Care of patient in the labor room from admission till discharge 

1. TITLE:

Care of patient in the labor room from admission till discharge 

2. PURPOSE:

To provide an evidenced based management and care for all pregnant patient admitted in Labor and Delivery Unit.

3. CONDITION/APPLICABILITY: 

1. A thorough revision and update of the guidelines should be carried out every three  (3) years or as required.

2. The guidelines should be read, understood and acknowledged by all the responsible staff in the department.

4. DEFINITIONS:

4.1. Multiparous- A woman who had two (2) or more pregnancies resulting viable offspring.

       4.2. Grand Multipara- A woman who had four (4) or more pregnancies resulting viable offspring

       4.3. Nulliparous – A woman who never delivered a baby.

    4.4. Latent first stage of labor – a period of time starts when there are painful contractions and there is some cervical change, including cervical effacement and dilatation up to 6 cm.

   4.5. CTG  monitoring follow the policy of intrapartum fetal monitoring 

4.6.The Bishop score: The cervical assessment system used in clinical practice, the score based upon the station of the presenting part and four characteristics of the cervix: dilation, effacement, consistency, and position.

4.7.  Episiotomy-  See policy LAD-025

4.8. high risk patient 

1. Patient with active antepartum hemorrhage.

2. Patients with revealed thick meconium stained liquor, regardless of cervical dilatation.

3. Patients with severe pre-eclampsia, Eclampsia.

4. Patients in labor with uncontrolled medical “cardiac disease , SLE ,thromboembolic disease ,sickle cell disease “or surgical disease.

5. Patients in active preterm labor (<37 weeks of gestation with cervical dilatation of > 3 cm and effacement of 75%).

6. Patients with non-cephalic presentation in active labor.

7. Patients with previously scarred uterus in active labor.

8. Patients with multiple pregnancy in active labor.

9. Clinically suspected fetal macrosomia or intra –uterine growth restriction.

10. Patient with paraplegia/hemiplegia in early labor.

4.9. Low risk cases are patients in labor at ≥ 37 weeks of gestation with no obstetric or non-obstetric risk factor.

5. POLICY: 

   1. This policy explains the process of admission to the labor room and responsibilities of nurses and doctors for the follow up of the patient

6. PROCEDURE:

6.1. The responsibilities of Labor and Delivery:

6.1.1. The Nurse responsibility 

          6.1.1.1.Nurse should receive the patient and welcoming her and tell the patient her right “ treat her with respect and dignity ,and to take her permission before examination and to explain any procedure”

6.1.1.2.Nurse should inform the resident/registrar if any of the following occur 

      6.1.1.2.1. pulse over 120 beats/minute on 2 occasions 30 minutes apart

      6.1.1.2.2. a single reading of either raised diastolic blood pressure of 90 mm Hg or more  or raised systolic blood pressure of 140 mm-Hg or more

      6.1.1.2.3. a reading of 2+ of protein on urinalysis 

      6.1.1.2.4. temperature of 38°C or above on a single reading, or 37.5°C or above on

                                 2 consecutive readings 1 hour apart

      6.1.1.2.5.any vaginal blood loss 

      6.1.1.2.6. the presence of meconium 

       6.1.1.2.7.pain reported by the woman that differs from the pain normally   

                 associated with contractions

            6.1.1.2.8.  any abnormal presentation, including cord presentation , transverse or    

               oblique lie ,free-floating head in a nulliparous woman － suspected fetal 

                                     growth restriction or macrosomia , suspected anhydramnios or 

                                     polyhydramnios 

    NB: The midwife can directly contact the consultant or  registrar regarding any abnormality in patient condition or progress if the Registrar /residents are busy or prompt  decision is necessary.

 6.1.1.2. CTG abnormality 

          Inform the resident on call in any of the suspicious or abnormal feature see the LAD-024

6.1.2. The Consultant responsibility 

          6.1.2.1. Consultant should do two rounds with the on call team” senior registrar &resident” at 8 AM and 4 pm in labor word or if needed more.

          6.1.2.2. Consultant should attend in the following situation 

                   6.1.2.2.1. If the patient develops eclampsia 

                   6.1.2.2.2. If the patient develops uncontrolled postpartum hemorrhage 

                   6.1.2.2.3. If the patient has pulmonary embolism

                   6.1.2.2.4.  If the patient has postpartum collapse  

                         6.1.2.2.5. If the patient required exploration in OR 

                         6.1.2.2.6. whenever he asked by registrar to attend 

                   6.1.2.2.7. 3rd and 4th degree perineal laceration 

                   6.1.2.2.7. Anticipated difficult cesarean sections (e.g. transverse lie

, dense adhesions, fibroid,2nd stage cesarean section, previous one cesarean section or more, scar uterus, placenta previa, preterm in labor).

6.1.3. The registrar responsibility

     6.1.3.1. The Registrar must inform the Consultant on duty and discuss the line of       

                  management in the following situations.

6.1.3.1.1 All proposed surgeries.

      6.1.3.1.2. Medically complicated cases.

6.1.3.1.3. Major deviation from accepted practice.

6.1.3.1.4. Inform the consultant in all obstetric emergency and complication.  

6.1.3.1.5. Registrar should do round with resident in labor word to follow the progress of labor as needed.

6.1.4. Resident responsibility 

           6.1.4.1. resident should attend the patient within thirty (30) minutes of admission.

and should introduce himself to the patient and take permission before examination and do counselling about the plan of management including the availability of analgesia and epidural anesthesia, possible complication of normal vaginal delivery including instrumental delivery complication ,2nd 3rd perineal tear, shoulder dystocia, and postpartum hemorrhage.

         6.1.4.2. Resident should review the patient antenatal records, the vital signs and follow up the results of the requested investigations within two (2) hours of sending samples to laboratory.

         6.1.4.3. follow up the patient progress and inform the registrar if there is any abnormal CTG finding, or abnormal progress of labor Vaginal examination need not to be repeated unless found necessary (patient bearing down, spontaneous rupture of membranes, abnormal cardiotocograph tracings etc.).

        6.1.4.4. Residents are allowed to perform certain procedures under the supervision of the Registrar, Senior Registrar or Consultants including; cesarean sections, 

instrumental deliveries and assisted breech deliveries.

6.1.4.5. Episiotomies and perineal lacerations are to be repaired by residents under supervision of registrar.

     6.1.4.6. Residents covering Labor and Delivery Unit should inform the registrar 

immediately if:

6.1.4.6.1. Abnormal Cardiotocography (CTG) tracing.

6.1.4.6.2. Vaginal examination repeatedly showing no progress.

6.1.4.6.3. Meconium stained liquor.

6.1.4.6.4. Cord prolapse or presentation.

      6.1.4.6.5. Full cervical dilatation with intact membranes and fetal not engaged.

6.1.4.6.6. Primigravid in second stage for more than two hour or multigravida in the 

second stage for more than one hour.

      6.1.4.6.7. Intrapartum hemorrhage.

       6.1.4.6.8. Shoulder dystocia.

6.1.4.6.9. Prolonged third stage of labor for more than thirty (30) minutes.

6.1.4.6.10. Incompletely delivered placenta.

6.1.4.6.11. Postpartum hemorrhage.

6.1.4.6.12. Deviation of maternal vital signs from normal.

6.1.4.6.13. Extended episiotomy or third- or fourth-degree perineal tear.

6.1.4.6.14. Neonatal birth trauma, flat baby, apparent congenital abnormality.

               NB: The midwife can directly contact the registrar regarding any abnormality in

 patient condition or progress if the Residents are busy or prompt registrar decision is necessary.

6.1.5. hand over in labor room 

 6.1.5.1. At the time of the changing of the shifts, the nurse should review all the cases at Labor and Delivery Unit before handover to the coming shift using ISBAR Handover Communication Tool.

6.1.5.2. At the time of the changing of the shifts, the specialist and resident/s should review all the cases at Labor and Delivery Unit before handover to the coming shift using ISBAR Handover Communication Tool 

6.2. Managing the patient in labor  

6.2.1. Patient admitted to the labor room 

         6.2.1.1.all the patient will be received by nurse welcoming and history and examination should be done and documented, and she should inform the resident about the presence of the case, low risk cases should be assessed and examined within one hrs. of the admission, BUT high-risk patient should be assessed and examined immediately 

         6.2.1.2. All patients in active labor should be managed in Labor and Delivery Unit.

                      A positive diagnosis of labor should be made as soon as possible following 

                     admission to the labor room by abdominal palpation and vaginal examination

2. Antepartum hemorrhage with active hemorrhage

3. . Severe hypertension at >20 weeks of gestation and/or patient with severe pre-eclampsia /eclampsia.

       6.2.1.4. Patient with postpartum delivery in Accident & Emergency Department

       6.2.1.5. patient in latent phase and need pain management or require monitoring due to 

                     suspicious CTG.

      6.2.1.6. monitoring of high risk under induction of labor. 

 In a condition that Labor and Delivery Unit is full and cannot accommodate the laboring patient and the delivery is imminent the Accident and Emergency-Labor Room or word  shall be utilized. 

6.2.2. intrapartum monitoring and management  

         6.2.2.1. At all times the patient should be informed of the procedures being undertaken 

                      and the findings by the treating physician.

        6.2.2.2. Management of Labor

                    6.2.2.2.1. Upon admission to Labor and Delivery Unit

                    6.2.2.2.2. The physician shall update the obstetric and medical history.

                    6.2.2.2.3. General and Obstetric examination should be performed.

                    6.2.2.2.4. The Partogram shall be initiated as soon as the patient admitted in 

                         Labor and Delivery Unit (see” Guidelines on Partogram) by the midwives    

                         assigned to the patient.

                   6.2.2.2.5. assessment of patient’s labor progress “every 4 hours in primigravida and every 2 hours in multi gravida and previous cesarean section OR sooner if indicated” with the resident and to document the patient progress, and plotting on the patient’s partogram by mid wife or “nurse”. 

                   6.2.2.2.6. Cardiotocography tracing review every 30 min in 1st stage of labor and every 15 min in the 2nd stage of labor by resident on call.

                 6.2.2.2.7. high risk patient induce in the labor word should use Bishop Score  

6.2.3. Hygiene in Labor.

      6.2.3.1. Use tap water for cleaning prior vaginal examination.

     6.2.3.2. Single use non-sterile gloves is appropriate in intact membrane.

6.2.4. pain relives 

          6.2.4.1. Advise the woman for breathing exercises, and massage may reduce pain during the 

                           latent first stage of labor. 

         6.2.4.2. discusses with the patient the availability of deferent modality of pain  

                      management “policy of pain management “in the active stage of labor. 

         6.2.4.3. Analgesia: refer to “Guidelines on Analgesia in Labor “

6.2.5. Intravenous Fluids

6.2.5.1. Nurses are responsible for setting up intravenous fluids 

      using large IV cannula size 16 or 18 G (if it is not initiated) and take blood samples. IV Ringer Lactate should be set at a rate of 125/hr. or 500 ml/ 4 hr” consider IV fluid restriction in specific situation like sever PET, cardiac patient “.

  6.2.5.2. In case of hemorrhage, IV crystalloid-Ringer lactate or 0.9% Normal 

Saline to be started.

6.2.6. Nutrition in Labor  

 6.6.1. offer dry tray for patient with latent phase.

6.6.2. Offer water/clear liquid diet for patient with active labor, or Trial of Labor After Cesarean (TOLAC).

6.6.2. regular diet allowed after delivery if labor was entirely normal.

6.2.7. Antacid in labor 

            6.2.7.1. Consider Pantoprazole tablet 20 mg or injection 40 mg iv for those who 

                          receives opioids.

6.2.8. Admission Investigation / Order:

 6.2.8.1. Cardiotocograph (CTG) for thirty (30) minutes.

 6.2.8.2. Complete Blood Count, blood type &Rh incompatibility screen, group and save and   cross match in high risk patient and, serology (rubella and hepatitis, HIV) coagulation profile for epidural, serum electrolyte for high risk.

     6.2.9. Uterine Activity Assessment: 

 6.2.9.1. Palpation and external/electronic methods can be used to monitor 

uterine activity. Palpation yields information about frequency ( 

number in ten (10) minutes), duration (in seconds) and relative 

intensity.

6.2.9.2. External monitoring provides recording of frequency and duration but not the intensity. The sensitivity adjustment of the topography is adjusted to a resting pressure of 10-20 mmhg.

6.2.8.6. The recording gives a relative reading and cannot be used to define actual strength of the contractions. Maternal weight, maternal position during recording of the pattern, maternal and fetal movement and tightness of the belt may all alter the reading.

6.2.10. Duration and progress of the 1st Stage of labor:

                  6.2.10.1. The active first stage usually takes up to 8-12 hours in a primipara 

                  6.2.10.2. The active first stage usually takes up to 6-8 hours in multipara.

            6.2.10.3. Latent phase; painful contractions and dilatation up to four (4-6) cm.

            6.2.10.4. Assessing the rate of cervical dilatation and descent of presenting part 

is the most accurate method of assessing progress in labor. 

6.2.10.5. Established first stage; 4-5 regular painful contractions in 10 minutes lasting for more than thirty (30) seconds and cervical dilatation from dilatation of 0.5-1.2-cm per 

hour is considered adequate progress in labor.

6.2.10.6. Routine observations 4 hourly  for temperature, blood pressure, hourly pulse rate and urine analysis on admission.

6.2.10.7. Vaginal examinations to be performed (every four hours for primigravida and every two hours for multigravida , provided that   contractions are regular) and cardiotocograph (CTG) monitoring for all patients in labor and delivery unit.

6.2.10.8.Abnormal progress of labor in the 1st stage  is indicated by :

                       6.2.10.8.1.Lack of cervical dilatation  (less than two (2) cm in four (4)  hours in primigravida and less than one cm every 2 hrs in multigravida and previous cesarean section ) over two consecutive examination as indicated on the partogram.

                  6.2.10.8.2..No Descent or rotation of the fetal head.

                 6.2.10.8.3.Changes in strength, duration and frequency of uterine contractions.

6.2.11. Duration and progress of the 2nd  Stage of labor

6.2.11.1. Assess progress hourly by vaginal examination.

6.2.11.2. In passive stage; allow one hour for head descent in the presence of regional 

anesthesia or absence of involuntary expulsive contractions.

6.2.11.3. Nulliparous Women 

6.2.11.3.1.Birth would be expected to take place within three (3) hours  of the 

start of the active second stage in most women.

6.2.11.3.2..A diagnosis of delay in the active second stage should be made when 

it has lasted for two (2) hours without epidural and three hours with epidural  and women should be referred to a Senior Resident On-call Obstetrician/ Senior Registrar Obstetrician to 

undertake an operative vaginal delivery or Cesarean section  if birth is not imminent.

6.2.11.6. Multiparous Women

6.2.11.6.1. Birth would be expected to take place within two (2) hours of the 

start of the active second stage in most women.

6.2.11.6.2.A diagnosis of delay in the active second stage should be made when 

it has lasted one hour without epidural and two hours with epidural and women should be referred to a Senior 

Obstetrician On-call to do assessment and decide on the mode of deliver.

6.2.11.7. Routine regular observations; hourly blood pressure, maternal pulse rate, four (4) hourly temperature. Regular check and document frequency of bladder emptying.

6.2.11.8. Management of Delay in Progress

           6.2. 11.8.1. Review of the history and patient records; abdominal palpation for lie, presentation and station; fetal size; frequency and duration of contractions.

          6.2. 11.8. 2. Review the Fetal heart record recording or cardiotocograph (CTG) and the color and 

                            quantity of the liquor if membranes have been ruptured. Maternal hydration 

                             and analgesia should be reviewed.

          6.2. 11.8.3.A vaginal assessment should identify the presentation and, if vertex, the 

                             caput, molding and the position. The station of the leading bony skull and 

                             degree of flexion should be noted along with assessment of the bony pelvic 

                              adequacy.

      6.2. 11.8. 4. Oxytocin should be considered if contractions is inadequate and the  registrar shall be informed.

       6.2. 11.8.5. In grand multiparous women and in women with a uterine scar, the Senior 

                         Obstetrician should review the case prior to commencement of Oxytocin.

        6.2. 11.8.6. The management option is delivery by Lower Segment Cesarean Section    

                     (LSCS) if there is obvious Cephalopelvic Disproportion (CPD) or fetal distress

6.2. 11.8.7. If uterine activity is inadequate with no contraindications for augmentation with oxytocin infusion should be started according to the protocol aiming at 3-4 contractions /ten (10) minutes each lasting for at least thirty (30) seconds.

6.2.12. If the patient has CTG abnormality should be manage according to the classification  see the LAD-024

6.2.13. amniotomy 

        6.2.13.1. advice not to performing amniotomy routinely in patients in spontaneous labor.

        6.2.13.2. patient induce or develop abnormal feature in CTG advice to do   

                     amniotomy to clear if the patient have meconium or bloody liquor 

6.3. delivery procedure 

6.3.1. Residents are allowed to deliver the patient under supervision, but if there is any difficulty or complication arise during the delivery registrar should take over.

       6.3.2. Senior resident ”R3,R4,R5” are allow to conduct instrumental deliveries and assisted breech deliveries under supervision .

6.3.3.The Registrar should attend (conduct or supervise) the delivery of all high- risk 

cases.

6.3.4. Vaginal Delivery 

6.3.5.in case if  the women became fully dilated and non of the doctors available “busy in other emergency situation  “ nurse/midwife  can take over  till the doctor be available 

      6.3.5. patient high risk should be deliver by registrar/senior registrar/consultant 

                 6.3.5.1.Patients clinically suspected large babies (Senior Obstetrician).

           6.3.5.2.. Patients with twin pregnancy (Senior Obstetrician).

           6.3.5.3. Instrumental Deliveries 

           6.3.5.4. breech delivery.

           6.3.5.4.Instrumental delivery shall be documented in operative delivery 

                               sheet by the doctor who performed the procedure (refer to Guidelines for   

                                Instrumental delivery).

