Labour Ward Guidelines

Aneurin Bevan University Health Board
Labour Ward Guidelines
N.B. Staff should be discouraged from printing this document. This is to

avoid the risk of out of date printed versions of the document. The
Intranet should be referred to for the current version of the document.
Status: Issue 8.2 Issue date: 30 November 2021

Approved by: Maternity Clinical Effectiveness Forum Review by date: 29 November 2024
Owner: Maternity Services Ref No: ABUHB/F&T/0226
Aneurin Bevan University Health Board Ref No: ABUHB_F&T_0226
Title: Labour Ward Guidelines
Owner: Maternity Service
Contents:
1 Policy Statement ......................................................................... 2
1.1 Scope of guideline ..................................................................... 2
1.2 Essential Implementation Criteria ................................................ 2
2 Aims ............................................................................................ 2
3 Responsibilities ........................................................................... 2
4 Training ....................................................................................... 2
5 Equality Audit and Review ........................................................... 2
6 Index ........................................................................................... 3

Page 1 of 100
1 Policy Statement
This document should act as a guideline for the management of all patients
in labour. The views expressed in these guidelines are evidence based on
Royal College of Obstetrics and Gynaecology, NICE and MOET guidelines
and reflect professional opinion. They are designed to support safe and
effective practice.
1.1 Scope of guideline
This guideline applies to all clinicians working within maternity services.
1.2 Essential Implementation Criteria
Auditable standards are stated where appropriate.
2 Aims
To provide support for clinical decision making
3 Responsibilities
The Maternity Management team.
4 Training
Staff are expected to access appropriate training where provided.
Training needs will be identified through appraisal and clinical supervision.
5 Equality Audit & Review
Local service Improvement Plan will guide monitoring and effectiveness.
This policy has undergone an equality impact assessment screening

process using the toolkit designed by the NHS Centre Equality & Human
Rights. Details of the screening process for this policy are available from
the policy owner.

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6 Index
7 Diagnosis and Management of labour 5
7.2 Nutrition in Labour 5
7.3 Hygiene in Labour 5
7.4 Pain relief in Labour 5
7.5 First stage of Labour 6
7.6 Progress of Labour 6
7.7 Second stage of Labour 6
7.8 Third stage of Labour 7
7.9 Delayed cord clamping 8
7.10 Perineal repair 9
7.11 Fetal Heart Monitoring in First stage of labour 10
7.12 Performing Electronic Fetal Monitoring 10
7.13 Overall assessment of hypoxia and management 15
7.14 Fetal Blood sampling 18
7.15 Regimen for Syntocinon Infusion 18
7.16 Cord Blood Sampling 18
8 Care of the ‘unbooked woman’ presenting in labour 19
9 Induction of labour 21
10 Management of women with previous Caesarean Section in labour 22
11 Pre Labour Rupture of Membranes (PROM) 24

11.1 Management of PROM >37 weeks 25
11.2 Management of PROM <37 weeks (PPROM) 25
11.3 Corticosteroids 26
11.4 Tocolytics 26
11.5 Atosiban 27
12 Pre term labour 28

13 Guidance on Use of Magnesium Sulphate in Preterm labour 30
14 Group B Streptococcal (GBS) Prophylaxis in pregnancy and Labour 35

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15 Pre- eclampsia and eclampsia & Flowchart 38
16Management of labour in Women with Diabetes 44
17 Protocol for Genital Herpes in pregnancy and labour 48
18 Instrumental delivery 50
19 Pre-requisites for Caesarean Sections & 2nd stage 52

Caesarean Section
20 Guideline for difficult delivery of fetal head 54
21 Surgical Management of Post Partum Haemorrhage 56
22 Breech delivery 60
23 Management of expected and Unexpected Breech presentation in 61
labour in Hospital
24 Breech trouble shooting 62
25 Twin Delivery 63
26 Management of twin delivery 64
27 Shoulder dystocia 70
28 Cord Prolapse 71
29 Uterine Inversion 72
30 Uterine rupture 73
31 Retained Placenta 74

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32 Management of Jehovah’s Witnesses in pregnancy 75

& Care plan for women in labour refusing blood transfusion
33 Extremely premature babies between 22-26 weeks gestation 77
34 Management of Sepsis in Labour Ward 82
35 Management Late Inter Uterine Death and of 88

Stillbirth
36 Appendix 1 lignocaine toxicity
37 Appendix 2 scribe sheet PPH
7 Diagnosis and Management of Labour:

7.1Diagnosis of Labour
A positive diagnosis of labour should be made as soon as possible

following admission to the Labour Ward by an abdominal palpation
and vaginal examination. A woman is in labour when the cervix is
more than 4cm dilated, fully effaced and her contractions are
regular (4-5/10 mins lasting for >30secs).
Initial assessment by midwife and registrar (MDU)/career SHO with full

history, identifying risk factors by reviewing clinical records with physical
observations of temperature, pulse, respiratory rate, blood pressure and
urinalysis.
To start on continuous electronic fetal monitoring in accordance with clinical

need for all Obstetric led care patients (OLC) in MDU
One to one care with midwife
MW/ doctor to gain IV access, bloods for FBC, group and antibody screen in
all women under OLC
Baseline clotting screen should be requested in all high-risk patients with
risk of bleeding
Ring the blood bank and porter to state as urgent bloods and document this
in the notes
7.2 Nutrition in Labour

• Offer water or isotonic drinks to sip during labour
• Offer light diet unless they have received opioids
• Consider Ranitidine 150mg TDS for those who receive opioids
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7.3 Hygiene in Labour

Use tap water for cleaning prior to vaginal examination
Single use non-sterile gloves are appropriate
7.4 Pain Relief in Labour

Acupuncture, acupressure and hypnosis is not offered routinely, but should
not be prevented if the woman wishes
Transcutaneous electrical nerve stimulation (TENS) should not be offered in
established labour
Entonox (50:50 N2O and O2) should be available
Pethidine, Diamorphine and other opioids should be available and
administered with antiemetic
Remifentanyl is available at The Grange University Hospital
Epidural analgesia should be offered as per women’s wishes including the
latent first stage if in severe pain
Intravenous access should be secured prior to regional analgesia
While siting epidural, ensure continuous fetal heart monitoring is
carried out, if necessary by use of fetal scalp electrode prior to
siting the epidural
7.5 First Stage of Labour

Latent phase- painful contractions, cervical effacement and dilatation up to
4cm.
Established first stage- regular painful contractions 4-5 in 10 minutes and
cervical dilatation from 4cms
7.6 Progress of Labour

The most accurate method of assessing progress in labour is by assessing
the rate of cervical dilatation and descent of the presenting part.
Partogram to be commenced at 4cm of cervical dilatation

Where the partogram includes an action line, the World Health
Organization recommendation of a 4-hour action line should be used
Contractions should be 4-5 in 10 minutes lasting for more than 30secs
Cervical dilatation of 0.5cm per hour is considered adequate progress in
labour
Routine observations - 4 hourly temperature, blood pressure, respiratory

rate urine analysis (changes as per clinical needs)

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Palpate the pulse hourly to differentiate between the maternal and fetal
heartbeats
Vaginal examination to be offered every four hours to assess progress of

labour, provided contractions are regular unless clinically indicated
Examinations are carried out after obtaining verbal consent from the
woman.
Continuous CTG monitoring for all obstetric led care patients based on
clinical need
Any deviation from the above plan should be discussed with Obstetric
Registrar/Consultant and should be documented
7.7 Second stage of Labour

Regular observations- hourly blood pressure, half hourly maternal pulse
rate and four hourly temperatures (changes as per clinical needs) and
five-minute fetal heart rate
Regularly check and document frequency of bladder emptying
Assess progress hourly by vaginal examination
Ensure manual perineal protection (to prevent OASI) to all Perform
60° mediolateral episiotomy if concerned risk of
significant/extensive tear
Passive stage- allow one hour for head descent in the presence of
regional anaesthesia or absence of involuntary expulsive contractions
Active stage- Primiparous women:
Allow 2 hours of active second stage
If baby not delivered, inform duty registrar for further management
Oxytocin should be considered if contractions inadequate with an option of
regional analgesia after full assessment
Maximum active second stage can last 3 hours in primiparous women
Multiparous women:
Allow one hour of active second stage
If baby not delivered, inform duty registrar for further management
Maximum active second stage can last 2 hours in multiparous women
Do not start oxytocin without thorough assessment and senior input
7.8 Third Stage of Labour

Average length is 30 minutes with active management and 60 minutes with
physiological management

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Physiological management
Oxytocic drugs should not be used, and the cord should not be clamped and
cut until it has stopped pulsating. There should be no cord traction.
Women should be informed that with physiological management the

incidence of:-
• Nausea/vomiting is 50 in 1000 women
• PPH more than 1L is 29 in 1000 women
• Blood transfusion is 40 in 1000 women

Active management
The cord should not routinely be clamped and cut before one minute unless
there is fetal distress
If the woman requests that the cord is clamped and cut later than five
minutes, support her in her choice
An uterotonic agent (Syntocinon 10iu IM) is administered
The placenta is delivered by controlled cord traction
Women should be informed that active management of the third stage

shortens the third stage and that the incidence of:-
• Nausea/vomiting is 100 in 1000 women
• PPH more that 1L is 13 in 1000 women
• Blood transfusion is 14 in 1000 women
Observations of the woman include general physical condition by her

colour, respiration and women’s own report of how she feels and vaginal
blood loss
Full set of observations as pulse, respiratory rate, BP and temperature
should be performed immediately after the third stage. Documentation on
contractility of uterus and lochia should be done
In the presence of haemorrhage, retained placenta or maternal collapse
frequent observations (every 5 – 10 minutes or continuous monitoring) to
assess the need of resuscitation are required
Measurement of blood loss is done by weighing all the swabs, linen, draw
sheets, inco pads and measuring the blood clots

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7.9 Delayed cord clamping
1. Clamping of the umbilical cord should be delayed for at least 60

seconds after every delivery unless there are contraindications:
- postpartum haemorrhage,
- placenta praevia,
- morbidly adherent placenta,
- placental abruption,
- vasa praevia,
- tight nuchal cord,
- concerns with integrity of the cord
-poor condition of neonate at delivery requiring immediate
assessment and resuscitation. Rapid milking of the cord (three times)
could be considered in these cases.
2. It is recommended to perform delayed cord clamping in preterm

deliveries without fetal compromise. Practice should be discussed with
the attending paediatrician
3. Uterotonics should be given as usual.
4. Keep neonate warm and at a lower level than the level of the uterus (for
deliveries under 28 weeks gestation the neonate should be placed in a
sterile plastic bag to ensure temperature control)
5. Record duration of interval between delivery and clamping of the cord

on the delivery proforma. Reasons for deviating from the
recommendations of delayed cord clamping should be documented for
audit purposes
6. Where there is need for substantial cord blood samples (eg. stem cell
harvesting) a plan for timing of cord clamping should be discussed with
mother and documented
7.10 Perineal repair
Repair of perineum should be undertaken as soon as possible to minimise

the risk of infection and blood loss Adequate effective analgesia with
either
- infiltration of 1% lignocaine at a maximum dose of 3 mg per kilogram body
weight
Body weight > 33kgs (10 mls 100 mg)
Body weight > 50 kgs (15 mls 150 mg)

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Body weight > 66 kgs (20 mls 200 mg

(SEE APPENDIX 1 lignocaine toxicity)
- epidural top up should be considered
Rectal non-steroidal anti – inflammatory should be offered routinely
following perineal repair unless contraindicated
Document in the perineal repair proforma
Measurement of blood loss is done by weighing all the swabs, linen, draw
sheets, inco pads and measuring the blood clots
7.11 Fetal Heart Monitoring in First Stage of labour
Offer intermittent auscultation of the fetal heart rate to women at low risk
of complications in established first stage of labour:
Use either a Pinard stethoscope or doppler ultrasound
Carry out intermittent auscultation immediately after a contraction for at

least 1 minute, at least every 15 minutes, and record it as a single rate
Record accelerations and decelerations if heard
Palpate the maternal pulse hourly, or more often if there are any concerns,
to differentiate between the maternal and fetal heartbeats
If no indication for immediate continuous fetal monitoring, consider

mobilisation and intelligent intermittent auscultation
Continuous EFM is recommended when:

• Obstetric led care women in accordance with clinical need
• Women who have exited the low-risk pathway
• Meconium-stained liquor (significant)
(*Continuous EFM should be considered for women with light

meconium-stained liquor depending on a risk assessment which should
include as a minimum their stage of labour, volume of liquor, parity,
the FHR) If in doubt consult with obstetrician.
7.12 Performing Electronic Fetal Monitoring (EFM))
• The date and time clock on the EFM machine should be correctly set,
ensure machine is set to 1cm/hour.
• (The cardiotocograph label should be used to record mother’s name, date
of birth and hospital number, maternal pulse rate, reason for EFM, date
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and time of trace commenced, signature of midwife in the manual CTG

monitor)
• STAN should be considered and used in all high-risk women > 36/40
• Pinnard should be utilised to confirm the presence of a feta heart prior to
CTG USS.
• Any antenatal/intrapartum events that may affect the FH rate should be
noted contemporaneously on the CTG electronically and in the maternal
notes, signed and the date and time noted (VE’s, siting of an epidural
etc).
• The fetal heart should be documented on the partogram
• On initial assessment ensure checklist completed to exclude chronic
hypoxia and pre-existing fetal injury (see figure 1)
• On reviewing CTG, use CTG stickers for classification as per FIGO
guideline and document clearly with plan of action in maternal notes
• Fresh eye review of CTG by another midwife/obstetrician (not GP trainee)
every hour and use CTG assessment tool (see figure 2)
• When categorising CTG according to FIGO Fetal heart traces should be
categorised into normal, suspicious and pathological according to
categorisation criteria
• If it is difficult to categorise or interpret a cardiotocograph trace, obtain
a review by a senior midwife or a senior obstetrician
Figure 1

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Figure 2
STAN Guidelines
ST Analysis is used
• More than 36 gestational weeks
• Ruptured membranes
• No contraindication for scalp electrode
• At first stage with normal CTG
For STAN analysis CTG should be categorised as per FIGO classification

abnormal, intermediary, abnormal or preterminal according to
classification criteria

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At onset of ST event
-Check for reactivity and non-deteriorating fetal state: classify CTG
-Check ECG signal quality
-Use FIGO classification for CTG interpretation and manage accordingly
If any concerns discuss with senior Obstetricians
During 2nd stage of labour with active pushing, immediate delivery should
be considered in 15-20 minutes.
- In the presence of maternal pyrexia even intermediary CTG may be
regarded as significant with ST event
When called to review suspicious/pathological/abnormal CTG

Always consider MOTHERS
• Meconium
• Oxytocin
• Temperature
• Hyperstimulation/Haemorrhage
• Epidural
• Rate and progress of labour
• Scar

Page 13 of 100

Page 14 of 100
7.13 Overall assessment of hypoxia and management

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SUSPICIOUS or Use conservative measures

PATHOLOGICAL  Left lateral position
classification of CTG  IV fluids (if appropriate)
 Paracetamol if raised
temperature
 Stop Oxytocin
 Give Terbutaline 0.25 mg SC
 Do not use maternal facial
oxygen therapy for intrauterine
fetal resuscitation
 Oxygen should only be
administered for maternal
hypoxia, or as part of
preoxygenation of the mother
prior to a potential anaesthetic
If hyperstimulation – give Injection of Terbutaline 250µgm

subcutaneously or IV Terbutaline 10µgm/min or GTN aerosol spray
(400µgm/metred dose) – 1-2 doses under the tongue or GTN sublingual
tablets (300µgm tablet- 1 to 2 tablets – single dose)
MECONIUM-STAINED AMNIOTIC FLUID (MSAF)
Passage of meconium is usually secondary to the physiological maturation

of the fetal gut. However, underlying maternal, placental and fetal
pathological causes of meconium passage should be excluded Chronic
utero-placental insufficiency and chorioamnionitis are important causes
Meconium Aspiration Syndrome (MAS) is associated with serious perinatal
morbidity and mortality.
Higher than expected baseline FHR for the given gestation, repetitive
atypical variable decelerations, loss of baseline variability, saltatory
pattern, subacute hypoxia and fetal bradycardia may increase the risk of
MAS
Oxytocin should be used with caution in the presence of MSAF
Overall clinical picture such as parity, rate of progress of labour, features
on the CTG and ongoing chronic hypoxia or infection should be considered
The neonatal team should be informed of MSAF to ensure appropriate
assessment and resuscitation of the new-born
MANAGEMENT OF MECONIUM-STAINED AMNIOTIC FLUID (MSAF)

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Infants born through Meconium – Postnatal Management

Guideline
Introduction
Meconium-stained liquor occurs in up to 10% of deliveries – approximately
2% of these babies (0.2% of total births) develop meconium aspiration
syndrome (MAS). It is possible that symptoms associated with meconium
aspiration will not appear immediately. So it is recommended that babies

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born through meconium-stained liquor are observed for a period of time in

all birth settings
Definition
Light meconium-stained liquor (MSL) is defined as a thin greenish/yellow-

tinged fluid. Significant MSL is defined as dark green or black amniotic
fluid that is thick or tenacious, or any meconium-stained amniotic fluid
containing lumps of meconium. This guideline provides information to
personnel caring for infants born to mothers who have had meconium
stained liquor during labour and thus are at increased risk of developing
meconium aspiration syndrome.
Delivery Room Management

A doctor or ANNP should attend the delivery if there is significant MSL. A
doctor or ANNP should attend the delivery if there is light MSL and an
additional sign of fetal compromise. Stabilisation of the infant is in line with
NLS guidance and is not the focus of this document. If the infant has
respiratory distress from birth or requires resuscitation, then NICU
management is indicated. If the infant has no respiratory distress and no
oxygen requirement from birth, then manage as below.
Light MSL
Light MSL does not necessarily trigger any change of care pathway for the
mother. MLC can continue; this judgement will be made by those
managing the mother. The infant should have observations using NEWTT
chart at 1 hour and 2 hours of age. These can be performed in any setting.
If normal at 2 hours, no further observations are required and revert to
normal newborn baby care. If observations outside normal range, refer to
neonatal team.
Significant MSL
Observations using NEWTT chart at 1 hour and 2 hours and 2 hourly until
12 hours of age. If normal at 12 hours, no further observations and revert
to normal newborn baby care. If observations outside normal range, refer
to neonatal team.
References
Newborn babies born to Mothers with Meconium Stained Liquor. Norfolk and Norwich University Hospital NHS
Foundation Trust. 2020
Guideline for the Intrapartum and Immediate Neonatal Management of Meconium Stained Liquor. Cwm Taf
Morgannwg University Health Board Obstetric and Gynaecology Directorate. 2020
National Institute for Health and Clinical Excellence. Intrapartum care for healthy women and babies 2014 (last
updated Feb 2017)

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7.14 Fetal Blood Sampling
Do not perform FBS (no evidence to support this practice)
7.15 Regimen for Syntocinon Infusion

Syntocinon is normally added to normal saline even in hypertensive women
(30 IU of Oxytocin is added to 500ml of Normal Saline 1ml/hour =
1 milliunits per minute)
Administration is via appropriate pump and giving set
Escalation of the tabulated dose in 30-minute intervals permits the

optimum dose to be reached in a reasonable period of time by titration
against contractions. When achieved effective uterine contractions,
consider reducing the dose of Syntocinon.
Contractions should not be more than 3-4 in 10 minutes and should not last
longer than 60 seconds. The uterus should relax adequately between
contractions
Time after Oxytocin Dose Volume infused

starting in (mU/min) (mls/hour)
minutes Dilution 30iu
oxytocin in 500mls
normal saline
0 1 1
30 2 2
60 4 4
90 8 8
120 12 12
150 16 16
180 20 20
210 24 24
240 28 28
270 32 32
If no adequate contractions have been achieved at 20 mls per hour discuss

with Registrar and/or Consultant

Page 19 of 100
Syntocinon should not be started for six hours following

administration of vaginal prostaglandins (Pessary) and half an hour
after Propess
7.16 Cord Blood Gases/Sampling

All women under obstetric led care should have cord blood sampling but it
is obligatory:
• after instrumental deliveries
• after emergency CS
• if baby’s condition is poor at delivery
Women who have an elective caesarean section do not require cord blood
sample unless at birth the baby’s condition is poor
Procedure:
Double clamp umbilical cord, collect paired samples from the umbilical
artery and umbilical vein either with a pre-heparinised syringe or a
preheparinised tube. NB: the specimen remains stable at room temperature
for up to 1 hour. However, please process the sample at the earliest. If
there is a delay, record time samples taken and time sample processed.
Consider refrigerating immediately if significant delay and perform when
able.
Interpretation: Values of Arterial Ph <7.00 should generate a neonatal

review and all should be reported via datix for risk management
References: Physiological CTG Interpretation, Intrapartum Fetal Monitoring Guideline
November 2017
Meconium stained amniotic fluid, Edwin Chandraharan and Sian Mitchell, 2018
8 Guidelines for the care of 'un-booked women'

presenting in labour
The woman should be admitted to the main delivery unit
• Old notes, if applicable, should be obtained. If old notes do not

exist a temporary set of notes should be compiled
• Look in CWS and CSC for information
• A brief relevant history should be taken, to include previous
pregnancies, deliveries, medical and family history
• Examination including;

Page 20 of 100
• Temperature, pulse, blood pressure, respiratory rate

• Abdominal palpation
• Fetal heart auscultation/CTG
• Scan for placental localisation
• If placenta clear, for vaginal examination
Blood should be taken for
• Group and antibody screen – 2 samples (long, pink-topped bottle)

• FBC (purple topped bottle)
• Treponemal antibody test (orange/yellow bottle)
• Routine antenatal virology screen (Hep B, HIV) (orange/yellow
topped bottle)
• Others indicated from history and examination eg PET bloods
(orange/yellow topped bottle) and clotting (blue topped bottle)
• The blood should be sent to the lab immediately with a request to

telephone results back to the ward. (If a positive Hepatitis B result
is found the midwife must inform the Paediatric SHO as the first
Hepatitis B vaccine and HBIG must be prescribed and given within
the first 12 hours of life). For follow up care see Hepatitis B policy
• Inform the Obstetrician and anaesthetist regarding admission
• USS performed if feasible for placental localisation and presentation
• Vaginal examination to assess stage of labour
• Care of the labouring mother should proceed as usual, governed by
any risk factors identified in the history, examination, USS, or
vaginal examination
• Midwife must check the Confidential file for Social Service alerts
and high-risk alerts on mothers

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Induction of Labour (IOL) without uterine scar

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Previous LSCS (up to x2)

Patient’s Obstetrician to decide on timing of induction (consider term+12
IOL) and amount of prostaglandins to be used
Patient to be fully informed of risks including scar dehiscence and rupture –
ensure documented in patient’s notes
Consider Propess (unlicensed) with informed consent as it is safer than
Prostin
Consider Dilapan-S / Dilasoft
Once the contractions are regular commence continuous fetal monitoring
and if feasible transfer the patient to the labour ward
IOL for intrauterine growth restriction (IUGR)

Please perform CTGs 8 hourly during the induction process and consider
continuous monitoring once contractions are regular
IOL for PROM and SROM

Consider propess (unlicensed) with informed consent as it is safer than
prostin as it reduces repeated examination and can be removed if there is
foetal distress
Consider immediate induction with propess if primip and cervix unfavourable
Reference: NICE Clinical guideline No- 190, Intrapartum care for healthy
women and babies; 3/12/2014
10 Management of women with previous Caesarean

