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The four stages of labour from the nursing side: the partograph and the WHO Labour Care Guide

  • Fundamental

Labour has four stages. The nurse supports the woman, records her and the baby's observations at the time and calls for help at any alert value.

Updated

What it is

Nursing care in labour has two jobs: support and surveillance. Support means a companion of the woman's choice, freedom to move, oral fluids and pain relief she chooses. Surveillance means recording the woman's vital signs, the fetal heart rate, contractions and progress on a tool that is filled in as care happens. Colombia's Res. 3280 de 2018 asks for the CLAP partograph for every woman. The WHO Labour Care Guide (2020) is a newer tool that starts at 5 cm, sets an alert value for each observation and asks the team to write an assessment and a plan each time. This page covers the stages and the record; the fetal heart, pain relief and the third stage have their own pages.

Key points

  • First stage: the latent phase (painful contractions, slower change up to 5 cm by the WHO definition) and the active phase (regular contractions and faster dilatation up to full dilatation).
  • Second stage: from full dilatation to the birth. Res. 3280 splits it into a passive phase (no urge to push) and an active phase (the baby is visible, or there are expulsive contractions or spontaneous pushing).
  • Third stage: from the birth of the baby to the delivery of the placenta, with active management according to protocol.
  • Fourth stage: the first 2 hours after birth (immediate puerperium), when most haemorrhages happen.
  • Res. 3280 admission criteria for labour: regular contractions, effacement over 50 % and dilatation of 4 cm. A woman sent home leaves with clear warning signs to come back.
  • Vaginal examinations: WHO recommends one every 4 hours in the active first stage for low-risk women; Res. 3280 suggests no more than 3 and none before 4 hours unless there is a reason.

Components

  • The CLAP partograph (Res. 3280) records the mother's position, her vital signs, the fetal heart rate, dilatation, effacement, station, membranes, the position of the presenting part, contractions (frequency, duration, intensity) and the pain relief used.
  • The Labour Care Guide has 7 sections: 1 identifying information and labour characteristics at admission; 2 supportive care; 3 the baby; 4 the woman; 5 labour progress; 6 medication; 7 shared decision-making (assessment and plan).
  • Supportive care in the guide: companion present, pain relief, oral fluids and posture (supine or mobile). «No» or «supine» is an alert.
  • Cervix alert times in the guide (no progress for): 6 h at 5 cm, 5 h at 6 cm, 3 h at 7 cm, 2.5 h at 8 cm and 2 h at 9 cm. Second stage: 3 h in a first labour, 2 h in later labours.

What it is for

  • Shows a deviation in time to act, instead of finding it after the birth.
  • Puts the woman's choices (companion, position, fluids, pain relief) in the record next to the clinical values.
  • Gives the team a shared plan agreed with the woman.

Step by step

  1. On admission, ask about contractions, membranes, bleeding, fetal movements and pre-eclampsia symptoms — this finds the risks early.
  2. Offer a companion of her choice and continuous support — WHO and Res. 3280 recommend it for every woman.
  3. Encourage walking, upright positions and oral fluids if she is low risk — WHO recommends them for women at low risk.
  4. Count contractions in 10 minutes every 30 minutes in the first stage and every 15 in the second — too few and too many are both alerts.
  5. Record each observation at the time you make it — a record filled in later cannot trigger action in time.
  6. Circle any alert value and tell the senior midwife or doctor — then write the plan agreed with the woman.
  7. In the second stage, let her push with her own urge and in the position she chooses — directed pushing and lying supine are not routine.
  8. After the birth, keep the baby skin to skin and check uterus, bleeding, pulse and pressure every 15 minutes — the first 2 hours carry most risk.

In nursing practice

  • Labour Care Guide alert values: fetal heart below 110 or 160 and above; late decelerations; thick meconium or blood-stained fluid; maternal pulse below 60 or 120 and above; systolic pressure below 80 or 140 and above; diastolic 90 and above; temperature below 35.0 °C or 37.5 °C and above.
  • Contractions are an alert when there are 2 or fewer, or more than 5, in 10 minutes, or when they last less than 20 or more than 60 seconds; recount over another 10 minutes before calling.
  • Oxytocin, amniotomy or caesarean to speed labour before 5 cm are not recommended when mother and baby are well (WHO).
  • Res. 3280: no routine enemas, shaving, fundal pressure or episiotomy; respectful treatment and no remarks that hurt the woman's dignity.
  • Third and fourth stages, fetal heart and pain relief: see the linked pages.

Common mistakes

  • Filling in the partograph or guide at the end of the shift instead of in real time.
  • Labelling a labour «slow» with the old 1 cm per hour line.
  • Leaving the woman lying on her back, alone or without fluids when she wants them.
  • Seeing an alert value and not calling, or calling and not writing the plan.

Test yourself

Think of the answer, then tap the question to see it.

At how many centimetres does the WHO Labour Care Guide start to be used?

At 5 cm, when the active first stage starts.

How often does Res. 3280 ask for the fetal heart in the active phase and in the second stage?

One full minute every 30 minutes in the active phase and every 5 minutes in the second stage.

What must the nurse do with a value that falls in the guide's «Alert» column?

Circle it, tell the senior midwife or doctor, and record the assessment and the action taken.

Is a dilatation slower than 1 cm per hour, on its own, a reason to intervene?

No. WHO says it is not, on its own, an indication for intervention.

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Connections

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Resolución 3280 de 2018: lineamientos técnicos y operativos de la Ruta de Promoción y Mantenimiento de la Salud y de la Ruta Materno Perinatal (Ministerio de Salud y Protección Social de Colombia, 2018); WHO Labour Care Guide: user's manual (World Health Organization, 2020); WHO next-generation partograph: revolutionary steps towards individualised labour care (BJOG, 2021) (PubMed Central (open access), 2021).

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Representative model, for educational purposes only.