Taylor Rackey

MDWF 2030
Assignment 2.10
November 23, 2019

Protocol: Management of Normal Labor (1st and 2nd Stages)

Attendance​: the midwife will make the decision in regards to when the client will meet the staff
at the facility to admit for labor; this decision will consider factors such as specific needs,
emotional wellness, and any clinically relevant information. Based on the information found,
the client may be:
a) Sent home (parity and distance from the facility should be considered in this decision)
i) If the client is sent home, the following should be discussed with them and their
support person:
1) Review the s/sx of labor
2) Inquire whether they have the necessary items for the birth. If not,
instruct them to prepare the items and bring them when they return.
3) Instruct the client to continue normal activities, emphasizing the
importance of rest, adequate food, fluid intake, and to return when
appropriate.
ii) The client should return to the facility when:
1) Ctx are 4-1-1 pattern (q4min, lasting 1 minute in length, for at least 1
hour in duration)
2) Client with precipitous birth hx reporting strong ctx pattern
3) Labor pattern does not mirror 4-1-1 BUT is progressing quickly
4) Rupture of membranes with meconium-stained fluid
5) Client reports absent to decreased fetal movement
6) Client with marginal baseline vitals during routine prenatal care (ie. blood
pressure)
7) Client has concerns/fears or is not coping well
8) Client requests midwife’s attendance
b) Admitted for labor and delivery

Clients can expect that a midwife will meet them at the facility within 15 minutes of agreement
during communication. For clients who have a longer distance to travel, a plan will be
developed during the 36wk appointment to address any gaps in the protocol that may be
necessary.

In regards to the time of the midwife’s departure, one (or more) of the criteria must be met:
● The client is determined to not be in active labor and a plan has been made to help the
client cope and periodically check in with the midwife.
 Taylor Rackey
MDWF 2030
Assignment 2.10
November 23, 2019

● A higher level of care is determined to be necessary and emergency transport services

will be called; the midwife will facilitate transfer and travel with the client to ensure
continuity of care and safe arrival (see intrapartum labor transport protocol).
● Following labor and birth, the birthing parent and baby are both stable and 2-4 hours
have passed since delivery.
Arrival
My students and staff will assemble the appropriate that is necessary to facilitate your delivery
at the birth center. Upon arrival, the staff will:
● Initiate a labor flow chart - charting themselves in at the time of their arrival
● Observe the client as they are coping through contractions
● Monitor the birthing parent’s vitals - including contraction frequency, duration, and
intensity
● Assess fetal baseline heart rate for a minimum of 2-10 minutes; noting the range
recorded during prenatal visits
● Cervical exam should be performed to evaluate dilation, fetal position, and station.
● Encourage the birthing parent to continue eating, drinking and urinating frequently.

Preparation
Once it has been determined that the client is in active labor, all vitals are stable and FHT’s are
reassuring, the following will be performed/assembled in preparation for delivery:
● Client’s bed prepared for use and comfort:
○ Top blanket and sheet folded back
○ Chux pad (washable and disposable) placed on the bed
● Tub to be rinsed, ensuring that all sanitizer is removed
● Room temperature checked for comfort
● Oxygen verified and unlocked
● Heating pad on baby board turned on
● Adult and neonatal masks and Ambu bags are verified to be in order
● Infant stethoscopes on baby board verified
● All medical equipment going into birth room will be sanitized (e.g. blood pressure cuff,
thermometer, doppler, ultrasound gel, etc.)

Birth carts are assembled and ready at all times in the hallway at the facility in the event of
imminent delivery, with items that include:

● Medications (anti-hemorrhagic) ● Sterile gloves

 Taylor Rackey
MDWF 2030
Assignment 2.10
November 23, 2019

● Sterile gauze ● IV equipment

● De Lee suction trap ● Homeopathic remedies
● Birth instruments ● Herbal Tinctures
● Cord clamp ● Mirror
● Chux pads ● Flashlight
● Sterile lube

Assessment
Routine monitoring and timely assessment of both the birthing parent and the fetus ensure
safe labor and delivery. The following guidelines will be adhered to, and additionally where
there is a clinical indication:

Birthing parent
● All vitals will be assessed upon admittance
○ Blood pressure
○ Pulse
○ Temperature
● Vitals will be repeated q4hrs, or more frequently if clinically indicated
● Assess uterine contractions q30-60 mins. for frequency, duration, and intensity
● Assess the client’s perceived ability to cope through contractions

