Normal Labor

Recommendation

Strength

History taking:

·      Review history, pregnancy notes and screening results including:

-    Gestational age

-    Past history (medical, obstetric, gynecological, surgical, social, family)

-    Medications, allergies

-    Pregnancy complications

-       Investigation results (including placental location)

·   Ask her about the length, strength and frequency of her contractions

·   Ask about fetal movements in the last 24 hours

·   Ask for vaginal losses

·   Review if there are any antenatal or intrapartum risk factors for fetal hypoxia (see the NICE guideline on fetal monitoring in labor)

·     Review ER visit history and clinical circumstances at each visit

·     Assess emotional and psychological needs

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Geneal examination:

·   Temperature, pulse, respiratory rate, blood pressure (BP), and urinalysis

·       Assess nutrition and hydration status and general appearance

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Abdominal examination

·   Observation, and palpation including:

-    fundal height, fetal lie, attitude, presentation, position, engagement/descent

·   Record time of maternal account of regular, painful contractions:

Assess strength, frequency, duration and resting tone for 10 minutes

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Auscultation of FHS

·      Intermittent auscultation using either a Pinard stethoscope or a handheld Doppler ultrasound device (e.g. Doptone® or SonicAid®).

·              Auscultate the fetal heart rate for a minimum of 1 minute immediately after a contraction; palpate the woman's pulse to differentiate between the heartbeats of the woman and the baby.

·     Differentiate between maternal and fetal heartbeat.

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Vaginal examination

Indication of VE

·   If there is uncertainty about whether the woman is in established labor, a vaginal examination may be helpful after a period of assessment, but is not always necessary

·   If the woman appears to be in established labor, offer a vaginal examination.

·  If spontaneous rupture of membranes (SROM) suspected, consider a dry sterile speculum examination.

·   Routine clinical pelvimetry on admission in labor is not recommended for healthy pregnant women.

·     Assess and record vaginal loss

-   Discharge—note color, odor, consistency

-   Blood—note color, volume

-    Liquor—note color, volume, odor, consistency

-    Presence of meconium

·      Document the presence or absence of meconium.

-      If meconium is present, consider the character of the meconium.

-        Meconium may increase the risk to the baby means that:

-        Continuous CTG monitoring may be advised

-        Healthcare professionals trained in advanced neonatal life support are needed as soon as the baby is born.

Contraindication to VE

·    Antepartum hemorrhage

·    Ruptured membranes and not in labor

·   Placenta previa

·    Placental position unknown

·    Suspected preterm labor

Prior to VE

·    Review history and most recent ultrasound scan result

·       Explain procedure and gain verbal consent prior to each examination

·   Ensure the woman's privacy, dignity and comfort

·   Ensure bladder is empty

·   Perform abdominal examination and FHR auscultation

·    Tap water may be used if cleansing is required before vaginal examination.

During VE

·   Maintain privacy, dignity and respect

·   Keep the woman informed of findings during the examination

·   Perform VE between contractions

·    Assessment:

-        Observe general appearance of perineal and vulval area

-        Position of cervix—posterior, mid, anterior

-        Dilatation

-        Effacement

-        Consistency—soft, medium, firm

-        Application of presenting part

-        Membranes intact/no membranes felt

-        Liquor—note color, volume, odor

-        Fetal station: level of presenting part in relation to ischial spines (- 3 to + 3)

-        Presence of caput and molding

-        Fetal position and attitude

After VE

·   Discuss any potential impact on the birth plan

·    Auscultate FHR

·   Document findings

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Laboratory investigation:

·              Hb concentration (if not performed in the past month)

·              Blood group and Rh typing (if not performed before)

–       In Rh negative mothers with Rh positive husband, request indirect Coomb’s test if available

GPS

Admission

Criteria for admission to labor ward

·              Admission decisions should take into account:

-        Maternal and fetal wellbeing

-        Labor progress (e.g., dilation, contractions)

-        Complicating risk factor indicating hospital admission.

·              Criteria of admission to labor ward in low-risk women:

-        Active stage of labor

-        ROM

·              Women with cervical dilatation < 5cm and good uterine contractions should be observed for 2 hours and admit to labor ward if the cervix dilates 1 cm or more.

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General Care and support for normal labor

·              Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought.

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·              Maintain the minimum level of birth intervention compatible with safety.

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Eating and drinking

·              Explain to the woman or pregnant person that they should drink during labor when they are thirsty, and that isotonic drinks may be more beneficial than water. Also explain that there is no benefit to drinking any more than normal, and overconsumption may be harmful.

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·              Inform the woman or pregnant person that they can eat a light diet in established labor if they wish, unless they have received opioids or they develop risk factors that make a caesarean birth more likely.

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Fluid intake and output:

·              Discuss with the woman or pregnant person that:

–       it is important to drink during labor when thirsty

–       it is important to regularly empty the bladder

–       excessive intake of oral or intravenous fluids may be harmful as this can cause hyponatremia (a sodium level of less than 130 mmol/L in a pregnant woman or pregnant person) and lead to maternal and neonatal seizures or death

–       their midwife will ask about and check up on their fluid intake and output throughout labor

–       fluid balance monitoring may be advised during labor to reduce the risk of hyponatremia or dehydration

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·              Monitor and record fluid balance, if:

–       there are any concerns about fluid intake, for example the woman or pregnant person is drinking too much (also take into account fluid intake before labor care began)

–       the woman or pregnant person is receiving intravenous fluids

–       the woman or pregnant person is receiving an oxytocin infusion

–       there are any concerns about fluid output, for example there is an inability to pass urine, nausea, vomiting or diarrhea there are certain medical conditions, such as hemorrhage or pre-eclampsia

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·              If there is a positive fluid balance of 1500 ml or more, or there are clinical concerns (for example, signs and symptoms of hyponatremia):

–       explain to the woman or pregnant person that it is possible they are developing, or have developed, hyponatremia

–       request an obstetric review

–       offer a blood test to check their sodium level

–       advise that they will need to be transferred to an obstetric setting if they are currently in a midwifery-led setting

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·              Do not routinely advise oral fluids or give intravenous fluids for the treatment of ketonuria in pregnant women who are not diabetic.

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Pain management

·              When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques (such as breathing exercises, having a shower or bath, massage or application of warm packs) may be beneficial.

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Hygiene

·              Routine hygiene measures taken by staff caring for women in labor, including standard hand hygiene and single-use non-sterile gloves, are appropriate to reduce cross-contamination between women, babies and healthcare professionals.

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Perineal/pubic shaving

·              We recommend against routine perineal/pubic shaving prior to giving vaginal birth.

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Enema on admission

·              We recommend against administration of an enema for reducing the use of labor augmentation.

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Return/remain at home

·              If there is no indication for immediate admission, and the woman returns or remains at home, provide information on:

–       When to return/make contact, including if:

-  Increased frequency, strength and duration of contractions

-  Increased pain or discomfort requiring additional support

- Vaginal bleeding and//or membrane rupture

-  Reduced or concern about fetal movements

–       Plan an agreed time for reassessment at each contact

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First stage of labor

Latent phase:

·              Duration of the latent stage: Women should be informed that a standard duration of the latent first stage has not been established

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·              Assessment in latent phase:

–       Review birth plan and provide individualized support including:

-  Encourage ongoing resilience and positive self-belief

§  Rest, hydration, nutrition, mobilization, support

§  Reassurance

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·              Slow progress in latent stage:

–       Limited high-quality evidence to provide a contemporary definition

–       Historically, limits of more than 20 hours (nulliparous women) and more than 14 hours (multiparous women) were applied to identify prolonged latent phase

–       Limits not recommended as an indication for intervention when maternal and fetal condition are reassuring

–       Labor may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. Therefore, the use of medical interventions to accelerate labor and birth (such as oxytocin augmentation or caesarean section) before this threshold is not recommended, provided fetal and maternal conditions are reassuring

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·              If slow progress is suspected, assess to identify:

–       Developing complications

–       Reassuring maternal and fetal condition

–       Emotional and physical needs

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Active phase of 1^st stage

·              Duration of the active first stage: The duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labors, and usually does not extend beyond 10 hours in subsequent labors.

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·              Progress of the first stage of labor: In active labor, cervical dilatation of 0.5 cm per hour (2 cm in 4 hours) is considered normal

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·              Consider all aspects of labor progress including:

–       Maternal behavior

–       Fetal condition

–       Cervical dilatation and rate of change

–       Descent and rotation of the fetal head

–       Strength, duration and frequency of contractions

–       Parity

–       Previous labor history

–       Slowing of progress in the multiparous woman

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·              We recommend against the use of active management of labor for prevention of delay in labor.

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·              Do not routinely use amniotomy and or oxytocin to prevent delayed progress in 1st stage of labor.

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·              We recommend against the use of intravenous fluids with the aim of shortening the duration of labor.

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·              We recommend against the use of oxytocin for prevention of delay in labor in women receiving epidural analgesia.

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·              We recommend against routine vaginal cleansing with chlorhexidine during labor for the purpose of preventing infectious morbidities.

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Ongoing care during active phase of first stage:

·              Digital vaginal examination (VE)

–       Minimize VE: VE at intervals of two hours is recommended for routine assessment of active first stage of labor in low-risk women.

–       Offer additional VE if:

§  At time of ROM

§  Suspected second stage

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·              Advice the woman to pass urine regularly to avoid full bladder.

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·              Maternal mobility and position:

–       There is little evidence that any one position is optimal in labor

–       Avoid supine position as it is associated with adverse effects including

- Supine hypotension

-  Abnormal FHR

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Fetal heart assessment:

·              We recommend against the use of continuous cardiotocography for assessment of fetal well-being in normal labor

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·    Intermittent fetal heart rate monitoring: Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device (e.g. Doptone® or SonicAid®) or a Pinard fetal stethoscope is recommended for normal labor.

·   Interval: Auscultate every 15–30 minutes in active first stage of labor, and every 5 minutes in the second stage of labor.

·     Duration: Each auscultation should last for at least 1 minute; if the FHR is not always in the normal range (i.e. 110–160 bpm), auscultation should be prolonged to cover at least three uterine contractions.

·      Timing: Auscultate during a uterine contraction and continue for at least 30 seconds after the contraction.

·    Recording: Record the baseline FHR (as a single counted number in beats per minute) and the presence or absence of accelerations and decelerations.

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Partogram

·    Start using partogram when active labor is confirmed for documentation and providing a visual overview of progress.

·   Record the following observations during the first stage of labor in the partogram:

–       half-hourly documentation of frequency of contractions

–       hourly pulse

–       4-hourly temperature, blood pressure and respiratory rate as a minimum; in addition to other observations according to situation

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Maternal and fetal warning signs

·   If any of the warning signs are present or developed during labor, consult a specialist care:

–       pulse over 120 beats/minute on 2 occasions 15 to 30 minutes apart

–       a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more

–       either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 15 to 30 minutes apart

–       a reading of 2+ of protein on urinalysis and a single reading of either

–       raised diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure (140 mmHg or more)

–       respiratory rate of less than 9 or more than 21 breaths per minute on 2 occasions 15 to 30 minutes apart

–       temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart; for advice on intrapartum antibiotics

–       fresh red bleeding or blood-stained liquor

–       the new appearance of meconium

–       pain reported by the woman that differs from the pain normally associated with contractions

–       confirmed delay in the first stage of labor

–       obstetric emergency, including antepartum hemorrhage, cord prolapse, maternal seizure or collapse, or a need for advanced neonatal resuscitation

–       any non-cephalic presentation, including cord presentation

–       high (4/5 to 5/5 palpable) or free-floating head in a nulliparous woman

–       suspected fetal growth restriction or macrosomia

–       suspected anhydramnios or polyhydramnios

–       any alarming fetal heart rate pattern

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 Delayed progress in active first stage (protracted labor)

·              If delayed progress in the established first stage is suspected, assess:

–       cervical dilatation of less than 2 cm in 4 hours

–       descent and rotation of the baby's head 

–       strength, duration and frequency of uterine contraction

–       condition of fetal membranes

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·  Offer the woman support, hydration, and appropriate and effective pain relief.

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Management of delayed/protracted first stage or arrest of labor

·    Discuss the findings and the options available with the woman, and support her decision.

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·    For women with intact membranes in whom delay in the established first stage of labor is confirmed:

–       consider amniotomy if membranes are intact

–       oxytocin if inertia was diagnosed and

–       repeat vaginal examination 2 hours later.

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·   If available, offer the woman an epidural analgesia before oxytocin is started or if she requests it later.

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·    If oxytocin is used in the first stage of labor, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 3 to 4 contractions in 10 minutes.

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·  Oxytocin must be discontinued immediately if there is abnormality in fetal heart rate is observed.

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·  Consider restarting oxytocin in the first stage of labor if:

–  Obstetric review has been carried out and the FHR is no longer abnormal.

–   Base the dose when restarting on a full clinical assessment, taking into consideration the previous dose.

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·   Perform vaginal examination 2 hourly after the oxytocin infusion has led to regular contractions:

–   If cervical dilatation has increased by less than 2 cm after 4 hours of oxytocin, or there is arrest of labor, further obstetric review is needed by a senior obstetrician to assess whether a caesarean birth is advisable.

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Second stage of labor

·              Assessment of women during the second stage of labor

–       Continue with observations of the woman and baby, and assessment of risk as described for the first stage of labor and, but be aware that the frequency of fetal monitoring should increase.

–       Increase Frequency of observations if clinically indicated.

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·              Vaginal examination.

–       To assess progress, the vaginal examination should include:

-  position of the head

-  descent

-  caput and molding

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·   Fundal pressure

–       Application of manual fundal pressure to facilitate childbirth during the second stage of labor is not recommended.

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·  Techniques for preventing perineal trauma

–       For women in the second stage of labor, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended

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Episiotomy policy

· Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth.

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· If an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy.

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·              Perform an episiotomy if there is a clinical need, such as birth with forceps or ventouse or suspected fetal compromise.

·              Provide tested, effective analgesia before carrying out an episiotomy, except in an emergency because of acute fetal compromise.

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Shortening of the 2nd stage

·              Delay in active second stage is diagnosed when:

–       In nulliparous woman (any of): either insufficient flexion/rotation/descent within 1 hour or the second stage duration is > 2 hours.

–       In multiparous woman (any of): either insufficient flexion/rotation/descent within 30 minutes or the second stage duration is > 1 hour.

–       Longer durations may be appropriate where maternal and fetal conditions are optimal.

GPS

·              A specific absolute maximum length of second stage (passive plus active) has not been identified. Rather than rigid time limits, base decision-making on continuing assessment of:

–       Maternal physical and emotional condition

–       Fetal condition

–       Progress of labor

–       Maternal preferences

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·              Operative vaginal delivery in second stage of labor by experienced and well-trained physicians should be considered safe, acceptable alternative to cesarean delivery.

·              Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged.

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Third stage of labour

Management of third stage of labor

·       The use of uterotonics for prevention of PPH during the third stage of labor is recommended for all births.

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·        Cord clamping:

–       Late cord clamping (performed approximately 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.

–       Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.

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·              Controlled cord traction:

–       Consider Controlled cord traction (CCT) as part of active/modified active management of third stage as it may.

–       Providers employing CCT should only do so after signs of placental separation, and traction should be performed with uterine contraction as these measures reduce the risk of uterine inversion, cord avulsion, and partial detachment of the placenta.

