INTRODUCTION — In 1997, the World Health Organization defined 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 caring for 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.

Intrapartum care of women with a complicated labor and delivery is discussed in separate topic reviews (eg, malpresentation, protraction and arrest disorders, preterm labor, operative vaginal delivery, maternal medical/obstetric disorders, hemorrhage; refer to individual topic reviews on each subject).

COVID-19 — Management of labor and delivery during the coronavirus disease 2019 (COVID-19) pandemic is reviewed separately. (See "COVID-19: Intrapartum and postpartum issues", section on 'Approach to infection control during the pandemic'.)

CREATING A SATISFACTORY CHILDBIRTH EXPERIENCE — 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 (eg, respect, communication, continuity of care), and her involvement in decision making.

Childbirth preparation 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 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".)

WHEN SHOULD LOW-RISK LABORING WOMEN BE ADMITTED TO THE HOSPITAL? — The appropriate time for hospital admission for women in labor with uncomplicated pregnancies is unclear. There is consensus that women in active labor should be admitted. The National Partnership for Maternal Safety suggests assessing the presence of the following factors in making the diagnosis of active labor: regular contractions that require the woman's focus and attention, significant effacement (≥80 percent), and 4 to 5 cm dilation with documented cervical change [3] since most women enter the active phase of labor at 4 to 6 cm.

Given that women cannot check their cervical dilation or effacement, many women will present for a labor check before cervical dilation reaches 4 cm. If mother and fetus are well and transport to the hospital is not a concern, should these patients be admitted to the Labor and Delivery Unit or sent home? Both approaches are probably reasonable. Although women admitted before 4 cm cervical dilation are at higher risk for iatrogenic intervention, the maternal and perinatal consequences of sending these patients home have not been studied adequately.

In Washington State, the Bree Collaborative Obstetrics Care Report attempted to influence clinical practice by recommending admission for spontaneously laboring women at term with uncomplicated pregnancies only when cervical dilation was ≥4 cm [4]. The clinician determined whether the pregnancy was low risk, as well as appropriate counseling and reassessment of women not admitted. Adherence to the recommendation was not mandatory. After publication of this report, a retrospective cohort study of over 11,000 singleton, term deliveries in Washington State observed a 10 to 15 percent increase in hospital admissions at cervical dilation ≥4 cm [5]. Women admitted with cervical dilation <4 cm were more likely to have epidural anesthesia, oxytocin augmentation, and a cesarean delivery than women admitted with cervical dilation ≥4 cm. The authors were unable to identify women evaluated for labor, sent home because of cervical dilation <4 cm, and subsequently admitted; thus, the safety and efficacy of the change in clinical practice could not be evaluated.

A large study from Texas reported that, after evaluation, discharging patients with false labor at term was not associated with an increase in adverse outcome [6]. Criteria for discharge were intact membranes, cervical dilation <4 cm, no cervical change or contractions at the end of two hours observation, and normal fetal heart rate tracing. Patients were excluded from the study if they had pregnancy complications or a previous cesarean delivery.

MANAGEMENT OF THE FIRST STAGE OF LABOR

Initial examination — The goals of the initial examination of the parturient are to review her prenatal record for medical or obstetric conditions that need to be addressed intrapartum, check for development of new disorders since the last prenatal visit, establish baseline cervical status so that subsequent progress can be determined, and evaluate fetal status.

On admission to the labor unit, vital signs include the woman's blood pressure; heart and respiratory rates; temperature; frequency, quality, and duration of uterine contractions; and fetal heart rate (FHR).

Determining whether a woman is in labor is sometimes difficult as painful uterine contractions alone are not sufficient to establish a diagnosis of labor. Typically, the diagnosis is reserved for women with uterine contractions that result in cervical dilation and effacement over time. A recent history of membrane rupture or bloody show (vaginal discharge of a small amount of blood and mucus [ie, mucus plug]) supports the diagnosis.

Physical examination is performed with particular emphasis on the cervical examination. Digital examination is performed after placenta previa and prelabor rupture of membranes (PROM) have been excluded (by history and physical, laboratory, and ultrasound examinations, as appropriate).

The purpose of the initial examination is to determine:

●Whether fetal membranes are intact or ruptured – (See "Prelabor rupture of membranes at term: Management".)

If the membranes have ruptured, the presence of meconium is noted because of the possibility of meconium aspiration. (See "Meconium aspiration syndrome: Pathophysiology, clinical manifestations, and diagnosis".)

●Whether uterine bleeding is present and excessive – Bleeding can be due to placenta previa, vasa previa, and abruptio placentae, and these disorders are potentially life-threatening to the mother and/or fetus. (See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality" and "Velamentous umbilical cord insertion and vasa previa" and "Placental abruption: Pathophysiology, clinical features, diagnosis, and consequences".)

●Cervical dilation and effacement – In women with contractions, progressive cervical dilation and effacement on serial examinations or advanced cervical dilation and effacement on an initial examination are evidence of labor. The rate of cervical dilation becomes faster after the cervix is completely effaced [7].

●Fetal station – Fetal station is expressed as the number of centimeters of the leading bony edge of the presenting part above or below the level of the ischial spines (figure 1); the maximum denominator is 5 (eg, 1 cm beyond the ischial spines corresponds to +1/5 cm). Effacement and station are shown in the figures (figure 2A-B).

If a cervical examination is not performed because of ruptured membranes or vaginal bleeding, engagement of the fetal head can be described in terms of fifths of the fetal head palpable above the symphysis pubis [8]. If the fetal head is not engaged (ie, three-fifths are palpable above the pelvic inlet) in labor, this should raise concerns about cephalopelvic disproportion.

●Fetal lie, presentation, and position – Document fetal lie, presentation, and position. Lie refers to the long axis of the fetus relative to the longitudinal axis of the uterus; it can be longitudinal, transverse, or oblique.

Presentation refers to the fetal part that directly overlies the pelvic inlet; it is usually vertex (cephalic) or breech but can be a shoulder, compound (eg, head and hand), or funic (umbilical cord).

Fetal position is the relationship of a nominated site of the presenting part to a denominating location on the maternal pelvis (eg, right occiput anterior). The fontanelles and suture lines of the fetal skull and their orientation according to fetal position are illustrated in the figures (figure 3 and figure 4A-C and figure 5 and figure 6). Ultrasound examination can be useful if digital assessment is unclear, particularly for occiput posterior [9-11]. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) has published practice guidelines for intrapartum ultrasound. (See "Occiput posterior position", section on 'Diagnosis'.)

Asynclitism refers to an oblique position of the fetal head where the head is tilted toward the shoulder and the parietal bone is the point of presentation.

●Fetal size and pelvic capacity – The clinician should make an attempt to determine whether the fetus is macrosomic and may evaluate the pelvic type (figure 1); however, these assessments are poorly predictive of the newborn weight and course of labor. (See "Shoulder dystocia: Risk factors and planning delivery of high-risk pregnancies".)

Pelvimetry (ie, quantitative measurement of pelvic capacity) can be performed clinically or via imaging studies (radiography, computed tomography, magnetic resonance imaging (figure 7A-B) [12-14]). Average and critical limit values for the various parameters of the bony pelvis have been established but do not accurately predict women at risk for cephalopelvic disproportion [15]. Routine clinical pelvimetry is not recommended [16]. Pelvimetry has been replaced, in large part, by clinical trial of the pelvis ("trial of labor").

●Fetal and maternal well-being – Fetal status is assessed by the FHR pattern (see "Intrapartum fetal heart rate monitoring: Overview"). Maternal assessment is primarily directed toward identifying development of new pregnancy complications, such as preeclampsia, infection, or abruption.

Laboratory tests — Results from the following laboratory tests should be available at delivery, but intrapartum assessment is not always necessary.

●Hemoglobin/hematocrit – Although laboratory assessment of hemoglobin/hematocrit is commonly performed upon admission, there is no evidence that this practice is necessary in uncomplicated pregnancies. Relying on a normal hemoglobin result obtained at 26 to 28 weeks (ie, at the time of screening for gestational diabetes) appears to be a safe and acceptable approach [17,18].

●Blood type and screen – Approximately 1 to 2 percent of women receive a blood transfusion in the peripartum period [19,20].

