intra partum care pathway

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Midwifery Care Pathway for Normal Birth Date of first issueVersion 2 Date of Current Issue June 2011

Review date June 2013

Directorate of Obstetrics & Gynaecology

INTRAPARTUM CAREPATHWAY FOR LOW

RISK WOMEN

Document Reference Number:

Ratified By: Maternity Governance Group

Date Ratified: June 2011

Date(s) Reviewed: February 2010

Next Review Date: June 2013

Responsibility for Review: Maternity Clinical Effectiveness Group

Contributors : Anne Taylor Senior Midwife

Jan Butler Senior MidwifeAnne Richley Senior Midwife (Community)


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Review date June 2013Page 1 of 26

CONTENTS

Section Page

1 Introduction & Aims 2

2 Scope 2

3 Definitions 2

4 Roles and Responsibilities 3

4.1 Midwife 3

4.2 Obstetrician 3

4.3 Maternity Support Worker 35 Intrapartum Care Pathway for Low Risk Women 4

5.1 Choices for Birth 5

5.2 Supporting and involving womens birth companions 6

5.3 Supporting women during the latent phase of labour 7

5.4 Criteria for entering pathway for normal care 8

5.5 Supporting women in labour 9

5.6 Nutrition in labour 10

5.7 Assessing progress in 1st stage of labour 11

5.8 Second stage of labour 13

5.9 Third stage of labour 16

5.10 Criteria for exit from pathway 19

5.11 Record keeping 20

6 References and Associated Documents 21

Appendix 1 4 Hour Action Line 23

Appendix 2 Delay in the First Stage 24

Appendix 3 Delay in the Second Stage 25


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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 evidencebased approach. (CEMACH 2007).

A review comparing midwife-led models of care with other models for childbearingwomen and their infants concluded that women who had midwife-led models of carewere less likely to experience antenatal hospitalisation, less likely to use regionalanalgesia, have an episiotomy and were more likely to experience no intrapartumanalgesia/anaesthesia, a spontaneous vaginal birth, to feel in control in labour andchildbirth, attendance at birth by a known midwife and initiate breastfeeding. Inaddition, women who were randomised to receive midwife-led care were less likely toexperience fetal loss before 24 weeks gestation, and their babies were more likely to

have a shorter length of hospital stay. There were no statistically significantdifferences 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. Itshould be supported by evidence-based, written information tailored to the woman'sneeds. Care and information should be culturally appropriate. All information shouldalso be accessible to women with additional needs such as physical, sensory orlearning disabilities, and to women who do not speak or read English. NICE (2008)

1 SCOPE

The care pathway provides an evidence based framework which will ensure that allwomen have equal access to high quality care in normal labour. It informs womenand midwives in making decisions about that care and is to be read in conjunctionwith 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 historyor in their current pregnancy

3 DEFINITIONS AND ABBREVIATIONS

Normal labour is defined as spontaneous in onset, low risk at the start of labour andremaining so throughout labour and delivery. The infant is born spontaneously in thevertex 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:-


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

Term/Word Definition

ARM Artificial Rupture of MembranesBP Blood pressureCCT Controlled Cord TractionDoH Department of HealthEFM Electronic Fetal MonitoringLSCS Lower Segment Caesarean SectionMSW Maternity Support WorkerPN PostnatalPV Per vaginaSRoM Spontaneous Rupture of Membranes

VE Vaginal Examination

4 ROLES AND RESPONSIBILITIES

4.1 The Midwife - midwives are the experts in normal birth. They are responsiblefor taking a clinical risk assessment, recognising and promoting normality anddetermining and reacting when labour deviates from normal and referring for anobstetric opinion. The midwife will encourage open communication with the

obstetrician

4.2 The Obstetrician will support the midwife in providing care to low risk womenand responding to deviations from normal

4.3 Maternity Support Worker - may be involved in the care of the women workingunder the direction of the midwife


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Midwifery Care Pathway for Normal Birth Date of first issVersion 2 Date of Curren

Review date Page 4 of 26

5. INTRAPARTUM CARE PATHWAY FOR LOW


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5.1 Choices for Birth

CARE RATIONALE/EVIDENCE Place of birth will have been discussedantenatally though women can be given afurther opportunity to discuss this in earlylabour

All women assessed in labour will beoffered another opportunity to discuss aplan for birth including her wants andexpectations

The healthcare professionals and other care giversshould establish a rapport with the labouring womanasking her about her wants and expectations forlabour..... NICE Intrapartum Care 2007

Choice of birth should not occur in the early stages ofpregnancy and in some cases may not be determineduntil the onset of labourEast Midlands Strategic Health Authority 2008

Not providing alternatives in midwifery serviceprovision is to expose women to unnecessaryinterventions, reduce choices and control in care and

place of birth, along with dissatisfaction in birthexperience (Walsh D 2000)

There is no evidence to suggest that it is inadvisablefor women without complications to book for birth athome/midwifery-led unit (Midirs 2003)


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5.2 Supporting and involving womens birth companions

CARE RATIONALE/EVIDENCE

Acknowledge and facilitate birthcompanions supporting role

Provide birth companions with informationon

Coping strategies for labour What to expect

Their role as coach

Generally women in the UK are supported in labour bytheir partners but this must not be assumed. Careshould be woman centered and holistic and must notmake assumptions on the basis of ethnicity or religion(MIDIRS 2003)

Involvement of birth partners/companions in thedecision making process is essential and practicalsupport tasks can be of great value in the care of thewoman 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 forchildbirth should be available to women and theirpartners together with the opportunity to discuss theseoptions throughout the antenatal period including,where appropriate, in the early stages of labour.Maternity Matters (2007)


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5.3 Supporting women during the latent phase of labourCARE RATIONALE/EVIDENCE During the latent phase women should beprovided with information on copingstrategies -

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 individualisedsupport and offered early assessment athome where possible.

How the care of a woman is managed during thelatent phase is of vital importance and hasimplications for the whole labour experience BJM15(12)2007

Women and their chosen birth partners should beoffered good education about the latent phaseantenatally. RCM 2008

NICE 2007 define the latent phase as a period oftime not necessarily continuous where there are

painful contractions and there is some cervicalchange, including cervical effacement and dilation

Labour wards do not provide the optimumenvironment for women in the latent phase. This isbest experienced in the womans own home with thesupport of the named midwife/birth partner (McNivenet al 1998)


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5.4 Criteria for entering pathway for normal labourCARE RATIONALE/EVIDENCE 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

Guideline for Care of Women in Labour NGHT 2009

Midwives should be astute assessors of risk andhighly skilled practitioners of normal birth, recognisingdeviations from normal and take appropriate action(Walsh 2004)


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5.5 Supporting women in labourCARE RATIONALE/EVIDENCE

Establish rapport with the woman andher birthing partners.

Ask about her wants and expectations Discuss her birth plan (if any) assess

her strategies for coping

Encourage her to adapt the birthenvironment to her needs and remainmobile.

Obtain her consent for all proceduresand observations

Ensure she knows how to summonhelp

Encourage labouring in water as firstline of pain relief (NICE 2007)

Support womans use ofbreathing/relaxation techniques

Massage and music

Continuous support of woman is associated with lower

use of pharmacological analgesia, operative birth andfewer reports of dissatisfaction (Hodnet et al 2004)

All midwives should keep up to date with non-pharmacological methods of pain relief and theirbenefits, i.e. water immersion, massage, positionsand movement and alternative therapies (Mander1998)

The option to labour in water is recommended for painrelief (NICE 2007)Intrapartum Care

There is good evidence that one to one care andsupport in labour reduces obstetric intervention andimproves outcomesEast Midlands Strategic Health Authority 2008


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5.6 Nutrition in LabourCARE RATIONALE/EVIDENCE Low risk women should be encouraged toeat and drink during labour

A woman may:

Drink during established labour and should be

informed that isotonic drinks are more beneficialthan water (NICE 2007)

Eat a light diet during established labour unlessshe has received opioids or develops risk factorsthat make a general anaesthetic more likely (NICE2007)


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Assessing progress in first stage of labour continued

CARE RATIONALE/EVIDENCE Encourage mobilisation, hydration andnutrition

There are times when women rest andnest coming up to second stage. Ifmaternal and fetal wellbeing are withinnormal limits, continue.

For delay in first stage refer to Appendix 2- Delay in First Stage of Labour

Expected duration of first stage:

Nulliparous > 2cm cervical dilatation in 4 hours

Parous > 2cm dilatation in 4 hours(NICE 2007)


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5.8 Second Stage of Labour

CARE RATIONALE/EVIDENCE Ensure warm and calm environment

Encourage woman to adopt alternativepositions to aid descent of the presentingpart - they should be discouraged fromlying supine or semi-supine

Encourage woman to push instinctivelyrather than directed

Record following observations onpartogram and also contemporaneously inwomans 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

Midwives should be pro-active in encouraging womento use alternative positions in labour (MIDIRS 2003;

NICE 2007)

Women should be discouraged from lying supine orsemi-supine in the second stage of labour and shouldbe encouraged to adopt any other position that theyfind most comfortable.

Women should be informed that in the second stagethey should be guided by their own urge to push(NICE 2007)


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Second stage of labour - continuedCARE RATIONALE/EVIDENCE

provide support and encouragement

assess progress, including fetalposition and station

Offer an episiotomy if indicated

If there is delay in the second stage of

labour refer to Appendix 3 - Delay inSecond Stage of Labour

An episiotomy is not to be routinely offered followingprevious 3rd or 4th degree trauma. Where episiotomyis performed, technique is mediolateral originating at

the vaginal fourchette and directed to the right side.The angle to the vertical axis will be between 45and60at 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 active second stage, refer appropriately if delayed

Once referred, birth occurs 3 hours of start ofactive second stage

For parous women

Birth occurs spontaneously within 1 hour of start oactive second stage, refer appropriately if delayed

Once referred, birth occurs 2 hours of start ofactive second stage

(NICE 2007)


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Second stage of Labour ..continued

CARE RATIONALE/EVIDENCE Women often choose to do what is expected of themand the most common image of the labouring woman i

on the bed in a recumbent position. Midwivestherefore should be more proactive in encouraging andshowing women alternative positions in labour. Theadvantages being:

shorter labour

reduced pain

reduced anxiety

reduced medical intervention

increased fetal well-being(MIDIRS and the NHS Centre for Reviews and

Dissemination [2003])


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5.9 Third Stage of Labour


Obtain informed maternal consent for

formal management of third stage.

Observations of maternal health

Physical condition of woman and herown 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 ofSyntometrine, early clamping and cuttingof the cord and controlled cord traction.

1ml Syntometrine is given IM followingdelivery of the anterior shoulder orimmediately following delivery of thebaby.

Clamp and cut the cord afterapproximately 1 minute, using plasticcord clamp approximately 2.5 cm away

from babys umbilicus. Await signs of separation (this can be

physically seen as lengthening of theumbilical cord and trickle of blood pervagina).

Active management is deemed superior tophysiological 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 bereferred to an obstetrician(NICE 2007)

(Resuscitation Council, Oct 2010)


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Third Stage of Labour ..continuedCARE RATIONALE/EVIDENCE Guard the uterus and apply steadydownward 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 obstetricianCheck the placenta and membranes forcompleteness

Physiological Management of ThirdStage

Physiological Management of the thirdstage is only appropriate for low risk

women and who have had a normalphysiological labour.

Give no oxytocic drug.

Leave the cord to pulsate. Do notclamp, pull or cut.

Encourage breastfeeding

If the babys cord is clamped and cutbefore delivery of the placenta, do notclamp the maternal end of the cord.This reduces the retro-placental clotand reduces the risk of feto-maternaltransfusion.

Wait for positive signs of separation (thiscan be physically seen as lengthening ofthe umbilical cord and trickle of blood pervagina).

