labour - 1st 2nd and 3rd stage carehealth.act.gov.au/sites/default/files/new_policy_and_plan... ·...

CHHS15/063

Canberra Hospital and Health ServicesClinical ProcedureLabour: Care During First, Second and Third StageContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – First Stage of Labour...............................................................................................3

Comfort Measures and Emotional Wellbeing.......................................................................3

Section 2 – Meconium Stained Liquor......................................................................................4

Meconium liquor before or during Labour...........................................................................4

Mobility.................................................................................................................................8

Fluids and Nutrition..............................................................................................................8

Bladder management............................................................................................................8

Monitor the progress of labour by:.......................................................................................8

Delay in the first stage - signs of delay in first stage.............................................................8

Recognition of delay.............................................................................................................9

Recommend repeat abdominal and vaginal examination:....................................................9

Documentation:....................................................................................................................9

Section 3 – Second Stage of Labour........................................................................................10

Clinical Practice...................................................................................................................10

Documentation...................................................................................................................10

Educational Notes...............................................................................................................11

Section 4 – Third Stage of Labour...........................................................................................11

Provision of information regarding the third stage (antenatal period and on admission for labour and birth).................................................................................................................11

Provision of care during third stage of labour.....................................................................12

Active management........................................................................................................12

Physiological third stage management...........................................................................13

Clamping and Cutting of the Umbilical Cord.......................................................................14

Cord clamping.................................................................................................................14

Doc Number Version Issued Review Date Area Responsible PageCHHS15/063 1.3 10/03/2015 01/03/2019 Maternity Unit

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Retained placenta...............................................................................................................15

Observations during and immediately after third stage.....................................................15

Implementation...................................................................................................................... 16

Related Policies, Procedures, Guidelines and Legislation.......................................................16

References.............................................................................................................................. 17

Definition of Terms................................................................................................................. 19

Search Terms.......................................................................................................................... 21

Attachments............................................................................................................................21

Attachment 1: First Stage of Labour Care...........................................................................23

Attachment 2: Second Stage Labour...................................................................................24

Attachment 3: Sterile water Injections for labour pain relief..............................................25


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Purpose

The purpose of this document is to support midwives, student midwives under supervision, and medical staff to provide safe, effective care during all stages of labour.

A woman’s right to make an informed choice about what method of labour management she would like should be recognised and respected. Support for the choice she has made is to be provided, along with discussion of any identified risk factors. Prompt effective treatment of abnormal blood loss, prolonged stages of labour or retained placenta is essential.

Care should be focussed on careful observation of both maternal and newborn wellbeing during labour. It is important to maintain a quiet, private and warm environment where unnecessary interruptions are avoided and the woman’s privacy is maintained.

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Alerts

If during the third stage of labour the woman is experiencing postpartum haemorrhage (blood loss greater than 500 mL) immediately provide emergency assistance; call for assistance and implement the Post Partum Haemorrhage (PPH) pathway. For further information refer to the Obstetric Emergencies clinical procedure.


Scope

This document applies to: Medical officers, Registered midwives who are working within their scope of practice (Refer to Scope of

Practice for Nurses and Midwives Policy), and Student midwives under direct supervision.


Section 1 – First Stage of Labour

Comfort Measures and Emotional Wellbeing A woman in active labour should receive supportive care A woman in active labour should not be left on her own except for short periods or at

the woman's request Offer individualised care including:

o Facilitating the woman's cultural needso Maintaining a quiet, calm and private atmosphere


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o If clinically indicated, provide the woman with reasons, risks and benefits of any proposed interventions and support her to make an informed decision

o Assist with the use of non-pharmacological methods of pain relief - TENS, relaxation and breathing, acupuncture, massage, water (refer to Use of Baths during Labour and Birth procedure), hot packs and sterile water injections (see attachment 3)

o Ensure the woman is aware of and has consented to the presence of other care providers.


Section 2 – Meconium Stained Liquor

Meconium liquor before or during LabourBackground: Meconium stained liquor whether old or fresh is a sign of potential fetal compromise.

However, it is often associated with postdates pregnancy in an otherwise well baby. Meconium aspiration syndrome occurs in 1-3% of all neonates. Intra Uterine Growth

Restricted (IUGR) babies and post mature babies are at increased risk. Complications of meconium aspiration are most likely to occur where the liquor volume

is reduced and consequently the meconium is more concentrated, and if there is co-existing fetal asphyxia.

Assessment of a women with meconium stained liquor: Confirm correct gestational age. Review antenatal record for current pregnancy to identify any other potential antenatal

risk factors such as IUGR, oligohydramnios, decreased fetal movements. In the presence of thick, fresh or frank meconium, confirm presentation as cephalic. Ask the woman about fetal movement pattern over past few days. The onset of fresh thick meconium after initially clear liquor, particularly in the presence

of fetal heart rate abnormalities indicates potential fetal compromise. Explain to the women the risks of meconium stained liquor and recommendation for

continuous electronic fetal monitoring (EFM). Explain the recommendation for a neonatal medical officer to be present at the birth

(refer to Birth Requiring the Presence of a Neonatal Team Member clinical guideline) in case suction under direct vision and intubation is indicated.

Apply Continuous Cardiotocography (CTG) monitoring (external transducer or scalp electrode) and monitor as per Fetal Surveillance Clinical Guideline. Notify: Obstetric registrar or specialist obstetrician of the presence of meconium stained liquor

and of any fetal heart rate anomalies Delivery Outreach Neonatal Registrar/Senior Resident Medical Officer (SRMO) of the

need for their presence at the birth and inform them of the current labour progress Delivery Outreach Neonatal Registrar/SRMO when birth is imminent, allowing time for


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neonatal registrar to attend for birth.

Prepare equipment Prepare neonatal resuscitation trolley or cosycot (resuscitaire) Increase room temperature in birth room or operating theatre in adequate time for

optimum warmth Prepare cord gas collection equipment - cord blood gases should be collected from all

babies with meconium liquor.

Document in partogram and notes presence of meconium time meconium noted time Obstetric Registrar and Neonatology Registrar notified.

Birth Centre and/ or labouring in water Women who are labouring in the Birth Centre should have continuous fetal monitoring

applied when meconium liquor is identified and should transfer to Birthing, if time allows and it is clinically safe and appropriate to do so.

Women labouring in the bath should get out of the bath when meconium liquor is identified, if it is clinically safe and appropriate to do so and birth is not imminent.

Should it be unsafe to transfer to Birthing, call for Delivery Outreach Neonatal Registrar/SRMO attendance at the birth in the Birth Centre.

At birth: Most babies born at term with meconium stained liquor will be healthy and vigorous. The healthy vigorous baby at birth that has immediate spontaneous respirations and has

good tone and colour may remain skin to skin with the mother. A small number of babies with meconium stained liquor will be unwell at birth and

require immediate medical assistance at birth. The woman should be made aware of this possibility and the need for the Delivery Outreach Neonatal Registrar/SRMO to be present at the birth.

If the baby at birth has poor colour and/or tone and does not initiate spontaneous respirations: Baby should be taken to the resuscitaire immediately after the cord is clamped and cut,

keep the baby warm and commence stimulation. Commence neonatal resuscitation as per Neonatal Advanced Life Support algorithm. Call for urgent attendance by the Delivery Outreach Neonatal Registrar/SRMO or call a

Neonatal Code Blue if not already present. Consider gentle suction of oropharynx if meconium is pooled in the baby’s mouth. Babies with meconium stained liquor may be at risk of hypoglycaemia, hypothermia,

sepsis and meconium aspiration syndrome. All babies will have a Neonatal Risk assessment as per the Neonatal General Observation

Chart and observations carried out as required following risk assessment including Oxygen saturation levels.


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If any signs of respiratory distress develop i.e. respiratory rate >60 or <30, nasal flaring, grunting, sub or intercostal recession, central cyanosis or any other change in the baby’s clinical condition, contact the neonatal registrar to review the baby.

If the baby continues to be well, routine care is provided.

Labour Observations:Assess and record the following observations (more frequently if indicated and less frequently if attempting to sleep or going for long walks in early first stage) as follows:

Temperature On admission4 hourly1 hourly if woman febrile

Pyrexia may be caused by infection or ketosis and is associated with epidural analgesia

Maternal Heart Rate and Respirations

On admissionDuring the latent phase:4 hourlyDuring the active phase: every 30 mins

Maternal tachycardia may indicate infection, ketosis, dehydration or anxiety

Blood Pressure

On admissionDuring the latent phase: 4 hourlyDuring the active phase: 2 hourly

Labour may cause further elevation of BP if a woman has chronic (essential, secondary or white coat) hypertension, gestational hypertension or preeclampsia

Contractions During the latent phase:2hourlyDuring the active phase of first stage: every 30 minsIf woman reports changing nature of contractionsIf clinical condition has changed

CTG if clinically indicated

Fetal well being

On admission with Pinard and/or Doppler (or CTG if indicated)During the latent phase of first stage : 2 hourlyDuring the active phase of first stage and passive stage of second stage: every 15 -30 minsDuring the active second stage of labour: after each contraction or at least every 5 minutes.Commence CTG if clinically

Auscultation should commence toward the end of a contraction and be for at least 30 – 60 seconds after the contraction has finished.

Fetal scalp electrode if clinically indicated or difficulty obtaining good quality trace.


