Normal Labour: Stages and Management
Written by Dr. Muhammad Salar Raza · Manually reviewed by Dr. Muhammad Salar Raza · Content updated
Clinical Pathway
Labour begins with regular painful contractions causing progressive cervical dilation and effacement. The latent phase extends to about 6 cm dilation; the active phase runs from 6 cm to full dilation, and normal progress is roughly 1 cm per 2 hours in nulliparas once established. Monitor contractions, maternal vital signs, and fetal heart rate, using the partograph to plot progress and detect delay early. The second stage is full dilation to birth, limited to about 2-3 hours with regional analgesia before reassessment. The third stage is placenta delivery; active management with oxytocin after birth reduces postpartum hemorrhage. Offer continuous support, hydration, mobility, and analgesia options including epidural.
Clinical Reasoning
The modern threshold for the active phase is 6 cm, not 4 cm, and many exam questions hinge on this. A partograph alert line crossed signals slow progress needing review before augmentation is considered. Artificial rupture of membranes and oxytocin augment labour only after excluding obstruction and confirming fetal well-being; oxytocin with a non-reassuring trace or cephalopelvic disproportion is dangerous. Prolonged latent phase alone is not an indication for cesarean. In the second stage, delayed pushing and fetal position affect duration, and operative vaginal delivery requires full dilation, ruptured membranes, engaged head, and known position.
Sample MCQ
A 25-year-old primigravida at 39 weeks has regular contractions every 3 minutes. The cervix is 6 cm dilated and fully effaced, membranes are intact, and the fetal heart trace is reassuring. She is coping well with entonox. What is the most appropriate management?
- AContinue routine intrapartum monitoring and supportive care
- BImmediate cesarean section
- CStart oxytocin infusion now
- DTransfer to theatre for instrumental delivery
Correct Answer: Continue routine intrapartum monitoring and supportive care
At 6 cm with regular contractions she has entered the active phase, progress is normal, and the fetus is reassuring, so expectant management with partograph monitoring and support is correct. Cesarean section is indicated for obstructed labour, fetal compromise, or failed progress, none of which is present. Oxytocin augmentation is reserved for confirmed slow progress after membranes are assessed; augmenting normally progressing labour adds risk without benefit. Instrumental delivery applies only in the second stage with a fully dilated cervix and specific fetal or maternal indications, which are absent here.
Guidelines and further reading
Related Clinical Topics
Preeclampsia: Diagnosis and Management
Diagnose preeclampsia with new hypertension (140/90 mmHg or higher) after 20 weeks of gestation plus proteinuria or maternal organ dysfunction. Severe features include pressure of 160/110 mmHg or higher, severe headache, visual disturbance, epigastric pain, thrombocytopenia, renal impairment, or pulmonary edema. Severe preeclampsia mandates admission, magnesium sulfate for seizure prophylaxis, and antihypertensive therapy with labetalol, oral nifedipine, or hydralazine. The definitive treatment is delivery, timed by gestational age and severity: immediate stabilization then delivery at term or with severe features, and expectant management only in carefully selected preterm cases without severe features. Continue magnesium for 24 hours postpartum.
Chronic Hypertension: Diagnosis and Management
Chronic hypertension is a persistent and sustained elevation of blood pressure, typically defined as a systolic blood pressure greater than or equal to 130 mmHg or a diastolic blood pressure greater than or equal to 80 mmHg on multiple occasions. It is a major modifiable risk factor for various cardiovascular diseases, stroke, and kidney disease. Treatment for chronic hypertension involves a multi-faceted approach, starting with lifestyle modifications such as dietary changes (e.g., DASH diet), regular physical activity, weight loss, and reduced sodium and alcohol intake. Pharmacological therapy is often necessary and may include various classes of antihypertensive medications like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, and calcium channel blockers, frequently used in combination to achieve target blood pressure. Chronic hypertension is often referred to as 'the silent killer' because it is frequently asymptomatic for many years, even at high levels. When symptoms do occur, they are typically non-specific and may include headaches, dizziness, nosebleeds, or shortness of breath, usually manifesting in severe or long-standing cases or during a hypertensive crisis. Most diagnoses are made during routine medical screenings.
Gestational Diabetes Mellitus (GDM): Screening and Management
Screen all pregnant women at 24-28 weeks with a 75 g oral glucose tolerance test, or earlier when risk factors such as obesity or previous GDM exist. First-line management is medical nutrition therapy with structured physical activity and daily glucose self-monitoring. If fasting or postprandial targets are repeatedly exceeded despite lifestyle measures, start insulin, with metformin as an accepted alternative in many guidelines. Monitor fetal growth because GDM drives macrosomia, and plan delivery around 38-39 weeks when medication is required. After delivery, insulin needs fall sharply; arrange a 75 g OGTT at 6-12 weeks postpartum because about half of women with GDM later develop type 2 diabetes.
SMLE Preparation Resources
Master the 2026 SMLE
Explore more clinical protocols in the SMLEREVISE Clinical Knowledge Library.
Try the QBank & Scaled Mocks