeding may result when the contractions of the uterus after delivery are impaired, and the blood vessels that opened when the placenta detached from the wall of the uterus continue to bleed. It can also result from other causes such as cervical or vaginal lacerations.

Post-term pregnancy and post-maturity

In most pregnancies that go a little beyond 41 to 42 weeks, called late-term pregnancy, there are usually no problems. But problems may develop if the placenta can no longer provide enough nourishment to maintain a healthy environment for the baby. The risks can become significant in post-term pregnancies, those that go to 42 weeks or more.

How Do I Prevent Problems With Labor and Delivery?

The most important thing you can do to try to have a healthy baby is getting early and adequate prenatal care. The best prenatal care begins even before you are pregnant, so you can be in the best of health before pregnancy.

To help prevent complications, if you smoke, quit. Smoking can trigger preterm labor.  Researchers have found a link between gum disease and preterm birth, so brush and floss your teeth daily. It may also be helpful to reduce your stress level by setting aside quiet time every day and asking for help when you need it.

Transvaginal ultrasound

Your doctor will check you for risk factors for preterm labor and premature delivery, and discuss any precautions you should take. Measuring the length of the cervix using a transvaginal ultrasound probe can help predict a woman's risk of delivering prematurely. This procedure is usually done in a doctor's office between 20 and 28 weeks of pregnancy for women who may be at risk.

Fetal fibronectin testing

Fetal fibronectin testing can also be used as a possible predictor of preterm labor for women who may be at risk. This test is done like a Pap smear,  and test results are used to predict your risk of preterm labor. The fetal fibronectin test can't tell for sure if you're in preterm labor, but it can tell you if you're not. A woman at risk for premature delivery can be forewarned about what to do if preterm labor symptoms occur, and can undergo further screening tests.

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CHAPTER 23:  Abnormal Labor

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Abnormalities of the expulsive forces.

• PREMATURELY RUPTURED MEMBRANES AT TERM
• PRECIPITOUS LABOR AND DELIVERY
• FETOPELVIC DISPROPORTION
• COMPLICATIONS WITH DYSTOCIA
• Full Chapter
• Supplementary Content

Labor arrest, abnormal fetal presentation, or fetal jeopardy are indications for a large percentage of primary cesarean deliveries in the United States ( Boyle, 2013 ). Lowering dystocia rates offers the potential to decrease rates of this surgery and associated maternal morbidity.

Dystocia literally means difficult labor and is characterized by abnormally slow labor progress. Causes are grouped into three distinct categories. Mechanistically, these simplify into abnormalities of the powers —poor uterine contractility and maternal expulsive effort; of the passenger —the fetus; and of the passage —the pelvis and lower reproductive tract.

These three groups act singly or in combination to produce dysfunctional labor ( Table 23-1 ). For the powers, uterine contractions may be insufficiently strong or inappropriately coordinated to efface and dilate the cervix. This is termed uterine dysfunction . Moreover, during second-stage labor, voluntary maternal pushing may be inadequate. For the passenger, fetal abnormalities of presentation, position, or anatomy may slow progress. Last, for the passage, structural changes can contract the maternal bony pelvis. Or, soft tissue abnormalities of the reproductive tract may block fetal descent.

OP = occiput posterior; OT = occiput transverse.

To describe ineffective labors, two commonly used terms are cephalopelvic disproportion (CPD) and failure to progress . CPD describes obstructed labor resulting from disparity between the fetal head size and maternal pelvis. The term CPD originated at a time when the main indication for cesarean delivery was overt pelvic contracture from rickets ( Olah, 1994 ). Such absolute disproportion is now rare, and most cases result from malposition of the fetal head within the pelvis (asynclitism). True disproportion is a tenuous diagnosis because 50 to 75 percent of women undergoing cesarean delivery for this reason subsequently deliver even larger newborns vaginally ( Lewkowitz, 2015 ; Place, 2019 ).

A second phrase, failure to progress in either spontaneous or stimulated labor, has become an increasingly popular description of ineffectual labor. This term reflects lack of progressive cervical dilation or halted fetal descent.

Types of Uterine Dysfunction

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Abnormal Labor Clinical Presentation

• Author: Nina S Olsen, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Abnormal Labor
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Laboratory Studies
• Medical Care
• Surgical Care
• Diet and Activity
• Medication Summary
• Beta-adrenergic blocking agents
• Media Gallery

Evaluate every pregnant patient who presents with contractions in the labor and delivery unit. Any patient in labor is at risk for abnormal labor regardless of the number of previous pregnancies or the seemingly adequate dimensions of the pelvis. Plot the progress of any patient in labor, and evaluate it on a labor curve (see images below).

Upon admission to the labor and delivery unit, determine and document clinical findings.

Clinical pelvimetry, which is best performed at the first prenatal care visit, is important in order to assess the pelvic type (eg, android, gynecoid, platypelloid, anthropoid). Evaluate the position of the fetal head in early labor because caput and moulding complicate correct assessment as labor progresses. Establish and document an estimated fetal weight. Monitor fetal heart rate and uterine contraction patterns to assess fetal well-being and adequacy of labor. Perform a cervical examination to determine whether the patient is in the latent or active phase of labor.

Addressing these issues allows for an assessment of the current phase of labor and anticipation of whether abnormal labor from any of the 3  P'  s may be encountered.

Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol . 1955 Dec. 6(6):567-89. [QxMD MEDLINE Link] .

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Rouse DJ, Owen J, Hauth JC. Criteria for failed labor induction: prospective evaluation of a standardized protocol. Obstet Gynecol . 2000 Nov. 96(5 Pt 1):671-7. [QxMD MEDLINE Link] .

Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?. Am J Obstet Gynecol . 2004 Sep. 191(3):933-8. [QxMD MEDLINE Link] .

Rinehart BK, Terrone DA, Hudson C, Isler CM, Larmon JE, Perry KG Jr. Lack of utility of standard labor curves in the prediction of progression during labor induction. Am J Obstet Gynecol . 2000 Jun. 182(6):1520-6. [QxMD MEDLINE Link] .

El-Sayed YY. Diagnosis and management of arrest disorders: duration to wait. Semin Perinatol . 2012 Oct. 36(5):374-8. [QxMD MEDLINE Link] .

Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol . 2010 Dec. 116(6):1281-7. [QxMD MEDLINE Link] . [Full Text] .

Arulkumaran S, Koh CH, Ingemarsson I, Ratnam SS. Augmentation of labour--mode of delivery related to cervimetric progress. Aust N Z J Obstet Gynaecol . 1987 Nov. 27 (4):304-8. [QxMD MEDLINE Link] .

American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol . 2014 Mar. 123 (3):693-711. [QxMD MEDLINE Link] .

Harper LM, Caughey AB, Roehl KA, Odibo AO, Cahill AG. Defining an abnormal first stage of labor based on maternal and neonatal outcomes. Am J Obstet Gynecol . 2014 Jun. 210 (6):536.e1-7. [QxMD MEDLINE Link] .

Allen VM, Baskett TF, O'Connell CM, McKeen D, Allen AC. Maternal and perinatal outcomes with increasing duration of the second stage of labor. Obstet Gynecol . 2009 Jun. 113(6):1248-58. [QxMD MEDLINE Link] .

Laughon SK, Berghella V, Reddy UM, Sundaram R, Lu Z, Hoffman MK. Neonatal and maternal outcomes with prolonged second stage of labor. Obstet Gynecol . 2014 Jul. 124 (1):57-67. [QxMD MEDLINE Link] .

Frolova AI, Stout MJ, Tuuli MG, López JD, Macones GA, Cahill AG. Duration of the Third Stage of Labor and Risk of Postpartum Hemorrhage. Obstet Gynecol . 2016 May. 127 (5):951-6. [QxMD MEDLINE Link] .

Cunningham FG, Leveno KL, Bloom SL, et al. Abnormal labor. Williams Obstetrics . 22nd ed. Appleton & Lange; 2007. 415-434.

Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev . 2005 Oct 19. CD000331. [QxMD MEDLINE Link] .

Treacy A, Robson M, O'Herlihy C. Dystocia increases with advancing maternal age. Am J Obstet Gynecol . 2006 Sep. 195(3):760-3. [QxMD MEDLINE Link] .

Zhu BP, Grigorescu V, Le T, et al. Labor dystocia and its association with interpregnancy interval. Am J Obstet Gynecol . 2006 Jul. 195(1):121-8. [QxMD MEDLINE Link] .

Pergialiotis V, Bellos I, Antsaklis A, Papapanagiotou A, Loutradis D, Daskalakis G. Maternal and neonatal outcomes following a prolonged second stage of labor: A meta-analysis of observational studies. Eur J Obstet Gynecol Reprod Biol . 2020 Sep. 252:62-9. [QxMD MEDLINE Link] .

Butchart AG, Mathews M, Surendran A. Complex regional pain syndrome following protracted labour*. Anaesthesia . 2012 Nov. 67(11):1272-4. [QxMD MEDLINE Link] .

Gabbe SJ, O'Brien WF, Cefalo RC. Labor and delivery. Obstetrics: Normal and Problem Pregnancies . 5th ed. 2007. 322-326.

Sanchez-Ramos L, Quillen MJ, Kaunitz AM. Randomized trial of oxytocin alone and with propranolol in the management of dysfunctional labor. Obstet Gynecol . 1996 Oct. 88(4 Pt 1):517-20. [QxMD MEDLINE Link] .

Mitrani A, Oettinger M, Abinader EG, Sharf M, Klein A. Use of propranolol in dysfunctional labour. Br J Obstet Gynaecol . 1975 Aug. 82(8):651-5. [QxMD MEDLINE Link] .

Roth C, Dent SA, Parfitt SE, Hering SL, Bay RC. Randomized Controlled Trial of Use of the Peanut Ball During Labor. MCN Am J Matern Child Nurs . 2016 May-Jun. 41 (3):140-6. [QxMD MEDLINE Link] .

Tussey CM, Botsios E, Gerkin RD, Kelly LA, Gamez J, Mensik J. Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural. J Perinat Educ . 2015. 24 (1):16-24. [QxMD MEDLINE Link] .

Cheng YW, Kaimal AJ, Snowden JM, Nicholson JM, Caughey AB. Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes. Am J Obstet Gynecol . 2012 Dec. 207(6):502.e1-8. [QxMD MEDLINE Link] .

Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev . 2007 Oct 17. CD006167. [QxMD MEDLINE Link] .

Le Ray C, Serres P, Schmitz T, Cabrol D, Goffinet F. Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Obstet Gynecol . 2007 Oct. 110 (4):873-9. [QxMD MEDLINE Link] .

Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med . 2011 Jan. 24 (1):65-72. [QxMD MEDLINE Link] .

Mollberg M, Hagberg H, Bager B, Lilja H, Ladfors L. Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction. Obstet Gynecol . 2005 Nov. 106(5 Pt 1):913-8. [QxMD MEDLINE Link] .

Mehta SH, Bujold E, Blackwell SC, Sorokin Y, Sokol RJ. Is abnormal labor associated with shoulder dystocia in nulliparous women?. Am J Obstet Gynecol . 2004 Jun. 190(6):1604-7; discussion 1607-9. [QxMD MEDLINE Link] .

