Risk Assessment for care in labour

and proforma (GL863)

Approval
Approval Group Job Title, Chair of Committee Date
th
Maternity & Children’s Services Chair, Maternity Clinical 7 June 2019
Clinical Governance Committee Governance Committee

Change History
Version Date Author, job title Reason
5.0 July 2017 C Harding Amended to reflect current
practice prior to major review
within next 6 months
5.1 Oct 2017 C Harding (Consultant MW) Live change
6.0 April 2019 C Harding (Consultant MW) Reviewed – obstetric
cholestasis added to risk
assessment tool (pg 4/5)
6.1 July 2020 C Harding (Consultant MW) Traffic light pg 3 & 4 updated
to include recent changes
regarding meconium liquor

To be read in conjunction with

• Planning place of birth (GL887)
• Fetal monitoring (GL964)
• Meconium stained liquor (GL877)

Author: C Harding Date: July 2020

Job Title: Consultant Midwife Review Date: June 2021
Policy Lead: Group Director Urgent Care Version: V6.1 July 2020
Location: Policy hub/ Clinical/Maternity/ Intrapartum/ GL863 V6.0 ratified 7/6/19

This document is valid only on date last printed Page 1 of 4

 Labour risk assessment proforma for care in labour (GL863) July 2020

Overview: for the majority of women birth is a safe experience without complications. For
some women however, there are risks that may be present prior to pregnancy or become
apparent during the pregnancy. Midwives and medical staff need to be carrying out
clinical risk assessments on all women and communicating those women at risk to the
correct health care professional.

Aim/purpose
To ensure that all pregnant women have a clinical risk assessment performed when
admitted in labour to minimize adverse outcomes for both mother and/or baby.
Risk assessment in labour in all care settings:
• On admission in labour
• On taking over care in labour
• At any point in the labour when there is a change in the circumstances which
change the risk to the woman
The findings of the risk assessment must be documented within the woman’s health
record.
Following the risk assessment, a written management plan should be made.
Identified risks/complications should be referred to the appropriate health care professional
and individual plan of care developed and documented.
This guideline should be read alongside the Place of birth guideline (GL887) and Fetal
monitoring guideline (GL964).

Auditable standards:
1. All women classified in the red area if the intrapartum risk assessment proforma will be
referred to obstetric care. All women classified in the amber area if the intrapartum risk
assessment proforma will be discussed with the duty obstetrician.
2. All women will be risk assessed on admission on established labour using the Labour
Risk Assessment tool and reviewing and documenting previous history, fetal and
maternal condition, progress of labour, risk factors and devising a plan of action. This
will be documented in the intrapartum section in the maternal health care record.
3. In all cases where care has been taken over by a new member of staff during
established labour, a risk assessment will be carried by reviewing and documenting
previous history, fetal and maternal condition, progress of labour, risk factors and
devising a plan of action. This will be documented in the intrapartum section and filed in
the maternal health care record.
4. All women in labour when delivery is not imminent will be risk assessed after the first
completed hour in active second stage by reviewing and documenting previous history,
fetal and maternal condition, progress of labour, risk factors and devising a plan of
action. This will be documented in the maternal health care record.

Author: Christine Harding Date: July 2020

Job Title: Consultant Midwife Review Date: June 2021
Policy Lead: Group Director Urgent Care Version: V6.1 July 2020
Location: Policy hub/ Clinical/Maternity/ Intrapartum/ GL863 V6.0 ratified 7/6/19

This document is valid only on date last printed Page 2 of 4

 Risk assessment for place of labour assessment, place of birth and lead professional for labour
Initial history taking on admission to include: Relevant social and demographic details, parity, EDD, gestation, reason for and source of referral, maternal condition, medical history, obstetric history, anaesthetic
history, clinical assessment and findings. All un-booked women especially from abroad should have a full medical examination. All records should show evidence of on-going risk assessment.
Undertake a risk assessment using the following Proforma as a guide - remember this is an on-going assessment that may change as labour progresses.
Document your findings in the maternal labour notes/ labour pathway.
MLU
All women who do not fit into Delivery Suite/DAU category (red)
PLUS
• One previous CS planning VBAC
• Gestational diabetes
Green: Midwife led care in labour,
recommend MLU
Current situation • 37-42 weeks gestation
• Maternal age from 16-40 years at conception
• HB >105g/l
• Primip - BMI 35 or less at booking
• Multip – BMI 40 or less at booking with
history of previous vaginal birth
• Spontaneous onset of labour
• Pre-labour SROM at Term < 24 hours
• Induction of labour with either propess, CRB
or ARM and no additional risk factors
Previous • Previous 3rd or 4th degree tear
obstetric factors
Medical factors • Group B strep
• Hypothyroidism
• Obstetric cholestasis with bile acids
<40micromol/l
Midwifery Assessment & review
Follow appropriate guidelines
NB These lists are not exhaustive
Labour risk assessment tool
Authors: C Harding, V6.1 (July 2020)
Appropriate place for labour assessment
Delivery Suite/DAU
• Pre-term labour • Type 1 & 2 diabetes • Confirmed pre-eclampsia
• Multiple pregnancy • Current APH • PIH on medication
• Placenta praevia • Unbooked women • Booked for CS
• Known malpresentation • Substance misuse
• Woman suspected of being in advance labour who is within the red category below
Amber: Lead professional and place of birth
dependent on clinical assessment antenatally/in
Red: Consultant led care in labour, recommend delivery suite
labour – liaise with senior midwife / obstetrician
and follow relevant guidelines
• Grand multiparity (Para 4 and above) • Pre-term labour less than 37 weeks
• Women who decline blood/blood products • Multiple pregnancy
• Elevated blood pressure on admission returning to • Malpresentation
normal without medication
• meconium stained liquor
• Hb 85g/l - 105g/l at onset of labour
• Un-booked women
• Induction of labour not requiring oxytocin • Hb <85g/l at onset of labour
• Hypertension/pre-eclampsia/eclampsia
• Pre-labour ruptured membranes >24 hours/augmentation for SROM
• Greater than 40 years at conception > 40 weeks gestation
Red category for fetal wellbeing assessment
• Previous retained placenta requiring theatre • Previous PPH > 1 litre
• Previous shoulder dystocia • Previous Caesarean Section in established labour
• Previous baby >4.5kg
• Current significant mental health issues on medication • Diabetes/hyperthyroidism • Active viral infection e.g. chickenpox,
parvovirus, measles
• Platelets <100x10/L • Present history of substance misuse
• Rhesus iso-immunisation • Hyperthyroidism
• Obstetric cholestasis • OC with bile acids of 100 or more
Obstetric/ Senior Midwifery Review Obstetric Review Required
Arrange medical review dependant on clinical findings
 Risk assessment for fetal monitoring during labour
Red: CTG required/recommended
Green: IA FHR Amber: to be decided following Any abnormal findings during initial maternal or fetal wellbeing assessment
Absence of risk factors as listed in Red category discussion with senior
obstetrician/midwife with
PLUS assessment of full clinical picture Fetal factors Maternal factors
• Normal fetal movements experienced in last 24 hours • BMI >40 at booking • Malpresentation • Obstetric cholestasis with bile
• Normal findings on abdominal palpation • Maternal age >40 at conception • Suspected or confirmed acids of 100 or greater
IUGR / SGA
• Maternal observations normal (MOWS 0) • Gestational diabetes well • T1, T2 Diabetes, GDM on
• Multiple pregnancy
• Baseline between 110 – 160 as assessed over 1 minute between controlled with diet (in insulin or poorly controlled
• Oligohydramnios/Polyhydra
contractions spontaneous labour) • Significant or recurring APH
mnios
• Absence of decelerations immediately following contractions • Essential hypertension well • Abnormal fetal heart rate on • Present history of substance
controlled IA misuse
• Fetal heart differentiated from maternal pulse
• Obstetric cholestasis with bile acids • Reduced fetal movements • Hyperthyroidism
• Clear liquor or intact membranes
40 – 100 micromol/l • Meconium stained liquor
• Accelerations auscultated during period of fetal movement • Rhesus iso-immunisation
•
• Obstetric cholestasis with bile acids <40micromol/l • Hypertension/pre-
eclampsia/eclampsia
• Active viral infection e.g.
chickenpox, parvovirus,
measles
• Maternal request
When to change from IA to CEFM
• Repeatable decelerations heard immediately following a contraction Labour factors
• Repeatable accelerations heard immediately following a contraction • Pre term labour less than 37 weeks
• Baseline above 160 bpm or rising baseline • Post term labour greater than 42 weeks
• Maternal pulse over 120 beats per minute for more than 30 minutes • Previous CS in established labour
• BP greater than 110 diastolic, 160 systolic on a single reading or persistently increased BP above • Abnormal/Suspicious FHR
140/90 • Pre-labour ruptured membranes >24 hours/augmentation for
• 2+ protein on urinalysis with raised BP as recorded above SROM
• Maternal temp of 38 0C or above on single reading or 37.5 0C or above on 2 consecutive readings 1 • Oxytocin infusion administration
hour apart • Epidural analgesia administered (continue for 20 minutes)
• Vaginal blood loss • Confirmed delay in first or second stage of labour
• Meconium stained liquor
• Confirmed delay in the first or second stage of labour
• Pain reported by the woman which differs from the pain normally associated with contractions
• Contractions that last longer than 60 seconds or more than 5 contractions in 10 minutes
• Prior to the initiation of epidural analgesia
• Development of additional risk factors normally associated with needing obstetric led care

Labour risk assessment tool

Authors: C Harding, V6.1 (July 2020)