Normal Labor, the Partograph and WHO Labour Care Guide, the Term Newborn Infant, Transitory Features of the Newborn, the Apgar Score, and Neonatal Resuscitation
1. Singh Lakshit
2. Osmonova Gulnaz Zhenishbaevna
(1. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic
2. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
Normal labor is the physiological process in which regular uterine contractions produce progressive cervical effacement and dilatation, culminating in the spontaneous vaginal birth of a term infant and the placenta. Contemporary monitoring relies on the World Health Organization Labour Care Guide, which replaced the classical partograph and incorporates evidence-based time limits, supportive care, and shared decision-making. The healthy term newborn undergoes a rapid transition to extrauterine life during which several transient clinical findings are expected. The Apgar score provides a standardized record of the infant’s condition at one and five minutes, while modern neonatal resuscitation guidelines emphasize preparation, delayed cord clamping when appropriate, effective ventilation as the primary intervention, and a measured approach to oxygen and circulatory support. This review examines the physiology and clinical management of normal labor, the structure and application of current labor-monitoring tools, the characteristics and common transitory features of the term newborn, the correct use of the Apgar score, and the principles of neonatal resuscitation according to the most recent international consensus.
Introduction
The birth of a healthy infant after uncomplicated labor remains the most frequent and desired outcome of pregnancy, yet the underlying physiology is among the most complex events in human biology. Labor requires the transformation of a quiescent uterus into an organ capable of generating coordinated, forceful contractions while the cervix undergoes profound structural change. Once the infant is born, an equally intricate transition must occur within minutes: the lungs must clear fluid and fill with air, the circulatory pattern must switch from fetal to neonatal pathways, and independent thermoregulation, glucose homeostasis, and breathing must be established.
For many years the partograph served as the principal graphical instrument for tracking labor progress and detecting deviation from expected norms. Accumulating evidence that normal labor progresses at highly variable rates, together with a global emphasis on respectful and individualized care, led the World Health Organization to develop the Labour Care Guide. This tool redefines the onset of active labor, replaces fixed alert and action lines with evidence-based time limits at each centimeter of dilatation, and integrates supportive care and shared decision-making into routine monitoring.
At the same time, neonatal care has shifted from routine aggressive intervention toward support of physiological transition. Delayed cord clamping in stable infants, skin-to-skin contact, and effective lung aeration have become central recommendations. The Apgar score, first described more than seventy years ago, continues to offer a rapid, standardized description of the newborn’s condition, although its limitations as a long-term prognostic tool are now clearly recognized.
This review addresses each of these topics in sequence. It describes the mechanisms and stages of normal labor, the design and clinical use of the Labour Care Guide, the expected features and common transient findings in the term newborn, the proper application of the Apgar score, and the current principles of neonatal resuscitation. The discussion is intended to provide students and clinicians with a coherent, practical understanding grounded in contemporary evidence.
Methods
This narrative review draws on peer-reviewed literature, clinical practice guidelines, and consensus statements published principally between 2018 and 2026. Primary sources include the World Health Organization recommendations on intrapartum care and the Labour Care Guide, the 2025 American Heart Association and American Academy of Pediatrics neonatal resuscitation guidelines, the European Resuscitation Council 2025 newborn life support guidelines, and the International Liaison Committee on Resuscitation consensus on science. Additional material was taken from major obstetric and neonatal textbooks, systematic reviews, and institutional protocols. Emphasis was placed on quantitative descriptions of normal labor progress, current monitoring recommendations, transitional newborn physiology, and evidence-based resuscitation algorithms. The synthesis prioritizes clinical relevance and educational clarity.
Results
Physiology and Clinical Course of Normal Labor
Normal labor is defined as the spontaneous onset of regular, painful uterine contractions that produce progressive cervical effacement and dilatation, resulting in the spontaneous vaginal delivery of a term fetus in cephalic presentation and the subsequent delivery of the placenta, without significant intervention and with a healthy mother and infant. The process is driven by a cascade of hormonal, inflammatory, and mechanical events. Throughout most of pregnancy the uterus remains relatively quiescent under the influence of progesterone. As term approaches, a functional withdrawal of progesterone action, rising estrogen levels, increased inflammatory mediators, and mechanical stretch of the myometrium and fetal membranes lead to cervical ripening and the onset of coordinated contractions.
Labor is divided into three principal stages. The first stage begins with the onset of true labor and ends when the cervix reaches full dilatation of 10 cm. It is subdivided into a latent phase and an active phase. In current World Health Organization guidance the active phase is considered to begin at 5 cm of cervical dilatation. During the latent phase contractions become progressively more coordinated and the cervix softens and begins to dilate slowly. The active phase is marked by more rapid dilatation. Earlier partograph designs assumed a minimum progress of 1 cm per hour throughout the active phase; contemporary evidence shows that many women with ultimately normal outcomes progress more slowly at certain centimeters, so the Labour Care Guide replaces a single fixed rate with evidence-based time limits at each centimeter of dilatation.
The second stage begins at full cervical dilatation and ends with the birth of the infant. It includes a passive phase of descent onto the pelvic floor and an active phase of maternal expulsive effort. Duration varies with parity, use of epidural analgesia, and fetal position. Prolonged second stage is associated with higher rates of maternal morbidity and warrants careful clinical assessment rather than automatic intervention.
The third stage begins immediately after delivery of the infant and ends with delivery of the placenta and membranes. Active management of the third stage—administration of a uterotonic agent (most commonly oxytocin 10 IU intramuscularly or intravenously), controlled cord traction, and uterine massage after the placenta is delivered—substantially reduces the incidence of postpartum hemorrhage and is recommended for every birth.
In the common left occipito-anterior position the fetal head negotiates the birth canal through a sequence of cardinal movements: engagement of the biparietal diameter into the pelvic inlet, continued descent, flexion of the head, internal rotation so that the occiput moves toward the pubic symphysis, extension as the head crowns and passes under the pubic arch, restitution (realignment of the head with the shoulders), external rotation of the head as the shoulders rotate, and finally expulsion of the trunk and lower limbs. Successful progress requires both effective uterine contractions and an adequate relationship between fetal size and maternal pelvic dimensions.
The Partograph and the WHO Labour Care Guide
The classical partograph plotted cervical dilatation against time, with an alert line drawn at a rate of 1 cm per hour and an action line placed parallel and several hours later. Its purpose was to identify prolonged labor early enough to permit intervention or transfer. Although widely adopted, the original design was based on average rates of progress that do not capture the substantial normal variation among women, and rigid application sometimes led to unnecessary augmentation or cesarean birth.
In 2020 the World Health Organization introduced the Labour Care Guide as a next-generation monitoring tool. Active first-stage labor is defined as beginning at 5 cm of cervical dilatation. Instead of a single alert line, the Guide provides evidence-based time limits for each centimeter of dilatation derived from the 95th centiles of women who delivered healthy infants. The tool contains seven sections: identifying information and labor characteristics at admission; supportive care (presence of a companion, pain relief, oral fluid intake, and posture); care of the baby (fetal heart rate, amniotic fluid, fetal position, moulding, and caput); care of the woman (pulse, blood pressure, temperature, and urine); labor progress (cervical dilatation and descent of the presenting part); medication; and shared decision-making. Abnormal observations are circled to prompt timely clinical response. The Guide also monitors the second stage and emphasizes continuous assessment rather than automatic intervention when a fixed line is crossed.
Correct use requires accurate digital cervical assessment, regular recording of fetal and maternal parameters, and clinical judgment that integrates the plotted progress with the overall condition of the woman and fetus. When progress exceeds the suggested time limits, the first response is careful reassessment of contraction strength and frequency, fetal position and station, and maternal well-being, followed by supportive measures or carefully considered augmentation only when clearly indicated.
The Term Newborn Infant
A term newborn is an infant born between 37 weeks 0 days and 41 weeks 6 days of gestation. The healthy term infant typically weighs between 2500 g and 4000 g, measures 48–52 cm in length, and has a head circumference of 33–37 cm. Immediately after birth the infant should establish regular respirations, maintain a heart rate above 100 beats per minute, and demonstrate good muscle tone and reflex irritability. Routine care for the stable term infant includes delayed umbilical cord clamping for at least 60 seconds when the infant does not require immediate resuscitation, immediate skin-to-skin contact with the mother, and initiation of breastfeeding within the first hour of life.
The transition from fetal to neonatal circulation involves a rapid fall in pulmonary vascular resistance as the lungs expand with air, a rise in systemic vascular resistance, functional closure of the foramen ovale, and gradual closure of the ductus arteriosus and ductus venosus. Lung liquid is cleared by a combination of thoracic compression during passage through the birth canal, lymphatic and pulmonary venous absorption, and active epithelial sodium transport. Thermoregulation becomes critical because the newborn has a high surface-area-to-volume ratio and limited capacity for shivering; heat production occurs mainly through non-shivering thermogenesis in brown adipose tissue. Maintenance of a neutral thermal environment is therefore an essential component of immediate newborn care.
Transitory Features of the Newborn
Many clinical findings that may appear concerning to inexperienced observers are in fact normal and self-limited in the healthy term newborn. Acrocyanosis—bluish discoloration of the hands and feet—is common in the first hours after birth and reflects peripheral vasoconstriction; it must be distinguished from central cyanosis of the lips and mucous membranes, which requires immediate evaluation. Erythema toxicum neonatorum appears as erythematous macules, papules, or small pustules, typically beginning on the second or third day of life, sparing the palms and soles, and resolving spontaneously within days to two weeks. Milia are tiny white keratin-filled cysts on the nose, cheeks, and chin that disappear over several weeks. Epstein pearls are similar small cysts on the hard palate.
Caput succedaneum is a soft, boggy swelling of the scalp caused by pressure during labor; it crosses suture lines and resolves within a few days. Cephalhematoma is a subperiosteal collection of blood limited by suture lines and may take weeks to resolve. Physiological jaundice typically becomes visible after 24 hours of age, peaks around the third or fourth day, and resolves by the end of the first week in most term infants. Jaundice appearing within the first 24 hours is regarded as pathological until proven otherwise and requires prompt investigation. Transient tachypnea of the newborn may occur as residual lung fluid is cleared and usually settles within 24 to 72 hours. Recognition of these common transitory features prevents unnecessary investigation, avoids separation of mother and infant, and allows accurate reassurance of parents.
The Apgar Score
The Apgar score, introduced by Virginia Apgar in 1953, assigns 0, 1, or 2 points for each of five components: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. The score is recorded at one minute and at five minutes after birth, and every five minutes thereafter up to 20 minutes if the five-minute score remains below 7. A total score of 7–10 is generally regarded as reassuring, 4–6 as moderately abnormal, and 0–3 as low. The one-minute score largely reflects the infant’s condition at the moment of birth and the immediate need for assistance; the five-minute score provides information about the infant’s response to resuscitative measures and correlates more closely with short-term morbidity.
It is essential to understand that the Apgar score is not used to decide whether resuscitation should begin. That decision rests on the simultaneous clinical assessment of breathing effort, heart rate, and tone. A low Apgar score documents the need for and the response to resuscitation; it does not reliably predict long-term neurodevelopmental outcome and should not be used in isolation for prognostic counseling of parents.
Neonatal Resuscitation
Approximately 5 to 10 percent of newborns require some assistance to begin breathing at birth, and roughly 1 percent need more extensive resuscitative measures. The 2025 neonatal resuscitation guidelines issued by the American Heart Association, the American Academy of Pediatrics, and the European Resuscitation Council emphasize anticipation, preparation, team training, and a stepwise physiology-based approach.
The initial assessment consists of three questions: Is the infant term? Is the infant breathing or crying? Does the infant have good muscle tone? If the answer to all three is affirmative, the infant remains with the mother for routine care that includes delayed cord clamping of at least 60 seconds when feasible and immediate skin-to-skin contact.
If any answer is negative, the infant is placed under a radiant warmer. The initial steps are provision of warmth, correct positioning of the head to open the airway, clearing of secretions only if they are obstructing the airway, drying, and tactile stimulation. If the infant remains apneic or gasping, or if the heart rate is below 100 beats per minute after these steps, positive-pressure ventilation is commenced without delay. Effective ventilation is the single most important action in neonatal resuscitation. Current guidance recommends beginning with 21 percent oxygen for term infants and higher concentrations for preterm infants, thereafter titrating oxygen according to preductal oxygen-saturation targets that rise gradually over the first ten minutes of life.
Chest compressions are indicated if the heart rate remains below 60 beats per minute despite 30 seconds of effective ventilation, using a compression-to-ventilation ratio of 3:1. Epinephrine and volume expansion are considered for persistent bradycardia or clear signs of hypovolemic shock. Throughout the process continuous assessment of heart rate, breathing, and oxygen saturation directs the next intervention, and clear team communication is maintained. After resuscitation the infant requires ongoing monitoring for transitional problems such as hypoglycemia, hypothermia, or respiratory distress.
Discussion
Normal labor, systematic monitoring with the Labour Care Guide, accurate recognition of the healthy term newborn and its transient features, appropriate use of the Apgar score, and competent neonatal resuscitation together constitute the foundation of safe childbirth. The transition from a rigid partograph based on average rates of progress to an individualized Labour Care Guide reflects a broader movement toward respectful, evidence-based care that reduces unnecessary intervention while still identifying true dystocia in a timely manner.
Neonatal resuscitation practice has similarly evolved from routine aggressive measures toward support of physiological transition, with delayed cord clamping and effective lung aeration as central principles. The Apgar score retains value as a standardized method of communication and as a record of the infant’s response to resuscitation, yet its limitations must be clearly understood so that it is neither over-interpreted for long-term prognosis nor neglected as a documentation tool.
Common transitory findings in the newborn are frequent; their correct identification prevents unnecessary separation of mother and infant and reduces parental anxiety. Implementation of the Labour Care Guide requires adequate training and system support. Resuscitation skills must be maintained through regular simulation, particularly in settings where advanced resuscitation is uncommon. Ongoing research continues to refine optimal oxygen targets, cord-management strategies for non-vigorous infants, and the long-term significance of borderline Apgar scores.
The overarching goal of care during labor and the immediate newborn period is to support natural physiological processes whenever possible and to intervene skillfully and promptly when those processes are delayed or disrupted. By integrating current knowledge of labor mechanisms, modern monitoring tools, newborn transitional physiology, and evidence-based resuscitation, clinicians can help ensure the safest possible start for each infant.
References
World Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva: WHO; 2018 and subsequent updates.
World Health Organization. WHO Labour Care Guide and implementation resources. 2020–2025.
American Heart Association & American Academy of Pediatrics. 2025 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Neonatal Resuscitation.
European Resuscitation Council. Guidelines 2025: Newborn Resuscitation and Support of Transition of Infants at Birth.
International Liaison Committee on Resuscitation. Neonatal Life Support Consensus on Science with Treatment Recommendations 2025.
StatPearls. Normal Labor: Physiology, Evaluation, and Management. NCBI Bookshelf. Updated 2025.
Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32:260-267.
American Academy of Pediatrics Committee on Fetus and Newborn. The Apgar Score. Pediatrics. 2015 and later affirmations.
FIGO position statement on the WHO Labour Care Guide. 2025.
Additional contemporary reviews on mechanisms of normal labor, transitional newborn physiology, and neonatal resuscitation (2023–2026).