Normal labor and delivery

Last updated: August 17, 2023

Summarytoggle arrow icon

Childbirth begins with the onset of labor, which consists of contractions that lead to progressive cervical dilation and effacement, eventually resulting in the birth of the infant and expulsion of the placenta. The process of normal childbirth depends on a high degree of anatomical and physiological compatibility between the mother and child. The birth canal is the passage consisting of the mother's bony pelvis and soft tissues through which a fetus passes during vaginal delivery. Fetal orientation during childbirth is described in terms of lie, presenting part, position, attitude of the presenting part, and station. The clinical status of the mother and fetus should be consistently monitored during labor and delivery and prophylaxis for neonatal GBS infection given during labor when indicated. While vaginal delivery is typically preferred, cesarean delivery may be indicated under certain circumstances. Complications of normal vaginal delivery include perineal lacerations, hemorrhage, nerve injuries, and coccydynia.

See “Abnormal labor and delivery” for intrapartum complications and their management.

Orientation in uterotoggle arrow icon

Fetal lie

  • Definition: relation of the fetal long axis to the long axis of the maternal uterus
  • Types
    • Longitudinal lie: fetus is in the same axis (most common)
    • Transverse lie: fetus is at a 90° angle
    • Oblique lie: fetus is at a 45° angle

Fetal presentation

  • Definition: part of the fetus that overlies the maternal pelvic inlet
  • Types
    • Cephalic presentation: head (most common)
    • Breech presentation: buttocks or feet
      • Frank breech: flexed hips and extended knees (buttocks presenting)
      • Complete breech: thighs and legs flexed (cannonball position)
      • Single Footling breech: hip of one leg is flexed and the knee of the other is extended (one foot presenting)
      • Double Footling breech: both thighs and legs are extended (feet presenting)
    • Compound presentation: ≥ 1 anatomical presenting part (e.g., cephalic or breech presentation with presentation of an extremity)
    • Shoulder presentation: shoulder presentations combined with a transverse or oblique lie

Fetal position

  • Definition: relationship and orientation (i.e., fetal occiput pointing towards maternal left or right) of the presenting fetal part to the maternal pelvis
  • Types
    • Occiput anterior position: Fetal occiput points towards maternal symphysis pubis; fetus faces downwards.
      • Left occiput anterior (LOA): Fetal back faces the maternal left, anterior fontanelle faces the maternal right, sagittal suture lies in the right oblique diameter (most common position).
      • Right occiput anterior (ROA): Fetal back faces the maternal right, anterior fontanelle faces the maternal left, sagittal suture lies in the left oblique diameter.
    • Occiput posterior position: Fetal occiput points towards the maternal sacral promontory with face to pubis symphysis; the fetus faces upward
    • Sacrum in breech presentation
    • Mentum (chin) in extended cephalic (face) presentation

Fetal attitude [1]

Station (Obstetrics) [2]

  • Definition: measurement (in cm) of the presenting part above and below the maternal ischial spine
    Station Description
    0 the presenting part is at the level of the ischial spines
    -1, -2, -3 1, 2, and 3 cm above the level of the ischial spines, respectively
    +1, +2, +3 1, 2, and 3 cm below the level of the ischial spines, respectively
  • Engagement (Obstetrics)
    • When the widest transverse diameter of the head (presenting part) passes through the pelvic inlet
    • Use the rule of fifths: engagement is clinically identified when ≤ 2/5 of the fetal head are felt above the symphysis pubis through the maternal abdomen


Normal spontaneous labortoggle arrow icon

Obstetric contractions (uterine muscle contractions) [3][4]