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Prophylactic Uterotonics:

·              Oxytocin:

–       In most circumstances, oxytocin is the prophylactic uterotonic of choice.

–       For vaginal birth

-  If vaginal birth with IV access: Oxytocin 10 IU IV injected slowly over 3–5 minutes is recommended in preference to IM

-  If vaginal birth without IV access: Oxytocin 10 IU IM

–       For CS birth:

-  Oxytocin 5 IU IV over 1–2 minutes

-  Monitor for hemodynamic impact

- Avoid rapid IV bolus administration

–       If cardiovascular compromise exists (e.g. hypovolemia, shock, cardiac disease), use caution with IV administration.

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·   Ergometrine:

–       Ergometrine can be given IM or, in life-saving circumstances, as a slow IV injection.

–       Ergometrine should not be used in patients with essential or gestational hypertension, or in patients on HIV protease inhibitors.

–       Though undisputedly extremely effective, potential adverse effects limit ergometrine to a second-line agent.

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·              Carbetocin:

–       Routinely use oxytocin in preference to carbetocin if vaginal birth and cold-chain storage of oxytocin can be guaranteed (e.g. hospital setting).

–       If vaginal birth and cold-chain storage of uterotonics cannot be guaranteed:

§  Carbetocin is an effective alternative uterotonic

§  IM is preferred route of administration

–       If CS birth under regional anesthetic: IV carbetocin may be considered as a cost-effective uterotonic.

–       If CS birth under general anesthetic: Carbetocin is not recommended due to insufficient evidence.

–       If used: used as a single dose only, not for repeated use

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·              Misoprostol:

–       Not recommended if alternative injectable uterotonics are available

–       Use only if no other injectable uterotonic is available (e.g. due to unexpected birth in low resource setting or if storage conditions for uterotonics are inadequate).

–       The dose is 600 micrograms orally or sublingual single dose immediately after birth

–       If in a low resource setting with limited PPH treatment capability, consider use if:

-  an injectable uterotonic has been administered and

-  continued bleeding is anticipated and/or blood loss is estimated to be greater than or equal to 350 mL  

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Tranexamic Acid (TXA) For Prophylaxis in High-Risk Women

·              Tranexamic acid can be used as a prophylactic agent as an adjunct to uterotonics in patients at high risk for postpartum hemorrhage.

·              Use TXA within 3 hours of birth of the baby in a fixed dose of 1 g in 10 mL IV over 10 minutes (100 mg/min i.e. 1 ml /minute)

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Prolonged third stage

·              Diagnose a prolonged third stage of labor if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management

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Placenta and membranes examination

·              Perform a thorough examination of the placenta and membranes:

–       Placenta:

-  General shape and appearance

-  Calcification or infarctions

-  Evidence of abruption

-  Missing cotyledons

-  Succenturiate lobe/s

–       Membranes:

-  One amnion and one chorion

- Complete or ragged

-  Presence of vessels

–       Cord:

-  Cord insertion site

-  Two arteries and one vein

§  Velamentous insertion: Vessels noted in membranes

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Immediate Postpartum Risk Management

·              Uterine massage:

–       Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin.

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·              Uterine tonus assessment:

–       Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.

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·              Nipple stimulation & breast feeding:

–       Nipple stimulation and/or early breastfeeding may increase uterine activity but has not been shown to reduce bleeding or incidence of PPH.

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·              Observation for women in the first 2 hours postpartum:

–       Vital signs: Respiratory rate, pulse rate, and blood pressure, every 15-30 minutes in the first hour and every 30 minutes in the second hour.

–       Blood Loss every 15-30 minutes by visualizing the labia and perineum and be alert for slow steady trickle.

–       Uterine tonus assessment

–       Temperature every 30 minutes

–       Urine output: after the first 2 hours

·              After the first 2 hours continue as clinically indicated

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·              Women who have had regional analgesia or anesthesia:

–       Check that women who have had regional analgesia or anesthesia can perform a straight leg raise by 4 hours after the last anesthetic dose. If not, contact the obstetric anesthetist for urgent review.

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·              Antibiotics use with normal labor:

–       Use according to the local protocols

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Episiotomy/1st and 2nd degree perineal tears repair

·              Ensure that tested effective analgesia is in place, using infiltration with up to 20 ml of 1% lidocaine or equivalent

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·              Top up the epidural or insert a spinal anesthetic if necessary

·              If the woman reports inadequate pain relief at any point, manage immediately with pharmacological and/or non-pharmacological measures

·              In episiotomy and first/second degrees tears, the wound should be sutured in order to improve healing.

·              Suture use a continuous subcuticular technique

·                    Undertake perineal repair using a continuous non-locked suturing technique for the vaginal wall and muscle layer.

·              Use an absorbable synthetic suture material to suture the perineum.

·              Offer rectal non-steroidal anti-inflammatory drugs routinely after perineal repair of first- and second-degree trauma provided these drugs are not contraindicated.

·              Ensure that suture material has not been accidentally inserted through the rectal mucosa by carrying out a rectal examination after completing the repair

·              After completion of the repair, document an accurate detailed account covering the extent of the trauma, the method of repair and the materials used

·              Give the woman information about the extent of the trauma, pain relief, diet, hygiene and the importance of learning to do pelvic floor exercises, what to expect as they recover, and where and when to seek advice or psychological support if needed.

Postnatal discharge following uncomplicated vaginal birth

·              After an uncomplicated vaginal birth in a health care facility, we advise that healthy mothers and newborns receive care in the facility for 12 - 24 hours after birth.

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·              Physiological care

–       Respond to requests for pain management

–       Consider personal hygiene needs

–       Observe emotional and psychological response to labor and birth

–       Observe response towards the baby and encourage breast feeding

–       Venous thromboembolism (VTE) risk re-assessment

–       Iron supplementation is advised.

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·              Rh D negative blood group

–       Test the baby’s Rh status

–       We recommend Rh D immunoglobulin if maternal indirect Coomb’s test is negative

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Intrapartum analgesia

·              Non-pharmacological pain-relieving strategies

–       Advise women that breathing exercises, and having a shower or bath, may reduce pain during the latent first stage of labor.

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·              Pharmacological analgesia

–       Opioid analgesia for pain relief

-  Parenteral opioids, such as fentanyl, diamorphine and pethidine, are options for healthy pregnant women requesting pain relief during labor, depending on a woman’s preferences and availability.

-  Inform the woman that these drugs will provide limited pain relief during labor and may have side effects for both her (for example, drowsiness, nausea and vomiting) and her baby (for example, short-term respiratory depression and drowsiness, which may last several days and may make it more difficult to breastfeed).

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-  It is not advisable to give opioids if delivery is expected with 3 hours

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-  If an intravenous or intramuscular opioid is used, also administer an antiemetic.

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–       Antispasmodic agents

-  The use of antispasmodic agents for prevention of delay in labor is not recommended.

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·              Epidural analgesia for pain relief

–       Epidural analgesia may be offered for healthy pregnant women requesting pain relief during labor, depending on a woman’s preferences and availability.

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–       Obstetric care and observations for women with epidural analgesia

-  Care and observations for women with epidural analgesia should be jointly managed with the anesthetist.

- Insert urinary catheter.

-  Perform continuous cardiotocography for at least 30 minutes during establishment of epidural analgesia and after administration of each further bolus of 10 ml or more.

-  On confirmation of full cervical dilatation in a woman with epidural analgesia, unless the woman has an urge to push or the baby's head is visible, pushing may be delayed by 1 hour for multiparous women and up to 2 hours for nulliparous women, after which actively encourage her to push during contractions.

-  Do not routinely use oxytocin in the second stage of labor for women with epidural analgesia.

-  Continue epidural analgesia until after completion of the third stage of labor and any necessary perineal repair.

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