Labour Management (term)
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Established labour/birth, concerning maternal observations, abnormal fetal assessment, significant bleeding, rupture of membranes with risk factors, or a need for analgesia/monitoring requires the appropriate maternity setting.
- Scar pain, collapse, bleeding or fetal bradycardia during TOLAC requires urgent assessment for rupture and operative care.
When clinic, day care or home care may be suitable
- Latent labour may be managed at home only after assessment excludes complications and the woman has a safe return plan. TOLAC requires a facility with immediate access to caesarean/transfusion when labour is established.
Before going home
- After an uncomplicated vaginal birth, the Indian NHM pathway keeps the woman under observation for at least 48 hours. The international WHO minimum is 24 hours; local clinical needs may require longer.
- Before home care assess bleeding/uterine tone, observations, pain/perineum, bladder function and mobility; assess the newborn separately and observe an effective feed or document a safe feeding plan.
Discharge medicines and treatment changes
- Reconcile prescribed postnatal supplements, pain relief and any indicated VTE/anti-D care. Routine birth does not create a blanket need for take-home antibiotics.
- For TOLAC ending in caesarean or a significant complication, use that recovery/discharge pathway instead of the uncomplicated vaginal-birth timetable.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
For maternal pain when prescribed.
- Indication: Short-term maternal postoperative/postpartum pain or other mild pain after assessment; adult ≥50 kg
- MSF oral monograph: no pregnancy or breastfeeding contraindication. The dose does not replace assessment of the cause of pain.
- Pain and functional recovery; investigate increasing pain, fever or other warning symptoms.
- Check all prescribed/OTC paracetamol, weight and hepatic risk; suspected excess dosing requires urgent assessment.
Postpartum only when bleeding, renal and other contraindications have been excluded.
- Indication: Short-term pain relief after birth or gynaecological surgery when NSAIDs are appropriate; not an antenatal regimen
- Short-term use is compatible with breastfeeding in the MSF reference. Do not prescribe while bleeding or renal contraindications remain unresolved.
- Pain response, hydration/urine output, GI pain or bleeding; review renal function when clinically indicated.
- Check current bleeding, renal/hepatic function, allergy/asthma history, anticoagulants and interacting medicines before prescribing.
Tests, pending results and their reviewer
- Review maternal risk/results and the need for Hb testing after significant blood loss. Record any maternal/newborn screening or result still outstanding and its reviewer.
Home care and counselling
- Discuss lochia, hygiene/perineal or wound care, bladder/bowel recovery, feeding support, contraception, pelvic-floor exercise and emotional wellbeing; give the maternity contact/transport plan.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Within 36 hours after transfer (NICE service model) | Arrange the first face-to-face postnatal contact; the local Indian service may organise this differently. |
WHO routine contacts: 48–72 hours, day 7–14 and week 6 after birth | Ensure the actual appointment/home-visit arrangements are recorded; add earlier reviews for complications. |
Return urgently
- Heavy/increasing bleeding, fainting, fever/offensive lochia, worsening pain, severe headache/visual symptoms, dyspnoea/chest pain or unilateral leg swelling need urgent care.
- A baby with poor feeding, abnormal breathing, unusual sleepiness, temperature concerns or early/worsening jaundice needs prompt newborn assessment.
Open the complete discharge checklist →
Treatment
① Immediate stabilization — first minutes
Emergencies during labour follow their own protocols (cord, dystocia, PPH, CTG).
③ First-line treatment & drug regimens
- ONE-TO-ONE midwifery care throughout established labour (better outcomes, less intervention)
- Mobility/positions encouraged; oral hydration; bladder emptying q2-3h
- Slow progress FIRST: supportive measures - repositioning, hydration, analgesia optimisation, emotional support
- AUGMENTATION when diagnosed delay: amniotomy (if membranes intact) then oxytocin titration per protocol
- Inadequate contractions after obstetric assessment; exclude obstruction and contraindications to vaginal birth
- Continuous fetal monitoring and contraction frequency; target 3–4 contractions/10 min
- Stop/reduce for excessive contractions or abnormal fetal heart rate; evaluate immediately
- Analgesia ladder: TENS/Entonox -> opioids (pethidine 50-100 mg IM or fentanyl PCA where available) -> regional (epidural/spinal) per NG235 pain-relief chapter
Definitive treatment
Birth. Second stage: pushing with contractions, no fundal pressure; assisted vaginal birth criteria if second stage prolonged (nullip >2h / multip >1h active pushing, regional-adjusted). Third stage ACTIVE MANAGEMENT: uterotonic within 1 min (oxytocin 10 IU IM/IV), controlled cord traction, uterine massage (WHO 2025).
