Download MANAGEMENT OF NORMAL LABOUR AND PROLONGED

MANAGEMENT OF NORMAL LABOUR AND PROLONGED
LABOUR IN LOW RISK PATIENTS
Developed in response to:
Contributes to CQC Outcome
Consulted With
Anita Rao/
Alison Cuthbertson
Madhu Joshi
Sam Brayshaw
Alison Cuthbertson
Paula Hollis
Chris Berner
Ros Bullen-Bell
CLINICAL GUIDELINES
Register No: 09079
Status:
Public
Intrapartum NICE Guidelines
National Services Framework for Children, Young People and
Maternity Services. DoH: Maternity Matters
9, 12
Post/Committee/Group
Clinical Director for Women’s and Children’s Directorate
Consultant for Obstetrics and Gynaecology
Consultant Anaesthetist
Head of Midwifery/Nursing
Lead Midwife Acute Inpatient Services
Lead Midwife Clinical Governance
Acting Lead Midwife Community Services
Angela Woolfenden
Senior Midwife St Peters
Jo Gowers
Senior Midwife Antenatal Clinic
Wendy Patarou
Senior Midwife Labour Ward
Professionally Approved By
Miss Rao
Lead Consultant for Obstetrics and Gynaecology
Version Number
Issuing Directorate
Ratified By
Ratified On
Trust Executive Board Date
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by
Distribution Method
Related Trust Policies (to be
read in conjunction with)
Date
September 2015
September 2015
4.1
Obstetrics and Gynaecology
DRAG Chairmans Action
th
10 June 2016
June 2016
13 June 2016
May 2019
Sarah Moon, Specialist Midwife for Clinical Guidelines and Audit
Midwives, Obstetricians, Paediatricians
Intranet & Website.
09046 Guideline for the Completion of the Partogram in Pregnancy
04216 Guideline for the attachment and detachment of identification labels for the newborn
04270 Guideline for the Augmentation of Labour
04253 Guideline for the nutrition in labour and antacid prophylaxis for the pregnant patient at term.
04245 Guideline for the management of retained placenta
04265 Guideline for fetal monitoring in pregnancy
04237 Guideline for waterbirth, labour and delivery in water and third stage management
08095 Guideline for the administration vitamin K
07043 Guideline for abdominal palpation
09095 Guideline for the management of the severely ill pregnant patient
12030 Aromotherapy massage in pregnancy and labour
12029 Management of the latent phase of labour
Document Review History:
Version No
Authored/Reviewed by
Active Date
1.0
2.0
2.1
2.2
2.3
3.0
3.1
3.2
3.3
3.4
4.0
4.1
Nina Smethurst
Chris Berner
Clarification to point 24.3
Clarification to point 23.2
Clarification to passive second stage, point 23.6
Sarah Moon
Sarah Moon – clarification to point 22.1
Sarah Moon – clarification to point 24.0
Sarah Moon – clarification to point 40.0
Sarah Moon – clarification to points 24.6 and 24.7
Sarah Moon
Angela Woolfenden– clarification to point 17.9
August 2007
September 2009
February 2010
February 2010
November 2010
November 2012
December 2012
January 2013
February 2013
November 2013
th
13 June 2016
20 September 2016
1
INDEX
1.
Purpose
2.
Equality and Diversity
3.
Scope
4.
Definition
5.
Background
6.
The Key Professionals who Provide Antenatal Care
7.
The Booking Procedure
8.
Criteria for Choosing the Place of Birth
9.
Indications for a Consultant Led Unit Booking
10.
Considerations for a Consultant/Specialist Referral Regarding Individual
Assessment
11.
Indications for Intrapartum Transfer
12.
Self-diagnosis of Labour
13.
The Latent Phase of Labour
14.
Determining the Latent Phase
15.
Diagnosis of a Prolonged Latent Phase
16.
Treatment to Consider for the Prolonged Latent Phase
17.
Established Labour
18.
Coping Strategies
19.
Pain in Labour
20.
Regional Analgesia
21.
Normal Labour
22.
Initial Observations on Admission
23.
First Stage of Labour
24.
Observations during the first stage of labour
25.
Complicated Labour
26.
The Second Stage
27.
Delay in the Second Stage of Labour
2
28.
Observations in the Second Stage of Labour
29.
Management of a Delay in the Second Stage of Labour
30.
Intrapartum Intervention to Reduce Perineal Trauma during the Second Stage
31.
The Third Stage
32.
Observations in the Third Stage of Labour
33.
Delay in the Third Stage of Labour
34.
Care of the Patient Immediately following Delivery
35.
Inspection of the Perineum
36.
Care of the Baby Immediately after Birth
37.
Staff and Training
38.
Infection Prevention
39.
Supervisor of Midwives
40.
Audit and Monitoring
41.
Guideline Management
42.
Communication
43.
References
44.
Appendices
A.
Appendix A - Indications for a Consultant-led Unit Booking
B.
Appendix B - Considerations for a Consultant/Specialist Referral Regarding
Individual Assessment
C.
Appendix C - Delay in the first stage
D.
Appendix D - Delay in Second Stage
E.
Appendix E - Permissible time limits in normal labour-based on cervical dilatation
of 2cm in 4 hours
3
1.0
Purpose
1.1
To provide health care professionals with guidance regarding the management of healthy
patients and their babies who wish to undergo a normal vaginal delivery.
1.2
This guideline includes patients without co-existing morbidities (including previous uterine
surgery or complications of previous deliveries which may impact upon this delivery).
1.3
Patients need to have commenced labour spontaneously and who have a single healthy
fetus of between 37 and under 42 weeks of gestation. The fetus needs to be presenting
head first without any clinical confirmation of intrauterine growth retardation or
macrosomia
2.0
Equality and Diversity
2.1
Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is
fair, accessible and meets the needs of all individuals.
3.0
Scope
3.1
This guideline covers the care of healthy patients and babies at term (37-42 completed
weeks of gestation) in the following care settings:
•
Home births
•
In a Midwife-Led Unit (MLU)
•
In a Consultant-Led Unit (CLU); to include the Co-located Birthing Unit
4.0
Definition
4.1
Labour is a normal physiological process characterised by a spontaneous onset between
37 and 42 weeks in a patient whose pregnancy has been uncomplicated.
5.0
Background
5.1
The government is committed to ensuring that all patients will have a choice in where
and how they have their baby and whichever pain relief to use, depending on their
individual circumstances.
5.3
Maternity Services throughout the UK are aiming to increase the normal birth rate
towards a realistic objective of 60%. With appropriate care and support the majority of
healthy patients can give birth with a minimum of medical procedures and most prefer to
avoid interventions, providing that their baby is safe and they can feel that they can
cope.
5.4
Throughout her pregnancy the patient should be fully involved in planning her birth so
that care is flexible and tailored to meet her needs and those of her baby. Patients
should have the opportunity to make informed decisions regarding their care and any
treatment needed.
5.5
Decisions should be supported by the provision of evidence-based written information
tailored to the needs of the individual patient.
4
5.6
Maternity Services, senior staff and all health care professionals should ensure that in all
birth settings there is a culture of respect for each woman as an individual undergoing a
significant and emotionally intense life experience, so that the woman is in control, is
listening to and is cared for with compassion, and that appropriate informed consent is
sought.
5.7
Senior staff should demonstrate, through their own words and behaviour, appropriate
ways of relating to and talking about women and their birth companions and of talking
about birth and their choices to be made when giving birth
6.0
The Key Professionals who Provide Antenatal Care
6.1
The midwife - the midwife specialises in normal birth. By working across a variety of
health care settings, the midwife can provide optimal care for all patients regardless of
the place of delivery.
6.2
Patients in established labour receive one-to-one care from a midwife.
6.3
General practitioner - the general practitioner works in collaboration with the midwife
and the obstetric consultant providing overall care for the patient and her family.
6.4
The obstetrician - the obstetrician is the lead professional for all patients with confirmed
or suspected complications of pregnancy.
6.5
The Antenatal and Newborn Screening Coordinator - the role of the Antenatal and
Newborn Screening Coordinator is to coordinate antenatal screening services for
patients and health care professionals providing advice, support and counselling. To
contact the Antenatal and Newborn Screening Coordinator phone: 01245 513333
between the hours of 0900 -1700, Monday to Friday.
7.0
The Booking Procedure
7.1
Patients should be offered the choice of planning birth as follows:
•
•
•
7.2
At home
Midwife-led Unit (MLU)
Consultant –led Unit (CLU)
Patients should be informed of the following:
•
That giving birth is generally very safe for both the mother and her baby
•
Although the available information on planning the place of birth is not of good quality,
it suggests that there is a higher likelihood of normal birth, with less intervention for
those patients who plan to deliver at home or within a MLU.
•
Consideration needs to be given with regards to the time delay in transfer
•
That the CLU provides direct access to obstetricians, anaesthetists and
paediatricians.
•
That if something goes unexpectedly, seriously wrong during labour at home or in a
MLU, then the outcomes for the mother and baby could be worse than if they were in
the CLU with access to specialised care
5
8.0
Criteria for Choosing the Place of Birth
8.1
The clinical reasons for choosing a delivery at home or in a MLU are as follows:
•
Between 37 completed weeks and under 42 weeks of pregnancy
