MANAGEMENT OF THE LATENT PHASE OF LABOUR CLINICAL GUIDELINES

Register No: 12029

Status: Public

Developed in response to: Intrapartum NICE Guidelines

RCOG guideline
Contributes to CQC Regulation 9,11

Consulted With Post/Committee/Group Date

Anita Rao/ Clinical Director for Women’s and Children’s Directorate August 2015
Alison Cuthbertson Consultant for Obstetrics and Gynaecology
Vidya Thakur Head of Midwifery/Nursing for Women’s and Children’s Services
Alison Cuthbertson Lead Midwife Labour Ward and Acute Inpatient Services Manager
Paula Hollis Antenatal and Newborn Screening Coordinator
Nicky Leslie Lead Midwife Community Services; Named Midwife Safeguarding
Diane Roberts Specialist Midwife Guidelines and Audit
Sarah Moon Pharmacy
Claire Fitzgerald
Professionally Approved By
Anita Rao Lead Consultant for Obstetrics and Gynaecology August 2015

Version Number 2.1

Issuing Directorate Obstetrics and Gynaecology
Ratified By Documents Ratification Group
Ratified On 22nd October 2015
Trust Executive Sign Off Date Date December 2015
Implementation Date 16th November 2015
Next Review Date October 2018
Author/Contact for Information Angela Wrobel, Senior Midwife
Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians
Distribution Method Intranet & Website. Notified on Staff Focus
Related Trust Policies (to be read in 04071 Standard Infection Prevention
conjunction with) 04072 Hand Hygiene
06036 Guideline for Maternity Record Keeping including
Documentation in Handheld Records
09079 Management of normal labour and prolonged labour
in low risk patients
04237 Waterbirth labour, delivery in water and third stage
management
Document History Review:
Version No Authored/Reviewed by Active Date
1.0 Angela Wrobel October 2012
2.0 Angela Wrobel, Senior Midwife November 2015
2.1 Sarah Moon – clarification to point 5.2, 5.3, 7.1, 7.2, 7.3 14th June 2016

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INDEX

1. Purpose

2. Equality and Diversity

3. Definition

4. Determining the Latent Phase

5. Pain Management during the Latent Phase

6. Diagnosis of Prolonged Latent Phase

7. Antenatal Education of Latent Phase

8. Staff and Training

9. Supervisors of Midwives

10. Infection Prevention

11. Audit and Monitoring

12. Guideline Management

13. Communication

14. References

15. Appendix

A. Appendix A - Telephone Message Proforma

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1.0 Purpose of the Guideline

1.1 To ensure consistency of advice and care offered to women who present in the latent
phase of labour.

1.2 To encourage women to remain at home during this period as this is where labour is
more likely to become established.

1.3 To provide women with appropriate analgesia; which will enable them to remain at home
in the early stages of labour.

2.0 Equality and Diversity

2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is
fair, accessible and meets the needs of all individuals.

3.0 Definition

3.1 This is the earliest phase of labour when changes in the body start occurring in
preparation for labour. This phase may be known as the ‘latent phase’, ‘pre-labour’, or
early stages of labour.

3.2 ‘A period of time, not necessarily continuous, where there are painful contractions and
there is some cervical change, including cervical effacement and dilation up to 4cm’.

3.3 This phase can take from 6-10 hours to up to 2-3 days however it is often considerably
shorter for second and subsequent babies.

4.0 Determining the Latent Phase

4.1 Assessment will be made by a midwife. Firstly the contractions should be palpated to
determine whether vaginal assessment is necessary. In some cases it is appropriate to
provide analgesia without performing a vaginal examination, if the contractions are found
to be weak/irregular.
(Refer to the guideline entitled ‘Management of normal labour and prolonged labour in
low risk patients’; register number 09079)

4.2 In many cases women will attend the maternity unit needing reassurance that what they
are experiencing is normal. If a vaginal assessment is performed, the midwife must
consider cervical effacement and station of the head as well as the dilatation.

4.3 It is also important to note when the contractions first began i.e. a woman who began
contracting one hour ago and now has a cervix which is 2 cms dilated and fully effaced
should not be sent home.

5.0 Pain Management During the Latent Phase

5.1 During the latent phase women should be encouraged to stay at home. Midwives should
encourage these women to carry on with normal activities as much as they can. Staying
at home in a known environment will encourage production of oxytocin as well as
endorphins (the woman’s own natural pain relievers).

5.2 The midwife should advise the woman and her birth partner that breathing exercises,
immersion in water and massage may reduce pain during the latent phase of labour.
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5.3 Do not offer or advise aromatherapy, yoga or acupressure for pain relief during the latent
phase of labour. If a woman requests to use any of these techniques, respect her wishes.

5.4 Whilst women are at home they should be encouraged to:

• Perform normal activities

• Go for a walk
• Use of water (warm shower/baths)
• Distractions though listening to music, watching television/ DVD
• TENS machine when they become uncomfortable
• Focus on breathing techniques and relaxation
• Trying different positions and use of birthing ball
• Use of hot water bottle
• Try massage. Women with babies in the occipito posterior position often experience
increased back pain, massage and back rubbing may help this.
• Trying to sleep/ rest/ nap
• Keep well hydrated
• Eat well at this stage, in order to maintain energy levels throughout labour
• Monitor fetal movements

5.3 Women who come to the hospital for labour checks may be offered analgesia before
being sent home. These analgesics include:

• Paracetamol – women can also self medicate this at home. Midwives must ensure
women are aware of dosage and frequency of administration
• Co-dydramol – 10mg Dihydrocodeine & 500mg Paracetamol
(Refer to Patient Group Direction (PGD)
• Oramorph – 10mg/5mls

5.4 The midwife must identify any known drug allergies before giving women any analgesics
and ensure all drugs given are charted on the woman’s drug chart as well as
documented in her hand-held maternity notes.

6.0 Diagnosis of Prolonged Latent Phase

6.1 The midwife should ensure that if a woman contacts either the Co-located Birthing Unit or
Labour Ward for advice or assessment, it is the midwife’s responsibility to complete the
telephone message proforma. Furthermore, the midwife should take into consideration
whether the woman has contacted the maternity unit in the last 24 hours. If the
woman/partner is contacting the maternity unit on the third occasion, she should be
reassured and invited in for assessment.
(Refer to Appendix A)

6.2 Diagnosis of the latent phase is not an exact science. The overall condition of the woman
must be considered including her hydration and ability to cope with pain.
If prolonged latent phase is suspected, the case should be discussed with the on call
registrar. In some cases, particularly if the gestation is post mature, it may be appropriate
to induce labour.

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7.0 Antenatal Education of Latent Phase

7.1 Provide all nulliparous women with information antenatally about:

• What to expect in the latent phase of labour

• How to work with any pain they experience
• How to contact their midwifery care team and what to do in an emergency.

7.2 Offer nulliparous women antenatal education about the signs of labour, consisting of:

• How to differentiate between Braxton Hicks contractions and active labour

contractions
• The expected frequency of contractions and how long they will last
• Recognition of aminiotic fluid
• Description of normal vaginal loss

7.3 If a woman seeks advise or attends a midwifery-led unit or obstetric unit with painful
contractions, but is not in established labour:

• Recognise that a woman may experience painful contractions without cervical

change, and although she is described as not being in labour, she may well think that
herself as being ‘in labour’ by her own definition
• Offer individualised support, and analgesia if needed
• Encourage her to remain at home, unless doing so leads to a significant risk that she
could give birth without a midwife present or become distressed

7.4 The midwife should include the following in any early or triage assessment of labour:

• Ask the woman how she is, about her wishes, expectations and any concerns she has
• Ask the woman about the baby’s movements, including any changes
• Give information about what a woman can expect in the latent phase of labour and
how to work with any pain that she experiences
• Give information about what to expect when she accesses care
• Agree a plan of care with the woman, including guidance about who she should
contact next and when
• Provide guidance and support to the woman’s birth companion

7.5 A latent phase leaflet should be discussed and made available to all women if
appropriate.

8.0 Staffing and Training

8.1 All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training.

8.2 All midwifery and obstetric staff are to ensure that their knowledge and skills are
up-to-date in order to complete their portfolio for appraisal.

9.0 Supervisor of Midwives

9.1 The supervision of midwives is a statutory responsibility that provides a mechanism for
support and guidance to every midwife practising in the UK. The purpose of supervision
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 is to protect women and babies, while supporting midwives to be fit for practice'. This role
is carried out on our behalf by local supervising authorities. Advice should be sought
from the supervisors of midwives are experienced practising midwives who have
undertaken further education in order to supervise midwifery services. A 24 hour on call
rota operates to ensure that a Supervisor of Midwives is available to advise and support
midwives and women in their care choices

10.0 Infection Prevention

10.1 All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively ‘decontaminate their hands’ before and after each procedure.

10.2 All staff should ensure that they follow Trust guidelines on infection prevention. All
invasive devices must be inserted and cared for using High Impact Intervention
guidelines to reduce the risk of infection and deliver safe care. This care should be
recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork
(Medical Devices).

11.0 Audit and Monitoring

11.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy, the Maternity annual audit work
plan and the NHSLA/CNST requirements. The Audit Lead in liaison with the Risk
Management Group will identify a lead for the audit.

11.2 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will
be developed to address any identified deficiencies. Performance against the action plan
will be monitored by this group at subsequent meetings.

11.3 The audit report will be reported to the monthly Maternity Directorate Governance
Meeting (MDGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.

11.4 Key findings and learning points from the audit will be submitted to the Patient Safety
Group within the integrated learning report.

11.5 Key findings and learning points will be disseminated to relevant staff.

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12.0 Guideline Management

12.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.

12.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

12.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

12.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for future training
needs will be met using methods such as ‘workshops’ or to be included in future ‘skills
and drills’ mandatory training sessions.

13.0 Communication

13.1 A quarterly ‘maternity newsletter’ is issued to all staff to highlight key changes in clinical
practice to include a list of newly approved guidelines for staff to acknowledge and
familiarise themselves with and practice accordingly. Midwives that are on maternity
leave or ‘bank’ staff have letters sent to their home address to update them on current
clinical changes.

13.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.

13.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

13.4 Regular memos are posted on the guideline and audit notice boards in each clinical area
to notify staff of the latest revised guidelines and how to access guidelines via the intranet
or clinical guideline folders.

14.0 References

Bailit JL, Dierker L, Blanchard et al. (2005) Outcomes of women presenting in active
versus latent phases of spontaneous labour. Obstetrics and Gynaecology 105 (1): 77-79.

NICE (2014) Intrapartum care: management and delivery of care to women in labour.
RCOG, London. December

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 MID ESSEX HOSPITAL SERVICES NHS TRUST Appendix A
WOMEN’S, CHILDREN’S AND SEXUAL HEALTH DIRECTORATE
Telephone Message Proforma

Date and time of telephone call :

Name: Hospital No: DOB:

(or NHS No:)
Telephone number:

S Reason for Call:

(Situation)
Parity: Primip Multip Gestation Blood Group:
B
Booked for delivery at: BMFD STP WJC
(Background)
Relevant Medical, Mental Health, and Social History:

Relevant Obstetric History:

History of Previous Births:

(Assessment)

Fetal Movements: (please circle) Normal Reduced Absent Time last movements
felt

Has the woman phoned in the last 24 hours? If Yes, how many times?
(If this is the third occasion, invite her in for assessment)
Has the woman been assessed by a midwife or doctor within the last 24 hours
If Yes, outcome:

R Advice given

(Recommendation)

Is the woman happy with the advice/plan of care? (please circle) Yes No
Name and grade of midwife taking call:

Audit Trail: (please circle if this referral originated from either):

A&E Department Essex Ambulance Service GP

If circled above, a photocopy should be placed in the appropriately labelled filing tray for risk management or
safeguarding in the Labour Ward Office