Luton and Dunstable NHS Foundation Trust
Intrapartum Care Pathway
HB, MC, KC Aug 2011
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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:
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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
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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
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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
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Maternal Monitoring
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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 healthy women with no complications
 Normal fetal heart rate should be between 110-160 bpm on auscultation
 Intermittent auscultation for 1 minute every 15 minutes after a contraction
 Be aware of a rising or changing FHR as an indicator of potential fetal compromise and
consider changing to Electronic Fetal Monitoring
Reference
Care of the Woman in Labour (CG114)
MLBU operational Policy (CG287)
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PATHWAYS FOR MIDWIFERY LED CARE – 1ST STAGE OF LABOUR
Is the woman suitable for
midwifery led care?
Assess for labour and confirm
established first stage
(see 1st stage notes )
YES
Continually assess progress in
labour and contemporaneously
document
Commence partrogram
YES
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(see 1st stage notes)
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NO
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NO
Consultant Led
Care
Assess for and
confirm latent phase
of labour
Follow latent phase
of labour advice
(see 1st stage notes)
Continue on
normal birth
pathway
Frequency and strength
of contractions
Presence and colour of
any PV loss
Descent and position of
presenting part on
abdominal palpation
Vaginal examinations
Maternal behaviour
Suspected
delay in 1st
stage
Consider delay in
1st stage notes
Diagnosed delay
in 1st stage
Follow delay in 1st
stage notes
Reassess progress
in 4 hours
No progress
Transfer to
consultant led
care
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PATHWAYS FOR MIDWIFERY LED CARE – 1ST STAGE NOTES
Assess suitability for midwifery led
care in labour
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Complete intrapartum risk
assessment documentation
tool ( see CG287)
Delay in 1st stage
Definition
of established
first stage
of labour
Definition
of established
first stage
of labour
( CG114)
Established first stage of labour is when:
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There are regular painful contractions, and/or
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There is progressive cervical dilatation from 4cm
Reference: NICE Intrapartum Care (2008)
Latent phase of labour
Definition: a period of time, not necessarily continuous,
when:
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There are painful contractions, and
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There is some cervical change, including
cervical effacement and dilatation up to 4cm
Consider:
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Mobilsation
Optimal fetal positioning/ maternal positions in labour
Nutrition
Hydration
Emotional support/Environment
Immersion in water
Rest
Maternal and fetal well being
Amniotomy should only be performed after careful
consideration of all the possible implications
Setting:
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Delivery suite or MLBU may not be the
appropriate environment for latent phase and
may be best experienced in the woman’s own
home
Women need reassurance that the latent phase
of labour is normal
Repeated request by the woman for repeat
assessment in the latent phase may indicate the
need for a hospital assessment of the mother
and fetus
Reassess in a further four hours if mother and baby well and
with maternal consent
If no progress after the reassessment, transfer the woman to
the care of the consultant led team
Advice:
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Rest and sleep if possible if feeling tired,
although mobilising may encourage the
contractions to establish
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Eat light meals and keep hydrated ( isotonic
drinks may be favourable)
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Warm showers and baths may provide some
pain relief
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Paracetamol 1 gram six hourly can be taken
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TENS machines can be of benefit, as can
massage or back rubs
Reference: NICE Intrapartum Care (2008)
RCM Evidence based guidelines for midwifery
led care in labour (2008)
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Principles of Care for women in 2nd Stage of Labour
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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
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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)
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PATHWAYS FOR MIDWIFERY LED CARE – 2nd STAGE OF LABOUR
Assess for 2nd
stage of labour
YES
Active 2nd stage
confirmed
YES
Continuously assess progress in
active 2nd stage of labour and
contemporaneously document:
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YES
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Passive second
stage confirmed
(follow 2nd stage
notes)
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Spontaneous vaginal birth
Frequency and strength of
contractions
Presence and colour of PV
loss
Descent and position of
presenting part on abdominal
palpation
Fetal heart rate on
auscultation
Vaginal examinations
Visual advancement of fetal
head at introitus
Maternal behaviour
Maternal observations
Maternal position
Suspected delay in
passive 2nd stage
(follow 2nd stage
notes)
Diagnosed delay in
passive 2nd stage
Transfer to
consultant led care
Suspected delay in
active 2nd stage
(consider 2nd stage
notes)
Diagnosed delay in
active 2nd stage
(follow 2nd stage notes)
Re assess progress in
one hour
No Progress
Transfer to consultant led
care
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PATHWAYS FOR MIDWIFERY LED CARE – 2nd STAGE NOTES
Definition of 2nd stage of labour
Passive 2nd stage:
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The finding of full dilatation of the cervix
prior to or in the absence of involuntary
expulsive contractions
Active 2nd stage:
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The baby is visible
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Expulsive contractions with a finding of
full dilatation of the cervix on vaginal
examination or other signs of full
dilatation
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Active maternal effort following
confirmation of full dilatation of the cervix
in the absence of expulsive contractions
Delay in passive or active 2nd stage of labour should be considered
after one hour
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Assess fetal and maternal well being
Assess strength and frequency of contractions on abdominal
palpation
Assess descent and position of presenting part on abdominal
palpation or vaginal examination if indicated
Ensure adequate hydration
Ensure bladder empty
Consider maternal position and mobilisation – encourage
upright posture
Give gentle verbal support and praise
Consider environment
Consider amniotomy if membranes intact
Reference: NICE Intrapartum care (2008)
RCM Evidence based guidelines
for midwifery led care in labour
(2008)
Definition of delay in the 2nd stage of labour
Nulliparous women:
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Birth should be expected to take place within
3 hours of the start of the active second stage
in most women
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If birth is not imminent after one hour of active
second stage there must be a discussion with
the senior midwife who may discuss the
woman with the obststrician
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If birth is not imminent within 2 hours of active
second stage there must be a discussion with
the senior midwife and the obstetrician
Parous women:
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Episiotomy
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Carry out episiotomy only when there is clinical need eg
suspected fetal compromise
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Do not offer episiotomy routinely for previous third or fourth
degree tear
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Use mediolateral technique ( between 45 and 60 degrees to
the right side, originating at the vaginal fourchette)
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Use tested effective analgesia/anaesthesia
Birth should be expected to take place within
2 hours of active second stage in most
women.
If birth is not imminent after one hour of active
second stage there must be a discussion with
the senior midwife and the obstetrician
Reference: NICE Intrapartum care (2008)
Reference: NICE Intrapartum care (2008)
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PRINCIPLES OF CARE FOR WOMEN IN 3RD STAGE OF LABOUR
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Birth environment - relaxed, private, safe
Support women’s choice for either physiological or active management of 3 rd stage of
labour
Assess maternal observations
Check placenta and membranes for completeness
Record estimated blood loss
Maintain accurate contemporaneous records
Physiological 3rd Stage
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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
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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)
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PATHWAYS FOR MIDWIFERY LED CARE – PHYSIOLOGICAL 3rd STAGE OF LABOUR
Offer skin to skin contact
and encourage
breastfeeding
Await signs of placental
separation ( usually within
60 minutes)
Placenta visible at
vulva and/or strong
urge to push
Placenta delivered by maternal effort
Assess maternal observations
Check placenta and membranes are
complete
No signs of placental
separation within one
hour of birth
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Encourage
breastfeeding/nipple
stimulation
Change maternal position
( preferably to an upright
position)
Ensure bladder empty
( if in doubt, empty the
bladder with an
intermittent catheter)
Observe maternal
condition
No signs of placental separation
after one hour of birth
Transfer to active management of 3rd stage
of labour pathway (following which, if
placenta not delivered within 30 minutes,
transfer to consultant led care)
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PATHWAYS FOR MIDWIFERY LED CARE – ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR
Administer one ampoule of
intramuscular Syntometrine
as soon as possible after the
delivery of the anterior
shoulder
Offer skin to
skin contact
Clamp and cut the
umbilical cord
Await signs of
placental
separation
(usually within
15 minutes)
Deliver placenta by controlled cord
traction
Assess maternal observations
Check placenta and membranes
are complete
No signs of placental
separation
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Encourage
breastfeeding/nipple
stimulation
Change maternal
position ( preferably to
an upright position)
Ensure bladder empty
( if in doubt, empty the
bladder with an
intermittent catheter)
Assess for signs of
separation within 30
minutes
No signs of placental separation within
30 minutes
Observe maternal
condition
Transfer to consultant led care
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PATHWAYS FOR MIDWIFERY LED CARE – 3rd STAGE NOTES
Definition of 3rd stage of labour:
The time from birth of the baby to the expulsion of the placenta and
membranes.
Management of the third stage of labour should be chosen by the
woman following discussion and an informed decision. Physiological
3rd stage is only suitable for low risk women
Physiological 3rd stage is the natural conclusion to a physiological
1st and 2nd stage of labour. It involves a pathway of care which
includes the following three components:
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No routine clamping and cutting of the umbilical cord
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No clamping of the cord until at least pulsation has ceased
( unless clinically indicated)
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Delivery of placenta by maternal effort
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No pulling the umbilical cord or palpation of uterus
Active management of 3rd stage involves a pathway of care which
includes the following three components:
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Routine use of oxytocic drugs
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Clamping and cutting of the umbilical cord following birth of
the baby
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Delivery of placenta by controlled cord traction
Reference: NICE Intrapartum care (2008)
Predisposing factors to post partum haemorrhage
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History of Post partum haemorrhage
Previous retained placenta
Multiple pregnancy
Grandmultiparity
Abnormalities of the placenta
Coagulation abnormalities
Anaemia ( Hb less than 8.5 at onset of labour)
Ketoacidosis
Polyhydramnios
Fibroids
Antepartum haemorrhage
Prolonged first stage of labour
Prolonged second stage of labour
Prolonged third stage of labour
Precipitate labour
Shoulder Dystocia
Instrumental birth
Raised BMI ( greater than 35 kg/m2)
Maternal age ( greater than 35 years)
This is not an exhaustive list. Any identification of a
risk factor for PPH indicates active management of 3rd
stage of labour
Reference: NICE Intrapartum Care (2008)
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PRINCIPLES OF CARE FOR WOMEN AND BABIES IN THE FIRST HOUR AFTER
BIRTH
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Post Birth environment - relaxed, private, safe, unhurried
Maternal Monitoring
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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
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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)
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PATHWAYS FOR MIDWIFERY LED CARE – Mother’s 1st hour
Skin to skin
contact
Maternal observations
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Temperature
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Pulse
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Blood pressure
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Fundal palpation
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Blood loss
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General physical
condition
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Assess
emotional/physchological
condition
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Examine placenta and
membranes
Normal
observations
Inspect vulva,vagina and
perineum to assess
trauma
Intact
perineum
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Ensure hydration and
nutrition needs met
Ensure personal hygiene
needs met
Measure first void
Continue to postnatal
pathway
Perineal tear classified as
1st or 2nd degree and
repaired as required
Perineal tear classified as
3rd or 4th degree
Observations
outside of normal
range
Consider:
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Measures to reduce
temperature/pulse
Analgesia
Empty bladder
Stimulate a contraction
Observations continue to
be outside of normal
range
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Implement obstetric
early warning score
system
Transfer to consultant led
care
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PATHWAYS FOR MIDWIFERY LED CARE –Baby’s 1st hour
Skin to skin
contact
Assess baby’s
wellbeing using
Apgar score at 1
and 5 minutes
Initiate and support
chosen method of
feeding
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Initiate
resuscitation
and call for
assistance if
indicated
Complete
two neonatal
identification
bands.
Confirm
details with
parents
Secure
identification
bands to
baby’s
ankles
(hospital
only)
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Undertake initial
examination of the
newborn
Weigh the baby
Measure head
circumference
Discuss findings
with the parents
Deviation
from normal
identified at
newborn
examination
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Give unbiased
information to enable
informed choice
about neonatal
Vitamin K
administration.
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Administer neonatal
Vitamin K by chosen
route
Continue to
postnatal
pathway
Vitamin K
declined
Refer to
neonatologist
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PATHWAYS FOR MIDWIFERY LED CARE – MOTHER AND BABY’S FIRST HOUR NOTES
In the initial post birth period:
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Ensure maternal and infant physical
wellbeing
Do not separate mother and newborn in the
first hour after birth
Support women in the immediate care of
the newborn
Promote maternal/infant emotional
connection
Support infant feeding choice
Measure maternal first void of urine
Ensure women who have sustained
perineal trauma make an informed decision
regarding repair
Competent midwives can suture perineal
trauma that meet the following
definitions:
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First degree – injury to skin only
Second degree – injury to the
perineal muscles but not the anal
sphincter
Episiotomy
o
o
Women should be advised that:
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Reference: NICE Intrapartum care (2008)
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First degree tear should be sutured
to improve healing unless the skin
edges are well opposed
Second degree tear should have the
muscles sutured to improve healing. If
the skin is well opposed it may not
require suturing
Perineal repair should only be
undertaken with tested effective
analgesia
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A continuous non locked suturing
technique should be used for the
vaginal wall and muscle layer
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A continuous subcuticular technique
should be used for the skin
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An absorbable synthetic suture
material should be used
Third degree – injury to the perineum
involving the anal sphincter complex
o
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3a – less than 50% of the
external anal sphincter
thickness torn
3b – more than 50% of the
external anal sphincter
thickness torn
3c – internal anal sphincter
torn
Fourth degree - injury to the perineum
involving the anal sphincter complex and
anal epithelium
Third and fourth degree perineal tears
must be sutured by a competent
obstetrician
Reference: NICE Intrapartum care (2008)
Reference: NICE Intrapartum Care (2008)
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