Directorate of Obstetrics & Gynaecology

INTRAPARTUM CARE PATHWAY FOR LOW RISK WOMEN

Document Reference Number: Ratified By: Date Ratified: Date(s) Reviewed: Next Review Date: Maternity Governance Group June 2011 February 2010 June 2013

Responsibility for Review: Contributors :

Maternity Clinical Effectiveness Group Anne Taylor Senior Midwife Jan Butler Senior Midwife Anne Richley Senior Midwife (Community)

Midwifery Care Pathway for Normal Birth Version 2

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CONTENTS

Section 1 2 3 4 4.1 4.2 4.3 5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 6 Appendix 1 Appendix 2 Appendix 3

Introduction & Aims Scope Definitions Roles and Responsibilities Midwife Obstetrician Maternity Support Worker Intrapartum Care Pathway for Low Risk Women Choices for Birth Supporting and involving womens birth companions Supporting women during the latent phase of labour Criteria for entering pathway for normal care Supporting women in labour Nutrition in labour Assessing progress in 1st stage of labour Second stage of labour Third stage of labour Criteria for exit from pathway Record keeping References and Associated Documents 4 Hour Action Line Delay in the First Stage Delay in the Second Stage

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1 INTRODUCTION AND AIMS

Adopting a care pathway has been shown to be the best way of providing women centred co-ordinated and clinically driven care. They provide the best evidence based approach. (CEMACH 2007). A review comparing midwife-led models of care with other models for childbearing women and their infants concluded that women who had midwife-led models of care were less likely to experience antenatal hospitalisation, less likely to use regional analgesia, have an episiotomy and were more likely to experience no intrapartum analgesia/anaesthesia, a spontaneous vaginal birth, to feel in control in labour and childbirth, attendance at birth by a known midwife and initiate breastfeeding. In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks gestation, and their babies were more likely to have a shorter length of hospital stay. There were no statistically significant differences between groups for overall fetal loss/neonatal death of at least 24 weeks (Hatem et al. 2008). Good communication between healthcare professionals and women is essential. It should be supported by evidence-based, written information tailored to the woman's needs. Care and information should be culturally appropriate. All information should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. NICE (2008)

SCOPE

The care pathway provides an evidence based framework which will ensure that all women have equal access to high quality care in normal labour. It informs women and midwives in making decisions about that care and is to be read in conjunction with Trust Policies and Guidelines which are cross referenced within the pathway. This pathway will be followed by women who are low risk, i.e. women who: Have no significant problems in their Obstetric, medical, social or surgical history or in their current pregnancy

DEFINITIONS AND ABBREVIATIONS

Normal labour is defined 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. (WHO 1997)

Intermittent Auscultation is defined as:Midwifery Care Pathway for Normal Birth Version 2 Page 2 of 26 Date of first issue Date of Current Issue June 2011 Review date June 2013

Intermittent surveillance of the fetal heart rate at specified intervals using a pinard stethoscope or a hand held ultrasound doppler (NICE 2007; WHO 1997)

Term/Word ARM BP CCT DoH EFM LSCS MSW PN PV SRoM VE

Definition Artificial Rupture of Membranes Blood pressure Controlled Cord Traction Department of Health Electronic Fetal Monitoring Lower Segment Caesarean Section Maternity Support Worker Postnatal Per vagina Spontaneous Rupture of Membranes Vaginal Examination

4 ROLES AND RESPONSIBILITIES

4.1 The Midwife - midwives are the experts in normal birth. They are responsible for taking a clinical risk assessment, recognising and promoting normality and determining and reacting when labour deviates from normal and referring for an obstetric opinion. The midwife will encourage open communication with the obstetrician 4.2 The Obstetrician will support the midwife in providing care to low risk women and responding to deviations from normal 4.3 Maternity Support Worker - may be involved in the care of the women working under the direction of the midwife

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5.

INTRAPARTUM CARE PATHWAY FOR LOW RISK WOMEN

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5.1 Choices for Birth

CARE Place of birth will have been discussed antenatally though women can be given a further opportunity to discuss this in early labour All women assessed in labour will be offered another opportunity to discuss a plan for birth including her wants and expectations RATIONALE/EVIDENCE The healthcare professionals and other care givers should establish a rapport with the labouring woman asking her about her wants and expectations for labour..... NICE Intrapartum Care 2007 Choice of birth should not occur in the early stages of pregnancy and in some cases may not be determined until the onset of labour East Midlands Strategic Health Authority 2008 Not providing alternatives in midwifery service provision is to expose women to unnecessary interventions, reduce choices and control in care and place of birth, along with dissatisfaction in birth experience (Walsh D 2000) There is no evidence to suggest that it is inadvisable for women without complications to book for birth at home/midwifery-led unit (Midirs 2003) STANDARD 1. All women assessed in labour will have their plan for birth discussed and documented in the birth notes

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5.2 Supporting and involving womens birth companions

CARE RATIONALE/EVIDENCE Generally women in the UK are supported in labour by their partners but this must not be assumed. Care should be woman centered and holistic and must not make assumptions on the basis of ethnicity or religion (MIDIRS 2003) Involvement of birth partners/companions in the decision making process is essential and practical support tasks can be of great value in the care of the woman and infant (Chan and Paterson-Brown 2002; Beardshaw 2001; Spiby et al 1999; Singh and Newburn 2000; Encourage involvement of birth partners NICE (2007) Intrapartum Care Robust information on the types and places for childbirth should be available to women and their partners together with the opportunity to discuss these options throughout the antenatal period including, where appropriate, in the early stages of labour. Maternity Matters (2007) STANDARD

Acknowledge and facilitate birth companions supporting role Provide birth companions with information on Coping strategies for labour What to expect Their role as coach

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5.3 Supporting women during the latent phase of labour

CARE During the latent phase women should be provided with information on coping strategies Breathing/relaxation techniques Warm water, showers and bath Massage Music Empathetic support from midwife When a woman is not in established labour she will be offered individualised support and offered early assessment at home where possible. RATIONALE/EVIDENCE How the care of a woman is managed during the latent phase is of vital importance and has implications for the whole labour experience BJM 15(12)2007 Women and their chosen birth partners should be offered good education about the latent phase antenatally. RCM 2008 NICE 2007 define the latent phase as a period of time not necessarily continuous where there are painful contractions and there is some cervical change, including cervical effacement and dilation Labour wards do not provide the optimum environment for women in the latent phase. This is best experienced in the womans own home with the support of the named midwife/birth partner (McNiven et al 1998) STANDARD 2. Antenatal education is offered to women and birth partners about the latent phase of labour

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5.4 Criteria for entering pathway for normal labour

CARE Perform clinical risk assessment, i.e. Review records History of labour Ask about vaginal loss and contractions Check maternal temperature, pulse, BP and urinalysis Observe contractions Palpate abdomen Auscultate FHR pinard/doppler Offer VE RATIONALE/EVIDENCE Guideline for Care of Women in Labour NGHT 2009 Midwives should be astute assessors of risk and highly skilled practitioners of normal birth, recognising deviations from normal and take appropriate action (Walsh 2004) STANDARD 3. Women in active labour will have their initial assessment completed in the birth notes

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5.5 Supporting women in labour

CARE Establish rapport with the woman and her birthing partners. Ask about her wants and expectations Discuss her birth plan (if any) assess her strategies for coping Encourage her to adapt the birth environment to her needs and remain mobile. Obtain her consent for all procedures and observations Ensure she knows how to summon help Encourage labouring in water as first line of pain relief (NICE 2007) Support womans use of breathing/relaxation techniques Massage and music STANDARD 4. A woman in established Continuous support of woman is associated with lower labour will receive one-touse of pharmacological analgesia, operative birth and one care from a midwife fewer reports of dissatisfaction (Hodnet et al 2004) All midwives should keep up to date with nonpharmacological methods of pain relief and their benefits, i.e. water immersion, massage, positions and movement and alternative therapies (Mander 1998) The option to labour in water is recommended for pain relief (NICE 2007) Intrapartum Care There is good evidence that one to one care and support in labour reduces obstetric intervention and improves outcomes East Midlands Strategic Health Authority 2008 RATIONALE/EVIDENCE

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5.6 Nutrition in Labour

CARE Low risk women should be encouraged to eat and drink during labour RATIONALE/EVIDENCE A woman may: Drink during established labour and should be informed that isotonic drinks are more beneficial than water (NICE 2007) Eat a light diet during established labour unless she has received opioids or develops risk factors that make a general anaesthetic more likely (NICE 2007) STANDARD 5. Low risk women will be encouraged to eat and drink during labour

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5.7 Assessing progress in first stage of labour CARE RATIONALE/EVIDENCE Start partogram by plotting a 4 hour The first stage of labour is defined as when there are Action Line (see Appendix 1) regular painful contractions and there is progressive cervical dilatation (NICE2007) Record following observations on partogram and also contemporaneously in Progress must be considered in the context of the womans record womans total wellbeing (Simkin and Ancheta 2000) Quarter-hourly FHR for 1 minute after a contraction Half-hourly Contractions - strength and frequency Membranes intact/ruptured Colour of liquor Comments on progress in labour Hourly Maternal pulse 4 hourly BP Temperature Offer VE (abdominal palpation prior to VE) Regularly (within 4 hours)check and document Frequency of bladder emptying Urinalysis Womans emotional and psychological needs Vaginal examinations should only be carried out when clinically necessary. Where possible, they should be conducted by the same midwife (Enkin et al 2000)

STANDARD 6. All observations will be documented in birth notes 7. A partogram with a 4 hour action line will be started when established labour commences 8. Contemporaneous record keeping will be the norm, with each entry signed, name printed, dated and timed.

Monitoring the progress of labour requires more than assessment of cervical changes and fetal descent. Midwives need to use other skills, including abdominal palpation and knowledge of womans changing 9. A clear plan of care will be behaviour at different stages in labour (Gross et al documented after each VE 2003; Burvill 2002; Enkin et al 2000;) 10. The initial set of Progress in labour can be confirmed on VE if: observations in labour to be documented on the The cervix moves from posterior to anterior Maternity Obstetric Early position Warning chart The cervix softens and ripens The cervix effaces The cervix dilates The head rotates, flexes and moulds The fetus descends (Enkin et al 2000)

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Assessing progress in first stage of labour continued

CARE Encourage mobilisation, hydration and nutrition There are times when women rest and nest coming up to second stage. If maternal and fetal wellbeing are within normal limits, continue. For delay in first stage refer to Appendix 2 - Delay in First Stage of Labour RATIONALE/EVIDENCE Expected duration of first stage: Nulliparous > 2cm cervical dilatation in 4 hours Parous > 2cm dilatation in 4 hours (NICE 2007) STANDARD

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5.8 Second Stage of Labour

CARE Ensure warm and calm environment Encourage woman to adopt alternative positions to aid descent of the presenting part - they should be discouraged from lying supine or semi-supine Encourage woman to push instinctively rather than directed Record following observations on partogram and also contemporaneously in womans record: Every 5 minutes FHR for 1 minute after a contraction Half hourly Document frequency of contractions Hourly BP Pulse Offer VE Regularly (within 4 hours) Frequency of bladder emptying Womans position Hydration Pain relief needs
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RATIONALE/EVIDENCE Midwives should be pro-active in encouraging women to use alternative positions in labour (MIDIRS 2003; NICE 2007) Women should be discouraged from lying supine or semi-supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable. Women should be informed that in the second stage they should be guided by their own urge to push (NICE 2007)

STANDARD 11. The length of the stages of labour will be clearly documented in the birth notes

Second stage of labour - continued

CARE provide support and encouragement assess progress, including fetal position and station RATIONALE/EVIDENCE An episiotomy is not to be routinely offered following previous 3rd or 4th degree trauma. Where episiotomy is performed, technique is mediolateral originating at the vaginal fourchette and directed to the right side. The angle to the vertical axis will be between 45 and 60 at the time of the episiotomy. (NICE 2007) An episiotomy will only be undertaken when there is Clinical need such as instrumental birth Suspected fetal compromise For nulliparous women Birth occurs spontaneously within 2 hours of start of active second stage, refer appropriately if delayed Once referred, birth occurs 3 hours of start of active second stage For parous women Birth occurs spontaneously within 1 hour of start of active second stage, refer appropriately if delayed Once referred, birth occurs 2 hours of start of active second stage (NICE 2007) 12. If a nulliparous woman has not birthed within 2 hours the obstetrician will be informed and review requested. 13. If a parous woman has not birthed within 1 hour the obstetrician will be informed and review requested. STANDARD

Offer an episiotomy if indicated

If there is delay in the second stage of labour refer to Appendix 3 - Delay in Second Stage of Labour

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Second stage of Labour ..continued

CARE RATIONALE/EVIDENCE Women often choose to do what is expected of them and the most common image of the labouring woman is on the bed in a recumbent position. Midwives therefore should be more proactive in encouraging and showing women alternative positions in labour. The advantages being: shorter labour reduced pain reduced anxiety reduced medical intervention increased fetal well-being (MIDIRS and the NHS Centre for Reviews and Dissemination [2003]) STANDARD 12.

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5.9
CARE

Third Stage of Labour

RATIONALE/EVIDENCE STANDARD 13. Placenta and membranes will be examined. Any abnormalities detected will be reported to the obstetrician and documented in the birth notes

Obtain informed maternal consent for formal management of third stage. Observations of maternal health Physical condition of woman and her own report of how she feels Vaginal blood loss Active Management of Third Stage Active Management of the third stage is a package of care involving the use of Syntometrine, early clamping and cutting of the cord and controlled cord traction. 1ml Syntometrine is given IM following delivery of the anterior shoulder or immediately following delivery of the baby. Clamp and cut the cord after approximately 1 minute, using plastic cord clamp approximately 2.5 cm away from babys umbilicus. Await signs of separation (this can be physically seen as lengthening of the umbilical cord and trickle of blood per vagina). Active management is deemed superior to physiological management in terms of blood loss (Edozien 2004; Prendiville et al 2004) Expected duration of 3rd stage: Active management 30 mins Physiological management 1hr

Diagnosed delay in duration of 3rd stage will be referred to an obstetrician (NICE 2007) (Resuscitation Council, Oct 2010)

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Third Stage of Labour ..continued

CARE Guard the uterus and apply steady downward traction on the cord and deliver the placenta and membranes by controlled cord traction. If placenta is not delivered within thirty minutes, refer to the obstetrician Check the placenta and membranes for completeness Physiological Management of Third Stage Physiological Management of the third stage is only appropriate for low risk women and who have had a normal physiological labour. Give no oxytocic drug. Leave the cord to pulsate. Do not clamp, pull or cut. Encourage breastfeeding If the babys cord is clamped and cut before delivery of the placenta, do not clamp the maternal end of the cord. This reduces the retro-placental clot and reduces the risk of feto-maternal transfusion. Wait for positive signs of separation (this can be physically seen as lengthening of the umbilical cord and trickle of blood per vagina).
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RATIONALE/EVIDENCE

STANDARD

Women at low risk of post partum haemorrhage who request physiological management of the 3rd stage should be supported in their choice (NICE 2007)

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Third Stage of Labour ..continued

CARE The placenta and membranes are delivered by maternal effort and gravity. If placenta is not delivered within one hour, inform obstetrician Check the placenta and membranes for completeness. Where delay with the third stage is suspected consider emptying the bladder and putting baby to the breast Midwife will assess woman for perineal trauma after birth. (see Guideline for Management of Perineal Trauma NGHT 2009) RATIONALE/EVIDENCE STANDARD

Guideline for Management of Perineal Trauma (NGHT 2009) Accurate assessment of perineal trauma and its prompt management minimises infection and blood loss (NICE 2007)

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5.10 Criteria for exit from pathway

CARE Delay in 1st or 2nd stages of labour Maternal request for epidural pain relief Indications for continuous EFM, including abnormalities of FHR on intermittent auscultation Meconium stained liquor Obstetric emergency: Antepartum haemorrhage Cord presentation/prolapsed Postpartum haemorrhage Maternal collapse Need for advanced neonatal resuscitation Retained placenta Maternal pyrexia (38.0 C) once or 37.5 C twice, 2 hours apart) Undiagnosed breech or malpresentation in labour Raised BP>90 diastolic or >140 systolic on 2 consecutive occasions 30 minutes apart Uncertainty re fetal heartbeat Significant meconium stained liquor may indicate fetal compromise and thus necessitate active management of labour (NICE 2007) RATIONALE/EVIDENCE Care in labour is aimed towards achieving the best possible outcome for mother and baby (NICE 2007) Maternal morbidity is linked with 2nd stage of labour > 2 hours STANDARD 14. Any concern about maternal or fetal wellbeing or progress of labour will be referred to an obstetrician 15. Exit from the care pathway will be documented in the management plan in the birth notes

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5.11 Record Keeping

CARE Midwife should ensure that the high standard of clinical care provided is reflected in a high standard of record keeping RATIONALE/EVIDENCE STANDARD Good record keeping has many important functions 16. The lead carers in labour including are clearly documented on the front of the birth notes Improving accountability Showing how decisions related to care were made 17. Anyone writing in the birth Supporting clinical judgments and decisions notes will record their Supporting care and communications name and signature on the Facilitating continuity of care front page Providing documentary evidence of care Improving communication and sharing of information in the multi-professional team Identifying risks and enabling early detection of complications Supporting clinical audit Helping to address complaints or legal processes (NMC 2009)

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6. REFERENCES AND ASSOCIATED DOCUMENTS