Shields SG, Ratcliffe SD, Fontaine P, Leeman L. Dystocia in nulliparous women. Am Fam Physician . 2007 Jun 1. 75(11):1671-8. [QxMD MEDLINE Link] .

Brüggemann C, Carlhäll S, Grundström H, Blomberg M. Labor dystocia and oxytocin augmentation before or after six centimeters cervical dilatation, in nulliparous women with spontaneous labor, in relation to mode of birth. BMC Pregnancy Childbirth . 2022 May 13. 22 (1):408. [QxMD MEDLINE Link] . [Full Text] .

Oppenheimer LW, Labrecque M, Wells G, et al. Prostaglandin E vaginal gel to treat dystocia in spontaneous labour: a multicentre randomised placebo-controlled trial. BJOG . 2005 May. 112(5):612-8. [QxMD MEDLINE Link] .

• Labor curve for nulliparas.
• Labor curve for nulliparas versus multiparas.
• Abnormal labor curve.
• Average labor curves by parity in singleton term pregnancies with spontaneous onset of labor. Reprinted from Seminars in Perinatology, Vol 36(5), El-Sayed YY, Diagnosis and Management of Arrest Disorders: Duration to Wait, pgs 374-8, Oct 2012, with permission from Elsevier.
• The 95th percentiles of cumulative duration of labor from admission among singleton term nulliparous women with spontaneous onset of labor, vaginal delivery, and normal neonatal outcomes. Reprinted from Seminars in Perinatology, Vol 36(5), El-Sayed YY, Diagnosis and Management of Arrest Disorders: Duration to Wait, pgs 374-8, Oct 2012, with permission from Elsevier.
• Table. Abnormal Labor Indicators

Contributor Information and Disclosures

Nina S Olsen, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine Nina S Olsen, MD is a member of the following medical societies: American Academy of Family Physicians , American College of Obstetricians and Gynecologists , American College of Physicians , Virginia Academy of Family Physicians Disclosure: Nothing to disclose.

Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , North American Society for Pediatric and Adolescent Gynecology Disclosure: Received income in an amount equal to or greater than $250 from: Merck<br/>Served as Nexplanon trainer for: Merck.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

John G Pierce, Jr, MD Chairman of Women’s Health and Medical Specialties, Liberty University College of Osteopathic Medicine; Obstetrician/Gynecologist, Women’s Health of Central Virginia John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Christian Medical and Dental Associations , Medical Society of Virginia , Society of Laparoscopic and Robotic Surgeons Disclosure: Nothing to disclose.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Robert K Zurawin, MD Associate Professor, Chief, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine Robert K Zurawin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Society for Reproductive Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society of Laparoscopic and Robotic Surgeons , Texas Medical Association , AAGL , Harris County Medical Society , North American Society for Pediatric and Adolescent Gynecology Disclosure: Received consulting fee from Ethicon for consulting; Received consulting fee from Bayer for consulting; Received consulting fee from Hologic for consulting.

Deborah Lyon, MD Director, Division of Gynecology, Associate Professor, Department of Obstetrics and Gynecology, University of Florida Health Science Center at Jacksonville Deborah Lyon, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of American Medical Colleges , Association of Professors of Gynecology and Obstetrics , Florida Medical Association Disclosure: Nothing to disclose.

Saju Joy, MD, MS Associate Director, Division Chief of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Carolinas Medical Center Saju Joy, MD, MS is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Society for Maternal-Fetal Medicine , American Medical Association Disclosure: Nothing to disclose.

Patricia L Scott, MD Tennessee Maternal-Fetal Medicine Patricia L Scott, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Tennessee Medical Association Disclosure: Nothing to disclose.

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Chapter 7. Normal & Abnormal Labor & Delivery

Carol L. Archie, MD; Ashley S. Roman, MD, MPH

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• Labor and Delivery
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Essentials of Diagnosis

• Labor is a sequence of uterine contractions that results in effacement and dilatation of the cervix and voluntary bearing-down efforts, leading to the expulsion per vagina of the products of conception.
• Delivery is the mode of expulsion of the fetus and placenta.

Pathogenesis

Labor and delivery is a normal physiologic process that most women experience without complications. The goal of the management of this process is to foster a safe birth for mothers and their newborns. Additionally, the staff should attempt to make the patient and her support person(s) feel welcome, comfortable, and informed throughout the labor and delivery process. Physical contact between the newborn and the parents in the delivery room should be encouraged. Every effort should be made to foster family interaction and to support the desire of the family to be together. The role of the obstetrician/midwife and the labor and delivery staff is to anticipate and manage complications that may occur that could harm the mother or the fetus. When a decision is made to intervene, it must be considered carefully, because each intervention carries both potential benefits and potential risks. The best management in the majority of cases may be close observation and, when necessary, cautious intervention.

Physiologic Preparation for Labor

Before the onset of true labor, several preparatory physiologic changes commonly occur. The settling of the fetal head into the brim of the pelvis, known as lightening , usually occurs 2 or more weeks before labor in first pregnancies. In women who have had a previous delivery, lightening often does not occur until early labor. Clinically, the mother may notice a flattening of the upper abdomen and increased pressure in the pelvis. This descent of the fetus is often accompanied by a decrease in discomfort associated with crowding of the abdominal organs under the diaphragm (eg, heartburn, shortness of breath) and an increase in pelvic discomfort and frequency of urination.

During the last 4–8 weeks of pregnancy, irregular, generally painless uterine contractions occur with slowly increasing frequency. These contractions, known as Braxton Hicks contractions , may occur more frequently, sometimes every 10–20 minutes, and with greater intensity during the last weeks of pregnancy. When these contractions occur early in the third trimester, they must be distinguished from true preterm labor. Later, they are a common cause of “false labor,” which is distinguished by the lack of cervical change in response to the contractions.

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Normal and Abnormal Labor

Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy , which culminates in expulsion of the fetus and the products of conception. Labor has 3 stages: the 1st stage starts with the onset of regular Regular Insulin contractions, the 2nd stage starts with full cervical dilation, and the 3rd stage starts immediately after fetal delivery and ends with delivery of the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity . The primary factors required for labor to progress normally are the three Ps PS Invasive Mechanical Ventilation : power (uterine contractions), passenger (the fetus), and passage (the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy ). Labor may become abnormally protracted and require augmentation, usually with oxytocin, to prevent maternal and fetal complications.

Last updated: Feb 21, 2023

The 3 Ps: Power, Passenger, and Passage

The 1st stage of labor, the 2nd stage of labor, the 3rd stage of labor, clinical relevance.

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Definition: Normal labor

Labor is defined as regular Regular Insulin uterine contractions that cause cervical dilation and effacement, leading to delivery of the fetus and the products of conception. Characteristics of normal labor include:

• Gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care : occurs at 37–42 weeks of gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care (full-term)
• Onset: spontaneous (as opposed to induced)
• Progression: spontaneous, without complications 

There are subtle differences in normal labor between primiparous and multiparous women (reviewed below).

• Primiparous: a woman’s 1st delivery
• Multiparous: a woman with prior deliveries

Monitoring progress of labor

Labor progress is followed by serial cervical exams to assess dilation, effacement, and fetal station.

• A measurement of the diameter of the cervical canal Cervical canal Uterus, Cervix, and Fallopian Tubes: Anatomy
• Reported in centimeters
• Full dilation: 10 cm
• An estimate of cervical thinning
• Cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy starts at > 2 cm → effaces to paper thin (full effacement)
• Reported as a percentage of progress
• Full effacement: 100% effaced 
• How high (or low) the presenting fetal part is compared to the maternal ischial spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
• Positive numbers denote a lower fetal station, closer to the vaginal introitus
• Negative numbers denote a fetal station higher in the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
• Fetal head at the introitus: +3–5 cm

Cervical changes during the first stage of labor: At the onset of the labor, the cervix is usually undilated. The first stage ends when the cervix is fully dilated (10 cm).

Cervical effacement: Left: 0% effacement Right: 75% effacement

Fetal station: The distance of the presenting fetal part from the maternal ischial spines is measured in centimeters. Negative numbers denote a higher fetal station, while positive numbers denote a lower fetal station as the fetus descends in the birth canal.

Stages of labor

There are 3 stages of labor:

• Begins with the onset of regular Regular Insulin uterine contractions that cause cervical change
• Ends with full cervical dilation (10 cm)
• Begins when the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy reaches full dilation (10 cm)
• Ends with delivery of the fetus
• Begins immediately after delivery of the fetus 
• Ends with delivery of the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity

Progression through the 3 stages of labor

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For labor to progress normally, there needs to be adequate power from uterine contractions, the fetus needs to tolerate the contractions, and the fetus needs to fit through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy . These requirements are referred to as the 3 Ps PS Invasive Mechanical Ventilation : P ower, P assenger, and P assage.

Power: Uterine contractions

• Contractions must be powerful enough to dilate the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy and expel the fetus
• External pressure transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) (tocometry): measures frequency and strength of contractions relative to each other
• Internal uterine pressure catheter (IUPC): measures frequency and numerical strength of contractions in Montevideo units (MVUs)
• “Adequate power” to effect delivery: ≥ 200 MVUs in 10 minutes
• “Inadequate power” is a cause of abnormal labor progress.

Passenger: Fetus

Multiple characteristics of the fetus are required in order to safely deliver vaginally. The fetal head must ultimately be flexed and directly aligned with the maternal spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy in order to fit through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .

• Vertex: head down
• Frank breech: bottom down, legs extended
• Complete breech: bottom down, legs flexed
• Footling breech: feet down
• Mentum anterior (MA): chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma is anterior, face can flex → compatible with vaginal delivery
• Mentum posterior (MP): chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma is posterior, face cannot flex, incompatible with vaginal delivery
• Remember: “MA can, PA can’t” for vaginal deliveries
• Brow: forehead Forehead The part of the face above the eyes. Melasma down, large diameter, incompatible with vaginal delivery
• Occiput anterior ( OA OA Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting Osteoarthritis ): fetus is facing maternal spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy ; easiest for delivery
• Occiput posterior (OP): fetus is facing maternal bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess ; more challenging
• Fetus typically enters the pelvic inlet Pelvic inlet Pelvis: Anatomy in an OT position before undergoing internal rotation Internal Rotation Examination of the Upper Limbs .
• The fetal head will not fit under the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types in this position.
• Fetal tolerance Tolerance Pharmacokinetics and Pharmacodynamics of labor: infant must tolerate the relative ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage that occurs during uterine contractions without becoming acidotic
• Normal size infant: infant must fit through maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
• Singletons and twins are candidates for a trial of labor
• Surviving triplets and higher-order multiples should be delivered via cesarean 

Diameters of the fetal head: Vertex presentation: suboccipitobregmatic diameter of approximately 9.5 cm Vertex presentation with deflexed head: occipitofrontal diameter of approximately 11.5 cm Brow presentation: supraoccipitomental diameter of approximately 13 cm Face presentation: submentobregmatic diameter of approximately 9.5 cm

Face presentations. Mentum anterior positions are able to flex and allow passage of the fetal head, however mentum posterior positions are unable to flex and thus cannot be delivered vaginally.