Section in labour
Information for Staff
• 25% of women attempting a VBAC will need an emergency caesarean
delivery in labour
• 0.2 to 0.7% (22-47/10000) risk of scar rupture with one previous
LSCS
• 1.36% risk of scar rupture with two previous LSCS
• Risk of scar rupture is 2% with inverted T or J incision
• Risk of scar rupture with induction -2-to-3-fold increase
- Non prostaglandin agents – 89 per 10000 (0.89%)
- Prostaglandins 140 per 10000 (1.6%)
• Overall success rate for VBAC is 72 to 76%
• Planned VBAC compared with ERCS carries around 1% additional risk
of blood transfusion or endometritis and 2-3/10000 additional risk of
birth related perinatal loss
Labour and Birth (VBAC)

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1. Labour is managed to optimise a normal outcome

2. Delivery is planned at an obstetric unit with availability of obstetric
theatre and onsite blood transfusion. Should the woman decline,
involve the consultant midwife to evaluate clinical risk
3. IV Access with FBC and Group and Antibody screen (ensure electronic
issue)
4. One to one care with midwife
5. Continuous CTG monitoring following the onset of uterine contractions
for the duration of planned VBAC is advised (fetal distress has been
reported to precede uterine rupture)
6. Meticulous monitoring of progress of labour
7. Serial cervical assessments should be preferably done by the same
person if possible
8. Decision to augment with oxytocin, time intervals for serial vaginal
examination, decision of discontinuing VBAC should be consultant led
decisions
9. Oxytocin augmentation should be titrated such that the contraction
frequency would not exceed 4 in 10 minutes. Once the adequate
contractions achieved try reducing the syntocinon dose
10. Concerns with progress of labour should be reported to on call
registrar on labour ward
11. The use of Syntocinon to augment poor progress or secondary arrest
must be discussed with the consultant
12. Strength of Syntocinon in VBAC is identical to the normal induction
and augmentation (same protocol see earlier)
13. Epidural analgesia is available on request
14. Regular maternal observations including BP, Pulse, respiratory rate
and Temperature
15. Awareness of classical symptoms of scar rupture –
• abnormal CTG,
• severe abdominal pain if persisting between contractions
• acute onset of scar tenderness
• Chest pain or shoulder tip pain or sudden onset of shortness of breath
• abnormal vaginal bleeding
• maternal tachycardia, hypotension or shock
• loss of station of the presenting part
16. Post-partum scar palpation not required
17. Involve and explain to the patient with the decisions made during
labour

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Post-natal care after emergency caesarean section
1. Doctors and midwives should discuss pregnancy and labour events

with each woman, the reasons for her CS and her suitability of VBAC and
implications for future pregnancy. This should be recorded in the clinical
notes
2. Review the patient before they leave the postoperative support ward
and document in the clinical notes
References
1. ‘Birth after previous caesarean birth’ Green top guideline No45 RCOG 2015
2. NHS Institute for Innovation and Improvement 2006 Delivering Quality and Value Focus on:
Caesarean Section DH, London
3. Saving Mothers Lives the seventh report of the Confidential Enquiries into Maternal Deaths in
the United Kingdom. CEMACH London: December 2007
4. Nice Guideline Caesarean Section Guideline 13 2004
5. MacKenzie IZ, Bradley S, Embrey MP. (1984) Vaginal prostaglandins and labour induction for
patients previously delivered by caesarean section. BJOG 91: 7-10
6. Flamm BL, Goings JR, Fuelberth N-J et al (1987) Oxytocin during labour after previous
caesarean section: results of a multi-centre study. Obstetrics & Gynaecology 70: 709-12
7. Lydon-Rochelle M et al 2001 Risk of uterine rupture during labour among women with a prior
Caesarean delivery New England Journal of Medicine 345(1):3-8
8. Meehan FP, Rafla NM, Burke G (1990) Regional epidural analgesia for labour following previous
caesarean section. J.Obst.Gynaecol. 10: 312-6
9. Morton SC, Williams MS, Keeler EB et al Effect of epidural analgesia for labour on the caesarean
delivery rate. Obstetr. Gynaecol. 1994 83(6): 1045-52
NICE guideline Intrapartum Care 2007
11 PRE LABOUR-RUPTURE OF MEMBRANES (PROM)

Diagnosis
• Record the accurate time of PROM, colour of liquor

• Perform maternal temperature, pulse, BP, RR and urinalysis
• CTG
• Confirm the evidence of liquor draining
• If no evidence of liquor draining – perform speculum examination to
confirm PROM
• If in doubt, perform ROM plus test and consider USS for liquor volume
if necessary
• Immediate IOL may be offered depending on labour ward and
antenatal ward activity
• Primip with unfavourable cervix consider immediate IOL with propess
to avoid prolonged ruptured membranes
• >24 hours, to deliver in hospital with access to neonatal unit and stay
in hospital for >12 hours
• IV antibiotics not required unless choriamnionitis/ GBS+

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• Risk of neonatal infection is 1%
11.1 MANAGEMENT OF PROM >37 WEEKS

IMMEDIATE IOL EXPECTANT MANAGEMENT
• Chorioamnionitis • Patient allowed to go home with

▪ Maternal pyrexia information sheet, thermometer
▪ Maternal tachycardia to record temperature
▪ Leucocytosis
▪ Uterine tenderness • To check temperature at home 4
▪ Offensive vaginal discharge hourly during waking hours
▪ Fetal tachycardia
Antenatal history of GBS

•
• Meconium-stained liquor
• • If temperature >38°c or >37.5°c
Signs of fetal compromise on 2 occasions ≥2 hours apart
and feeling unwell should to
•
Any other obstetric risk factors return to hospital
• Maternal request (depends on

labour ward occupancy)
• Offer IOL (depends on labour ward

occupancy)
• IOL after 24 hours

• Prophylactic antibiotics if risk
factors present as per guideline
11.2 PRE TERM PRE LABOUR RUPTURE OF MEMBRANES (PPROM)

<37 WEEKS
• Perform speculum examination under aseptic technique to assess the

cervix and take an HVS
• Do not perform digital vaginal examination unless indicated

Page 26 of 100
• Regular monitoring for signs of infection

• Give corticosteroids if <35 weeks
• Tocolysis not routinely recommended
• Prescribe Erythromycin 250mg QDS for 10 days
• Consider Magnesium sulphate if <34 weeks in preterm labour
• Inform SCBU
• After discussion with consultant, consider delivery from 37 weeks
• Consider propess – 10 mg (unlicensed) with informed consent as it is
safer than prostin as it reduces repeated examination and can be
removed if there is foetal distress
• Give prophylactic antibiotics in labour
• Avoid ventouse delivery before 34 weeks
• All transfers– inform the consultant
11.2 Corticosteroids
Dose: Betamethasone 12mg IM – 2 doses 24hrs apart

or
Injection of Dexamethasone 6mg IM – 12hrs apart for 4 doses
Indications for steroids
• If delivery anticipated between 24 and 33+6 weeks give steroids and

consider between 34 and 35+6 weeks
• Steroids at gestation 23-24 weeks – should be decided by the
consultant after discussion with the patient
• Elective Caesarean section <39 weeks
• PPROM
• Ante Partum haemorrhage
Contraindications for steroids
• Sepsis
• Systemic infection including tuberculosis
• Chorioamnionitis
If steroids given at <26 weeks, single rescue course may be considered if

the woman presents again after discussing with the consultant
11.3 Tocolytics
Should be considered to complete a course of steroids or facilitate in utero

transfer

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First drug of choice:

Nifedipine regime – 20mg of oral Nifedipine (capsule) as loading dose
followed by 10-20mg of modified release tablets, three to four times
daily, adjusted according to uterine activity up to 48hrs (total dose of
60mg including the loading dose)
For low BMI women –the loading and the maintenance dose is reduced to
10mg
CONTRAINDICATIONS RELATIVE
CONTRAINDICATIONS
• Cardiogenic shock & Aortic
stenosis
• Severe PET • Non reassuring CTG
• Intrauterine infection • IUGR
• Placental abruption • Multiple pregnancy
• Advanced cervical • Mild haemorrhage due to
dilatation placenta praevia
• Evidence of fetal
compromise
• Placental insufficiency
*After giving nifedipine loading dose please check the pulse rate and BP
every 30 minutes for first 2 hours then 4 hourly until next dose
11.4 Atosiban
The choice of Atosiban (licensed) should be discussed with the duty Consultant
Step Regimen Injection Atosiban dose

Rate
Bolus Over 1 min 0.9 ml 6.75 mg
Loading dose 3 hours 24 ml/hour 18 mg/hour

(300 mcg/min)
Maintenance Up to 45 hours 8 ml/hour 6 mg/hour
dose (100 mcg/min)
Preparation:
Atosiban = Tractocile = 7.5mg/ml
Infusion can be given in 0.9% saline, Ringer solution, or 5% Dextrose

Page 28 of 100
From a 100 ml bag, withdraw 10 ml and discard, replace it with 10 mls

Atosiban 7.5 mg/ml=75 mg in 100ml
Loading infusion 24ml/hour=18mg/hour over 3 hours then reduce the

infusion rate to 8ml/hour
11.5.1.1Contraindications to Atosiban
<24 weeks and >33 weeks

PROM>30 weeks
Abnormal FH/CTG
Placenta praevia or abruption
Severe Pre-eclampsia
No data on women with abnormal liver or renal function
(No specific antidote)
References: Preterm labour and birth. NICE guideline (NG25) November 2015
12 PRE-TERM LABOUR
Pre-term is birth of a baby less than 37 weeks of gestational age Painful

contractions occurring >1 in 10 mins with cervical effacement and
dilatation
Imminent Preterm labour between 24 to 34 weeks give magnesium
sulphate regime (see guideline on magnesium sulphate for preterm
labour)
13 Guidance on Use of Magnesium Sulphate in Preterm

labour
13.1 Indications
Magnesium sulphate should be considered in all women who are at risk of

early preterm imminent birth (24-34 weeks)
Administration of magnesium sulphate antenatally to women less than 34
weeks gestation where early preterm birth is planned or definitely expected
within 24 hours will help to reduce the risk of cerebral palsy following
preterm birth
13.2 Place of Administration
Magnesium sulphate must be administered on Delivery Suite with one-toone

midwifery care

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This does NOT need to be in HDU
13.3 Timing of Administration
1. In the case of planned delivery before 34 weeks gestation, the bolus

should be given four hours prior to delivery and the maintenance
infusion continued until birth
2.
3. In spontaneous preterm labour, if delivery is expected within 24
hours (i.e., in established labour), commence magnesium sulphate
and continue maintenance infusion until delivery or 24 hours,
whichever is sooner
4. If birth before 34 weeks is expected to occur sooner than four hours
(e.g., Category 2 or 3 caesarean section or late presentation to
hospital with >4 cm dilatation), administer magnesium sulphate as
there is still advantage likely from administration within this time
5. Where urgent delivery is necessary because of maternal or fetal
compromise (e.g., severe fetal distress or antepartum haemorrhage)
then birth should not be delayed administering magnesium sulphate.
6. Magnesium sulphate infusions should not be used during antenatal
transfer. If a clinical decision is made to transfer a woman who is
receiving magnesium sulphate for neuroprotection, the maintenance
infusion should be stopped during the transfer
13.4 Dosage and Administration
Loading dose:
1. Medical staff to administer a loading dose (bolus) of 4g should be

given via the Asena Syringe Driver pump over 30 minutes
2. Take a 10ml ampoule of magnesium sulphate (50%) and draw off 8
mls which equates to 4grams of magnesium. Dilute in 12mls of
sodium chloride 0.9% which equates to 4grams in 20ml solution
Administer via a syringe pump at 40mls per hour which will give the
solution slowly over 30 mins

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Maintenance Dose:
3. Midwife to commence maintenance infusion immediately following

loading dose of 1g/hr (10ml/hr) until delivery or for 24 hours,
whichever is sooner
(Adding 50mls of magnesium sulphate (50%) to the 200mls of 0.9%

sodium chloride will provide a 250mls solution. This will contain 25g
magnesium sulphate in the 250ml solution equating to a 10%
magnesium solution i.e., 1g in 10mls)
Administer through an Alaris pump at 10mls per hour therefore giving
1g of magnesium per hour
13.5 Repeat doses
In the event that birth does not occur after giving magnesium sulphate for
neuroprotection of the infant, and preterm birth (less than 34 weeks’
gestation) again appears imminent (planned or definitely expected within
24 hours), a repeat dose of magnesium sulphate as described above may
be considered at the discretion of the consultant on call
13.6 Maternal Monitoring
Magnesium toxicity is unlikely with the above regimens and magnesium

levels do not need to be routinely measured (see section 6.8 for
indications when levels should be monitored)
Loading dose:
1-Pulse, blood pressure, respiratory rate, and patellar reflexes before

loading dose, 10 minutes after loading dose infusion has started and at
the end of the loading dose infusion (30 minutes)1
2-Observe for adverse effects (see Section 6.7)
3-Stop infusion and call for medical assessment if respiratory rate decreases
more than 4 breaths per minute below baseline, or is less than
12 breaths per minute; or diastolic blood pressure decreases more than
15 mm Hg below baseline level1
Maintenance infusion:

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Observe for any adverse effects.

Pulse, blood pressure, respiratory rate, patellar reflexes, and urine output
4-hourly1
Stop infusion and call for medical assessment if respiratory rate is less
than 12 breaths per minute; if patellar reflexes are absent, if hypotension
occurs or if urine output is less than 100ml over 4 hours1
If on calcium channel blockers (e.g., nifedipine) or evidence of renal
impairment, observations must be carried out hourly
13.7 Side Effects
Intravenous magnesium sulphate is associated with minor maternal side

effects such as facial flushing, warmth, nausea and vomiting and headaches
Very rarely, hypotension, respiratory depression, muscle weakness and
paralysis can occur (see Section 6.8)
When given in conjunction with calcium channel antagonists, cardiovascular
and neuromuscular effects may be exaggerated.1 Close monitoring is
therefore required if used in conjunction with calcium channel blockers
(e.g., nifedipine).
If hypotension occurs, nifedipine and magnesium sulphate administration
should cease, and urgent medical review requested
There is no evidence of an effect on maternal death, cardiac respiratory
arrest, pulmonary oedema, respiratory depression, severe postpartum
haemorrhage, or caesarean section rates3
There is no association with adverse long-term fetal or maternal outcomes1
13.8 Toxicity
Magnesium toxicity is unlikely with the regimens recommended in these

guidelines and serum magnesium concentrations do not need to be
routinely measured (RCOG 2006)
If toxicity is suspected, urgent medical review is required
In women with renal compromise or on calcium channel blockers (eg
nifedipine), where the risk of toxicity is increased, closer observation is
required (see Section 6.6)
Calcium gluconate 1g (10 ml of 10% solution) slowly via intravenous route
over 10 minutes is the antidote for magnesium toxicity
9. References
1. Australian Research Centre for Health of Women and Babies. Antenatal
Magnesium Sulphate Prior to Preterm Birth for Neuroprotection of the Fetus,

Page 32 of 100
Infant and Child – National Clinical Practice Guidelines. Adelaide. ARCH; 2010
2. For more reference see the main guideline

Page 33 of 100
Appendix 1 Flowchart for the use of Magnesium Sulphate in

preterm labour up to 34 weeks
*
See

Page 34 of 100
Corticosteroids/Tocolytic regime in the SROM guideline
References: Tocolytic Drugs for Women in Preterm Labour - RCOG greentop

guideline No 1B, February 2011
14 Group B Strep (GBS) prophylaxis in pregnancy and labour

Incidence of early onset GBS (EOGBS) disease in UK and Ireland in 2015
has increased and was 0.57/1000 births
Antenatal
• Routine screening is not recommended for Antenatal GBS carriage
• A maternal request is not an indication
• GBS urinary tract infection (growth of greater than 105 cfu/ml) during
pregnancy should receive appropriate treatment at the time of
diagnosis as well as IAP
• Antenatal treatment is not recommended for GBS +ve vaginal or rectal
swab
• If GBS +ve in previous pregnancy, offer the woman either IAP
(intrapartum antibiotics) or repeat testing (between 35-37 weeks or
3-5 weeks prior to delivery date)
• Swabs collected from low vagina and around anal region

Risk Factors for EOGBS
• Having a previous affected baby with GBS
• Discovery of maternal GBS carriage through bacteriological
investigation during pregnancy (eg- urine infection or a vaginal swab)
• Preterm birth
• Prolonged rupture of membranes
• Suspected maternal intrapartum infection, including suspected
chorioamnionitis
• Pyrexia
Intrapartum Antibiotic prophylaxis (IAP)
• Previous Pregnancy +ve for GBS
• Previous GBS affected baby
• PPROM
• GBS urinary tract infection (growth of greater than 105cfu/ml) during
pregnancy)

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• Known GBS carriers who are to be delivered by caesarean section after

spontaneous ROM
• Raised temperature of >/= 37.5°C on two occasion

• ROM at >37+0 weeks GBS+ve should be offered immediate IAP and
induction of labour as soon as reasonably possible (If –ve or unknown
carrier status: Offer IOL after 24 hrs)
• Intrapartum pyrexia (38°C or greater) broad-spectrum antibiotic IV

Amoxicillin 2g every 6 hours (or IV cefuroxime 1.5g every 6 hours)
• Birthing pool is not contraindicated if the woman is a known GBS

carrier provided she is offered appropriate IAP.
• Women who have no other known risk factors can birth in the
alongside birth unit with cannula and offered appropriate IAP.
• Preterm labour
Preterm/PPROM
• The risk of GBS infection is higher with preterm delivery and the
mortality rate from infection is increased (20–30% versus 2–3% at
term) Therefore, IAP is recommended for women in confirmed preterm
labour
• If GBS +ve <34 wks
Risk of prematurity higher than risk of infection. Offer oral
erythromycin 250 mg, qds for 10 days. Oral penicillin considered for
the same duration in women who cannot tolerate erythromycin. IAP
should be given once labour starts
• GBS+ve >34 weeks
Beneficial to expedite delivery with intrapartum antibiotic prophylaxis
Antibiotics regime
• Antibiotics should be started as soon as possible after the onset of

labour
• 3g IV Benzylpenicillin be given as soon as possible after the onset of
labour and 1.5g 4 hourly until delivery
• To optimise the efficacy of IAP, the first dose should be given at least
4 hours prior to delivery. Within 2 hrs is still beneficial
• Amoxicillin is an alternative

Page 36 of 100
• Non severe allergy to beta-lactams (i.e., no anaphylaxis, angioedema,

respiratory distress or urticaria), then a cephalosporin can be
administered intravenously (e.g., cefuroxime, 1.5 g every 8 hours)
• If the allergy to beta-lactams is severe, then intravenous Vancomycin
(1g every 12 hours) is recommended
• Clindamycin can no longer be recommended as the current resistance
rate in the UK is 16%
Women who decline IAP
Women should be made aware that the risk of the baby developing
EOGBS infection is higher than if they had received IAP. The overall
risk remains low.
The baby will require clinical evaluation at birth and monitoring of vital
signs at 0, 1, 2 hrs and then 2hrly for 12 hours
Diagnosis of Clinical Chorioamnionitis
Temperature ≥ 37.9 0C and presence of ≥ 2 of the following

Page 37 of 100
• Maternal Tachycardia
• Fetal Tachycardia
• Tender/ Irritable uterus
• Foul smelling /Purulent discharge
• Consider Clinical Chorioamnionitis if there is meconium-stained liquor,
fetal tachycardia/ Other CTG abnormalities especially in early labour
• Raised CRP (>30% baseline) (Prior to onset of labour)
• WCC>15,000 (Prior to onset of labour)
Note: If it triggers sepsis, please follow sepsis pathway
Management
• Expedite delivery (IOL or augmentation of labour or Caesarean section

as appropriate)
• Institute continuous electronic fetal monitoring with STAN if this is not
in place already
• Inform on call consultant
• Inform neonatalogy team
• Obtain Blood cultures
• Give a single dose of gentamicin 5mg/kg body weight stat and
Amoxicillin 2gm 6-hrly or Cefuroxime 1.5g 6-hourly IV until delivery if
allergic to penicillin
• Give regular paracetamol and tepid sponge. Consider a cooling fan
• Chase any outstanding microbiology specimens
References: Prevention of Early‐onset Neonatal Group B Streptococcal

Disease. Greentop guideline 36. RCOG. September 2017
15 Pre- eclampsia and Eclampsia
Definitions
Hypertension - BP 140-159/90-109 mmHg

Severe hypertension - BP ≥ 160/110 mmHg
Anti-hypertensives
Aim of the therapy is to keep BP 135/85 mmHg
Choice of antihypertensives
First line
Page 38 of 100
Labetolol- it improves cerebral perfusion, thereby reduces the risk of

eclampsia. Compared with hydralazine it has less maternal and fetal side
effects
Oral
If patient not on antihypertensives and can tolerate oral therapy – •
Give oral Labetolol 200mg - stat dose
• Recheck the BP in half an hour
• If BP high second dose can be given in 1 hour
Intravenous
Indicated if
• Severe hypertension (BP > 160/110 or MAP >125 mmHg)
• BP not controlled by oral therapy or if oral cannot be tolerated
Bolus Dose
Give 50 mg IV Labetolol over 1 minute (10 ml equals 50mg)
Effect seen in 5 minutes- recheck the BP
If BP not controlled repeat the bolus every 20 minutes to a maximum dose
of 200 mg
Maintain the pulse rate > 60 beats/min
Maintenance Dose
Draw 90ml out of a 250ml bag of sodium chloride and discard, leaving
160ml
Add 200 mg of labetolol sodium chloride (2 ampoules/40ml)
You now have 200mg of labetalol in 200ml of sodium chloride
Infuse at 20 mg/hour which is 20ml per hour
The dose can be doubled every 30 minutes to a maximum dose of 160mg
per hour if necessary and prescribed by a doctor
Second line
Nifedipine and hydralazine are vasodilators. Use of Magnesium sulphate with
Nifedipine is not seen as a problem (MAGPIE study)
Nifedipine
• Give 10 mg oral tablet (not a slow-release tablet) initially
• BP measured every 10 minutes in the first half an hour
• Continous CTG monitoring
• Dose repeated 6th hourly
• Postnatally dose can be changed to slow-release tablets which lasts
12 hours

Page 39 of 100
Hydralazine
• Expansion of the circulating blood volume prior to treatment is
recommended
• Liaise with anaesthetist
• Consider using up to 500ml of crystalloid fluid before or at the same
time as the first dose of IV hydralazine
Hydralazine 60 mg in 60 ml normal saline (3 amps of hydralazine with 60mls

of sodium chloride) via syringe driver
Bolus
IV Hydralazine 10 mg (10ml) slowly over 1-minute, repeated doses of 5 mg
at 20 minutes interval up to 30 mg maximum. The drug has affect up to 6
hours
Maintenance
Infusion of 2 mg/hour, increased by 0.5 mg/hour to a maximum of 20
mg/hour
Fluid management prior to delivery
Total intravenous input should be restricted to 80 ml/hour (approximately

1ml/kg/hr)
During labour, oliguria should not precipitate any specific intervention except
to progress to delivery
Consider fluid loading prior to establishing regional block
Seizure prophylaxis
Magnesium sulphate protocol –

a. Loading Dose
4grams of magnesium sulphate given slowly IV over 20 mins
Take a 10ml ampoule of magnesium sulphate (50%) and draw off 8mls
which equates to 4 grams of magnesium. Dilute in 12mls of sodium
chloride 0.9% which equates to a 4grams in 20ml solution.
Administer via a syringe pump at 60mls per hour which will give the solution
slowly over 20 mins.

Page 40 of 100
b. Maintenance Dose
Continuous IV infusion of 1 gram per hour.
c. How to prepare 10% magnesium sulphate

1. Take a 250ml bag of 0.9% sodium chloride
2. Draw off 50mls, leaving 200mls in the bag
3. Add 5 x 10ml ampoules (contains 5g) of magnesium sulphate to the bag
(Adding 50mls of magnesium sulphate to the 200mls of 0.9% sodium

chloride will provide a 250mls solution. This will contain 25g magnesium
sulphate in the 250ml solution equating to a 10% magnesium solution
i.e., 1g in 10mls)
Administer through an Alaris pump at 10mls per hour therefore giving 1g of
magnesium per hour.
d. Adverse effects
• nausea, vomiting, flushing, hypotension, and arrhythmias
Recurrence of seizures
Repeat IV loading dose of 2g magnesium sulphate if ≤70 kg or 4 g if ≥70
kg over 5-10 minutes.
If this fails, inform the anaesthetist, and consider diazepam 10 ml IV or
thiopentone 3-5 mg/kg IV to paralyse and intubate.
Monitor and record in HDU chart

• Continuous pulse oximetry
• Hourly urine output
• Hourly respiratory rate
• Deep tendon (patellar)reflexes- every 10 minutes for first 2 hours and
then every 30 minutes
Stop magnesium sulphate infusion and check the levels if

• Urine output is < 100 ml in 4 hours
• Patellar reflexes are absent (assuming not due to regional block)
• Respiratory rate < 12 beats/ minute
• O2 saturation is < 90%
There is no need to measure magnesium levels if urine output is maintained

Check magnesium levels if toxicity is suspected on clinical grounds The
antidote is 10ml of 10% calcium gluconate slow IV
Page 41 of 100
Restart the magnesium sulphate if urine output improves.
POST PARTUM FLUID PROTOCOL – PRE-ECLAMPSIA
• Only 2% of women develop severe oliguria

• No response needed until 8hr period Error! Reference
source not found.
References: NICE CG 107, Hypertension in pregnancy, August 2010

Page 42 of 100
Aneurin Bevan University Health Board ABHB/F&T/ABHB 0226
Owner: Maternity Services
Please refer to the dose regime
16 Management of Labour in Women with Diabetes (type I, II and
Status: Issue 8 Issue date: 30 November 2021

Approved by: Maternity Clinical Effectiveness forum Review by date: 29 November 2024
Page 43 of 100
GDM)
Induction of labour
The mode and timing of delivery will be decided by the joint Obstetric and
Medical team
The standard IOL protocol will be followed (propess/prostin, CTG monitoring
etc)
During latent phase whilst on a normal diet, continue routine insulin
(usually basal bolus and will be prescribed by the team) and blood
glucose monitoring an hour after every meal
In established labour
Once labour is established, the woman should be transferred to the labour
ward (LW). If there is delay in transfer to LW, commence sliding scale on
the ward
The basal insulin (long-acting insulin, usually given at bedtime - i.e.

Glargine/Lantus; Detemir/Levemir; Insulatard; Humulin I) should be
continued even if on sliding scale
Inform Obstetric and Anaesthetic registrar
Standard high-risk monitoring- maternal observations, continuous CTG,

maintenance of partogram
Check BMs hourly and ensure maintained between 4-7mmol/L

Page 44 of 100
Keep consultant on call informed about progress, use of syntocinon for

augmentation of labour and need for assisted delivery
Anticipate shoulder dystocia at birth especially if assistance is required. Have

a low threshold for trial in theatre for instrumental delivery
Post delivery
Continue sliding scale in women with pre-existing diabetes until they are back
on regular meals
Check BMs hourly whilst on sliding scale
Switching from sliding scale to subcutaneous insulin (bolus/short

acting) involves giving the short acting insulin (pre-pregnancy dose-
written in puerperium and intrapartum section) followed by a meal. The IV
infusion is stopped after 30 minutes. Stop dextrose infusion at the same
time as IV insulin
Ensure long-acting insulin is given at bedtime (pre pregnancy dose or as

instructed in the notes)
Women who had insulin only during pregnancy (e.g., GDM or Type 2 DM
who were on oral therapy prior to pregnancy) will not need any further
insulin once the IV insulin infusion is stopped after completion of 3rd stage
of labour. The team would decide if this were not the case and document
the plan in the notes
On the PN wards, continue to check fasting (on waking up in the morning)

and blood sugars 1 hour after every meal until discharged by the team on
appropriate dose of insulin
If breastfeeding, the insulin dose may need to be reduced by further 2530%

and advice about hypo management should be re-iterated.
Metformin is compatible with breastfeeding
If BMs are erratic (mostly above 15, discuss with medical/diabetic team and
they may advice to recommence sliding scale until their review)
Neonate will be observed for signs of hypogylcaemia as per protocol
Elective Caesarean section

Page 45 of 100
Admit patient the previous night. If on long acting/basal insulin, (i.e.,

Glargine/Lantus; Detemir/Levemir; Insulatard; Humulin I) ensure it is given
Commence sliding scale on the morning of the procedure (7am)
Actrapid 50 IU in 50 ml normal saline + 500 ml of 5% glucose and 0.45%saline infusion

with 0.15% KCl (premixed bags) at 100mls/hr
Hourly BMs to be checked from 7am (even during the surgery)
Continue sliding scale and hourly BMs post operatively until normal eating
commences when pre-pregnancy insulin should be started.
Nausea, vomiting and complications during or after surgery may necessitate delay in
switch over from IV to S/C short acting insulin and this should be individualised
Basal/long-acting insulin-pre pregnancy dose is continued on the day of

the operation (along with sliding scale if has not commenced eating.) As
long as on sliding scale, BMs should be checked hourly
Emergency Caesarean section
If already on sliding scale, follow the instructions as above for switching

from sliding scale to pre-pregnancy short acting insulin and frequency of BM
monitoring. The long acting (basal) insulin is continued
Preterm Labour
Commence IV sliding scale along with first dose of steroid
Use the Supplemental IV Insulin Regime in addition to their usual

subcutaneous insulin as long as the patient is eating normally. Dextrose
infusion is not given in this regime
Use the proforma to record dose of insulin and BMs for 12 hours after the last
dose of dexamethasone or 24 hours after betamethasone
Nifidipine/atosiban regime for tocolysis

Follow the management of preterm labour protocol
* See GHT DIR 1221 Management of Diabetic Ketoacidosis in Adults

Page 46 of 100
(DKA)- ISSUE 2.PDF

** See GHT/DIR/Guide to the management of Hypoglycaemia in Adult

Page 47 of 100
Error! Reference source not found.
Breastfeeding is only contraindicated in the event of a herpetic lesion

on the breast
Reference: Management of genital Herpes in Pregnancy, RCOG/BASHH

October 2014

Page 48 of 100

Page 49 of 100
18 Pre-Requisites for Caesarean Section Error!

Reference source not found.
Second Stage Caesarean Section

Page 50 of 100

Page 51 of 100

Page 52 of 100
Owner: Maternity
Services
Status:
Issue 8
Issue date: 30 November 2021
Page 53 of 100
Owner: Maternity
Services
21 Surgical Management of Post-Partum Haemorrhage
(for medical management see Major Obstetric Haemorrhage management

Guideline – ABHB/W&C/0293)
http://howis.wales.nhs.uk/sitesplus/documents/866/ABHB_Clinical_0576%
2 0Management%20of%20Massive%20Haemorrhage_Issue%203.pdf see
page 17-23 appendix 1
1. If medical treatment fails, consider another cause of bleeding. Inform an

Obstetric Consultant on call, ask an Anaesthetist to contact an Anaesthetic
Consultant and perform EUA
2. Ensure Rotem is performed (>1000ml blood loss) and further bleeding regularly
monitor coagulation screen and FBC
3. Inform relatives that a hysterectomy may be necessary for persistent uterine
atony, placenta accreta or ruptured uterus
In the case of massive postpartum haemorrhage before resorting to
hysterectomy try locally accepted methods including the Bakri
tamponade balloon, the Brace Suture and uterine artery ligation
without delay. Consider Interventional Radiology input if available. If
resorting to hysterectomy get a second opinion and help from another
consultant
1. SOS Bakri tamponade balloon

The balloon is made of silicon with a capacity of 500ml of saline achieving
tamponade effect to control bleeding. It can be helpful in assisting
stopping the bleeding from placenta praevia/accreta during CS or after
in the immediate post-partum period. Before closing the uterine incision
introduce the distal end of the deflated balloon into the cervix where it
is pulled by an assistant though the vagina. Leave in situ for 24 hours.
To increase pressure to further tamponade the bleeding, the distal part
of the shaft can be loaded by stretching and attaching to the leg of the
woman. Balloon can also be inserted into the uterus by retrograde
placement via the vagina.
2. Brace suture (B-lynch) for massive postpartum haemorrhage

GA/Regional if appropriate
Pfannenstiel incision or if bleeding after CS reopen and same incision Lower

segment is opened after dissecting bladder off, or a recent CS suture is
Status:
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Owner: Maternity
Services
removed, and cavity entered. Evacuate cavity and examine cavity.

Exteriorise uterus and check for any bleeding points.
Try bimanual compression of uterus to assess the potential chance of
success of B Lynch suture. If bleeding is stopped by compressing the
uterus, start suturing.
Use number 2 polysorb taper cut needle (150cm).
Puncture the uterus 3 cm from the left lateral border. The stitch is threaded
through the uterine cavity to emerge at the upper incision margin 3 cm
above and approximately 4 cm from the lateral border (because the uterus
widens from below upwards).
The polysorb is passed over to compress uterine fundus approximately 3-4
cm from the left cornual border. The polysorb is fed posteriorly and
vertically to enter the posterior wall of the uterine cavity at the same level
as the upper anterior entry point. The polysorb is pulled under moderate
tension assisted by manual compression exerted by the first assistant. The
length of the polysorb is passed back posteriorly through the same surface
marking as for the left side with the suture lying horizontally.
The polysorb is fed through posteriorly and vertically over the fundus to
lie anteriorly and vertically to compress the fundus on the right side. The
needle is passed on the same fashion on the right side through the uterine
cavity and put approximately 3 cm anteriorly and below the lower incision
margin on the right side.
The two lengths of the polysorb are pulled taught assisted by bimanual
compression to minimise trauma and to achieve or to aid compression.
When bleeding is controlled double throw knot followed by 2 or 3 further
throws inserted to secure tension
The lower uterine incision is now closed in the normal way in 2 layers.
See diagrams (next page)
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Services
B-Lynch et al, BJOG 1997, 104, 372-375
Uterine artery ligation in the control of post Caesarean haemorrhage
The aim is to devascularize the post caesarean uterus with bilateral mass ligation
of the ascending branches of the uterine arteries and veins:
1. Make sure the bladder is pushed well down
2. The ligation is performed 2-3 cm below the level of the uterine incision and
needs to include 2-3 cm of the myometrium in the suture
3. Stand on the left side of the woman and grasp and elevate uterus with the
left hand (figure 1) and tilt it away from you to expose the vessels on the
left side of the uterus (figure 2)
4. Use no 1 Mayo needle with no 1 Vicryl
5. Start ligating the left uterine artery and vein by passing the needle 2-3 cm
medial to the vessels including almost the full thickness of the myometrium
and then bring it through the avascular area lateral to the vessels
6. Next ligate the right uterine artery by passing the needle through the broad
ligament's avascular area lateral to the vessels and then medially through
almost the full thickness of the uterine wall (figure 2)
7. Perform only a single ligation on each side (figure 3). Mass ligation does not
enter the uterine cavity but does include almost a full thickness of the wall
(figure 3)
8. Then compress the uterus with the hot pack
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9. Inspect vaginal bleeding, if controlled, close abdomen
Figure 1
Figure 2
The uterus is tilted to

the side to expose the
vessels, and the
ligature is placed 2-
3 cm inferior to the
incision. It includes
2-3 cm of uterine wall
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Figure 3
A coronal view of the lower uterine segment. The suture is inserted into the
substance of the cervix without entering the uterine cavity and medial to
the blood vessels
Ref - Bakri Y.N. Uterine tamponade-drain for hemorrhage secondary to placenta previaaccreta.
Int J Gynecol Obstet 1992,37
O'Leary "Uterine artery ligation in the control of Postcaesarean Haemorrhage" J Reprod Med
1995; 40: 189-193.
22 Breech Delivery
The decision as to the mode of delivery is made in the clinic by a Senior

