Normal Labor — Stages, Partograph & Management

WHO defines normal labor as: spontaneous onset between 37-42 weeks, vertex presentation, no artificial intervention, completed within 24 hours, no complications. Stages:

1. 1st stage: Onset of regular painful contractions to full cervical dilation (10 cm). Divided into latent phase (0-4 cm, slow) and active phase (4-10 cm, faster). Active phase progress should be ≥ 1 cm/hour in primigravida and ≥ 1.5 cm/hour in multigravida.
2. 2nd stage: Full dilation to delivery of baby. Duration: 1 hour (primigravida), 30 minutes (multigravida). Prolonged 2nd stage: > 2 hours primigravida, > 1 hour multigravida.
3. 3rd stage: Delivery of baby to delivery of placenta. Normal: 5-15 minutes. Prolonged: > 30 minutes.
4. 4th stage: First 1 hour after placental delivery — observation for PPH.

1st Stage (Latent + Active Phase):

• Latent phase: 0-4 cm dilation, contractions mild, every 5-10 min. Duration: 6-8 hours primigravida, 4-6 hours multigravida
• Active phase: 4-10 cm dilation, contractions strong every 2-3 min, lasting 40-60 seconds
• Monitor: maternal BP, pulse, temp every 4 hours; FHS every 30 min (1st stage) and every 15 min (2nd stage); cervical dilation every 4 hours; liquor colour; descent of presenting part
• Maternal position: upright and mobile in latent phase; recumbent in active phase if exhausted

2nd Stage (Delivery of Baby):

• Signs: Full dilation, urge to bear down, show, bulging perineum
• Mechanism of labor (for vertex): Engagement, descent, flexion, internal rotation, extension, restitution, external rotation, expulsion
• Episiotomy: Mediolateral, when head crowns (3-4 cm diameter visible) — selectively, not routinely
• Immediate newborn care: Dry, warm, skin-to-skin, initiate breastfeeding within 1 hour, delayed cord clamping (1-3 min), APGAR at 1 and 5 min, vitamin K 1 mg IM

3rd Stage (Placental Delivery):

• Signs of placental separation: Gush of blood, lengthening of cord, fundus becomes firm and globular, rises upwards
• Active Management of 3rd Stage of Labor (AMTSL): Oxytocin 10 IU IM within 1 minute of baby delivery, controlled cord traction, uterine massage after placenta out
• Examine placenta: Maternal surface (complete cotyledons), fetal surface (membranes complete, vessels), umbilical cord (2 arteries, 1 vein)

4th Stage (1 hour post-placenta):

• Monitor: Pulse, BP, uterine tone, lochia, perineum every 15 min x 4
• Watch for PPH — primary cause of maternal death in India
• Initiate breastfeeding, ensure warmth, monitor urine output (voiding within 4 hours is normal)

The WHO partograph is a graphic record of labor progress — used from active phase (4 cm dilation) onwards. Components:

• Patient information: Name, age, gravida/para, gestational age, risk factors
• Fetal condition: Fetal heart rate every 30 min (normal 110-160), liquor colour (clear, meconium-stained, blood-stained), moulding
• Labor progress: Cervical dilation, descent of presenting part (in fifths above brim), uterine contractions (frequency, duration, intensity)
• Alert line: Cervical dilation rate 1 cm/hour. Patient on left of alert line = satisfactory progress
• Action line: 4 hours to the right of alert line. Patient crossing action line = prolonged labor — needs intervention
• Maternal condition: Pulse, BP, temp, urine output, oxytocin titration, drugs given

Partograph is mandatory in all facility deliveries under LaQshya standards. Its use reduces prolonged labor, PPH, and perinatal mortality.

AMTSL reduces PPH incidence by 60% and is standard of care for all deliveries:

1. Oxytocin 10 IU IM within 1 minute of baby delivery (or 10 IU IV in 1 L NS over 4 hours)
2. Controlled cord traction (CCT): Once signs of placental separation appear (cord lengthens, gush of blood, fundus firms up), guard the uterus above symphysis with one hand and apply steady traction to the cord with the other. Do NOT pull before separation — risk of cord snap or uterine inversion.
3. Uterine massage: Immediately after placenta delivered, massage fundus every 15 minutes for 1 hour to maintain uterine tone

Alternatives if oxytocin unavailable: Misoprostol 600 mcg oral/sublingual, or Ergometrine 0.2 mg IM (avoid in hypertension, preeclampsia).

Normal labor management is the foundation of obstetric practice. For UPSC CMS aspirants, 4 stages, partograph interpretation, AMTSL, and mechanism of labor are extremely high-yield OBG topics.