Face presentation (mentum posterior position)

Brow presentation (mentum posterior position)

Breech presentations

Overview of different vertex positions LOA: left occiput anterior LOP: left occiput posterior LOT: left occiput transverse OA occiput anterior OP: occiput posterior ROA: right occiput anterior ROP: right occiput posterior ROT: right occiput transverse

Passage: Pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy

The maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy must be large enough to accommodate the fetus. The pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy is assessed as “adequate” or “inadequate” for a trial of labor on the initial exam.

• Gynecoid: round and most spacious → most easily allows the fetal head to rotate to OA OA Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting Osteoarthritis
• Anthropoid: longer anteroposterior diameter and narrow → more commonly causes the head to rotate to OP
• Platypelloid: wider and narrow → more commonly causes the head to stay OT
• Android: heart shaped → fetal head may have difficulty engaging
• Difficult to determine on exam
• No shape is a contraindication for a trial of labor.
• Gynecoid is the easiest for vaginal delivery
• Android and platypelloid are the most difficult for vaginal delivery
• May contribute to abnormal labor patterns

Gynecoid pelvis: The female pelvis is classified based on the shape of the pelvic inlet. The gynecoid pelvis is ideal for delivery, due to its round, spacious shape.

Anthropoid pelvis: The female pelvis is classified based on the shape of the pelvic inlet. The anthropoid pelvis has a longer anterior-posterior length.

Platypelloid pelvis: The female pelvis is classified based on the shape of the pelvic inlet. The platypelloid pelvis is wide and narrow.

Android pelvis: The female pelvis is classified based on the shape of the pelvic inlet. The android pelvis has a heart-shaped inlet.

Definitions

• Cervical change (dilation and effacement)
• Descent of the fetus
• Ends with full cervical dilation (10 cm) 
• Divided into latent and active phases

Divisions and typical timing of the 1st stage of labor: Accel.: acceleration Decel.: deceleration Max: maximum

Latent phase

In the late 3rd trimester, irregular contractions and runs of nonpersistent regular Regular Insulin contractions are common. The latent phase is the establishment of true labor, with regular Regular Insulin persistent contractions that will continue through delivery.

• Dilation: 0 to 4–6 cm 
• Primiparous: cervical effacement usually occurs before significant dilation
• Multiparous: dilation usually precedes significant effacement 
• Station: high (< 0)
• Frequency: regular Regular Insulin , ≥ 3 per 10 minutes
• Intensity: mild to moderate
• Anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts is generally not required.
• Primiparous: < 20 hours
• Multiparous: < 14 hours

Active phase

The active phase is a time of more rapid cervical change leading up to delivery.

• Primiparous: 1.2 cm/hour
• Multiparous: 1.5 cm/hour
• Effacement: continues to 100%
• Station: progressive descent to at least the ischial spines (0 station)
• Intensity: strong
• Anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts is often requested.

Labor management

General management:

• Continuous care and emotional support to the mother
• Ambulation in low-risk women 
• Adequate hydration

Maternal assessment:

• Labor progression: serial cervical exams
• Contraction adequacy: Assess strength and frequency via palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination and/or monitoring.
• Vital signs
• Urine output

Fetal assessment:

• Intermittent auscultation of the fetal heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology (lowest-risk women only)
• Includes women with any medical pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways management
• Includes most women with any medical or obstetric complications

Abnormalities in the 1st stage of labor

The 2nd stage of labor begins with complete dilatation of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy and ends with delivery of the infant.

The cardinal movements of labor

The cardinal movements of labor describe the movements a fetus goes through as it moves through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy . These movements align the largest parts of the infant with the largest diameter through the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy (the anteroposterior diameter between the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy ).

• Passage of the fetal head into the pelvic inlet Pelvic inlet Pelvis: Anatomy
• Fetal head is in an OT position: looking sideways, with the fetal head aligned with the fetal spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
• Descent: downward passage of the fetal head through the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
• Passive flexion Flexion Examination of the Upper Limbs of the fetal head (fetal chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma touches the fetal chest) as the head is pushed against maternal bony structures
• Allows the narrowest diameter of the head to present
• Rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays of the fetal head to an anteroposterior direction
• Example: The fetal head is now looking down, while the fetal body is still mostly facing to the side.
• This prepares the fetal head to move under the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types in the next step
• Extension Extension Examination of the Upper Limbs : fetal head extends ( chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma lifts off the chest) as it moves under the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and appears through the vaginal opening
• Head rotates back to transverse to align with the fetal spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy again.
• Allows delivery of the shoulders beneath the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types
• Delivery of the rest of the fetal body, which has a smaller diameter than the fetal head and shoulders
• Usually rapid

Normal parameters

• Evaluated with the descent of the fetal head (station).
• Primiparous versus multiparous
• Epidural versus no epidural
• Infant should be making continuous downward progress throughout the 2nd stage.

• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control
• Cardiotocography (FHR tracing), or
• Intermittent auscultation with palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination of contractions
• Discourage lying flat → woman should have a hip roll under 1 side to keep the baby off the inferior vena cava Inferior vena cava The venous trunk which receives blood from the lower extremities and from the pelvic and abdominal organs. Mediastinum and Great Vessels: Anatomy
• Push/bear down with each contraction

The 3rd stage of labor starts immediately after delivery of the baby and ends with complete expulsion of the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity .

Clinical presentation

Signs that the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity is ready to deliver include:

• Lengthening of the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity
• Gush of blood
• Uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy becomes hard and globular
• Gentle downward traction on the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity with countertraction on the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy (to avoid uterine inversion)
• IM or IV injection of oxytocin
• Observation until spontaneous placental delivery occurs
• Associated with higher rates of postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage
• < 30 minutes
• Typically takes 5–10 minutes 

Prolonged 3rd stage of labor

• Diagnosis: 3rd stage > 30 minutes
• Abnormal placentation (e.g., placenta accreta Placenta Accreta Abnormal placentation in which all or parts of the placenta are attached directly to the myometrium due to a complete or partial absence of decidua. It is associated with postpartum hemorrhage because of the failure of placental separation. Placental Abnormalities )
• Separated but trapped placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity due to rapid contraction of the lower uterine segment
• Manual uterine exploration
• Uterine relaxants (if lower uterine segment is preventing expulsion)
• Surgical exploration

Human placenta shown a few minutes after birth: The side shown faces the baby with the umbilical cord top right. The unseen side connects to the uterine wall.

• False labor (also known as Braxton-Hicks contractions Braxton-Hicks contractions Irregular contractions that do not cause cervical change and become more noticeable as the pregnancy progresses Pregnancy: Diagnosis, Physiology, and Care ): irregular uterine contractions or runs of regular Regular Insulin contractions without cervical changes. These contractions do not increase in intensity or duration, and they are common and normal in the 3rd trimester. Women should be reassured and counseled about hydration, as dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration was found to be associated with false labor.
• Prelabor rupture of membrane: the rupture of membranes ( chorion Chorion The outermost extraembryonic membrane surrounding the developing embryo. In reptiles and birds, it adheres to the shell and allows exchange of gases between the egg and its environment. In mammals, the chorion evolves into the fetal contribution of the placenta. Placenta, Umbilical Cord, and Amniotic Cavity and amnion Amnion The innermost membranous sac that surrounds and protects the developing embryo which is bathed in the amniotic fluid. Amnion cells are secretory epithelial cells and contribute to the amniotic fluid. Placenta, Umbilical Cord, and Amniotic Cavity ) before the onset of labor. Women usually present with a “gush of amniotic fluid Amniotic fluid A clear, yellowish liquid that envelopes the fetus inside the sac of amnion. In the first trimester, it is likely a transudate of maternal or fetal plasma. In the second trimester, amniotic fluid derives primarily from fetal lung and kidney. Cells or substances in this fluid can be removed for prenatal diagnostic tests (amniocentesis). Placenta, Umbilical Cord, and Amniotic Cavity ” from the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy followed by a continuous dribble. Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease frequently develop after the membranes have been ruptured for a prolonged period (> 18 hours). Sterile Sterile Basic Procedures speculum examination Speculum Examination Diagnostic Procedures in Gynecology is done to visualize the presence of amniotic fluid Amniotic fluid A clear, yellowish liquid that envelopes the fetus inside the sac of amnion. In the first trimester, it is likely a transudate of maternal or fetal plasma. In the second trimester, amniotic fluid derives primarily from fetal lung and kidney. Cells or substances in this fluid can be removed for prenatal diagnostic tests (amniocentesis). Placenta, Umbilical Cord, and Amniotic Cavity pooling within the posterior vaginal fornix Fornix Vagina, Vulva, and Pelvic Floor: Anatomy . Prelabor rupture of membrane may precipitate labor, but it is not considered to be labor in and of itself.
• Ehsanipoor, R.M., Satin, A. (2020). Normal and abnormal labor progression. UpToDate. Retrieved March 18, 2021, from https://www.uptodate.com/contents/normal-and-abnormal-labor-progression
•  American College of Obstetricians and Gynecologists Committee on Obstetrics (2019). Approaches to limit intervention during labor and birth. Committee opinion 766. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth  
• American College of Obstetricians and Gynecologists Obstetric Care Consensus No. 1. (2014). Safe prevention of the primary cesarean delivery. Retrieved Feb 10, 2022 from https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2014/03/safe-prevention-of-the-primary-cesarean-delivery
• Ehsanipoor, R.M., Satin, A. (2021). Labor: Diagnosis and management of an abnormal first stage. UpToDate. Retrieved Feb 10, 2022 from https://www.uptodate.com/contents/labor-diagnosis-and-management-of-an-abnormal-first-stage
• Ehsanipoor, R.M., Satin, A. (2021). Labor: Diagnosis and management of a prolonged second stage. UpToDate. Retrieved Feb 10, 2022 from https://www.uptodate.com/contents/labor-diagnosis-and-management-of-a-prolonged-second-stage

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Approaches to Limit Intervention During Labor and Birth

• Committee Opinion CO
• Number 766
• February 2019

Recommendations and Conclusions

Introduction, latent labor: labor management and timing of admission, term prelabor rupture of membranes, continuous support during labor, routine amniotomy, intermittent auscultation, techniques for coping with labor pain, hydration and oral intake in labor, maternal position during labor, second stage of labor: pushing technique, immediate versus delayed pushing for nulliparous women receiving epidural analgesia, family-centered cesarean birth, for more information.

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Number 766 (Replaces Committee Opinion No. 687, February 2017. Reaffirmed 2021)

Committee on Obstetric Practice

The American College of Nurse-Midwives endorses this document. This Committee Opinion was developed by the Committee on Obstetric Practice in collaboration with committee members Allison S. Bryant, MD, MPH and Ann E. Borders, MD, MSc, MPH.

ABSTRACT: Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated or proscribed. Obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.

Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.

When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.