6.3.6. Episiotomy 

See policy LAD-025

6.4. Management of the Third Stage of Labor

            6.4.1. Active Management Recommendations:

                 6.4.1.1. Give 5 “u” oxytocin IM or slow Intravenously OR 

                 6.4.1.2. Syntometrine 500 microgram Methergin/ 5 IU synthetic oxytocin OR 

                 6.4.1.3. Methergin (0.4 mg intramuscular) with the delivery of anterior 

                        Shoulder, Methergin  is contraindicated in hypertensive and  with cardiac disease patient, and sickle cell disease.

6.4.1.4. Delivery of the placenta should be done by obstetrician conducted the delivery by controlled cord traction within two (2) minutes after administration of oxytocin or  Syntometrine.

6.4.1.5.The placenta and membranes must be examined by physician or any 

two nurses present during delivery.

6.4.1.6. The resident should call the registrar to examine the patient if there is delay in 

the delivery of placenta for more than thirty (30) minutes and/or if excessive 

bleeding is seen.

6.4.1.7. Epistolary repair ,refer to the policy of repair of episiotomy and perineal tear  

 6.4.1.8. Discharge /Transfer of patient from the Delivery Room to Obstetric Ward.

              6.4.1.8.1. For uncomplicated deliveries; mothers may be transferred to Postpartum 

              area by the assigned nurse within one hour after delivery after the assessment of 

              resident on call .

              6.4.4.8.2. complicated cases need to be assessed by registrar before transfer to the 

                            word 

6.4.1.10. Transfer of baby to nursery as soon as possible after bonding and breast feeding

6.4.1.11.Vital signs must be taken every 15 min , uterine contractility and amount of lochia 

should be observed while in postpartum area at Labor and Delivery and patient 

status should be documented by nurse ,if there is any abnormality should inform the resident /registrar for evaluation .

6.4.1.12. Postpartum patient must be voided prior to transfer out of Labor and Delivery 

             Unit

6.4.1.13. Postpartum patient should be assessed included VTE  risk assessment /reviewed by residents one hours and documentation should be done. 

6.4.1.14. Postpartum orders must be written by residents for all patients before    

transferring the patient, including CBC  12 hrs postpartum.

6.4.1.15. Following uncomplicated deliveries, patients are routinely transferred to 

obstetric ward by midwife.

6.4.1.16. complicated and high-risk patient can be kept in observation till further order from registrar on call.

6.4.1.17. if the patient needs close monitoring, without need to stay in labor room for intra venous  medication registrar can order close monitoring in the word and single room if needed, head nurse should be contact to arrange for close monitoring .

6.4.1.18. critical patient need follow up should be transfer to ICU after communicating with ICU doctor.

6.4.1.18. The following information must be documented and available in patient’s 

medical record before discharge from the delivery room.

                  6.4.1.18.1. Completed assessment and re-assessment.

                  6.4.1.18.2. Completed Partogram.

                  6.4.1.18.3. Secured cardiotocography tracing paper.

                  6.4.1.18.4. Initial neonatal assessment.

                  6.4.1.18.5. Delivery summary including method of delivery, date and time of 

                  delivery, name and designation of the midwife/nurse or obstetrician who 

                  conducted the delivery and any assistants, type of anesthesia or 

                  sedation used on delivery, neonatal outcome, umbilical cord pH if needed status    

                  of placenta and membranes, any postpartum instructions and postpartum    

                 observations and discharge criteria. 

                 6.4.1.18.6. VTE risk assessment and documentation in the file.

7.RESPONSIBILITY:

   All the physician and nurses in labor and delivery room 

8. FORMS/EQUIPMENTS

9. REFERENCE:

7.1CBAHI Saudi Central Board for Accreditation of healthcare Institutions, National Hospital Standards, Labor and Delivery, Third Edition 2015 Effective January 1,2016.

1. JCI Accreditation Standards for Hospital 5th Edition 2014.

2. Guidelines for Obstetrics and Gynecology, Kingdom of Saudi Arabia Ministry of Health Assistant Deputyship Minister for Hospital Affairs General Directorate of Hospitals 2012.

3. NICE Intrapartum Care, Care of Healthy Women and their babies During Childbirth February 2017.

4.  Doctor’s order –MSD –H-1-COP-001.

5. Initial Patient Assessment (Medical, Nursing and others)- MSD-H-1-AOP-001.

6. Hand off / Hand Over Communication - MSD-H-1- IPSG- 007.

10. REVISION:

1. REVISION:

2. APPROVALS: