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1. Introduction
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The Royal Women's Hospital (the Women's) has over 5,500 births each year. Maternity care is provided in a number of models. Women assessed as low risk of developing complications (at booking, antenatal and intrapartum) receive individualised midwife lead care supported by obstetric medical staff.
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The continuum of maternity care begins at booking when women are assessed for risk factors and are allocated to an appropriate model of care. Antenatal care occurs in the hospital antenatal clinics, community clinics and shared care facilities. Labour and birth care occurs in the birthing suites, including the Family Birth Centre (FBC). Postnatal care occurs in the postnatal wards, FBC and at home.
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Purpose
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The purpose of this CPG is to inform and support decision making by midwives on the care of women assessed as low risk of developing complications during normal labour, birth and early postnatal period.
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Core assumptions
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This CPG has been developed around the following assumptions, informed by international standards and best practice in maternity care:
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- Labour and birth is considered to be a normal physiological process until established otherwise1
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- There should be a valid reason before intervening with the natural process of normal labour and birth2
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- The midwife will keep the woman informed of progress throughout labour3
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- The midwife in collaboration with the woman is responsible for decision making (in the absence of risk factors)1
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- Collaboration and cooperation between the professional groups underpins optimal care for women1
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- The woman and the midwife work together during labour and birth recognising the active role that both play in the woman's care1
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- When care is transferred to a medical model, the midwife will continue to provide midwifery care and support to the woman1
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2. Definition of terms
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Normal labour
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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"2,3.
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Low risk
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A pregnant woman is considered low risk when no risk factors have been identified during the antenatal or intrapartum period.
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Refer to Procedure: Intrapartum risk factor identification and response (pdf 31kb)
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Onset of labour
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- Painful, regular contractions
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- Effacement and/or dilatation of the cervix, and/or
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- With or without rupture of membranes (assess presence of vaginal loss for quantity, colour)2
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Active first stage of labour
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- Painful, regular contractions
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- Descent of the presenting part
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- Cervix is fully effaced, dilatation is 3cm and progressively dilating
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- With or without spontaneous rupture of membranes, and/or
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- Additional information from an abdominal examination to determine the fetal lie, presentation and position
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Normal progress of labour
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In the presence of painful, regular uterine contractions (and no identified risk factors), the progress of labour is assessed as normal when there is:
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- Descent of the presenting part, and/or
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- At least 2cm additional dilatation within 4 hours of the previous vaginal examination 6
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Second stage of labour
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Full dilatation of the cervix until the birth of the baby2
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3. Management
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3.1 Risk factor identification and response
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Guideline
| A woman assessed at low risk of developing complications will have midwife led care.
| Assessment of risk is ongoing2
| Midwives are responsible for:
| - continual assessment for, and identification of risk factors
| - informing the senior midwife in Birth suite and
| - initiating the response to the risk factor according to the codes. Refer to Procedure: Intrapartum risk factor identification and response (pdf 31kb)
| In the event any risk factor(s) is identified the midwife will respond according to the following code:
| A = Discuss the risk factor(s) with a senior midwife
| B = Consult with a medical officer regarding plans for ongoing care and/or
| C = Consult with medical officer including review of patient, regarding plans for ongoing care and/or
| D = Transfer responsibility for ongoing care to the medical officer1,2,5
| Any risk factor identified, response and plan of action will be documented in the patient record.
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3.2 Telephone assessment of labour
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Guideline
| During telephone contact the midwife will speak with the woman, ask the following questions and document all responses on the Telephone Assessment of Labour Record. The responses aim to enable the midwife to:
| | - assess suitability for the woman to remain at home
| - identify women who need assessment in hospital, and
| - arrange appropriate followup6
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3.3 Admission to Birth Suite / Family Birth Centre
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Guideline
| The midwife will welcome the woman and her support person(s) on their arrival to the Birth Suite / Family Birth Centre.
| The midwife will approach the admission to the birth environment using a sensitive, woman centred approach to undertake the routine admission tasks as outlined below7
| All care providers will explain procedures routinely undertaken during the woman's birth experience2
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This interaction is important as it forms the basis for ongoing care. The time of admission to the birthing environment is a vulnerable time for women who may have expectations, fears and uncertainties related to labour and birth7.