Women at low risk of post partum haemorrhage whorequest physiological management of the 3rd stageshould be supported in their choice(NICE 2007)


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Third Stage of Labour ..continued


The placenta and membranes aredelivered by maternal effort and

gravity. If placenta is not delivered within one

hour, inform obstetricianCheck the placenta and membranes forcompleteness.

Where delay with the third stage issuspected consider emptying the bladderand putting baby to the breast

Midwife will assess woman for perinealtrauma after birth. (see Guideline forManagement of Perineal Trauma NGHT2009)

Guideline for Management of Perineal Trauma(NGHT 2009)Accurate assessment of perineal trauma and itsprompt management minimises infection and bloodloss(NICE 2007)


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5.10 Criteria for exit from pathway

CARE RATIONALE/EVIDENCE Delay in 1st or 2nd stages of labour

Maternal request for epidural pain relief

Indications for continuous EFM, includingabnormalities of FHR on intermittentauscultation

Meconium stained liquor

Obstetric emergency:

Antepartum haemorrhage

Cord presentation/prolapsed Postpartum haemorrhage

Maternal collapse

Need for advanced neonatalresuscitation

Retained placenta

Maternal pyrexia (38.0C) once or37.5C twice, 2 hours apart)

Undiagnosed breech ormalpresentation in labour

Raised BP>90 diastolic or >140systolic on 2 consecutive occasions 30minutes apart

Uncertainty re fetal heartbeat

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

Significant meconium stained liquor may indicate fetalcompromise and thus necessitate active managementof labour(NICE 2007)


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5.11 Record Keeping

CARE RATIONALE/EVIDENCE Midwife should ensure that the highstandard of clinical care provided is

reflected in a high standard of recordkeeping

Good record keeping has many important functionsincluding

Improving accountability Showing how decisions related to care were made

Supporting clinical judgments and decisions

Supporting care and communications

Facilitating continuity of care

Providing documentary evidence of care

Improving communication and sharing ofinformation in the multi-professional team

Identifying risks and enabling early detection ofcomplications

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: 4

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 anGynae 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 Univers

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 CochraWiley

Johnson C et al (1989) Nutrition and Hydration in Labour in Chalmers et al (eds). Effective care in pregnancOUP: 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:

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. Infoleaflet

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 Rev2004

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

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 PregnancLondon: NCT

Spiby H et al (2003) Selected coping strategies in labour: an investigation of Womens Experience. Birth 30

Walsh D (2007) Evidence based Care for Normal Labour and Birth: A Guide for Midwives. Abingdon, Oxon

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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Midwifery Care Pathway for Normal Birth Date of first issueVersion 2 Date of Current Issue


Once a woman is confirmed to be inestablished labour, the partogram wcommenced.The action line will start from the dilaconfirmed at thi s point.Acceptable progress is 2cm in 4 hthe first stage of labour.

Acceptable progress is on or the right of the Action line.

Unacceptable progress is tothe left of the Action line.


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Appendix 2

DELAY IN THE FIRST STAGE

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

Vaginal Examination

Nulliparous: < 2cmdilatation in 4 hours

Has there been progress in

Descent Rotation Strength, duration and frequency of

contractions

Parous: < 2cmDilatation in 4hours or a slowingin progress

Progress 1cm:

continue oncare athwa

Progress< 1cm

Inform obstetrician.

EXIT care pathway Advise ARM

Yes No

Are membranes intact

No Yes

VE 2 hours

Progress at least 1cm

Continue care pathway. Re-assess in 4 hours and if anyfurther delay EXIT pathway and refer to obstetrician. If there s

any concern over strength, duration and frequency ofcontractions, re-assess earlier

Progress inadequateEXIT pathway

Refer to obstetrician

Re-assess in2 hours


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Appendix 3

DELAY IN THE SECOND STAGE

Nulliparous:Delay suspected if inadequate progress after1 hour of active second stage

Parous:Active second stage = 1 hour

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

Birth within second hour:continue with care pathway

Offer vaginal exam; advise amniotomy if membranesintact

Continue to offer support and encouragement andconsider analgesia/anaesthesia, change of position,descent and bladder care

Diagnosis of delay in the second stage.Exit care pathwayInform obstetrician