•
A low risk obstetric history
(Refer to appendix A)
•
A singleton pregnancy
•
A cephalic presentation
•
A baby of normal growth
•
The absence of abnormal bleeding or meconium per vaginum
9.0
Indications for a Consultant Led Unit Booking
9.1
Maternal indications
(Refer to appendix A)
10.0 Considerations for a Consultant/Specialist Referral Regarding Individual
Assessment
(Refer to Appendix B)
10.1
Patients who are referred to a consultant obstetrician or anaesthetist, or whose condition
has been referred to a paediatrician may resume the normal care pathway once their
condition has been assessed as appropriate for low risk care.
10.2
It should be made clear on the patient’s health care records whom the lead professional
is at all times. When patients are identified as requiring consultant led care the reason for
this must be stipulated on the antenatal notes at the end of the booking.
11.0
Indications for Intrapartum Transfer
(Consider likelihood of delivery during transfer)
11.1
Abnormalities or uncertainty regarding presence of the fetal heart rate (FHR)
necessitating continuous electronic fetal monitoring
(Refer to the ‘Guide for monitoring in pregnancy’. Register number 04265)
11.2
Delay in first, second or third stages of labour, retained placenta or significant meconium
stained liquor (dependent on risk factors).
11.3
Maternal request for epidural anaesthesia
11.4
Obstetric emergency (antepartum haemorrhage, cord presentation/prolapse, postpartum
haemorrhage, maternal collapse or need for advanced neonatal resuscitation.
11.5
Maternal pyrexia in labour (38.0˚c on one occasion or 37.5˚c on two occasions two hours
apart)
11.6
Malpresentation
6
11.7
Raised blood pressure:
•
Raised diastolic (over 90mmHg)
•
Raised systolic (over 140mmHg)
•
A rise of 15mmHg above the booking diastolic
•
A rise of 30mmHg above the booking systolic
On two consecutive readings taken 30 minutes apart
11.8
Third, fourth or complicated tears regarding specialist suturing or stronger anaesthesia.
12.0
Self-diagnosis of Labour
12.1
Patients may either contact their community midwife when they believe that labour has
commenced or directly contact the MLU’s or Labour Ward.
12.2
The community midwives may visit these patients at home to determine if labour is
established prior to either delivering at home or admission to the MLU’s or CLU.
12.3
Clinical intervention should not be offered where labour is progressing normally.
12.4
Patients should be encouraged to remain at home for as long as possible with analgesia,
light diet and relaxation techniques such as immersion in water
13.0
The Latent Phase of Labour
(Refer to the guideline entitled ‘Management of the latent phase of labour’; register
number 12029)
13.1
The latent phase is described as the phase prior to the active first stage of labour and
may last up to 12 hours in primigravid patients and 8 hours in multigravid patients.
During this phase the cervix dilates from 0 to 4cm and the cervical canal shortens from
3cm long to less than 0.5cm long.
14.0
Determining the Latent Phase
(Refer to the guideline entitled ‘Management of the latent phase of labour’; register
number 12029)
14.1
There is a history of regular contractions which may be inconsistent in strength and
duration but are described as painful
.
14.2
.
14.3
May have had a ‘show’
The membranes are intact.
14.4
There are changes in the effacement of the cervix 4 hours following the initial
assessment. (In false labour the primigravid cervix remains long or closed. The
multigravid cervix is not effaced, even though it may be 1-2 cm dilated).
15.0
Diagnosis of a Prolonged Latent Phase
(Refer to the guideline entitled ‘Management of the latent phase of labour’; register
number 12029)
7
15.1
After 12 hours of painful contractions in a primigravid patient and 8 hours in a
multiparous patient.
15.2
Contractions remain regular and painful, but continue to be inconsistent in strength and
duration.
15.3
The cervix is completely effaced (80% in multiparous patient) but remains about 2cm
dilated.
15.4
Underlying conditions such as urinary tract infection will need to be considered.
Studies have shown that patients admitted to hospital in the latent phase have higher
rates of obstetric intervention.
16.0
Treatment to Consider for the Prolonged Latent Phase
(Refer to the guideline entitled ‘Management of the latent phase of labour’; register
number 12029)
16.1
Encourage the patient to remain or stay at home to rest, offering support and
reassurance, ensure adequate analgesia is offered.
16.2
Encourage ambulation and adequate hydration.
16.3
Consider management in a CLU following informed choice regarding the care pathway,
such as amniotomy with active management and epidural anaesthesia.
17.0
Established labour
17.1
Support in labour - always maximise the communication between the patients and the
healthcare professionals.
17.2
Ensure an approach of warmth and calm, demonstrating confidence in both the patient
and her midwife.
17.3
Ensure that the patient and her partner have access to privacy, confidentiality and
dignity throughout their time with the health care professionals. Permission should be
sought before others enter the room.
17.4
Discuss the patient’s birth plan, involve her in care decisions and staff handovers.
17.5
Encourage the patient to adapt the environment to her individual needs including her
birth supporters.
17.6
Ensure consent is gained before all procedures are undertaken.
17.7
Ensure one-to-one midwifery is implemented throughout labour. If the health professional
needs to leave the room for a short period she will need to stipulate why and
demonstrate how assistance can be sought in her absence.
17.8 Do not leave a woman in established labour on her own except for short periods or at the
woman’s request.
17.9
Following assessment at the Midwife-led Unit during an antenatal/DAU appointment
where a woman booked for Consultant-led care is found to be in established labour. The
woman can be transported to Broomfield Hospital arranging her own transport if none of
the criteria in point 3.6 are present or if labour is not found to be advanced.
8
18.0
Coping strategies
18.1
Positions in labour – patients should be encouraged to adopt whichever position they find
most comfortable. Use of aids and labour supports must be appropriate.
18.2
Eating and drinking in labour - encourage drinking during labour; isotonic drinks may be
more beneficial than water. A light diet may be taken in established labour unless the
patient has received opioids or she develops risk factors making general anaesthesia
more likely. (Refer to guideline for the nutrition in labour and antacid prophylaxis for the
pregnant patient at term. Register number 04253)
19.0
Pain in Labour
19.1
Healthcare professionals should ensure that their care and attitudes with regards to pain
in labour supports the patient’s choices.
19.2
If a woman chooses to use breathing and relaxation techniques in labour, support her in
this choice.
19.3
If a woman chooses to use massage techniques in labour that have been taught
to birth companions, support her in this choice.
(Refer to the guideline entitled ‘Aromotherapy massage in pregnancy and labour’;
register number 12030)
19.4
The use of non-pharmacological analgesia i.e. homeopathic remedies or aromotherapy
oils.
(Refer to the guideline entitled ‘Aromotherapy massage in pregnancy and labour’;
register number 12030)
19.5
Offer women the choice to opportunity to labour in water for pain relief.
19.6
Submersion in water is recommended for pain relief.
(Refer to ‘Guideline for waterbirth, labour and delivery in water and third stage
management. Register number 04237)
19.7
For patients who wish to labour and birth in the birthing pool, the normal waterbirth
guidelines apply.
(Refer to ‘Guideline for waterbirth, labour and delivery in water and third stage
management. Register number 04237)
19.7
Transcutaneous electrical nerve stimulation (TENS) - this can be used throughout labour
in all birth settings (excluding waterbirths). Its commencement is not recommended in
established labour (i.e. if the cervix is dilated by 4cm or more).
19.8
Inhalational analgesia or entonox (50% nitrous oxide and 50% oxygen) can be used in all
birth settings. Patients should be informed that it may make them feel nauseous and
light-headed, but this is short lived.
19.9
Intramuscular opioids such as pethidine can be used in all birth settings. They will
provide limited pain relief during labour and may have significant side effects for both the
patient (drowsiness, nausea and vomiting, therefore administered with an anti-emetic)
and her baby (short-tem respiratory depression and drowsiness which may last several
days). Opioids may interfere with breastfeeding.
9
19.10 Do not use water papules.
19.11 Do not offer acupuncture, acupressure or hypnosis, but do not prevent women
who wish to use these techniques from doing so.
19.13 Encourage the woman to communicate her need for analgesia at any point
during labour.
19.14 Support the playing of music of the woman’s choice in labour.
20.0
Regional Analgesia
20.1
If a woman is contemplating regional analgesia, talk with her about the risks and
benefits and the implications for her labour, including the arrangements and time
involved for transfer of care to an obstetric unit if she is at home or in a midwifery unit.
20.2
Before choosing epidural analgesia, patients should be informed about the risks and
benefits and the implications for their labour. Patients should be informed that epidural
analgesia is:

Only available in the obstetric unit

Provides more effective pain relief than opioids

Is associated with a longer second stage of labour and in increased chance of a
vaginal instrumental birth

It is not associated with long-term backache

It is not associated with a longer first stage of labour or an increased chance of
caesarean birth.

It will be accompanied by a more intensive level of monitoring and intravenous access

Modern epidural solutions contain opioids which can cross the placenta in larger
doses (greater than 100 micrograms in total). This may cause short-term respiratory
depression in the baby and make the baby drowsy

Regional analgesia should not be denied to patients in whichever stage of labour
20.3
If a woman in labour asks for regional analgesia, comply with her request. This
includes women in severe pain in the latent first stage of labour.
21.0
Normal Labour
21.1
In all stages of labour, patients who have left the normal care pathway due to the
development of complications can return to it if or when the complications are resolved.
22.0
Initial Observations on Admission
22.1
When performing an initial assessment of a woman in labour, listen to her story and
review of the clinical records; and take into account her preferences and her emotional
and psychological needs.
10
22.2 The initial assessment by the midwife to determine if midwifery-led care in any setting is
suitable for the woman, irrespective of any previous plan. The assessment should
comprise of the following:
Observations of the woman:
•
Maternal and fetal assessment to be undertaken within 30 minutes of admission to
unit; once the woman has been shown to her bed or assessment area
•
Review of the antenatal notes (including all antenatal screening results) and discuss
these with the woman
•
Physical observation including temperature, blood pressure, pulse, respirations, and
undertake urinalysis
•
Ask the woman about her length, strength and frequency of her contractions which
should be documented in the health care records
•
Record any vaginal loss to include show, liquor and blood
•
Assessment of the patient’s pain, including her wishes for coping with labour along
with the range of options available for pain relief
•
Patients who are not in established labour but report painful contractions should be
offered support and analgesia. They should be encouraged to remain or return home.
Observations of the unborn baby:
•
Ask the woman about the baby’s movements in the last 24 hours
•
Abdominal palpation to include fundal height, lie, presentation, position and
station/engagement of the presenting part; and duration of contractions
(Refer to ‘Guideline for abdominal palpation’. Register number 07043)
•
The FHR (fetal heart rate) should be auscultated for 1 minute immediately after a
contraction for at least 1 minute; the maternal pulse should be palpated to differentiate
between the heart rates of the woman and the baby
•
A vaginal examination should be offered if either the patient appears to be in
established labour, or if after a period of assessment; and clearly not in established
labour
•
If there is uncertainty about whether the woman is in established labour, a vaginal
examination may be helpful after a period of assessment, but is not always necessary
•
If the woman appears to be in established labour, offer a vaginal examination
23.0
The first Stage of Labour
23.1
Do not offer or advise clinical intervention if labour is progressing normally and the
woman and baby are well.
23.2
In all stages of labour, women who have left the normal care pathway because of the
development of complications can return to it if/when the complication is resolved.
11
23.3
23.4
Labour is deemed established when there are:

Regular painful contractions,

There is progressive cervical dilatation from 4cm.
Risk assessment is an ongoing process throughout labour. When labour is deemed
established the midwife responsible for the patient should:

Undertake a risk assessment, encompassing a full review of the antenatal health care
records i.e. whether the patient is low or high risk (identifying the risk factors) and
document the findings in the healthcare records

If any risks are identified the midwife should refer the patient to the appropriate
professional for advice/review, develop or update an individual management plan;
which should be documented in the health care records

Where a referral is required and the midwife is unable to contact the health
professional concerned; this should be escalated to ensure that the identified risks are
addressed appropriately

All findings should be documented in the health care records contemporaneously by
the responsible health care professional.
23.5 Inform women that, while the length of established first stage of labour varies between
women:

First labours last on average 8 hours but are unlikely to exceed 18 hours

Second and subsequent labours last on average 5 hours but are unlikely to
exceed 12 hours

The length of labour will vary between individuals (Refer to Appendix D)

The cervix is expected to dilate:
> or equal to 2cm in 4 hours for first labours
> or equal to 2cm in 4 hours for second and subsequent labours

The head will rotate and descend

The contractions will remain frequent, strong and the duration of each contraction will
lengthen.
24.0
Observations during the First Stage of Labour
24.1
Obtain and review all health care records including ultrasound scans, blood results and
any relevant referral reports filed in the patient’s main notes.
24.2
Obtain history from the patient regarding the onset of labour and the description of any
loss per vaginum. Time and date of any reports of suspected or confirmed spontaneous
rupture of the membranes.
12
24.3 Record the following observations during the first stage of labour:
(Any observations regarding overall medical condition of the patient; this should be
recorded on the MEOWS chart, linked to the partogram in the Labour Care Record).
•
Half-hourly documentation of frequency of contractions
hourly pulse
•
4-hourly temperature, respirations and blood pressure
•
Frequency of passing urine
•
Offer a vaginal examination 4-hourly or if there is concern about progress or in
response to the woman's wishes (after abdominal palpation and assessment of
vaginal loss)
If any of the indications for transfer are met transfer the woman to obstetric-led care.
Follow the general principles for transfer of care described in the guideline entitled
‘Transfer of mothers and babies to different care settings’; register number 06029.
24.4
Undertake an abdominal palpation which will include palpation of the fundal height, lie,
presentation, position and station of the fetal head measured if fifths palpated above the
pelvis. Observe the abdomen for shape, any previous scars, and any specific areas of
tenderness. (Refer to ‘Guideline for abdominal palpation’. Register number 07043)
24.5
Contractions should be assessed and findings documented every 30 minutes.
Assessment of the contractions should include the length, strength and frequency.
24.6
The bladder should be emptied 4 hourly and a urinalysis performed; this should be
recorded on the MEOWS chart, linked to the partogram in the Labour care Record.
(Refer to the guideline entitled ‘Management of bladder care in maternity services’;
register number 09007)
24.7
In labour, the bladder should be emptied via intermittent catheterisation if women are
unable to void.
24.8
Best practice recommends that the midwife caring for the patient should assess the FHR
every 15 minutes after a contraction for at least 1 minute during the first stage of labour;
however, if the circumstances prevent this assessment occurring, the midwife should
refer to point 24.8
(Refer to the guideline entitled ‘Fetal heart rate monitoring in pregnancy and labour’
(04265)
24.9
If the midwife responsible for the patient is unable to assess the fetal heart rate as
stipulated in point 24.7, the following reasons should be documented in the patient’s
healthcare records as outlined below:
•
•
•
•
Vomiting
Out to the toilet
Patient declines assessment of FHR
Vaginal examination
24.10 Best practice recommends that the midwife caring for the patient should assess the FHR
every 5 minutes after a contraction during the commencement of the active phase of the
second stage of labour; however, if the circumstances prevent this assessment
occurring refer to point 24.8
13
24.11 The maternal pulse should be palpated hourly simultaneously with the FHR assessment
and recorded:
•
•
•
During labour, to ensure that the correct assessment of FHR is recorded
To monitor any deviations from the baseline assessment (maternal/fetal) on admission
If an abnormality is detected to be able to differentiate the two heart rates
These observations should be recorded in the health care records
24.12 Electronic fetal monitoring (EFM) via a cardiotogograph (CTG) is not recommended in
any birth setting.
24.13 Assess the patient’s pain, discussing her preferred coping strategies and advising on the
available methods of pain relief.
24.14 If the patient reports having intact membranes and she appears to be in established
labour a vaginal examination should be offered.
24.15 In normally progressing labour, do not perform amniotomy routinely.
24.16 Vaginal examination should be performed 4 hourly or where there is concern about
progress or in response to the patient’s wishes (after abdominal palpation and
assessment of vaginal loss). Obtain consent before examination, discuss findings after
the examination. Ensure privacy and dignity are maintained throughout.
24.17 Consideration should be given to the patient’s emotional and psychological needs,
including her desire for pain relief and this should be available throughout her labour.
24.18 Observations during the first stage of labour should be recorded in the healthcare
records by the midwife. (Refer to ‘Guideline for completion of the partogram in
pregnancy’. Register number 09064)
24.19 Do not offer either H2-receptor antagonists or antacids routinely to low-risk women.
25.0
Complicated Labour
25.1
If delay in the established first stage is suspected, assess all aspects of progress
in labour when diagnosing delay, including:

Cervical dilatation of less than 2cm in 4 hours for first labours

Cervical dilatation of less than 2cm in 4 hours for second and subsequent labours

Descent and rotation of the fetal head

Changes in the strength, duration and frequency of uterine contractions.
(Refer to appendix B)
25.2
If delay is diagnosed, transfer the woman to obstetric-led care.
25.3
If delay in the established first stage of labour is suspected, amniotomy should be
considered for all women with intact membranes, after explanation of the procedure and
advice that it will shorten her labour by about an hour and may increase the strength and
pain of her contractions.
14
25.4
Perform a vaginal examination 2 hours after the amniotomy, if the progress is less
than 1cm then a delay is diagnosed.
25.5
For women with intact membranes in whom delay in the established first stage of labour
is confirmed, advise the woman to have an amniotomy, and to have a repeat vaginal
examination 2 hours later whether her membranes are ruptured or intact.
25.6
When delay is diagnosed in the nulliparous patient, review from the obstetric registrar or
consultant should be sought; a decision about management options, including the use of
oxytocin; explain to her that using oxytocin after spontaneous or artificial rupture of the
membranes will bring forward the time of birth but will not influence the mode of birth or
other outcomes. All findings should be documented in the health care records
contemporaneously by the responsible health care professional. (Refer to ‘Guideline for
the Augmentation of Labour’. Register number 04270)
25.7
When delay is diagnosed in the multiparous patient, the obstetric registrar or consultant
will need to make a full assessment, including:
•
Parity
•
Abdominal palpation
•
Cervical dilatation and rate of change
•
Station and position of presenting part
•
Woman’s emotional state
•
Referral to the appropriate healthcare professional
25.8
Offer the woman support, hydration and appropriate and effective pain relief.
25.9
Abdominal palpation and vaginal examination before deciding if syntocinon® is to be
used and again all findings should be documented in the health care records
contemporaneously by the responsible health care professional.
25.10 Inform the woman that oxytocin will increase the frequency and strength of her
contractions and that its use will mean that her baby should be monitored continuously.
Offer the woman the use of an epidural before syntocinon® commences.
(Refer to ‘Guideline for the Augmentation of Labour’. Register number 04270)
25.11 A vaginal examination should be performed 4 hours after commencing syntocinon®) in
established labour. If the cervix has dilated less than 2cm after 4 hours of syntocinon®)
further obstetric review must be sought.
(Refer to Appendix C)
25.12 Continuous cardiotocograph (CTG) monitoring must be used throughout a syntocinon®)
infusion.
25.13 Either H2-receptor antagonists or antacids should be considered for women who receive
opioids or who have or develop risk factors that make a general anaesthetic more likely.
26.0
The Second Stage
26.1
Definition of the second stage of labour is when the cervix is fully dilated until complete
expulsion of the baby. It is defined in two stages.
15
26.2
Active second stage of labour :