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The woman and her needs are the priority of the midwife.
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3.4 Key admission assessments
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Guideline
| During admission, assessment of all relevant information will be ascertained and findings documented. The admission assessment will enable the midwife to:
| - assess and respond to risk factors according to the Procedure: Intrapartum risk factor identification and response (pdf 31kb) and
| - assess whether a woman is in active first stage of labour, and
| - identify women who do not require ongoing care in the Birth Suite / Family Birth Centre
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The following assessments will determine ongoing care.
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3.4.1 Assess risk status
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Maternal assessment
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The midwife will assess and document findings on the admission page of the partogram, including baseline information from the:
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- Current Pregnancy Record, including maternal blood group, Hb, and recent ultrasound findings
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- Clarification of allergies
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- Maternal vital signs (temperature, pulse, blood pressure), and
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Fetal assessment:
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The midwife will assess and document findings on the admission page of the partogram, baseline:
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- Abdominal examination to assess position, presenting part and station, fetal size, liquor volume
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- Monitoring of the fetal heart (auscultation or electronically) according to RANZCOG Intrapartum Fetal Surveillance Guidelines8
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- All monitoring of the fetal heart will be interpreted and documented consistently in the woman's record
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Admission CTG - Refer to RANZCOG guidelines.
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3.4.2 Assess whether a woman is in active first stage of labour
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Onset of labour
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The midwife will assess and document findings regarding the onset of labour as the basis for the ongoing care of a woman. Assessment to identify signs of the onset of labour includes:
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- Painful, regular contractions
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- Effacement and/or dilatation of the cervix, and/or
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- With or without rupture of membranes (assess presence of vaginal loss for quantity, colour)2
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Active first stage of labour
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It is essential to identify a woman who is in active first stage of labour.
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The midwife will assess and document findings regarding the progress of active labour to enable appropriate planning for ongoing care of a woman. Assessment to identify signs of active labour includes:
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- Painful, regular contractions
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- Descent of the presenting part
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- Cervix is fully effaced, dilatation is 3 cm(4) and progressively dilating
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- With or without spontaneous rupture of membranes, and/or
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- Additional information from an abdominal examination to determine the fetal lie, presentation and position
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Women admitted in active labour to Birth Suite will have a baseline vaginal examination within two hours of admission.
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3.4.3 Triage assessment: Suitability for women to receive ongoing care in the Birth Suite / Family Birth Centre.
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A woman in active labour will be cared for in the Birth Suite/ Family Birth Centre according to the remaining guidelines.
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A woman who is not in active labour does not require ongoing care in the Birth Suite / Family Birth Centre as it is not the appropriate environment for women not in labour. It is important to reassure women who are not in the active first stage of labour that this may be the 'latent phase' of labour and is normal. The latent phase of labour is best experienced in the woman's own home, however the antenatal ward could be an alternative option for those women who do not feel comfortable to go home (6).
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The midwife will support a woman who is not in active labour when fetal wellbeing has been assessed as within normal limits (according to RANZCOG IFS guidelines) to be discharged from the Birth Suite / Family Birth Centre. The midwife will provide advice to the woman and her support personnel regarding ongoing care.
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3.5 Care during active first stage of labour
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Guideline
| During the active first stage of labour the midwife will ascertain relevant information and document all findings. The ongoing labour assessment will enable the midwife to:
| | - Assess the progress of labour 6,7
| The midwife will discuss with the woman ongoing care during the active first stage of labour to promote or maintain optimal health and wellbeing for the woman and her baby, taking into account the woman's preferences.
| The midwife will discuss the additional aspects of care with the woman, including:
| - Establishing key maternal preferences for the birth of her baby (refer to her birth plan)
| - Relevant strategies and interventions available during labour such as:
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3.5.1 Assess risk status
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Maternal assessment
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The midwife will assess and document findings on the partogram:
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Temperature - 4 hourly3
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Pulse - ½ hourly3(with fetal heart)
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Blood Pressure - 4 hourly2,3
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Fluid input / output
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- Encourage oral fluids during labour3
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- May have other oral intake as desired3
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- 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
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- Where there is a palpable bladder and the woman is unable to void, consider urinary catheterization3. Refer to CPG Peripartum Bladder Management.
