[CG] Latent phase labour

Objectives

This guideline aims to provide a structured approach for midwives to assist them in helping women manage the latent phase of labour.

The guideline is divided into three sections:

telephone contact
face-to-face contact
admission to hospital in the latent phase of labour.

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Introduction

The management of the latent phase of labour, especially for women expecting their first babies, will always be a challenge. The evidence base would indicate that admission to hospital in latent phase of labour increases the likelihood of a cascade of intervention. The challenge for midwives lies in assisting the woman to stay at home until labour becomes established. This may be achieved by increasing the woman’s confidence in her inherent ability to cope and work with her body.

Nolan (2005) states that some women expressed feelings of fear at home whilst in the latent phase of labour. Worrying leads to increased adrenalin levels thereby causing decreased oxytocin levels. A possible consequence of this is a woman presenting in an exhausted, tense and miserable state with irregular and incoordinate uterine activity.

Studies report that midwives attitudes can impact on women, a dismissive or critical attitude can have a negative impact on labour by further increasing adrenalin levels. During initial telephone conversations and face to face contact it is essential for the health care professional to be caring and compassionate (Draft Framework for Maternity Services 2010)

Although many factors contribute to a prolonged latent phase, two problems consistently associated are high maternal anxiety and a mal-positioned fetal head. It is useful to consider both of these factors when offering advice and support to women.

Telephone Contact

L	Listen – Listen to what the woman has to say, take a history of her pregnancy and recent events and document on telephone triage form.
A	Assess - Talk to the woman, assess contractions - frequency / strength. Note reaction to contractions during conversation. How does she feel she is coping? Enquire about fetal movements.
T	Time – Give the woman time to tell her story, show interest and that you value her experience.
E	Encouragement - Give her encouragement. Talk to her to turn negative thoughts into positive thoughts. Discuss positions for comfort. Has she a companion to offer support?
N	Non-pharmacological pain relief - Talk to the woman about coping mechanisms such as the use of breathing and relaxation techniques, TENS and birthing balls. Discuss the use of heat and cold, massage, showers and baths. Encourage her to carry on every day activities, mobilising, eating and drinking as normal, advise to rest if appropriate.
T	Telephone – during the conversation advise that staff are available for further consultation and inform her that she is welcome to call back for further advice or reassurance, or if she has any concerns.

On the third telephone contact the woman should be offered the opportunity to come in for a face-to-face assessment.

Face to Face Contact

NB. The NICE (National Institute for Clinical Excellence ) definition of established labour is when there are regular painful uterine contractions and there is progressive cervical dilatation from 4cms.

The clinician should adopt the following when assessing women either in hospital or at home in the Latent Phase:

Look and listen - Observe the woman and take a history of her pregnancy and recent events.

Assess maternal and fetal condition - Fetal heart , contractions - frequency / strength. Assess her pain using the following pain score and document in notes. Palpate the uterus to determine fetal position. Undertake a vaginal examination as determined by pain score. Obtain urine sample and test for glucose, protein and ketones.–correct ketosis by fluids and diet if appropriate.

Pain score	Description	Action
3	Severe pain / agony Pain causes extreme distress Not smiling	Consider use of bath/shower before opioids. Vaginal examination
2	Moderate/bothersome pain Pain causes some distress but is able to perform activities Still smiling	Offer TENS, water, paracetamol before opioids Vaginal examination
1	Mild pain or discomfort	Offer TENS, mobilisation, paracetamol, normal food and drink Offer vaginal examination
0	No pain Comfortable	No action required

Time - Take the woman to a quiet area and give her time – one hour if at all possible as the stress of change in environment can often make contractions decrease in frequency and strength. Watch and listen.

Encouragement - Give her encouragement, ask her to describe her feelings. Talk to her to turn negative thoughts into positive thoughts. Discuss positions for comfort.

Non-pharmacological pain relief - Talk to the woman about coping mechanisms, breathing and relaxation techniques. Advise use of TENS, birthing balls. Discuss the use of heat and cold, massage, showers and baths.

If the woman is still distressed in latent labour, despite nonpharmacological methods of coping, 30mgs Dihydrocodeine may be prescribed by medical staff (tablet to be given in maternity assessment unit, women may be sent home following administration).