Obstetrician–gynecologists and other obstetric care providers should recommend labor induction to pregnant women with term prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) who are candidates for vaginal birth, although the choice of expectant management for a limited time may be considered after appropriate counseling. Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term PROM who decline labor induction in favor of expectant care of the potential risks associated with expectant management and the limitations of available data. For appropriately counseled women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for 12–24 hours may be offered. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.

Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.

For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.

To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.

Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions that best meet the needs of each individual woman.

Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.

When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each woman should be encouraged to use her preferred and most effective technique.

Collectively, and particularly in light of recent high-quality study findings, data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia. Delayed pushing has not been shown to significantly improve the likelihood of vaginal birth and risks of delayed pushing, including infection, hemorrhage, and neonatal acidemia, should be shared with nulliparous women receiving neuraxial analgesia who consider such an approach.

Birthing units should carefully consider adding family-centric interventions (such as lowered or clear drapes at cesarean delivery) that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode.

This Committee Opinion reviews the evidence for labor care practices that facilitate a physiologic labor process and minimize intervention for appropriate women who are in spontaneous labor at term. The desire to avoid unnecessary interventions during labor and birth is shared by health care providers and pregnant women. Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction 1 . This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

As used in this document, “low risk” indicates a clinical scenario for which there is not clear demonstrable benefit for a medical intervention. What constitutes low risk will, therefore, vary depending on individual circumstances and the proposed intervention. For example, a woman who requires oxytocin augmentation will need continuous electronic fetal monitoring (EFM) and, therefore, would not be low risk with regard to eligibility for intermittent auscultation. Rather than categorize laboring women as low or high risk, the goal of this document is to ensure that the obstetrician–gynecologist or other obstetric care provider carefully selects and tailors labor interventions to meet clinical safety requirements and the individual woman’s preferences.

Observational studies have found that admission in the latent phase of labor is associated with more arrests of labor and cesarean births in the active phase and with a greater use of oxytocin, intrauterine pressure catheters, and antibiotics for intrapartum fever 2 3 4 . However, these studies were unable to determine whether these outcomes reflected interventions associated with earlier and longer exposure to the hospital environment or a propensity for dysfunctional labor among women who present for care during the latent phase. A randomized controlled trial (RCT) that compared admission at initial presentation to the labor unit (immediate admission) versus admission when in active labor (delayed admission) found that those allocated to the delayed admission group had lower rates of epidural use and augmentation of labor, had greater satisfaction, and spent less time in the labor and delivery unit. Although there were no significant differences between study groups in operative vaginal or cesarean births or newborn outcomes, the study was underpowered to assess these outcomes 5 .

Importantly, recent data from the Consortium for Safe Labor support updated definitions for latent and active labor. In contrast to the prior suggested threshold of 4 cm, the onset of active labor for many women may not occur until 5–6 cm 6 7 8 . These data suggest that expectant management is reasonable for women at 4–6 cm dilatation and considered to be in latent labor, as long as maternal and fetal status are reassuring. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. An agreed-upon time for reassessment should be determined at the time of each contact. Care of women in latent labor may be enhanced by having an alternate unit where such women can rest and be offered support techniques before admission to labor and delivery.

Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue 9 10 . When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial 11 12 .

When membranes rupture at term before the onset of labor, approximately 77–79% of women will go into labor spontaneously within 12 hours, and 95% will start labor spontaneously within 24–28 hours 13 14 . In the TERMPROM trial, a RCT of labor induction versus expectant management of rupture of membranes at term, the median time to delivery for women managed expectantly was 33 hours; 95% had delivered by 94–107 hours after rupture of membranes 15 . A 2017 Cochrane review that compared immediate induction with expectant management did not find a difference in cesarean delivery or definite early-onset neonatal sepsis, but did find a decreased risk of chorioamnionitis or endometritis, or both (relative risk [RR], 0.49; 95% CI, 0.33–0.72), a decreased risk of definite or probable early-onset neonatal sepsis (RR, 0.73; 95% CI, 0.58–0.92), and a decreased risk of neonatal admission to a special or intensive care unit (RR, 0.75; 95% CI, 0.66–0.85) in the induction group 16 . The Cochrane authors commented that the quality of evidence to support reduced risk of maternal and probable neonatal infection remains low and that “women should be appropriately counselled in order to make an informed choice between planned early birth and expectant management for PROM at 37 weeks’ gestation or later.” However, given the available evidence, obstetrician–gynecologists and other obstetric care providers should recommend labor induction to pregnant women with term PROM who are candidates for vaginal birth, although the choice of expectant management for a limited time may be considered after appropriate counseling.

The RCTs that addressed women who were experiencing term PROM included expectant care intervals that ranged from 10 hours to 4 days. The risk of infection increases with prolonged duration of ruptured membranes. However, the optimal duration of expectant management that maximizes the chance of spontaneous labor while minimizing the risk of infection has not been determined. In line with the knowledge that a large proportion of women will go into spontaneous labor within 12–24 hours after term PROM and recognizing questions that remain unanswered, obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term PROM who decline labor induction in favor of expectant care of the potential risks associated with expectant management and the limitations of available data. For appropriately counseled women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for 12–24 hours may be offered 15 16 . For women who are GBS positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.

Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Benefits described in randomized trials include shortened labor, decreased need for analgesia, fewer operative deliveries, and fewer reports of dissatisfaction with the experience of labor 1 17 . As summarized in a Cochrane evidence review, a woman who received continuous support was less likely to have a cesarean birth (RR, 0.75; 95% CI, 0.64–0.88) or a newborn with a low 5-minute Apgar score (RR, 0.62; 95% CI, 0.46–0.85) 1 . Continuous support for a laboring woman that is provided by a nonmedical person also has a modest positive effect on shortening the duration of labor (mean difference −0.69 hours; 95% CI, −1.04 to −0.34) and improving the rate of spontaneous vaginal birth (RR, 1.08; 95% CI, 1.04–1.12) 1 .

It also may be effective to teach labor-support techniques to a friend or family member. This approach was tested in a randomized trial of 600 nulliparous, low-income, low-risk women, and the treatment resulted in significantly shorter duration of labor and higher Apgar scores at 1 minute and 5 minutes 18 . Continuous labor support also may be cost effective given the associated lower cesarean rate. One analysis suggested that paying for such personnel might result in substantial cost savings annually 19 . Given these benefits and the absence of demonstrable risks, patients, obstetrician–gynecologists and other obstetric care providers, and health care organizations may want to develop programs and policies to integrate trained support personnel into the intrapartum care environment to provide continuous one-to-one emotional support to women undergoing labor.

Amniotomy is a common intervention in labor and may be used to facilitate fetal or intrauterine pressure monitoring. Amniotomy also may be used alone or in combination with oxytocin to treat slow labor progress. However, whether elective amniotomy is beneficial for women without a specific indication has been questioned. A Cochrane review of 15 studies found that among women in spontaneous labor, amniotomy alone did not shorten the duration of spontaneous labor (mean difference, –20.43 minutes; 95% CI, –95.93 to 55.06) or lower the incidence of cesarean births. Likewise, when compared with women who did not undergo amniotomy, those who did were similar in terms of patient satisfaction, frequencies of 5-minute Apgar scores less than 7, umbilical cord prolapse, and abnormal fetal heart rate patterns 20 . Another study evaluated the combination of early amniotomy with oxytocin augmentation as a joint intervention for women in spontaneous labor or for women with mild delays in labor progress 21 . This meta-analysis of 14 trials found that amniotomy together with oxytocin augmentation is associated with modest reduction in the duration of the first stage of labor (mean difference, –1.11 hours; 95% CI, −1.82 to −0.41) and a modest reduction in cesarean birth rates when compared with expectant management (RR, 0.87; 95% CI, 0.77–0.99). Overall, these data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.

Continuous EFM was introduced to reduce the incidence of perinatal death and cerebral palsy and as an alternative to the practice of intermittent auscultation. However, the widespread use of continuous EFM has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Low risk in this context has been variously defined but generally includes women who have no meconium staining, intrapartum bleeding, or abnormal or undetermined fetal test results before giving birth or at initial admission; no increased risk of developing fetal acidemia during labor (eg, congenital anomalies, intrauterine growth restriction); no maternal condition that may affect fetal well-being (eg, prior cesarean scar, diabetes, hypertensive disease); and no requirement for oxytocin induction or augmentation of labor. A Cochrane review of 13 RCTs included women with varying degrees of a priori risk of fetal acidemia at the onset of labor 22 . This meta-analysis found that continuous EFM was associated with an increase in cesarean deliveries (RR, 1.63; 95% CI, 1.29–2.07; n=18,861, 11 RCTs) and an increase in instrumental vaginal birth rate (RR, 1.15; 95% CI, 1.01–1.33; n=18,615, 10 RCTs) when compared with intermittent auscultation. However, continuous EFM was associated with a halving of the rate of early neonatal seizures (RR, 0.50; 95% CI, 0.31–0.80, n=32,386, nine trials, 0.15% for EFM versus 0.29% for intermittent auscultation group), but the authors found no significant difference in the rates of perinatal death or cerebral palsy when compared with intermittent auscultation 22 . In the largest RCT conducted, the group that had early onset seizures had a neonatal death similar to those allocated to EFM versus intermittent auscultation. Moreover, at 4 years of age, there was no difference in the rate of cerebral palsy (1.8 per 1,000 in the EFM group versus 1.5 per 1,000 in the intermittent auscultation group) 23 .

To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor 24 25 26 27 28 29 30 . In considering the relative merits of intermittent auscultation and continuous EFM, patients and obstetrician–gynecologists and other obstetric care providers also should evaluate how the technical requirements of each approach may affect a woman’s experience in labor; intermittent auscultation can allow freedom of movement, which some women appreciate. The effect on staffing is an additional important consideration. Guidelines, indications, and protocols for intermittent auscultation are available from the American College of Nurse–Midwives 30 , the National Institute for Health and Care Excellence 31 , and the Association of Women’s Health, Obstetric and Neonatal Nurses 29 .

Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. These techniques can be used sequentially or in combination. Some nonpharmacologic methods seem to help women cope with labor pain rather than directly mitigating the pain. Conversely, pharmacologic methods mitigate pain, but they may not relieve anxiety or suffering. Data about the relative effectiveness of nonpharmacologic techniques are limited because, until recently, evaluation of labor pain has relied on the use of the numeric pain scale of 1–10, which some have argued is insufficient to assess the complex and multifactorial experience of labor 32 . As an alternative, a coping scale has been developed and approved by the Joint Commission. The coping scale asks, “On a scale of 1 to 10, how well are you coping with labor right now?” 33 . Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions that best meet the needs of each individual woman.

Most women can be offered a variety of nonpharmacologic techniques. None of the nonpharmacologic techniques have been found to adversely affect the woman, the fetus, or the progress of labor, but few have been studied extensively enough to determine clear or relative effectiveness. During the first stage of labor, water immersion has been found to lower pain scores without evidence of harm 8 34 . Intradermal sterile water injections, relaxation techniques, acupuncture, and massage may result in reduction in pain in many studies, but methodologies for rating pain and applying these techniques have been varied; therefore, exact techniques that are most effective have not been determined 35 36 . Other techniques, such as childbirth education, transcutaneous electrical nerve stimulation, aromatherapy, or audioanalgesia, may help women cope with labor more than directly affect pain scores 11 36 . The importance of avoiding versus seeking pharmacologic analgesia or epidural anesthesia will vary with individual patient values and medical circumstances. In the hospital setting, pharmacologic analgesia should be available for all women in labor who desire medication 37 .

Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. Although safe, intravenous hydration limits freedom of movement and may not be necessary. Oral hydration can be encouraged to meet hydration and caloric needs. Arguments for limiting oral intake during labor center on concerns for aspiration and its sequelae. Current guidance supports oral intake of moderate amounts of clear liquids by women in labor who do not have complications. However, particulate-containing fluids and solid food should be avoided 38 39 . These restrictions have recently been questioned, citing the low incidence of aspiration with current obstetric anesthesia techniques 40 . This information may inform ongoing review of recommendations regarding oral intake during labor. Assessment of urinary output and the presence or absence of ketonuria can be used to monitor hydration. If such monitoring indicates concern, intravenous fluids can be administered as needed. If intravenous fluids are required, the solution and the infusion rate should be determined by individual clinical need and anticipated duration of labor. Despite historic concerns regarding the use of dextrose-containing solutions and the possibility that these solutions may induce neonatal hypoglycemia, recent RCTs did not find lower umbilical cord pH values or increased rates of neonatal hypoglycemia after continuous administration of 5% dextrose in normal saline 41 42 .

Observational studies of maternal position during labor have found that women spontaneously assume many different positions during the course of labor 43 . There is little evidence that any one position is best. Moreover, the traditional supine position during labor has known adverse effects such as supine hypotension and more frequent fetal heart rate decelerations 44 45 . Therefore, for most women, no one position needs to be mandated or proscribed.

In research studies, it was difficult to isolate the independent effect of position on labor progress. Women are unlikely to stay in a single position during the course of a study and cannot be expected to do so. Nonetheless, a recent meta-analysis that compared upright positioning (including walking, sitting, standing, and kneeling), ambulation, or both, with recumbent, lateral, or supine positions during the first stage of labor found that upright positions shorten the duration of the first stage of labor by approximately 1 hour and 22 minutes (mean difference, −1.36; 95% CI, −2.22 to −0.51), a mean difference that exceeded the effect of amniotomy with oxytocin (mean difference, −1.11 hours). Women in upright positions also were less likely to have a cesarean delivery (RR, 0.71; 95% CI, 0.54–0.94) 43 . A second Cochrane meta-analysis of RCTs that examined the effect of position during the second stage of labor found that upright or lateral positions compared with supine positions are associated with fewer “abnormal” fetal heart rate patterns (RR, 0.46; 95% CI, 0.22–0.93), a reduction in episiotomies (RR, 0.75; 95% CI, 0.61–0.92), and a decrease in the incidence of operative vaginal births (RR, 0.75; 95% CI, 0.66–0.86) 46 . In this analysis, however, upright positions were associated with a possible increase in second-degree perineal tears (RR, 1.20; 95% CI, 1.00–1.41) and an increase in estimated blood loss greater than 500 mL (RR, 1.48; 95% CI, 1.10–1.98) 46 . A 2017 RCT of upright versus lying positioning during the second stage of labor among nulliparous women with low-dose epidurals demonstrated that fewer spontaneous vaginal births occurred among women assigned to upright positioning (adjusted risk ratio 0.86, 95% CI, 0.78–0.94) without evidence of other associated harms. 47 . Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.

Obstetrician–gynecologists and other obstetric care providers in the United States often encourage women in labor to push with a prolonged, closed glottis effort (ie, Valsalva maneuver) during each contraction. However, when not coached to breathe in a specific way, women push with an open glottis 48 . A Cochrane review of eight RCTs that compared spontaneous to Valsalva pushing in the second stage of labor found no clear differences in the duration of the second stage, spontaneous vaginal delivery episiotomy, perineal lacerations, 5-minute Apgar score less than 7, or neonatal intensive care admissions, or duration of pushing 49 .

A meta-analysis that included three RCTs of low-risk nulliparous women at 36 weeks of gestation or more without epidural analgesia found no differences in the rates of operative vaginal delivery, cesarean delivery, episiotomy, or perineal lacerations. However, the study found a somewhat shorter second stage of labor with Valsalva, although confidence intervals were wide (mean difference −18.59 minutes; 95% CI, −0.46 to −36.75) 50 . One of these RCTs found an increased frequency of abnormal urodynamics 3 months after giving birth in association with Valsalva pushing 51 . The long-term clinical significance of this finding is uncertain. However, in consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each woman should be encouraged to use her preferred and most effective technique 49 50 .

Offering nulliparous women receiving epidural analgesia a rest period at 10 cm dilatation before pushing is based on the theory that a rest period allows the fetus to passively rotate and descend while conserving the woman’s energy for pushing efforts 52 . This practice is called delayed pushing, laboring down, or passive descent. The second stage of labor has two phases: 1) the passive descent of the fetus through the maternal pelvis and 2) the active phase of maternal pushing. Studies that suggest an increased risk of adverse maternal and neonatal outcomes with increasing second-stage duration generally do not account for the duration of these passive and active phases 53 54 .

Two meta-analyses of RCTs compared maternal and neonatal outcomes in women assigned to immediate versus delayed pushing have been published 49 55 . Both studies found that delaying pushing for 1–2 hours extended the duration of the second stage by a mean of approximately 1 hour and was associated with approximately 20 minutes less active maternal pushing efforts. Although both reports noted a significantly increased spontaneous delivery rate, this difference was no longer significant when the analysis was restricted to high quality RCTs (RR, 1.07; 95% CI, 0.98–1.16) 55 . However, a recent large retrospective analysis found that delaying pushing by 60 minutes or more was associated with modest increases in cesarean delivery (adjusted odds ratio [AOR], 1.86; 95% CI, 1.63–2.12) and operative vaginal delivery (AOR, 1.26; 95% CI, 1.14–1.40), postpartum hemorrhage (AOR, 1.43; 95% CI, 1.05–1.95), and transfusion (AOR, 1.51; 95% CI, 1.04–2.17), but no increase in adverse neonatal outcomes 56 . The study design does not determine causation and was not able to account for important confounders such as the indications for delayed pushing or fetal station at the onset of the second stage of labor that were addressed by the more recent randomized trial 56 .

A recent 2018 multicenter RCT of more than 2,400 nulliparous women receiving epidural analgesia, assigned participants to begin pushing at the start of the second stage of labor or to delay pushing for 60 minutes unless the urge or health care provider recommendation to push occurred sooner. The trial was stopped before the intended recruitment was complete because of concern for excess morbidity in the delayed pushing group 57 . No differences in rates of spontaneous vaginal births were noted even after consideration of fetal station and head position. Women assigned to push at the start of the second stage had lower rates of chorioamnionitis (RR, 0.7; 95% CI, 0.6–0.9) and postpartum hemorrhage (RR, 0.6; 95% CI, 0.3–0.9), and had neonates with lower risk of acidemia (overall risk 0.8% versus 1.2%, RR, 0.7; 95% CI, 0.6–0.9) 57 . Collectively, and particularly in light of recent high-quality study findings 57 , data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia. Delayed pushing has not been shown to significantly improve the likelihood of vaginal birth and risks of delayed pushing, including infection, hemorrhage, and neonatal acidemia, should be shared with nulliparous women receiving neuraxial analgesia who consider such an approach.

Although the delivery goal for many low-risk women is vaginal birth, delivery by cesarean is sometimes the result, whether for obstetric indications or by maternal request. Recent attention has focused on the description and implementation of techniques in the operating room to promote increased involvement of the family in the procedure itself. One 2008 study, described the “natural cesarean” 58 . Various institutional protocols have adopted some or all of the principles, which include preparation of the operating room itself with low lighting and minimal extraneous noise, positioning women to best allow access to the neonate after delivery (eg, not securing the upper extremities to arm boards, placing pulse oximetry probes on nondominant hands, or on toes rather than fingers), allowing women and their partners to view the birth (by lowering the drapes or using drapes with specially-designed viewing windows), slowed delivery of the neonate through the hysterotomy to allow autoresuscitation, delayed umbilical cord clamping, and early skin-to-skin contact 58 59 . A large body of evidence to support efficacy of these techniques, whether each on its own or in combination, is lacking, though the merits of delayed umbilical cord clamping and early skin-to-skin contact have been extensively reviewed elsewhere. One randomized trial of a number of family-centered cesarean birth interventions demonstrated greater parental satisfaction in the intervention group; skin-to-skin care was achieved in 72% of women assigned to the intervention, and the intervention was associated with higher breastfeeding rates than in the traditional cesarean group 60 .

In one U.S. academic medical center, the family-centered cesarean birth was introduced in 2013 and the efforts studied. Skin-to-skin care in the operating room increased from 13% to 39% of cases, with exclusive breastfeeding rates among neonates born by cesarean similarly increasing from 35% to 64%. An increase in neonatal hypothermia associated with skin-to-skin care, a theoretic concern given the ambient temperatures in operating rooms, was not noted 59 . In a cohort study that compared women who gave birth by cesarean delivery after the introduction of family-centered cesarean delivery with historical controls, unplanned nursery admission, but not respiratory morbidity or hypothermia, increased (unplanned admission in 21% in the period of study compared with 7% of historical controls).

Absent better-quality evidence of benefit or harms of these interventions, birthing units should carefully consider adding family-centric interventions (such as lowered or clear drapes at cesarean delivery) that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode.

Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient–caregiver relationship, and the patient’s involvement in decision making 61 . Therefore, obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor.

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/LimitInterventionDuringLabor .

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

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Published online on December 20, 2018.

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Approaches to limit intervention during labor and birth. ACOG Committee Opinion No. 766. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e164–73.

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Labor with abnormal presentation and position

Affiliation.

• 1 Department of Obstetrics and Gynecology, West Virginia University School of Medicine, 1 Medical Center Drive, PO Box 9186, Morgantown, WV 26506-9186, USA. [email protected]
• PMID: 15899353
• DOI: 10.1016/j.ogc.2004.12.005

Abnormal presentation and position are encountered infrequently during labor. Breech and transverse presentations should be converted to cephalic presentations by external cephalic version or delivered by cesarean section. Face, brow, and compound presentations are usually managed expectantly. Persistent occiput transverse positions are managed by rotation to anterior positions and delivered as such. Occiput posterior positions can be delivered as such or rotated to occiput anterior positions. As with any position or presentation, an obstetrician should not hesitate to abandon any rotational or operative vaginal procedure and proceed to cesarean delivery if rotation or descent does not occur with relative ease.

