Philosophy of Care for Women in 1St Stage of Labour

Luton and Dunstable NHS Foundation Trust

Intrapartum Care Pathway

INTRODUCTION

The Intrapartum Care Pathway has been developed to provide evidence based guidance for midwives leading care of normal women during labour and the immediate post birth period.

The pathway focuses on the following aspects of intrapartum care:

First stage of labour
Second stage of labour
Third stage of labour

-physiological

-active

Care of mother and baby in the first hour after birth

The woman’s journey through her intrapartum care is depicted through a series of flow diagrams, which are underpinned by philosophies and principles of care. Guidance notes are also provided to support midwives’ use of the flow diagrams.

A red, amber, green (RAG) trigger system is incorporated throughout the intrapartum care pathway in order to aid midwives’ clinical decision making.

Green = continue midwifery led care and progress along normal birth pathway

Amber =continue midwifery led care but consider and employ as necessary, alternative midwifery actions that may be needed to continue along normal birth pathway

Red = transfer to consultant led care

Philosophy of caring for women in labour

To promote the physiological processes of birth and reduce medical interventions in labour
To increase the number of women experiencing normal birth outcomes
To reduce the rate of instrumental births and caesarean sections
To increase satisfaction with the birth experience for women and families

Principles of Care for women in 1st Stage of Labour

Birth environment - relaxed, private, safe
Low technology and one to one support from a health professional and birthing partner(s)
Discuss and support women’s birth plans
Midwives are able to offer options for non pharmacological and pharmacological pain relief and support women in their choice
Support eating and drinking in labour. Encourage women to bring isotonic drinks

Maternal Monitoring

Abdominal palpation for descent and position on admission and prior to vaginal examination
Offer vaginal examinations on admission and 4 hourly to assess progress in labour
Palpation and assessment of uterine contractions half hourly
Continuous assessment of pain
Continuous assessment of colour of PV loss
Maternal observations:4 hourly Temperature and BP, hourly pulse
Refer to local guidance on observations if labouring in water
Encourage regular bladder emptying 3-4 hourly

Fetal monitoring

Intermittent auscultation of the fetal heart rate (FHR) is recommended for low-risk women in established labour in any birth setting
There is no evidence to support admission CTG in healthywomen with no complications
Normal fetal heart rate should be between 110-160 bpm on auscultation
Intermittent auscultation for 1 minute every 15 minutesafter a contraction
Be aware of a rising or changing FHR as an indicator ofpotential fetal compromise and consider changing to Electronic Fetal Monitoring

ReferenceCare of the Woman in Labour (CG114)

MLBU operational Policy (CG287)

HB, MC, KC Aug 2011

PATHWAYS FOR MIDWIFERY LED CARE – 1ST STAGE OF LABOUR

HB, MC, KC Aug 2011

PATHWAYS FOR MIDWIFERY LED CARE – 1ST STAGE NOTES

HB, MC, KC Aug 2011

Principles of Care for women in 2nd Stage of Labour

Birth environment - relaxed, private, safe
Low technology and one to one support from a health professional and birthing partner(s)
Support and encourage women to adopt positions of comfort that are upright where possible
Support non directed pushing and avoid valsalva manoeuvre
Support drinking to maintain hydration. Encourage isotonic drinks.

Maternal Monitoring

Abdominal palpation for descent and position as required to assess progress and prior to vaginal examination
Palpation and assessment of uterine contractions
Continuous assessment of colour of PV loss
Vaginal examination or observation of external signs to confirm full dilatation of the cervix
Vaginal examination as required if no obvious signs of progress
Continuous assessment of pain
Continue maternal observations 4 hourly Temperature and BP, hourly pulse
Refer to local guidance on observations if birthing in water
Encourage regular bladder emptying 3 - 4 hourly

Fetal monitoring

Intermittent auscultation of the fetal heart rate (FHR) following a contraction every five minutes
Normal fetal heart rate should be between 110-160 bpm on auscultation
Maternal pulse should be taken if suspected fetal bradycardia or other abnormality to differentiate between the maternal and fetal heart rate

Reference Care of the Woman in Labour (CG114)

PATHWAYS FOR MIDWIFERY LED CARE – 2nd STAGE OF LABOUR

PATHWAYS FOR MIDWIFERY LED CARE – 2nd STAGE NOTES

PRINCIPLES OF CARE FOR WOMEN IN 3RD STAGE OF LABOUR

Birth environment - relaxed, private, safe
Support women’s choice for either physiological or active management of 3rd stage of labour
Assess maternal observations
Check placenta and membranes for completeness
Record estimated blood loss
Maintain accurate contemporaneous records

Physiological 3rd Stage

Ensure informed maternal consent
Do not clamp and cut the cord unless clinically indicated
Offer and encourage skin to skin contact
Await signs of separation
Await maternal urge to push or visibility of placenta at vulva
Do not interfere with the fundus or pull the cord
Physiological 3rd stage should be complete within 60 minutes
Active management is recommended at 60 minutes

Active management of 3rd stage

Ensure informed maternal consent
Administer Syntometrine IM as soon after delivery of the anterior shoulder as possible
Offer and encourage skin to skin contact
Clamp and cut the umbilical cord after birth
Await signs of separation ( should occur within 15 minutes)
Deliver the placenta by controlled cord traction

Reference Care of Woman in labour (CG114)

PATHWAYS FOR MIDWIFERY LED CARE – PHYSIOLOGICAL 3rd STAGE OF LABOUR

PATHWAYS FOR MIDWIFERY LED CARE – ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR

PATHWAYS FOR MIDWIFERY LED CARE – 3rd STAGE NOTES

PRINCIPLES OF CARE FOR WOMEN AND BABIES IN THE FIRST HOUR AFTER BIRTH

Post Birth environment - relaxed, private, safe, unhurried

Maternal Monitoring

Assess maternal observations
Assess involution of the uterus
Assess perineal trauma
Advice regarding immediate management of perineal trauma
Meet personal hygiene needs
Ensure adequate hydration and nourishment
Ensure successful voiding of bladder

Neonatal monitoring

Assess neonatal well being and identify any resuscitative measures required

Facilitate one hour of uninterrupted skin to skin contact as soon as possible after birth
Initiate infant feeding in first hour after birth
Maintain infant’s body temperature
Identify and label infant in line with local guidance
Ensure initial examination of the infant is undertaken
Administer Vitamin K based on informed decision of parents

Reference: Care of the woman in labour (CG114)

The promotion, protection and support of breastfeeding within the Luton and Dunstable NHS Foundation trust (CG12)

Identification of babies

Definition and repair of perineal tear (CG131)

PATHWAYS FOR MIDWIFERY LED CARE – Mother’s 1st hour

PATHWAYS FOR MIDWIFERY LED CARE –Baby’s 1st hour

PATHWAYS FOR MIDWIFERY LED CARE – MOTHER AND BABY’S FIRST HOUR NOTES