For women at low risk of postpartum hemorrhage, Rh typing with a negative antibody screen at the first prenatal visit is probably adequate [21-24], but obtaining and holding a clot is also reasonable. Some clinicians obtain a type and screen on these women.

For women at moderate risk of needing a transfusion, a type and screen should be performed, at a minimum. These women include those with multiple gestation, trial of labor after cesarean, preeclampsia/HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) without coagulopathy, grand multiparity, intraamniotic infection, or large fibroids.

For women at high risk of needing a transfusion, type and crossmatch should be done [25]. These women include those with placenta previa or accreta, preeclampsia/HELLP with coagulopathy, severe anemia, congenital or acquired bleeding diathesis, previous postpartum hemorrhage.

●Human immunodeficiency virus (HIV) – Women who have not had HIV screening in pregnancy or whose HIV status is undocumented should have rapid HIV testing in labor if possible or, otherwise, in the immediate postpartum period, using an opt-out approach [26-30]. Some states require all women be screened at delivery. If the rapid test is positive, then antiretroviral prophylaxis should be initiated while waiting for the results of confirmatory testing. (See "Prenatal evaluation of women with HIV in resource-rich settings" and "Antiretroviral selection and management in pregnant women with HIV in resource-rich settings".)

●Hepatitis B – Women who were not screened for hepatitis B surface antigen prenatally, engage in behaviors that put them at high risk for infection (eg, having had more than one sex partner in the previous six months, evaluation or treatment for a sexually transmitted infection, recent or current injection-drug use, a hepatitis B antigen-positive sex partner), or have clinical hepatitis should be tested at hospital admission for delivery [30]. Some states require screening of all women at delivery. The infant should receive immunoprophylaxis if the results are positive. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'HBsAg-positive mother or mother with other evidence of HBV infection'.)

●Syphilis – Women who are at high risk for syphilis acquisition (eg, more than one or a new sex partner, sex in conjunction with drug use or transactional sex, entry to prenatal care during the second trimester or later or no prenatal care, methamphetamine or heroin use, incarceration of the woman or her partner, unstable housing or homelessness, she or her partner had another sexually transmitted infection during pregnancy), live in areas of high rates of syphilis, have a fetal death after 20 weeks of gestation, or are previously untested should be screened at delivery [30]. Some states require screening all women at delivery. (See "Syphilis in pregnancy".)

●Group B streptococcus (GBS) – Women with unknown GBS status can be tested with a nucleic acid amplification test (NAAT), such as polymerase chain reaction for GBS, where available. However, such testing is less reliable than routine GBS screening at 36+0 to 37+6 weeks. Chemoprophylaxis is indicated if NAAT is positive or if the GBS carrier status is unknown but intrapartum risk factors for early-onset GBS infection develop (delivery at <37 weeks gestation, temperature ≥100.4°F [≥38.0°C] or rupture of amniotic membranes ≥18 hours). Some women with a history of GBS colonization in a previous pregnancy may also receive chemoprophylaxis. (See "Early-onset neonatal group B streptococcal disease: Prevention", section on 'Use of rapid diagnostic tests'.)

Patient preparation — Meta-analyses of randomized trials support avoidance of routine enemas and perineal shaving as these interventions are not beneficial and have bothersome or harmful side effects [31,32].

Women can be encouraged to empty their bladder regularly; a urinary catheter is unnecessary unless the woman is unable to void. Available data suggest that bladder distention does not affect labor progress [33,34].

Activity — Women should be encouraged to move and ambulate freely during early labor unless there is a specific contraindication [35].

Fluids and oral intake — Historically, oral intake has been restricted during active labor because of the risk of aspiration pneumonitis, a major cause of anesthetic-associated morbidity and mortality. However, this risk is very low in the current era, and restriction of oral intake can lead to hypovolemia (dehydration) and ketosis.

We allow clear liquids to women at low risk of cesarean delivery (eg, uncomplicated pregnancy, nonobese, fetal weight appropriate for gestational age, no previous cesarean, category 1 FHR tracing) and who have an adequate airway, but restrict consumption of solid foods in accordance with guidelines by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia that recommend avoidance of solid foods in laboring women [36]. The volume of liquid consumed is less important than the presence of particulate matter in the liquid.

If oral intake is inadequate or restricted because of increased risk for cesarean delivery (eg, category 2 or 3 FHR tracing or other pregnancy complications), we provide maintenance intravenous fluids with 5 percent dextrose in 0.45 percent saline, normal saline, or Lactated Ringer solution [37,38]. Glucose requirements in labor are analogous to the requirement observed with sustained and vigorous exercise, and intrapartum administration of glucose may be important for optimal myometrial function [37,39].

Hypovolemia adversely affects exercise performance and may be a factor contributing to longer duration of labor. Physiologists have shown that fluid replacement improves skeletal muscle performance during prolonged exercise; however, the effects of fluid replacement on smooth muscle are less clear [40,41]. Among nulliparous women, a meta-analysis of seven randomized trials found that the duration of labor may be shortened by approximately one hour with administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour (mean difference -64.38 minutes, 95% CI -121.88 to -6.88) [42]. The risk of cesarean delivery overall and for dystocia was also reduced (overall: 12.5 versus 18.1 percent, relative risk [RR] 0.70, 95% CI 0.53-0.92; dystocia: 4.9 versus 7.7 percent, RR 0.60, 95% CI 0.38-0.97). Women had no or restricted oral intake in five of these trials and unrestricted oral intake in two trials. The data did not allow a clear conclusion as to whether the beneficial effects of intravenous fluids would be mitigated or eliminated in women with unrestricted oral intake during labor.

The effect of dextrose-containing intravenous fluids on length of labor has not been studied extensively. In a meta-analysis of 16 trials (n = 2503 low risk pregnancies ≥36 weeks) that evaluated the length of labor when patients received intravenous fluid with versus without dextrose, both groups has a similar total length of labor, but dextrose appeared to shorten the first stage (mean difference -76 minutes, 95% CI -121 to -31) [43]. Variations in oral intake and infusion rates in the trials limits interpretation of these findings. In one of the only trials that compared length of labor in women randomly assigned to 250 mL/hour of normal saline, 125 mL/hour of 5 percent dextrose in normal saline, or 250 mL/hour of 2.5 percent dextrose in normal saline with oral intake restricted to sips of water and ice chips, length of labor was similar for all three groups [44]. Based on these data, the type and rate of intravenous infusion does not appear to have a significant impact on labor duration.

A 2017 systematic review of 10 randomized trials comparing less restrictive food intake policies with more restrictive food intake policies during labor in women with low-risk singleton pregnancies found that less restrictive policies resulted in a slightly shorter duration of labor (-7 to -25 minutes) [45]. No other benefits or harms were noted; however, a key outcome, aspiration rate, could not be assessed because no events occurred. Maternal satisfaction was also not assessed.

Antacids — We do not routinely administer sodium citrate to our laboring patients, but give it to all patients before cesarean delivery. Some authors have suggested administering a clear antacid (eg, 10 to 30 mL sodium citrate) to all laboring women since aspiration pneumonitis results from the acidity of the aspirated gastric contents; however, the utility of this approach in laboring women has not been proven [46].

Medication management — Women can take their usual daily medications orally during labor; however, gastric absorption is unpredictable if labor is advanced. If this is a clinically important concern, a nonoral route of administration is preferable.

Women who have been taking glucocorticoids in a dose equivalent to prednisone 5 to 20 mg daily for more than three weeks may have hypothalamic-pituitary-adrenal axis suppression and either should undergo testing or receive empiric glucocorticoid coverage. Perioperative management of specific medications, including glucocorticoid coverage, is reviewed separately. (See "The management of the surgical patient taking glucocorticoids".)

Infection prophylaxis

Systemic antibiotics — Intrapartum chemoprophylaxis to prevent early-onset neonatal GBS infection is indicated for patients who meet standard criteria; the agent of choice is penicillin G. A minimum of four hours of intrapartum intravenous therapy has been recommended prior to delivery; however, bactericidal levels in cord blood are achieved within 30 minutes of administration to the mother, so antibiotics should be administered even if delivery seems imminent. Prevention of early-onset neonatal GBS infection, including management of women with penicillin allergy, is reviewed in detail separately. (See "Early-onset neonatal group B streptococcal disease: Prevention".)