Overview of obstetric contractions [1][5]
Time Characteristics

Uterine contractions during pregnancy

  • Physiological; occur after 20 weeks of pregnancy
  • Low intensity, high frequency
Braxton Hicks contractions (false labor)
  • Irregular, uncoordinated uterine contractions of moderate intensity (helps with fetal positioning)
  • Frequency: typically ≤ 2 times/hour
  • Duration: ≤ 1 minute
  • Do not increase in frequency, intensity, or duration
  • Cervical changes are absent.
  • Typically stop with rest, walking, and/or a change in position.
  • 3–4 days before birth
  • Irregular contractions of high intensity, which occur every 5–10 min shortly before phase 1 begins. They are responsible for correctly positioning the fetal head in the pelvis.
Labor Stage 1: cervical dilation and effacement
  • Coordinated, regular, rhythmic contractions of high intensity; occur approximately every 10 minutes. Shortly before stage 2, they occur every 2–3 min. These contractions are responsible for cervical dilation.
Stage 2: fetal expulsion
  • Coordinated and regular contractions of high intensity; occur approximately every 4–10 min and are responsible for fetal expulsion. Towards the end of the stage, they occur very often (every 2–3 minutes) and are of higher intensity (≥ 200 Montevideo units).
Stage 3: placental expulsion or afterbirth
  • Irregular contractions of very low intensity, which force the placenta through the vaginal canal within 30 min after fetal expulsion
  • Irregular contractions of varying intensity, which cause uterine involution and bleeding cessation

False labor only requires reassurance.

Rupture of membranes (ROM)

Stages of labor [3][4][6]

Overview of the stages of labor
Stage Characteristics Duration Clinical features
Nulliparous patients Multiparous patients
First stage of labor Latent phase of labor
  • Occurs during the onset of labor and ends at 6 cm of cervical dilation [7]
  • Characterized by mild, infrequent, irregular contractions with a gradual change in cervical dilation (< 1 cm/hour) [8]
  • ≤ 20 hours
  • ≤ 14 hours
Active phase of labor
Second stage of labor
  • < 2 hours (< 3 hours in patients who received an epidural)
  • < 1 hour (< 2 hours in patients who received an epidural)
  • Completely dilated cervix
  • Regular uterine contractions increasing in frequency and intensity
  • Crowning: the appearance of the fetus's head at the vaginal opening as contractions progress
Third stage of labor
  • 30 minutes
  • Uterine contractions (to expel the placenta)
  • Signs of placental separation
    • Cord lengthening
    • Gush of vaginal blood (usually accompanied by a blood loss of 300 mL)
    • Uterine fundal rebound (the uterus becomes less elongated and more spherical)
Fourth stage of labor
  • N/A
  • Uterine contractions
  • Expulsion of any remaining contents

Management of labor by stage

Normal mechanics of childbirth [1]

Adaptation to the different forms of the pelvic region requires a great deal of rotation.

  1. Engagement, descent, and increased flexion (occur simultaneously)
    • The head engages below the plane of the pelvic inlet.
    • The presenting part begins to descend into the birth canal.
    • The chin of the fetus moves towards its chest.
  2. Internal rotation: The fetal head rotates by 90° (two 45° steps) in the midpelvis, from a transverse to anterior-posterior position.
  3. Extension: The fetal head, lying behind the symphysis pubis bone and the pelvic floor, acts upwards and forwards.
  4. Restitution: The fetal head rotates 45° in the opposite direction as it passes through the pelvic outlet.
  5. External rotation: The anterior shoulder rotates 45° anteriorly as it meets the maternal pelvic floor. This action is transmitted to the head which also rotates 45°, placing the head in its original transverse position.
  6. Expulsion: Delivery of the head, anterior shoulder followed by the posterior shoulder, and the body

Manually assisted vaginal deliverytoggle arrow icon

The following describes the uncomplicated delivery of an infant in the occiput anterior position, the most common fetal presentation. Begin active management of labor as soon as crowning occurs. [11][12][13]


  • Help the mother into the most comfortable position. [14]
  • Cleanse the vulvar and perineal area.
  • Don PPE.

Delivery of the infant

Delivery of the head

  1. Support the perineum with a warm compress. [15]
  2. Once the vaginal introitus is distended ≥ 5 cm, apply gentle pressure to the fetal occiput with one hand.
  3. Lift the fetal chin by applying upward pressure through the perineum with the other hand.
  4. Support the head during passage through the vaginal introitus.
  5. Check for a nuchal umbilical cord and, if present, slip it over the fetal head.

Delivery of the shoulders

  1. Assist delivery of the shoulders, if not delivered spontaneously.
  2. Hold the fetal head with both hands and apply gentle downward traction.
  3. Once the anterior shoulder appears below the symphysis pubis, apply gentle upward traction until the posterior shoulder is free.

Delivery of the body and immediate care of the newborn

  1. Apply gentle long-axis traction, if necessary, without placing fingers under the axillae.
  2. Once delivered, wipe the face and mouth to clear the airway. [11][12][16]
  3. Quickly dry the infant to prevent hypothermia and stimulate crying. [15]
  4. If necessary, initiate neonatal resuscitation.
  5. Initiate skin-to-skin contact, e.g., by placing the infant on the mother's abdomen.

