Labour: a comprehensive guide to delivery, birthing locations and how babies may be monitored

Whilst every birth is unique, bringing a baby into the world is usually safe, and most families experience a good outcome regardless of how their baby is born. At the same time, labour can change quickly, and there are moments during a pregnancy and delivery when clear communication and timely action matter most.

This article provides an overview of induction of labour, the different types of delivery, options for where delivery can take place, and the forms of fetal monitoring you might encounter. It also explores how concerns can arise and when to seek legal advice.

Induction of labour (IOL)

Induction of labour is when labour is started artificially rather than beginning spontaneously. It is commonly offered if your baby is overdue or if there is a concern about your health or your baby’s wellbeing – for example, if your waters break and labour does not start, or if there are issues such as high blood pressure or queries around baby’s growth.

Induction of labour is a medical intervention and can affect your birth options and experience, including where you can give birth and what monitoring or pain relief might be available. You should be given information about why induction is being offered, what alternatives exist (including waiting for labour to begin naturally), and what happens if induction does not work. You should then be supported to decide on the best option for you and your family.

More information on the induction of labour can be found in our previous articles:

Types of delivery: vaginal birth, assisted birth and caesarean

There are four main types of delivery. The risks and benefits of each are explored in more detail below:

  • Spontaneous vaginal birth (without instruments): many parents find that a straightforward vaginal birth supports a faster physical recovery and shorter hospital stay compared with caesarean. It also allows for more maternal choice including water births and can take place in most birthing locations. Tearing and perineal soreness can occur, and occasionally tears can be significant and require specialist repair by a doctor.
  • Assisted vaginal birth (ventouse/vacuum or forceps): an assisted vaginal birth may be recommended if labour is not progressing or if the baby needs to be born more quickly. Assisted birth can be beneficial when used appropriately and safely, however complications for mother and baby can occur. This is why the experience of your medical team, correct assessment (sometimes aided by ultrasound), and appropriate supervision matter. There is a higher risk of obstetric anal sphincter injury compared with uncomplicated vaginal birth, and this should form part of informed decision‑making when mothers are given information about different modes of delivery.
  • Caesarean birth (planned or emergency): caesarean birth can be a calm, planned experience, or an urgent, life‑saving intervention when labour changes quickly. Most women recover well after a caesarean, but this is major surgery carrying associated surgical risks and generally a longer recovery time is required than after a vaginal birth.
  • Vaginal birth after a previous caesarean (VBAC): if you have had a caesarean for a previous delivery, you may be thinking about how to give birth next time. Planning for a vaginal birth after caesarean (VBAC) or choosing an elective repeat caesarean section (ERCS) have different benefits and risks. When considering your options, your previous pregnancies and medical history (including previous surgeries) are important factors to take into account. To help you decide, your healthcare professionals will discuss your birth options with you at your antenatal visit, ideally before 28 weeks.

Where to give birth – hospital, midwifery units/birth centres or home?

Where you chose to give birth will likely depend on the kind of support, interventions and transfer pathways that are best suited to you and your baby’s needs.

  • Hospital birth (obstetric unit): a hospital birth offers direct access to obstetricians, anaesthetists (who will be needed if you would like to have an epidural), and teams specialising in neonatal support if complications arise. Hospital settings are generally recommended for higher‑risk pregnancies because specialist care is immediately available.
  • Midwifery units / birth centres (AMU or FMU): midwifery units can feel calmer and more homely, and for low‑risk pregnancies they are associated with fewer interventions. It is often possible to have a water birth in these locations. Although units such as these can be excellent choices for many low-risk pregnancies, parents should be aware that the units generally do not have their own designated surgical theatres on site. Should you require an urgent caesarean section or other specialist intervention, you would need to be transferred to a hospital obstetric unit, so it is worth asking about transfer times and pathways when making your decision.
  • Home birth: for low‑risk pregnancies, a home birth can reduce the likelihood of interventions, but for first time mothers, there is a small increase in the risk of serious complications for the baby when compared with a hospital birth. Higher transfer rates to hospital have been reported for first‑time mothers planning a home birth (around 45%)[1], as well as an increased rate for adverse outcomes for mother or baby when compared with care in an obstetric unit. Outcomes for women having a home birth for a second or third child however were similar across all birthing locations, and no increased risks were identified[2].