Obstetrician if the breech has been diagnosed antenatally. If the breech
is first diagnosed in labour, decision regarding the mode of delivery is
taken by the duty Registrar in discussion with the Consultant. If you are
not certain about the presentation, use the ultrasound scanner.
Breech deliveries are conducted by the most senior clinician, normally the duty
Registrar, assisted by an SHO.
An Anaesthetist and Paediatrician are present at the delivery. Epidural

analgesia, spinal analgesia or epidural/spinal analgesia is the analgesia of
choice, if mother agrees.
If the progress of labour is slow, do not accelerate it with Syntocinon until you
have discussed your management with a consultant.
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26 Management of Twin Delivery

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Equipment available in labour room -

2 resuscitaires.
- Delivery trolley with 2 delivery packs.
- Portable ultrasound scanner.
- Lithotomy set.
- Instrumental delivery trolley.
- Amnihook.
- Syntocinon 30iu in 500mL normal saline infusion for augmentation.
- Syntocinon 40iu in 500mL normal saline infusion for PPH prophylaxis.
- Ensure an obstetric theatre is kept available during second stage.
Admission to MDU
- Baseline observations.
- Commence CTG/STAN.
- Inform obstetric registrar:
o Review:
▪ handheld notes if no hospital notes available,
▪ EFW of both twins and amnionicity & chorionicity,
▪ Identify additional risk factors,
▪ Document and discuss plan of care.
o Confirm lie and presentation of both twins, o Inform consultant on call, o
Discuss epidural analgesia.
- Site large bore cannula and ensure G&S and FBC available, consider crossmatch.
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Inform obstetric anaesthetist:
o Keep the anaesthetist informed of progress throughout.
- Inform SCBU.
First Stage of Labour

- Routine observations, bladder care and diet as per NICE guidance on
intrapartum care.
- Give ranitidine 150mg PO every 6 hours.
- Continuous monitoring of CTG/STAN:
o Consider FSE for twin 1.
o Caesarean section is indicated if there are concerns about fetal

wellbeing of twin 2.
o Pulse oximeter for maternal pulse. o Beware of same twin
monitoring.
- Analgesia:
o Epidural is recommended but maternal choice is key.
o An effective epidural is beneficial as it allows for top-up for

trial of instrumental delivery, external or internal version of
twin 2 and emergency caesarean section.
o Elective epidural top-up of 5-10mL of 0.5% levobupivacaine

after the delivery of twin 1 will facilitate manipulation,
instrumental delivery and rapid top-up for emergency
caesarean section of twin 2.
- Augmentation of the first stage of labour is not contraindicated. The

same indications apply as for singleton pregnancies.
- Consider tocolysis for transfer to theatre or caesarean section.

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-
Personnel to be present in labour room at time of delivery -
2 midwives (at least one experienced midwife).
- Experienced obstetrician.
2 neonatal teams (if preterm)
- Obstetric anaesthetist (present and aware on labour ward) and ODP.
Delivery of twin 1
- Deliver as for a singleton pregnancy.
- Withhold third stage oxytocic after delivery of twin 1.
- Clamp and cut the umbilical cord after delivery of twin 1.
- The length of the second stage for twin 1 should not differ from
management of a singleton pregnancy if there are no concerns about
fetal wellbeing of twin 2.
Delivery of twin 2
- Continue to monitor CTG of twin 2 continuously.
- Perform abdominal palpation and vaginal examination immediately

after delivery of twin 1.
- Presentation and lie of twin 2 could be confirmed by ultrasound

immediately after delivery of twin 1 and should be kept stable if
longitudinal until presenting part descents into pelvis.
- If the lie is not longitudinal perform external cephalic version (ECV)

or internal podalic version (IPV). IPV is ideally done in theatre and
with intact membranes. The membranes may break spontaneously,
otherwise rupture them as late as possible once the rotation is
complete.
- If the contractions cease and if the lie of twin 2 is longitudinal,

augmentation syntocinon infusion should be commenced to shorten
the delivery interval. Consider commencing at 4mL/hr and double
the rate every 5 minutes up to 16mL/hour to achieve maximum of

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-
4 contractions in 10 minutes as long as the CTG is satisfactory and
with safe consideration.
- Perform ARM when clinically appropriate. Exclude cord presentation

and confirm fetal presentation prior to ARM. Perform ARM during a
contraction and when the presenting part is in the pelvis.
Ideally aim to deliver twin 2 within 30 minutes of twin 1 because of
the risk of fetal distress. If there are no concerns about fetal
wellbeing the interval may be longer to allow for spontaneous
delivery. If there are concerns about fetal wellbeing or there is
significant delay an assisted delivery / caesarean section is
indicated.
Third stage
- Active management of third stage with i.m. oxytocin 10iu after
delivery of twin 2.
- Prophylactic Syntocinon 40iu in 500mL normal saline infusion at 125

mL/hr.
- Manage a PPH according to PPH protocol.
- Paired cord gases should be taken for both twins.
- Precise documentation of the delivery.
- Debrief woman and partner of events.
Obstetric considerations
- MCMA twins should be delivered by caesarean section.
- The risk of intra- and postpartum haemorrhage is increased in

multiple pregnancy.
- There is an increased risk of operative delivery in multiple pregnancy.
- Keep a low threshold for transfer to theatre in second stage.

Instrumental delivery or internal manipulation should ideally be
performed in theatre.

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-
- If twin 1 is non-vertex at presentation caesarean section could be
advised but maternal choice should be respected.
- Vaginal twin delivery after previous caesarean section is not

contraindicated.
IPV, ECV and breech extraction are of equal outcome when
manipulation of twin 2 is needed. Caesarean section is associated
with increased maternal morbidity.
- Acute TTTS could happen after delivery of twin 1. Continuous CTG

monitoring of twin 2 is essential.
- If there are any concerns about fetal wellbeing of twin 2 consider

caesarean section.
Anaesthetic considerations
- Epidural does not increase the twin-twin interval.
- Instrumental delivery is as high as 8% after spontaneous delivery of

twin 1.
- Caesarean section is as high as 6% after spontaneous delivery of twin

1.
- Internal manipulation may be necessary for delivery of twin 2.
- Engorged epidural veins make a bloody tap more likely.
- Compressed epidural and spinal spaces increase the likelihood of a

high regional block.
- Aorto-caval compression is likely to be more severe.
- Surgery can be prolonged (especially for higher order deliveries).
- There is an increased likelihood of premature or prolonged labour,

instrumental delivery, and PPH.
References
• The MOET Course Manual: Managing Obstetric Emergencies and
Trauma. Cambridge 2014.

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-
• PROMPT Course manual. Cambridge 2017.
• Oxford specialist handbooks in anaesthesia: Obstetric Anaesthesia.

Oxford 2008.
• Analgesia, anaesthesia and pregnancy: a practical guide. Cambridge

2007.

Page 67 of 100
• Best practice in Labour and Delivery. Warren, Arulkumaran. Cambridge

2010.
• Intrapartum Care for the MRCOG and beyond. RCOG Press.
• Queen Charlottes Hospital Twin Guideline.

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27 Algorithm for cord prolapse

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Page 73 of 100
31 Error! Reference source not found. MANAGEMENT OF JEHOVAH’S

WITNESSES IN PREGNANCY
(& care plan for women in labour refusing blood transfusion)
ANTENATAL
• To be seen by consultant obstetrician at booking.
• Respect patient wishes and Make clear Advance Directive.
• Clear statement and documentation of accepted/refused products.
• Offer the patient to speak with Hospital Liaison Committee for Jehovah’s.
• Ensure patient has an opportunity to speak with the obstetrician in
privacy.
• Clear record of discussion.
• Take document consent in the presence of a witness.
• Witness and the doctor should sign the record of discussion and consent
as made.
• Risk of massive obstetric haemorrhage and the importance of blood
transfusion, early recourse to hysterectomy should be discussed and
documented.
• Check serum B12, Folate and Ferritin at booking and replace as required.
• Consider IV Iron (Ferrinject) if evidence of anaemia and low Ferritin (1g
IV if >70 kg)
• Anaesthetic Review
• Ensure clear plan of delivery in notes
ELECTIVE CAESAREAN SECTION •

Arrange cell saver.
• Inform consultant anaesthetist/obstetrician.
• LSCS to be performed by consultant obstetrician/anaesthetist.
• Syntocinon 40 units infusion in 500ml Normal saline -125ml/hr
postnatally.
CARE PLAN FOR WOMEN IN LABOUR REFUSING BLOOD TRANSFUSION

Patient in Labour
• Admit to labour ward.
• IV access.
• FBC, Group & Save.
• Inform consultant obstetrician and anaesthetist.
• Active III stage management.
• Do not leave the patient alone for first hour after delivery.
• IV Oxytocin infusion if any risk factors of PPH present.

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Risk Factors for Post-Partum Haemorrhage

• Previous history of bleeding, ante or post-partum haemorrhage.
• Prolonged labour (especially when augmented with Oxytocin).
• Abnormal presentation.
• Large baby (>3.5kg) and/or polyhydramnios.
• Increased maternal age (>40 yrs).
• Fibroids/myomectomy scars.
• P3 and more.
• Maternal obesity.
• Multiple pregnancy.
MANAGEMENT IN ACTIVE HAEMORRHAGE
• Involve obstetric, anaesthetist and haematology consultants.

• Establish IV colloid infusion (e.g Gelofusine).
• Give Oxytocin drugs first, then exclude retained products of conception
or trauma.
• Proceed with bimanual uterine compression.
• Give oxygen
• Catheterise and monitor urine output.
• Consider CVP line, aortic compression against the spine, using the fist
above the umbilicus (may buy time in emergency).
• Persistent blood loss requiring action - Anticipate Coagulation problems.
• Keep patient fully informed.
• Injection Ergometrine 500 micrograms IV, Oxytocin 10 units IV slowly.