Clamping the umbilical cord

  1. Delay clamping by at least 30–60 seconds after delivery (unless immediate neonatal resuscitation is required). [10][15]
  2. Place two Kelly clamps 6–8 cm from the abdominal insertion and cut the cord between them.

Delivery of the placenta

  1. Palpate the uterine fundus and monitor for signs of placental separation.
  2. Once placental separation occurs, ask the patient to bear down to expel the placenta.
  3. If the placenta is not expelled with maternal effort, apply controlled umbilical cord traction.
  4. Administer oxytocin to prevent postpartum hemorrhage. [13][17][18]

Never apply forceful traction to the umbilical cord, as this may result in uterine inversion or separation of the cord from the placenta. [12]

Immediate postpartum care [11]

Intrapartum fetal monitoringtoggle arrow icon

Electronic fetal heart rate monitoring [19][20]

Fetal heart rate [21][22][23]

Fetal heart rate (FHR) tracing

Fetal heart rate tracing categories
Category I FHR tracing Category II FHR tracing Category III FHR tracing
  • Includes all FHR measurement outside category I FHR tracings (normal) or category III FHR tracings (abnormal)
  • May progress to normal or abnormal



  • No interventions necessary
  • Surveillance and frequent reassessment until category II FHR tracings resolve (category I FHR tracings) or progress (category III FHR tracings)

Fetal heart rate variability [24]

On CTG, variability of FHR is represented by the oscillation of the FHR around the baseline and is determined by measuring the amplitude between the highest and lowest turning point of the FHR curve.

Overview of fetal heart rate variability
Type Oscillation amplitude Causes
Moderate variability
  • 6–25 bpm
  • Physiological fluctuation of FHR
  • Normal finding
Absent variability
  • Undetectable amplitude
Minimal variability
  • < 6 bpm
Marked variability
  • > 25 bpm
Sinusoidal variability
  • 5–15 bpm
  • FHR wave resembles a sinus wave
Pseudosinosoidal variability
  • Similar appearance to sinusoidal variability
  • Irregularly shape and amplitude of the FHR curves

Acceleration (CTG) [23]

  • Description: a normal temporal increase in the FHR from the baseline by > 15 bpm for more than 15 seconds but less than 10 minutes if the gestational age is > 32 weeks, or by > 10 bpm for more than 10 seconds if the gestational age is < 32 weeks
  • Interpretation

Decelerations (CTG) [19][25][26][27][28]

  • Description: a temporary decline in the FHR of > 15 bpm for a maximum duration of 3 minutes
Overview of types of fetal deceleration
Type Etiology Characteristics Measures

Early deceleration

  • Compression of the head during a contraction triggering a vagal response
  • The beginning and end of decelerations correspond with the progression of a contraction (the deceleration reaches its minimum, referred to as the nadir, when the contraction curve attains its peak).
  • Onset to nadir is gradual (≥ 30 seconds).
  • Typically occurs during active labor when the cervix is dilated ≥ 5 cm and the head is engaged within the pelvic cavity
Late deceleration
  • Decrease in the FHR following the maximum contraction curve
  • Onset to nadir is gradual (≥ 30 seconds).
Variable deceleration
  • Variable presentation and temporal relation to the changes in contractions
  • Onset to nadir is abrupt (< 30 seconds) and lasts ≥ 15 seconds but < 2 minutes.
Prolonged deceleration
  • A decrease in FHR of ≥ 15 bpm from the baseline, lasting ≥ 2 minutes but < 10 minutes

Consider umbilical cord compression or umbilical cord prolapse in patients with recurrent variable decelerations (≥ 50% of contractions).

MNEMONIC for etiology of fetal HR alterations: VEAL CHOP
Variable decelerations → Cord compression/prolapse
Early decelerations → Head compression
Accelerations → OK
Late decelerations Placental insufficiency/Problem



See “Intrauterine resuscitation” for details.

Complications of deliverytoggle arrow icon

Life-threatening complications

Perineal lacerations

Complications of fourth-degree lacerations include rectovaginal fistulae.

Obstetric nerve injuries [35]

Acute nerve injury can occur during childbirth due to compression, transection, traction, or vascular injury to the nerve.

