Launceston General Hospital Clinical Guidelines P2010/0484-001 2.

1-07WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Care of Normal (Low Risk) Women in Labour Management of Normal Labour 2.1 Midwifery care of women during normal, low risk, labour and birth Midwifery and Medical Staff, Queen Victoria Maternity Unit Labour, birth, first stage, second stage, third stage P2010/0490-001 Group B Streptococcus P2010/0486-001 Intrapartum Fetal Monitoring P2010/0506-001 Intradermal Sterile Water Injections P2010/0488-001 Perineal Repair P2010/0496-001 Management of Post Partum Haemorrhage P2010/0503-001 Retained Placenta P2010/0382-001 Care of the Well Newborn P2010/0301-001 Peripartum Bladder Management Principles: Labour and birth is considered to be a normal physiological process until established otherwise There should be a valid reason before intervening with the natural process of normal labour and birth The midwife is responsible for providing woman centred care for women during a normal labour and birth Communication, collaboration and cooperation between the professional groups, the woman and her partner/family, underpins optimal care for the woman Risk can change during labour and referral to the obstetric registrar or consultant for ongoing obstetric management may be required. Midwives will consult and refer women in accordance with the Australian college of Midwives National Midwifery Guidelines for Consultation and Referral (Appendix 2). Woman requiring obstetric management of their labour (high risk) will have a detailed obstetric management plan documented by the obstetric registrar or consultant. Admission Assessment Review current pregnancy history, maternal blood group, Hb, allergies, Group B streptococcus status. Baseline maternal observation temperature, pulse, blood pressure, urinalysis. Abdominal palpation - fundal height, lie, presentation, position and station. Length, strength and frequency of contractions. Vaginal loss (show, liquor, blood).
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Assessment of fetal wellbeing including documentation of recent fetal movement and auscultation of fetal heart rate. The fetal heart rate should be auscultated for a minimum of one minute immediately after a contraction. The maternal pulse should be palpated to differentiate between maternal and fetal heart rate. Admission CTG is not recommended for low risk woman in labour (as per Intrapartum Fetal Monitoring Clinical Guideline). If requested by the woman, or considered appropriate by the clinician, a vaginal examination may be performed. If, after 4 hours, birth is not imminent a vaginal examination should be carried out to determine whether the woman is in established labour. Notify Midwife-in-charge of the Maternity Unit of admission. The obstetric registrar or consultant and RMO should be made aware of the admission but are not necessarily involved in the care of the low risk woman

Women who seek advice or present with painful contractions but who are not in established labour should be offered individualised support and encouraged to remain at or return home. The antenatal ward would be a suitable alternative for women who do not feel comfortable to go home. ACTIVE FIRST STAGE OF LABOUR Monitoring Maternal Wellbeing during the First Stage of Labour The midwife will assess and document findings on the partogram and notify the obstetric registrar or consultant if any delay in the progress of labour or changes in maternal or fetal observations. Temperature - 4 hourly Pulse - hourly Blood Pressure - 4 hourly Urinalysis: 4 hourly Fluid input / output: o Encourage oral fluids o Diet as desired o Encouraged regular 2 3 hourly voiding. A full bladder is uncomfortable and may inhibit the progress of labour by inhibiting the decent of the presenting part and effective uterine action o Where there is a palpable bladder and the woman is unable to void, consider urinary catheterisation. Monitoring Fetal Wellbeing during the First Stage of labour Fetal heart rate (FHR) assessment by intermittent auscultation every 30 minutes, using a hand held Doppler with signal on speaker, after a contraction for a minimum of 60 seconds as per Intrapartum Fetal Monitoring Clinical Guideline. Continuous electronic fetal monitoring (EFM) should be commenced and the obstetric registrar or consultant informed: o if there is evidence on auscultation of a baseline rate of less than 110 beats per minute (bpm) or greater than 160 bpm. o if there is evidence on auscultation of any decelerations o if any intrapartum risk factors develop. Vaginal loss - hourly assessment of liquor colour if membranes are ruptured. Monitoring the Progress of Labour Contractions should be palpated and documented at least half-hourly for frequency, duration, strength and resting tone.

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Abdominal palpation should be carried out four hourly or prior to vaginal examinations to confirm the lie remains longitudinal, the position of the fetus, and that the presenting part is progressively descending. Vaginal examination frequency should be individualised and performed regularly enough to assess progress and identify problems early. Vaginal examination should be performed four hourly or if the woman is requesting pharmacological pain relief. More frequent examinations should not be performed unless indicated eg. delay in labour, suspected fetal compromise.

Artificial Rupture of Membranes (ARM) ARM should not be performed routinely. Where there is a delay in the progress of labour the obstetric registrar or consultant should be informed. An ARM may be performed after consultation by an experienced midwife or under the supervision of an experienced midwife, obstetric registrar or consultant if: confident that the presentation is cephalic the presenting part is at station -1 or lower the women is in labour (cervix is > 4 cm dilated). Non Pharmacological Pain Relief Relaxation / Breathing Techniques / Massage Positioning and Movement Temperature Modulation: Hot or cold packs, hot or cold water Immersion in Water Transcutaneous Electrical Nerve Stimulation Intradermal Sterile Water Injections by an accredited midwife (as per Intradermal Sterile Water Injections WACSClinProc 2.25) Aromatherapy, hypnosis, herbal preparation. acupuncture Pharmacological Pain Relief Nitrous Oxide (Entonox, N2O+O2) Mothers should be instructed in the self administration of Nitrous Oxide in labour. It should be given at least 20 seconds before the onset of a contraction in order to be fully active. The concentration is commenced at the lowest rate and should not exceed 70% nitrous, 30% oxygen. Side effects associated with the administration of nitrous oxide include hyperventilation, nausea and dehydration. Woman using nitrous oxide in the bath must be supervised at all times. Morphine In accordance with the General Orders midwives are permitted to administer a single dose of Morphine 5 mg to patients in labour. The assessment of the dose and its timing is made by the midwife and/or medical officer. Assessment of the stage of labour by clinical (vaginal) examination is essential before Morphine is given. Morphine should be given in conjunction with metoclopramide 1 dose 10 mg IM (In accordance with General Orders). Subsequent dosage should be administered with the approval of the medical staff and a written order on the Drug Chart. It is important to note that the maximum absorption of Morphine by the fetus occurs at approximately 2 hours post maternal administration and this should be taken into consideration in the timing of the dose in relation to the expected time of birth. SECOND STAGE OF LABOUR Monitoring Maternal Wellbeing during the Second Stage of Labour Continue as for the first stage of labour. Monitoring Fetal Wellbeing during the Second Stage of Labour
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Intermittent auscultation of the fetal heart should be by hand held doppler on speaker mode after a contraction for a minimum of 60 seconds every 5 minutes in the absence of active pushing and after each contraction with active pushing. Continuous electronic fetal monitoring should be commenced if abnormal fetal heart rate detected.

Assessing the Progress of Second Stage of Labour The midwife will assess for: The presence of regular, effective, expulsive uterine contractions and Descent of the fetal head. The obstetric registrar or consultant should be notified: after an hour of pushing in nulliparous women half an hour of pushing in parous women in the absence of progress any change in the fetal or maternal observations. Positions in Second Stage Women should be discouraged from remaining supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable Women who do not have a preference or who have had a previous precipitate delivery should be encouraged to birth in the left lateral position. Pushing in the Second Stage During the descent phase, descent of the fetal head should occur naturally. Directed sustained pushing with contractions, including holding of breath should be discouraged as it is not beneficial to the fetus, mother and progress of second stage During the active phase, women will have the urge to push. Midwives will provide support to women as they establish their own pattern of pushing If pushing is ineffective or if requested by the woman, strategies to assist birth can be used, such as support, change of position and encouragement. Intrapartum Perineal Massage Perineal massage should not be performed in the second stage of labour Routine versus Restricted Use of Episiotomy A routine episiotomy should not be carried out during spontaneous vaginal birth. A mediolateral episiotomy should be performed if there is a clinical need such as suspected fetal compromise or anticipated severe perineal trauma. Adequate pain relief should be provided prior to carrying out an episiotomy. Midwives may infiltrate the perineum with Lignocaine 1% 20ml (as per General Orders). MANAGEMENT OF THIRD STAGE OF LABOUR Active management of the third stage of labour is recommended for all women. The risk of PPH can be reduced by 50% with routine administration of oxytocic drugs as part of active third stage management. Active Management (Low Risk) Administration of a prophylactic oxytocic agent (Syntocinon 10 unit IMI at the birth of the baby with the anterior shoulder, as per General Orders). Early cord clamping
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Prepare to birth the placenta and membranes Controlled cord traction, and Birth the placenta and membranes.

The obstetric registrar or consultant should be informed if the placenta is not delivered after 30 minutes and management as per Retained Placenta Clinical Guideline WACSClinProc2.33. If blood loss is more than 500ml then management as per Management of Post Partum Haemorrhage Clinical Guideline WACSClinProc2.9 Assessment of Perineal/Genital Trauma explain the need for inspection to the woman offer inhalation analgesia if required the womans position should be one of comfort but also one that allows for the structures to be visualised adequately appropriate lighting conduct a careful and gentle examination, both external and internal genitalia Accredited midwives may repair first or second degree tears (as per Episiotomy and Perineal Repair WACSClinProc2.5) or notify RMO if repair is required. Adequate analgesia following perineal trauma. Postnatal Care Maternal observations Offer refreshments or meal Assist/supervise shower Encourage woman to void and monitor for first void. Documentation partogram, obstetric summary, perinatal data collection, commence vaginal birth clinical pathway. Transfer to the postnatal ward or discharge home on EMS. Attachments
Attachment 1 Attachment 2 Attachment 2 Attachment 3

Definitions ACM National Midwifery Guidelines for Consultation and Referral Physiological Management of Third Stage References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services
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Stakeholders: Developed by:

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Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 DEFINITIONS Normal birth WHO defines normal birth as: "spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition". Low risk A pregnant woman is considered low risk when no risk factors have been identified during the antenatal and intrapartum. Assessment of risk is ongoing. Labour Painful, regular contractions, associated with effacement and/or dilation of the cervix Active labour Painful, regular contractions Descent of the presenting part Cervix is fully effaced, dilatation is 3 cm and progressively dilating With or without spontaneous rupture of membranes. Normal Progress In the presence of painful, regular uterine contractions (and no identified risk factors), the progress of labour is assessed as normal when there is: Descent of the presenting part, and/or At least 2cm additional dilatation within 4 hours of the previous vaginal examination The duration of established labour varies from woman to woman, and is influenced by parity. Progress is not necessarily linear. In established labour, most women in their first labour will reach the second stage within 18 hours without intervention. In their second and subsequent labours, most women will reach the second stage within 12 hours without intervention. (NICE 2006 p.393) Delay in the first stage of labour (NICE 2006 p.395) A diagnosis of delay in the first stage of labour needs to take into consideration all aspects of progress in labour and should include: cervical dilatation of less than 2 cm in 4 hours for first labours cervical dilatation of less than 4 cm in 4 hours for second or subsequent labours descent and rotation of the fetal head changes in strength, duration and frequency of uterine contractions. Second Stage of Labour Commences at full dilation and ends at the birth of the baby. Onset of second stage (descent) Full dilatation of the cervix may become evident: Prior to the descent of the fetal head to the pelvic floor, or When the fetal head has reached the pelvic floor. The midwife will assess and document signs and the time of onset of the second stage of labour including: The woman experiences an urge to 'bear down Membranes may rupture spontaneously Confirmation of full cervical dilatation by vaginal examination is recommended when there is doubt a woman has achieved full dilatation.
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Pushing prior to full dilatation can result in maternal exhaustion, cervical trauma and possibly increased instrumental births. Active second stage of labour: involuntary expulsive contractions, and the baby is visible or there are signs of full dilatation of the cervix, or there is active maternal effort, following confirmation of full dilatation of the cervix, in the absence of expulsive contractions. Third Stage of labour The time following the birth of the baby to the expulsion of the placenta and membranes

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ATTACHMENT 2 INDICATIONS DURING LABOUR FOR OBSTETRIC REFERRAL Gestational hypertension Preterm labour <36 completed weeks Preterm prelabour rupture of membranes (PPROM) before 36 completed weeks Prolonged rupture of membranes Abnormal presentation Breech presentation Meconium stained liquor Suspected placenta abruption and/or previa Pre-eclampsia Pyrexia Active genital herpes at time of labour Multiple pregnancy Confirmed non-reassuring fetal heart rate patterns Prolonged active phase Prolonged second stage Unengaged head in active labour in primipara Prolapsed cord or cord presentation Vasa praevia Shoulder dystocia Uterine rupture Third or fourth degree perineal tear Retained placenta Uterine inversion Postpartum haemorrhage > 1000ml Fetal death during labour Shock

Australian College of Midwives National Midwifery Guidelines for Consultation and Referral Full document available online at: http://www.midwives.org.au/ForMidwives/PracticeGuidelines/tabid/308/Default.aspx

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ATTACHMENT 3 PHYSIOLOGICAL MANAGEMENT OF THE THIRD STAGE OF LABOUR Active management of the third stage of labour is recommended for all women. The risk of PPH can be reduced by 50% with routine administration of oxytocic drugs as part of active third stage management. All women should be fully informed of the current evidence regarding benefits and harms of active and physiological management of the third stage of labour. This includes the recommended use of oxytocics for the prevention of PPH and associated side effects and risks. Physiological management of the third stage of labour is suitable only for healthy low risk women who have had a normal labour and birth and who have declined active management of third stage. Procedure: Do not administer Syntocinon at birth Do not clamp the cord unless clinically indicated (cord around babys neck or active resuscitation required. Continually observe the woman and her blood loss, assessing the need for active management Wait for signs of separation and descent of the placenta: o Small fresh blood loss o Lengthening of the cord o Fundus becomes rounded, smaller and palpable below the umbilicus Allow the placenta and membranes to be birthed by maternal effort Maternal positioning, such as squatting or sitting, by utilising the forces of gravity, will aid expulsion. If the placenta and membranes remain in-situ after 30 minutes, notify the obstetric registrar or consultant on duty.

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ATTACHMENT 4 REFERENCES King Edward Memorial Hospital Clinical Guidelines 2003 Care during the first stage of labour Online: http://www.kemh.health.wa.gov.au/development/manuals/sectionb/index.htm#5 Joanna Briggs Institute Clinical Information Service 2006 Labour stage 1 Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php Joanna Briggs Institute Clinical Information Service 2007 Labour stage 2 Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php Joanna Briggs Institute Clinical Information Service 2006 Labour stage 2: descent phase Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php Joanna Briggs Institute Clinical Information Service 2006 Labour stage 2: active phase Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php Joanna Briggs Institute Clinical Information Service 2006 Labour stage 3: active management Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php Joanna Briggs Institute Clinical Information Service 2007 Labour stage 3: physiological management Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php Joanna Briggs Institute Clinical Information Service 2007 Labour: partogram Online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php National Institute of Clinical Excellence (NICE) 2006 Draft Guidelines for Intrapartum Care Online: http://www.nice.org.uk/page.aspx?o=guidelines.inprogress.intrapartumcare Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Royal Hobart Hospital Clinical Practice Guidelines & Protocols 2006 Care of normal (low risk) labour Online: http://intra.dhhs.tas.gov.au/dhhs-online/page.php?id=16562 Royal Womens Hospital Clinical Practice Guidelines 2006 Normal labour and birth low risk Online: http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=8789

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