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indicated as per Fetal Surveillance Clinical Guideline

Amniotic Fluid On admissionDuring the latent phase: 2 hourlyDuring the active phase: every 30 mins

If significant bleeding noted, the odour of the liquor changes or liquor becomes offensive smelling the woman needs medical review and continuous CTG

Abdominal palpation/Vaginal examination (VE)

The frequency of examination should be based on clinical indication.

Abdominal examination should be performed prior to each vaginal examination.

Generally recommended frequency of examination per vagina is at least every 4 hours, but shorter intervals between assessments may be recommended depending on individual circumstances

E.G. Consider offering to perform a VE prior to intramuscular analgesic injection or an epidural

Abdominal examination to determine and document fetal: size lie presentation position engagement / descent

Examination per vagina to determine and document: Cervical:

o effacement/lengtho thicknesso dilatation

Presenting part:o identificationo positiono station in relation to ischial spines

Moulding:o Absence / Presenceo Degree of moulding

Caputo Absence /Presenceo Degree of caput

Presence or absence of forewaters Assessment of liqour

To assess progress of labour

Alert: If the BP is abnormal or the woman has an epidural analgesia, observations will be required more frequently according to these guidelines, in consultation with the medical team.

MobilityEncourage women to mobilise during labour and to adopt upright positions which may facilitate labour progress.


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Fluids and NutritionThe woman should be encouraged to eat and drink as desired and tolerated.

AlertWomen who decide to have an epidural anaesthetic in labour should not eat once the epidural is in use although they may feel hungry once their pain has been relieved.

Administer intravenous fluids proactively for: Women at risk of dehydration Fasting women.

Administer intravenous fluids reactively for: Women who are not tolerating oral fluids Women experiencing persistent nausea and vomiting Women who are clinically dehydrated (ketosis).

Bladder management Encourage voiding 2 hourly with urinalysis If woman unable to void 2 hourly assess hydration and palpate for presence of

distended bladder Consider in/out catheter or IDC for women with urinary distension.

Monitor the progress of labour by: Assessing the contractions and descent of the presenting part Abdominal palpation Vaginal examination External signs of progress.

Notify medical staff of any deviations from the normal progress of labour as per Australian College of Midwives (ACM) guidelines.

Delay in the first stage - signs of delay in first stage Contractions change to incoordinated or do not become coordinated with lack of

descent, increased maternal fatigue, progress <0.5cm per hour for 4 hours or < 1 cm hour beyond 7 cms dilated consider offering artificial rupture of membranes (ARM), empty bladder and consider whether the woman may be either dehydrated or over hydrated

Failure to establish coordinated strong contractions with midwifery interventions with no signs of descent, notify medical staff.


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Recognition of delayRecognition of delay in the first stage of labour should not rely on cervical dilation alone, contraction strength and regularity, descent of presenting part on palpation and external signs of progress should all be considered with the VE findings.

Delay can be recognised when the woman is well, there is no progress (progress <0.5cm per hour for 4 hours or < 1 cm hour beyond 7 cm) in the presence of strong, regular contractions and there are no other contributing factors.

When delay in the active phase of labour is confirmed initiate, as necessary, appropriate interventions. In nulliparous women, advice should be sought from the obstetric registrar and the use of Oxytocin should be considered.

Recommend repeat abdominal and vaginal examination: After 2 hours if ARM only After 4 hours if Syntocinon commenced After 2 hours if cervix was 8cm After 2 hours if ARM +/- Syntocinon is declined Inform medical officer and midwifery team leader of ongoing progress

Continue with the labour if cervical dilatation is O.5cm- 1cm per hour, +/- descent and rotation of the presenting part, and reassuring maternal - fetal status, otherwise arrange medical review (See Appendix A).

AlertThe rate of progress of labour must be considered in the context of the woman's total wellbeing. Slow progress should alert the midwife to the possibility of abnormal labour but SHOULD NOT AUTOMATICALLY RESULT IN INTERVENTION.

Documentation: Ensure there is a clear, concise and contemporaneous record of the first stage of labour complete the following:

o admission summaryo woman's clinical recordso partogramo fluid balance chart, as appropriateo medication chart, as appropriateo update clinical pathway/outcomes summaryo enter or update BOS information.



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Section 3 – Second Stage of Labour

Clinical Practice Confirm that the cervix is fully dilated by vaginal examination on all the nulliparous

women prior to pushing unless the head is on view. Confirm that the cervix is fully dilated by vaginal examination on all multiparous women

if descent of presenting part is not evident when the woman has an expulsive urge to push for greater than 15 minutes.

Encourage woman to adopt positions that are the most comfortable for her to aid her expulsive efforts.

Ensure adequate hydration and encourage woman to void, or recommend urinary catheterisation if bladder is palpable and woman is unable to void.

ALERTContinue epidural top-ups as required in second stage of labour. Sudden return of severe pain may cause distress to the woman. Consider low dose analgesia epidural administration.

Perform and record intermittent auscultation of the fetal heart rate immediately after a contraction for at least 1 minute, at least every 5 minutes. Palpate the woman's pulse every 15 minutes to differentiate between the two heart rates (NICE, 2014).

Allow for 1 hour of passive descent if woman has no urge to push, whether epidural block (EDB) is in situ or not.

Diagnose delay in the second stage of labour:o in a nulliparous woman after 2 hours of full dilation or 1 hour of pushing.o in a multiparous woman after 90 minutes of full dilation or 30 minutes of pushing.

If the baby is in a posterior position the woman’s labour will be prolonged. It should be recognised that most babies in posterior position in second stage will rotate to an occipitoanterior but may require more time for this to occur.

Referral and consultation with medical staff and team leader should be according to ACM guidelines, and when delay in labour is diagnosed.

Determine action plan according to the women’s parity, preferences, analgesia, fetal and maternal wellbeing, and her consent to recommendations, as well as the suspected cause of delay (Appendix B).

Birth One to one midwifery care is essential during the second stage. As a safety requirement,

two clinicians should be present at the time of birth.

Documentation Partogram Integrated clinical notes Birthing Outcome Systems (BOS).


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Educational Notes Women should be informed that in the second stage they should be guided by their own

urge to push. If pushing is ineffective or if requested by the woman, strategies to assist birth can be

used such as support, change of position, emptying of the bladder and changing from spontaneous to coached pushing techniques.

There is a wide range of ‘normal’ when observing progress in labour and the following factors have been shown to promote physical labour:o Encouraging an atmosphere of calm, privacy and safetyo Offering continuity of midwifery care whenever possibleo Encouraging continuous non-professional support persons and/or doulaso Listening to the woman and acknowledging her preferences and birth plan.

The midwife needs to be alert to progress (or lack of) and refer to medical staff and midwifery team leader when delay is suspected or diagnosed.

Offering timely intervention is aimed at reducing the risk of further interventions. If an epidural is in situ the second stage is more likely to be prolonged and there is an

increased chance of an instrumental birth. A second stage of labour duration of ≥2 hours is associated with a two times risk of

postpartum haemorrhage, and appropriate prophylactic measures to reduce this risk should be taken.

Although the maximum durations for second stage of labour are stated as 4 hours for a nulliparous woman and 3 hours for a multiparous woman, these should be considered absolute maximums, particularly in cases where birth occurs in the operating theatre.

Alert: The absolute maximum time of second stage until the baby should be born is within 4 hours of onset of second stage. Within these four hours, there must be continuous assessment and surveillance.


Section 4 – Third Stage of Labour

Provision of information regarding the third stage (antenatal period and on admission for labour and birth)Women should be supported to make informed choices about care during third stage of labour and this includes benefits and risks associated with each package of care. It is best achieved when the woman has been provided with adequate information during the antenatal period.

When discussing third stage care to the woman during the antenatal period, ensure the woman has been advised of the following: Explain to the woman that active management: Shortens the third stage compared with physiological management Is associated with nausea and vomiting in about 100 in 1000 women Is associated with an approximate risk of 13 in 1000 of a haemorrhage of more than1

litre


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Is associated with an approximate risk of 14 in 1000 of a blood transfusion Fundal massage can lead to early, partial separation of the placenta and subsequent

haemorrhage and should not be attempted.

Explain to the woman that physiological management: Is associated with nausea and vomiting in about 50 in 1000 women Is associated with an approximate risk of 29 in 1000 of a haemorrhage of more than 1

litre Is associated with an approximate risk of 40 in 1000 of a blood transfusion Physiological management is not advised for women with identified risk factors for PPH.

Low risk women who are choosing this method should be prepared to have active management, if at the time of labour and birth other risk factors such as prolonged labour are identified, or heavy blood loss at birth occurs.

This discussion should occur again when the woman is admitted to the maternity unit for labour and birth to ensure she is aware of her options and to confirm her choices and to gain consent for any intervention, including active management during third stage.

At the initial assessment in labour, to ensure the woman is aware of the different options for managing third stage, and ask if she has any preferences. Document the discussion and the decision made by the woman. Assess for the presence of any risk factors for postpartum haemmorhage and provide advice to the woman and plan her care accordingly.

Active management of third stage is advised because of the lowered risk of postpartum haemorrhage and blood transfusion. However, if a woman at low risk of postpartum haemorrhage and requests physiological management of the third stage, she should be supported in her choice.

Provision of care during third stage of labourActive management After obtaining informed consent from the woman, administer 10 international units

(IU) of Oxytocin by intramuscular injection, with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is clamped and cut. Use Oxytocin as it is associated with fewer side effects than Oxytocin plus Ergometrine.

After administering Oxytocin, clamp and cut the cord after no less than 1 minute from birth. Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is significant concern about the integrity of the cord or the baby has a heartbeat less than 60 beats/minute that is not increasing.

Clamp the cord before 5 minutes in order to perform controlled cord traction (CCT) as part of active management. If the woman requests that the cord is clamped and cut later than 5 minutes, she should be supported in her choice as this is unlikely to have any significant impact on the length of third stage or blood loss

Perform controlled cord traction as part of active management only after administration of Oxytocin and only once signs of separation of the placenta are present. Avoid


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applying excessive cord traction as this may increase risk of cord separation and third stage delay.

Signs of placental separation include lengthening of the cord at the vulva accompanied by a small gush of bright blood.

Encourage the women to push her placenta out if she is having a contraction, and birth the placenta using CCT. CCT is achieved by placing one hand above the level of the symphysis pubis and apply pressure in an upward inward direction, thus stabilising the uterus by applying counter pressure. At the same time, apply gentle downward traction to the umbilical cord at 45 degrees by applying a Howard Kelly clamp to the cord, close to the introitus. As the placenta becomes visible at the introitus, traction is then applied outwards and upwards following the physiological curve. Maintain traction on the cord and deliver the placenta using gentle rotation to ease the membranes out. Ragged membranes may be trailing after the placenta so gently rotating the placenta as it is delivered will assist in delivering the membranes completely. As the third stage is completed, always carefully observe for broken or trailing membranes.

While applying CCT, if resistance is felt, release traction (do not continue to pull on the cord). Wait until the uterus is well contracted again then repeat CCT. This may take a few minutes and a few attempts.

If placenta is not delivered within 30 minutes then notify obstetric registrar (earlier if there is any concern regarding blood loss or maternal condition) and follow clinical pathway for retained placenta found on the Clinical Forms Register.

Physiological third stage management Physiological third stage management approach for labour and birth may be chosen by

healthy low risk women, after informed discussion both antenatally and at the time of admission.

This option is only suitable for women who have experienced a healthy pregnancy with normal haemoglobin, a singleton pregnancy and after uncomplicated spontaneous vaginal birth with normal progress and where the woman remains well at the end of second stage.

Women choosing this option will be educated that management will need to change to active in the event of risk factors developing during labour or in the event of heavy blood loss during or immediately after second stage.

Physiological management of 3rd stage relies on spontaneous, uterine contractions stimulated by a surge of natural oxytocin at birth. Anything that interferes with this Oxytocin release (such as a disturbed birth space, anxiety, maternal exhaustion, epidural anaesthetic, use of synthetic Oxytocin) may reduce the effectiveness of this physiological process and active management should be strongly recommended if this occurs.

Physiological third stage may take up to one hour for completion and the woman should not be left unattended during this time. Close observation of any maternal blood loss should be continuously observed. She should be encouraged to maintain skin to skin contact with her baby, encouraged to breastfeed when baby is ready and a warm quiet and private environment maintained at all times.


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At completion of 2nd stage the midwife unobtrusively observes for separation and descent of the placenta such as lengthening of the cord and a small gush of blood.

The placenta is birthed by maternal effort and gravity and the accoucheur should avoid applying traction or pulling on the cord.

No palpation or massage of fundus is attempted until the placenta has been expelled. Cord clamping should be delayed at least until the cord has stopped pulsing. Clamping

and cutting of the cord can occur after the completion of third stage unless the woman requests it is clamped sooner or to aid the woman to move with her baby to a different position, for example, moving from the bath to bed or to assist the woman to move to an upright position or to pass urine.

Cord blood may need to be collected from the fetal surface of the placenta with a needle and syringe after third stage is completed if there is insufficient obtainable from the cord due to delayed clamping.

Advise a change from physiological management to active management ifeither of the following occur: haemorrhage or the placenta is not delivered within 1 hour of the birth of the baby.

Offer a change from physiological management to active management if thewoman wishes to shorten the third stage.

Clamping and Cutting of the Umbilical CordCord clamping Ensure a plastic cord clamp is available in the birth bundle prior to birth. Record the timing of cord clamping in both active and physiological management. Before clamping the cord, milk any cord blood left in the cord back toward the infant. Attach the plastic cord clamp 1 - 2cms from umbilicus, taking care not to pull on the

umbilicus. Attach a Howard Kelly clamp to the umbilical cord 3-4 cm from the plastic cord clamp device

Offer support person/partner/woman the opportunity to cut the cord with guidance if both mother and baby are well and maternal blood loss is normal and neither are requiring emergency action.

Cut the cord using sterile scissors. If cord blood collection is required, place the maternal end of cord in a gallipot or kidney

dish and allow to drain freely to enable collection of 5 - 10ml of cord blood. If blood is required for cord gas analysis, ensure that two Howard Kelly clamps are

placed on the umbilical cord approximately 5 - 10 cm apart. These should not be removed until blood has been collected from both the umbilical vein and artery for paired cord gas analysis.

If required, collect cord blood for newborn blood group and Direct Coombs Test (DCT) in appropriate, correctly labelled blood tubes.

If the woman has advised that she is having cord blood collected for the purposes or private stem cell storage, please refer to the instructions accompanying the collection kit.

Retained placentaDiagnose a prolonged third stage of labour if it is not completed:Doc Number Version Issued Review Date Area Responsible PageCHHS15/063 1.3 10/03/2015 01/03/2019 Maternity Unit

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Within 30 minutes of the birth with active management or Within 60 minutes of the birth with physiological management.

In the event of diagnosis of prolonged third stage ensure the following occurs: Reassess for signs of placental separation and constantly monitor blood loss. Monitor maternal wellbeing and complete maternal observations of blood pressure,

pulse, respirations and colour every 15 minutes. If blood loss is excessive and third stage is not completed, move immediately to PPH

pathway (see Obstetric Emergencies clinical procedure). Do not place excessive traction on the cord as this increases the risk of cord separation,

the risk of uterine inversion, the need for manual removal and subsequent PPH. Encourage the woman to pass urine if her bladder is full or palpable or she has not

passed urine recently. Encourage the woman to keep her baby skin to skin and to breastfeed if possible, as this

will help to promote uterine contractions and completion of third stage. Encourage the woman to adopt an upright position and encourage her to attempt to

push her placenta out. Asking the woman to have a small cough or blow through a straw may help to facilitate third stage completion.

Insert IV cannula and collect blood for full blood count (FBC) and Group and hold. If the woman has had a physiological third stage up to this point, advise the woman to

have active management and with her consent give an IM injection of an oxytocin as per active management.

Commence an Oxytocin infusion only if the woman has heavy bleeding. If there is concern about the woman’s condition and/or heavy bleeding a vaginal

examination is recommended to assess the need for manual removal of placenta. She should be advised this can be painful and offered analgesia prior to an examination

During vaginal examination, if the woman reports pain, immediately stop the examination and provide analgesia before proceeding, or arrange for transfer to theatre for anaesthesia prior to further examination and or manual removal.

Do not carry out uterine exploration and manual removal of the placenta without anaesthesia.

Observations during and immediately after third stageWomen should not be left unattended after birth before the completion of third stage and until blood loss is within normal limits.

Ongoing close visual observation of the woman and newborn is required while maintaining minimal interference in maternal newborn bonding. Alter the frequency of observations as clinically indicated.

Care and Assessment: Observe breastfeeding/nipple stimulation Encourage upright position Ensure empty bladder Observe general physical condition including :Doc Number Version Issued Review Date Area Responsible PageCHHS15/063 1.3 10/03/2015 01/03/2019 Maternity Unit

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o Colouro Respirationo Vaginal Losso Woman’s self report

Following birth of placenta, assess: temperature, pulse, BP Blood Loss/lochia Fundus- if indicated, massage Placenta and membranes Perineum

Documentation: Time of birth of placenta Management, care and assessment Estimated Blood Loss Communication, advice, management plan.


Implementation

Midwives and medical staff will be aware of the differences between labour stages and current evidence relating to active and physiological management 3rd stage, through regular, mandatory updates in continuing education.

Related Policies, Procedures, Guidelines and Legislation

ACT Health Consent and Treatment policy ACT Health Consent and Treatment procedure Canberra Hospital and Health Services Obstetric Emergencies guideline Canberra Hospital and Health Services Birth Requiring the Presence of a Neonatal Team

Member clinical guideline Canberra Hospital and Health Services, Fetal surveillance practice guideline Canberra Hospital and Health Services, Epidural infusion and patient controlled epidural

analgesia (PCA) management procedure Canberra Hospital and Health Services, Perineal care clinical procedure Women, Youth and Children, collection of cord blood and tissue for private banking

procedure Women, Youth and Children, Use of baths in labour and birth procedure Women, Youth and Children, Induction of labour procedure Women, Youth and Children, Female genital mutilation procedure Australian College of Midwives (ACM) Guidelines


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ACM guidelines for consultation and referral.


References

1. Ahanya AN, Lakshmanan J, Morgan BLG, Ross MG. (2004) Meconium Passage in Utero: Mechanisms, Consequences, and Management. Obstetrical and Gynecological Survey.;60(1):45-56.

2. Anum-Somuah M, Smyth RMD, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.:CD000331. DOI:10.1002/14651858.CD000331.pub3.

3. Apantaku, 0. and Mulik, V. (2007). Maternal intra-partum fever. Journal of Obstetrics and Gynecology.: 27(1):12-5.

4. Baston H. The first stage of labour. (2004) The Practising Midwife.;7(1):32-6. McCormick C. (2003) The First Stage of Labour: Management. In: Fraser OM, Cooper MA, editors. Myles Textbook for Midwives. London: Churchill Livingstone;. p. 455-69.

5. Begley CM, Gyte GML, Murphy DJ, et al. (2011) Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews, Issue 11. Chichester: John Wiley and Sons

6. Bengly, C, Gyte, G, Devane, D, McGuire, W, Weeks A. (2011). Active versus expectant management for women in the third stage of labour (Review). The Cochrane Collaboration. Issue 11. Wiley.

7. Dixon, L, Tracy, S, Guilliland, K, Fletcher, L, Hendry, C, Pairman, S. (2013). Outcomes of physiological and active third stage labour care amongst women in New Zealand. Midwifery 29, p 67-74. Elsevier.

8. Edwards RI. (2005) Chorioamnionitis and Labor. Obstetrics and Gynecology Clinics of North America.;32:287-96.

9. Fahy, K, Hastie, C, Bisits, A, Marsh, C, Smith, L, Saxton, A. (2010). Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: A cohort study. Women and Birth 23, p 146-152.

10. Hastie, C, Fahy, K. (2009). Optimising psychophysiology in third stage of labour: Theory applied to practice. Women and Birth 22, p 89-96. Elsevier.

11. Jangsten, E, Hellstrom, A-L, Berg, M. (2010). Management of third stage of labour- focus group discussions with Swedish midwives. Midwifery 26, p 609-614. Elsevier.

12. Hodnett E D, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth (Cochrane Review). 2004. In the Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.

13. Hutton EK, Hassan ES. (2007) Late verus early clamping of the umbilical cord in Fullterm neonates: Systematic recview and metaanalysis of controlled trials JAMA (2007); 297 (11): 1241-1252 doi:10.1001/jama.297.11.1241

14. Harris, T. (2011) Care in the third stage of labour. In:Macdonald S and Magill-Cuerden J (Eds) Mayes’ Midwifery. London: Bailliere Tindall Elsevier

15. Lavender T, Hart A, Smyth R. 2009 Effect of partogram use on outcomes for women in spontaneous labour at term (Review). The Cochrane Library: (3)


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16. McDonald S J, Middleton P (2009) Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews, Issue 2. Chichester: John Wiley and Sons

17. National Institute of Clinical Excellence (NICE) (2014) Intrapartum Care: care of healthy women and their babies. London: NICE https://www.nice.org.uk/guidance/cg190

18. National Institute for Clinical Excellence (2007). lntrapartum care. Care of healthy women and their babies during childbirth. London.

19. NHS, Quality Improvement Scotland. Pathways for maternity care. Keeping Childbirth Natural and Dynamic programme. 2009.

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22. Women and newborn health service, King Edward memorial hospital, Section B Obstetric and midwifery guidelines. intrapartum care http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/5/b5.9.1.pdf

23. National Institute of Clinical Excellence United Kingdom Clinical Guideline 2007. Guidelines for intrapartum care.

24. Royal Womens’s Hospital, Melbourne:2010 Clinical Practice Guideline Care during Second Stage of Labour.

25. Frigoletto, FD Jr.,Lieberman, E. et al. 1995 A clinical trial of active management of labor New England journal of Medicine 333(12):745-750

26. Zhang, J. et al (2010) Contemporary Patterns of Spontaneous Labour with Normal Neonatal Outcomes Obstetrics and Gyaecology 116(6): 1281-7

27. Meconium Aspiration Syndrome: https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/neonatal-ehandbook/conditions/meconium-aspiration-syndrome

28. Halliday, H. Sweet, D. 2009 The Cochrane library, Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term

29. International Guidelines for Neonatal Resuscitation: Paediatrics, 201030. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

(2014). lntrapartum Fetal Surveillance Clinical Guideline. 3rd ed. Melbourne.31. Jones L1, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T,

Neilson JP. (2012) Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012 Mar 14;(3):CD009234. doi: 10.1002/14651858.CD009234.pub2.

32. Derry S, Straube S, Moore RA, Hancock H, Collins SL. (2012) Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour. The Cochrane Library (Published 18 January, 2012)

33. Labour and birth—sterile water injections for relief of back pain in labour. http://brochures.mater.org.au/home/brochures/mater-mothers-hospital/sterile-water-injections-for-relief-of-back-pain-i . 2012 Mater Misericordiae Ltd. ACN 096 708 922


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https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/neonatal-ehandbook/conditions/meconium-aspiration-syndrome



http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/5/b5.9.1.pdf

http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/5/b5.9.1.pdf

https://www.nice.org.uk/guidance/cg190

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34. Hutton EK, Kasperink M, Rutten M, Eitsma A, Wainman B (2009) Sterile water injection for labour pain: a systematic review and meta-analysis of randomised controlled trials. British Journal of Obstetrics and Gynecology (Published Online: 14 May, 2009).


Definition of Terms

Physiological management: involves no prophylactic uterotonic drug administration, no cord clamping until after the placenta has been delivered and no cord traction.

Expectant management: The birth of the placenta and membranes are expelled by maternal effort only and without using uterotonic agents or controlled cord traction.

Active Management: the administration of a prophylactic uterotonic drug around the time of the baby’s birth, clamping and cutting of the umbilical cord and controlled cord traction to expedite delivery of the placenta and membranes.

Mixed/piecemeal management: Mixed or piecemeal management is the term used to describe care involving one or two components of active management.

Delayed cord clamping: is carried out more than one minute after the birth or when cord pulsation has ceased. This allows blood flow between the placenta and neonate to continue.

Midwifery guardianship: is premised on the assumption that what women and midwives think, feel and imagine has actual physiological effects. Midwifery Guardianship aims to optimise the woman’s reproductive psychophysiology. The midwifery guardian’s focus is on nurturing the woman’s sense of confidence and safety through a trusting relationship within which the woman’s attitudes, values and beliefs are respected and of primary importance.

Cascade of intervention: describes how accepting one medical intervention or test during the intrapartum period can create a flow on effect leading to more interventions like a domino effect.

Third stage of LabourThe third stage of labour is the time from the birth of the baby to the expulsion of theplacenta and membranes.

Active management of the third stage involves a package of care comprising thefollowing components: Routine use of uterotonic drugs Delayed clamping and cutting of the cord for at least 60 seconds Controlled cord traction after signs of separation of the placenta.

Physiological management of the third stage involves a package of care that


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includes the following components: No routine use of uterotonic drugs Delayed clamping of the cord until pulsation has stopped Delivery of the placenta by maternal effort.

Prolonged third stageDiagnose a prolonged third stage of labour if it is not completed: Within 30 minutes of the birth with active management or Within 60 minutes of the birth with physiological management.


Search Terms

Third stage of labour, 3rd stage, Placenta, Retained placenta, Cord clamping, Labour, Meconium Liquor, Water Injections


Attachments

Attachment 1: First Stage of Labour CareAttachment 2: Second Stage Labour CareAttachment 3: Sterile water Injections for labour pain relief

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services, Women, Youth and Children Division specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.


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Date Amended Section Amended Approved By31 August 2015 Minor amendments to entire

documentCHHSPC Chair

23 June 2016 Minor amendment to Section 2 – addition of the need for 2 clinicians to be present at birth

CHHS Policy Team

24 Jan 2018 Information pertaining to Meconium Stained Liquor and Water for Injections added

CHHS Policy Committee


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Attachment 1: First Stage of Labour Care


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Attachment 2: Second Stage Labour


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Attachment 3: Sterile water Injections for labour pain relief

BackgroundWomen can experience low back pain in labour, often described as persistent, severe and intractable in contrast to the rhythmic intensity of uterine contractions. As this pain is felt continuously, it often affects a woman’s ability to relax between contractions. Sterile water injections may play a role in relieving this low back pain in labour.

The mode of action of sterile water injections is understood by the gate control theory of pain. Low back pain arises due to stimulus of the C afferent nerve fibres. Hypotonic sterile water causes firing of the A-delta fibres, which overwhelms the input from the C fibres such that the back pain is no longer noticeable. This painful stimulus may also cause endorphin release.

Advantages: Inexpensive, requires only basic equipment, can be performed by a midwife, and appears to have few side effects, often immediate effect, no effect on mother’s consciousness and no effect to baby, allows for continued mobility, will not affect labour progress, and can be repeated as needed.

Disadvantages: Possibly only useful for back pain in labour, transient pain at injection site, minimal robust evidence to support use. Procedure: A small bleb of 0.1- 0.2mL of sterile water is placed intracutaneously at four sites approximately corresponding to the borders of the sacrum (marked by Michaelis’ rhomboid). As the injections are associated with an acute pain response, ideally they are timed to coincide with the height of a contraction. The pain at the site lasts approximately 30 seconds, and it is purported that as the acute pain begins to subside, so too does the back pain. The effect lasts for two to three hours.

Recommended placement of sterile water injections in lower back region.


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