Monitoring
| Parameter | Frequency (established, low-risk) |
|---|---|
BP/pulse/temp | Hourly BP+pulse; 4-hourly temp |
Contractions | Half-hourly palpation |
FHR auscultation (low-risk) | After contraction x1 min q15 min first stage; q5 min second stage |
PV exams | Offered 4-hourly active phase |
Bladder | q2-3h emptying |
Response assessment
- Progressive dilatation (~1 cm/h active typical but individualised)
- Descent of presenting part
- Reassuring CTG category
Treatment failure
- Dystocia: protraction/arrest - reassess 4Ts + pelvis; caesarean for arrest despite adequate contractions
- Chorioamnionitis suspected (fever>38, foul liquor, dual tachycardia): antibiotics NOW (ampicillin+gentamicin +/- metronidazole) + expedite birth
Escalation
- Senior obstetric review for any delay diagnosis
- Anaesthetist involvement for pain/BP/theatre conversion
⑮ Complications & their management
Meconium-stained liquor
Thin: standard monitoring. Thick/particulate: continuous CTG; neonatal team at birth (routine intrapartum suction not recommended)
Retained placenta (>30-60 min)
- Empty bladder + repeat oxytocic attempt
- IV access + crossmatch
- Theatre manual removal under regional/GA + single-dose antibiotic
- Check completeness; PPH vigilance
Perineal tears
Systematic repair per degree; 3c/3d in theatre by trained repairer + laxatives + physio follow-up
Post-treatment care
- First hour = fourth stage: obs q15min, tone, bleeding watch
- Early skin-to-skin + breastfeeding initiation
- Bladder care (retention check after epidural)
- VTE assessment + prophylaxis
- Newborn vitamin K per NG235 Jun-2026 reintroduced guidance
Diagnosis & assessment
- Abnormal CTG (see ctg-fetal-monitoring)
- Cord prolapse
- Shoulder dystocia
- Haemorrhage
- Maternal fever/sepsis
- Failure of descent with moulding/caput progression
Definition: Regular painful contractions with progressive cervical change. Latent phase irregular vs established first stage; modern frameworks treat ~6 cm as the augmentation decision point.
Initial assessment
- Admission assessment: vitals, urinalysis, abdominal exam (lie/presentation/engagement), PV exam (dilatation, membranes, station, caput/moulding), CTG 20-30 min if risk factors
- Risk stratification: low-risk (midwifery-led) vs risk factors -> obstetric unit
- Partogram started at admission; PV exams offered 4-hourly in active phase
- Pain relief discussion + birth plan review
Investigations
| Test | Looking for |
|---|---|
CBC/group&save (risk cases) | Baseline anaemia; readiness |
Urinalysis | Proteinuria/glucose |
CTG on admission (risk factors) | Baseline fetal wellbeing |
Principles & follow-up
Management principles
Sources (12)
2023-09-29 · updated 2026-06-09 · checked 2026-08-23 · verified-live
Open source ↗
NICE overview + Update information page (dates above confirmed)
2025-10 · checked 2026-10-17 · verified-summary
Open source ↗
Targeted recheck: WHO 2025 recognition/treatment trigger (≥500 mL or ≥300 mL with abnormal haemodynamics), concurrent first-response bundle and refractory-haemorrhage fibrinogen target ≥2 g/L if replacing a level <2 g/L. Primary recommendation chapter/table indexed at https://www.ncbi.nlm.nih.gov/bo…
· checked 2026-10-17 · verified-live
Open source ↗
Term-labour induction/augmentation dose increments, pump-compatible dilution, 20 milliunits/minute regimen ceiling, contraction/fetal monitoring and rapid-bolus risk.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary PDF downloaded; term prelabour rupture, selected expectant care and induction around 24 hours, temperature/return precautions, maternal post-birth assessment and newborn observation after prolonged membrane rupture checked. This is scoped to the implemented admission/transfer recommenda…
31 March 2021 · updated 10 June 2025 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for lscs, vbac-tolac. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admission/discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary oral monograph read: adult 1 g 3–4 times daily, maximum 4 g/day, ≥50 kg adult table, 500 mg tablets, duration according to response, hepatic caution and pregnancy/breastfeeding. Pain chapter also checked for 6–8-hour interval. Smaller adults require an individual weight-based prescripti…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary monograph read: pain 200–400 mg, maximum 1200 mg/day; postoperative every 8 hours, maximum 8 days; meals/formulations, renal/GI/bleeding/dehydration/infection contraindications and interactions, short-term breastfeeding. New card restricted to postpartum/nonpregnant care; OHSS renal cau…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.