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Fetal assessment
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Fetal heart rate (FHR)
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During active first stage, the FHR assessment by intermittent auscultation is:
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- By hand held Doppler with signal on speaker8
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- For a minimum of 60 seconds, and
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Liquor - ½ hourly assessment of liquor colour if membranes are ruptured.
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3.5.2 Assess the progress of labour
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The midwife is responsible for monitoring the progress of labour. This ensures early identification of problems and action taken to ensure appropriate care is provided.
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The progress of labour is assessed primarily by abdominal palpation and assessment of contractions. Vaginal examinations are also used to assess the progress of labour3.
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In the presence of painful, regular uterine contractions (and no identified risk factors), the progress of labour is assessed as normal when there is:
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- Descent of the presenting part, and/or
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- At least 2cm additional dilatation within 4 hours of the previous vaginal examination6
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Contractions
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- Three consecutive uterine contractions will be palpated (and documented minimum ½ hourly) for frequency, duration and strength.
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Abdominal palpation
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- Prior to vaginal examination(s)
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- 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.
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Vaginal examination
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A vaginal examination is an intrusive procedure. Midwives will perform a vaginal examination only following adequate explanation and with sensitivity and attention to privacy.
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Frequency should be individualized and performed regularly enough to assess progress and identify problems early:
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- The woman is requesting intramuscular analgesia or epidural
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- More frequent examinations should not be performed unless indicated.
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Before performing a VE consider the following:
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- What decision needs to be made now, which requires information from a VE?
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- Can this information be obtained by less intrusive means?
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Findings:
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- Cervix: position, effacement, application to presenting part, dilatation
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- Presenting part: relationship to ischial spines, descent with contraction, position, presence of caput or moulding
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- Membranes: present or absent
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- Liquor: present or absent, colour
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- Cord, limbs or malpresentation: felt or not felt6
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Following vaginal examination
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3.5.3 Relevant strategies and interventions available during labour
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Support during labour and birth
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Continuity of care from pregnancy to labour should be provided wherever possible. Care giver continuity has been shown to result in less need for induction, pharmacologic pain relief, neonatal resuscitation, fewer episiotomies but more perineal tears and increased satisfaction11.
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In addition, the midwife will encourage women to have access to continuous emotional and psychological support throughout labour and birth. This type of support has greatest benefits when commenced early in labour12.
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Continuous support is enhanced by ensuring that every effort is made to provide a birth environment that is empowering, nonstressful, affords privacy, communicates respect, and is not characterized by routine interventions that add risk without clear benefit12.
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Supportive care includes facilitating, providing and/or assisting the woman to achieve rest, change position, back rubs, ambulate, bath / shower etc4.
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Refer to Policy: Support Persons in Birthing Suite (Intranet only)
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Mobilisation and position during labour
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Women should be encouraged to mobilize during labour. When not mobilizing, women should adopt their choice of comfortable non-supine position (unless contraindicated)³
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Immersion in water
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The use of water including immersion during the first stage of labour should be encouraged for all women as it reduces the use of analgesia and reported pain without adverse outcomes13.
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Non pharmacological alternatives and pharmacological methods for pain relief and relaxation in labour, including explanations of each on request
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The midwife will refer to CPG: Pain relief in labour to guide discussion and care provision.
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Satisfaction for women following childbirth is not dependent upon the absence of pain during labour. Women are willing to experience the pain of labour, but they do not want the pain to overwhelm them7.
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Artificial rupture of membranes (ARM)
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ARM should not be performed routinely3. Where there is a delay in the progress of labour (Refer to: Procedure: Intrapartum risk factor identification and response) or a woman requests an ARM, a medical officer will be notified and a revised labour management plan discussed.
