A practical clinical education guide to monitoring the woman, the baby and labour progress using a structured, person-centred approach aligned with the WHO Labour Care Guide and WHO intrapartum-care recommendations.
Core principle
WHO describes labour monitoring as a continuous cycle of assessment, documentation, comparison with reference thresholds and planning. A threshold should prompt further clinical assessment rather than automatically determine a procedure.
Assess the woman, baby and progress of labour using appropriate clinical methods.
Document observations clearly, consistently and at the appropriate time.
Compare findings with relevant reference thresholds and the overall clinical context.
Discuss and document the next step, including escalation or referral when required.
Important: The WHO Labour Care Guide is a guide to structured clinical decision-making. It is not a substitute for clinical judgement, local protocols, emergency preparedness or individualized assessment.
Monitoring framework
Intrapartum monitoring brings together maternal wellbeing, fetal wellbeing, labour progress and the woman’s experience of care.
Observe the woman’s physical and emotional condition throughout labour.
Assess fetal wellbeing using an appropriate method for the woman’s risk status and clinical situation.
Monitor progress using current evidence rather than a rigid one-centimetre-per-hour rule.
Monitoring should occur within respectful, person-centred care.
Document interventions that may change maternal, fetal or labour observations.
Monitoring must connect to an operational plan for senior review, referral and emergency care.
01 · Maternal wellbeing
Maternal observations help identify deterioration, infection, hypertensive complications, dehydration, excessive bleeding, medication effects and other problems that can affect both the woman and the baby.
Measure and document according to the clinical situation and facility protocol. Abnormal findings require assessment in context and may require more frequent observations or escalation.
Monitor temperature as clinically indicated and be alert to fever, infection risk and other clinical changes, particularly where risk factors or prolonged labour are present.
Assess hydration, oral intake where appropriate, urine passage and relevant urinary findings. Urinary retention or reduced output may require assessment.
New severe headache, visual symptoms, significant bleeding, severe abdominal pain, breathlessness, collapse, fever or other concerning symptoms require prompt clinical assessment.
02 · Fetal wellbeing
Fetal heart rate assessment is one component of fetal wellbeing assessment. The method and frequency should be individualized according to risk status, stage of labour, interventions, clinical findings and local protocol.
WHO identifies intermittent fetal heart rate assessment as an intrapartum monitoring approach for women in labour when clinically appropriate. Use a suitable device and document the finding and time accurately.
A single fetal heart rate value should not be interpreted in isolation. Consider maternal condition, contractions, stage of labour, medicines, fetal movement and other clinical information.
Monitoring intervals are not identical for every woman. The appropriate schedule depends on risk status, stage of labour and clinical events. Follow the applicable guideline and local protocol.
If a fetal assessment is concerning, reassess promptly, review reversible contributors, obtain senior clinical review and follow the facility’s fetal surveillance and emergency pathway.
03 · Uterine activity
The WHO Labour Care Guide records the number of uterine contractions in 10 minutes and the duration of contractions in seconds.
| Observation | How to assess | WHO Labour Care Guide reference | Clinical response |
|---|---|---|---|
| Contractions / 10 min | Count uterine contractions during a 10-minute period. | Alert: ≤2 or >5 contractions per 10 minutes. | Verify the finding over another 10 minutes if the threshold is reached. If confirmed, alert a senior provider and follow applicable clinical guidance. |
| Duration | Assess and record contraction duration in seconds. | Alert: <20 seconds or >60 seconds. | Verify the finding over another 10 minutes if the threshold is reached. If confirmed, alert a senior provider and follow applicable clinical guidance. |
| Routine reassessment | When contraction findings are within the reference range. | 3–5 contractions per 10 minutes and duration ≥20 to ≤60 seconds. | WHO LCG manual indicates assessment every 30 minutes during the first stage and at least every 15 minutes during the second stage when findings are within these reference ranges. |
Clinical interpretation: More than five contractions in 10 minutes or continuous contractions can be associated with uterine hyperstimulation or obstructed labour. Consider medications and the wider clinical picture, and follow local protocols for assessment and management.
04 · Labour progress
WHO's Labour Care Guide replaces reliance on the traditional 1 cm/hour screening rule with updated reference values and a broader assessment of cervical dilatation, descent, contractions and the woman and baby's wellbeing.
| Stage / observation | WHO Labour Care Guide reference | Practical meaning |
|---|---|---|
| 5 cm | Alert if cervical dilatation remains at 5 cm for ≥6 hours. | Reassess the overall clinical picture and consider appropriate action. |
| 6 cm | Alert if cervical dilatation remains at 6 cm for ≥5 hours. | Review progress, maternal/fetal wellbeing and contributing factors. |
| 7 cm | Alert if cervical dilatation remains at 7 cm for ≥3 hours. | Undertake structured reassessment and plan care. |
| 8 cm | Alert if cervical dilatation remains at 8 cm for ≥2.5 hours. | Reassess and escalate according to clinical circumstances. |
| 9 cm | Alert if cervical dilatation remains at 9 cm for ≥2 hours. | Assess for progress, wellbeing and causes of delay. |
| Second stage | Alert if birth is not completed by ≥3 hours from the start of active second stage in a nulliparous woman or ≥2 hours in a multiparous woman. | Interpret alongside maternal behaviour, effectiveness of pushing, fetal position, fetal wellbeing and the clinical context. |
05 · Cervical assessment
A vaginal examination should have a clear clinical purpose. WHO's Labour Care Guide manual emphasizes obtaining the woman's consent, ensuring privacy and using aseptic technique.
Explain why the examination is being offered and obtain consent before proceeding.
Protect dignity, privacy and confidentiality throughout the examination.
Use appropriate infection-prevention measures and avoid unnecessary examinations.
Record the time and relevant findings so that progress can be interpreted over time.
WHO LCG first-stage reference: when labour is progressing as expected, assess cervical dilatation every 4 hours unless otherwise indicated. A vaginal examination performed sooner should add important information to clinical decision-making.
06 · Descent & second stage
Cervical dilatation is only one part of labour progress. The WHO Labour Care Guide also considers descent and, in the second stage, the woman’s behaviour, effectiveness of pushing, fetal position and fetal wellbeing.
Assess descent by abdominal palpation and document the level using the appropriate fifths palpable above the symphysis pubis. WHO LCG does not assign a single alert threshold for descent because it varies between cases.
Assess the whole clinical picture, including maternal condition, effectiveness of pushing, fetal position, fetal wellbeing and progress.
Continue communication, support, privacy and appropriate choice of position. Monitoring should not unnecessarily restrict movement or impose a single birth position.
07 · Respectful intrapartum care
WHO's intrapartum model combines clinical safety with a positive childbirth experience. Monitoring should be integrated into care rather than becoming an isolated documentation exercise.
Explain assessments, findings and proposed actions in understandable language.
Where clinically appropriate, involve the woman in decisions about her care and preferences.
Supportive companionship and respectful communication are important components of quality intrapartum care.
Maintain privacy, confidentiality, respectful language and non-discriminatory care.
Do not make monitoring itself a reason to unnecessarily restrict movement when clinical circumstances permit.
Clinical surveillance and respectful care should occur together throughout labour and birth.
08 · Documentation
The record should allow another clinician to understand the woman’s condition, the baby's wellbeing, the progression of labour, the care provided and the decisions made.
| Documentation area | Record clearly | Why it matters |
|---|---|---|
| Maternal observations | Time, pulse, BP, temperature and relevant symptoms/findings. | Shows maternal wellbeing and changes over time. |
| Fetal assessment | Method, time and fetal heart rate findings. | Allows trends and changes to be recognized. |
| Contractions | Number per 10 minutes and duration in seconds. | Supports assessment of uterine activity. |
| Cervical findings | Time and findings when vaginal examination is performed. | Allows progress to be assessed against current references. |
| Descent | Level of fetal head and relevant findings. | Provides another dimension of labour progress. |
| Interventions | Medicines, analgesia, procedures, fluids and response. | Clinical context can change interpretation of observations. |
| Shared decisions | Discussion, agreed plan, escalation and referral. | Creates a transparent clinical record and supports continuity of care. |
09 · Monitoring to action
A monitoring threshold should trigger a structured response. The WHO Labour Care Guide explicitly connects assessment to recording, threshold checking and planning.
Confirm the observation when the guideline or clinical situation calls for repeat assessment.
Review the woman, baby, labour progress, medicines and other relevant factors.
Inform the appropriate senior clinician and activate referral or emergency pathways when required.
Agree the next step where appropriate, implement it and document the rationale and response.
10 · Safety
The following are examples of concerning findings that should not be managed by this educational page alone. Follow local emergency protocols.
Collapse, severe breathlessness, altered consciousness, severe hypertension, significant bleeding or other acute deterioration.
An abnormal or concerning fetal assessment requiring immediate reassessment and appropriate escalation.
Bleeding during labour that is clinically concerning requires prompt assessment and appropriate management.
Fever or other findings suggesting infection require assessment and treatment according to clinical guidance.
Progress outside the applicable reference thresholds requires reassessment and a documented plan.
If the required level of care is unavailable, activate the facility's referral and transport pathway without unnecessary delay.
Practical checklist
Use this as an educational checklist and adapt it to the woman's condition, local policy, available equipment and applicable national guidance.
Practice update
WHO explains that the Labour Care Guide was developed to put current intrapartum recommendations into practice and move away from inappropriate intervention triggers based solely on a fixed cervical dilatation rate.
| Older simplified approach | WHO Labour Care Guide approach |
|---|---|
| May focus heavily on a 1 cm/hour cervical dilatation rule. | Uses updated reference values for labour progress and recognizes variation between women. |
| May treat a chart position as the primary trigger for intervention. | Uses Assess → Record → Check → Plan and considers the whole clinical picture. |
| Can become documentation-focused. | Connects monitoring to clinical reasoning, supportive care and shared decision-making. |
| May separate labour progress from maternal/fetal wellbeing. | Brings maternal wellbeing, fetal wellbeing, labour progress and experience of care together. |
WHO's 2025 implementation resource: WHO describes the Labour Care Guide as supporting standardized monitoring and timely decision-making, and as a tool to support implementation of evidence-based, respectful and person-centred intrapartum care.
For learners & educators
Intrapartum monitoring is best understood as a clinical reasoning process, not merely a charting exercise.
Every observation should contribute to understanding maternal wellbeing, fetal wellbeing or labour progress.
Monitoring intervals depend on the observation, stage, risk and clinical context.
Understand what a reference threshold means and what reassessment it should prompt.
Explain assessments and decisions to the woman and document important discussions.
Monitoring is useful only when findings can lead to timely review, referral and treatment.
Compare local protocols with current WHO, national and professional guidance and use the applicable version.
Frequently asked questions
Guideline references
The clinical framework on this page is based primarily on WHO intrapartum-care and Labour Care Guide resources. Local/national protocols should also be checked before clinical implementation.
WHO comprehensive guideline for evidence-informed, woman-centred intrapartum care across levels of care.
View WHO source
Practical guidance for structured monitoring, recording, checking thresholds and planning care during labour.
View WHO source
Implementation guidance supporting standardized, evidence-based, respectful and person-centred use of the Labour Care Guide.
View WHO source