The baby is visible

Persistent involuntary expulsive contractions with a finding of full dilatation of the
cervix or other signs of full dilatation of the cervix

Active maternal effort following confirmation of full dilatation of the cervix in the
absence of expulsive contractions
26.3
Passive second stage of labour is defined as full dilatation of the cervix prior to or
in the absence of persistent (occurring with every contraction) involuntary expulsive
contractions. This would be expected to last for no more than 1 hour in both nulliparous
and multiparous patients.
26.4
The duration of the second stage of labour in a nulliparous patient; the birth would be
expected to take place within 3 hours of the start of the active second stage.
26.5 In a parous patient the birth would be expected to take place within 2 hours of the start
of the active second stage.
(Refer to Appendix D)
26.6 After diagnosis of full dilatation in a woman with regional analgesia, agree a plan with the
woman in order to ensure that birth will have occurred within 4 hours regardless of parity.
26.7
Discourage the woman from lying supine or semi-supine in the second stage of
labour and encourage her to adopt any other position that she finds most comfortable.
26.8 Inform the woman that in the second stage she should be guided by her own urge to
push.
26.9 If pushing is ineffective or if requested by the woman, offer strategies to assist birth, such
as support, change of position, emptying of the bladder and encouragement
27.0 Delay in the Second Stage of Labour
(Refer to Appendix D)
27.1
In a nulliparous patient delay is diagnosed when the active second stage has reached
2 hours, at this point the patient should be referred to the obstetric registrar unless the
birth is imminent. All findings should be documented in the health care records
contemporaneously by the responsible health care professional.
27.2
CTG monitoring will need to commence after 2 hours of active pushing.
27.3
In a multiparous patient delay is diagnosed when the second stage has lasted I hour, at
this point the patient should be referred to the obstetric registrar unless the birth is
imminent. All findings should be documented in the health care records
contemporaneously by the responsible health care professional.
27.4
CTG monitoring will need to commence after 1 hour of active pushing
27.5
For patients without an epidural who have a fully dilated cervix and who do not have an
urge to push, a vaginal assessment should be undertaken 1 hour after full dilatation.
27.0
Observations in the Second Stage of Labour
16
28.1
Observations during the second stage of labour should be recorded in the healthcare
records by the midwife. (Refer to ‘Guideline for completion of the partogram in
pregnancy’. Register number 09064)

Hourly blood pressure and pulse

4 hourly temperature

Vaginal examination should be offered hourly in the active second stage or as the
patient wishes, acknowledging the fetal position and station at the onset of the second
stage; or in response to woman’s wishes

Abdominal palpation (with reference to the presentation and position of the baby) prior
to vaginal examination

Half-hourly documentation on the frequency and strength of contractions

Ensure bladder emptied at least 4 hourly and a urinalysis performed; record frequency
of passing urine

Observation on the colour and the amount of the liquor if membranes ruptured
28.2
Consideration should be given to the patient’s emotional and psychological needs,
including her desire for pain relief and this should be available throughout her labour
28.3
Assessment of progress should include maternal behaviour, effectiveness of pushing and
fetal wellbeing, taking into account fetal position and station at the onset of the second
stage and the subsequent descent of the presenting part. These factors will assist in
deciding the timing of further vaginal examination and the need for obstetric review.
28.4
Document the effectiveness of pushing, the patient’s position, behaviour and how she
feels she is managing her labour.
28.5
Intermittent auscultation of the fetal heart rate should occur after a contraction for at least
1 minute, every 5 minutes; to commence during the active phase of labour. The fetal
heart rate should be recorded in the Labour Care Record and following delivery the
partogram should be completed to include the following:
•
The time and mode of delivery
(Refer to the ‘Guideline for fetal monitoring in pregnancy. Register number 04265)
28.6
If an abnormality is detected in the FHR simultaneously palpate the maternal pulse
28.7
If unclear of the normality of the FHR-the CTG monitoring must commence.
28.8 On-going consideration should be given to the woman's position, hydration, coping
strategies and pain relief throughout the second stage
28.9
Patients should be discouraged from the supine and semi-supine positions. Employ the
use of different positions and birthing aids to maximise descent of the fetus and comfort
for the patient.
28.10 Patients should be informed that in second stage they should be guided by their own
urge to push.
17
29.0
Management of a Delay in the Second Stage of Labour
29.1
In a nulliparous patient, if after 1 hour of active second stage progress is inadequate,
delay is suspected. Amniotomy should be performed for intact membranes.
29.2
In multiparous patient, if after ½ an hour of active second stage progress is inadequate,
delay is suspected. Amniotomy should be performed where the membranes are intact.
29.3
Syntocinon infusion should be considered in nulliparous patient if the contractions are
inadequate at the onset of the second stage. NICE do not recommend the use of
oxytocin in parous patients.
29.4
If full dilatation of the cervix has been confirmed in a woman without regional analgesia,
but she does not get an urge to push, carry out further assessment after 1 hour.
29.5
Do not routinely use oxytocin in the second stage of labour for women with regional
analgesia.
29.6 Patients with confirmed delay in the second stage should be assessed by an obstetric
registrar or consultant. Oxytocin should not be started.
(Refer to Appendix D - permissible time limits in normal labour-based on cervical
dilatation of 2cm in 4 hours)
29.7
If there is delay in the second stage of labour, or if the woman is excessively distressed,
support and sensitive encouragement and the woman's need for analgesia/anaesthesia
are particularly important.
29.8
After initial obstetric assessment of a woman with delay in the second stage, maintain
on-going obstetric review every 15–30 minutes.
29.9
If the birth needs to be expedited for maternal or fetal reasons, assess both the risk to
the baby and the safety of the woman. Assessments should include:
• The degree of urgency
• Clinical findings on abdominal and vaginal examination
• Choice of mode of birth (and whether to use forceps or ventouse if an instrumental
birth is indicated)
• Anticipated degree of difficulty, including the likelihood of success if instrumental birth
is attempted
• Location
• Any time that may be needed for transfer to obstetric-led care
• The need for additional analgesia or anaesthesia
• The woman's preferences
Talk with the woman and her birth companion(s) about why the birth needs to be
expedited and what the options are. Inform the team about the degree of urgency. Inform
the team about the degree of urgency.
30.0
Intrapartum Intervention to Reduce Perineal Trauma during the Second Stage
30.1
Perineal massage should not be performed.
30.2
‘Hands on’ (guarding the perineum and flexing the baby’s head) or the ‘hands poised’
(with hands off but in readiness) techniques can be used.
18
30.3
For episiotomy technique: (Refer to ‘Guideline for Episiotomy’. Register number 07045)
•
Only perform for clinical need:
•
Suspected fetal compromise
•
To perform an operative delivery
30.4
An episiotomy should not be routinely offered at vaginal birth following previous third or
fourth degree trauma.
30.5
In order for the patient to make an informed choice, discussion regarding her future mode
of birth should encompass:
•
Current urgency or incontinence symptoms (urine, faeces and flatus)
•
The degree of the previous trauma
•
Risk of recurrence
•
The success of the repair undertaken
•
Psychological effects
•
Management of her labour
30.6
Patients with infibulated genital mutilation should be informed of the risks and difficulties
with vaginal examination, catheterisation and application of fetal scalp electrodes. There
is also a risk in delay in the second stage, spontaneous laceration, the need for an
anterior episiotomy and the need for difibulation in labour.
(Refer to the ‘Guideline for female genital mutilation. Register number 08040)
31.0
The Third Stage
31.1
The third stage of labour is the time from the birth of the baby to the expulsion of the
placenta and membranes.
31.2 Explain to the woman antenatally and during the initial assessment in labour about what
to expect with each package of care for managing the third stage of labour and the
benefits and risks associated with each. Active management of the third stage involves a
package of care comprising the following components:
• Routine use of uterotonic drugs deferred clamping and cutting of the cord controlled
cord traction after signs of separation of the placenta. Physiological management of
the third stage involves a package of care that includes the following components: no
routine use of uterotonic drugs no clamping of the cord until pulsation has stopped
delivery of the placenta by maternal effort.
31.3
Physiological management as follows:
•
Uterotonic (syntocinon or syntometrine®) drugs are not used
•
The cord is not clamped until the pulsations have ceased
•
The placenta is delivered by maternal effort
19
31.4
Explain to the woman that physiological management:
•
•
•
31.4
31.5
Active management as follows:
•
Use of uterotonic drugs (1ml of syntometrine®) intramuscularly or 5 units of syntocinon
given intravenously in the presence of hypertension and maternal cardiac problems);
•
Early clamping and cutting of the cord
•
Controlled cord traction
•
Guarding of the uterus
Explain to the woman that active management:
•
•
•
•
31.6
Is associated with nausea and vomiting in about 50 in 1000 women
Is associated with an approximate risk of 29 in 1000 of a haemorrhage of more than
1 litre
Is associated with an approximate risk of 40 in 1000 of a blood transfusion
Shortens the third stage compared with physiological management
Is associated with nausea and vomiting in about 100 in 1000 women
Is associated with an approximate risk of 13 in 1000 of a haemorrhage of more than1
litre
Is associated with an approximate risk of 14 in 1000 of a blood transfusion
Advise the woman to have active management of the third stage, because it is
associated with a lower risk of a postpartum haemorrhage and/or blood transfusion.
31.7 If a woman at low risk of postpartum haemorrhage requests physiological management
of the third stage, support her in her choice. Document in the records the decision that is
agreed with the woman about management of the third stage
31.8
Changing from physiological management to active management is indicated as follows:
•
Excessive bleeding of haemorrhage occurs
•
Failure to deliver the placenta within one hour
•
The patient’s desire to shorten the third stage
31.9 After administering oxytocin plus ergometrine, clamp and cut the cord. Do not clamp the
cord earlier than 1 minute from the birth of the baby unless there is concern about the
integrity of the cord or the baby has a heartbeat below 60 beats/minute that is not getting
faster. Clamp the cord before 5 minutes in order to perform controlled cord traction as
part of active management. If the woman requests that the cord is clamped and cut later
than 5 minutes, support her in her choice.
31.10 After cutting the cord, use controlled cord traction.
31.11 Perform controlled cord traction as part of active management only after administration of
oxytocin and signs of separation of the placenta.
31.12 Record the timing of cord clamping in both active and physiological management.
20
31.13 Advise a change from physiological management to active management if either of the
following occur:
•
Haemorrhage
•
The placenta is not delivered within 1 hour of the birth of the baby
31.14 Advise a change from physiological management to active management if either of the
following occur: haemorrhage the placenta is not delivered within 1 hour of the birth of the
baby.
31.15 Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage
of labour
(Refer to guideline entitled ‘Management of retained placenta’; register number 04245)
32.0
Observations in the Third Stage of Labour
32.1
Observations by a midwife of a patient in the third stage of labour should be documented
in the health care records and should include:
•
Estimating the amount of vaginal blood loss
•
Assessing the general condition of the mother i.e. her respirations, colour and her own
report of how she feels
•
In addition, where haemorrhage, retained placenta or maternal collapse diagnosed,
observations of the mother’s pulse, respiration rate, blood pressure and oxygen
saturation levels are required, to assess the need for resuscitation, ensuring all
findings are documented in the health care records. (Refer to the ‘Guideline for the
management of the severely ill pregnant patient’. Register number 09095)
33.0
Delay in the Third Stage of Labour
33.1
Delay is diagnosed if not completed within:
•
60 minutes of physiological management
•
30 minutes of active management
(Refer to Appendix D)
33.2
Ensure intravenous access is obtained; take bloods for group and save and a full blood
count.
33.3
In a patient where a delay in the third stage has been identified, referral to an obstetric
registrar or consultant should ensue. All findings should be documented in the health
care records contemporaneously by the responsible health care professional.
33.4
If there is postpartum haemorrhage, a retained placenta or maternal collapse, or
any other concerns about the woman's wellbeing: transfer her to obstetric-led care; carry
out frequent observations to assess whether resuscitation is needed.
33.5
Ensure adequate analgesia/anaesthesia is maintained and transfer into the Consultantled Unit.
33.6
For the management of a retained placenta refer to the ‘Guideline for the management
of retained placenta’. Register number 04245)
21
34.0
Care of the Patient Immediately following Delivery
34.1
Initial assessment of the mother:
•
Mother’s psychological wellbeing
•
Observations of blood pressure, pulse, respirations and temperature
•
Ensure that the uterus is contracted; observe any further loss per vaginum.
•
Examination of the placenta and membranes-assessment of their condition, structure,
cord vessels and completeness. Ensure correct disposal.
•
In terms of bladder care, the time and volume of the first void should be recorded in
the health care records
•
Re-inspect the perineum, if the mother complains of continued discomfort.
34.2 Recognise that the time immediately after the birth is when the woman and her birth
companion(s) are meeting and getting to know the baby. Ensure that any care or
interventions are sensitive to this and minimise separation or disruption of the mother and
baby.
35.0
Inspection of the Perineum
35.1
Repair of the perineum should be undertaken as soon as possible to minimise the risk of
infection and blood loss.
35.2
Patients should be advised of the following:
•
First degree trauma, that the wound should be sutured to improve healing, unless the
skin edges are well opposed.
•
Second degree trauma, that the muscle should be sutured to improve healing.
•
If the skin is well opposed following suturing of the muscle, there is no need to suture
it.
(Refer to guideline for ’Perineal repair’. Register number 07066)
36.0
Care of the Baby Immediately after Birth
(Refer to the ‘Guidelines for the Examination of the Newborn’ Register number 04225)
36.1
Record the APGAR score at 1 and 5 minutes (if born in a poor condition; at 1, 3, 5 and
10 minutes or until the baby’s condition is stable). Record the time from birth to regular
respirations
36.2
If there are any concerns regarding the babies wellbeing or for an operative delivery,
double clamp the cord 10cm apart immediately after delivery to allow paired blood gases
to be obtained. Continue to evaluate and record the baby’s conditionuntil it is improved
and stable. Do not take paired cord samples routinely. Ensure a double clamp for paired
cord blood samples is available in all care settings
36.3
Skin-to-skin bonding should be initiated immediately after delivery, covering the baby
with a warm dry towel and a hat.
22
36.4
Initiate breast-feeding, ideally within one hour of birth.
36.5
Avoid separation of the baby from the mother within the first hour after birth for routine
procedures (weighing, checking and labelling) unless the mother requests it or the baby’s
condition is concerning. Undertake an initial examination to detect any major physical
abnormality and identify any problems that may need referral.
36.6
An initial examination of the newborn is to be undertaken with parental consent, to detect
any abnormalities and to identify any problems that may require referral.
36.7
Take measurements of the head circumference, weight (undressed) in kilograms, axilla
temperature, apply two identity ankle bracelets writing on each the mother’s name and
the baby’s date of birth and sex soon after the first hour following birth (include the baby’s
hospital number if referral to the NNU is required). (Refer to ‘Guideline for the
attachment and detachment of identification labels for the newborn. Register number
04216)
36.8
Administer vitamin K 1 mg intramuscularly with prior parental consent. (Refer to
‘Guideline for the administration vitamin K’. Register number 08095)
37.0
Staffing and Training
37.1
All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training.
37.2
All midwifery and obstetric staff are to ensure that their knowledge and skills are
up-to-date in order to complete their portfolio for appraisal.
38.0
Infection Prevention
38.1
All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively ‘decontaminate their hands’ before and after each procedure.
38.2
Normal warm tap water is to be used for cleansing prior to vaginal examination. Normal
infection prevention and control measures are to be taken in compliance with Trust
guidelines.
38.2
All staff should ensure that they follow Trust guidelines on infection prevention. All
invasive devices must be inserted and cared for using High Impact Intervention
guidelines to reduce the risk of infection and deliver safe care. This care should be
recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork
(Medical Devices).
39.0
Supervisor of Midwives
39.1
The supervision of midwives is a statutory responsibility that provides a mechanism for
support and guidance to every midwife practising in the UK. The purpose of
supervision is to protect women and babies, while supporting midwives to be fit for
practice'. This role is carried out on our behalf by local supervising authorities. Advice
should be sought from the supervisors of midwives are experienced practising midwives
who have undertaken further education in order to supervise midwifery services. A 24
hour on call rota operates to ensure that a Supervisor of Midwives is available to advise
and support midwives and women in their care choices.
40.0
Audit and Monitoring
23
40.1
Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual
audit work plan; to encompass national and local audit and clinical governance
identifying key harm themes. The Women’s and Children’s Clinical Audit Group will
identify a lead for the audit.
40.2
As a minimum the following specific requirements will be monitored:
•
•
•
•
•
•
•
Maternal observations to be carried out on admission
Maternal observations to be carried out during established first stage of labour
Maternal observations to be carried out during second stage of labour
Maternal observations to be carried out during third stage of labour
Documentation of all of the above maternal observations
Guidance on duration of all stages of labour
Guidance on referral to obstetric care
•
Timing of the clinical risk assessment in all care settings
•
Medical conditions to be considered, including anaesthetic history
•
Factors from previous pregnancies
•
Lifestyle history to be considered
•
Risk assessment for appropriate place of birth
•
Documentation of an individual management plan when risks are identified during the
clinical risk assessment
•
Process for referral of women when risks are identified during the clinical risk
assessment
•
Documentation of all the above, where clinically relevant
40.3
A review of a suitable sample of health records of patients to include the minimum
requirements as highlighted in point 40.2 will be audited. A minimum compliance 75% is
required for each requirement. Where concerns are identified more frequent audit
will be undertaken.
40.4 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will be
developed to address any identified deficiencies. Performance against the action plan will
be monitored by this group at subsequent meetings.
40.5
The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.
40.6
Key findings and learning points from the audit will be submitted to the Clinical
Governance Group within the integrated learning report.
40.7
Key findings and learning points will be disseminated to relevant staff.
41.0
Guideline Management
24
41.1
As an integral part of the knowledge, skills framework, staff are appraised annually
to ensure competency in computer skills and the ability to access the current
approved guidelines via the Trust’s intranet site.
41.2
Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.
41.3
Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.
41.4
Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During
this meeting the practice development midwife can highlight any areas for further
training; possibly involving ‘workshops’ or to be included in future ‘skills and drills’
mandatory training sessions.
42.0
Communication
42.1
A quarterly ‘maternity newsletter’ is issued and available to all staff including an update
on the latest ‘guidelines’ information such as a list of newly approved guidelines for staff
to acknowledge and familiarise themselves with and practice accordingly.
42.2 Approved guidelines are published monthly in the Trust’s Focus Magazine that is sent via
email to all staff.
42.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.
42.4 Regular memos are posted on the guideline notice boards in each clinical area to notify
staff of the latest revised guidelines and how to access guidelines via the intranet or
clinical guideline folders.
43.0
References
National Institute for Health and Clinical Excellence, Intrapartum care
care of healthy women and their babies during childbirth (2014) CG190 London.
December.
C Barnett, V Hundley, H Cheyne, F Kane (2008). Not in Labour: Impact of sending
women home in the Latent Phase. British Journal of Midwifery,16 (3), p144 – 153.
Department of Health: Maternity Matters: Maternity matters: choice, access and
continuity of care in a safe service (2007). London.
National Childbirth Trust, Royal College of Midwives, Royal College of Obstetricians:
Making Normal Birth a Reality (2007)
National Institute for Health and Clinical Excellence: Induction of Labour Guidelines
(2008). London.
http://www.nice.org.uk/nicemedia/pdf/CG070FullGuideline.pdf
25
26
Appendix A
Indications for a Consultant Led Unit Booking
Maternal indications
Respiratory
Cardiovascular
Asthma requiring a ‘step-up’ in treatment of
hospital treatment within the last year
Cardiac disease
Hypertensive disorders
Cystic fibrosis
Renal
Gastro-intestinal
Renal disease requiring supervision by a renal
specialist
Liver disease
Abnormal renal function
Crohn’s disease
Ulcerative colitis
Recurrent infection
Infective
Haematological
TB-under treatment
Haemoglobinopathies such as beta
Thalassaemia major, sickle-cell disease
HIV-carrier and infected
Sexually transmitted disease
Hepatitis B/C with abnormal liver function tests
Toxoplasmosis if occurs when pregnant
Chicken pox if occurs when pregnant
Rubella-if pregnant
Genital herpes if pregnant
Group B streptococcus
Family history of previous thromboembolism
Evidence of or suspected
thromboembolitic disorders
Suspected thrombocytopaenia, a platelet
count below 100,000 or abnormal platelet
formation
Von Willibrand’s disease
Bleeding disorders in the woman or the
unborn baby
Immune
Endocrine
Rheumatoid arthritis
Thyroid disorders
SLE (systemic lupus erethromatosis)
Diabetes or previous history of gestational
diabetes or current gestational diabetes
APS (antiphosphoid antibody syndrome)
Scleroderma
Other significant disorders e.g. Cushing’s
disease
Other connective tissue disease.
27
Neurological
Psychiatric disease
Epilepsy
Substance misuse
Myasthenia gravis
Alcohol dependency requiring
assessment or treatment.
Spinal abnormalities
Previous cerebrovascular accident
Neurological defects
Body Mass Index greater than 35 at
booking
Disorders requiring current inpatient care.
Anaesthesia risk
Surgical
Known airway problems
Myomectomy
History of drug
Hysterectomy
Latex allergy
Spinal surgery
Spinal abnormalities
Vascular surgery
Previous fractured pelvis
Obstetric problems
Obstetric problems
Previous complications
Current pregnancy
Previous still birth/neonatal death
Multiple pregnancy
Previous baby with neonatal encephalopathy
Unstable lie
Pre-eclampsia requiring pre-term delivery
Malpresentation
Eclampsia/HELLP syndrome
Placenta praevia
Uterine rupture
Recurrent antepartum haemorrhage
Placental abruption with adverse outcomes
Placental abruption
Primary postpartum haemorrhage requiring
additional treatment or blood transfusion.
Pre-term (less than 37 weeks gestation)
Retained placenta requiring manual removal in
theatre
Caesarean section
Obstetric cholestasis
Babies >4.5 kg
Shoulder dystocia
Fetal indications
Rhesus disease
Atypical antibodies
Confirmed uterine death
Pre-eclampsia or pregnancy induced
hypertension BP >140/90 or 15mmhg
above booking diastolic or 30mmhg
above booking systolic.
Proteinuria >+1on dipstick (30mg of
protein)
Epigastric pain
Pre-term rupture of the membranes
Pre-labour rupture of the membranes
Induction of labour
Anaemia Haemoglobin less than 8.5 g/dl
at the onset of labour
Seizures
Maternal age of less than 16 or > 40
28
Appendix B
Considerations for a Consultant/Specialist Referral Regarding Individual Assessment
Disease area
Medical condition
Cardiovascular
Cardiac disease without intrapartum implications
Haematological
Atypical antibodies which are not putting the baby at risk of
haemolytic disease
Sickle cell trait
Thalassaemia trait
Anaemia-haemoglobin of 8.5-10.5 g/dl at onset of labour
Infective
Hepatitis B/C with normal liver function tests
Immune
Non-specific connective tissue disorders
Endocrine
Unstable hyperthyroidism such that a change in treatment is
required
Skeletal/ neurosurgical
Spinal abnormalities
Previous fractured pelvis
Neurological deficits
Gastrointestinal
Liver disease without current abnormal liver function
Crohn’s disease
Ulcerative colitis
Previous complications
Stillbirth/neonatal death with a known non-recurrent cause
Pre-eclampsia developing at term
Placental abruption with good outcome
History of a previous baby more than 4.5kg
Extensive vaginal, cervical,or third or fourth degree perineal
trauma
Previous term baby with jaundice requiring exchange transfusion.
Fetal indications
Fetal abnormality
Previous gynaelogical history
Major gynaecological surgery
Cone biopsy or large loop excision of the transformation zone
Fibroids
Social reasons
Women who may need protection from domestic abuse
Women whose babies need a child protection strategy plan
Women who may require the services of an interpreter.
29
Delay in the First Stage
Appendix C
Definition of delay in the first
stage
Consider also:
Descent and rotation of the
fetal head
Changes in strength,
duration and frequency of
the uterine contractions.
Station and position of the
presenting part
Woman’s emotional state
Nulliparous: <2cm
dilated in 4 hours
Parous: <2 cm
dilatation in 4 hours
or a slowing in
progress
Delay suspected: consider Amniotomy (ARM) if membranes intact-advice VE 2
hours later
Progress >1cm
manage as normal
Progress < 1cm= delay
Continuous EFM
Analgesia
Syntocinon
Offer epidural
If membranes
ruptured
If membranes intact
advise amniotomy.
Repeat VE in 2 hours
Progress < 1cm
Increase every
30 min until 4-5
contractions in
10 min are
achieved
Progress > 1cm continue
normal management
Nulliparous
Consider syntocinon following
spontaneous rupture of
membranes (SRM) or ARM
Parous
-Abdominal palpation
-vaginal examination (VE)
Before considering syntocinon
Vaginal examination 4 hours after
commencing syntocinon when
labour is established
Progress > 2 cm: VE
hourly
Progress < 2cm, consider
caesarean section
30
Appendix D
Delay in the second stage
Nulliparous: delay suspected if inadequate
progress after 1hr of active second stage
Offer vaginal
examination,
Offer amniotomy
Offer analgesia
Birth within 1 hr
Return to normal
management
No birth within next
hour (total active
second stage = 2
hours
Parous:
active
second =
1 hour
Diagnosis of delay in the second stage
Assessment and ongoing review every 15-30 min by obstetric
registrar/consultant
Good progress-return to
normal management
Birth: return to
normal
management
Consider instrumental delivery if concerned re:
fetal wellbeing or for prolonged second stage.
-Advise caesarean section if vaginal birth is not
possible
-Birth expected to take place within 3 hours of
the start of the active second stage for
nulliparous patients, and 2 hours for parous
patients
Instrumental birth: Use effective anaesthesia
-if declined or concerned re: fetal wellbeing
-use pudendal block with local anaesthesia to the perineum
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Appendix E
Permissible time limits in normal labour-based on cervical dilatation of 2cm in 4 hours
Labour
First stage of labour
Nulliparous
Multiparous
12 hours
12 hours
1 hour
1 hour
2 hours
1 hour
Amniotomy after 1 hour
Amniotomy after 30
minutes
Epidural
1 hour
1 hour
Third stage
I hour
1 hour
physiological
30 mins
30 mins
17.30 hours
16.30 hours
Second stage of labour
Passive stage
Active stage
active
Total
32