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3.6 Care during second stage of labour
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Guideline
| During the second stage of labour the midwife will ascertain relevant information and document all findings. The assessments will enable the midwife to:
| - Identify and document the onset of second stage
| - Assess and respond to risk factors during second stage according to the Procedure: Intrapartum risk factor identification and response (pdf 31kb)
| - Assess the progress of second stage6,7
| Additional aspects of care undertaken by the midwife include:
| - The provision of support to women to establish their own pattern of pushing
| | | | - Access appropriate equipment for a normal birth
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3.6.1 Onset of second stage
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Full dilatation of the cervix may become evident:
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- Prior to the descent of the fetal head to the pelvic floor or;
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- When the fetal head has reached the pelvic floor3
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The midwife will assess and document signs and the time of onset of the second stage of labour including:
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- The woman experiences an urge to 'bear down'2
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- Membranes may rupture spontaneously2
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- Confirmation of full cervical dilatation by vaginal examination is recommended when there is doubt a woman has achieved full dilatation3
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Pushing prior to full dilatation can result in maternal exhaustion, cervical trauma and possibly increased instrumental births3.
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3.6.2 Assess risk status
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In the absence of identified risk factors, (refer to Procedure: Intrapartum risk factor identification and response [pdf 31kb]) and descent of the fetal head is occurring, there is no reason to intervene. The chance of a timely spontaneous birth decreases (in the absence of epidural analgesia) when the duration of second stage for a nulliparous woman is >2 hours and >1 hour in a multiparous woman2.
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The following assessments will assist in the identification of risk factors during second stage.
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Maternal assessment
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The midwife will assess and document findings on the partogram:
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Temperature - 4 hourly
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Pulse - 15 minutely (not during a contraction)3
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Blood Pressure - hourly (not during a contraction)3
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Fluid input / output
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- Encourage sips of oral fluids
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- Encourage regular voiding
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- Where there is a palpable bladder and the woman is unable to void, consider urinary catheterization3. Refer to CPG Peripartum Bladder management.
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Fetal assessment
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Fetal heart rate (FHR)
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In the second stage of labour, the FHR assessment by intermittent auscultation is:
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By hand held Doppler with signal on speaker8
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- For a minimum of 60 seconds Every 5 minutes in the absence of active pushing8 and
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- After each contraction with active pushing8
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Liquor - Liquor - ½ hourly assessment of liquor colour.
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3.6.3 Assess the progress of second stage
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The midwife is responsible for monitoring the progress of second stage. This ensures early identification of problems and action taken to ensure appropriate care is provided.
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The midwife will assess for:
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- The presence of regular, effective, expulsive uterine contractions and;
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- Descent of the fetal head6
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The midwife will monitor and document the strength, duration and frequency of contractions.
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3.6.4 Additional aspects of care
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Ensure support
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The midwife will ensure women have support throughout second stage. This support may be by the midwife or a significant other. Provision of this support will result in less intervention and increased satisfaction3.
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The midwife will ensure the woman is informed of progress.
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Support women to establish their own pattern of pushing
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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 stage3,7.
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During the descent phase, descent of the fetal head will occur naturally.
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During the active phase, women will have the urge to push. Midwives will provide support to women as they establish their own pattern of pushing6.
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Maternal position
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Wherever possible, midwives will support the woman to maintain a comfortable, upright position. These positions increase pelvic outlet diameters and efficiency of expulsive uterine activity, thereby reducing the length of second stage2,3,14. In addition, changing of maternal positions may assist fetal rotation to anterior³.
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Where women are unable to assume an upright position, lateral positioning is preferable.
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Pain relief
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The midwife will refer to CPG: Pain relief in labour to guide discussion and care provision.
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Care of perineum
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It is recommended that an episiotomy is not performed routinely when it is presumed a perineal tear is imminent. This practice increases the rate of intact perineum and the rate of only minor trauma, which reduces postpartum perineal pain without maternal or neonatal adverse effects15.
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An episiotomy should be preceded by infiltration of the perineum where possible.
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3.7 Normal birth
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The midwife will manage a normal birth according to Procedure: Normal Vaginal Birth (Intranet only).