Telephone – if not in active labour advise that she is welcome to call back for further advice or reassurance or if any change in circumstances.

Green	Amber	Red
Clinical assessment by midwife	Clinical assessment by MW and medical staff	Clinical assessment by MW and medical staff
Follow LATENT mnemonic Intermittent monitoring of FH If not in established labour offer - Home with advice Consider 30mgs oral Dihydrocodeine If admission required (i.e for anxiety/pain control/ geography) transfer to Amber pathway	Follow LATENT mnemonic CTG If not in established labour - Inform obstetric registrar, plan of care may include Home with advice Consider 30mgs oral Dihydrocodeine Admission to hospital (i.e for anxiety/pain control/ geography) Women should be admitted to hospital following the 3^rd presentation in latent labour	Follow LATENT mnemonic CTG If not in established labour - Inform obstetric registrar, plan of care may include Home with advice Consider 30mgs oral Dihydrocodeine Admission to hospital (i.e for anxiety/pain control/ geography) Women should be admitted to hospital following the 3^rd presentation in latent labour
Document plan of care in SWHHMR and in base notes.

Women who require admission to hospital

A woman who has had a prolonged latent phase of labour may have high levels of anxiety and be exhausted which may be exacerbated by negative or dismissive attitudes. Remember the importance of reassuring the woman in order that her hormonal feedback loop is not compromised.

On admission to antenatal ward from Maternity Assessment Unit

Plan of care to include -

Auscultation of the fetal heart to be performed on admission to ward and at each further assessment.
Perform CTG 6 hourly or earlier if clinical condition indicates {if patient asleep wait until she awakens}
Full reassessment to include abdominal palpation, maternal and fetal observation, +/- VE to be repeated 6 hourly or earlier if clinical condition indicates.
Medical re-assessment at each shift change/ward round. Care options include further assessment of fetal condition with scan, discharge home with follow up plan, induction of labour – particularly if in latent labour for over 24 hours.

On admission to antenatal ward from DCC/ ANC

Midwife performs maternal and fetal observation, abdominal palpation.
Clerk in by medical staff
Document plan of care
Auscultation of the fetal heart to be performed on admission to ward and at each further assessment.
Perform CTG 6 hourly or earlier if clinical condition indicates {if patient is asleep wait until she awakens}
Full reassessment to include abdominal palpation, maternal and fetal observation, +/- VE to be repeated 6 hourly or earlier if clinical condition indicates.
Medical re-assessment at each shift change/ward round. Care options include further assessment of fetal condition with scan, discharge home with follow up plan, induction of labour – particularly if in latent labour for over 24 hours.

Maternal observations

Temperature, pulse, respirations, BP, abdominal palpation, PV loss, urinalysis in Triage/admission and daily if admitted to antenatal ward.

Fetal observations

Initial auscultation of the fetal heart for one minute at first contact, and at each further assessment to determine fetal wellbeing.

CTG to be undertaken if - patient in amber or red pathway in Triage; 6 hourly or earlier if clinical condition indicates during stay in antenatal ward

Analgesia

Consider – emotional support, use of TENs, water therapy, consider nonpharmacological and pharmacological analgesia.

References

The ‘Latent Phase Care Bundle’ included in this guideline was developed by Maggie E. Davies, Consultant Midwife, Abertawe Bro Morgannwg University Health Board, and is used with permission.

Hodnett ED et al. (SELAN - Structured Early Labour Assessment and Care by Nurses - Trial Group). Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial. BMJ 2008;337:a1021.

NICE (2014) Intrapartum care for healthy women and babies, CG190.

Healthcare Improvement Scotland (2009) Pathways for Maternity Care. Edinburgh: HIS.

Nolan M. Childbirth and parenting education: what the research says and why we may ignore it. in: Nolan, M., & Foster, J. (2005). Birth and parenting skills : New directions in antenatal education. Edinburgh ; New York: Elsevier Churchill Livingstone.

Scottish Government (2010) Refreshed Framework for Maternity Services, Edinburgh.

Last reviewed: 21 December 2015

Next review: 31 December 2018

Author(s): Angela Duffy

Co-Author(s): Dorothy Finlay, RAH; Sheona Brown, PRM.

Approved By: GONEC