Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of normal labor and delivery

Edmund F Funai, MD
Errol R Norwitz, MD, PhD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


The World Health Organization (WHO) defines normal birth as "spontaneous in onset, low-risk at the start of labor and remaining so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in good condition" [1].

This topic will present a paradigm for intrapartum management of women who are expected to have a normal birth. Many of the options for managing these women have not been studied in clinical trials or the data from clinical trials are insufficient for making strong recommendations for a specific approach [2]. Therefore, much of our approach is based upon our clinical experience, data from observational studies, and expert opinion.

Management of women with complicated labor and delivery is discussed in separate topic reviews (eg, malpresentation, protraction and arrest disorders, preterm labor, operative vaginal delivery, maternal medical/obstetrical disorders, hemorrhage) (see individual topic reviews on each subject).


Four factors important in determining a woman's satisfaction with her childbirth experience are personal expectations, the amount of support she receives, the quality of the caregiver-patient relationship, and her involvement in decision-making. Childbirth education classes inform women and their partners about what to expect during labor and birth and provide a foundation for developing personal plans for the birth experience. (See "Preparation for labor and childbirth".)

One-on-one support by a doula during the birthing process may lower intrapartum analgesia requirements, decrease the rate of operative delivery, and increase satisfaction with the birth experience. (See "Continuous labor support by a doula".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2016. | This topic last updated: Apr 8, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. World Health Organization, Maternal and Newborn Health/Safe Motherhood Unit. Care in normal birth: a practical guide. http://www.who.int/maternal_child_adolescent/documents/who_frh_msm_9624/en/.
  2. Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008; 199:445.
  3. Obstetrics Care Workgroup. Obstetrics care topic report and recommendations. In: Quinn R, editor. Seattle (WA): Dr. Robert Bree Collaborative; 2012.
  4. Kauffman E, Souter VL, Katon JG, Sitcov K. Cervical Dilation on Admission in Term Spontaneous Labor and Maternal and Newborn Outcomes. Obstet Gynecol 2016; 127:481.
  5. Langen ES, Weiner SJ, Bloom SL, et al. Association of Cervical Effacement With the Rate of Cervical Change in Labor Among Nulliparous Women. Obstet Gynecol 2016; 127:489.
  6. Department of Reproductive Health and Research. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. World Health Organization, Geneva, reprinted 2007.
  7. Chou MR, Kreiser D, Taslimi MM, et al. Vaginal versus ultrasound examination of fetal occiput position during the second stage of labor. Am J Obstet Gynecol 2004; 191:521.
  8. Kreiser D, Schiff E, Lipitz S, et al. Determination of fetal occiput position by ultrasound during the second stage of labor. J Matern Fetal Med 2001; 10:283.
  9. Youssef A, Ghi T, Pilu G. How to perform ultrasound in labor: assessment of fetal occiput position. Ultrasound Obstet Gynecol 2013; 41:476.
  10. van Loon AJ, Mantingh A, Serlier EK, et al. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term. Lancet 1997; 350:1799.
  11. Raman S, Samuel D, Suresh K. A comparative study of X-ray pelvimetry and CT pelvimetry. Aust N Z J Obstet Gynaecol 1991; 31:217.
  12. Zaretsky MV, Alexander JM, McIntire DD, et al. Magnetic resonance imaging pelvimetry and the prediction of labor dystocia. Obstet Gynecol 2005; 106:919.
  13. Pattinson RC. Pelvimetry for fetal cephalic presentations at term. Cochrane Database Syst Rev 2000; :CD000161.
  14. Sherard GB 3rd, Newton ER. Is routine hemoglobin and hematocrit testing on admission to labor and delivery needed? Obstet Gynecol 2001; 98:1038.
  15. Ries LT, Kopelman JN, Macri CI. Evaluation of routine antepartum and postpartum blood counts. J Reprod Med 1998; 43:581.
  16. Cousins LM, Teplick FB, Poeltler DM. Pre-cesarean blood bank orders: a safe and less expensive approach. Obstet Gynecol 1996; 87:912.
  17. Ransom SB, Fundaro G, Dombrowski MP. Cost-effectiveness of routine blood type and screen testing for cesarean section. J Reprod Med 1999; 44:592.
  18. Ransom SB, Fundaro G, Dombrowski MP. The cost-effectiveness of routine type and screen admission testing for expected vaginal delivery. Obstet Gynecol 1998; 92:493.
  19. Palmer RH, Kane JG, Churchill WH, et al. Cost and quality in the use of blood bank services for normal deliveries, cesarean sections, and hysterectomies. JAMA 1986; 256:219.
  20. Goodnough LT, Daniels K, Wong AE, et al. How we treat: transfusion medicine support of obstetric services. Transfusion 2011; 51:2540.
  21. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
  22. Committee opinion no: 635: Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Obstet Gynecol 2015; 125:1544.
  23. Reveiz L, Gaitán HG, Cuervo LG. Enemas during labour. Cochrane Database Syst Rev 2013; 7:CD000330.
  24. Basevi V, Lavender T. Routine perineal shaving on admission in labour. Cochrane Database Syst Rev 2014; 11:CD001236.
  25. Kerr-Wilson RH, Parham GP, Orr JW Jr. The effect of a full bladder on labor. Obstet Gynecol 1983; 62:319.
  26. Read JA, Miller FC, Yeh S, Platt LD. Urinary bladder distention: effect on labor and uterine activity. Obstet Gynecol 1980; 56:565.
  27. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 441: Oral intake during labor. Obstet Gynecol 2009; 114:714.
  28. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843.
  29. Singata M, Tranmer J, Gyte GM. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev 2013; 8:CD003930.
  30. Shrivastava VK, Garite TJ, Jenkins SM, et al. A randomized, double-blinded, controlled trial comparing parenteral normal saline with and without dextrose on the course of labor in nulliparas. Am J Obstet Gynecol 2009; 200:379.e1.
  31. Jamal A, Choobak N, Tabassomi F. Intrapartum maternal glucose infusion and fetal acid-base status. Int J Gynaecol Obstet 2007; 97:187.
  32. Dawood F, Dowswell T, Quenby S. Intravenous fluids for reducing the duration of labour in low risk nulliparous women. Cochrane Database Syst Rev 2013; 6:CD007715.
  33. Gyte GM, Richens Y. Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects. Cochrane Database Syst Rev 2006; :CD005298.
  34. Lumbiganon P, Thinkhamrop J, Thinkhamrop B, Tolosa JE. Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV). Cochrane Database Syst Rev 2014; 9:CD004070.
  35. Bloom SL, McIntire DD, Kelly MA, et al. Lack of effect of walking on labor and delivery. N Engl J Med 1998; 339:76.
  36. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev 2013; 1:CD008070.
  37. Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013; 8:CD003934.
  38. Smyth RM, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2013; 6:CD006167.
  39. Locatelli A, Regalia AL, Patregnani C, et al. Prognostic value of change in amniotic fluid color during labor. Fetal Diagn Ther 2005; 20:5.
  40. Greenwood C, Lalchandani S, MacQuillan K, et al. Meconium passed in labor: how reassuring is clear amniotic fluid? Obstet Gynecol 2003; 102:89.
  41. Zapata-Vázquez RE, Rodríguez-Carvajal LA, Sierra-Basto G, et al. Discriminant function of perinatal risk that predicts early neonatal morbidity: its validity and reliability. Arch Med Res 2003; 34:214.
  42. Danilack VA, Nunes AP, Phipps MG. Unexpected complications of low-risk pregnancies in the United States. Am J Obstet Gynecol 2015; 212:809.e1.
  43. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol 2009; 114:192.
  44. Downe S, Gyte GM, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term. Cochrane Database Syst Rev 2013; 7:CD010088.
  45. Varney, H. Varney's Midwifery, 3rd, Jones and Bartlett, Boston 1997.
  46. Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 2013; 4:CD005123.
  47. Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011; :CD006672.
  48. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012; 5:CD002006.
  49. Ragnar I, Altman D, Tydén T, Olsson SE. Comparison of the maternal experience and duration of labour in two upright delivery positions--a randomised controlled trial. BJOG 2006; 113:165.
  50. Prins M, Boxem J, Lucas C, Hutton E. Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. BJOG 2011; 118:662.
  51. Lemos A, Amorim MM, Dornelas de Andrade A, et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev 2015; 10:CD009124.
  52. Grobman WA, Bailit J, Lai Y, et al. Association of the Duration of Active Pushing With Obstetric Outcomes. Obstet Gynecol 2016; 127:667.
  53. Corton MM, Lankford JC, Ames R, et al. A randomized trial of birthing with and without stirrups. Am J Obstet Gynecol 2012; 207:133.e1.
  54. Laine K, Pirhonen T, Rolland R, Pirhonen J. Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol 2008; 111:1053.
  55. Parnell C, Langhoff-Roos J, Møller H. Conduct of labor and rupture of the sphincter ani. Acta Obstet Gynecol Scand 2001; 80:256.
  56. Samuelsson E, Ladfors L, Wennerholm UB, et al. Anal sphincter tears: prospective study of obstetric risk factors. BJOG 2000; 107:926.
  57. Pirhonen JP, Grenman SE, Haadem K, et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby's head. Acta Obstet Gynecol Scand 1998; 77:974.
  58. McCandlish R, Bowler U, van Asten H, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 1998; 105:1262.
  59. Mayerhofer K, Bodner-Adler B, Bodner K, et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 2002; 47:477.
  60. Dahlen HG, Homer CS, Cooke M, et al. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth 2007; 34:282.
  61. Jönsson ER, Elfaghi I, Rydhström H, Herbst A. Modified Ritgen's maneuver for anal sphincter injury at delivery: a randomized controlled trial. Obstet Gynecol 2008; 112:212.
  62. Albers LL, Sedler KD, Bedrick EJ, et al. Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial. J Midwifery Womens Health 2005; 50:365.
  63. Hals E, Oian P, Pirhonen T, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 2010; 116:901.
  64. Moiety FM, Azzam AZ. Fundal pressure during the second stage of labor in a tertiary obstetric center: a prospective analysis. J Obstet Gynaecol Res 2014; 40:946.
  65. Fretheim A, Odgaard-Jensen J, Røttingen JA, et al. The impact of an intervention programme employing a hands-on technique to reduce the incidence of anal sphincter tears: interrupted time-series reanalysis. BMJ Open 2013; 3:e003355.
  66. Carrasco M, Martell M, Estol PC. Oronasopharyngeal suction at birth: effects on arterial oxygen saturation. J Pediatr 1997; 130:832.
  67. Waltman PA, Brewer JM, Rogers BP, May WL. Building evidence for practice: a pilot study of newborn bulb suctioning at birth. J Midwifery Womens Health 2004; 49:32.
  68. Estol PC, Piriz H, Basalo S, et al. Oro-naso-pharyngeal suction at birth: effects on respiratory adaptation of normal term vaginally born infants. J Perinat Med 1992; 20:297.
  69. Gungor S, Teksoz E, Ceyhan T, et al. Oronasopharyngeal suction versus no suction in normal, term and vaginally born infants: a prospective randomised controlled trial. Aust N Z J Obstet Gynaecol 2005; 45:453.
  70. Gungor S, Kurt E, Teksoz E, et al. Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section: a prospective randomized controlled trial. Gynecol Obstet Invest 2006; 61:9.
  71. Kelleher J, Bhat R, Salas AA, et al. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. Lancet 2013; 382:326.
  72. American Heart Association. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics 2006; 117:e989.
  73. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 379: Management of delivery of a newborn with meconium-stained amniotic fluid. Obstet Gynecol 2007; 110:739.
  74. Vain NE, Szyld EG, Prudent LM, et al. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet 2004; 364:597.
  75. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee Opinion No.543: Timing of umbilical cord clamping after birth. Obstet Gynecol 2012; 120:1522.
  76. Lainez Villabona B, Bergel Ayllon E, Cafferata Thompson ML, Belizán Chiesa JM. [Early or late umbilical cord clamping? A systematic review of the literature]. An Pediatr (Barc) 2005; 63:14.
  77. Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet 1969; 2:505.
  78. McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2013; 7:CD004074.
  79. Andersson O, Lindquist B, Lindgren M, et al. Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age: A Randomized Clinical Trial. JAMA Pediatr 2015; 169:631.
  80. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 2012; 8:CD003248.