Blood Pressure Pulse Temperature

Normal Normal Rate Normal range
91-120/61-80 60-80 bpm 97.7 °F - 99.5
Hypertensive Tachycardic Elevated
Temperature
140+/90+ S​ ustained pulse over 100 bpm 100.4 °F and above

Fetus
● Fetal heart tones will be assessed upon admittance
● Auscultate FHTs q30min for at least 60 seconds during the first stage of labor
 Taylor Rackey
MDWF 2030
Assignment 2.10
November 23, 2019

● Auscultate FHTs for a minimum of 60-120 seconds after ROM

● Auscultate FHTs q5min or every other contraction for a minimum of 30 seconds
during the 2nd stage

Fetal Heart Tone Range

Normal ​ on-reassuring
N ​Abnormal
110-160 BPM ​ 100-109 BPM (bradycardia) ​Less than 100 BPM
160-180 BPM (tachycardia) Higher than 180 BPM

First Stage Considerations

● Encourage nutrition (minimum 121 k/cal per hr.to prevent ketosis during labor)
● Encourage staying hydrated (minimum 4-8 oz. per hour)
● Suggest position changes, ambulation, and movement
● Suggest aromatherapy as appropriate (e.g. lavender to relax, clary sage to aid with ctx,
peppermint to curb nausea)
● Homeopathic remedies as appropriate (e.g. Aconite = fear, relieve anxiety, Kali
carbonicum to help alleviate back pain during labor)
● Suggest hydrotherapy (shower, bathtub, birth tub; consider ctx pattern with immersion,
too early could stall labor)
● Suggest music therapy
● Suggest a TENS unit
● Help to actively involve the partner and/or main support person
● In the even of ROM, evaluate the fluids for s/sx that may warrant concern (ie.
meconium, odor, etc.)

Second Stage Considerations

● Verify that all necessary equipment, emergency equipment, and medications are
available and within arms reach
● Offer a vaginal exam to all clients before pushing begins to evaluate for complete
dilation, cervical lip, fetal presentation, etc.
● Encourage all primiparous to consider a vaginal exam
● Verify that the temperature in the birth room, and tub, if applicable, are appropriate
● Avoid coached, purple-pushing, directed pushing, etc.
● Encourage focused breathing to avoid hyperventilation; before, during and after ctx
 Taylor Rackey
MDWF 2030
Assignment 2.10
November 23, 2019

● Avoid supine or lithotomy position; facilitate the chosen position as made by the
birthing parent
● Provide encouragement, give verbal reassurance, and informational feedback
● Offer the client a warm compress for perineal support
● Promptly remove any feces or vomit that may be produced by pushing efforts
● Offer for the client to reach down and internally feel their baby as it moves through the
birth canal
● Remain aware to redirect any activity that may potentially be disruptive to the birth
● Place the newborn skin-to-skin with the birthing person immediately following delivery
● Dry and stimulate the newborn, and complete newborn assessments (heart rate,
respiratory rate, APGAR scores)
● Remain aware of clinical indications that may show the need for active management of
the third stage

Other Considerations
If any complications arise for either the birthing parent and/or the newborn, immediately refer
to consultation, referral, or transport requirements per license guidelines. Any out of range vital
signs or fetal assessments should be followed closely.
 Taylor Rackey
MDWF 2030
Assignment 2.10
November 23, 2019

References

Davis, E. (2012). ​Heart and hands: A midwife's guide to pregnancy and birth.​ New York, NY:
Random House.
Frye, A. (2013). ​Holistic midwifery volume II: care during labor and birth​. ​Portland, Oregon:
Labrys Press.
King, T. L., Brucker, M. C., Krebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2013). ​Varney's
midwifery​ (5th ed.). Burlington, MA: Jones & Bartlett Learning.
​ yles textbook for midwives.​ ​Philadelphia, PA: Elsevier Ltd.
Marshall, J. E., Raynor, M. D. (2015).​ M
Simkin, P., Hanson, L., & Ancheta, R. (2017). ​The labor progress handbook: early interventions to
prevent and treat dystocia​ (4th ed.). Hoboken, New Jersey: John Wiley & Sons Inc.