Vaginal delivery is not an indication for routine antibiotic prophylaxis, even in women with cardiac lesions, since the rate of bacteremia is low (see "Antimicrobial prophylaxis for the prevention of bacterial endocarditis", section on 'Vaginal or cesarean delivery'). Although two randomized trials of a single dose of oral azithromycin prophylaxis in laboring women in Cameroon and The Gambia suggested a reduction in maternal and infant infections [47,48], the data were not definitive and may not be generalizable to high-income countries. A Cochrane review concluded that routine administration of antibiotics after a normal vaginal birth may reduce the risk of endometritis but did not reduce the incidence of urinary tract infections, wound infection, or the length of maternal hospital stay [49]. Severe maternal infectious morbidity, antimicrobial resistance, and women's satisfaction with care were not evaluated, and the overall quality of evidence was low.

Vaginal antiseptic antibacterial agents — Available data provide no convincing evidence to support the practice of intrapartum chlorhexidine vaginal irrigation for reducing the risk of maternal and neonatal infection [50].

Maternal activity and position — Maternal preferences can guide maternal activity. In a randomized trial, walking during the first stage did not enhance or impair active labor and had no harmful effects [51].

Laboring women should assume positions that are comfortable [52-54], unless specific positions are needed because of maternal-fetal status and need for close monitoring. Data from randomized trials provide no strong evidence to discourage maternal preference for choosing position during labor.

In a 2013 meta-analysis including 25 trials (5218 women), the duration of the first stage was more than one hour shorter in women randomly assigned to upright positions (standing, sitting, kneeling, walking around) than in those randomly assigned to recumbent positions or bed care (-1.36 hours, 95% CI -2.22 to -0.51 hours) and women in upright positions had a modest reduction in cesarean delivery (RR 0.71, 95% CI 0.54-0.94), but there were no statistical differences in use of oxytocin augmentation (RR 0.89, 95% CI 0.76-1.05), maternal pain requiring analgesia (RR 0.95, 95% CI 0.84-1.08), or duration of the second stage (-3.71 minutes, 95% CI -9.37 to 1.94 minutes) [52]. Some limitations of these trials include risk of bias since blinding was not possible and wide variation in the patients' positions and time spent in various positions.

Pain control and comfort measures — Multiple nonpharmacologic, pharmacologic, and anesthetic options are available to help women manage pain during labor. Use of nonpharmacologic measures can reduce the use of drugs during labor and may have a modest favorable effect on duration of labor. These options are reviewed in detail separately.

●(See "Nonpharmacologic approaches to management of labor pain".)

●(See "Pharmacologic management of pain during labor and delivery".)

●(See "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)

Amniotomy — We do not perform amniotomy routinely as there is no convincing evidence of benefit in spontaneously laboring women. Rupture of membranes increases the risk of ascending infection and cord prolapse. In a 2013 systematic review and meta-analysis of randomized trials, routine amniotomy did not shorten the first or second stage of labor or reduce the rate of cesarean delivery compared with planned preservation of intact membranes (15 randomized trials involving over 5500 women) [55]. A limitation of this analysis was the lack of consistency in the timing of amniotomy with respect to cervical dilation and substantial crossover: 20 to 60 percent of women assigned to the control group underwent amniotomy at some stage in their labor.

Although amniotomy allows assessment of meconium passage, this information alone has poor prognostic value and does not affect labor management [56,57].

On the other hand, women undergoing augmentation or induction of labor may benefit from the combination of oxytocin administration and amniotomy [58,59]. In a randomized trial not included in the analysis described above, early amniotomy within one hour of the diagnosis of labor by strict criteria and oxytocin augmentation if cervical dilation was <1 cm per hour reduced the median duration of labor by 2.7 hours (from 8.9 to 6.2 hours) [58]. Amniotomy during induction is reviewed separately. (See "Induction of labor with oxytocin", section on 'Amniotomy'.)

If amniotomy is performed in women with polyhydramnios or an unengaged presenting part, we suggest using a small gauge needle (rather than a hook) to puncture the fetal membranes in one or more places and performing the procedure in an operating room. "Controlled amniotomy" minimizes the risk of gushing amniotic fluid and permits emergency cesarean delivery in the event of an umbilical cord prolapse. (See "Umbilical cord prolapse".)

Amniotomy should be avoided, if possible, in women with active hepatitis B, hepatitis C, or HIV infection to minimize exposing the fetus to ascending infection. Positive GBS carrier status is not a contraindication to amniotomy, if indicated.

Monitoring — Frequent maternal-fetal assessment is important as intrapartum complications can arise rapidly even in low-risk women: 20 to 25 percent of all perinatal morbidity and mortality occurs in pregnancies with no underlying risk factors for adverse outcome [60] and a study of 10 million birth certificates in the United States found that 29 percent of low-risk pregnancies had at least one unexpected complication that would require nonroutine obstetric or neonatal care [61]. The lowest risk for an uncomplicated birth appears to be in multiparous women without a previous cesarean delivery or other risk factors for complications; the risk for a complicated birth in this group was 8 to 9 percent in one large English study [62].

Fetal heart rate — Although controversial, intrapartum electronic FHR monitoring has become the most common obstetric procedure for women in the United States because patients and clinicians are reassured by normal results and believe there is some value in detecting abnormal FHR patterns. In women with pregnancies at increased risk of fetal compromise during labor (eg, suspected fetal growth restriction, preeclampsia, abruptio placentae, type 1 diabetes), we perform continuous electronic FHR monitoring, in agreement with clinical management guidelines from the American College of Obstetricians and Gynecologists (ACOG) [63]. We also monitor low-risk pregnancies continuously because it is more practical than intermittent monitoring in terms of nursing staff resources, but we are not rigid about this if the patient understands the risks and benefits of intermittent monitoring and has an uncomplicated pregnancy, normal FHR tracing, and is not resting in bed. Intrapartum FHR monitoring is reviewed in detail separately. (See "Intrapartum fetal heart rate monitoring: Overview".)

Electronic FHR monitoring requires ongoing clinical assessment. At a minimum, ACOG suggests review of FHR tracings in low-risk pregnancies every 30 minutes in the first stage of labor and every 15 minutes in the second stage [63]. For higher-risk pregnancies, they suggest reviewing the tracing every 15 minutes in the first stage and every five minutes in the second stage. Closer assessment and intervention may be indicated when abnormalities are identified. (See "Intrapartum category I, II, and III fetal heart rate tracings: Management".)

The health care provider's interpretation of the tracing should be documented in the patient's medical record and should include a description of the uterine contractions, baseline FHR rate, baseline FHR variability, presence or absence of accelerations, presence or absence of periodic decelerations (ie, with contractions) or episodic decelerations (ie, unrelated to contractions), and changes in the FHR over time.

Uterine contractions — The frequency of contractions is documented as the number of contractions over a 30-minute period divided by three to give the number of contractions per 10 minutes. If this number is not a whole number, it may be rounded.

External tocodynamometry is a noninvasive means for recording contraction frequency and duration, and provides adequate information for most labors. If the tracing is inadequate, an internal pressure transducer can be placed to measure contraction frequency, duration, and strength. (See "Use of intrauterine pressure catheters".)

Information about contraction frequency, duration, and strength can help the clinician determine the cause of abnormal labor progression and interpret abnormal FHR patterns. (See "Labor: Overview of normal and abnormal progression" and "Intrapartum category I, II, and III fetal heart rate tracings: Management".)

Tachysystole is defined as >5 contractions over 10 minutes; any number greater than 5 (eg, 5.2) should be interpreted as tachysystole. When associated with administration of oxytocin, FHR abnormalities are the most common potential consequence of tachysystole; uterine rupture is a rare complication. Management is reviewed separately. (See "Induction of labor with oxytocin", section on 'Tachysystole'.)

Labor progress — Few randomized trials have evaluated the optimum frequency and timing of intrapartum vaginal examination of the cervix, fetal position, and fetal descent [64]. In most women, we perform vaginal examinations:

●On admission

●At two- to four-hour intervals in the first stage

●Prior to administering analgesia/anesthesia, or immediately after for patient comfort

●When the parturient feels the urge to push (to determine whether the cervix is fully dilated)

●At one- to two-hour intervals in the second stage to evaluate descent

●If fetal heart rate abnormalities occur (eg, to check for cord prolapse or a change in station due to uterine rupture, to assess fetal position and station for possible vacuum- or forceps-assisted vaginal delivery)

The number of examinations is kept to a minimum for patient comfort and to minimize iatrogenically exposing the intrauterine contents to vaginal flora. (See "Intraamniotic infection (clinical chorioamnionitis)", section on 'Risk factors'.)

Assessing whether labor is progressing normally is a key component of intrapartum care; however, determining the onset of labor, measuring its progress, and evaluating the factors (power, passenger, pelvis) that affect its course is an inexact science. Criteria for normal and abnormal progress and management of protracted labor are discussed in detail separately. (See "Labor: Overview of normal and abnormal progression".)

Precipitate or precipitous labor and delivery refers to a rapid labor and delivery of the fetus, variously defined as expulsion of the fetus within two to three hours of commencement of contractions. It is rare and not well-studied.

MANAGEMENT OF THE SECOND STAGE OF LABOR

Persistent anterior cervical lip — In most women, the final centimeter of cervix anteriorly between the pelvic brim and the fetal head rapidly disappears as the cervix fully dilates and the fetal head descends. Occasionally an anterior lip persists for >30 minutes and may indicate malposition or a labor abnormality, especially if the lip becomes edematous.

We manage these patients expectantly and avoid manually reducing the anterior lip because of the risk of lacerating the cervix and hemorrhage. However, with prolonged expectant management, cervical laceration, necrosis, or detachment of the lip may occur spontaneously. If manual reduction is attempted, the cervical lip is pushed backwards during a contraction until it slips over the fetal head and above the interior border of the symphysis pubis [65]. The cervix is gently held in this position until the fetal head descends with the next contraction and maternal pushing.

Perineal care — Application of warm compresses and perineal massage with a lubricant have been proposed as means of softening and stretching the perineum to reduce perineal trauma during birth.

In women who have not had a previous vaginal birth, a meta-analysis of randomized trials found that antepartum perineal massage reduced perineal trauma (mainly episiotomies) but did not reduce first- or second-degree perineal tears or third-/fourth-degree perineal trauma [66].

In another meta-analysis of randomized trials, applying warm compresses during the second stage of labor reduced third- and fourth-degree tears compared with a hands off or no warm compress technique (risk ratio [RR] 0.46, 95% CI 0.27-0.79; four trials, n = 1799 women); performing massage also reduced third- and fourth-degree tears compared with hands off/usual care (RR 0.49, 95% CI 0.25-0.94; five trials, n = 2477 women) [67]. Rates of minor trauma (eg, first- and second-degree tears) were similar for the intervention and nonintervention groups.

Although not harmful and supported by some meta-analyses [66,67], we do not routinely advise antenatal perineal massage, perform second stage perineal massage, or apply warm compresses, as available trials suggesting a benefit have major methodologic limitations due to lack of blinding, differences in the provision of usual care, and inability to address the importance of other factors related to perineal injury.

If used, warm compresses can be made from clean wash cloths or perineal pads immersed in warm tap water (up to 110 degrees Fahrenheit [43 degrees Celsius]) and wrung to release excess water [68,69]. They are held against the mother's perineum during and between pushes, and changed as needed to maintain warmth and cleanliness. Perineal massage is performed during and between pushes with two fingers of the lubricated gloved hand moving from side to side just inside the patient's vagina and exerting mild, downward pressure.

Manual perineal protection during delivery is discussed below. (See 'Delivery of the newborn' below.)

Pushing

Immediate versus delayed — The two most common approaches to pushing in the second stage of labor are to initiate pushing as soon as complete cervical dilation is identified (immediate pushing) or delay pushing for as much as an hour until the presenting part has descended further along the birth canal (ie, "laboring down" or delayed pushing).

We generally prefer that women begin pushing immediately to minimize the duration of the second stage; however, if the fetal heart rate (FHR) pattern is normal and the station is high, we often ask women to delay pushing until the further descent has occurred to reduce the duration of maximal maternal exertion. This decision is based on patient-specific factors, such as whether there is a need to expedite delivery, maternal fatigue, motor blockade from neuraxial anesthesia, and maternal preference. There is no strong evidence that one approach is better than another.

In a meta-analysis of term singleton pregnancies randomly assigned to delayed or immediate pushing (12 trials, 5445 participants) [70]:

●Delayed pushing resulted in less time spent actively pushing (mean difference -27.54 minutes, 95% CI -43.04 to -12.04) but at the expense of a much longer second stage (mean difference 46.17 minutes, 95% CI 32.63-59.71).

●The longer second stage was associated with an increased risk for chorioamnionitis (9.1 versus 6.6 percent, RR 1.37, 95% CI 1.04-1.81) and low umbilical cord pH, as defined by individual trial authors (2.7 versus 1.3 percent, RR 2.00, 95% CI 1.30-3.07).

●Rates of spontaneous vaginal delivery, assisted vaginal delivery, and cesarean delivery were similar for both approaches.

All of the participants had neuraxial analgesia. The overall quality of evidence was considered low because of inconsistency and indirectness due to the high heterogeneity of the included trials.

Position and technique — The optimum pushing position for labor and delivery and the optimum breathing/pushing technique are unclear. We have the patient push in the position she finds most comfortable. Upright positions where the pelvis is in a vertical plane (eg, walking, standing, sitting, supported kneeling) have several theoretical benefits, such as increasing pelvic dimensions [71], improving fetal alignment within the birth canal, increasing the capacity for pelvic joint movement, and optimizing gravitational force on the presenting part. The supine position should be avoided because of aortocaval compression, but a left or right lateral position avoids this complication and is acceptable. Data on outcomes with upright versus lying positions are reviewed below. (See 'Maternal position for delivery' below.)

We favor allowing the woman to bear down when she feels the need (ie, spontaneous pushing or physiologic pushing), unless neuraxial anesthesia has inhibited the bearing down sensation. Although a common practice is to tell women to pull back their knees, tuck in their chin, take a deep breath, bear down at the start of a contraction, and push for 10 seconds with the goal of three pushes per contraction, there is no clear evidence that coaching women in this way has any benefit over allowing them to bear down and push according to their own reflex needs in response to the pain of contractions and the pressure felt from descent of the fetal head. We advise against Valsalva pushing (pushing with a closed glottis) as there is no clinically significant benefit to this technique.

In a meta-analysis of randomized trials of different breathing and pushing techniques [72]:

●Women who followed their own instincts about breathing while pushing (ie, spontaneous pushing) and those who were told to take a deep breath at the beginning of a contraction and hold it as long as possible while bearing down (ie, directed pushing with Valsalva maneuver) had similar lengths of the second stage and duration of pushing. All of the trials were limited by lack of blinding and by crossover between groups.

Duration — As long as the FHR pattern is normal and some degree of progress is observed, there is no strict upper limit to the duration of the second stage (ie, time from full dilation to birth). There is no threshold at which maternal or neonatal outcomes abruptly worsen, but a second stage lasting longer than four hours in nulliparas and three hours in multiparas appears to be associated with a small increase in frequency of maternal and potentially serious neonatal complications, and this is concerning. (See "Labor: Diagnosis and management of a prolonged second stage".)

In a prospective study including over 53,000 women at term with singleton cephalic gestations, 78 percent of nulliparas and 82 percent of multiparas who continued to push longer these times achieved a vaginal delivery [73]. In nulliparas, the frequency of the neonatal composite adverse outcome at <60 minutes and ≥240 minutes was 1.3 and 2.4 percent, respectively. In parous women, the frequency of the neonatal composite adverse outcome at <60 minutes and ≥120 minutes was 1.1 and 2.8 percent, respectively. Of possible concern, seizures or hypoxia-ischemic encephalopathy accounted for almost all adverse neonatal outcomes at ≥240 minutes (10 newborns or 2.2 percent of the population pushing ≥240 minutes versus 0.4 percent of the population pushing <60 minutes). An increase in neonatal seizures and hypoxia-ischemic encephalopathy at ≥120 minutes was also noted in parous women (seven newborns or 1.5 percent of the population pushing ≥120 minutes versus 0.2 percent of the population pushing <60 minutes).

Maternal position for delivery — If no fetal manipulation or complications are anticipated, delivery can be accomplished with the mother in almost any position that she finds comfortable. Common positions include the lateral (Sims) position and the partial sitting position. Stirrups are not mandatory [74]. The lithotomy position is advantageous if fetal manipulation or need for optimal surgical exposure is anticipated.

In two meta-analyses of randomized trials:

●Compared with lying positions (lateral, semirecumbent, lithotomy, Trendelenburg), upright positions (sitting, squatting, kneeling) resulted in a 3 to 10 minute reduction in the duration of the second stage of labor, reduction in episiotomy rates (RR 0.75, 95% CI 0.61-0.92), and reduction in assisted vaginal deliveries (RR 0.75, 95% CI 0.66-0.86) but increased the risk for blood loss greater than 500 mL (RR 1.48, 95% CI 1.10-1.98) [53]. Cesarean delivery rates were similar for both positions. Participants in these trials did not have neuraxial anesthesia. In trials in which participants had neuraxial anesthesia, there was no clear difference in risk for operative birth (assisted vaginal or cesarean) between upright and lying positions [54].

●Maternal birth position did not appear to have a significant effect on risk of third and fourth degree lacerations, regardless of type of labor analgesia/anesthesia [53,54].

Episiotomy — Routine use of episiotomy is not beneficial and should be avoided. Episiotomy is reserved for deliveries with a high risk of severe perineal laceration, significant soft tissue dystocia, or need to facilitate delivery of a possibly compromised fetus. The evidence for this recommendation is discussed separately. (See "Approach to episiotomy".)

Delivery of the newborn — The procedure for spontaneous vaginal delivery is described below. Operative vaginal and abdominal delivery are reviewed separately (see "Operative vaginal delivery" and "Cesarean birth: Surgical technique and wound care"). Standard precautions for infection control should be followed.

The responsibilities of the health care provider at delivery are to reduce the risks of maternal perineal trauma and fetal injury during delivery and provide initial support of the newborn. There is no consensus regarding the best method for protecting the perineum at delivery [68,69,75-82], other than avoiding both routine episiotomy and fundal pressure [83]. Options include delivering the fetus between contractions versus during a contraction, and various methods of using the accoucheur's hands to control delivery of the fetal head. The latter may involve no touch ("hands-off"), passive perineal support, support of the fetal crown, and using fingers placed between the maternal anus and coccyx to actively lift the fetal chin anteriorly (ie, Ritgen maneuver). Warm compresses and perineal massage may be helpful to reduce perineal trauma. (See 'Perineal care' above.)

We use the following approach (called the "hands-on" technique) to prevent precipitous expulsion of the newborn, which can lacerate the perineum and anal sphincter [75,82,84]. We ask the woman to pant or make only small expulsive efforts when the head is fully crowning and delivery is imminent; this prevents the head from being propelled through the perineum. We use one hand to maintain the head in a flexed position and control the speed of crowning and use the other hand to ease the perineum away from the path of the emerging head ("manual perineal protection" [85]). Some providers support the perineum with a sponge, applying medial pressure. Once the fetal head delivers, external rotation (restitution) occurs spontaneously (figure 8). A meta-analysis of three trials that evaluated manual perineal support found that it did not significantly reduce obstetric anal sphincter injuries (OASIS; RR 1.03, 95% CI 0.32-3.36), although three nonrandomized studies suggested a benefit (RR 0.45, 95% CI 0.40-0.50). Since the techniques for perineal support were not well described, it is difficult to interpret these findings. The role of various obstetric factors on anal sphincter injury and postpartum function are discussed separately. (See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

If the cord is around the neck (nuchal cord), slipping the cord over the head usually successfully frees the fetus from the tether. If a single nuchal cord is not reducible, we doubly clamp and transect it. Other options for a cord that is difficult to reduce but not tight include slipping it over the shoulders and delivering the body through the loop and delivering the body without reducing the cord (somersault maneuver). It is important to avoid avulsing or tearing the cord while attempting to effect delivery. (See "Nuchal cord", section on 'Delivery'.)

Mucus is gently wiped from the newborn's nose and mouth. Most newborns do not need to be suctioned. (See 'Oropharyngeal care' below.)

After delivering the head, a hand is placed on each side of the head and the anterior shoulder is delivered with the next contraction, using gentle downward traction toward the mother's sacrum in concert with maternal expulsive efforts. In this way, the anterior shoulder is guided under the symphysis pubis. The posterior shoulder is then delivered by upward traction. These movements should be performed with as little downward or upward force as possible to avoid perineal injury and/or traction injuries to the brachial plexus. The delivery is then completed, either spontaneously or with a gentle maternal push.

Oropharyngeal care — There is no evidence that oro-nasopharyngeal suctioning by a bulb or catheter is beneficial in healthy term newborns [86-90] and, in some studies, suctioning slightly reduced neonatal oxygen saturation in the first few minutes of life [86,89,90]. However, suctioning immediately after birth is appropriate for newborns with obvious obstruction to spontaneous breathing due to secretions or who are likely to require positive-pressure ventilation. The mouth is suctioned first and then the nares to decrease the risk for aspiration (newborns are obligate nose breathers). Suctioning of the posterior pharynx should be avoided, as it can stimulate a vagal response, resulting in apnea and/or bradycardia. In a randomized equivalency trial, wiping the face, mouth, and nose with a towel was equivalent to suction with a bulb syringe [91]. The trial's primary endpoint was mean respiratory rate within the first 24 hours after birth; neonates who were nonvigorous or born with meconium stained amniotic fluid were excluded. (See "Overview of the routine management of the healthy newborn infant", section on 'Delivery room care' and "Neonatal resuscitation in the delivery room", section on 'Airway'.)

Meconium — The American Heart Association, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists (ACOG) recommend against routine nasopharyngeal suctioning of meconium-stained newborns [92,93]. Randomized trials have demonstrated that this approach does not decrease meconium aspiration syndrome or improve perinatal outcome [94]. (See "Meconium aspiration syndrome: Prevention and management".)

MANAGEMENT OF THE THIRD STAGE OF LABOR

Cord clamping and other approaches to the cord

Early versus delayed cord clamping — Delayed cord clamping has newborn benefits in both term and preterm births, but the optimum duration of delay remains unclear [95]. Delayed cord clamping does not appear to have maternal benefits or harms. Maternal blood loss was not increased compared with immediate clamping in a randomized trial [96].

●Term infants – We agree with an American College of Obstetricians and Gynecologists (ACOG) committee opinion that recommends delaying umbilical cord clamping after birth in vigorous term infants [97]. The American Academy of Pediatrics [98] and most other clinical practice guidelines also endorse this approach [99]. Although the optimal amount of time before cord clamping has not been studied extensively, we agree with the ACOG recommendation of a delay of at least 30 to 60 seconds; others have suggested a two- to five-minute delay (or longer if the mother requests) [100].

Delaying cord clamping should not interfere with timely care of the newborn and should never compromise the safety of the mother or newborn. For example, it is not appropriate when the mother or newborn is unstable or when the newborn-placental circulation is not intact (eg, abruption, previa, cord avulsion). It may not be appropriate in cases of fetal growth restriction with abnormal umbilical artery Doppler studies, as these newborns may already have polycythemia and hyperviscosity. Limited data in this specific population preclude a clear conclusion [101].

In term infants, the main advantage of delayed cord clamping is higher infant iron stores at six months of age, which may be particularly advantageous when the mother has a low ferritin level or plans to breastfeed without supplementing with iron or fortified formula. Preventing or reducing the occurrence of iron deficiency in infants may have favorable long-term developmental effects, since iron deficiency has been associated with impaired neurodevelopment. Disadvantages of delayed cord clamping include an increase in hyperbilirubinemia in the immediate newborn period resulting in more phototherapy and an increased risk of polycythemia in growth-restricted neonates. Delaying cord clamping also reduces the volume of umbilical cord blood available for harvesting stem cells; thus, the size and cell dose of collected cord blood units may not be adequate for a future hematopoietic cell transplant if cord clamping is delayed. This should be considered when cord blood collection is planned for this purpose. (See "Collection and storage of umbilical cord blood for hematopoietic cell transplantation".)

•A 2013 meta-analysis of 15 randomized trials including 3911 mothers and their infants evaluated early versus late (two to three minutes after birth) cord clamping in term infants [102]. Compared with early cord clamping,

-Late cord clamping resulted in higher neonatal hemoglobin levels at 24 to 48 hours after birth (mean difference 1.49 g/dL), but not in subsequent assessments, and a lower proportion of infants with iron deficiency at three to six months of age (14 percent of infants in the early clamping group versus 8 percent in the late clamping group).

-However, late cord clamping also resulted in a 40 percent increase in newborns needing phototherapy for jaundice (2.74 percent of infants in the early clamping group versus 4.36 percent in the late clamping group).

•In addition, the only randomized clinical trial that assessed longterm effects of delayed versus early cord clamping reported a possible benefit in some neurodevelopmental outcomes at four years of age, particularly in boys, and no harmful effects [103].

●Preterm infants – We delay cord clamping for at least 30 seconds in vigorous preterm infants [104], but available data (discussed below) do not strongly support one approach over another; therefore, physicians should use their judgment about whether and how long to delay cord clamping in individual preterm infants until definitive data are available. Although a benefit has not been demonstrated consistently, delayed cord clamping is unlikely to be harmful, even in small for gestational age preterm infants [105]. Differences among populations and physician judgment as to whether it was safe to delay cord clamping likely impacted the precision of the following data. ACOG recommends delaying umbilical cord clamping for at least 30 to 60 seconds after birth in both vigorous term and preterm infants [97].

In preterm infants, providing more time for the physiologic transition from fetal to newborn life is an advantage of delayed cord clamping and possibly accounts for the significant reductions in intraventricular hemorrhage (IVH) and necrotizing enterocolitis associated with this intervention seen in some trials, but not meta-analyses. Approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth [106]. Delaying cord clamping increases the volume of placental blood transfused to the fetus and thereby increases neonatal blood volume, improves neonatal and infant iron stores, and decreases neonatal and infant anemia. It also facilitates the fetal to neonatal transition. Clamping the cord before initiation of spontaneous respirations (mean onset of respiration is 10±15 seconds after expulsion [107]) appears to adversely affect cardiovascular hemodynamics during the fetal to neonatal transition, likely due to removal of umbilical venous return before dilation of the pulmonary vascular bed [108-111]. Lung aeration triggers an increase in pulmonary blood flow, which supplies most of the preload to the left ventricle; if cord clamping precedes onset of respiration, ventricular preload falls because the loss of umbilical venous return is not balanced by an increase in pulmonary venous return [111]. This may partially account for some of the nonhematologic benefits reported in trials of delayed cord clamping [112].

•<37 weeks: In a 2018 meta-analysis of randomized trials of delayed (typically ≥60 seconds) versus early (typically ≤10 seconds) cord clamping in preterm deliveries (18 trials, n = 2834 infants), delayed clamping, when safe to do so [113]:

-Reduced neonatal hospital mortality by approximately 30 percent (risk ratio 0.68, 95% CI 0.52-0.90; number needed to benefit 33, 95% CI 20-100).

-Increased peak hematocrit by 2.73 percentage points (95% CI 1.94-3.52) and reduced the proportion of infants having blood transfusion by 10 percent (95% CI 6-13 percent).

-Increased peak serum bilirubin by 4 micromol/L without increasing morbidity (eg, partial exchange transfusions for polycythemia, exchange transfusions for hyperbilirubinemia).

-Did not reduce the incidence of intubation for resuscitation, admission temperature, mechanical ventilation, severe IVH, brain injury, chronic lung disease, patent ductus arteriosus, necrotizing enterocolitis, late onset sepsis or severe retinopathy of prematurity, but also did not increase morbidity from these entities (subgroup analysis).

•<34 weeks: A 2021 meta-analysis of trials limited to newborns <34 weeks did not find statistically significant differences in survival to discharge when comparing early (<30 seconds) cord clamping, delayed (≥30 seconds or based on physiologic parameters) cord clamping, and cord milking [114]. Delayed cord clamping and cord milking improved hematologic outcomes compared with early cord clamping, but neither improved nor worsened major neonatal morbidities.

•<28 weeks: When only extremely preterm infants (≤28 weeks) are considered, a randomized trial found that placental transfusion (delayed cord clamping or cord milking) did not significantly affect the composite outcome of mortality or major morbidity by 36 weeks postmenstrual age (PMA; ie, the time period from the first day of the mother's last menstrual period to the present, thus including both prenatal and postnatal weeks; adjusted odds ratio [aOR] 1.26, 95% CI 0.95-1.66), but decreased mortality by 36 weeks PMA (aOR 0.71, 95% CI 0.55-0.92) and treatment for hypotension in the first 24 postnatal hours (aOR 0.66, 95% CI 0.53-0.82) [115]. Given other evidence linking cord milking with IVH, until this potential risk is better clarified, delayed clamping is advised over cord milking. (See 'Cord milking' below.)

Cord milking — We do not milk or strip the umbilical cord; however, some experts consider this practice an alternative to delayed clamping for enhancing blood transfusion, especially when delayed clamping is not feasible. Depending on technique, cord milking may be more efficient than delayed cord clamping for improving neonatal blood volume. A randomized trial in preterm infants found that milking the accessible length of the cord four times at a speed of 20 cm/2 seconds was equivalent to delaying cord clamping for 30 seconds [116].

Cord milking, like delayed cord clamping, may help stabilize blood pressure and increase urinary output in preterm infants [117-119], but a concern is that a nonquantifiable amount of blood will be given to an immature infant in an uncontrolled fashion, which could be harmful.

●In a meta-analysis of 19 randomized trials of the efficacy and safety of umbilical cord milking in preterm infants, compared with delayed cord clamping, cord milking increased the risk for severe IVH in newborns <34 weeks (relative risk [RR] 1.95, 95% CI 1.01-3.76) [120].

However, a subsequent network meta-analysis did not confirm this finding in newborns <37 weeks: Delayed cord clamping and cord milking resulted in similar odds of severe IVH (grade 3 or 4 IVH: OR 0.98, 95% CI 0.56-1.85) [121]. The mortality rate prior to discharge and other neonatal outcomes (transfusion, bronchopulmonary dysplasia, late onset sepsis, necrotizing enterocolitis, retinopathy of prematurity requiring treatment, neurodevelopmental impairment) were also similar, although data for some of these outcomes was sparse and none of the data were high quality.

Interpretation of available data is limited by the heterogeneity of milking techniques used in the trials, differences in gestational age, and the lack of information about cord milking in extremely preterm newborns (<28 weeks). However, there appears to be equipoise between delayed cord clamping and cord milking in the overall population of vigorous preterm newborns.

Delivery should not be unnecessarily delayed to milk the cord in situations where immediate pediatric assistance is needed, such as thick meconium or neonatal depression. Also, it should not be performed if cord blood collection is planned.

Data on cord milking versus delayed cord clamping in term newborns are limited and insufficient to make a conclusion regarding the best approach [122].

Physiological cord clamping — Physiological cord clamping (PCC) is a form of delayed cord clamping in which the time the cord is clamped is based on physiological parameters such as onset of respirations and cessation of cord pulsations rather than at a fixed time point. The cord generally remains unclamped for a longer period of time with PCC compared with nonphysiological delayed cord clamping (3 to 5 minutes versus 30 to 60 seconds [123]). Because some newborns may need intervention before their pulmonary and hemodynamic transitions to extrauterine life have been completed, resuscitation tables have been developed that enable a full standard of care for stabilization of newborns with an intact umbilical cord [123].

In the first randomized trial of PCC versus delayed cord clamping in preterm infants <32 weeks, the PCC group needed less time to reach respiratory stability (mean time 5:54±2:27 versus 7:07±2:54 minutes; mean difference -1:19 minutes, 95% CI -3.04 to 0.27) [124]. PCC was performed when the infant had regular spontaneous breathing, heart rate ≥100 beats per minute, and SpO₂ >90 percent while using FiO₂ <0.40. Although the investigators used a specialized resuscitation table designed to provide full standard care while the cord remained intact, 4 of 20 infants in the PCC group had moderate hypothermia compared with 1 of 17 infants in the delayed clamping group.

Umbilical nonseverance — In umbilical nonseverance (also called Lotus birth), the umbilical cord is not clamped and cut [125-128]. The cord and placenta remain attached to the newborn until the cord naturally detaches from the umbilicus, which typically takes 3 to 10 days. Proponents of this practice, which is uncommon and mostly done in home births, believe it is less stressful for the newborn, leads to a more robust immune system, and promotes maternal-infant bonding. There is no proven medical benefit and no biological plausibility that would suggest medical benefit [129]. It is neither natural nor physiologic since blood flow in the cord stops 5 to 10 minutes after birth. Some disadvantages include the odor associated with placental necrosis, hygienic and infection issues, and inability to perform histologic examination, if indicated. Data are limited to a few case reports, with at least two describing serious neonatal infections that may have been related to the practice [130,131]. We strongly discourage this practice.

Cord blood — Cord blood collected for diagnostic purposes is usually obtained by allowing blood to drain from the cut end into a glass tube prior to delivery of the placenta, if possible. Cord blood may be tested for blood and Rh type or for a variety of newborn conditions, as indicated. Newborn screening programs typically use blood from a heel stick obtained as close to hospital discharge as possible to permit the maximum accumulation of abnormal compounds in the infant's blood and the best chance of obtaining a positive result if disease is present. (See "Newborn screening".)

When indicated (eg, neonatal depression), fetal blood for acid-base analysis is collected from an umbilical artery using a needle and syringe to minimize exposure to air and avoid mixing of arterial and venous blood. (See "Umbilical cord blood acid-base analysis at delivery".)

Collection of cord blood for banking can be performed with a needle and syringe before or after delivery of the placenta. Delayed cord clamping significantly reduces the volume of cells available for cord blood donation and may prevent adequate collection. The procedure for collection of umbilical cord blood for banking is reviewed separately. (See "Collection and storage of umbilical cord blood for hematopoietic cell transplantation".)

Placental drainage — After the cord has been cut, there is no clinical benefit to allowing the placenta to drain any residual blood, although small differences in the length of the third stage and average blood loss were described in randomized trials before the era of delayed cord clamping [132]. Placental drainage does not reduce the incidence of postpartum hemorrhage or retained placenta.

Draining the placenta passively or actively prior to extraction may result in less fetomaternal bleeding; available data are sparse and discordant [133,134]. The clinical significance (ie, frequency of alloimmunization) has not been evaluated.

Maternal-newborn interaction — In the absence of maternal or neonatal complications, a healthy term infant can be dried to minimize heat loss and given to the mother. Skin-to-skin contact may benefit early mother-infant attachment and breastfeeding outcomes [135,136].

The location of the newborn (above or below the level of the placenta) before cord clamping did not appear to significantly affect the volume of placenta-to-newborn transfusion in a randomized trial [137]. Therefore, concerns about transfusion volume should not influence the decision to place the newborn on the mother's abdomen.

Breastfeeding — Early initiation of breastfeeding (within one hour of birth) and exclusive breastfeeding during the first month of life has substantial benefits in reducing neonatal mortality and morbidity. Several maternal benefits exist as well. (See "Initiation of breastfeeding" and "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)

Normal placental separation — Myometrial thickening after delivery of the infant leads to substantial reduction in uterine surface area, resulting in shearing forces at the placental attachment site and placental separation. This process generally begins at the lower pole of the placental margin and progresses along adjacent sites of placental attachment. A "wave of separation" spreads upward so that the uppermost part of the placenta detaches last [138,139].

Signs of placental separation include a gush of blood, lengthening of the umbilical cord, and anterior-cephalad movement of the uterine fundus, which becomes firmer and globular after the placenta detaches. Placental expulsion follows separation as a result of a combination of events including spontaneous uterine contractions, downward pressure from the developing retroplacental hematoma, and an increase in maternal intraabdominal pressure.

There is no universally accepted criterion for the normal length of the third stage. In two large series of consecutive deliveries, the average length was five to six minutes, 90 percent of placentas were delivered within 15 minutes, and 97 percent were delivered within 30 minutes of birth [140,141]. Gestational age is the major factor influencing the length of the third stage: Preterm deliveries are associated with a longer third stage than term deliveries [140-143]. (See "Retained placenta after vaginal birth".)

Active management and delivery of the placenta — We actively manage the third stage because active management reduced the risk of severe postpartum blood loss and blood transfusion compared with expectant management in randomized trials. (See "Management of the third stage of labor: Prophylactic drug therapy to minimize hemorrhage", section on 'Active management'.)

Active management generally consists of prophylactic administration of a uterotonic agent before delivery of the placenta plus controlled traction of the umbilical cord after cord clamping and transection; uterine massage also may be performed. Randomized trials have demonstrated that the uterotonic agent is the most important component of this regimen [144-146]; we use oxytocin. (See "Management of the third stage of labor: Prophylactic drug therapy to minimize hemorrhage", section on 'Oxytocin'.)

We use controlled cord traction to facilitate separation and delivery of the placenta. In a 2014 meta-analysis of randomized trials comparing controlled cord traction with a hands-off approach, controlled cord traction resulted in a reduced need for manual removal of the placenta (RR 0.70, 95% CI 0.58-0.84), as well as small statistical reductions in the duration of the third stage (three minutes), mean blood loss (10 mL), and incidence of postpartum hemorrhage (11.8 versus 12.7 percent, RR 0.93, 95% CI 0.87-0.99); the rates of severe postpartum hemorrhage, need for additional uterotonics, and blood transfusion were not statistically different [147]. Others have reported similar findings [148]. Although the benefits of controlled cord traction are small, there are no significant harms from the maneuver if performed gently without excessive traction, which can result in cord avulsion or uterine inversion.

Two maneuvers for applying cord traction have been described; we prefer the Brandt-Andrews maneuver.

●In the Brandt-Andrews maneuver, an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord [149].

●In the Crede maneuver, the clamped umbilical cord is held at a fixed position with one hand while the abdominal hand grasps the uterine fundus and applies sustained cephalad traction). If the cord avulses before delivery of the placenta, we wait up to 30 minutes for spontaneous placental separation and expulsion with maternal pushing. While waiting, preparations are initiated in case manual removal of the placenta is needed. We intervene promptly if bleeding becomes heavy. (See "Retained placenta after vaginal birth", section on 'Management'.)

As the placenta emerges from the vagina, the membranes flow behind it. Slowly rotating the placenta in circles as it is delivered or grasping the membranes with a clamp helps prevent them from tearing and possibly being retained in the uterine cavity.

Compared with oxytocin alone, performing uterine massage along with administering oxytocin provides no added benefit [146].

The placenta, umbilical cord, and fetal membranes should be systematically examined. The fetal side is assessed for any evidence of vessels coursing to the edge of the placenta and into the membranes, suggestive of a succenturiate placental lobe. The number of vessels in the cord is recorded. (See "Gross examination of the placenta".)

Of note, some women are requesting their placentas for consumption postpartum (placentophagia or placentophagy) [150-152]. Various commercial enterprises are available to desiccate and encapsulate placental tissue, or it has been consumed raw or cooked. In one study, most common reason for the practice was to prevent postpartum depression [153]. There is a lack of scientific-evidence of any health benefits in humans, but potential harms have been documented [154,155].

Bleeding — Average blood loss at vaginal delivery is estimated to be <500 mL. Excessive bleeding may be related to uterine atony, trauma, coagulopathy, placental abnormalities, or uterine inversion. A visual aid depicting known volumes of blood on common obstetric materials (eg, peri pad, bed pan, kidney basin, bed pad) can improve obstetric provider accuracy in estimating blood loss [156]. (See "Overview of postpartum hemorrhage" and "Postpartum hemorrhage: Medical and minimally invasive management" and "Puerperal uterine inversion".)

Repair of lacerations — The cervix, vagina, and perineum should be examined for evidence of birth injury. The major risk factors for third and fourth degree perineal lacerations are nulliparity, operative vaginal delivery, midline episiotomy, and delivery of a macrosomic newborn [157,158]. If a laceration is identified, its length and position should be noted and repair initiated with adequate analgesia (see "Repair of perineal and other lacerations associated with childbirth"). Failure to recognize and repair a rectal injury can lead to serious long-term morbidity, most notably fecal incontinence.

We perform a rectal examination after perineal repair to palpate sutures inadvertently placed through the rectal mucosa into the rectal lumen. If identified, the authors take down the repair and resuture, although this is probably unnecessary since there is no evidence that transmucosal stitches increase the risk of fistula formation. (See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

Instrument and sponge counts — At the end of the delivery, it is obviously important to ensure that no sponges or instruments are left in the vagina. (See "Retained surgical sponge (gossypiboma) and other retained surgical items: Prevention and management".)

POSTPARTUM ISSUES AND CARE — Postpartum issues and care, including care of the newborn, are reviewed separately. If a pediatric provider does not attend the delivery, the obstetric team may administer ophthalmic antibiotic agents, vitamin K, and the first dose of the hepatitis B vaccine to the infant. (See "Overview of the postpartum period: Normal physiology and routine maternal care" and "Overview of the routine management of the healthy newborn infant".)

ALTERNATIVE BIRTHING PRACTICES THAT SHOULD BE AVOIDED — The American Academy of Pediatrics advises avoiding the following alternative birthing practices because they have been associated with or may be associated with increased risks of neonatal morbidity and mortality (including infection) and have no clear benefits [159]. Supporting evidence linking each of these practices with increased risk is reviewed in the guideline and elsewhere in this topic. We agree with avoiding these practices.

●Water birth (water immersion in early labor for maternal comfort is not harmful)

●Vaginal seeding (See "Cesarean birth: Postoperative issues", section on 'Role of vaginal seeding'.)

●Nonseverance of the umbilical cord (See 'Umbilical nonseverance' above.)

●Placentophagy (See 'Active management and delivery of the placenta' above.)

●Nonmedical deferral of hepatitis B vaccination and ocular prophylaxis (See "Overview of the routine management of the healthy newborn infant", section on 'Hepatitis B vaccination' and "Overview of the routine management of the healthy newborn infant", section on 'Eye care'.)

●Delayed bathing of newborns exposed to active HSV genital lesions or when there is a known history of bloodborne pathogens (HIV, HBV, or hepatitis C virus)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor" and "Society guideline links: Delivery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Labor and delivery (childbirth) (The Basics)" and "Patient education: How to tell when labor starts (The Basics)" and "Patient education: Managing pain during labor and delivery (The Basics)")

SUMMARY AND RECOMMENDATIONS

●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 'Creating a satisfactory childbirth experience' above.)

●The goals of the initial examination of the parturient are to review her prenatal record for medical or obstetric conditions that need to be addressed intrapartum, check for development of new disorders since the last prenatal visit, establish baseline cervical status so that subsequent progress can be determined, and evaluate fetal status. (See 'Initial examination' above.)

●Results from the following laboratory tests should be available at delivery, but intrapartum assessment is not always necessary: hemoglobin/hematocrit, blood type and screen, HIV, hepatitis B antigen, syphilis, rectovaginal group B streptococcus. (See 'Laboratory tests' above.)

Women who have not had HIV screening or whose HIV status is undocumented should be offered rapid HIV testing in labor.

We recommend not performing routine enemas (Grade 1A) and we suggest not routinely shaving the perineum (Grade 2B). (See 'Patient preparation' above.)

●There is no consensus on acceptable maternal oral intake or need for and type of intravenous fluids during an uncomplicated labor. We allow patients at low risk of cesarean delivery to have clear liquids and we place an intravenous line or heparin lock for all women in labor. We administer a glucose containing solution to women receiving intravenous fluids, and provide maintenance fluids when oral intake is restricted or otherwise inadequate to avoid volume depletion and ketosis. (See 'Fluids and oral intake' above.)

●Vaginal delivery is not an indication for routine antibiotic prophylaxis, even in women with cardiac lesions, since the rate of bacteremia is low. Intrapartum chemoprophylaxis to prevent early-onset neonatal GBS infection is indicated for patients who meet standard criteria; the agent of choice is penicillin G. (See 'Systemic antibiotics' above and "Early-onset neonatal group B streptococcal disease: Prevention".)

●Maternal preferences can guide maternal activity. Walking during the first stage does not appear to enhance or impair labor progress. Laboring women should assume positions that are comfortable, unless specific positions are needed because of maternal-fetal status and need for close monitoring. (See 'Maternal activity and position' above.)

●Multiple nonpharmacologic, pharmacologic, and anesthetic options are available to help women manage pain during labor. (See "Nonpharmacologic approaches to management of labor pain" and "Pharmacologic management of pain during labor and delivery" and "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)

●We suggest not performing amniotomy routinely in patients in spontaneous labor (Grade 2B). There is no convincing evidence of benefit in spontaneously laboring women, and rupture of membranes increases the risk of ascending infection and cord prolapse. (See 'Amniotomy' above.)

●In women with pregnancies at increased risk of fetal compromise during labor, we perform continuous electronic fetal heart rate (FHR) monitoring, in agreement with clinical management guidelines from the American College of Obstetricians and Gynecologists. We also monitor low-risk pregnancies continuously because it is more practical than intermittent monitoring, but we are not rigid about this if the patient understands the risks and benefits of intermittent monitoring and has an uncomplicated pregnancy, normal FHR tracing, and is not resting in bed. Contractions and labor progress are also monitored. (See 'Monitoring' above.)

●Either immediate or delayed pushing is reasonable for most patients, and the choice is best made as a shared decision. We generally prefer that women begin to push upon full dilation to shorten the second stage, push in the position that they find most comfortable, and maintain an open glottis. However, if the FHR tracing is normal and station is high, we often ask women to delay pushing until further descent has occurred to reduce the duration of time of maximal maternal exertion.

●We recommend not performing episiotomy routinely (Grade 1A). (See "Approach to episiotomy".)

●We suggest a "hands-on" technique (Grade 2C). Preventing precipitous expulsion of the newborn can reduce the risk of obstetric and anal sphincter injury. (See 'Delivery of the newborn' above.)

●Routine oro-nasopharyngeal suctioning of newborns by a bulb or catheter is not beneficial, including those with meconium-stained amniotic fluid. Suctioning is appropriate for newborns with obvious obstruction to spontaneous breathing or who are likely to require positive-pressure ventilation. (See 'Oropharyngeal care' above and 'Meconium' above.)

●In preterm births that do not require resuscitation, we suggest delayed cord clamping (Grade 2C). Benefits may include reduced rates of transfusion, intraventricular hemorrhage, necrotizing enterocolitis, and hypotension, although a lack of benefit has also been reported. For term infants who do not require resuscitation, we suggest delayed cord clamping (Grade 2C). However, not routinely delaying cord clamping is also reasonable as the improvement in iron stores needs to be balanced with the disadvantage of an increased risk for hyperbilirubinemia and more need for phototherapy. We delay clamping for at least 30 seconds. (See 'Early versus delayed cord clamping' above.)

●Delaying cord clamping reduces the volume of umbilical cord blood available for harvesting stem cells; therefore, the size and cell dose of collected cord blood units may not be adequate for a future hematopoietic cell transplant if cord clamping is delayed. (See 'Early versus delayed cord clamping' above.)

●Active management of the third stage reduces maternal blood loss and risk of postpartum hemorrhage compared with expectant management. We administer oxytocin and apply controlled traction of the umbilical cord. The placenta should be examined to make sure it is intact. (See 'Active management and delivery of the placenta' above.)

●Average blood loss at vaginal delivery is estimated to be <500 mL. Excessive bleeding may be related to atony, trauma, coagulopathy, placental abnormalities, or uterine inversion. (See 'Bleeding' above.)

●Failure to recognize and repair a rectal injury can lead to serious long-term morbidity, most notably fecal incontinence. (See 'Repair of lacerations' above.)