Healthcare Safety Investigation Branch (2020) published a National Learning Support Summary whereby some mothers made multiple contacts with maternity triage services. With significant amount of emphasis being spent advising mothers to remain at home, mothers were not being invited into the clinical setting in what was perceived as ‘early labour’, without full assessment of the clinical picture. They frequently interacted with different clinicians each time. Initial documentation was often not adequate to ensure that subsequent clinicians were aware of all the previous information. This hampered clinicians’ decision making, leading them to focus on the issue presented in isolation and not appreciate the cumulative nature of the concerns.

Inviting a woman into Triage/Maternity Assessment should be based upon individual need. There is no validity or clinical rationale that supports a process, where women are only invited into hospital for a face to face assessment in correlation with the number of phone calls they have made.

For some mothers, delaying clinical attendance based on a telephone triage process may prevent them from receiving the care and assessment they needed to support safe management during labour and reduce the risk to their baby. From a thematic HSIB review of investigations, this appeared particularly true for mothers known to have:

• Group B streptococcus
• A baby who is small for gestational age
• A history of reduced/altered fetal movements
• Women with additional vulnerabilities (BAME, language/communication difficulties, SNIPs etc.)

In all of these situations, early clinical attendance upon signs of labour is important for appropriate care and intervention. Babies who are at increased risk of complications during labour need to be assessed when regular painful unterine activity commences.

The midwife should undertake a full examination to determine both maternal and fetal wellbeing in relation to the assigned carepathway. The midwife is responsibe for ensuring the minimum level of care is delivered and documented in the Badgernet Smart Assessment form:

• Maternal observations
• Urinalysis
• Abdominal Palpation – fetal presentation/strength/frequency of uterine activity.
• Auscultation of fetal heart – method of which will be determined by presenting problem, historic care pathway and current risk
• Pain Assessment – consider the need for (non) pharmacological analgesia. If pharmacological analgesia has been given, complete a medication tab in the BadgerNet
• Vaginal Examination- determined by clinical assessment.

Any contributing factors that may alter the original pathway of care will require obstetric review +/- further investigations and possible admission to the inpatient ward. An updated care plan and modified risk assesent should be documented in the BadgerNet electronic record.

If after clinical assessment the woman is found to be in the latent phase of labour, with all clinical findings considered normal, requiring minimal dose analgesia (currently 30mg dihydrocodeine) advice should be offered to return home. Studies have shown that hospital admissions in latent phase, subsequently have higher incidences of intervention.

Key factors supporting women in the latent phase of labour who opt to return home:

• Offer/encourage oral  analgesia  to  a  maximum  of  30mg  dihydrocodeine  in  conjunction  with  regular paracetamol
• Advice on coping strategies/non pharmacological pain relief
• Reassurance that events are progressing as normal
• Provide Patient Information Leaflet
• Highlight that timeframes to call back are not Labour is unique to each individual who should seek support as they feel necessary
• Establishing an appropriate social support
• Encourage light diet, oral fluids and rest where possible

There is no standardised definition for prolonged latent phase. Opinions are polarised in relation to the management. Some believe that it is clinically insignificant, however others consider a possible link and strong assosciaton with subsequent labour abnormalities and high risk outcomes ie. caesarean section.

Malposition may lead to a prolonged latent phase with 10-30% of all babies presenting in the occipito-posterior (OP) position. Prolonged latent phase can be an exhausting and challenging time for women. If any of the following signs and symptoms are evident in a woman who presents:

• Maternal exhaustion
• Failure of fetal head to descend into the pelvis
• Failure of cervical dilatation in the presence of regular uterine activity

Fetal monitoring at regular intervals (currently 6hrly inpatient CTGs on recomendation of senior obstetrician) or earlier if clinical condition indicates. Regular midwifery re assessment should be undertaken in conjunction with this.

If latent phase labour continues in excess of 24hrs, despite appropriate administration of inpatient analgesia, further obstetric review should be sought and consideration given to induction of labour.

Patient Information Leaflet: Latent Phase of Labour (pdf)