LABOUR 1st AND 2nd STAGE - CLINICAL GUIDELINE
1. Aim/Purpose of this Guideline
1.1. This guideline is for all midwives providing care to a woman in labour and birth.
2. The Guidance
2.1
This guideline covers care of a healthy woman in labour at term (37- 41+6 week’s
gestation). This guideline covers the care of all women in labour but should be used in
conjunction with the guidelines relating to specific conditions such as suspected or
confirmed preterm labour; women with an intrauterine death of their baby; women with
coexisting severe morbidities such as pre-eclampsia or diabetes; women who have multiple
pregnancy. The management of the third stage of labour is covered in a separate clinical
guideline.
2.2
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2.3
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Stages of labour
Latent first stage of labour: A period of time, not necessarily continuous, when:
there are painful contractions, and there is some cervical change, including
cervical effacement and dilatation up to 4cm
If a woman seeks advice or attends a midwifery led or obstetric unit, but is not in
established labour encourage the woman to remain at or return home, unless
doing so leads to a significant risk that she could give birth without a midwife
present or become distressed (new 2016)
The triage midwife should document the guidance that she gives to the woman
(new 2016)
Established first stage of labour: There are regular painful contractions, and
there is progressive cervical dilatation from 4cm
Second stage of labour: Diagnosed by either performing a vaginal examination
to confirm the cervix has reached full dilatation or when the fetal presenting part is
visible
Initial maternal and fetal Assessment
When performing an initial assessment of a woman in labour listen to her story and
take into account her preferences and her emotional and psychological needs
(new 2016)
Review the woman’s antenatal handheld records including all antenatal screening
results and record the reason for admission on the admission proforma
Ask about the length and strength and frequency of her contractions, and establish
when regular, painful contractions commenced
Discuss options for pain relief
Auscultate the fetal heart rate at first contact with the woman in labour, and at
each further assessment (new 2016)
Carry out initial auscultation with a pinards
Auscultate the fetal heart for a minimum of 1 minute immediately after a
contraction and record it as a single rate (new 2016)
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2.4
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Palpate the maternal pulse to differentiate between maternal heart rate and fetal
heart rate (new 2016)
Do not perform CTG on admission for low risk women in suspected or established
labour as part of initial assessment
Offer cardiotocography if intermittent auscultation indicates possible fetal heart
rate abnormalities. Remove the cardiotocography if the trace is normal after 20
minutes (new 2016)
The method of fetal surveillance will be planned according to the individual
assessed risk and maternal choice (refer to RCHT Electronic fetal monitoring
guidelines)
If fetal death is suspected despite the presence of an apparently recorded fetal
heart rate, offer ultrasound assessment to check fetal viability (new 2016)
Any suspected rupture of membranes, establish the time this occurred, and
assess the colour of the liquor, clear, meconium, stained or blood stained.
Any vaginal bleeding – is it a “show”, fresh blood? If the latter, is she still bleeding?
Approximate blood loss. Is it pain related? Is the pain constant?
Ask the woman about her baby’s movements in the last 24 hours. Are they
normal, are they reduced / excessive or absent? If absent, how long since fetal
movements were last felt?
Record pulse, blood pressure and temperature and carry out urinalysis
Palpate abdomen, document symphysis fundal height measurement (new 2016),
lie, presentation, position and engagement of presenting part
Palpate the strength of contractions if present
Observe the colour of the liquor (SROM)
Depending upon the history, a vaginal examination may be performed to confirm
the diagnosis of labour
All multiparous women to be encouraged to remain in midwife led or hospital
setting one hour post vaginal examination, even if in latent phase, prior to
discharging home (new 2016).
Ensure all findings are discussed with the woman and agree and document a plan
for labour
First stage of labour
Commence a partogram once labour is established and document the following
observations on the partogram
Every 15 minutes the fetal heart should be auscultated for a minute immediately
following a contraction and recorded as a single rate and any deviation
documented on the obstetric pages (New 2016)
Every 30 minutes: palpate the frequency, strength and duration of contractions
over a 10 minute period
Do not offer or advise clinical intervention if labour is progressing normally and the
woman and baby are well
Every hour: check maternal pulse
Check water temperature hourly, if using birthing pool
Every 4 hours (unless care dictates otherwise): check BP, temperature and
progress by abdominal palpation
Offer vaginal examination (VE) 4 hourly or if there is concern about progress or in
response to the woman’s wishes (new 2016)
Encourage and document frequent emptying of urinary bladder, adhering to the
RCHT clinical guideline for intrapartum bladder care
Expected progress is increasing cervical dilatation of ½ cm per hour
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2.5
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2.6
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Do not regard ARM alone for suspected delay as an indication to start CTG
For any deviation refer to ‘guidelines for the management of delay in first stage of
labour and transfer to obstetric led care
Selection of protective equipment must be based on the risk of transmission of
micro-organisms to the woman and the risk of contamination of the health care
workers clothing and skin by the woman’s blood, body excretions or secretions
Support and care throughout labour
A woman in established labour should receive supportive one-to-one care with
consideration of emotional and psychological needs
A woman in established labour should not be left on her own except for short
periods or at the woman’s request
The woman’s wishes in relation to her birth plan should be discussed with her and
her birth partner at the time of admission and on-going throughout her labour
Do not intervene if labour is progressing normally, any intervention should be
discussed with the woman and the discussion and rationale documented in her
notes
Do not leave the woman without means to request assistance.
Encourage involvement of birth partner(s).
Encourage the woman to mobilise and adopt comfortable positions.
Encourage the woman to adapt the environment to meet her individual needs
(new 2016)
Second stage of labour
Documentation during the second stage of labour should be written
chronologically on the obstetric notes page
Auscultation of the fetal heart should occur immediately after a contraction for at
least 1 minute at least every 5 minutes
Every 15 minutes: document frequency and strength of contractions
Every hour: check BP, pulse, continue 4 hourly temperature
Regularly check for full bladder
Assess progress- offer a vaginal exam hourly in second stage or in response to
woman’s wishes including fetal position and station
If woman has attained full dilatation but feels no urge to push, assess after 1 hour
Encourage upright position: standing, kneeling, squatting
Consider the woman’s hydration needs
For any deviation refer to ‘guidelines for the management of delay in labour in low
risk women, second stage’
Carry out an episiotomy only when there is a clinical need or suspected fetal
compromise
If a deviation from normal labour occurs, at any stage, seek medical advice and
consider transfer to consultant care
2.7 Swab count
When the delivery pack is opened swabs should be counted and the count repeated when
the delivery is completed. This should be documented in the notes following delivery using
the stamp provided.
Monitoring compliance and effectiveness
Element to be
monitored
Lead
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The audit will take into account record keeping by midwives
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Maternity Risk Management Midwife
Tool
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Was a partogram started once labour established
Are contractions documented every 30 minutes
Is maternal pulse documented hourly
Is the blood pressure documented every 4 hours
Is the temperature documented every 4 hours
Is a vaginal examination offered/considered 4 hourly
Is there evidence of regular bladder empting
Is the swab count documented
1% or 10 sets, whichever is the greatest, of all health records
of women who have delivered, will be audited over a 12
month period
A formal report of the results will be received at the maternity
Risk Management or Clinical Audit Forum
Frequency
Reporting
arrangements
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Acting on
recommendations
and Lead(s)
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Change in
practice and
lessons to be
shared
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Any deficiencies identified on the annual report will be
discussed at the Maternity Risk Management or Clinical Audit
Forum
Action leads will be identified and a time frame set for the action
to be completed
The action plan will be monitored by the Maternity Risk
Management Forum or Clinical Audit Forum
A lead member of the forum will be identified to take each
change forward where appropriate
Risk Management Newsletter
3 Equality and Diversity
3.2 This document complies with the Royal Cornwall Hospitals NHS Trust service Equality
and Diversity statement.
3.3
Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Appendix 1. Governance Information
Document Title
LABOUR 1st AND 2nd STAGE – CLINICAL
GUIDELINE
Date Issued/Approved:
7th April 2016
Date Valid From:
15th April 2016
Date Valid To:
15th April 2019
Directorate / Department responsible
(author/owner):
Obs and Gynae Directorate
Contact details:
01872 252879
Brief summary of contents
This guideline is for all midwives providing
care to a woman in labour and birth
Suggested Keywords:
Target Audience
Labour, 1st, 2nd, vertex, latent, established,
antacids, oral, intake
RCHT
PCH
CFT
KCCG
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Executive Director responsible for
Policy:
Medical Director
Date revised:
7th April 2016
This document replaces (exact title of
previous version):
Clinical guideline for care of a woman in 1st
and 2nd stage labour
Maternity Guidelines Group
Obs and Gynae Directorate
Divisional Board for noting
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Head of Midwifery
Name and Post Title of additional
signatories
Helen Ross - McGill
Clinical Governance Lead
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
{Original Copy Signed}
Internet & Intranet
 Intranet Only
Document Library Folder/Sub Folder
Clinical/Midwifery and Obstetrics
Links to key external standards
CNST 2.1
Related Documents/ References.
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RCHT Electronic fetal monitoring
guideline
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Training Need Identified?
RCHT Care of the bladder during
labour
RCHT Guideline for the
management of delay in first stage
of labour
RCHT Guideline for the
management of delay in the second
stage of labour.
NICE (2014) Intrapartum care for
healthy women and babies
No
Version Control Table
Date
2008
Version
Summary of Changes
No
V1.0
Initial guideline
Sept 2010 V1.1
Updated in line with NICE guidance
Sept 2011 V1.3
Reviewed and updated with compliance
monitoring tool
Aug 2012
V1.4
Change to compliance monitoring only
V1.5
Benchmarked with NICE Guidance CG190
And included following statement in
accordance with serious investigation action
plan:All multiparous women to be encouraged
to remain in midwife led or hospital setting one
hour post vaginal examination, even if in latent
phase, prior to discharging home
7th April
2016
Changes Made by
(Name and Job Title)
Theresa Williams and
Chris Edwards
Supervisors of
Theresa Williams and
Chris Edwards
Supervisors of
Theresa Williams and
Chris Edwards
Supervisors of
Jan Clarkson
Maternity risk
manager
Sarah-Jane Pedler
Interim Practice
Development
Midwife
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Appendix 2. Initial Equality Impact Assessment Form
Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter
referred to as policy) (Provide brief description): LABOUR 1ST AND 2ND STAGE - CLINICAL
GUIDELINE
Directorate and service area:
Obs & Gynae Directorate
Is this a new or existing Policy?
Existing
Name of individual completing
assessment: Elizabeth Anderson
Telephone:
01872 252879
1. Policy Aim*
Who is the strategy /
policy / proposal /
service function
aimed at?
2. Policy Objectives*
This guideline is for all midwives providing care to a woman
in labour
3. Policy – intended
Outcomes*
Safe delivery of babies and improved maternal experience
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Compliance Monitoring Tool
b) If yes, have these
*groups been
consulted?
N/A
C). Please list any
groups who have
been consulted about
this procedure.
N/A
To ensure all women in 1st and 2nd stage of labour receive the
appropriate level of care
All women in 1st and 2nd stage of labour
No
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Yes
No
X
Rationale for Assessment / Existing Evidence
Sex (male, female, trans-
X
gender / gender
reassignment)
Race / Ethnic
communities /groups
X
Disability -
X
learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion /
other beliefs
X
Marriage and civil
partnership
X
Pregnancy and maternity
X
Sexual Orientation,
X
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
X
9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director
Date of completion and submission
15th April 2016
Names and signatures of
1. Kate Putman
members carrying out the
2.
Screening Assessment
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed: Sarah-Jane Pedler
Date: 7th April 2016