Normal Labour and Birth - Low Risk CPG

• Definition of terms

• Management

• Documentation of labour

• Reference documents

1. Introduction

Purpose

Core assumptions

• Labour and birth is considered to be a normal physiological process until established otherwise1

• There should be a valid reason before intervening with the natural process of normal labour and birth2

• The midwife will keep the woman informed of progress throughout labour3

• The midwife in collaboration with the woman is responsible for decision making (in the absence of risk factors)1

• Collaboration and cooperation between the professional groups underpins optimal care for women1

• The woman and the midwife work together during labour and birth recognising the active role that both play in the woman's care1

• When care is transferred to a medical model, the midwife will continue to provide midwifery care and support to the woman1

2. Definition of terms

Normal labour

Low risk

Onset of labour

• Painful, regular contractions

• Effacement and/or dilatation of the cervix, and/or

• With or without rupture of membranes (assess presence of vaginal loss for quantity, colour)2
  
  

Active first stage of labour

• Painful, regular contractions

• Descent of the presenting part

• Cervix is fully effaced, dilatation is 3cm and progressively dilating

• With or without spontaneous rupture of membranes, and/or

• Additional information from an abdominal examination to determine the fetal lie, presentation and position

Normal progress of labour

• Descent of the presenting part, and/or

• At least 2cm additional dilatation within 4 hours of the previous vaginal examination 6
  
  

Second stage of labour

3. Management

3.1 Risk factor identification and response

3.2 Telephone assessment of labour

3.3 Admission to Birth Suite / Family Birth Centre

3.4 Key admission assessments

3.4.1 Assess risk status

• Current Pregnancy Record, including maternal blood group, Hb, and recent ultrasound findings

• Clarification of allergies

• Group B Streptococcus status Refer to CPG GBS colonisation: Strategies to prevent early-onset neonatal sepsis
  

• Maternal vital signs (temperature, pulse, blood pressure), and

• Urinalysis

• Abdominal examination to assess position, presenting part and station, fetal size, liquor volume

• Monitoring of the fetal heart (auscultation or electronically) according to RANZCOG Intrapartum Fetal Surveillance Guidelines8
  

• All monitoring of the fetal heart will be interpreted and documented consistently in the woman's record

3.4.2 Assess whether a woman is in active first stage of labour

• Painful, regular contractions

• Effacement and/or dilatation of the cervix, and/or

• With or without rupture of membranes (assess presence of vaginal loss for quantity, colour)2
  
  

• Painful, regular contractions

• Descent of the presenting part

• Cervix is fully effaced, dilatation is 3 cm(4) and progressively dilating

• With or without spontaneous rupture of membranes, and/or

• Additional information from an abdominal examination to determine the fetal lie, presentation and position

3.4.3 Triage assessment: Suitability for women to receive ongoing care in the Birth Suite / Family Birth Centre.

3.5 Care during active first stage of labour

3.5.1 Assess risk status

Maternal assessment

• Encourage oral fluids during labour3
  

• May have other oral intake as desired3
  

• Encourage regular 2 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 action3,9
  

• Where there is a palpable bladder and the woman is unable to void, consider urinary catheterization3. Refer to CPG Peripartum Bladder Management.
  
  

Fetal assessment

• By hand held Doppler with signal on speaker8
  

• After a contraction10
  

• For a minimum of 60 seconds, and

• Every 30 minutes8
  
  

3.5.2 Assess the progress of labour

• Descent of the presenting part, and/or

• At least 2cm additional dilatation within 4 hours of the previous vaginal examination6
  
  

• Three consecutive uterine contractions will be palpated (and documented minimum ½ hourly) for frequency, duration and strength.

• 2nd hourly

• Prior to vaginal examination(s)

• Confirm the lie is longitudinal, the position of the fetus (i.e.OP or OA), that the head is flexed, and the progress of descent of the presenting part.

Frequency

• Recommend 4th hourly.

• The woman is requesting intramuscular analgesia or epidural

• More frequent examinations should not be performed unless indicated.

• What decision needs to be made now, which requires information from a VE?

• Can this information be obtained by less intrusive means?

Findings:

• Cervix: position, effacement, application to presenting part, dilatation

• Presenting part: relationship to ischial spines, descent with contraction, position, presence of caput or moulding

• Membranes: present or absent

• Liquor: present or absent, colour

• Cord, limbs or malpresentation: felt or not felt6
  
  

Following

• Auscultate fetal heart

• Document findings.

3.5.3 Relevant strategies and interventions available during labour

3.6 Care during second stage of labour

3.6.1 Onset of second stage

• Prior to the descent of the fetal head to the pelvic floor or;

• When the fetal head has reached the pelvic floor3
  
  

• The woman experiences an urge to 'bear down'2
  

• Membranes may rupture spontaneously2
  

• Confirmation of full cervical dilatation by vaginal examination is recommended when there is doubt a woman has achieved full dilatation3
  
  

3.6.2 Assess risk status

Maternal assessment

• Encourage sips of oral fluids

• Encourage regular voiding

• Where there is a palpable bladder and the woman is unable to void, consider urinary catheterization3. Refer to CPG Peripartum Bladder management.
  
  

Fetal assessment

• After a contraction10
  

• For a minimum of 60 seconds Every 5 minutes in the absence of active pushing8 and
  

• After each contraction with active pushing8
  
  

3.6.3 Assess the progress of second stage

• The presence of regular, effective, expulsive uterine contractions and;

• Descent of the fetal head6
  
  

3.6.4 Additional aspects of care

3.7 Normal birth

3.8 Care during third stage of labour

3.9 Care during the four hours immediately following normal birth

3.9.1 Assess risk status

• Uterine height, tone and position - 15 minutely for 1 hour following birth, then 30 minutely for 1 hour if parameters are satisfactory3
  

• Lochia quantity and quality - 15 minutely for 1 hour following birth, then 30 minutely for 1 hour if parameters are satisfactory3
  

• Pulse - immediately following birth, then 30 minutely for the first hour then hourly for the second hour3
  

• Perineum for oedema and haematoma - immediately following birth, then 30 minutely for 1 hour then hourly for 1 hour3
  

• Blood pressure - immediately following birth, then 30 minutely for 1 hour then hourly for 1 hour3
  

• Temperature - immediately following birth

• Urine output - monitor for at least 2 hours post birth. Encourage woman to void if a bladder is palpable or there is increased PV loss and a high fundus. Refer to CPG: Peripartum Bladder Management.
  
  

• Uterine height, tone and position

• Lochia quantity and quality

• Temperature, pulse and blood pressure

• Perineum, and

• Whether the woman has voided3
  
  

Neonatal assessment

• Procedure: Immediate care of the newborn (Intranet only) and
  

• Procedure: Administration of Vitamin K Preparation (Konakion 1mg) to newborn infants to be given on discharge from labour ward

3.9.2 Additional aspects of care

• Ensure the woman is dry, warm and comfortable

• Offer refreshments to the woman and her support person(s)

• Assess the woman's weight bearing capability and range of movement before ambulation

• Assist the woman to have a shower or wash in bed and

• Assist the woman to toilet3
  
  

4. Documentation of labour

4.1 Documentation for admission assessment

4.2 Documentation for active first stage of labour

• Enables easy review of the progress of labour and birth

• Assists in the early recognition of problems, and

• Facilitates communication between caregivers to plan ongoing management.

• An admission assessment to record baseline observation(s)

• A graphical depiction of the progress of active first stage of labour

• Observations and key activities following birth, and

• The record of signatures.

• Risk factor identification

• Response of the midwife to risk factor identification

• Outcome of consultation with medical officer(s)

• Revised plan of management and/or special instructions

• Items discussed with women

• Rupture of membranes

• Fetal heart rate both for first and second stages

• Maternal heart rate, blood pressure and temperature

• Contraction frequency and duration

• Any oxytocics used

• Fetal Oximetry

• Cervical dilatation and station of presenting part (abdominally and vaginally)

• Intake and output

• Urinalysis

• Epidural information and observations (when required)

• Timing of end of 1st, 2nd and 3rd stages of labour

• Type of birth

• Management of third stage

• Estimated blood loss

• Cord pH

• Accoucheur

• Along with a section for general comments, drugs and fluids used.

4.3 Documentation following birth until 4 hours post birth (or prior to transfer to postnatal ward)

• Computer 'Delivery Summary" duplicate - once processed it generates hard copies of Delivery Summary (x2), Postnatal Care (x1), Birth Notification Forms (x2)

• Birth Registration form and Centrelink documents

• Partogram

• Drug chart (neonatal and maternal)

• Progress notes

• Child health care book

• Relevant sections of the: Postnatal Care Plan: Vaginal Birth.

5. Reference documents

5.1 References

5.2 Royal Women's Hospital reference documents for clinical staff

• GBS colonisation: Strategies to prevent early-onset neonatal sepsis

• Peripartum Bladder Management

• Pain Relief in Labour

• Labour: Third Stage Management

• Perineal Trauma: Assessment and Repair

• Breastfeeding: Best Practice Guidelines

• Policy: Support Persons in Birthing Suite

• Procedure: Intradermal injections of sterile water for the relief of backpain in labour

• Policy/Procedure: Use of Assessment Centre

• Policy/Procedure: Admission to the Royal Women's Hospital

• Procedure: Urinary catheterisation