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• Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Le Ray C, Serres P, Schmitz T, Cabrol D, Goffinet F. Le Ray C, et al. Obstet Gynecol. 2007 Oct;110(4):873-9. doi: 10.1097/01.AOG.0000281666.04924.be. Obstet Gynecol. 2007. PMID: 17906022
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• Published: 28 August 2024

Perspectives of midwives on the use of Kaligutim (local oxytocin) for induction of labour among pregnant women in the government hospitals in Tamale

• Ahmad Sukerazu Alhassan 1 ,
• Shivera Dakurah 2 &
• Joseph Lasong 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  561 ( 2024 ) Cite this article

Metrics details

The use of herbal medicine and/or its products is common throughout the world. In Tamale Metropolis, pregnant women frequently use local oxytocin to induce labour, as shown by the fact that 90% of midwives reported managing patients who used kaligutim (local oxytocin) to speed up labour. Early career midwives are also aware of this and have personally observed it being used by their clients. The purpose of the study was to assess midwives’ opinions on pregnant women’s use of the well-known kaligutim (local oxytocin) for labour induction in the Tamale Metropolis.

A facility-based, quantitative, cross-sectional research design was used for the study. A total of 214 working midwives from Tamale’s three main public hospitals participated. Data for the study were gathered through a standardized questionnaire. For the analysis and presentation of the data, descriptive and analytical statistics, such as basic frequencies, percentages, Fisher’s exact test, chi square test and multivariate analysis, were employed.

According to the findings of this study, the safety, dosages, and contraindications of kaligutim during pregnancy and labour are unknown. The cessation of contractions was reported by 44 (22.4%) of the respondents whose clients used local oxytocin. The study also revealed that women in Tamale metropolis use “walgu”, a spiritual form of oxytocin, to induce and augment labour. Respondents who responded, “yes” to baby admission to the new-born care unit were 25% more likely to use kaligutim (local oxytocin) than were those who responded, “no” to baby admission to the new-born care unit (AOR = 0.25 95% CI (0.01, 0.53), P  = 0.021).

Conclusions

It can be concluded that using kaligutim to start labour has negative effects on both the mother and the foetus. Additional research is required to evaluate the efficacy, effectiveness, biochemical makeup, and safety of these herbal medicines, particularly during pregnancy and delivery, as well as the spiritual significance of kaligutim (Walgu) and its forms.

Peer Review reports

Introduction

Herbal medicines, traditional treatments, and traditional practitioners are the main source of health care for many millions of people, and sometimes the only source of care [ 1 ]. Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products, that contain as active ingredients parts of plants, or other plant materials, or combinations [ 1 , 2 ]. Women in both developed and developing countries use herbal medicine before pregnancy and during pregnancy and delivery, which has several consequences [ 3 ]. The use of herbal medicine has a long history, tracing its roots back to ancient and biblical days when there was no Orthodox medicine. Currently, both developed and developing countries use herbal medicine due to the presence of many traditional medicine practitioners [ 4 ].

Many cultures worldwide use herbal medicine to induce or accelerate labour, and the incidence of labour induction to shorten the duration of labour is on the rise. Most herbal medicine users are pregnant women who have no formal education, who have a low level of income and who mostly stay far from health facilities [ 5 ]. The majority of pregnant women use herbal medicine through the oral route and have confidence in its efficacy, safety and effectiveness [ 6 ]. Herbal medicine is used by women for maternal health-related issues, such as to induce abortion and labour, to correct infertility, for the treatment of pregnancy-related issues, for breast milk secretion and for general wellbeing during pregnancy [ 5 ].

Women who use herbal medicine during pregnancy and/or labour usually have a high risk of postpartum complications [ 7 ]. The use of herbal uterotonics can lead to hyperstimulation of the uterus, foetal asphyxia and several other adverse effects of labour [ 8 ]. Moreover, traditional medicine used by pregnant women is associated with several complications, including a ruptured uterus, a fresh still birth, a macerated still birth, a caesarean section and even death [ 9 ]. These herbal medicines have both uterotonic and nonuterotonic effects on labour and delivery and are mostly used to induce or augment labour in prolonged labour or postdate or to relax or widen the pelvis for delivery [ 8 ].

Maternal and neonatal deaths are still major challenges for most developing countries, with obstetric complications, especially postpartum haemorrhage (P.P.H.) being the major cause of maternal mortality [ 10 ]. The delivery of healthcare services is still poor quality in developing nations [ 11 ]. Maternal and foetal mortality and morbidity have remained high due to inadequate health services and inadequate emergency obstetric treatment. Childbirth is accompanied by numerous customs that are subject to ethnological research and are often rooted in traditional medicine or religion. Cultural influences and sociodemographic characteristics play an important role in a woman’s decision to seek maternal and child health services.

The induction of labour is the process of artificially starting labour by stimulating the uterus with oxytocin or manually through the rupture of amniotic membranes. This process is usually not risk free, and most women find it to be uncomfortable [ 12 ]. The induction of labour is an obstetric procedure recommended when the benefits to the baby and mother outweigh the benefits of continuing the pregnancy. The procedure usually involves complications and failures and must be performed under close monitoring, proper selection of clients and good preparation [ 13 ].

Labour induction also changes the normal physiological processes that accompany childbirth and increases the risk of adverse pregnancy outcomes such as postpartum haemorrhage, neonatal mortality, foetal distress, uterine rapture and premature birth [ 14 ]. Oxytocin is a natural hormone produced by the hypothalamus and is responsible for the activation of sensory nerves during labour and breastfeeding [ 15 ]. Clinically, commercially manufactured synthetic oxytocin is administered to commence or increase uterine activity to reduce the duration of labour [ 16 ].

The induction of labour is not free from risk and must be performed with caution because the procedure involves hyperstimulation of the uterus and foetal distress. Herbal medicine used by pregnant women has long-term effects on both mothers and babies [ 17 ]. Many pregnant women in the Tamale Metropolis use prepackaged herbal medicine before and during pregnancy [ 18 ]. Health-related factors such as cost, distance, access and unavailability of medications influence the utilization of herbal medicine by pregnant women [ 17 ].

All women should be given a prophylactic dose of oxytocin as soon as they give birth. If they start to haemorrhage, they should also be given a treatment dose of oxytocin, which is greater than the prophylactic dose [ 19 ]. There is also a traditional manufactured form of oxytocin (kaligutim) that pregnant women use to start labour. Kaligutim is the local name for the mixture of some special plant parts or a combination of plants prepared and given to pregnant women to start or accelerate the process of labour in the northern part of Ghana [ 17 ].

Ideally, women should take medical drugs during pregnancy (folic acid and fersolate) to help prevent birth defects and congenital malformations such as neural tube defects of the foetus and spinal bifida during pregnancy [ 20 ]. However, in recent decades, women worldwide have used herbal medications during pregnancy and labour, with some taking both herbal medicine and orthodox medicine at the same time [ 21 ]. However, little is known about the use and safety of these medicines, especially during pregnancy, and their dosages, indications and contraindications are not known [ 22 ].

There are studies on herbal medicine use by women during pregnancy and labour, but there is currently no literature on the use of Kaligutim (local oxytocin) for labour induction among pregnant women in Ghana, but similar studies have been conducted in Uganda, Malawi, Tanzania, and Nigeria. Despite the efforts of the government and other nongovernmental organizations to ensure maximum coverage of skilled delivery to help reduce maternal and neonatal mortalities, women still use locally prepared oxytocin to induce labour. Although herbal medicine is commonly used by pregnant women, healthcare providers, especially midwives, are often unprepared to communicate effectively with patients or make proper decisions concerning complementary and alternative medicine use, especially during pregnancy and labour [ 23 ].

It is well known that herbs have played a vital role since the precolonial era during pregnancy, delivery and postpartum care in many parts of the country, but there are still few data on the use of herbs among pregnant women in Ghana [ 24 ]. Towards the end of pregnancy, many women are tired and eager to welcome their babies into the world. Moreover, as the expected date of delivery approaches, these women are given local oxytocin by their mothers’ in-laws, grandmothers, mothers, or TBAs or even by the women themselves to start labour at home before going to the health facility [ 25 ].

Medicinal plants that are used to hasten or speed up labour are mostly taken towards the end of pregnancy or the beginning of labour [ 26 ]. Even after delivery, these herbs may be found in small amounts in the mother’s breast, and some may cross the placental barrier and have harmful effects on the baby. The use of herbal medication by pregnant women is inevitable given that up to 80% of people who live in developing nations rely on traditional medicine for their healthcare needs [ 18 ].

The situation in Ghana, especially Northern Ghana, is not different, as pregnant women continue to use herbs despite the availability of health facilities [ 24 ]. The use of herbal medicine (kaligutim) among the Ghanaian population is alarming. Pregnant women in Tamale use herbal products at a rate of 42.5% prior to pregnancy and 52.7% during pregnancy [ 27 ]. Residents of Tamales who seek healthcare services in hospitals or herbal clinics are therefore at a greater risk of experiencing adverse consequences from drug-herb interactions [ 28 ].

Herbal product manufacturers should clearly state that pregnancy is a contraindication, and vendors should use caution when selling these items to pregnant women [ 27 ]. The use of Kaligutim (local oxytocin) by pregnant women is a maternal and child health problem. Herbal medicine used by pregnant women has long-term effects on both mothers and babies [ 17 ]. Unfortunately, maternal, and neonatal deaths may occur, and hence, there is a need to examine midwives’ perspectives on local oxytocin use during labour, its effects on the progress and outcome of labour, and the relationship between kaligutim use and birth outcomes among pregnant women in the three major government hospitals in Tamale Metropolis.

Theoretical foundation

This study adopted and adapted Andersen’s (1968) behavioural model of healthcare service utilization (use and nonuse of health services [ 29 ]. Andersen’s healthcare utilization model is a conceptual model aimed at demonstrating the factors that lead to the use/nonuse of health services [ 29 ]. This study was guided by Andersen’s behavioural model of health service use as a theoretical framework to identify the effects of Kaligutim on the progress and outcome of labour and to establish the relationship between the use of Kaligutim and nonuse of kaligutim and birth outcomes. The behavioural model is a multilevel model that incorporates both individual and contextual determinants of health service use.

Conceptual framework

Many people rely on products made from medicinal plants to maintain their health or treat illness, and current general development trends in developing and developed countries suggest that the consumption of medicinal plants is unlikely to decline in the short to medium term because of the benefits to consumers, producers, and society as a whole [ 29 ]. Therefore, there is a need to increase our understanding of what motivates the consumption of medicinal plants, despite the barriers to the establishment of solid evidence on the safety and efficacy of herbal medicines and related products [ 29 ].

This unified conceptual framework offers a step towards establishing a comprehensive approach to understanding the experiences midwives encounter when their clients use herbal medicine to induce their labour. The exposure variable in this study refers to kaligutim (local oxytocin) used by pregnant women in the three major government hospitals to induce labour through several routes, including oral, rectal, and vaginal routes, among others. When oxytocin is used by pregnant women, it can produce several results that can be immediate or late.

The results elicited on labour are termed the outcome variables, which can be immediate outcomes (the progress of labour) or outcomes after delivery (the outcome of labour). The progression of labour includes three stages: progressive dilatation of the cervix from 1 cm to 10 cm, delivery of the baby and expulsion of the placenta. Several factors can be used to determine the progress of labour (obstructed labour, prolonged labour, nature of uterine contractions, precipitated labour, foetal distress, and poor progress of labour).

The outcome of labour on the hand refers to what happens during the delivery of the baby, how the baby was delivered, foetal conditions and maternal conditions. The following factors were used for the purpose of this study to determine the outcome of labour (mode of delivery, postpartum haemorrhage, ruptured uterus, cervical tear, birth asphyxia, uterine atony, maternal mortality, and neonatal mortality). This study focused on the immediate effects of Kaligutim (on labour progress) and the effects of Kaligutim after delivery (on labour outcomes) and the relationship between the use of Kaligutim and birth outcomes.

The study was carried out in Tamale, which is the capital city of the northern region of Ghana. According to the 2021 World Urbanization Review, Tamales has an estimated population of 671,812 people. Tamale still has a blend of typical rural and urban communities, although it has attained the status of a metropolitan area. There are three major government hospitals in Tamale: Tamale Central Hospital, Tamale West Hospital and Tamale Teaching Hospital. The Tamale Teaching Hospital is the only tertiary facility in the northern region and serves as the main reference centre for the five regions of the north.

Study population

The main study population was midwives working in Tamale Metropolis. The sampling frame was all midwives practicing in the three major hospitals in Tamale Metropolis who were willing to participate in the study.

Study design

A facility-based cross-sectional research design was used for this study. A cross-sectional study is a type of observational study design carried out at one point in time or over a short period of time to estimate the prevalence of the outcome of interest for a given population for the purpose of public health planning [ 30 ]. This study adopted a quantitative research approach to obtain information.

Sampling technique

A purposive sampling technique was used for this study. Purposive sampling is a nonprobability sampling method in which participants are selected for inclusion in the sample based on their characteristics, knowledge, or experiences. This is because of the midwives’ knowledge, experiences, and objective of the study.

Sample size calculation

Total number of midwives = 458

Yamane formula (1967) was used with a confidence interval of 95% and a margin of error of 5%.

N = population size (458).

n = the sample size (?)

e = margin of error (5%).

n \(\:=\frac{N}{1\:+N\left(e\right)2}\)

n= \(\:\frac{458}{1\:+458\left(0.05\right)2}\)

n  = 214.01 = 214.

Sample size = 214 midwives.

Inclusion criteria

All midwives practicing in the three major government hospitals in Tamale Metropolis who were willing to participate in the study were included.

All midwives in the three-government hospital with experience with kaligutim use during labour were also included in the study.

Exclusion criteria

All midwives who were not practising at the three major government hospitals in Tamale Metropolis were excluded from the study.

Midwives who were practicing at the three major government hospitals in Tamale and who were not willing to participate in the study were also excluded from the study.

All midwives who did not have experience with kaligutim use for the induction of labour were excluded from the study.

Data collection instrument

The data collection tool that was used for the study was a standardized questionnaire. The questionnaire was constructed by reviewing various documents, including existing questionnaires that have been used in previous research. Close-ended questions with few open-ended questions were used as the question format. It was designed in line with the objectives of the study to help obtain the necessary information needed for the study. The questionnaire was pretested with midwives before the actual data collection took place.

Data management and analysis

Data collected from the field were coded, cleaned, and entered into the Statistical Package for Social Services (SPSS) version 21.0. Descriptive and analytical statistics, including simple frequencies and percentages, were used for the analysis and presentation of the data. The relationships between predictor and outcome variables were assessed by means of bivariate (chi-square test) analysis to determine potential predictors of kaligutim (local oxytocin) at p values less than 0.05. Adjusted odds ratios were reported, and p values less than 0.05 were deemed to indicate statistical significance at the 95% confidence level after multivariate analysis.

Ethical consideration

The following ethical principles guided this study: respect for persons, beneficence, and justice for all. These principles are based on the human rights that must be protected during any research project, including the right to self-determination, privacy, anonymity, confidentiality, fair treatment and protection from discomfort and harm. First, an introductory letter was obtained from the University for Development Studies authorities. This letter was then presented to the authorities of the three major government hospitals in Tamale, namely, Tamale West Hospital (T.W.H.), Tamale Central Hospital (T.C.H.) and Tamale Teaching Hospital (TTH.), to seek permission to undertake the study. Ethical clearance was also obtained from the Kwame Nkrumah University of Science and Technology (KNUST) (CHRPE/AP/332/22).

Permission was once sought through a consent form to which participants were asked to consent if they were willing to participate in the study. The participants were assured of the confidentiality of all the information they were going to provide. They were also encouraged to participate in the study as much as they could but were also made aware that the study was voluntary and that they could withdraw at any point in time during the process if needed. There was no compensation for the study participants.

The study revealed that 45% of the respondents were between the ages of 20 and 30. Most of the respondents were in their twenties or thirties. Those who were in the first half of their work life constituted 73% of the respondents, while 17% were in the second half of their working life. The majority of the respondents were diploma midwives, representing 48% of the respondents; post basic midwives, constituting 32%; and degree and master’s holders, representing 19% and 1%, respectively. Staff midwives composed the largest group of respondents, while Principal Midwifery officers composed the group with the lowest participation in the study. The lowest rank in midwifery practice in the study was staff midwives, and the highest was principal midwifery officers. This is presented in Table  1 .

The experience of using local oxytocin to induce labour

Approximately 90% of the respondents have prior knowledge or heard that some of their clients take local oxytocin at home to start labour, and only 10% of respondents have no prior knowledge of that. Approximately 63.4% of the respondents encountered local oxytocin cases more than three times every week. This is presented in Fig.  1 .

Average number of local oxytocin cases per week

Approximately 72.9% of the respondents said that their clients had ever induced labour during the previous C/S, and 59.6% of the respondents said that they met clients who also induced their labour during twin pregnancy. Another 64.5% of the respondents said that they also met clients with large babies who also induced labour using local oxytocin, while 86.2% of the respondents said that they also met clients who induced labour with local oxytocin even when they had grand multiparity. Another 11.3% of the respondents said that they met clients who used local oxytocin to induce labour during transverse lies, and 15.3% of the respondents said that they had experienced when clients with mal presentations used local oxytocin to induce labour. This is presented in Fig.  2 .

Induction of labour by clients through local oxytocin under certain conditions

The study additionally asked midwives to report on how pregnant women who had taken local oxytocin to induce labour coped during their care. Midwives were expected to respond whether the women they cared for experienced good, difficult, bad, painful, life-threatening, terrible, or normal labour. As shown in Fig.  3 , generally, the experience that pregnant women experience when they use local oxytocin to induce labour is not good. A total of 93.5% of the respondents said that the women who used local oxytocin had very bad experiences.

Experience of using local oxytocin to induce labour

The study further revealed that 15.2% of the respondents had experienced situations where some pregnant women died because of the use of local oxytocin.

Effects of local oxytocin on the progress of labour

The effects of local oxytocin (Kaligutim) on the progress of labour were diverse. The study revealed that the effects of Kaligutim on the progress of labour are negative, as it causes prolonged labour for some, obstructed labour for others, precipitated labour, and poor progress of labour for others. With obstructed labour being the leading effect of kaligutim on the progress of labour, most of the respondents chose caesarean section as the preferred delivery for most clients who used kaligutim at birth. The use of local oxytocin also has some effect on the amniotic fluid of pregnant women, as 99% of the midwives who responded to the study said that there were some levels of stain of the amniotic fluid, and only 1% said it was clear. It is evident from the study that for most pregnant women who use local oxytocin, there is hyperstimulation of the uterus, as most of the midwives confirmed this for the study. Most pregnant women who use kaligutim suffer excessive contractions, which could have an effect on both mothers and babies. Again, more than half (53.75) of the respondents also said that their foetal heart rate was above 160 bpm. The majority (77.65) of the respondents said that there was no cessation of the contractions for those who took the local oxytocin. The results are presented in Table  2 .

Impact of local oxytocin on the outcome of labour

To understand how local oxytocin impacts labour, the study went further to ask participants what the mode of delivery was for those who used Kaligutim. According to the data, caesarean section is the mode of delivery for most women (56.5%) who use local oxytocin, and most are unable to achieve spontaneous delivery. This has contributed to the increasing number of caesarean sections recorded daily. Most of the babies had an Apgar score of 4/10 to 6/10. Many babies born to mothers who used herbal oxytocin were born with moderate birth asphyxia (69.6%) and severe birth asphyxia (24%). The study also reported that 20.8% of midwives reported that hysterectomy was carried out on their clients who had used herbal preparations to induce or hasten labour. This is alarming because many women have their uterus removed as a result of herbal oxytocin (kaligutm) usage. Most clients who used Kaligutim experienced postpartum haemorrhage after delivery. It was also evident that some pregnant women (34.5%) had uterine atony, although it cannot be said that Kaligutim was the cause of uterine atony. Several pregnant women (65.3 years old) who used Kaligutim also developed a ruptured uterus. See Table  3 .

Relationship between kaligutim (local oxytocin) use and birth outcome

Table  4 shows the associations between kaligutim (local oxytocin) use and birth outcomes among the respondents. Fisher’s exact test and the chi-square test showed that several birth outcome variables were significantly associated with kaligutim (local oxytocin). Do women who go through the normal process of labour and those who use kaligutim to induce their labour have the same birth outcome? (P value = 0.021), what was the foetal wellbeing? (P value = 0.041), When do most neonates whose mothers have taken Kaligutim die? (P value = 0.038), was baby admitted at the Newborn Care Unit? (P value = 0.001), were significantly associated with kaligutim. Additionally, having recorded a maternal death because of the use of Kaligutim (p value = 0.002) was also significantly associated with kaligutim, as presented in Table  4 .

Multivariate analysis of birth outcome predictors of Kaligutim (local oxytocin) among pregnant women in three major government hospitals in Tamale metropolis

In Table  5 , three birth outcome variables strongly depicted kaligutim use among the respondents: foetal wellbeing, admission to the new-born care unit, and death of most neonates because of the use of Kaligutim by their mothers. Respondents who responded, “yes” to baby admission to the Newborn Care Unit were 25% more likely to use kaligutim (local oxytocin) than were those who responded “no” to baby admission to the Newborn Care Unit [(AOR = 0.25 95% CI (0.01, 0.53), P  = 0.021)].

Discussions

Although the respondents cut across with regard to the number of years of experience, most of the respondents were early career midwives. The fact that these early career midwives are familiar with and have experienced the use of local oxytocin by their clients shows that it is widely used by pregnant women in the Tamale metropolis. Approximately 90% of respondents were aware of the usage of kaligutim (local oxytocin) for inducing labour at home before going to the hospital for delivery. However, a study conducted in the Ashanti region of Ghana revealed that midwives and other healthcare professionals lack proper knowledge about herbal medicine usage among pregnant women, even though this information is urgently needed so that appropriate action may be taken to address the issue [ 31 ]. The study findings also demonstrated that pregnant women frequently utilize local oxytocin and that many of them are unaware of the potential negative effects that these herbs may have on them in certain circumstances. Figure  2 shows that the use of local oxytocin was not limited to only one condition. These findings further show that the use of local oxytocin by pregnant women is widespread and that pregnant women do not know the effect that local oxytocin can have on them when they have certain conditions. Additionally, pregnant women are ignorant of the fact that local oxytocin can be contraindicated under certain conditions and must be avoided. Hence, it may put the life of the pregnant mother and her baby in danger.