Obstetric nerve injuries
Nerve Clinical features Risk factors
Lumbar radiculopathy
Lateral femoral cutaneous nerve injury
Femoral nerve injury
Common peroneal nerve injury
  • Prolonged squatting during childbirth
  • Hyperflexion of the knees during childbirth
  • Direct compression of the nerve with direct pressure over the fibular head
  • Inadequate footrests or stirrups used during vaginal delivery
Pudendal nerve injury


  • Etiology: injury to the coccyx during childbirth as a result of internal and external pressure on the coccyx during labor and delivery
  • Clinical features
    • Pain and tenderness of the coccyx, esp. when sitting or leaning back
    • Pain may suddenly increase when the patient is changing from a sitting to a standing position.
    • Pain may also occur during defecation or sexual intercourse.
    • Physical examination: palpation of the coccyx elicits pain
  • Diagnosis: clinical
  • Management
    • Protection (e.g., sitting on Donut or wedge cushions)
    • Analgesics (e.g., NSAIDs)
    • Local heat or cooling according to patient preference
    • Exacerbating factors (e.g., sitting on hard surfaces, cycling) should be avoided if possible.
  • Prognosis: resolves spontaneously in the majority of patients (> 90%) [36]

Postpartum retroperitoneal hematoma

Planned home birthtoggle arrow icon

  • Statistics
    • In the US, approx. 1% of births per year are home births.
    • 75% of these home births are planned.
  • Indications
    • There is insufficient evidence to determine what makes a good candidate for a home birth.
    • Home births can be considered in individuals with no contraindications.
    • Patients who would like to plan a home birth should be advised about the benefits and risks of home birth compared to hospital delivery in order to make an informed decision.
  • Advantages compared to hospital delivery
  • Disadvantages compared to hospital delivery
    • Higher risk of perinatal death for both the mother and fetus
    • Higher risk of neurological complications for the newborn
  • Contraindications


Referencestoggle arrow icon

  1. Beckmann CRB. Obstetrics and Gynecology. Lippincott Williams & Wilkins ; 2010
  2. Buchmann EJ, Guidozzi F. Level of fetal head above brim: comparison of three transabdominal methods of estimation, and interobserver agreement. J Obstet Gynaecol. 2007; 27 (8): p.787-790.doi: 10.1080/01443610701667387 . | Open in Read by QxMD
  3. Leveno K, Bloom S, Casey B, et al.. Williams Obstetrics. McGraw-Hill Education Ltd ; 2018
  4. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  5. World Health Organization. WHO Recommendations on Intrapartum Care for a Positive Childbirth Experience. World Health Organization ; 2018
  6. Committee on Obstetric Practice. Committee Opinion No. 687: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol. 2017; 129 (2): p.e20-e28.doi: 10.1097/AOG.0000000000001905 . | Open in Read by QxMD
  7. Dresang LT, Yonke N. Management of Spontaneous Vaginal Delivery. Am Fam Physician. 2015; 92 (3): p.202-8.
  8. 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 (9889): p.326-330.doi: 10.1016/s0140-6736(13)60775-8 . | Open in Read by QxMD
  9. ACOG Committee. Delayed Umbilical Cord Clamping After Birth. Obstet Gynecol. 2020; 136 (6): p.e100-e106.doi: 10.1097/aog.0000000000004167 . | Open in Read by QxMD
  10. Dahlke JD, Mendez-Figueroa H, Maggio L, et al. Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines. Am J Obstet Gynecol. 2015; 213 (1): p.76.e1-76.e10.doi: 10.1016/j.ajog.2015.02.023 . | Open in Read by QxMD
  11. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology. 2017; 130 (4): p.e168-e186.doi: 10.1097/aog.0000000000002351 . | Open in Read by QxMD
  12. Callahan TL, Caughey AB. Blueprints Obstetrics and Gynecology. Lippincott Williams&Wilki ; 2013
  13. Madara B, Avery CT, Pomarico-Denino V, Wagner L. Quick Look Nursing: Obstetric and Pediatric Pathophysiology. Jones & Bartlett Learning ; 2008
  14. Dudenhausen JW, Obladen M. Practical Obstetrics. Walter de Gruyter GmbH & Co KG ; 2014
  15. Nation's Ob-Gyns Take Aim at Preventing Cesareans. Updated: February 19, 2014. Accessed: July 25, 2017.
  16. ACOG. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery.. Obstet Gynecol. 2014; 123 (3): p.693-711.doi: 10.1097/01.AOG.0000444441.04111.1d . | Open in Read by QxMD
  17. The stages of labour and birth. Updated: March 20, 2020. Accessed: February 25, 2021.
  18. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine - Concepts and Clinical Practice. Elsevier Health Sciences ; 2013
  19. Mikolajczyk RT, Zhang J, Troendle J, Chan L. Risk factors for birth canal lacerations in primiparous women. Am J Perinatol. 2013; 25 (5): p.259-264.
  20. Goh R, Goh D, Ellepola H. Perineal tears – A review. Australian Journal of General Practice. 2018; 47 (1-2): p.35-38.doi: 10.31128/afp-09-17-4333 . | Open in Read by QxMD
  21. Ozyurt S, Aksoy H, Gedikbasi A, et al. Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial.. Arch Gynecol Obstet. 2015; 292 (4): p.853-9.doi: 10.1007/s00404-015-3708-z . | Open in Read by QxMD
  22. Lallemant M, D'Antona A, Vidal C, et al. Conservative management versus systematic suture of isolated vaginal or first-degree perineal tears after delivery: A preliminary randomized efficacy trial.. Birth. 2022.doi: 10.1111/birt.12671 . | Open in Read by QxMD
  23. Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, Kenton K, Gossett DR. Wound complications after obstetric anal sphincter injuries.. Obstet Gynecol. 2015; 125 (5): p.1088-1093.doi: 10.1097/AOG.0000000000000833 . | Open in Read by QxMD
  24. $Obstetrical Nerve Injury.
  25. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain.. The Ochsner journal. ; 14 (1): p.84-7.
  26. Redondo Villatoro A, Azcona Sutil L, Vargas Gálvez D, Carmona Domínguez E, Cabezas Palacios MN. Diagnosis and Management of Postpartum Retroperitoneal Hematoma: A Report of 3 Cases. American Journal of Case Reports. 2022; 23.doi: 10.12659/ajcr.935787 . | Open in Read by QxMD
  27. Arulkumaran S, Regan L, Papageorghiou A, Farquharson D, Monga A. Oxford Desk Reference: Obstetrics and Gynaecology. Oxford University Press ; 2011
  28. Afors K, Chandraharan E. Use of continuous electronic fetal monitoring in a preterm fetus: Clinical dilemmas and recommendations for practice. J Pregnancy. 2011; 2011: p.1-7.doi: 10.1155/2011/848794 . | Open in Read by QxMD
  29. Feinstein N, Torgersen KL, Atterbury J, Association of Women's Health, Obstetric, and Neonatal Nurses. Fetal Heart Monitoring, Principles and Practices. Kendall/Hunt ; 1993
  30. $ACOG Practice Bulletin Number 106, July 2009 - Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles.
  31. Ayres-de-Campos D, Spong CY, Chandraharan E. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynaecol Obstet. 2015; 131 (1): p.13-24.doi: 10.1016/j.ijgo.2015.06.020 . | Open in Read by QxMD
  32. Macones GA, Hankins GD, et al.. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol.. 2008.doi: 10.1097/AOG.0b013e3181841395 . | Open in Read by QxMD
  33. Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth - NICE Clinical Guidelines, No. 190. Updated: December 1, 2014. Accessed: October 23, 2017.
  34. Bailey RE. Intrapartum fetal monitoring. Am Fam Physician. 2009; 80 (12): p.1388-1396.
  35. Chang KSG. Family Medicine. Lippincott Williams & Wilkins ; 2007
  36. Kennedy BB, Ruth DJ, Martin EJ. Intrapartum Management Modules. Lippincott Williams & Wilkins ; 2009
  37. Maharaj D. Intrapartum Fetal Resuscitation: A Review. The Internet Journal of Gynecology and Obstetrics. 2007; 9 (2).
  38. Committee on Obstetric Practice.. Committee Opinion No. 697: Planned Home Birth.. Obstet Gynecol. 2017; 129 (4): p.e117-e122.doi: 10.1097/AOG.0000000000002024 . | Open in Read by QxMD
  39. Ghofrani HA. [Pulmonary edema].. Internist (Berl). 2004; 45 (5): p.565-72.doi: 10.1007/s00108-004-1175-x . | Open in Read by QxMD

Icon of a lockAccess full content

Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer