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Guideline: Normal Birth Queensland Health Maternity and Neonatal Clinical Guideline Normal birth Queensland Clinical Guideline: Normal birth Document title: Normal birth Publication date: November 2017 Document number: MN17.25-V3-R22 The document supplement is integral to and should be read in conjunction Document supplement: with this guideline Amendments: Full version history is supplied in the document supplement Amendment date: June 2018 Replaces document: MN17.25-V2-R22 Author: Queensland Clinical Guidelines Health professionals in Queensland public and private maternity and Audience: neonatal services Review date: November 2022 Queensland Clinical Guidelines Steering Committee Endorsed by: Statewide Maternity and Neonatal Clinical Network (Queensland) Email: [email protected] Contact: URL: www.health.qld.gov.au/qcg Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: · Providing care within the context of locally available resources, expertise, and scope of practice · Supporting consumer rights and informed decision making, including the right to decline intervention or ongoing management · Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary · Ensuring informed consent is obtained prior to delivering care · Meeting all legislative requirements and professional standards · Applying standard precautions, and additional precautions as necessary, when delivering care · Documenting all care in accordance with mandatory and local requirements Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. © State of Queensland (Queensland Health) 2018 This work is licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 Australia. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en For further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected], phone (07) 3131 6777. For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479. Refer to online version, destroy printed copies after use Page 2 of 42 Queensland Clinical Guideline: Normal birth Flow Chart: Initial assessment Care is woman centred and includes informed choice, consent, privacy and respectful communication. Contemporaneous documentation is essential. Pregnant woman with signs of labour at term Discuss, consult, refer, manage Initial contact # as per professional and · Reason for presentation/contact Queensland guidelines · Preferences for labour and birth · Emotional and psychological needs Review history · Verbal Yes · Pregnancy Health Record · Obstetric, gynaecological, medical, surgical, social · Investigations and results · Medications and allergies Risk · Pregnancy complications factors? · Psychosocial, cultural and spiritual Contractions · Time commenced · Duration, strength, frequency and resting tone No Maternal observations · Temperature, pulse, respiratory rate, BP · Urinalysis Triage · Nutritional and hydration status stage of labour · General appearance Abdominal assessment · Observation and palpation · Fundal height, lie, presentation, attitude, position, engagement/descent, liquor volume Fetal wellbeing · Ask about fetal movements · Auscultate FHR towards the end of contraction Not yet in labour and continue for at least 30‒60 seconds after Antenatal assessment contraction finished · Differentiate fetal heart beat from maternal pulse Vaginal loss · Nil, discharge, liquor, blood · Note colour, odour, amount, and consistency Vaginal examination First stage · If stage of labour uncertain, may assist decision Refer to flow chart: making Normal Birth – First stage · Consider speculum examination if SROM Discomfort and pain · Reassure, promote, reinforce coping strategies · Assess response to contractions · Review birth plan and note preferences · Discuss advantages/disadvantages of options Second stage Repeat contacts Refer to flow chart: · Review entire contact history and clinical Normal Birth–Second stage circumstances with each contact · Refer/consult/request woman to present for assessment as required BP: blood pressure, FHR: fetal heart rate, VE: vaginal examination, SROM: spontaneous rupture of membranes, # Australian College of Midwives: National Midwifery Guidelines for Consultation and Referral. 3rd Edition, Issue 2. 2015 Queensland Clinical Guidelines: Normal birth. Flowchart version: F17.25-1-V2-R22 Refer to online version, destroy printed copies after use Page 3 of 42 Queensland Clinical Guideline: Normal birth Flow Chart: First stage Care is woman centred and includes informed choice, consent, privacy and respectful communication. Contemporaneous documentation is essential. First stage Latent first stage in the low risk woman at term Irregular painful contractions and some cervical effacement and dilatation less than 4–6 cm · Complete an initial assessment · Reassure latent phase is normal · Offer individualised support about rest, Regular hydration, nutrition painful contractions · Advise mobilisation may establish contractions No AND some cervical · Discuss comfort strategies and their risks and effacement AND benefits dilatation of at least · Involve support people/partner 4–6 cm? · Offer admission or return/remain at home according to individual need/circumstances · Provide information on when to return to Yes hospital and/or notify healthcare professional o Increasing strength, frequency, duration of Active first stage contractions o Requiring pain management Supportive care o Vaginal bleeding, rupture of membranes · Consider measures to promote, protect and o Reduced fetal movement support normal birth including: o Any concerns o One-to-one midwifery support · Plan an agreed time for reassessment o Review birth plan o Environment (privacy, calmness, setting) o Mobilisation and positioning o Involve support people/partner o Comfort and pain management strategies Discuss, consult, refer, manage Ongoing (following initial) assessment # · Maternal and fetal condition as per professional and · Progress and descent of the fetal head Queensland guidelines · FHR: every 15–30 minutes intermittent auscultation Yes o Differentiate from maternal pulse · Temperature and BP: 4 hourly · Maternal pulse: every 30 minutes Risk · Abdominal palpation: 4 hourly, prior to VE and factors or as required to monitor progress diagnosis of · Contractions: every 30 minutes for 10 minutes delay? · Vaginal loss: hourly · Offer VE: 4 hourly and if indicated · Nutrition as desired and encourage hydration No · Bladder: monitor/encourage 2 hourly voiding · Emotional coping, discomfort and pain · Continue care as per active first stage · Anticipate vaginal birth Delay in active first stage · Identify commencement of second stage · Protracted labour―cervical dilatation of: o Nulliparous: < 2 cm in 4 hours o Multiparous: < 2 cm in 4 hours or a slowing of progress · Arrest in labour: with cervical dilatation of ≥ 6 cm and ruptured membranes―there is no Second stage Refer to flow chart: or limited cervical change after 4 hours of Normal Birth—Second stage adequate contractions BP: blood pressure, FHR: fetal heart rate, VE: vaginal examination, >: greater than, ≥: greater than or equal to, <: less than # Australian College of Midwives: National Midwifery Guidelines for Consultation and Referral. 3rd Edition, Issue 2. 2015 Queensland Clinical Guidelines: Normal birth. Flowchart version: F17.25-2-V2-R22 Refer to online version, destroy printed copies after use Page 4 of 42 Queensland Clinical Guideline: Normal birth Flow Chart: Second stage Care is woman centred and includes informed choice, consent, privacy and respectful communication. Contemporaneous documentation is essential. Second stage (full dilatation) in the low risk, Passive second stage term woman Full cervical dilatation without the urge to push Care and assessment · FHR: every 15 minutes o Differentiate from maternal pulse Baby visible No · Delay pushing if no urge to push or urge to · Other care and assessment as per active push second stage Delay in passive second stage Yes · In 1
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