ST
ND
This document gives guidance to all midwives and obstetricians on how to identify and manage delay in the 1 st
and 2 nd
stage of labour, in a low risk woman. For further details regarding the use of Oxytocin please refer to the Guidance on the Use of
Oxytocin in the First and Second Stage of Labour.
2.1 Diagnosis of delay in 1 st
stage (appendix 3)
A diagnosis of delay in the established first stage of labour needs to take into
1 consideration all aspects of progress in labour and should include:

cervical dilatation of less than 2 cm in 4 hours for first labours

cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours

descent and rotation of the fetal head

Changes in the strength, duration and frequency of uterine contractions.
2.2 Management of delay in 1 st
stage of labour. (appendix 3)
Throughout labour all women should be offered support, hydration, and appropriate and effective pain relief if required.

If delay in the established first stage of labour is suspected, artificial rupture of membranes (ARM) should be considered for women with intact membranes, following explanation of the procedure and advice that it will shorten her labour by about an hour and may increase the strength and pain of her contractions.

Whether or not a woman has agreed to an ARM, all women with suspected delay in the established first stage of labour should be advised to have a vaginal examination 2 hours later, and if progress is less than 1 cm an hour diagnosis of delay is made.

Primigravid women for who delay in the established first stage of labour is confirmed, advice should be sought from an obstetrician and the use of
2 oxytocin should be considered

In women for whom delay in the established first stage of labour is confirmed, and ARM has been previously declined, an ARM should be advised and she should be advised to have a repeat vaginal examination 2 hours later whether her membranes are ruptured or intact.

The woman should be informed that the use of oxytocin following spontaneous or artificial rupture of the membranes will bring forward her time of birth but will not influence the mode of birth or other outcomes.

Multiparous women with confirmed delay in the first stage should be seen by an experienced obstetrician who should make an assessment to exclude obstructed labour, before making a decision regarding the use of oxytocin.
2
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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
All women with delay in the established first stage of labour should be offered support and effective pain relief.

The woman should be advised to have a vaginal examination 4 hours after commencing oxytocin in established labour. If there is less than 2 cm progress after 4 hours of oxytocin, further obstetric review is required to consider caesarean section.

If there is 2 cm or more progress, vaginal examinations should be advised 4 hourly.

ARM alone for suspected delay in the established first stage of labour is not an indication to commence continuous EFM.

Where a diagnosis of delay in the established first stage of labour is made, continuous EFM should be offered.
2.3 Diagnosis of delay in 2 nd
stage of labour. (appendix 4)
Primigravid:

Birth would be expected to take place within 3 hours of the start of the active second stage in most women.

A diagnosis of delay in the active second stage should be made when it has lasted 2 hours and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent .
Multiparous:

Birth would be expected to take place within 2 hours of the start of the active second stage in most women.

A diagnosis of delay in the active second stage should be made when it has lasted 1 hour and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent.
2.4 Management of delay in 2 nd
stage of labour. (appendix 4)

Where there is delay in the second stage of labour, or if the woman is excessively distressed, support and sensitive encouragement and the woman’s need for analgesia/anaesthesia are particularly important

If contractions are inadequate at the onset of the second stage, the use of oxytocin should be considered

In primiparous women, if after 1 hour of active second stage progress is inadequate, delay is suspected. Following vaginal examination, amniotomy should be offered if the membranes are intact

Women with confirmed delay in the second stage should be assessed by an obstetrician. If there is any concern about fetal wellbeing, delivery should be undertaken

Oxytocin is rarely indicated as treatment for delay in 2 nd
stage, however, if decision made to use it must be started by an Obstetrician only, and only after review (for multips this MUST be a senior obstetric decision)

A senior review is required prior to recommencing Syntocinon.

Following initial obstetric assessment for women with delay in the second stage of labour, on-going obstetric review should be maintained every 15 –30 minutes, for a maximum of 1 hour.
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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Element to be monitored
Lead
Tool
Frequency
Reporting arrangements
Acting on recommendations and Lead(s)
Change in practice and lessons to be shared
Notes to be reviewed of women who have had a prolonged second stage of labour
Maternity risk manager
Review in the clinical incident review meeting
When cases are identified
Reporting through the maternity risk management forum
As per action plan
Learning points in newsletters and/or 1:1 feedback
3.1 This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement.
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
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and 2 nd
stage in a low risk woman
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Document Title
Delay in first and second stage of labour, in the low risk woman (identification and management)
Date Issued/Approved: 31 st
October 2015
Date Valid From: 31 st
October 2015
Date Valid To: 31 st
October 2018
Directorate / Department responsible
(author/owner):
Contact details:
Karen Watkins
Obs and Gynae directorate
01872 252729
Brief summary of contents
Suggested Keywords:
This document gives guidance to all midwives and obstetricians on how to identify and manage delay in the 1st and 2nd stage of labour, in a low risk woman
Delay in labour
RCHT