  81. Backes CH, Rivera BK, Haque U, et al. Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstet Gynecol 2014; 124:47.
  82. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation 2012; 83:869.
  83. Bhatt S, Alison BJ, Wallace EM, et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 2013; 591:2113.
  85. Polglase GR, Dawson JA, Kluckow M, et al. Ventilation onset prior to umbilical cord clamping (physiological-based cord clamping) improves systemic and cerebral oxygenation in preterm lambs. PLoS One 2015; 10:e0117504.
  86. Hooper SB, Te Pas AB, Lang J, et al. Cardiovascular transition at birth: a physiological sequence. Pediatr Res 2015; 77:608.
  87. Ersdal HL, Linde J, Mduma E, et al. Neonatal outcome following cord clamping after onset of spontaneous respiration. Pediatrics 2014; 134:265.
  88. Rabe H, Erickson-Owens DA, Mercer JS. Long-term Follow-up of Placental Transfusion in Full-term Infants. JAMA Pediatr 2015; 169:623.
  89. Duley L, Dorling J, Gyte G. When should the umbilical cord be clamped? BMJ 2015; 351:h4206.
  90. Rabe H, Jewison A, Alvarez RF, et al. Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial. Obstet Gynecol 2011; 117:205.
  91. Hosono S, Mugishima H, Fujita H, et al. Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks' gestation: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2008; 93:F14.
  92. Hosono S, Mugishima H, Fujita H, et al. Blood pressure and urine output during the first 120 h of life in infants born at less than 29 weeks' gestation related to umbilical cord milking. Arch Dis Child Fetal Neonatal Ed 2009; 94:F328.
  93. Patel S, Clark EA, Rodriguez CE, et al. Effect of umbilical cord milking on morbidity and survival in extremely low gestational age neonates. Am J Obstet Gynecol 2014; 211:519.e1.
  94. Al-Wassia H, Shah PS. Efficacy and safety of umbilical cord milking at birth: a systematic review and meta-analysis. JAMA Pediatr 2015; 169:18.
  95. Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2007; :CD003519.
  96. Vain NE, Satragno DS, Gorenstein AN, et al. Effect of gravity on volume of placental transfusion: a multicentre, randomised, non-inferiority trial. Lancet 2014; 384:235.
  97. Herman A, Weinraub Z, Bukovsky I, et al. Dynamic ultrasonographic imaging of the third stage of labor: new perspectives into third-stage mechanisms. Am J Obstet Gynecol 1993; 168:1496.
  98. Herman A. Complicated third stage of labor: time to switch on the scanner. Ultrasound Obstet Gynecol 2000; 15:89.
  99. Dombrowski MP, Bottoms SF, Saleh AA, et al. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995; 172:1279.
  100. Combs CA, Laros RK Jr. Prolonged third stage of labor: morbidity and risk factors. Obstet Gynecol 1991; 77:863.
  101. Romero R, Hsu YC, Athanassiadis AP, et al. Preterm delivery: a risk factor for retained placenta. Am J Obstet Gynecol 1990; 163:823.
  102. Castadot RG. Pregnancy termination: techniques, risks, and complications and their management. Fertil Steril 1986; 45:5.
  103. Begley CM, Gyte GM, Devane D, et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2015; 3:CD007412.
  104. Gülmezoglu AM, Lumbiganon P, Landoulsi S, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet 2012; 379:1721.
  105. Chen M, Chang Q, Duan T, et al. Uterine massage to reduce blood loss after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2013; 122:290.
  106. Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2013; 7:CD006431.
  107. Du Y, Ye M, Zheng F. Active management of the third stage of labor with and without controlled cord traction: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2014; 93:626.
  108. Hofmeyr GJ, Mshweshwe NT, Gülmezoglu AM. Controlled cord traction for the third stage of labour. Cochrane Database Syst Rev 2015; 1:CD008020.
  109. Brandt ML. The mechanism and management of the third stage of labor. Am J Obstet Gynecol 1936; 25:662.
  110. Zuckerwise LC, Pettker CM, Illuzzi J, et al. Use of a novel visual aid to improve estimation of obstetric blood loss. Obstet Gynecol 2014; 123:982.
  111. Landy HJ, Laughon SK, Bailit JL, et al. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011; 117:627.