Beardshaw T (2001) Supporting the role of fathers around the time of birth. MIDIRS Midwifery Digest 11: 474-477 BJM (15)12 765-767 December 2007 Burvill S (2002) Midwifery diagnosis of labour onset. British Journal of Midwifery 10: 600-605 CEMACH (2007) Perinatal Mortality Chan K and Paterson-Brown S. (2002) How do Fathers Feel after accompanying their partners in Labour and Delivery? Journal of Obs & Gynae 22 11-15 East Midlands Executive Summary (2008) From Evidence to Excellence-our clinical vision for patient care Edozien L (2004) The Labour Ward Handbook, London: Royal Society of Medicine Press Enkin M et al (2000). A Guide to Effective Care in Pregnancy and Childbirth 3rd Ed. Oxford: Oxford University Press Gross M et al (2003) Womens Recognition of the Spontaneous Onset of Labour. Birth 30: 267-271 Hodnett ED et al (2004) Continuous Support for Women during Childbirth (Cochrane Review) in The Cochrane Library Iss 1, 2004. Chichester: Wiley Johnson C et al (1989) Nutrition and Hydration in Labour in Chalmers et al (eds). Effective care in pregnancy and childbirth. Vol 2 Oxford: OUP: 827-823 Mander R. (1998) Pain in Childbearing and its Control. Oxford: Blackwell Science Maternity Matters (2007)DOH McNiven P et al. (1998) An Early Labour Assessment Program: A Randomised Controlled Trial. Birth 25: 5-10 MIDIRS (2003) Place of Birth. Informed Choice for Professionals leaflet
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MIDIRS and The NHS Centre for Reviews and Dissemination (2003). Positions in Labour and Delivery. Informed Choice for Professionals leaflet NICE (2007) Intrapartum Care: Care of Healthy Women and their babies during Childbirth NMC 2009 Record Keeping: Guidance for Nurses and Midwives. London: Nursing and Midwifery Council Prendiville WJ et al (2004) Active versus Expectant Management in the 3rd Stage of Labour (Cochrane Review) in The Cochrane Library Iss 1, 2004 RCOG (2008) Standards for Maternity Care. London RCOG Press Roberts J (2002) The push for evidence: The management of the second stage. Journal of Midwifery and Womens Health 47: 2 - 15 Simkin P and Ancheta R (2000). The Labour Progress Handbook. Blackwell Science: Oxford Singh D, Newburn M. (2000) Becoming a Father: Mens Access to information and support about Pregnancy Birth and Life with a New Baby. London: NCT Spiby H et al (2003) Selected coping strategies in labour: an investigation of Womens Experience. Birth 30: 189-194 Walsh D (2007) Evidence based Care for Normal Labour and Birth: A Guide for Midwives. Abingdon, Oxon: Routledge

ASSOCIATED DOCUMENTS
Northampton General Hospital NHS Trust (2009) Guideline for Care of Women in Labour Northampton General Hospital NHS Trust (2009) Guideline for Management of Perineal Trauma

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Appendix 1

Once a woman is confirmed to be in established labour, the partogram will be commenced. The action line will start from the dilatation confirmed at this point. Acceptable progress is 2cm in 4 hours in the first stage of labour.

Unacceptable progress is to the left of the Action line. Acceptable progress is on or to the right of the Action line.

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Appendix 2

DELAY IN THE FIRST STAGE

Vaginal Examination

Nulliparous: < 2cm dilatation in 4 hours

Has there been progress in Descent Rotation Strength, duration and frequency of contractions

Parous: < 2cm Dilatation in 4 hours or a slowing in progress

Yes

No

Re-assess in 2 hours

Progress 1cm: continue on care pathway

Progress < 1cm

Are membranes intact

No

Yes

Inform obstetrician. EXIT care pathway

Advise ARM

VE 2 hours

Progress at least 1cm Continue care pathway. Re-assess in 4 hours and if any further delay EXIT pathway and refer to obstetrician. If there s any concern over strength, duration and frequency of contractions, re-assess earlier

Progress inadequate EXIT pathway Refer to obstetrician

Throughout labour consider and re-assess maternal position, mobilisation, nutrition, hydration, bladder and bowel care
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Appendix 3

DELAY IN THE SECOND STAGE

Nulliparous: Delay suspected if inadequate progress after 1 hour of active second stage

Offer vaginal exam; advise amniotomy if membranes intact Continue to offer support and encouragement and consider analgesia/anaesthesia, change of position, descent and bladder care

Birth within second hour: continue with care pathway

No birth within next hour (total active second stage = 2 hours)

Parous: Active second stage = 1 hour

Diagnosis of delay in the second stage. Exit care pathway Inform obstetrician

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