Chapter 2. Early assessment and admission in labour
Introduction
The early stages of labour may be a challenging time for many women, especially with their first baby. Fear and anxiety will play a part in the woman’s ability to cope, especially if she is alone and unsure what is happening. If she is having community-based care she will have an on-call system where she may contact a midwife for help and advice. If she is planning a hospital birth she will be given a telephone number for the labour ward to contact for advice. In some hospitals this is a special area where assessment may take place (Morgan 2007). These calls should normally be answered by a qualified midwife though students should have opportunity in their education programme to gain experience in speaking to labouring women on the phone. This chapter is more focused on the hospital situation, though the principles also apply for assessment in the home situation.
The stage at which a woman goes into hospital could have a significant impact on her labour experience (Rahnama & Faghigzadeh 2006). If she goes in too early, at a time when she is in pain and vulnerable, she may ask for or accept analgesia sooner than she otherwise might. Also, the longer she is on the hospital birth suite, the less likely she is to experience continuity of carer. However, many women lack confidence to stay at home and want to have access to midwifery care ‘just in case’ (Cheyne et al 2007).
The midwife who answers the telephone has a complex role to fulfil. She must rule out conditions that make admission to hospital advisable and, at the same time, instil confidence in the woman to stay at home longer if labour is not yet established. The response that the woman receives when she telephones the hospital birth suite is important for many reasons. She is potentially speaking to the midwife who will care for her when she is admitted, and the impression she forms following this interaction has the potential to relieve or raise anxiety.
For many women, hospital is seen as a place of safety when labour begins (Cheyne et al 2007). The hospital delivery suite is the place where she has often imagined herself during her mental preparation for the birth of her baby. To gain admission is to acknowledge that labour has really begun and that the unknown becomes a reality.
Home assessment
Women in early labour should have access to midwifery support and advice (Baxter 2007). In ideal circumstances, this care is provided in the woman’s own home by her community midwife, enabling her to remain in familiar surroundings for longer (Flint 1984). In some areas women do not decide where they will labour and birth until it begins and the midwife assesses them at home (Leap & Edwards 2006:110). However, access to such a service is limited and may not be available to all groups of women, for example high-risk women or those with complex social needs.
In a multi-centre trial conducted in Canada (Janssen et al 2006) comparing home assessment with telephone triage, women who were assessed at home were less likely to be admitted to the labour ward with cervical dilatation of 3cm or less, but there was no impact on the caesarean section rates. Recent randomised controlled trials of structured support in early labour suggest that women value and are highly satisfied with this service, but that there is little impact on clinical outcomes (Spiby & Renfrew 2008).
Further research is required in this area to look at specific and targeted support for particular groups of women who may benefit from additional care during early labour.
Communication by telephone
Face-to-face communication is the most effective means of sending and receiving messages. Our body language transmits so much more than our spoken words. When communicating by telephone, this aspect is not available and the midwife must pay particular attention to the tone, rate and timing of the spoken word, as well as the content of the conversation. This paralanguage has been described as ‘the vocal cues which accompany spoken words’ (Rungapadiachy 1999:210).
It is important that the midwife talks with the woman and not her partner or friend, as this can lead to a three-way conversation. There is then the potential for the middle person to either misinterpret the question the midwife asks or to reword what the woman says, leading to an inaccurate portrayal of events. Also, when the midwife speaks directly with the woman, she is able to assess how she is coping by her tone of voice. However, if a woman is in severe pain, or in water, she may be unable to reach a phone easily and her partner should not be ignored as some women may have rapid labours and births. Box 2.1 summarizes the 10 steps to be taken when talking to labouring women on the telephone.
Box 2.1
Ten steps for giving telephone advice to a labouring woman
1. Confirm name and hospital number
Rationale For identification purposes and also to enable the woman to be addressed by name during the conversation. If admission is recommended, it is also important that she is greeted by name on arrival
2. Confirm address
Rationale For identification purposes. Also necessary if an ambulance is required and to be aware of the distance to be travelled
3. Confirm gestation and parity
Rationale Essential information required to contextualize subsequent information
4. Assess recent pregnancy history
Rationale Need to identify if there is a reason why admission should not be delayed
5. Assess recent medical history
Rationale Need to identify if there is a reason why admission should not be delayed
6. Obtain history or reason for call
Rationale Identify nature of presenting concern(s)
7. Assess which coping strategies have been tried
Rationale To identify what other strategies to suggest
8. Outline the options available
Rationale To empower the woman to make a decision that reflects her current needs
9a. If the woman decides to stay at home, inform her of when she should ring again
Rationale To provide clear criteria of when admission is recommended and to enable her to feel comfortable to ring again at any time if she needs further advice
9b. If the woman decides to come in, confirm transport arrangements and remind her to bring her maternity records
Rationale To establish if an ambulance is required. To ensure that the woman brings her maternity records
10. Document advice given as per hospital policy
Rationale To provide record of advice given to inform future conversations. To provide useful audit information to inform future maternity services
Step 1: Confirm name and hospital number
The conversation should begin with the midwife introducing herself, and then confirming the woman’s name and hospital number. Asking for her number near the beginning of the conversation will also prompt the woman to bring her maternity records to the telephone. Confirmation of her name and number will also enable the midwife to access the correct woman’s hospital records in preparation for her admission.
Step 2: Confirm address
The woman’s location is required. It is essential that the correct address is written down and repeated back to her, especially in the event that she requires transport into hospital via ambulance. Her details will be given to an ambulance control operator and then to the ambulance crew. There is a possibility that information can be misheard; hence, it is important to start with the correct details to avoid delay.
Step 3: Confirm gestation and parity
If the woman is experiencing painful contractions before full term, she will need to be admitted without delay. There may be the possibility that labour can be delayed with the use of tocolytic therapy, depending on gestation and estimated fetal weight, although this course of action needs to be weighed carefully against the side-effects of the drugs used (Jordan 2002).
A woman who has already experienced a vaginal birth is likely to progress more quickly in labour than a primigravida, and this should be considered when giving advice, though this is not always the case.
Step 4: Assess recent pregnancy history
The woman should be asked about her general health and wellbeing during her pregnancy. Has she had any infections or worries about the baby’s growth or movements? She will be able to say from her maternity records (if she is unable to remember) what the presentation is and what her blood pressure has been. If she has had a previous caesarean section, she will also require close monitoring during labour, although the rate of uterine rupture is 0.3 per cent, according to a multi-centre study (Appleton et al 2000).
Step 5: Assess recent medical history
It is important to know if the woman has any underlying medical condition that will require close monitoring during labour, such as diabetes, hypertension or infection.
Step 6: Obtain history or reason for call
There will be a particular event or combination of events that has caused the woman to seek advice from the midwife or hospital delivery suite. In relation to diagnosis of labour, the midwife will need to assess when contractions started, how long they last and how frequently they are occurring.
The key to assessing that labour is progressing is that contractions are becoming more frequent, progressively more painful and lasting longer. If the woman thinks that her membranes may have ruptured, she is advised to come into hospital for confirmation. At term, in the absence of meconium-stained liquor, contractions or evidence of infection, some maternity units send women back home to await events. However, it has been suggested (Hannah et al 2000) that expectant management at home increases the risk of some adverse outcomes following the rupturing of membranes and women should be advised:
■ ‘The risk of serious neonatal infection is 1% rather than 0.5% for women with intact membranes
■ 60% of women with prelabour rupture of the membranes will go into labour within 24 hours
■ Induction of labour is appropriate approximately 24 hours after rupture of the membranes.’(NICE 2007: 22–23)
Step 7: Assess which coping strategies have been tried
There are many different scenarios for the use of coping strategies. The woman may have attended preparation for childbirth classes and considered the use of non-pharmacological means to alleviate pain in labour. Thus, she might ring the hospital birth suite having tried and used them all, with good effect, and hence be in established labour.
Alternatively, she may have tried some and found little benefit. She may feel she needs additional support. On the other hand, a woman might not know how to cope with contractions at home and may benefit from some simple advice. Thus, the midwife must assess what the woman has tried before she gives further advice.
Step 8: Outline the options available
The midwife needs to assimilate all the information she has gleaned from the conversation and assess the need for admission. She will then present the alternatives back to the woman in a balanced way. The woman should be in no doubt about what is recommended – for example, admission if spontaneous rupture of membranes is suspected. However, if it appears that birth is not imminent, and there are no medical or obstetric risk factors, she has the option of staying at home longer if she wishes.
Step 9a: If the woman decides to stay at home, inform her of when she should ring again
Unless there is a situation requiring urgent attention, such as evidence of second stage of labour or bleeding, a woman who feels confident to stay at home until labour becomes more established should be reassured that she can ring back for further advice at any time. She must be advised to ring back if she experiences any fresh vaginal bleeding, spontaneous rupture of membranes, constant abdominal pain or the need for analgesia.
Step 9b: If a woman decides to come in, confirm transport arrangements and remind her to bring her maternity records
Unless there is an emergency situation, such as indication of second stage, bleeding or prematurity, there is usually no reason why the woman cannot make her own way to hospital in private transport. If she does not have a car, a neighbour or friend might be delighted to be chosen to stand by to take her to the hospital birth suite.
Women can be advised antenatally that a trial run is a useful exercise, bearing in mind traffic at peak times and where the nearest hospital car park is. The labouring woman should not drive herself to hospital.
Step 10: Document advice given as per hospital policy
It is practice in some maternity units to document all telephone advice. This can provide valuable information in the event of a woman ringing again after a change of shift. If the midwife who took the initial call is still on duty then, where possible, it would be advantageous for both woman and midwife if the continuity of care was maintained.
The same midwife will be able to detect from the woman’s voice if there has been a change either in her progress in labour or her level of anxiety. The records will prompt the midwife to ask questions that build on previous interaction, confirming to the woman that she is being cared for as an individual. For example, ‘Did you have a bath? Did it help your backache?’ Such records have the potential to be a valuable data-collection tool for use in clinical audit. A study looking at the use of the telephone advice documentation used in the All Wales clinical pathway for normal labour (Spiby et al 2006) showed that women were satisfied with this service if they had been given a choice about coming into hospital and were made welcome to do so; if they were told when they should phone back and if they were treated in a friendly and encouraging manner. They were likely to feel dissatisfied, however, if the midwife whom they had spoken to previously had not passed on information, if they did not feel treated with respect, if their worries were not alleviated by the phone call or if they did not receive clear guidance.
