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Labor Care Quide By WHO 2025-08-07 .pptx
- 1. 2018 new WHO Recommendations: Intrapartumcare for a positive childbirth experience WHO Labour Care Guide (LCG) WHO LCG User’s Manual WHO Recommendations
- 2. Guiding principles ofthe WHO LCG Labour and childbirth should be individualized and woman-centered No intervention should be implemented without a clear medical or obstetric indication Only interventions that serve an immediate purpose and are proven to be beneficial should be promoted A clear objective that a positive childbirth experience for the woman, the newborn and her family should be at the forefront of labour and childbirth care at all times
- 3. This tool : Establishesessential good-quality and evidence-based clinical care in all settings Expands the focus of labour monitoring to non-clinical practices that promote a positive childbirth experience for every woman and baby. Respectful Care Definitions, Duration, and Progress of First Stage Effective Communication Labour Companionship Labour Care Guide:
- 4. WHO Labour CareGuide: Aims Guide the monitoring and documentation of the well-being of women and babies and the progress of labour Guide health personnel to offer supportive care throughout labour to ensure a positive childbirth experience for women Assist health personnel to promptly identify and address emerging labour complications, by providing reference thresholds for labour observations that are intended to trigger reflection and specific action(s) if an abnormal observation is identified Prevent unnecessary use of interventions in labour Support audit and quality improvement of labour management
- 5. Use of theWHO LCG: For whom? When? Where? For whom? • All women, regardless of their risk status. • High-risk women many require additional and specialized monitoring and care. When? • Initiated when the woman enters the active phase of the first stage of labour (5 cm or more cervical dilatation), regardless of her parity and membranes status Where? • All levels of care in health facilities • The plan of action will vary depending on level of care.
- 6. Structure of theWHO LCG
- 8. Labour monitoring toaction
- 9. Sections of theLCG Refer to page 2 of Aisha’s case study for a copy of the LCG. After I read the title of a section, list the parameters to assess for that section. • Section 1: Identifying information and labour characteristics at admission • New recommendations: DO NOT conduct routine clinical pelvimetry on admission of healthy pregnant women in labour. 1. What are some obstetric risk factors with implications for care provision and potential outcome of labour management? 2. What are some medical risk factors with implications for care provision and potential outcome of labour management?
- 10. Learning activity A:Review completion of Section 1 • Turn to page 2 of Aisha’s case study • In groups of 2, review how Section 1 of the LCG was completed. • Ask for clarification as needed. What is your general impression about how Section 1 of Aisha’s LCG was completed? How could incomplete completion of Section 1 affect a woman’s care?
- 11. Section 2: Whatsupportive care parameters will you monitor? Parameter Alert! Companionship: Y=Yes; N=No; D=Woman declines N Pain relief: Y=Yes; N=No; D=Woman declines N Oral fluid: Y=Yes; N=No; D=Woman declines N Posture: SP=Supine; MO=Mobile SP
- 12. Pain relief duringlabour Relaxation and Massage Techniques Epidural Analgesia Parenteral Opioids
- 13. Labour and birthpositions • Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended. • For women with or without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended. • Any particular position should not be forced on the woman and she should be encouraged and supported to adopt any position that she finds most comfortable. • The health care professional should ensure that the well-being of the baby is adequately monitored in the woman’s chosen position. Should a change in position be necessary to ensure adequate fetal monitoring, the reason should be clearly communicated to the woman. HMS. ECLB
- 14. Learning activity A:Review completion of Section 2 • Turn to page 2 of Aisha’s case study • In groups of 2, review how Section 2 of the LCG was completed, circle any alert values. • Ask for clarification as needed. What alert values in Section 2 of Aisha’s LCG should be circled? How could incomplete completion of Section 2 affect a woman’s care?
- 15. Supportive care • Dofacilities you work in have adequate private space to accommodate: • A companion of the woman’s choice? • Upright positions in labour and birth? • Mobility in labour? • If not, what can be done?
- 16. Section 3: Whatparameters will you monitor to assess well-being of the baby? Alert! Baseline FHR <110, ≥160 FHR deceleration: N=No; E=Early; L=Late; V=Variable L=Late Alert! Amniotic fluid: I=Intact membranes; C=Membranes ruptured, clear fluid; M=Meconium-stained fluid: record + (non-significant), ++ (medium), and +++ (thick); B=Blood-stained meconium M+++ (thick meconium), B = Blood • Timing: During a uterine contraction and for at least 30 seconds thereafter • Auscultate every 15–30 minutes in active first stage of labour, and every 5 minutes in the second stage of labour
- 17. Care of thebaby • WHO 2018 recommendations for intrapartum care: “Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound or Pinard stethoscope is recommended for healthy pregnant women. Continuous cardiotocography is not recommended in healthy women undergoing spontaneous labour.” • If it is difficult to assess FHR in the woman’s chosen position, explain why she needs to change position, assist her to change position and assess FHR, then assist her back into her chosen position. • Given these recommendations, are all providers able to assess: • Baseline FHR? • Decelerations? • If not, what can be done?
- 18. Section 3: Careof the baby parameters Alert! Fetal position: A=Any occiput anterior position; P= Any occiput posterior position; T= Any occiput transverse position P = Occiput posterior, T = Occiput transverse Caput: 0=None; +; ++; +++=Marked +++ Moulding: O=None; +=Sutures apposed; ++=Sutures overlapped but reducible; +++=Sutures overlapped and not reducible +++
- 19. Care of thebaby • Are all providers able to assess: • Fetal position? • Caput? • Moulding? • If not, what can be done?
- 20. Learning activity A:Review completion of Section 3 • Turn to page 2 of Aisha’s case study • In groups of 2, review how Section 3 of the LCG was completed , circle any alert values. • Ask for clarification as needed. What alert values in Section 3 of Aisha’s LCG should be circled? How could incomplete completion of Section 3 affect a woman’s care and perinatal outcome?
- 21. Section 4: Whatparameters will you monitor to assess well-being of the woman? Alert!! Pulse <60, ≥120 sBP <80, ≥140 dBP ≥90 Temperature <35.0, ≥ 37.5 Urine Protein ++, Acetone ++ • Does the frequency of recording maternal well-being in the LCG depend on a woman’s clinical status? Yes!!
- 22. Learning activity A:Review completion of Section 4 • Turn to page 2 of Aisha’s case study • In groups of 2, review how Section 4 of the LCG was completed , circle any alert values. • Ask for clarification as needed. What alert values in Section 4 of Aisha’s LCG should be circled? How could incomplete completion of Section 4 affect a woman’s care and perinatal outcome?
- 23. Section 5: Whatparameters will you assess to monitor labour progress in first stage?
- 24. Key WHO Recommendationsfor Section 5 – First stage • Women should be informed that a standard duration of the latent first stage has not been established and can vary widely from one woman to another. • Women should be informed that the duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labours, and usually does not extend beyond 10 hours in subsequent labours • Labour may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached
- 25. Key WHO Recommendationsfor Section 5 – First stage • For women with spontaneous labour onset, the cervical dilatation rate threshold of 1 cm/hour during active first stage is inaccurate to identify women at risk of adverse birth outcomes and is therefore not recommended • A slower than 1-cm/hour cervical dilatation rate alone should not be an indication for obstetric intervention. Before considering any medical interventions, women with suspected delay in labour progression should be carefully evaluated to exclude developing complications (e.g. cephalo-pelvic disproportion) and to determine whether their emotional, psychological and physical needs in labour are being met. • In health care facilities where interventions such as augmentation and caesarean operation cannot be performed and where referral-level facilities are difficult to reach, the alert line could still be used for triaging women who may require additional care. • Will any of these recommendations be difficult to implement? If so, how can you facilitate their implementation into maternity care?
- 26. Cervical dilatation • Howwill you assess labour progress with the new threshold values that have replaced the partograph threshold of 1cm/hour?
- 27. Section 5: Whatparameters will you assess to monitor labour progress in second stage?
- 28. Key WHO Recommendationsfor Section 5 – Second stage • Women should be informed in first labours, birth is usually completed within 3 hours whereas in subsequent labours, birth is usually completed within 2 hours. • Encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended. • Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push. Health care providers should avoid imposing directed pushing on women in the second stage of labour, as there is no evidence of any benefit with this technique. Remember-2nd stage has two phases: • Early (nonexpulsive) when the cervix is 10cm but the woman does NOT have the urge to push • Late (expulsive) phase when the presenting part of the fetus reaches the pelvic floor and the woman has the urge to push.
- 29. Key WHO Recommendationsfor Section 5 – Second stage • Techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended, based on a woman’s preferences and available options. • Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth. • Will any of these recommendations be difficult to implement? If so, how can you facilitate their implementation into maternity care?
- 30. Key WHO Recommendationsfor Section 5 – Second stage • Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended.
- 31. Learning activity A:Review completion of Section 5 • Turn to page 2 of Aisha’s case study • In groups of 2, review how Section 5 of the LCG was completed. , circle any alert values • Ask for clarification as needed. How could too frequent vaginal examinations affect perinatal outcomes? What alert values in Section 5 of Aisha’s LCG should be circled? How could incomplete completion of Section 4 affect a woman’s care and perinatal outcome?
- 32. Section 6: Whatwill you record regarding medications?
- 33. Learning activity A:Review completion of Section 6 • Turn to page 2 of Aisha’s LCG and review completion of Section 6. • Based on findings, do you agree that no medications were recorded? If not, what medications would you have offered?
- 34. Section 7: Shareddecision-making parameters
- 35. Medical/obstetric factors Supportive care findings Baby's well-being findings Woman'swell- being findings Labour progress findings Presence of alert values ASSESSMENT Making an assessment
- 36. Learning activity A:Review completion of Section 7 • Turn to page 2 of Aisha’s case study • In groups of 2, write an assessment for each time period in which there is data. • Ask for clarification as needed. What assessments have you written down? How could incomplete / incorrect assessment affect a woman’s care and perinatal outcome?
- 37.
- 38.
- 39. Record your initials!! Don’tforget to initial the findings, assessment, and plan you have recorded!!!!
- 40. Learning activity A:Review completion of Section 7 • Turn to page 2 of Aisha’s case study • In groups of 2, write a plan of care for each time period in which there is data. • Ask for clarification as needed. What is your general impression about care provided and completion of the LCG? What could you have done at 10:00 when she was admitted with two contractions in 10 minutes, each lasting 10 seconds? What care options will you offer Aisha?”
- 41.
- 42. Summary • What arethe steps in the care cycle? • What supportive care will you provide to women in labour? • How can you facilitate shared decision-making? • What will you consider when developing a plan of care? • What action will you take if you find (you may check the LCG User’s Manual): • Early decelerations in second stage of labour • Cervical dilatation was 5 cm at 06:00, 6 cm at 10:00, 6 cm at 14:00 • 2 uterine contractions/10 minutes lasting 30-40 seconds from 09:00-13:00 with cervical dilatation 6cm at 09:00 and 9cm at 13:00 • Late decelerations in first stage of labour
- 43. Knowledge quiz: True/False 1.The LCG should be started when cervical dilatation has reached 4 cm. 2. The goal of shared decision-making is to communicate your plan of care with the woman and her companion. 3. The LCG has been designed for the care of women and their babies during labour and birth, regardless of their risk status. 4. Alert values should only be circled on the LCG if you plan to intervene. 5. Frequency of monitoring may differ for women with identified medical/obstetric conditions. 6. The LCG and the user´s manual are intended to be a substitute for clinical judgment with respect to the individual women’s circumstances and preferences. 7. Supportive care interventions on the LCG provide opportunities to implement the WHO 2018 intrapartum care guidelines. False False True False False True True
- 44. Knowledge quiz: True/False 8.Late decelerations are associated with a greater degree of relative hypoxaemia than early or variable decelerations and result in hypoxic depression. 9. When suture lines of the fetal skull are overlapped but reducible, you will record “Moulding +++” on the LCG. 10. Where available, continuous cardiotocography is recommended in healthy women undergoing spontaneous labour 11. The routine administration of IV fluids for all women in labour is recommended to manage any unexpected complications. 12. The decision to intervene during first stage of labour can be taken when cervical dilatation is progressing at a rate of less than 1 cm/hour. True False False False False
Editor's Notes
- #2 To improve the quality of care during labour and childbirth, the World Health Organization (WHO) developed the 2018 intrapartum care recommendations and an intrapartum care model with the following guiding principles: • Labour and childbirth should be individualized and woman-centred • No intervention should be implemented without a clear medical or obstetric indication • Only interventions that serve an immediate purpose and are proven to be beneficial should be promoted • A clear objective that a positive childbirth experience for the woman, the newborn and her family should be at the forefront of labour and childbirth care at all times
- #3 Respectful Care Respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth – is recommended. Mechanisms should be put in place to ensure that all women are made aware of their right to RMC and the existence of a mechanism for raising and addressing complaints. RMC policies should be tailored to ensure that vulnerable subgroups of women are not excluded. Effective Communication Introducing themselves to the woman and her companion and addressing the woman by her name Offering the woman and her family the information they need in a clear and concise manner, avoiding medical jargon, and using pictorial and graphic materials Responding to the woman’s needs, preferences and questions with a positive attitude Ensuring that procedures are explained to the woman, and that verbal and, when appropriate, written informed consent for pelvic examinations and other procedures is obtained from the woman Labour Companionship: A companion of choice is recommended for all women throughout labour and childbirth. Policy-makers should develop culturally sensitive training programmes for companions, and consider ways of registering, retaining and incentivizing them. Definitions, Duration, and Progress of First Stage Introduction of these new definitions and concepts should involve pre-service training institutions and professional bodies, so that training curricula for intrapartum care can be updated as quickly and smoothly as possible.
- #5 Click on the question, give the participants a chance to respond, then click on the answer. Clarify any questions.
- #7 Unlike the partograph, the WHO LCG includes an “Alert” column that presents thresholds for abnormal labour observations that require further assessment and action by the healthcare provider. Alert values are based on WHO guidance and expert consensus, and are meant to be used as early-warning signals. However, reference alert values should be adapted in accordance with local guidelines and should not replace the expert clinical judgement of a care provider. If labour observations do not meet any of the criteria in the “Alert” column, labour progression should be regarded as normal, and no medical intervention is warranted. Understanding normal values should reduce unnecessary interventions; while identifying the presence of an alert value should improve taking timely action, including for non-clinical interventions. Whenever you find an “alert” value, circle the recorded assessment. This should help to highlight those observations that require special attention. Follow protocols for managing the alert values.
- #8 The LCG promotes a care cycle of “Assessing the woman, fetus, and labour progress → Recording your findings→Comparing to alert values→and then developing a care plan with the woman and her companion based on findings and options for care”. Each time you assess or check the woman, fetus, and labour progress you will need to record your findings, compare to alert values, and then develop a care plan based on findings and shared decisions with the woman.
- #9 Careful documentation of parameters and comparison to alert values assists providers to make decisions about labour management based on the status of a woman and her baby and whether or not labour is progressing normally. Section 1. Identifying information and labour characteristics at admission: Name; known obstetric, medical and social risk factors, labour admission characteristics that may impact outcomes and should be considered when planning for care and labour management. Ask the following questions: What are some obstetric risk factors with implications for care provision and potential outcome of labour management? Examples: pre-eclampsia, woman’s advanced age, adolescent pregnancy, preterm labour, group B Streptococcus colonization. History of obstructed labour, previous cesarean/instrumental birth, stillbirth, pre-term labour, genital mutilation, previous 3rd or 4th degree tears. What are some medical risk factors with implications for care provision and potential outcome of labour management? Examples: chronic hypertension, autoimmune disorders, chronic renal disease, obesity, malnutrition, diabetes, depression, substance use. Why is it important to identify these potential risk factors? Decisions on place of birth, level of care provision, type of provider who should manage her care, and frequency of monitoring should be based on risk factors and their potential impact on birth outcome.
- #10 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. Obstetric, medical and social risk factors, labour admission characteristics may impact outcomes and should be considered when planning for care and labour management. When these factors are not outlined, providers might not make an appropriate decision about place of care, type of provider to manage her labour, and frequency of monitoring maternal parameters.
- #11 Ask participants to list the parameters to assess for Section 2. Then click on the computer to review the parameters. Section 2. Supportive care: Interventions that optimise quality of care: labour companionship, pharmacological and non-pharmacological pain relief, oral fluid, and maternal posture WHO also recommends effective communication between maternity health providers and women in labour, including the use of simple and culturally appropriate language at every stage of labour care. Clear explanations of procedures and their purpose should always be provided to each woman. The findings of physical examinations should be explained to the woman and her companion, and the subsequent course of action made clear to enable shared decision-making. Key WHO Recommendations for Section 2: Respectful maternity care (RMC) is a fundamental human right of all pregnant women and is a core component of the WHO intrapartum care recommendations. A companion of choice is recommended for all women throughout labour and childbirth Relaxation and manual techniques, parental opioids and epidural analgesia are recommended for healthy pregnant women requesting pain relief during labour and childbirth, depending on a woman’s preferences Encouraging the adoption of mobility and a birth position of the individual woman’s choice, including an upright position, is recommended. For women at low risk, oral fluid and food intake during labour is recommended
- #12 It is likely that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the choices women make in relation to this need Relaxation and Massage Techniques: Most women desire some form of pain relief during labour, and qualitative evidence indicates that relaxation techniques can reduce labour discomfort, relieve pain and enhance the maternal birth experience. Epidural Analgesia: Epidural analgesia appears to be the more effective pain relief option but compared with opioid analgesia it also requires more resources to implement and to manage its adverse effects, which are more common with epidural analgesia. Parenteral Opioids: Despite being widely available and used, pethidine is not the preferred opioid option, as shorter-acting opioids tend to have fewer undesirable side-effects. Before use, health care providers should counsel women about the potential side-effects of opioids, including maternal drowsiness, nausea and vomiting, and neonatal respiratory depression, and about the alternative pain relief options available.
- #14 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. Supportive care measures should be offered and evaluated continuously during labour. However, to streamline documentation, observations regarding the provision of supportive care should be recorded every hour. When supportive care is not provided, this could have a negative impact on labour progress, the woman’s ability to cope, her perception of pain, and her experience of care.
- #16 Ask participants to list the parameters to assess for Section 3. Then click on the computer to review the parameters. Section 3. Well-being of the baby: Parameters to monitor the well-being of the baby: baseline fetal heart rate(FHR) and decelerations in FHR, amniotic fluid, fetal position, moulding, and caput succedaneum. To identify decelerations, check FHR for a full minute during a contraction and for 30-60 seconds after the contraction ends to decide when the FHR begins to decrease and returns to baseline in relation to the contraction. There are three types of decelerations: Early decelerations: Record “E” - The FHR lowers below baseline usually at the start of a contraction, reaches the lowest point (nadir) at the peak of the contraction, and then increases after the peak of a contraction. Variable decelerations: Record “V” - The timing of low FHR and return to baseline in relation to the contraction is variable. Variable decelerations are classified as severe when they last more than 60 seconds, fall below 70 beats/min, or have a drop of 60 beats/min below the baseline rate. Late decelerations: Record “L” - The FHR lowers below baseline usually after the peak of a contraction and continue after the end of the contraction. These decelerations are associated with a greater degree of relative hypoxemia and result in hypoxic depression.
- #18 Section 3. Well-being of the baby: Parameters to monitor the well-being of the baby: baseline fetal heart rate(FHR) and decelerations in FHR, amniotic fluid, fetal position, moulding, and caput succedaneum.
- #20 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. This section is to facilitate decision-making while monitoring the well-being of the baby. When monitoring is suboptimal, the fetus could suffer and this would not be identified and managed in a timely manner, resulting in poor perinatal outcomes.
- #21 Ask participants to list the parameters to assess for Section 4. Then click on the computer to review the parameters. Section 4. Well-being of the woman: Parameters to monitor the well-being of the woman: pulse, blood pressure, temperature and urine. Does the frequency of recording maternal well-being in the LCG depend on a woman’s clinical status? The correct answer is Yes. It is expected that the required frequency of assessment will depend on the results of labour observations and the status of the woman and her baby. Although the LCG and the user manual suggest a frequency of monitoring for the parameters included in the LCG, it is essential that health personnel adapt the monitoring frequencies to each particular clinical case and following local guidelines.
- #22 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. If the woman’s condition is not adequately monitored, complications will not be identified or managed appropriately.
- #23 Ask participants to list the parameters to assess for Section 5. Then click on the computer to review the parameters. Section 5. Labour progress: Intermittent monitoring of labour progression parameters - frequency and duration of contractions, cervical dilatation and descent of the baby’s head.
- #27 Section 5. Labour progress: Intermittent monitoring of labour progression parameters - frequency and duration of contractions, cervical dilatation and descent of the baby’s head.
- #31 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. Too frequent vaginal examinations could result in infection and will also negatively affect the woman’s perception of care. If vaginal examinations need to be conducted more often than every 4 hours, there should be a clear reason and information gathered should assist with decision-making. When monitoring labour progress is suboptimal, appropriate decisions about labour management cannot be made.
- #32 Ask participants to list the parameters to assess for Section 6. Then click on the computer to review the parameters. Section 6. Medication: All types of medication used during labour: oxytocin use and dose, name of the medication and dose, name of IV fluids and perfusion rate. If medications are already being provided, make sure you record them. Key WHO Recommendations for Section 6 Pharmacological pain relief is recommended according to a woman´s preference The use of oxytocin, antispasmodic agents and intravenous fluids for preventing labour delay is not recommended If they are not yet being administered, you must make a decision based on your findings and assessment: IVs are potential sources of infection, are costly, and may reduce mobility. They should therefore only be used if there are clear indications. When considering augmentation with oxytocin: For pregnant women with spontaneous labour onset, the cervical dilatation rate threshold of 1 cm/hour during the active first stage (as depicted by the partograph alert line) is inaccurate to identify women at risk of adverse birth outcomes. A minimum cervical dilatation rate of 1 cm/hour throughout the active first stage is unrealistically fast for some women and is therefore not recommended to identify normal labour progression. A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention. Cervical dilatation thresholds proposed in the LCG are based on recent evidence. Those thresholds are the ones included in the alert column. The duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labours, and usually does not extend beyond 10 hours in subsequent labours. However, the decision to intervene when the first stage of labour appears to be prolonged must not be taken on the basis of duration alone.
- #33 Give a few minutes for participants to work on the exercise, then facilitate a discussion about the question. Prolonged labour is most likely due to inefficient contractions. However, even though the contractions appear to be inefficient because of duration and number of contractions and there has been no descent, there is no information on caput/moulding, there is a need to rule out cephalopelvic disproportion (CPD) and obstructed labour before a decision can be made about augmenting labour.
- #34 Ask participants to list the parameters to assess for Section 7. Then click on the computer to review the parameters. Section 7. Shared decision-making: Assessment based on findings and plan of care based on continuous communication and informed consent. The provider must place initials under it. Shared decision-making, aims to facilitate continuous communication with the woman and her companion and consistent recording of all assessments, plans of care agreed upon, and initials of the provider. Key WHO Recommendations for Section 7: Respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth –is recommended Effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods, is recommended.
- #35 After assessing all the parameters, recording them, and comparing them to alert values, the provider must make and record an assessment. The LCG User’s Manual and/or local protocols will be used to help decide on options for care and actions to be taken.
- #36 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. Assessments: 10:00: Poor contractions 11:00: Normal baseline FHR – no other data available 13:00: Normal baseline FHR – no other data available 14:00: Possible dehydration given acetonuria 3+ and not taking fluids. Mostly supine which may contribute to poor contractions and labour progress. Elevated temperature. 16:00: Normal baseline FHR – no other data available 18:00: Mostly supine which may contribute to poor contractions and labour progress. Elevated temperature. Possible poor progress of cervical dilatation. 21:00: Mostly supine which may contribute to poor contractions and labour progress. Elevated temperature. Possible poor progress of cervical dilatation. Solid decision-making requires accurate evaluation of the woman’s well-being, the baby’s well-being, and progress of labour. Without accurate evaluations, assessments will be inaccurate or incorrect. The overall assessment must be correct to make an appropriate plan of care.
- #37 Once an assessment has been made, clinicians will share findings and options for care with the woman and her companion to develop a plan of care. This is called shared decision-making. Review how shared decision-making is different from typical ways of communicating and making plans of care. Shared decision-making is the process of applying person-centered communication, deliberation, and decision-making to ensure a woman receives the best, individualized care. To enable shared decision-making: - Ensure effective communication between maternity healthcare providers and women in labour. Take into consideration a woman’s values, preferences, fears and concerns regarding her hoped-for birth experience. Use appropriate language, and culturally appropriate terminology, taking into consideration the woman’s and her companion’s language, health literacy, education level and familiarity with the physiology of pregnancy and birth. Give clear, simple explanations of findings of physical examinations and their implications. Give clear explanations of a full array of care options, and unbiased explanation of potential benefits or risks for the woman and the baby. Give ample time for the woman to ask questions. Come to agreement on the plan of care and obtain informed consent. Women say they have a positive experience, regardless of outcome if they: feel free to make their own choices, even when things do not happen as they expect feel safe and cared for feel connected to providers, family and their babies feel they are being treated with respect understand what happened understand that they could not fully control what happened and that complications are not their fault
- #38 The plan of care will be developed with the woman and her companion. The plan of care will depend on priorities, care options recommended based on findings/alert values, provider capacity (if consultation may be needed with a senior provider), and the woman’s values, preferences, and concerns. The regular recording of a plan facilitates communication with other health care providers, facilitating continuous communication with the woman and her companion. If all the parameters are normal, then the plan would probably be “continuation of routine monitoring.”
- #40 Give a few minutes for participants to work on the exercise, then click to reveal each of the questions and facilitate a discussion after each question. “What care options will you offer Aisha?” • Encourage mobility and provide general labour support including pain management, labour companion, hydration/nutrition, and management of anxiety/fear. • Evaluate cause of elevated temperature. • Treat dehydration. • Contact a senior provider and conduct a comprehensive exam to determine the cause of prolonged labour and rule out cephalopelvic disproportion (CPD) and obstructed labour. If CPD and obstructed labour have been ruled out and inefficient contractions are the most probable cause of prolonged labour, offer augmentation with oxytocin. • Monitor the woman, baby, and labour progress per standards. “What could you have done at 10:00 when she was admitted with two contractions in 10 minutes, each lasting 10 seconds?” • Encourage mobility and provide general labour support including pain management, labour companion, hydration/nutrition, and management of anxiety/fear that may improve contractions. “What is your general impression about care provided and completion of the LCG?” • Information about labour onset and time that membranes ruptured is missing. Caput/moulding are not regularly assessed. Decelerations are not recorded. Supportive care, FHR, and contractions are not monitored as recommended. • No action seems to have been taken for alert values.
- #43 Review the answers and respond to any questions. False. Documentation on the LCG should be initiated when the woman enters the active phase of the first stage of labour (5 cm or more cervical dilatation), regardless of her parity and membrane status. The thresholds described in the alert column of the LCG are meant to be used during the active phase (not the latent phase). Premature plotting of the latent phase has been shown to be a source for unnecessary interventions during labour. Although the LCG should not be initiated in the latent phase of labour, it is expected that women and their babies are monitored and receive labour care and support during the latent stage. False. Shared decision-making, aims to facilitate continuous communication with the woman and her companion. Explaining findings of the physical exams and clear explanations of option for care, will enable informed decision making by the woman and her companion. True False. Healthcare providers should circle any observations meeting the criteria in the "Alert" column. False. It is expected that the required frequency of assessment will depend on the results of labour observations and the status of the woman and her baby. Although the LCG and the user manual suggest a frequency of monitoring for the parameters included in the LCG, it is essential that health personnel adapt the monitoring frequencies to each particular clinical case and following local guidelines. False. The User’s Manual serves as a guide and should not substitute clinical judgement and local protocols for care. True
- #44 Review the answers and respond to any questions. True. In late decelerations, the FHR lowers below baseline usually after the peak of a contraction. False. Sutures overlapped but reducible: This is when you feel that one skull bone is overlapping another, but when you gently push the overlapped bone it goes back easily. This is called degree 2 moulding (2+). False. From WHO 2018 recommendations for intrapartum care: “Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound or Pinard stethoscope is recommended for healthy pregnant women. Continuous cardiotocography is not recommended in healthy women undergoing spontaneous labour.” False. IVs are potential sources of infection, are costly, and may reduce mobility. They should therefore only be used if there are clear indications. False. For pregnant women with spontaneous labour onset, the cervical dilatation rate threshold of 1 cm/hour during the active first stage (as depicted by the partograph alert line) is inaccurate to identify women at risk of adverse birth outcomes. A minimum cervical dilatation rate of 1 cm/hour throughout the active first stage is unrealistically fast for some women and is therefore not recommended to identify normal labour progression. A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention. Cervical dilatation thresholds proposed in the LCG are based on recent evidence. Those thresholds are the ones included in the alert column.