Although herbal medicines are natural, not all herbs are safe to use while pregnant. Thus, expectant mothers should consult their midwives for guidance before taking herbal remedies. The experience that pregnant women have when they use local oxytocin to induce labour is not a positive one. A total of 188 respondents, or 93.5% of the respondents, stated that the women who used local oxytocin had a very unpleasant experience. This is supported by additional research results showing that between 50 and 80% of pregnant women use traditional plant remedies, which could have adverse perinatal effects [ 32 ]. The statistics indicate that local oxytocin is frequently used by pregnant women in the Tamale Metropolis. Most of the midwives reported seeing these cases virtually daily. This finding supports a study conducted in Ghana’s Ashanti region (Kumasi), which revealed that knowledge of herbal medicine is widely shared and that there is evidence of an increase in the usage of herbs [ 33 ].

The study revealed that local oxytocin (Kaligutim) has a diverse range of effects on the progress of labour, including precipitating labour, prolonging labour, obstructing labour, and slowing labour. The partograph is a great tool for keeping track of labour progress and serving as a warning system for abnormalities in normal labour, which helps to prevent obstructed labour and improves maternal and foetal outcomes [ 34 ]. This is supported by the study’s findings, which indicate that using a partograph to monitor labour progress and identify any deviations is essential [ 34 ].

According to this study, most midwives, who make up 65.2% of the respondents, also claimed that pregnant women who use local oxytocin (Kaligutim) have excessive contractions, while only 71 of them, or 34.8% of the respondents, claimed that they do not notice excessive contractions in their clients. This is supported by research performed in Zambia, which revealed that these herbal medicines also elicit greater than normal uterine contractions [ 26 ].

Most pregnant women who use kaligutim experience excessive contractions, which may have an impact on both the mother and the unborn child. Similarly, other authors have also claimed that using herbal remedies during labour causes stronger and more frequent uterine contractions, which do not necessarily result in cervical dilatation [ 35 ]. This was confirmed in the study’s findings, which also noted that herbal oxytocin not only produces excessive uterine contractions but also may cause contractions to cease, as 44 (22.4%) of the respondents reported that those who took local oxytocin had a halt in contractions. Intravenous fluids such as normal saline and Ringer’s lactate are used to flush out the local oxytocin in the system and CS in the case of an emergency. Nifedipine is also given in certain circumstances to prevent contractions.

According to the study, 121 midwives, or 59.6% of the respondents, stated that caesarean sections were the preferred method of delivery for women who used kaligutim to induce labour. Both [ 36 ] in South Africa and [ 34 ] in Western Uganda reported these findings. Moderate birth asphyxia (69.6%) and severe birth asphyxia (23%) are common in newborns whose mothers utilize herbal oxytocin. According to the survey, 20.8% of midwives said they had performed hysterectomy procedures on clients who had utilized herbal induction or hastening methods to induce labour.

One of the main causes of maternal deaths worldwide, including in Ghana, is postpartum haemorrhage [ 10 ]. 91% of midwives said that when their patients use herbal oxytocin during labour, more of them suffer from postpartum haemorrhage. This is corroborated by research by Frank (2018), who found a connection between postpartum haemorrhage and the use of herbal medications during labour [ 37 ]. In contrast, other studies [ 38 ] have shown that using herbal medication during childbirth is linked to a lower risk of postpartum haemorrhage. Individuals who experienced postpartum haemorrhage were managed with uterine massage, intravenous fluids, Cytotec, repairs to tears, expulsion of retained products, blood transfusions, cervical repairs, and catheter use.

This report supports the findings of a study conducted in the Ugandan village of Kiganda, where the researcher [ 37 ] reported that the use of herbal medicines has been linked to labour induction, which can cause significant birth canal tearing, postpartum haemorrhage, uterine atony, a raptured uterus, and, if untreated, maternal mortality. Medical experts who are aware of the dangers of herbal remedies and who are obliged to advise patients against using them do so themselves. The majority of women who use herbal preparations during pregnancy have a high school education or higher, according to evidence showing that more than 57.5% of pregnant women who use herbs have a high school diploma or higher, which is consistent with findings from Saudi Arabia by [ 39 ] that show that formal education cannot even prevent women from taking herbs during pregnancy and labour.

Kaligutim also causes excessive uterine contractions, foetal discomfort, excessive uterine stimulation, uterine atony, PPH, birth hypoxia, and premature bearing down, claims this study. This is supported by the results of a study carried out in Europe, where researchers [ 40 ] found that the majority of herbal drugs taken by pregnant women have undesirable side effects. An Iranian study, however, revealed that utilizing herbal treatments during labour can lessen discomfort, speed up the process, and enhance both the quality of a woman’s delivery experience and her odds of having a healthy baby [ 41 ].

According to the study’s findings, three birth outcome variables strongly affected kaligutim (local oxytocin) use among the respondents: foetal wellbeing, admission to the newborn care unit, and death of most neonates as a result of the use of Kaligutim by their mothers. Respondents who responded, “yes to baby” and were admitted to the new-born care unit were 25% more likely to use kaligutim (local oxytocin) than were those who responded, “no to baby” and were admitted to the new-born care unit (AOR = 0.25 95% CI (0.01, 0.53), P  = 0.021). This is probably one of the effects of taking local oxytocin. These infants were hospitalized for a variety of reasons, including asphyxia, respiratory distress, and low Apgar scores.

Additionally, the study results indicated that respondents who responded that a still birth outcome affected foetal wellbeing were 1.9 times more likely to use kaligutim (local oxytocin) than those who responded no to having live births were (AOR = 1.9 95% CI (0.01, 1.21), P  = 0.047)]. This finding is consistent with findings from a sub-Saharan African study that showed that herbal medications used to speed up and induce labour have uterotonic effects and increase the risk of neonatal asphyxia attributable to uterine hyperstimulation [ 42 ]. This could be ascribed to the fact that the respondents wanted fast and easy delivery, which subsequently caused this effect.

Another interesting finding was that respondents who responded that having a birth asphyxia outcome to foetal wellbeing were 0.16 times more likely to use kaligutim (local oxytocin) than were those who responded no to having live births (AOR = 0.16, 95% CI (0.08, 3.08), P  = 0.047). This result is similar to that of [ 42 ], who conducted their study in sub-Saharan Africa. This could be a result of the effects of kaligutim on foetal well-being, which results in birth asphyxia.

Furthermore, newborns whose mothers used kaligutim during labour and who died within the first hour of birth were 3.4 times more likely to use kaligutim (local oxytocin) than those whose mothers used kaligutim during labour [AOR = 3.4 95% CI (0.74, 1.5), P  = 0.045]. In support of the findings from this study, a study on the consumption of herbal drugs among pregnant women in rural Malawi revealed that consumption was linked to pregnancy-related issues and that users had a greater risk of neonatal mortality/morbidity within the first hour of life than nonusers [ 14 ]. This could be attributed to the dangers this herb poses to the foetus during delivery.

Newborns whose mothers used kaligutim during labor and who died within the first week of life were 2.23 times more likely to use kaligutim (local oxytocin) than those whose mothers used intrauterine kaligutim [(AOR = 2.23 95% CI (0.00, 0.02), P  = 0.045)]. This is supported by findings from a Malawian study that revealed that the use of labour-inducing plants during pregnancy has negative effects on obstetric and labour outcomes, such as uterine rapture, which can cause neonatal mortality and morbidity [ 35 ]. This could be attributed to the fact that PPH, uterine rapture, cervical tear, DIC, and hypoxia were the main causes of death.

Every life matter, which is why mothers’ lives and that of their newborn babies must be safeguarded at all costs. A sufficient level of knowledge is always vital since it exacerbates doubt. Therefore, it is crucial that people are informed of their rights, their health, and the services they can utilize to maintain and improve health to have a healthy increasing population. Although herbal medicine could be effective in treating certain ailments associated with pregnancy and delivery and is easily accessible to pregnant women, especially in rural communities, the possibility of overdose, drug-herb interactions, contraindications, and the unhygienic conditions under which they are prepared may influence both maternal and neonatal conditions.

The results showed that the use of kaligutim by pregnant women in Tamale Metropolis is on the rise. This means that much needs to be done to do away with the use of kaligutim, and this must start with midwives. Pregnancies and births can be improved with a healthy and qualified midwifery care model in improving and protecting women’s and newborn health in Tamale.

It can be concluded that the use of this herbal medicine (Kaligutim) poses a greater long-term health challenge for mothers and their babies. Midwives and other healthcare workers in the Tamale Metropolis must therefore intensify their public health campaigns against the use of Kaligutim for labour induction.

Recommendations

The findings of the study have important implications for maternal and child health. The nonuse of kaligutim (local oxytocin) for the induction of labour is the best option for pregnant women. Pregnant women should visit the hospital for all their health needs during the entire pregnancy. This will help prevent adverse pregnancy and labour outcomes as well as maternal and neonatal mortalities and morbidities.

Future researchers should perform further studies on the spiritual aspects of kaligutim (Walgu) and its types. Like synthetic oxytocin, an Islamic form of oxytocin is prepared by Mallams and causes uterine contractions and dilates the cervix.

However, studies should also be conducted on the efficiency, effectiveness and biochemical composition of these herbal preparations and their safety, especially during pregnancy and delivery. Samples of these herbal preparations should be taken for laboratory investigations.

Data availability

All data generated or analysed during this study are included in this article and its supplementary information files are available from the corresponding author on reasonable request.

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Acknowledgements

We thank the Management and Healthcare Staff of the Tamale West Hospital (T.W.H), Tamale Central Hospital (T.C.H) and Tamale Teaching Hospital (TTH) for their support throughout the data collection process. We acknowledge the contributions of all the midwives who shared their knowledge and experiences with us, your efforts are well appreciated.

No funding was available for the study.

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ASA and SD conceptualised and drafted the research proposal. ASA, SD, and JL performed the statistical analysis, assisted with interpretation of the results, and co-drafted the manuscript. All authors contributed to the discussion of the paper, read, and approved the final manuscript.

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An introductory letter from the University for Development Studies was presented to the three government hospitals, Tamale West Hospital (T.W.H), Tamale Central Hospital (T.C.H) and Tamale Teaching Hospital (TTH) to seek for permission to undertake the study. Ethical clearance was also obtained from the Kwame Nkrumah University of Science and Technology (KNUST) with reference number (CHRPE/AP/332/22). Permission was also sought through a consent form of which participants were asked to consent to if they were willing to participate in the study. They were assured of confidentiality of every information they were going to provide. All other methods were performed in accordance with relevant guidelines and regulations on subject selection and participation.

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Alhassan, A.S., Dakurah, S. & Lasong, J. Perspectives of midwives on the use of Kaligutim (local oxytocin) for induction of labour among pregnant women in the government hospitals in Tamale. BMC Pregnancy Childbirth 24 , 561 (2024). https://doi.org/10.1186/s12884-024-06745-z

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Received : 15 April 2024

Accepted : 08 August 2024

Published : 28 August 2024

DOI : https://doi.org/10.1186/s12884-024-06745-z

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• Local oxytocin
• Herbal medicine
• Traditional medicine

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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