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3.8 Care during third stage of labour
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The midwife will manage the third stage of labour according to CPG:Labour: Third Stage Management.
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3.9 Care during the four hours immediately following normal birth
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Guideline
| Immediately following the birth the midwife will ascertain relevant information and document all findings. The assessments will enable the midwife to:
| - Assess and respond to risk factors during four hours immediately following the birth according to Procedure: Intrapartum risk factor identification and response (pdf 31kb)
| - Assess the progress of the immediate postnatal period and
| - Complete the birth summary data requirements
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| Additional aspects of care undertaken by the midwife include:
| - Repair any laceration of the perineum
| - Support the initiation of breast feeding
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| - Support maternal hygiene activities
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3.9.1 Assess risk status
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Maternal assessment
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It is essential the woman is closely monitored in the immediate postnatal period as this is when there is the greatest risk of haemorrhage and other complications.
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All components of maternal assessment will be documented on the partogram. The following are minimal observation requirements to be used as a guide only. The midwife will use clinical judgment to determine if more frequent observations are necessary. Clarify with the midwife in charge or medical officer.
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- Uterine height, tone and position - 15 minutely for 1 hour following birth, then 30 minutely for 1 hour if parameters are satisfactory3
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- Lochia quantity and quality - 15 minutely for 1 hour following birth, then 30 minutely for 1 hour if parameters are satisfactory3
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- Pulse - immediately following birth, then 30 minutely for the first hour then hourly for the second hour3
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- Perineum for oedema and haematoma - immediately following birth, then 30 minutely for 1 hour then hourly for 1 hour3
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- Blood pressure - immediately following birth, then 30 minutely for 1 hour then hourly for 1 hour3
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- Temperature - immediately following birth
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- 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.
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The midwife will ensure a woman is assessed as within normal range for transfer to the postnatal ward. The following will be assessed and documented immediately prior to transfer:
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- Uterine height, tone and position
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- Lochia quantity and quality
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- Temperature, pulse and blood pressure
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- Whether the woman has voided3
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Neonatal assessment
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The midwife will manage the neonate according to:
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3.9.2 Additional aspects of care
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Repair any laceration of the perineum
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The midwife will facilitate early repair of any perineal laceration according to CPG Perineal trauma: assessment and repair . Consider the early application of an ice pack and observe for perineal haematoma.
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Support the initiation of breast feeding
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The midwife will provide support to a breastfeeding woman according to the Women's Breastfeeding: best practice guidelines.
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Pain relief
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The midwife will ensure any pain is investigated and provide appropriate analgesia3.
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Support maternal hygiene activities
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The midwife will:
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- Ensure the woman is dry, warm and comfortable
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- Offer refreshments to the woman and her support person(s)
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- Assess the woman's weight bearing capability and range of movement before ambulation
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- Assist the woman to have a shower or wash in bed and
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- Assist the woman to toilet3
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4. Documentation of labour
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Guideline
| Relevant aspects of labour and birth should be clearly documented contemporaneously and consistently by the healthcare personnel involved in the care of the woman5
| The progress of labour should be clearly identifiable from the patient record5
| In the event the woman deviates from the defined normal labour and birth or risk factors are identified, this will be documented in the patient record. In addition documentation will include, the action taken to consult with a medical officer, and the outcome of the consultation6
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4.1 Documentation for admission assessment
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This commences when a woman is admitted to the birthing environment. Documentation of the initial observations, a brief history of events to date and any relevant past history is on the first page of the partogram.
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4.2 Documentation for active first stage of labour
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When a woman is in active labour commence documentation on the partogram as the record labour and birth care are almost as important as performing the assessments and the care. The partogram is a legal document and is also used to identify accountability in midwifery practice7.
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All entries should include a date / time / signature / legible name and designation.
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A partogram:
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- Enables easy review of the progress of labour and birth
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- Assists in the early recognition of problems, and
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- Facilitates communication between caregivers to plan ongoing management.
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The Royal Women's Hospital partogram consists of the following compenents:
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