First Stage of Labour Management
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Direct answer
The first stage of labour runs from the onset of regular contractions with cervical change to full dilatation of 10 cm. It is managed by monitoring the mother, the fetus and progress, rather than by routine intervention. Care includes oral fluids, upright and mobile positions, pain relief tailored to the woman and vaginal examinations kept to the minimum needed. Amniotomy or oxytocin is reserved for documented delay on the partograph.
What you must remember
- Latent and active phases: the latent phase is slow and variable, and the Indian partograph convention starts the active phase at 4 cm, although WHO 2018 uses 5 cm and textbooks differ.
- Fetal monitoring: intermittent auscultation of the fetal heart in the first stage for low-risk women (every 30 minutes on the Indian partograph, every 15 minutes in some guidelines), with continuous CTG for high-risk women or abnormal findings.
- Hydration: oral fluids and light food are encouraged, and intravenous fluid is given when intake is poor, the woman is vomiting or medication is needed.
- Position: walking, upright and kneeling positions may shorten labour and ease pain, while prolonged supine lying can cause aortocaval compression.
- Pain relief: non-drug methods, Entonox, opioids and epidural analgesia are all options, and epidural analgesia is the most effective.
- Vaginal examinations: limited to the minimum needed, typically about every four hours or when there is a clinical change, with timing guided by the partograph.
- Avoid routine practices: routine enemas, routine shaving and routine amniotomy have no place in the low-risk first stage.
A labour-room sequence for a low-risk woman
A low-risk woman admitted at 4 cm in spontaneous labour is the typical scenario, and the steps follow the order in which decisions should be made. Each step is documented so that the next clinician can follow the progress.
- Admission assessment. Record the history, gestation, pulse, blood pressure, temperature and fetal heart, and open the partograph with the first cervical reading.
- Set the monitoring plan. Choose intermittent auscultation or CTG according to risk, and document the interval chosen.
- Support hydration and nutrition. Encourage oral fluids and light food, and start intravenous fluids if intake is inadequate or the woman is unwell.
- Promote mobility and position. Encourage walking and upright or kneeling positions, with a companion present where possible.
- Offer pain relief. Discuss non-drug methods first, then offer Entonox, opioids or epidural analgesia, and check the effect on the fetal trace.
- Examine on indication. Repeat vaginal examination about every four hours, or sooner with a change in the trace or the woman, and plot each finding on the partograph.
- Intervene only for delay. Consider amniotomy or oxytocin when progress stops against the partograph, after assessment for cephalopelvic disproportion.
Where the exam tries to catch you
The first stage questions test restraint, since most of the good practice lies in not doing unnecessary things.
- Trap: performing vaginal examinations every hour to track progress Correct: frequent examinations raise infection risk, so they are kept sparse and tied to clinical change.
- Trap: restricting oral fluids in labour as a routine precaution Correct: oral fluids and light food are encouraged in low-risk women, and intravenous fluids are used for specific reasons.
- Trap: treating the lying-down position as the default for monitoring Correct: upright and mobile positions are encouraged, and monitoring is chosen to fit the woman's mobility.
Frequently asked questions
How often should vaginal examinations be done in the first stage of labour?
Vaginal examinations in the first stage of labour are kept to the minimum needed, typically about every four hours or sooner after a clinical change. The partograph guides the timing. Frequent examinations increase the risk of infection and are avoided.
Which fetal monitoring is used in low-risk women in the first stage?
Intermittent auscultation of the fetal heart is used in low-risk women in the first stage, commonly every 30 minutes on the partograph, and every 15 minutes in some guidelines. Continuous CTG is reserved for high-risk women or when intermittent findings are abnormal. The chosen interval is documented in the notes.
Why are upright positions encouraged in the first stage of labour?
Upright positions let gravity assist descent and may shorten the first stage. They also tend to ease pain compared with lying down. A supine position can cause aortocaval compression and reduce uteroplacental blood flow.
When should amniotomy or oxytocin be considered in the first stage?
Amniotomy or oxytocin is considered when labour progress is documented as slow or stalled, usually against a partograph action line. Routine amniotomy is not recommended. The decision follows assessment for cephalopelvic disproportion and the condition of the fetus.
Is routine intravenous fluid needed in every labouring woman?
Routine intravenous fluid is not needed in every labouring woman, because oral fluids and light food are encouraged in low-risk cases. Intravenous fluid is started when oral intake is poor, the woman is vomiting or she needs medication. The decision is individual and documented.