The active phase of first stage labor is generally defined as the period between 3 cm to 4 cm to complete cervical dilatation, in the presence of regular uterine contractions. Most women will experience this portion of labor within hospital obstetric units, where care commonly features restriction to bed, electronic fetal monitoring, early treatment of "slow" labors, and few pain management options beyond epidurals and narcotics. However, the available evidence on appropriate care for healthy childbearing women favors activity in labor, intermittent auscultation, patience from caregivers, and nonpharmacologic methods of pain relief. This article reviews the evidence for care practices that support physiologic labor. Modifying intrapartum care to reflect current evidence will improve women's health, and will require a multilevel approach and consistent midwifery demonstration of the model.