• Carboprost (Haemabate) 250 mcg/ml im, every 15 minutes – maximum
8 doses (2mgm).
• Rectal misoprostol 1000 micrograms.
• Tranexamic Acid 1gm IV – three times daily.
• Consider IV vitamin K.
• Consider Recombinant Factor VII a – after discussing with haematology
consultant. 90 mcg/kg.
• Intrauterine balloon tamponade – Bakin balloon (300-500ml).
• B-Lynch brace suture.
• Involve interventional radiologist for arterial embolisation.
• Internal iliac artery ligation.
• Subtotal hysterectomy – early.
MANAGEMENT OF POSTPARTUM ANAEMIA

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• Severe anaemia – involve haematologist. Use recombinant human

erythropoietin 300 units/kg – three-weekly subcutaneously. Augment
with iron, vitamin B12 and folic acid.
• IV Ferrinject 1 gram if patient > 70 Kg- 15-minute infusion.
• Consider elective ventilation in ICU.
• Hyperbaric oxygen therapy – in life threatening anaemia.
Contacts:
Hospital Liaison Committee for Jehovah’s Witnesses
Curtis Wheatley (chairman) Tel: 01633 889035 Mobile: 07811670776
Stephen Goddard Mobile: 07970905951
Andrew Groucutt Tel: 01633 870462 Mobile: 07958502053
Chris Clark Mobile: 07776273233
James Clark Mobile: 07846223816
Terry Reed Tel: 02920 360639 Mobile: 07815646145
Members of the Hospital Liaison Committee for Jehovah’s Witnesses are
trained to facilitate communication between medical staff and Jehovah’s
Witness women and are available at any time, night, or day, to assist with
difficulties either at the request of the treating team or the woman.
21 Extremely Premature Babies between 22 and 26

weeks Gestation
Communication before Delivery
1) The most experienced clinicians available at the time (preferably

Consultant Obstetrician and Consultant Paediatrician with an
experienced Midwife), should agree a provisional management plan. If
possible, time should be allowed for all concerned to consider the options
and assimilate the information.
2) Management plans should be clearly recorded in the notes and
accessible to all clinical staff.
3) When appropriate, parents should be encouraged to seek support from
family members and religious advisers.
4) Warn parents that the provisional plan may need revising according to
clinical assessment of the baby post-delivery.
Gestational Assessment and Management Recommendations
1) Early ultrasound dates, if available, are usually reliable. Caesarean
section is rarely appropriate <25 weeks gestation, but in some cases a
second opinion may be helpful to the parents.

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2) Determine viability by auscultation with Sonicaid.

3) In-utero transfer may be appropriate from 22+0 weeks gestation when
considering the potential survival of the baby and providing transfer is
considered to be safe for the mother. Reasons for transfer must be
clearly discussed with parents prior to transfer.
4) When transfer is considered inappropriate, (<22 weeks), supportive
care must be provided for the family.
Neonatal resuscitation Initial

Resuscitation:
1. if gestation certain (confirmed by early ultrasound scan) and FH
heard during labour:
o >23+0 weeks gestation: An experienced paediatrician and
another clinician (neonatal nurse and / or) need to attend birth
to assess whether active resuscitation is appropriate depending
on condition of baby at birth
o <22+6 weeks gestation: Paediatrician does not routinely
attend birth. Parents need to be informed that baby might show
some signs of life perhaps for some time, but this does not
mean that active resuscitation would be successful
2. if gestation uncertain and FH audible during labour:
o A Paediatrician needs to attend all births thought to be >23+0
weeks to assess whether active resuscitation is appropriate
(depending on the condition of the baby)
Provisional intensive care:

The response of the baby to active resuscitation is critical in deciding
whether to institute “provisional” intensive care, especially in cases of
uncertain gestation if the heart rate picks up rapidly and the colour of the
baby improves, it is appropriate to arrange transfer to SCBU for
assessment. Further management should be decided by experienced
clinicians and will be dependent on the response of the baby to treatment.
Ethical Consideration:
1) When agreement between parents and clinical staff cannot be reached
over management of the baby after birth, provisional intensive care
should be offered, pending further assessment and discussion.
2) Parents of infants who die should be offered bereavement follow up and
counselling, including advice about postmortem examination and the
prognosis for future pregnancies.

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References:
1) The EPICure Study (provisional data – appendix c)
2) Perinatal management at the lower limit of viability. JM Rennie Arch Dis Child Fetal
Neonatal Ed 1996 May 74:3 F214-8.
3) Changing prognosis for babies of less than 28 weeks gestation in the north of England
between 1983 and 1994. Northern Neonatal Network. Tin W, Wariyar U, Hey E BMJ
1997 Jan 11;314 (7074): 107-11.
4) Caesarean section or vaginal delivery at 24 to 28 weeks gestation: comparison of survival
and neonatal and two-year morbidity. Kitchen W, Ford GW, Doyle LW, Rickards AL,
Lissenden JV, Pepperell RH, Duke JE Obstet Gynecol 1985 Aug 66:2 149-157.
5) Withholding or withdrawing Life Saving Treatment in Children – A Framework for
Practice. Royal College of Paediatrics and Child Health, September 1997.
Appendices:
a) Flowchart for action
b) Suggested criteria to be taken into consideration when determining
management of extremely premature babies
c) Epicure data.

Page 78 of 100
* Caesarean section rarely offers benefit to the fetus < 25+6 weeks
gestation and should be performed only when indicated for the health of
the mother except under exceptional circumstances.
** Infants under 21+6 weeks will not survive: however, the
Paediatrician may decide to offer active treatment for infants whose
gestational age is thought to have been underestimated.
*** There are wide variations in prognosis and outcome for infants born
between 23 to 25 +6 weeks. The management of the infant should be
consistent with parents’ wishes. For infants without fatal congenital
abnormalities, the decision to resuscitate at birth should depend on the
infant’s condition. Objective criteria include condition at birth, lack of
bruising and presence of spontaneous respiratory efforts.
Appendix b) Factors to be considered when determining management of

extremely premature babies
Antenatal factors influencing fetal outcome:
• Gestational age
• Steroid administration
• Fetal size
• Presence and severity of pathology
• IUGR
• Hypoxia
• Sepsis
• Fetal anomaly
Parental factors:
• Cultural and Religious
• Medical

Page 79 of 100
• Past obstetric history

• Previous pregnancy loss
• Sub-fertility Parental Expectations:
• Understanding of process
• In-utero transfers
• Postnatal assessment
• Paediatric involvement/interventions
• Outcome
• Survival
• Morbidity Condition of Infant at Delivery:
• Apparent maturity
• Birthweight
• Evidence of asphyxia
• Extensive bruising
• Heart rate and activity level
• Respiratory effort and evidence of sustained
response to resuscitation.
Appendix c) EPICure Data

The most reliable data available are from the EPICure Study. This was
the largest and most comprehensive study of the outcome for extremely
premature babies. The primary aim was to measure the survival and
health of all children in the United Kingdom and the Republic of Ireland
born at 25 weeks gestational age and below between 1st March and 31st
December 1995. The intention was to provide information for parents
and professionals when faced with the prospect of the birth of an
extremely premature baby.
<23 weeks 71% died in delivery room

6% overall survival
3% overall survival free of disability
24 weeks 18% died in delivery room
26% overall survived
13% overall survival free of disability
25 weeks 8% died in the delivery room
43% overall survived 22% survived
free of disability
22. Management of Sepsis in Labour ward

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Sepsis is responsible for 1 out of every 4 deaths in the UK during pregnancy

and within 6 weeks of childbirth.
The most common pathogen responsible for puerperal sepsis is E.Coli
closely followed by Group A Streptococcus.
THINK SEPSIS
RECOGNITION OF SEPSIS
All observations should be recorded on an early warning or MEOWS chart.

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PRINCIPLES OF "SEPSIS 6" PLUS 1 (FETUS)
ANTIBIOTICS FOR ABUHB
IV Tacozin 4.5g TDS

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If penicillin allergy – IV Imipenem 500mg TDS
CONTINUING CARE
• Retained products of conception should be removed as soon as the

maternal condition is stable
• Observations
o Monitor respiratory rate, pulse, BP and O2 saturations every

15 mins until stabilised, then reduce to 30 mins o
Recheck temperature at least 4-hourly
o Urinary catheter should have urometer for hourly urine output

measurement
RESPONSE TO TREATMENT
In those women starting the sepsis 6 pathway a clinical response should

be evident within 1 hour of completion of fluid resuscitation and giving
intravenous antibiotics
Failure to respond to treatment is consistent with:

• Systolic BP <90mmHg
• Reduced level of consciousness
• Respiratory rate >25
• Lactate not reduced by at least 25%
Alert a consultant to attend in person if the woman fails respond

to treatment
THROMBOPROPHYLAXIS
Pregnant and postpartum women with sepsis are at increased risk of

venous thromboembolism and should be given thromboprophylaxis with
low molecular weight heparin unless there are any ongoing issues with
haemostasis or coagulopathy.

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34 Late Intrauterine death
Introduction and definition
Delivery of a fetus with no signs of life known to have died after 24

completed weeks of gestation. Prior to 24 weeks it is classified as
miscarriage.
Diagnosis
An appropriately trained person should make the diagnosis by using real

time ultrasound. A second opinion should be obtained if practically possible.
Ideally the diagnosis should be confirmed by the presence of a second
observer. If patient wishes repeat USS should be offered.

Page 86 of 100
Communication
Parents should be told in the appropriate surroundings. If alone, offer to

call partner, family, or friends
Parents may need time to absorb any information
The diagnosis is often unexpected and sudden and this needs to be
considered
Empathy is critical
Explanations should be short and concise, and parents should be offered
written information to supplement the discussions
Show the USS to the parents if they wish
Timing of delivery
Parents and family may need time to accept the diagnosis.

The woman should be allowed to return home if she wishes with a planned
date for induction.
If there is any evidence of bleeding, infection, PET, ruptured membranes,
or abruption delivery should not be delayed. Immediate IOL offered.
Prolonged delay results in reduced quality postmortem findings due to
alteration of the appearance of the fetus (maceration) As
risk of DIC – need daily bloods (coag) until delivery
Mode of delivery
Vaginal birth should be the aim to reduce risks for future pregnancies. It
also reduces the length of stay and time spent on a postnatal ward (90 %
of women will deliver within 24 hours of IOL)
Caesarean section can be considered in some circumstances:
Placenta praevia, greater than 2 previous caesarean sections, psychological
reasons and if indicated, should be discussed with a consultant.
IOL see flowchart
A combination of mifepristone and prostaglandin preparation should usually

be recommended as the first- line intervention for IOL.

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Misoprostol can be used in preference to PG E2 due to its equivalent safety

and efficiency with lower cost.
Women advised that vaginal misoprostol is as effective as oral therapy with
fewer side effects. (Diarrhoea, vomiting, shivering, pyrexia)
Day 1: oral 200mg Mifepristone
Day 3: PV Misoprostol 50 mcg 4hrly X 4 doses.
Syntocinon augmentation should be a consultant decision
IMPORTANT POINTS:
Ensure regular analgesia

Regional analgesia and PCA should be available to women with an IUFD
(DIC and sepsis should be ruled out before regional analgesia)
Diamorphine should be used in preference to pethidine
Regular paracetamol as misoprostol can cause temperature rises
DO NOT rupture membranes to prevent CHORIOAMNIONITIS
If the patient finds it too distressing to wait or in the presence of infection
or bleeding Misoprostol can be given following the first dose of Mifepristone
but this may prolong the induction to delivery interval
*If previous uterine surgery, IOL should be discussed with a
consultant.
Women with one single scar should be advised that, in general, IOL with
prostaglandin is safe but not without risk.
Women with 2 previous LSCS should be advised that in general the absolute
risk of IOL with prostaglandin is only a little higher than for a woman with
single previous scar.
Women with > 2 LSCS or atypical scars should be advised that the safety
is unknown.
Preferred regime:
Mifepristone 200mg TDS for 2 days or Mifepristone 600mg once daily for 2
days
If still labour not established – give vaginal Misoprostol 50 mcg 4th hourly
x 4 doses
Syntocinon augmentation should be a consultant decision.
Isoimmunisation prevention
Anti-D should be administered at the earliest after presentation.

If there is large FMH the Anti-D dose should be adjusted and Kliehauer
should be repeated at 48hours to ensure fetal red cells have cleared. Anti-

Page 88 of 100
D provides reduced benefit when given beyond 72 hours, up to 10 days

after the sensitising event.
Antibiotics
Prophylaxis for GBS is not required if pt is known to be GBS

Antibiotics are not required unless there is evidence of infection
Thromboprophylaxis
Standard prophylaxis guidelines should be followed

IUD is not a risk factor
Suppression of lactation
Following delivery, women may begin to lactate, and some find this as
extremely distressing if not prepared. Pharmacological suppression of
lactation with a dopamine agonist may not be necessary in all cases 1/3 of
women who choose nonpharmacological measures are troubled by
excessive discomfort
This should be discussed with the patient. Good support and advice with
conservative measures may be sufficient
Conservative measures: Good breast support, Ice packs, NSAIDS
Cabergoline is superior to bromocriptine.