PCH
Medical Director
CFT KCCG
Target Audience
Executive Director responsible for
Policy:
Date revised:
This document replaces (exact title of previous version):
Approval route (names of committees)/consultation:
October 2015
It replaces two documents:
Guidelines for Management of Delay in
Labour in Low-Risk Women: First Stage:
Guidelines for Management of Delay in
Labour in Low-Risk Women: Second
Stage
Maternity Guideline Group
Obs and Gynae Directorate
Divisional Board for noting
Divisional Manager confirming approval processes
Head of Midwifery
Name and Post Title of additional signatories
Not Required
Signature of Executive Director giving approval
Publication Location (refer to Policy on Policies – Approvals and
{Original Copy Signed}
Internet & Intranet
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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
Intranet Only

Ratification):
Document Library Folder/Sub Folder Clinical/Midwifery and Obstetrics
Links to key external standards
Related Documents/ References.
CNST 2.1
References:
NICE 2008 : Intrapartum guidelines for low risk women.
RCHT 2012: Clinical guideline for the use of oxytocin
Training Need Identified?
Version Control Table
Date
Version
No
September
2008
1.0
October
2010
1.1
Initial document
No
Summary of Changes
Initial document
Changes Made by
(Name and Job Title)
Karen Watkins
Consultant
Obstetrician
Karen Watkins
Consultant Obstetrician
October
2010
1.1 Review of document, no changes
Karen Watkins
Consultant Obstetrician
December
2012
1.2
Review and amalgamation of 2 documents and compliance monitoring added
Karen Watkins
Consultant Obstetrician
1 st
October
2015
1.3
A Senior review is required prior to recommencing Syntocinon.
Karen Watkins
Consultant Obstetrician
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
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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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.
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy ) (Provide brief description):
Directorate and service area:
Obs & Gynae Directorate
Is this a new or existing Policy?
Existing
Name of individual completing assessment:
Elizabeth Anderson
1. Policy Aim*
Who is the strategy / policy / proposal / service function aimed at?
Telephone:
01872 252879
This document gives guidance to all midwives and obstetricians on how to identify and manage delay in the 1st and 2nd stage of labour, in a low risk woman
2. Policy Objectives* To ensure women are managed with upto date, evidenced based care
3. Policy – intended
Outcomes*
Appropriate identification and management of delay in 1 st
and 2 nd stage of labour
4. *How will you measure the outcome?
5. Who is intended to benefit from the policy?
Compliance monitoring tool
Pregnant women and their babies
6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these
*groups been consulted?
C). Please list any groups who have been consulted about this procedure.
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age X
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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Sex (male, female, transgender / gender reassignment)
X
Race / Ethnic communities /groups
X
Disability - learning disability, physical disability, sensory impairment and mental health problems
Religion / other beliefs
Marriage and civil partnership
X
X
X
Pregnancy and maternity X
Sexual Orientation,
Bisexual, Gay, heterosexual,
Lesbian
X
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
8. Please indicate if a full equality analysis is recommended. Yes No
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
Names and signatures of members carrying out the
Screening Assessment
1. Elizabeth Anderson
2.
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: Elizabeth Anderson
Date: 2 nd
September 2015
Delay in labour, 1 st
and 2 nd
stage in a low risk woman
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Appendix 3
Guidelines for Management of Delay in Labour in Low-Risk Women: First Stage:
Labouring? Vaginal examination (VE)
No Home
Yes - 4 hours
No
V/E - labour confirmed?
Yes
Progress <2 cm in 4 hours or slowing in progress in a multip
Yes Membranes intact?
No
>1 cm
Advise ARM
ARM
V/E
Yes
2 hours
<1 cm
Membranes intact?
<1 cm – transfer to
Consultant care.
Check hydration and ketonuria and correct; mobilise, exclude infection
2 hours
V/E >1 cm
V/E - 4 hours
No
SYNTOCINON after discussion with obstetrician
- If multiparous, patient must be assessed by obstetrician prior to Syntocinon and clear plan documented in notes
V/E - 4 hours
>2 cm <2 cm
V/E - 4 hours or anticipated time for full dilation
V/E - 4 hours
Review by
Obstetrician re
CS
Delay in labour, 1 st
and 2 nd
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Appendix 4
Active second stage diagnosed:-
Expulsive contractions
Or Active pushing
Or Vertex visible
Primiparous
2 hours*
Delay in second stage diagnosed
Ensure membranes have definitely ruptured
Transfer to consultant care
Multiparous
1 hour*
Obstetric assessment - Deliver if concerned re fetal wellbeing.
Respond appropriately to woman’s request
If decision made not to deliver then review by an Obstetrician every 15-30 minutes for up to a maximum of 1 hour.
If NOT delivered within this time, instrumental delivery or CS** with adequate analgesia
`
* If delay is anticipated or suspected arrangements for transfer to consultant unit can be made prior to the 2 hours for primips and 1 hour for multips.
If no progress then referral to an Obstetrician should be done at any time during this stage.
Syntocinon to be started by Obstetrician only, and only after review (for multips this MUST be a senior decision)
**Decision for whether CS or instrumental delivery should be made by Obstetrician assessing the patient. If there are any concerns regarding mode of delivery discuss with the consultant on call and delivery should then be performed in theatre.
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and 2 nd
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