Labour has three stages: The first stage is when the neck of the womb opens to 10cm dilated. The second stage is when the baby moves down through the vagina and is born. The third stage is when the placenta (afterbirth) is delivered. Labour and birth are intense and personal experiences. Pregnancy can be a time of great anticipation and excitement but parents-to-be often have lots of questions about ‘the big day’ when labour starts and the baby will finally arrive. It is important that midwives and parents discuss the aspects of labour that will need decisions, both as part of a birth plan and as labour progresses. This will include discussing the options involved in labour and delivery and understanding the situations in which it might be necessary to take a course of action that isn’t in the woman’s birth plan.
This Highlight presents recent research evidence on some aspects of the management of labour, including:
- the induction of labour
- interpretation of the fetal heart rate
- pain management
- position during the second stage of labour with or without an epidural
It provides information and context to the essential decisions for a mother-to-be and her midwife and care-givers. The evidence from these studies will be useful for all women – there is no particular focus on high-risk pregnancies. All the evidence we have included should be considered within the context of a woman’s medical and pregnancy history.
755,000 live births in the UK in 2017
32% of all labours were induced in 2017-2018 in England
64 Freestanding midwifery units in England
The evidence about induction was gathered from four studies: two systematic reviews looked at a wide range of trials and worked out the balance of the evidence, and two randomised controlled trials tested the impact that induction makes for particular groups of patients.
A review that looked at induction of labour at 41 weeks or more among low-risk women of any age found that inducing labour after the due date slightly lowers the risk of stillbirth or infant death soon after birth, compared with waiting for labour to start naturally. But the overall risk is low. The review also found that induction may reduce admissions to neonatal intensive care units. It reduces the likelihood of caesarean section but may slightly increase the chance of needing an assisted vaginal birth (for example, using forceps or vacuum extraction).
Focusing on the experience of women having their first baby at the age of 35 years or more, a trial found that having labour induced (rather than waiting for it to start naturally) did not increase the rate of caesarean section and that induction had no adverse short-term effects on outcomes for the women or their newborn babies - it had been thought that inducing labour might increase the rate of caesarean section.
A study conducted in the U.S. compared the outcomes for low-risk first time mothers of any age who had their labour induced at 39 weeks with those who waited for it to start naturally. It found that induction of labour at 39 weeks of pregnancy, as compared with expectant management, did not significantly reduce the frequency of problems in newborn babies, but did significantly reduce the rate of caesarean section. Mothers’ age did not make a significant difference to the results.
Of the various methods that can be used to induce labour, one systematic review found that misoprostol and, for women with favourable cervix, oxytocin with amniotomy (artificial rupture of membranes) appear to be more successful than other methods in achieving vaginal delivery within 24 hours. But the same review pointed out that what is less clear is how safe different methods are in terms of the risk of caesarean section, instrumental delivery such as forceps or ventouse, too-strong uterine contractions, admission to neonatal care unit and the newborn baby’s Apgar score.
What might this mean for a woman considering induction of labour?
Overall, the evidence from these studies suggests that having your labour induced may increase the likelihood of having an instrumental delivery but may also reduce the likelihood of having a caesarean section. It appears that inducing labour has no marked effect on the rate of problems occurring in newborn babies.
The evidence about waterbirth comes from a systematic review that compared the outcomes for women and their babies of immersion in water with no immersion in water during the first stage of labour, or the second stage of labour (waterbirth), or both first and second stages. All the trials in the review involved low-risk mothers. No trials evaluated third-stage of labour management (delivery of the placenta), and all took place in a hospital labour ward setting.
The limitations of the evidence are that there was not enough information to support, or not to support, the use of waterbirth during the second stage. Also there have not been any trials in a midwifery-led setting so no conclusions can be drawn about the risks of waterbirth under those arrangements.
The review found no evidence that labouring in water increases the risk of a bad outcome for women or their newborns, and it found that labouring in water during the first stage may reduce the chance of needing an epidural.
What might this mean for a woman considering waterbirth?
When considering immersion in water in the first or second stages of labour, it may be helpful to know that it does not appear to be risky and may help to avoid having an epidural.
A large randomised controlled trial of women having continuous electronic fetal monitoring in labour in labour wards across England, Scotland and the Republic of Ireland compared the outcomes for babies when midwives and doctors use computer software to support their decision-making about fetal heart monitoring information versus not using any such support.
The study found that computerised interpretation of the fetal heart rate in labour did not improve outcomes for babies in the neonatal period or at two years, compared to midwives /doctors looking at a trace of the heart rate without the help of computer analysis.
What might this mean for a woman whose midwife or doctor wish to use continuous fetal heart monitoring?
You may want to discuss with the clinicians how they will interpret the fetal heart monitoring data, if you need to have this done for part or all of your labour.
A trial involving first-time mothers, who were not planning an elective caesarean and did not have high blood pressure or psychological illness, across three NHS Trusts aimed to find out if self-hypnosis before birth affected epidural use. Women in the trial were randomly allocated to usual care, or to usual care plus two self-hypnosis training sessions with a daily audio self-hypnosis CD. The study found that going to the prenatal self-hypnosis groups did not reduce epidural use in labour, but did reduce expected levels of anxiety and fear during labour and birth, and cost less than £5 per woman.
The RESPITE trial compared the proportions of women receiving either remifentanil (via a patient-controlled pump into a vein) or pethidine (via injections) going on to have an epidural. Remifentanil halved the proportion of women who went on to have an epidural compared with pethidine. Women in the remifentanil group were happier with their pain relief, and went on to have fewer instrumental vaginal deliveries than those in the pethidine group - it is known that epidurals increase the risk of an instrumental vaginal delivery (i.e. with forceps or suction). More women in the remifentanil group were given extra oxygen; this did not affect the wellbeing of mother or baby, but this trial was not large enough to detect rarer safety outcomes.
What might this mean for a woman thinking about pain relief in labour?
You may want to consider using self-hypnosis during pregnancy as a way of relieving pain or anxiety during your labour. If so, you might need to investigate resources online or local sources of help. Your midwife will be able to tell you about the drugs that are used for pain relief in labour in the place where you are planning to give birth.
The BUMPES study compared the proportions of first-time mothers with an epidural who achieved a spontaneous vaginal birth when they either stayed upright or lying-down on their side during labour. The lying-down group in the second stage achieved more spontaneous vaginal births than those in an upright position.
A Cochrane systematic review looked at a range of trials of whether an upright labouring position for women without an epidural had benefits. An upright position for women without an epidural may bring benefits, such as a very small reduction in the duration of second stage of labour (around six minutes, mainly for first-time mothers), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk of blood loss greater than 500 ml, and there may be an increased risk of second degree tears, although this remains uncertain.
Another Cochrane systematic review looked at whether different birthing positions during the second stage of labour could change birth outcomes for women using an epidural and for their babies. The review brought together trials involving women in the second stage of a labour that had either started spontaneously or been induced and who were using an epidural. It compared upright and lying down positions during the second stage. Overall it found little or no difference between upright and lying down positions in terms of the proportions of women who needed an instrumental delivery or a caesarean but the better conducted studies found that lying down reduced the need for operative birth and caesarean section without increasing instrumental delivery. There was no difference between the two groups in the number of women who had tears requiring stiches or suffering excessive bleeding. The quality of evidence from different studies in this review varied; the high-quality evidence showed better outcomes for women moving between lying-down on the side positions that avoided lying flat on the back. These positions result in more normal births, a better experience and no harm to mother or baby when compared with an upright position.
What might this mean for a woman thinking about a preferred position during labour and for delivery?
You may want to include labouring and delivery position as part of your birth plan. Your midwife will be able to help you think about the options.
The headline findings from the studies featured in this Highlight are as follows:
- For induction of labour, the use of misoprostol and of oxytocin together with artificial rupture of membranes (only for women with favourable cervix) are more successful than other methods in achieving vaginal delivery within 24 hours
- For women aged 35 or older, inducing labour at 39 weeks of pregnancy rather than waiting for it to start spontaneously did not increase the rate of caesarean section and had no adverse short term effects on outcomes for the mothers or their babies
- Among low-risk first-time mothers of any age, inducing labour at 39 weeks rather than waiting for it to start spontaneously did not significantly reduce the frequency of problems in newborn babies but did significantly reduce the rate of caesarean section
- For women whose pregnancy had gone beyond term (usually 41 weeks or more), inducing labour after the due date slightly lowers the risk of stillbirth or infant death soon after the birth, although this risk is low
- A review found no evidence that labouring in water increases the risk of adverse outcome for women or their newborn babies and labouring in the water may reduce the number of women having an epidural. But there has not been a trial in a midwifery-led setting so at present there is not enough information either way on the use of immersion in water during the second stage of labour. A study is underway to establish the safety of waterbirth for mothers and babies
- For women having continuous electronic fetal monitoring while in labour, computerised interpretation of the fetal heart rate (as compared to midwives & doctors looking at the graphs without computer assistance) did not improve outcomes in the neonatal period at two years after the birth
- First-time mothers who were in good health and were not planning an elective caesarean found that attending two self-hypnosis groups and using a daily audio self-hypnosis CD did not reduce their use of epidural in labour, but did reduce their expected levels of anxiety and fear during the labour and birth
- For women who asked for opioid pain relief during labour, it was found that the use of remifentanil via a patient-controlled pump halved the proportion who went on to have an epidural, compared with those receiving pethidine by injections. Women in the remifentanil group were happier with their pain relief, and went on to have fewer instrumental vaginal deliveries
- For women with an epidural in place, lying down on their side as the baby is being delivered achieved more spontaneous vaginal births than in an upright position]
- For women without an epidural, it was found that an upright position for delivery brought about a very small reduction in the duration of the second stage of labour together with a reduction in episiotomy rates and rates of assisted deliveries, but there was an increased risk of blood loss greater than 500ml
This Highlight is based upon the following published studies. You may also find it useful to be aware of studies that are still underway, listed at the end of each section.
Induction of labour
- Alfirevic Z, Keeney E, Caldwell D, Welton N, Medley N, Dias S, et al. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2016;20(65)
- Walker KF, Bugg GJ, Macpherson M, McCormick C, Grace N, Wildsmith C, et al. Randomized Trial of Labor Induction in Women 35 Years of Age or Older. The New England Journal of Medicine 2016; 374(9):813-822. https://europepmc.org/abstract/MED/26962902
- Middleton P, Shepherd E, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. https://discover.dc.nihr.ac.uk/content/signal-000641/inducing-labour-at-or-after-41-weeks-reduces-risks-to-infants?
A non-NIHR study conducted in the US that may be of interest and whose findings are consistent with the Walker study (above) is as follows:
- Grobman WA, Rice MM, Reddy UM, Tita ATN, Silver RM, Mallett G, et al. Labor Induction versus Expectant Management in Low-Risk Nulliparous Women. The New England Journal of Medicine 2018;379:513-523. https://www.nejm.org/doi/full/10.1056/NEJMoa1800566
Ongoing research about induction of labour
- Trans-cervical balloon catheter and its comparison to sustained release prostaglandin use for out-patient induction of labour in low-risk women: A feasibility study for a randomised controlled trial. Bhide et al. Funder: NIHR Research for Patient Benefit Programme
- Cluett ER, Burns E, Cuthbert A. Immersion in water during labour and birth. Cochrane Database of Syst Rev 2018; Issue 5, Art. No. CD000111. http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD000111.pub4/full
Ongoing research about waterbirth
- The POOL Study. Establishing the safety of waterbirth for mothers and babies: A cohort study with nested qualitative component. Sanders et al. Funder: NIHR Health Technology Assessment Programme
Interpreting fetal heart rate
- Brocklehurst P, Field D, Greene K, Juszczak E, Kenyon S, Linsell L, et al. Computerised interpretation of the fetal heart rate during labour: a randomised controlled trial (INFANT). Health Technol Assess. 2018;22(9).
- Downe S, Finlayson K, Melvin C, Spiby H, Ali S, Diggle P et al. Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness. BJOG 11 May 2015;122(9):1226-1234.
- Wilson MJA, MacArthur C, Hewitt CA, Handley K, Gao F, Beeson L et al. Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. The Lancet 25 August 2018;392(10148):662-672.
Position for delivery
- Bick D, Briley A, Brocklehurst P, Hardy P, Juszczak E, Lynch L, et al. A multicentre, randomised controlled trial of position during the late stages of labour in nulliparous women with an epidural: clinical effectiveness and an economic evaluation (BUMPES). Health Technol Assess. 2017;21(65).
- Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Syst Rev 2017; Issue 5. Art. No. CD002006. http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD002006.pub4/full
- Walker KF, Kibuka M, Thornton JG, Jones NW. Maternal position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD008070. DOI: 10.1002/14651858.CD008070.pub4 https://www.cochrane.org/CD008070/PREG_maternal-position-second-stage-labour-women-epidural-anaesthesia
Ongoing research on factors that may influence delivery:
Interactional practices of decision making during childbirth in maternity units. Annandale et al. Funder: NIHR Health Services and Delivery Research Programme
Delay in labour
High Or Low Dose Syntocinon for delay in labour (HOLDS). Kenyon et al. Funder: NIHR Health Technology Assessment Programme
- The evidence presented here may help inform woman/midwife discussions, but the key source for treatment decisions is NICE’s intrapartum care guidelines: https://www.nice.org.uk/guidance/conditions-and-diseases/fertility--pregnancy-and-childbirth/intrapartum-care
- The very large Birthplace in England study compared outcomes for mothers and babies by place of birth: obstetric unit, midwife led unit or home. Read more about it in our Signal.
- Lots more evidence relating to the topics presented here is available from the Cochrane Pregnancy and Childbirth Group https://pregnancy.cochrane.org/., in particular the review of midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early
Cochrane also have interesting visual summaries of some of their reviews: https://pregnancy.cochrane.org/whats-new
- The NHS website provides information about all aspects of pregnancy, labour and delivery https://www.nhs.uk/conditions/pregnancy-and-baby/?tabname=labour-and-birth
Questions to consider - for pregnant women and their birthing partner
- If my labour needs to be induced what methods will be offered to me?
- Will waterbirth facilities will be available where I plan to give birth? Is there information about when and how I will be able to use birthing pool facilities?
- What is the standard procedure on fetal heart monitoring in the place where I plan to give birth? What choices will I have about whether my baby’s heartbeat is continuously monitored?
- Are there local resources and support if I want to explore using self-hypnosis for my labour?
- What pain relief options will there be in the place where I plan to give birth?
- Do I have a preference about the position I would like to use for giving birth?
- Have I discussed all the above elements of my labour and delivery with my midwife?
- Have I recorded my preferences about these things in my birth plan?
- What additional sources of information and help about labour and delivery are available?
Questions to consider – for midwives
- For the pregnant women that you support, does the information that you provide make clear all the standard local procedures on labour and delivery?
- Do you have a checklist that includes the pregnant woman’s options for: induction, waterbirth, pain relief, fetal heart monitoring and position for delivery?
- Do you have information about local self-hypnosis courses if this is something that pregnant women would like to pursue?
Interview with mother of two young children, Annie, about the management of labour Highlight
Annie lives in Sheffield. She has two children, a two year old son and a daughter aged five months.
Q. What have been your experiences of labour and delivery?
A. I had long labours with both my children. With my son my waters broke naturally but the labour didn’t get going so I was induced. I ended up having an emergency caesarean section because I had ‘run out of time’ after 72 hours in labour. With my daughter, we had planned to try a VBAC (vaginal birth after caesarean) but in the later stages of that labour I developed eclampsia so there was no option but to go for another emergency C-section, even though only 48 hours had gone by.
Q. Of the studies in the Highlight, which did you find most interesting?
A. I found the studies about induction particularly relevant to me as I had been induced both times and I have no way of knowing if I ever would have gone into labour naturally. With my daughter, I had induction by means of a pessary and then oxytocin drip but again the labour was slow. My little ones were good at stubbornly staying put! I needed C-sections for both my babies so I don’t know what the eventual outcome might otherwise have been, but I can say that if I were ever to have a third baby I would still happily go for induction, as I can see from the evidence that it may reduce the rate of C-sections.
Q. What did you make of the section on pain relief?
A. Personally I had very little pain relief in either of my labours – I’m a bit hardcore like that! – so it didn’t directly relate to my own experience, but the evidence was interesting. I was struck at my NHS ante-natal classes just how much information is given out and discussed about pain relief. I came away from the classes well-informed but there was new stuff in the Highlight that I hadn’t come across before.
Q. Did anything in the Highlight surprise you?
A. Just the bit about the position in labour. As I ended up with C-sections on both occasions I never got the chance to choose a delivery position but I thought it was good that this is being so closely looked at – and it would certainly help some people to think it through.
Q. Do you think the Highlight would be useful for pregnant women and their midwives?
A. Yes I think it would be a useful extra to all the other information you get. Everyone likes a real-life story but if you are making decisions, such for a birth plan, it’s good to have hard evidence. Midwives play a crucial role in pregnancy – they are usually the only professional you see and you tend to save up your questions for them. I could imagine using the evidence in the Highlight as a way into some of those discussions.
Emma had her first baby eight months ago, talking about our Highlight: Management of Labour she said:
The information in this Highlight about trials and the statistics of birthing is an interesting read for pregnant women. This information would also be useful for midwives to feed back to the women they support. Midwives and doctors will advise on options for a delivery that is safe for mother and baby. However, I personally feel that there should be more emphasis on advising expectant mothers that regardless of a birthing plan, babies have their own ideas of how their birth pans out and it’s not always possible to stick to the plan! Nevertheless, discussing a delivery plan and having the knowledge of pain relief and delivery options available prior to the birth can help the woman make informed decisions, which – as midwives will advise – can be changed as the labour progresses.
This Highlight has featured some very useful information and statistics about labour and delivery which expectant mothers will find informative once discussed with their midwives.