Cabergoline is an ergot derivative; it should not be used if there is a history
of PET or a strong F/H of CVS disease or thromboembolic disease 1mg
Carbergoline STAT during the first day post-partum before lactation
begins, 250mcg 12 hourly for two days if lactation has begun Bromocriptine
(2.5mg BD) X 14 days.
Investigations
As many investigations as possible should be taken while in hospital, to

minimise the need to return, which the women may find distressing. They
should be explained the need for each test. Following should be considered:
FBC
Kleihauer test
Blood group and antibody screen
Coagulation and fibrinogen (abruption, DIC) – daily
HbA1C if known diabetes, random blood glucose if not

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Urea and Electrolytes

Liver function tests
Bile acids
TFT’s (occult thyroid disease)
CRP, Blood cultures (sepsis)
Maternal and Paternal blood for karyotyping
Syphilis / Parvovirus / CMV / Toxoplasmosis / Rubella serology
Thrombophilia screen only after 12 weeks postnatal
Anti-red cell Ab (hydrops)
Anti-Ro abd anti-La Ab (hydrops, endomyocardial fibro-elastosis or AV node
calcification on PM)
Alloimmune anti-platelet Ab (fetal intracranial haemorrhage on PM) Urine
culture
Urine toxicology if indicated in suspected drug use (consent needed)
High vaginal swab
Cervical swabs Placental
swab
Placental histology
Fetal blood for culture
Fetal skin swabs for culture
Fetal skin biopsy / placental biopsy for karyotyping (NOT FIXED IN
FORMALIN)
Postmortem
Consent for postmortem (PM)

Parents should be offered a full post-mortem examination to help explain
the cause of IUFD.
40% of post-mortem cases find a cause for otherwise unexplained losses
and even in the presence of a diagnosis of fetal abnormality, postmortem
finds new and further findings in 25% of cases
Appropriately trained and registered clinicians should only take consent
Attempts to persuade parents to choose PM must be avoided; individual,
cultural and religious beliefs must be respected
Parents should be offered a description of what happens during the
procedure and the likely appearance of the baby afterwards and the funeral
arrangements. Discussions should be supplemented by the offer of a leaflet
Parents who decline post-mortem should be offered limited examination
Pathological examination of the cord membranes and placenta should be
recommended whether PM examination is requested or not

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Support and follow up
Use the checklist for investigations and procedure/checklist for midwives to

make sure all paperwork has been complete before the discharge of women
Follow up should be continuous but not forced. Parents should be given
contacts for all appropriate specialists including:
Community midwife
GP should be informed
Obstetric Consultant follow up and secretary contacts
Help groups e.g., SANDS
It is not possible to predict how parents will deal with the tragic news of a
stillbirth. There are no predictors. Each case should be treated individually.
Ensure all antenatal clinic appointments are cancelled
Future pregnancy
This should not be discussed at the time of delivery or discharge.

Decisions will be made depending on the pending results of any
investigations and after discussion with the patient in clinic.
Future pregnancies, it is good practice for reassurance, to have a

neonatologist present for a baby check post-delivery. Parents will need
extra reassurance that this baby is fit, well and healthy.
Legal Clarification
Only deaths after 24 weeks need to be registered

Losses before 24 weeks are not recognised by registration, this does not
mean that parents cannot make funeral arrangements, as they should wish.
Please use the SANDS birth certificate to mark the birth of the baby.
The death certificate is required for the parents to register a death after 24
weeks. It must be completed and signed by a doctor.
- Date and sign in the correct places
- Do not guess at the cause of death, it is difficult to change later
- Do not use abbreviations
- Write clearly
Page 91 of 100
- Include GMC number and qualifications

Incomplete forms will delay the registration of the death. This causes
unnecessary upset for the grieving parents. Under the law, the coroner
does not have any jurisdiction over the cases of foetal loss including those
intra partum. They should not be contacted or involved in these cases.
References:
1. BNF
2. Best Practice in Labour Ward and Delivery Arulkumaran, Warren.
Cambridge Press 2010
3. Obstetrics and Gynaecology: An evidence-based text for the MRCOG
Luesley and Baker. 2nd Edition 2010
4. RCOG Guideline No. 55 Oct 2010
5. Medical Management of late intrauterine death using a combination of
Mifepristone and Misoprostol. Wagaarachchi et al BJOG 2002
6. Medical Management of late intrauterine death using a combination of
Mifepristone and Misoprostol - experience of two regimes. Fairly et al.
European Journal of Obstetrics and Gynaecology 2005

Page 92 of 100
Status: Issue 8 Issue date: November 2021

Approved by: Maternity Clinical Effectiveness forum Review by date: November 2024
Page 88 of 93
TREATMENT TO DO THIS
SIGNS OF SEVERE TOXICITY:

Appendix 1 Local • SUDDEN ALTERATION IN MENTAL STATUS, SEVERE AGITATION OR
Anaesthetic toxicity LOSS OF CONSCIOUSNESS, WITH OR WITHOUT
TONIC-CLONIC
CONVULSIONS
• CARDIOVASCULAR COLLAPSE: SINUS BRADYCARDIA,
CONDUCTION BLOCKS, ASYSTOLE AND VENTRICULAR
TACHYARRHYTHMIAS MAY ALL OCCUR
• LOCAL ANAESTHETIC (LA) TOXICITY MAY OCCUR SOME TIME AFTER AN INITIAL INJECTION
• STOP INJECTING THE LA IN CRCULATORY ARRET• START
CARDIOPULMONARY RESUSCITATION
• CALL FOR HELP
(
• MAINTAIN THE AIRWAY AND, IF NECESSARY, SECURE
IT WITH A TRACHEAL TUBE
C
P
• GIVE 100% OXYGEN AND ENSURE ADEQUATE LUNG
R
VENTILATION (HYPERVENTILATION MAY HELP BY INCREASING
)
PLASMA PH IN THE PRESENCE OF METABOLIC ACIDOSIS) U
• CONFIRM OR ESTABLISH INTRAVENOUS ACCESS • CONTROL SEIZURES: GIVE A BENZODIAZEPINE, S
I
THIOPENTAL OR PROPOFOL IN SMALL INCREMENTAL DOSES
N
• ASSESS CARDIOVASCULAR STATUS THROUGHOUT G
• CONSIDER DRAWING BLOOD FOR ANALYSIS , BUTIssue
Status: 8DELAY DEFINITIVE
DO NOT S
Issue date: November 2021
Approved by: Maternity Clinical Effectiveness forum
Review by date: November 2024
Page 94 of 100
TANDARD PROTOCOLS • MANAGE ARRHYTHMIAS USING THE • CONSIDER THE USE OF CARDIOPULMONARY BYPASS IF
SAME PROTOCOLS, RECOGNISING THAT AVAILABLE
ARRHYTHMIAS MAY BE VERY REFRACTORY TO TREATMENT

Approved by: Maternity Clinical Effectiveness forum Review by date: November 2024
Page 89 of 93
Obstetric Haemorrhage – ABUHB Scribe sheet
Time of call-out………………………. Call out by…………………………. Date……………………...
Drug Dose Time

Syntocinon 10iu
Ergotmetrine 500 mcg/ 1amp (if BP normal) IM/ 5 IU/0.5 mg IM)

or repeat bolus of above
Syntocinon 40iu in 500ml normal saline IV via IVAC pump @ 125mls/hr
Carboprost 250mcg/1 amp IM

Owner: Maternity
Services
Misoprostol 200mcg x 5 tablets rectally

Approved by: Maternity
Clinical Effectiveness forum Review by date: November 2024
Page 96 of 100
Team member Name Time arrived
On-call obs cons
On-call obs SpR
On-call obs SHO
On-call anaes con
On-call anaes SpR
On-call ODP
Blood Porter
On-call gyna SHO
Midwife
Midwife
Blood bank Tech
Blood sent Time Observations
Time Pulse BP
FBC
Group and Crossmatch units
4 Thrombin Clotting

Page 97 of 100
S Fibrinogen
Placenta delivered Yes ⁭No ⁭
Urinary catheter with urimeter
Factor v11a in consultation with haematologist
Fluids
Type Volume Time
Initial Management Time
Call for Help
Airway, Breathing, circulation checked
Oxygen given (151/ Min)
Venflon No 1 (14-16G )
Venflon No 2 (14-16G)
Birth Center / Homebirth
1.Tone Contraction rubbed up

Page 98 of 100
2.Tissue Placenta Membrane Checked
3.Trauma Examination for trauma
Bi Manual Compression applied
Ambulance called
Arrival at Hospital
Transfer to Theatre

Page 99 of 100

Labour Ward Guidelines

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Aneurin Bevan University Health Board

Labour Ward Guidelines

N.B. Staff should be discouraged from printing this document. This is to

Status: Issue 8.2 Issue date: 30 November 2021

1 Policy Statement ......................................................................... 2

1.1 Scope of guideline ..................................................................... 2

1.2 Essential Implementation Criteria ................................................ 2

5 Equality Audit and Review ........................................................... 2

Status: Issue 8.2 Issue date: 30 November 2021

1.1 Scope of guideline

This guideline applies to all clinicians working within maternity services.

1.2 Essential Implementation Criteria

Auditable standards are stated where appropriate.

5 Equality Audit & Review

Local service Improvement Plan will guide monitoring and effectiveness.

This policy has undergone an equality impact assessment screening

Status: Issue 8.2 Issue date: 30 November 2021

10 Management of women with previous Caesarean Section in labour 22

11 Pre Labour Rupture of Membranes (PROM) 24

12 Pre term labour 28

14 Group B Streptococcal (GBS) Prophylaxis in pregnancy and Labour 35

Status: Issue 8.2 Issue date: 30 November 2021

15 Pre- eclampsia and eclampsia & Flowchart 38

16Management of labour in Women with Diabetes 44

17 Protocol for Genital Herpes in pregnancy and labour 48

19 Pre-requisites for Caesarean Sections & 2nd stage 52

20 Guideline for difficult delivery of fetal head 54

21 Surgical Management of Post Partum Haemorrhage 56

Status: Issue 8.2 Issue date: 30 November 2021

32 Management of Jehovah’s Witnesses in pregnancy 75

33 Extremely premature babies between 22-26 weeks gestation 77

34 Management of Sepsis in Labour Ward 82

35 Management Late Inter Uterine Death and of 88

7 Diagnosis and Management of Labour:

A positive diagnosis of labour should be made as soon as possible

Initial assessment by midwife and registrar (MDU)/career SHO with full

To start on continuous electronic fetal monitoring in accordance with clinical

7.2 Nutrition in Labour

7.3 Hygiene in Labour

7.4 Pain Relief in Labour

7.5 First Stage of Labour

7.6 Progress of Labour

Partogram to be commenced at 4cm of cervical dilatation

Routine observations - 4 hourly temperature, blood pressure, respiratory

Status: Issue 8.2 Issue date: 30 November 2021

Vaginal examination to be offered every four hours to assess progress of

7.7 Second stage of Labour

7.8 Third Stage of Labour

Status: Issue 8.2 Issue date: 30 November 2021

Women should be informed that with physiological management the

• Nausea/vomiting is 50 in 1000 women

• PPH more than 1L is 29 in 1000 women

• Blood transfusion is 40 in 1000 women

Women should be informed that active management of the third stage

• Nausea/vomiting is 100 in 1000 women

• PPH more that 1L is 13 in 1000 women

• Blood transfusion is 14 in 1000 women

Observations of the woman include general physical condition by her

Status: Issue 8.2 Issue date: 30 November 2021

7.9 Delayed cord clamping