Fetal monitoring in labour (including CTG): what it tells us and what it cannot

Fetal monitoring during labour is used to assess how your baby is coping during labour, especially during contractions when the baby’s oxygen supply can fluctuate. It is one part of a wider assessment, and your medical team should always interpret fetal monitoring alongside:

  • your wellbeing (to include observations such as your temperature, pulse, and blood pressure and any symptoms that suggest infection, bleeding, or severe pain);
  • your contractions (how often they occur, how long they last, and whether they are becoming too frequent);
  • progress of labour (how the cervix is changing, baby’s position, and whether labour is progressing appropriately);
  • the baby’s heart rate pattern, checked either intermittently or continuously, depending on risk factors and preference.

There are two main ways your baby’s heart rate could be monitored during labour:

  • Intermittent auscultation (IA): your midwife will listen to your baby’s heartbeat at regular intervals (usually with a handheld Doppler or a Pinard stethoscope), rather than recording it continuously with a machine. Checks should happen at least every 15 minutes in the established first stage of labour, or every five minutes in the second stage. It is also important to check the maternal pulse, so the fetal heartbeat is not confused with the mother’s heartbeat, particularly in the second stage.
  • Continuous CTG monitoring: a CTG (cardiotocograph) is a monitor that provides an ongoing picture of the baby’s heart rate pattern alongside contraction frequency and duration over time. CTG monitoring is an extremely useful tool to help your medical team to identify patterns and any changes in these patterns which may indicate that the baby’s condition is changing or the baby is under stress (for example, signs that oxygen levels may be affected). CTG also helps to support decisions such as changing mum’s position, stopping or reducing oxytocin, treating suspected infection, seeking a senior review or expediting the birth if baby appears not to be coping. You may have continuous CTG monitoring if there are antenatal or intrapartum risk factors such as maternal fever, meconium, slow progress, epidural, and oxytocin use. Although CTG is useful, it could affect your birth experience as it may reduce your mobility and limit use of water in some circumstances. For women on CTG, NICE recommends that each hourly assessment is also reviewed in person by another clinician before the next assessment. This ‘fresh eyes’ approach is designed to reduce misinterpretation of CTG traces and support safer decisions.

Practical, empowering questions parents can ask in labour

Many parents find it helpful to have a few clarifying questions ready to ask their medical team when making decisions about birth choices and understanding more about their labour pathway. These questions can support shared decision making and reduce misunderstandings.

Examples of questions to consider include:

  • ‘What’s the plan right now – and what would make the plan change?’
  • ‘What are the benefits and downsides of induction/this intervention for me and my baby?’
  • ‘Are we low risk or higher risk at the moment, and does that change the recommended monitoring?’
  • ‘Can someone else take a ‘fresh eyes’ look at the CTG?’
  • ‘If we’re considering assisted birth, what are the options and what would make you stop and change approach?’
  • ‘If we need transfer (from home/birth centre), how will it happen and what timeframe are we expecting?’

Why independent advice can help if you have been offered an investigation (Maternity and Newborn Safety Investigations (MNSI) / Early Notification Scheme

If your labour/birth experience leaves you with unanswered questions, it can be appropriate to ask for a debrief with the maternity team and seek emotional and practical support.

If your baby has suffered an injury during your labour or birth, you may hear about:

  • MNSI investigations into term babies following labour (including intrapartum stillbirth, early neonatal death, or potential severe brain injury);
  • NHS Resolution’s Early Notification Scheme, which investigates specific brain injuries happening at birth to assess whether they were caused by negligent care and to support earlier decision making and learning.

These processes are designed for improved learning outcomes, safety improvement, and (in some situations) early legal triage, so families often find it helpful to have independent legal support in these situations to understand what is happening and what their choices are.

