TITLE: OB-FBC GUIDELINES FOR MANAGEMENT OF LABOR CURRENT EFFECTIVE DATE: October 1, 2012 REFERENCE NUMBER: NA. PAGE: 1 of 11

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1 PAGE: 1 of 11 SCOPE: Registered Nurse with orders from Provider MD, CNM, DO Presbyterian Delivery System: (Check where this policy is applicable. The shading represents facilities where specific services are not available and must not be changed.) CDS PRMC EH LCMC SGH DCT CGH Hospital(s) x x x x x x Presbyterian Medical Group Rural Clinics Ambulance Healthplex Home Healthcare, except for Inpatient Hospice Inpatient Hospice Skilled Nursing Facility Intermediate Care Facility Swing Bed PURPOSE: To outline the nursing management of intrapartal patients. Supportive nursing care provides comfort and emotional support. Evidence-based nursing care fosters the normal and safe progression of the labor process. GUIDELINE Steps: 1. Assess the following on admission to FBC: Maternal BP, pulse, respirations, temperature All maternal body systems Maternal and significant other (SO coping and support) Uterine contractions o Frequency, duration, intensity, interval o Resting uterine tone Assess the fetal status and implement EFM management Guideline for monitoring. Place the maternal pulse-oximetry or toco MP transducer whenever the fetal monitor is in use and recording the fetal trace. Assess as applicable: o Cervical dilation, effacement, station, fetal presentation and position o Fetal presentation and position per Leopold s Maneuvers

2 PAGE: 2 of Obtain urine specimen for protein (if not done in Triage). 3. Validate that all lab work is completed as ordered. 4. When ordered, establish peripheral IV access with INT or IV fluid. 5. Review plan of care with patient/so and discuss preferences/requests for labor process. 6. Identify patient with wristband and allergy band (if applicable). ON GOING CARE 1. Assess the following in patients WITHOUT identified risk factors: Maternal BP, pulse and respiratory rate every hour during first stage of labor, every 30 minutes during second stage Temperature every 4 hours if membranes intact, every 2 hours if membranes ruptured OR patient is febrile Uterine contraction pattern every 30 minutes during 1 st stage (active labor) and every 15 minutes during second stage Palpate abdomen for uterine resting tone and contraction intensity when using an external tocotransducer Quantify uterine resting tone and contraction intensity in mmhg if using IUPC. Montevideo units of indicate adequate contractions. FHR pattern based on NICHD criteria Patient/SO comfort/coping 2. Repeat complete maternal assessment every shift or more frequently if condition indicates. 3. Perform cervical exam as indicated Assess dilation, effacement, station, presentation and position Exam is contraindicated with known placenta previa or abnormal vaginal bleeding Limit excessive vaginal exams after rupture of membranes unless delivery is imminent 4. Use Delivery Flow Map for decision management by stage of labor (active and 2 nd stage) Notify provider for patients with inadequate cervical change based on expected average for active labor (cervical dilatation 4-10 cm). 5-8 hours for nullipara 5-6 hours for multipara

3 PAGE: 3 of 11 Notify provider for patients when active labor has exceeded: 8 hours for nullipara 6 hours for multipara Active labors exceeding 12 hours are considered abnormal Notify provider when second stage is prolonged (2 nd stage begins when cervical dilatation is complete) >2 hours for nullipara (with epidural >3 hours) (avg. = 50 minutes) >1 hour for multipara (with epidural >2 hours) (avg. = 20 minutes) 5. Observe for rupture of membranes Assess amount, nature (clear, bloody, meconium, malodorous) and FHR at time of rupture and throughout labor at regular intervals. Assist provider with artificial rupture of membranes and note above data 6. Encourage voiding a minimum of every two hours Palpate bladder for distention every two hours following epidural placement Catheterize bladder if unable to void and bladder is distended 7. Assist with oral hygiene and perineal care PRN Assist with shower, soak tub or bed-bath as indicated Minimal hygiene care is once every 24 hours unless contraindicated by clinical situation 8. Prepare and provide the appropriate equipment and environment for the infant and ensure resources are available for neonatal resuscitation if necessary 9. Initiate stabilization and immediate care of the newborn 10. Promote newborn/maternal/family bonding 11. Process specimens obtained according to hospital policy ACTIVITY 1. Instruct/encourage patient in activity level: Low risk stable patients with a NICHD Category I FHR may ambulate following initial assessment Patient in labor receiving Magnesium Sulfate, epidural anesthesia or sedation are placed on bed rest. All patients are instructed to avoid the supine position All patients on bed rest are encouraged/assisted in frequent change of position Patients who require continuous EFM may sit in a chair or stand at the bedside or ambulate with cordless monitoring unless contraindicated for one of the above conditions.

