Latent phase labour (409)

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Introduction

Managing the latent phase of labour is without doubt a challenging time for both women and midwives’ alike. Whilst we know that labour happens in stages it is important to remember that there is no such thing as a typical labour or birth – each woman’s experience will be individual and different as will their plan of care. The requirement of support for each woman throughout the latent phase will inevitably be unique and require a person centred, holistic approach.

NICE (2014) defines the latent phase of labour as - a period of time, not necessarily continuous, when there are painful contractions with cervical change. Including cervical effacement and dilatation up to 4 cm.

Most often the first episode of care in early labour will be sought from Triage/Maternity Assessment, whereby women are seeking support and advice via telephone. In this instance communication is key. The RCOG identified a recommendation in their Safer Childbirth (2007) publication, whereby there is a need to improve communication between healthcare professionals and women. Each care provider should foster a team approach based upon mutual respect, a shared philosophy of care and transparent lines of communication.

Midwives are tasked with disseminating large volumes of information to women they care for. The process of education and information sharing, aids women’s decision making, increases their confidence and ultimately enables them to feel empowered. Maxwell (2019) refers to this as “The Midwife Effect”, where midwives have the inherent ability to empower women physically, psychologically and socially. There are 2 defining attributes in the empowerment of women in childbirth - a woman’s belief in herself and a meaningful interconnectedness with carers (Niewehuisze and Warren 2019).

Aim of the Guideline

This guideline is intended to provide a structured support for midwives to assist in supporting women contacting Triage/Maternity Assessment in the latent phase of labour.

Studies report that midwives' attitudes can impact on women. A dismissive or critical attitude can have a negative impact, evoking feelings of fear at home whilst in the latent phase. During initial telephone conversations and face to face contact it is essential for healthcare professionals to be caring and compassionate (Framework for Maternity Services 2016).

Inadequate verbal and written communication is recognised as being the most common root cause of serious errors - both clinically and organisationally. Communication is more effective in teams where there are standard communication structures in place.This is where LATENT can add real value:

Listen Assess Talk Empower Normalise Together

These are the KEY components in communicating critical information that requires attention and action - thus contributing to effective management with increased patient satisfaction and safety.

Listen - Listen to what the woman is saying. Take a history from her including obstetric, medical and social history. Acknowledge her concerns and rationale for seeking advice. Consider her emotional and psychological needs.

Assess - Use scope of clinical experience to make an appropriate risk assessment. Ask questions to determine clinical condition. Make it a priority where possible to speak with the woman directly, providing safe, effective person centred care.

Talk - Offer the woman your time and the opportunity to talk. Acknowledge and value her feelings and opinions. Offer your support and encouragement. Adopt a person centred approach and give advice that is tailored to meet the needs of each individual. Awareness that there may be barriers to effective communication requiring face to face assessment.

Empower - Offer encouragement and reassurance, identify the woman's physiological and psychological needs. Take a holistic approach and encourage women to take control of their birth experience.

Normalise - Providing there are no additional risk factors and the woman herself feels she is coping and is well supported; encourage her to stay at home. Research shows that fear and anxiety inhibit the labour process and in turn can lead to a cascade of intervention. Therefore, it is important to discuss the benefits of being at home with familiar surroundings.

Together - Collaboratively discuss a plan of care that is both appropriate and acceptable to the woman. Adopt an individualised approach and advise that staff are available to advise and assess at any given interval. Highlight the importance of women making contact if there are any changes to their clinical condition or if they require reassurance.

Risk Assess

Healthcare Safety Investigation Branch (2020) published a National Learning Support Summary whereby some mothers made multiple contacts with maternity triage services. With significant amount of emphasis being spent advising mothers to remain at home, mothers were not being invited into the clinical setting in what was perceived as ‘early labour’, without full assessment of the clinical picture. They frequently interacted with different clinicians each time. Initial documentation was often not adequate to ensure that subsequent clinicians were aware of all the previous information. This hampered clinicians’ decision making, leading them to focus on the issue presented in isolation and not appreciate the cumulative nature of the concerns.

Inviting a woman into Triage/Maternity Assessment should be based upon individual need. There is no validity or clinical rationale that supports a process, where women are only invited into hospital for a face to face assessment in correlation with the number of phone calls they have made.

For some mothers, delaying clinical attendance based on a telephone triage process may prevent them from receiving the care and assessment they needed to support safe management during labour and reduce the risk to their baby. From a thematic HSIB review of investigations, this appeared particularly true for mothers known to have:

Group B streptococcus
A baby who is small for gestational age
A history of reduced/altered fetal movements
Women with additional vulnerabilities (BAME, language/communication difficulties, SNIPs etc.)

In all of these situations, early clinical attendance upon signs of labour is important for appropriate care and intervention. Babies who are at increased risk of complications during labour need to be assessed when regular painful unterine activity commences.

Face to Face Assessment

The midwife should undertake a full examination to determine both maternal and fetal wellbeing in relation to the assigned carepathway. The midwife is responsibe for ensuring the minimum level of care is delivered and documented in the Badgernet Smart Assessment form:

Maternal observations
Urinalysis
Abdominal Palpation – fetal presentation/strength/frequency of uterine activity.
Auscultation of fetal heart – method of which will be determined by presenting problem, historic care pathway and current risk
Pain Assessment – consider the need for (non) pharmacological analgesia. If pharmacological analgesia has been given, complete a medication tab in the BadgerNet
Vaginal Examination- determined by clinical assessment.

Any contributing factors that may alter the original pathway of care will require obstetric review +/- further investigations and possible admission to the inpatient ward. An updated care plan and modified risk assesent should be documented in the BadgerNet electronic record.

If after clinical assessment the woman is found to be in the latent phase of labour, with all clinical findings considered normal, requiring minimal dose analgesia (currently 30mg dihydrocodeine) advice should be offered to return home. Studies have shown that hospital admissions in latent phase, subsequently have higher incidences of intervention.

Key factors supporting women in the latent phase of labour who opt to return home:

Offer/encourage oral analgesia to a maximum of 30mg dihydrocodeine in conjunction with regular paracetamol
Advice on coping strategies/non pharmacological pain relief
Reassurance that events are progressing as normal
Provide Patient Information Leaflet
Highlight that timeframes to call back are not Labour is unique to each individual who should seek support as they feel necessary
Establishing an appropriate social support
Encourage light diet, oral fluids and rest where possible

Prolonged Latent Labour

There is no standardised definition for prolonged latent phase. Opinions are polarised in relation to the management. Some believe that it is clinically insignificant, however others consider a possible link and strong assosciaton with subsequent labour abnormalities and high risk outcomes ie. caesarean section.

Malposition may lead to a prolonged latent phase with 10-30% of all babies presenting in the occipito-posterior (OP) position. Prolonged latent phase can be an exhausting and challenging time for women. If any of the following signs and symptoms are evident in a woman who presents:

Maternal exhaustion
Failure of fetal head to descend into the pelvis
Failure of cervical dilatation in the presence of regular uterine activity

Fetal monitoring at regular intervals (currently 6hrly inpatient CTGs on recomendation of senior obstetrician) or earlier if clinical condition indicates. Regular midwifery re assessment should be undertaken in conjunction with this.

If latent phase labour continues in excess of 24hrs, despite appropriate administration of inpatient analgesia, further obstetric review should be sought and consideration given to induction of labour.

Appendix 1: Latent Phase of Labour Algorithms (Green & Red pathways)

Patient Information Leaflet: Latent Phase of Labour

Patient Information Leaflet: Latent Phase of Labour (pdf)

Last reviewed: 31/12/2021

Next review date: 31/07/2025

Author(s): Gillian McKeown.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 409

References

Healthcare Safety Investigation Branch. (2019) [Online]. Available at: https://www.hsib.org.uk/investigations- cases/final-report/ [Accessed 25 January 2020].

Intrapartum care for healthy women and babies Clinical guideline Published: 3 December 2014 www.nice.org.uk/guidance/cg190.

Latent phase of labour guideline Royal Berkshire Hospital. Available :https://www.RoyalBerkshire.nhs.uk

Maxwell, C. (2019). ‘The Midwife Effect’, Public Health England. Available at: https://vivbennett.blog.gov.uk/ [Accessed: 02 February 2021].

Niewehuisze, M and Leahy-Warren, P. (2019) ‘Women’s empowerment in Childbirth and pregnancy. A concept analysis’. Available at: https://sciencedirect.com [Accessed: 18 January 2021].

Framework for Maternity Services (2016) ‘Communication’, Standard 22.

Royal College of Obstetricians and Gynaecologists, Towards Safer Childbirth: Minimum Standards for the Organisation and delivery of Care in Labour. London: RCOG Press https://www.rcog.org.uk/globalassets/documents/guidelines/wprsaferchildbirthreport2007