How medical negligence concerns can arise during labour

Labour can be unpredictable, and complications can occur even with good care. However, medical negligence claims and hospital investigations sometimes arise when care is alleged to have fallen below an acceptable standard and this is likely to have caused (or materially contributed to) avoidable harm to the mother or baby.

Common grounds for claims and investigations can include:

  • failure to monitor/act: failure to interpret fetal heart rate (CTG) monitoring, leading to hypoxia (oxygen starvation);
  • delayed intervention: unreasonable delay in performing a necessary caesarean section or instrumental delivery, leading to preventable harm;
  • mismanagement of labour: inappropriate use of induction drugs or failing to manage high-risk pregnancies, including when induction/augmentation leads to hyperstimulation of the uterus, or when new risk factors emerge (maternal fever, meconium, delay in labour);
  • physical trauma: incorrect use of forceps or ventouse, resulting in skull fractures, brachial plexus injuries (Erb’s palsy), clavicle fractures, nerve damage, or injury to the mother;
  • perineal tears: failing to identify or properly repair third or fourth-degree tears;
  • postnatal failures: negligence in care immediately following delivery.

When to seek legal advice after a difficult labour or birth

You may wish to seek legal advice when an injury to mum or baby is significant, ongoing, or when you are being informed about an internal investigation by the hospital trust.

You have three years to make a medical negligence claim from the date of the injury, or the ‘date of knowledge’ (when you first knew or reasonably could have known you had suffered a significant injury attributable to the care). This is referred to as the limitation date. For claims on behalf of children, a claim must be brought before their 21st birthday. If the injured person lacks mental capacity, then the three-year limitation period will not apply, unless they regain mental capacity at a later date (at which point the three-year limitation period countdown would begin).

You may decide to make a complaint to the hospital trust where you delivered your baby. This should be done within one year of the care/treatment you have concerns about. If you are not ready to make a complaint within 12 months because of trauma, grief, or ongoing neonatal care required for your baby, you can still contact the hospital trust and explain why you could not complain sooner.

You can choose to raise concerns informally at first, otherwise the trust’s Patient Advice and Liaison Service (PALS) team can provide you with support with making a complaint and communicating your concerns.

You may decide to make a formal complaint, which can be done in person, by phone, email or a letter to the hospital trust (or, in some cases, to the commissioning body/ICB). A formal complaint should include:

  • patient details (and consent if complaining on behalf of someone else);
  • dates/locations of treatment;
  • a clear summary of what went wrong;
  • and the outcome you want (explanation, apology, learning, meeting).

Many NHS complaint processes aim to acknowledge receipt (often within three working days), agree a plan and timescale with you, as well as keep you updated if that timescale changes.

If you are unhappy with the hospital’s response, you have the option to escalate your concerns to the Parliamentary and Health Service Ombudsman (PHSO) to independently review the complaint.

Action against Medical Accidents (AvMA) also produces guides to help families understand investigation pathways and the Early Notification process. More information and advice can be found at www.avma.org.uk.

This article is part of a series produced by our specialist maternity care team which considers the different types of care provided to expectant mothers, both during the antenatal period and labour, with a view to raising awareness, improving knowledge and empowering expectant mothers and their families.

 

[1] NPEU (University of Oxford), Birthplace in England – Key findings: ‘For women having a first baby… the peri‑partum transfer rate was 45% for planned home births…‘ https://www.npeu.ox.ac.uk/birthplace#the-cohort-study-key-findings, and Birthplace in England Collaborative Group: Perinatal and maternal outcomes by planned place of birth; BMJ 2011;343:d7400. This peer-reviewed study reports that ‘Transfers from non‑obstetric settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%).‘ https://www.bmj.com/content/343/bmj.d7400

[2] NPEU (University of Oxford), Birthplace in England – Key findings: ‘For multiparous women, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.’ https://www.npeu.ox.ac.uk/birthplace#the-cohort-study-key-findings, and Birthplace in England Collaborative Group: BMJ 2011;343:d7400. ‘For multiparous women, there were no significant differences in the incidence of the primary outcome event by planned place of birth.‘ https://www.bmj.com/content/343/bmj.d7400

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