4 PAGE: 4 of 11 REPORTABLE CONDITIONS 1. Report the following to the provider using SBAR: Spontaneous rupture of membranes, meconium or blood-stained amniotic fluid Vaginal bleeding beyond normal bloody show Analgesia or anesthesia needs of the patient using pain scale NICHD Category II or III fetal tracing Significant system assessment findings Failure to make adequate cervical changes or failure to make adequate fetal descent Complete dilatation for all patients Cervical dilatation of 7-8 cm. for multiparous patients and pre-term patients Imminent delivery Urine protein > 1+ (if specimen not contaminated) 2. Report the following parameter for maternal vital signs: Repeated BP >140/90 BP < 90/60 Oral Temp >38.0 degrees Celsius (100.4 degrees F). Axillary temp > 37.5 degrees Celsius (99.5 degrees F) Persistent pulse >100 at rest Respirations <14 or >24 at rest COMFORT/SAFETY Instruct/assist patient/so in breathing patterns and relaxation techniques with contractions Provide other coping/comfort measures such as: Laboring in shower or in soak tub Use of massage/pressure points Alternate positions such as standing or sitting in rocking chair Use of doula personnel DIET: INTAKE/OUTPUT Implement the guideline for oral intake for the laboring patient on FBC. Document intake and output following IV placement for each shift.

5 PAGE: 5 of 11 COMPLICATIONS MANAGEMENT For precipitous delivery: Call for assistance and precip delivery pack DO NOT leave patient s bedside Request assistance of any available provider Provide supportive measures for mother and deliver infant when necessary For NICHD Category II or III FHR patterns: Implement EFM Management guidelines PATIENT/FAMILY INSTRUCTION 1. Instruct/review the following with patient and family: Plan of care Unit routine Use of electronic fetal monitor Pain management options Use of video-taping equipment during labor and delivery Visitor policy DOCUMENTATION REQUIREMENTS IN THE EMR: 1. Record maternal and fetal assessment data, interventions and response, and patient teaching 2. Record provider notification, indication and response. 3. Complete birth documentation 4. Record discharge/transfer time and unit.

6 PAGE: 6 of 11 DEFINITIONS: PDS: Presbyterian Delivery System, which includes CDS (formerly PDS-A) and RDS (formerly PDS-R) REFERENCES: 1. AWHONN templates for Protocols and Procedures for Maternity Services. (2002). AWHONN. 2. American Academy of Pediatrics & The American College of Obstetricians and Gynecologists: (2007), Guidelines for perinatal care (6 th ed.). 3. Cunningham. F., Leveno, K., Bloom, S., Hauth, J. & Rouse D. (2010). Williams Obstetrics (23 rd ed.) McGraw-Hill. 4. Kennedy, B., Ruth, D., & Martin E. (2009). Intrapartum management modules (4 th ed.). Wolters Kluwer/Lippincott Williams & Wilkins. 5. Murray, M. & Huelsmann, G. (2009). Labor and delivery nursing: a guide to evidencebased practice. Springer.

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9 PAGE: 9 of 11 DELIVERY FLOW MAP; KEY DECISIONS FOR 2 ND STAGE OF LABOR B EXPECTED RANGE: Primip = 3 hr 1 Multip = 2 hr 2 Labor RN 2 ND Stage Epidural? Yes Fetal descent as expected in time range? Yes Labor RN/Provider Vaginal Delivery 3 No 4 No Provider Conversation with patient/consult Yes Provider Delivery decision 2 nd stage should not extend beyond normal without compelling indications and second opinion Protracted Descent: Primip: <1 cm per hour Multip: < 2 cm per hour Arrest of Descent: Primip: > 2 hours Multip: >1 hour EXPECTED RANGE Primip = 2 hr Multip = 1 hr Fetal descent as expected in range? Yes 5 RN/Provider Vaginal Delivery 6 7 No Provider Conversation with patient/consult Provider Delivery decision 2 nd stage should not extend beyond normal without compelling indications and second opinion

10 PAGE: 10 of 11 Central Delivery System Central Delivery System PROCEDURE - APPROVAL AND TRACKING INFORMATION Approvals: Medical Director: T. Dandade, MD OB/GYN Executive Committee OB/GYN Division Nursing Director: Mary Taylor MSN, RNC Date: May 15, 2012 May 15, 2012 July 10, 2012 May 15, 2012 Current Author(s): G. Huelsmann RNC Next Review Date (Every Three Years): July, 2015 Replaces Guideline/Procedure Named and Dated: None FACILITY-SPECIFIC PROCEDURES: Note: Any facility that adopts another facility s procedure shall not repeat the procedure but instead shall note Procedure is the same as (name of the facility). in the Procedure section. Espanola Hospital PROCEDURE - APPROVAL AND TRACKING INFORMATION Approvals:): Date: Current Author(s): Next Review Date (Every Three Years): xx/xx/xxxx Replaces Policy(ies) Named and Dated: Lincoln County Medical Center PROCEDURE - APPROVAL AND TRACKING INFORMATION Approvals:): Date: Current Author(s): Next Review Date (Annually): xx/xx/xxxx Replaces Policy(ies) Named and Dated:

11 PAGE: 11 of 11 Plains Regional Medical Center PROCEDURE - APPROVAL AND TRACKING INFORMATION Approvals: le): Date: Current Author(s): Next Review Date (Every Three Years): xx/xx/xxxx Replaces Policy(ies) Named and Dated: Socorro General Hospital PROCEDURE - APPROVAL AND TRACKING INFORMATION Approvals: Date: Current Author(s): Next Review Date (Annually): xx/xx/xxxx Replaces Policy(ies) Named and Dated: