Labour & Delivery Nursing Guide Intrapartum

GCC Nurses — Normal & Assisted Labour · Pain Relief · Delivery Care · Third Stage Management

Stages of Labour — Overview

StageDefinitionNulliparous DurationMultiparous Duration
Stage 1Onset of regular contractions → full cervical dilatation (10 cm)Up to 12 h (active phase)Up to 6 h (active phase)
Stage 2Full dilatation → delivery of the babyUp to 3 h (with epidural); 2 h (without)Up to 2 h (with epidural); 1 h (without)
Stage 3Delivery of baby → expulsion of placenta & membranesActive management: 30 min; Physiological: up to 60 min

Stage 1 — Phases

Latent Phase

  • Cervix 0–3 cm dilated; irregular or mild contractions
  • Cervical effacement and softening (ripening)
  • Duration highly variable — can last many hours or days
  • Woman may be managed at home if maternal/fetal condition is satisfactory
  • GCC practice: many hospitals admit early — educate on expected duration

Active Labour (Established)

Definition: Cervical dilatation ≥4 cm with regular, painful contractions (at least 2 contractions in 10 minutes).
  • Expected dilatation rate: ≥1 cm/h in active phase
  • Frequency of VEs: every 4 h unless clinical concern
  • Document on partogram — every VE plotted against time

Transition Phase

  • 7–10 cm; intense, frequent contractions (3–4 per 10 min)
  • Woman may feel urge to push before full dilatation — confirm before permitting pushing

Cervical Changes

Effacement

Shortening and thinning of the cervix. Expressed as a percentage (0% = thick, 100% = fully effaced). Precedes dilatation in nulliparous women; may occur simultaneously in multiparous.

Dilatation

Opening of the cervical os from 0 to 10 cm. Assessed by digital vaginal examination. Required: aseptic technique, document findings, warm hands.

Application (Station)

Relationship of fetal presenting part to maternal ischial spines:

StationPosition
-5 to -1Above ischial spines (floating → engaged)
0At ischial spines (engaged)
+1 to +5Below ischial spines (descending → crowning)

Engagement = station 0 or below (biparietal diameter past pelvic inlet). Nulliparous: usually engaged before labour. Multiparous: may engage in labour.

WHO Partogram — Usage & Interpretation

Purpose

  • Visual record of labour progress, fetal & maternal condition
  • Early identification of prolonged/obstructed labour
  • Standardised communication tool
  • Mandatory in most GCC labour wards

Components Recorded

  • Cervical dilatation (X) and fetal head descent (O)
  • Contractions: frequency, duration, strength per 10 min
  • Fetal heart rate (every 30 min), liquor colour, moulding
  • Maternal vitals: BP, pulse, temperature, urine output
  • Drugs, IV fluids, oxytocin dose

Alert & Action Lines

Alert Line: Begins at 4 cm; slope of 1 cm/h. Reaching the alert line = prepare for possible intervention, increase monitoring frequency.
Action Line: 4 hours to the right of the alert line. Cervical dilatation crossing the action line = obstetric review mandatory; transfer to higher level of care; consider augmentation or LSCS.

Partogram Plot Symbols

  • X = cervical dilatation
  • O = fetal head station (descent in fifths palpable abdominally: 5/5 = none engaged; 0/5 = fully engaged)
  • FHR plotted in dedicated row; contractions shaded by duration/strength

Labour Progress Assessment Calculator

Partogram Position Estimator

Intermittent Auscultation (IA)

Indications

Recommended for low-risk labours without complications.

Frequency

PhaseFrequency
Active Stage 1Every 15–30 min
Stage 2 (second stage)Every 5 min (after each contraction)

Technique

  • Palpate abdomen first — locate fetal back/heart position
  • Listen for minimum 1 minute after a contraction
  • Count rate and note any irregularities
  • Normal FHR: 110–160 bpm
  • Document: time, rate, presence of accelerations or decelerations

Equipment

Pinnard Stethoscope Hand-held Doppler

Doppler preferred — allows confirmation of FHR. Pinnard provides direct auscultation. Both valid.

Continuous CTG Indications

Continuous electronic fetal monitoring (EFM) indicated in high-risk situations:
  • Previous caesarean section (risk of uterine rupture)
  • Oxytocin induction or augmentation
  • Epidural analgesia in situ
  • Meconium-stained liquor
  • Abnormal intermittent auscultation finding
  • Prematurity (<37 weeks)
  • Multiple pregnancy
  • IUGR / oligohydramnios
  • Pre-eclampsia / gestational hypertension
  • Maternal diabetes (insulin-requiring)
  • Antepartum haemorrhage in labour
  • Maternal fever (>38°C)
  • Post-dates ≥42 weeks
GCC practice: Many units apply CTG to all labouring patients on admission for at least 20 minutes (admission CTG). Low-risk women may then switch to IA if normal.

CTG Systematic Interpretation — RCDM Framework

R — Rate (Baseline FHR)

FeatureNormalConcerning
Baseline110–160 bpm<110 (bradycardia) or >160 (tachycardia)
Baseline changeStable ± 5 bpmRise/fall >20 bpm sustained

C — Contractions

  • Normal: ≤5 contractions per 10 min (over 30-min period)
  • Tachysystole: >5 contractions per 10 min — increases hypoxia risk
  • If on oxytocin and tachysystole: reduce/stop infusion

D — Decelerations

TypeSignificance
Early (mirrors contraction)Benign — head compression
Variable (V-shaped, rapid onset)Usually cord compression — watch trend
Late (onset after peak)Uteroplacental insufficiency — concerning
Prolonged (>3 min)Emergency — immediate action

M — Movements & Variability

  • Variability (beat-to-beat): normal ≥5 bpm over 1-min segments
  • <5 bpm for >40 min = reduced variability (concerning)
  • Accelerations (≥15 bpm, ≥15 sec): reassuring sign of fetal wellbeing

NICE CTG Classification

CategoryDefinitionAction
NormalAll 4 features reassuring: baseline 110–160, variability ≥5, accelerations present, no decelerationsContinue current management; document hourly
Suspicious1 non-reassuring featureCorrect reversible causes; senior midwife review; increase documentation frequency
Pathological2+ non-reassuring or 1 abnormal featureImmediate obstetric review; consider fetal blood sampling or expedite delivery

Actions for Pathological CTG

IMMEDIATE steps (ABCDE approach):
  1. Position change — left lateral decubitus (relieves aortocaval compression)
  2. Administer facial oxygen at 10–15 L/min via mask
  3. Stop oxytocin infusion immediately if running
  4. IV fluid bolus (crystalloid) if hypotension
  5. Call obstetric registrar immediately
  6. Consider fetal blood sampling (FBS) if cervix accessible and >34 weeks (scalp pH <7.20 = immediate delivery; 7.20–7.25 = repeat in 30 min)
  7. Prepare for emergency LSCS if FBS contraindicated or failed

Meconium-Stained Liquor

Light/thin meconium: Continuous CTG; paediatric team at delivery.
Thick/heavy meconium: Category 2 emergency; immediate obstetric assessment; risk of meconium aspiration syndrome (MAS). Suction of oropharynx at delivery NOT routine — paediatric team present for active intervention if needed.

Non-Pharmacological Methods

Mobilisation & Positioning

  • Upright positions (walking, kneeling, squatting) reduce pain and shorten Stage 1
  • Avoid prolonged supine — causes aortocaval compression
  • Birth ball: pelvic rocking reduces pressure
  • All-fours position useful for occipitoposterior labour

Water Immersion

  • Warm water bath or birthing pool during active Stage 1
  • Reduces pain, anxiety, and oxytocin use
  • Safe if: membranes intact or recently ruptured, no evidence of infection, FHR normal
  • Water temperature: ≤37.5°C; continuous FHR monitoring via waterproof Doppler
  • GCC context: available in some private hospitals (UAE, Qatar); less common in public sector

TENS (Transcutaneous Electrical Nerve Stimulation)

  • Electrodes placed on lower back (T10–L1 and S2–S4 dermatomes)
  • Best used in early labour — less effective in advanced active labour
  • No fetal risk; can be self-administered; incompatible with water

Breathing Techniques

  • Slow, deep breathing through contractions — activates parasympathetic system
  • Lamaze technique: patterned breathing at different labour stages
  • Hypnobirthing: self-hypnosis and guided relaxation — gaining popularity in GCC private sector

Psychological & Social Support

  • Continuous support from midwife, husband, or female companion reduces pain scores and LSCS rate
  • In GCC: husband commonly present during labour (UAE, Qatar, Saudi Arabia)
  • Doula (trained birth companion): uncommon in GCC but increasing in private hospitals
  • Female midwife/obstetrician strongly preferred; male staff require explicit patient consent
  • Quranic recitation and prayer as coping strategies — respect and facilitate
Nurse role: Reassurance, presence, clear explanation of labour progress, and advocacy for patient preferences significantly reduce perceived pain and anxiety.

Pharmacological Methods

Entonox (50% Nitrous Oxide + 50% Oxygen)

  • Self-administered via mouthpiece or mask — patient controls usage
  • Begin inhaling 30 seconds before contraction peaks for maximum effect
  • Maximum effective dose: 9 breaths per contraction
  • Onset: 45–60 seconds; wears off rapidly when removed
  • Side effects: dizziness, nausea, light-headedness, tingling
  • Safe for fetus; excreted by mother via lungs
  • Requires adequate room ventilation
Contraindications:
Vitamin B12 deficiency, recent bowel surgery, pneumothorax, air embolism, raised ICP, first trimester (no evidence of harm but avoid conventionally)
GCC: Entonox widely available across GCC labour wards. Ensure equipment checked pre-shift; scavenging system required.

Opioid Analgesia

DrugDose & RouteOnset / DurationKey Points
Pethidine (Meperidine)100 mg IM (max 150 mg); repeat after 4 h20–30 min / 3–4 hNeonatal respiratory depression if delivered within 4 h of dose; antidote: naloxone (neonatal: 0.01 mg/kg IM/IV/ETT)
Morphine5–10 mg IM or 2–5 mg IV15–30 min / 4 hLess commonly used in labour; same neonatal risk
Remifentanil PCA0.5 mcg/kg IV bolus, lockout 2 minSeconds / 3–5 minAvailable in specialist units only; requires 1:1 nursing; risk of maternal apnoea — continuous SpO2 monitoring mandatory
All opioids: Monitor maternal respiratory rate, sedation level, SpO2. Naloxone (adult: 400 mcg IV/IM) available at bedside. Opioids cross placenta — inform paediatric team of timing.

Epidural Analgesia

Low-Dose Combined Spinal-Epidural (CSE)

  • Most common technique in GCC private hospitals
  • Spinal component: fentanyl 25 mcg + bupivacaine 2.5 mg → rapid onset (<5 min)
  • Epidural catheter for ongoing top-ups or PCEA (patient-controlled epidural analgesia)
  • Standard epidural solution: 0.1% bupivacaine + 2 mcg/mL fentanyl
  • Mobile epidural (walking epidural): low concentration preserves motor function

Nursing Management Post-Epidural

  • BP monitoring: every 5 minutes × 30 minutes post-insertion, then every 30 min
  • If BP drops >20% from baseline: left lateral position + IV fluids + call anaesthetist; ephedrine may be required
  • Motor block assessment: Bromage scale (0 = full movement, 3 = unable to flex foot)
  • Insert urinary catheter (Foley) — patient cannot feel urge to void
  • Continuous CTG monitoring mandatory
  • Hourly documentation of pain score, motor block, sensory level
Pushing guidance in Stage 2 with epidural:
Allow passive descent for 1–2 h (passive second stage) before active pushing. Use pressure sensation, not pain, to guide pushing effort. Directed pushing with encouragement at peak of contraction. Extended time limits apply (up to 3 h nulliparous/2 h multiparous with epidural).

Complications to Monitor

ComplicationSigns
HypotensionBP drop >20%, dizziness, pallor
Dural punctureSevere positional headache post-delivery
Total spinalRapid high block — apnoea, loss of consciousness
Local anaesthetic toxicityPerioral tingling, tinnitus, seizures, cardiac arrest
Fever (>37.5°C)Epidural-related or chorioamnionitis — clinical differentiation required
Always check: epidural catheter secured, filter intact, infusion labelled "EPIDURAL ONLY", no IV connections possible (coloured connectors).

Instrumental Delivery

Indications

  • Prolonged Stage 2 (beyond time limits)
  • Fetal distress in second stage (pathological CTG)
  • Maternal exhaustion or inability to push effectively
  • Maternal conditions where Valsalva contraindicated (severe cardiac/eye disease)

Prerequisites (all must be met)

  • Cervix fully dilated (10 cm)
  • Membranes ruptured
  • Presentation: vertex (cephalic)
  • Station: ≥+1 (head accessible)
  • Position of head known
  • No CPD (clinical estimation)
  • Maternal consent obtained
  • Adequate analgesia (spinal/epidural preferred)
  • Bladder emptied (catheterise)
  • Neonatal team informed/present

Ventouse vs Forceps Comparison

FeatureVentouseForceps
Maternal traumaLessMore (vaginal/perineal tears)
Neonatal complicationsMore (cephalohaematoma, scalp abrasion, retinal haem.)Less neonatal injury
EpisiotomyNot always requiredAlmost always required
Failure rateHigher (~15%)Lower (~5%)
AnaesthesiaRegional/local adequateRegional preferred
Use in premature (<34w)AvoidPreferred if required
After failed instrumental delivery → immediate Category 1 LSCS. Maximum 3 pulls with ventouse; 3 contractions with forceps. Never combine instruments if first fails (exception: senior decision).

Episiotomy

Indications

  • Instrumental delivery (forceps — near routine; ventouse — selective)
  • Imminent severe perineal tear
  • Fetal distress requiring rapid delivery
  • Shoulder dystocia (gaining access)

Technique

  • Timing: at crowning, with a contraction
  • Angle: mediolateral 45–60° from midline (reduces risk of OASIS)
  • Midline incisions have higher OASIS rate — avoid in GCC if mediolateral feasible
  • Local anaesthetic (lidocaine 1%) if no regional block
  • Scissors or scalpel — blunt-ended scissors preferred

Repair

  • Continuous subcuticular suture for skin (Vicryl Rapide 2-0 or 3-0)
  • Vaginal wall: continuous locked; muscle: continuous
  • Document: anatomy, method, suture used, swab/needle count

OASIS — Third & Fourth Degree Tears

Classification:
3a: <50% external anal sphincter (EAS)
3b: >50% EAS
3c: EAS + internal anal sphincter (IAS)
4th degree: EAS + IAS + anorectal mucosa

Management: Surgeon/consultant repair in theatre; overlapping sphincter repair; antibiotics (co-amoxiclav); laxatives; physiotherapy referral

Emergency Caesarean Section

LSCS Categories (NICE / RCOG)

CategoryDefinitionTarget Decision-to-Delivery
Cat 1Immediate threat to life of mother or fetus<30 minutes
Cat 2Maternal/fetal compromise — not immediately life-threatening<75 minutes
Cat 3No maternal/fetal compromise; early delivery neededWithin hours (same day)
Cat 4Elective — at woman's or clinical requestScheduled

Nursing Role — Pre-op Preparation

  • Consent verified; identity band correct
  • IV access ×2 large-bore (16G minimum)
  • Blood group & save or crossmatch if Category 1/2
  • Urinary catheter (Foley) in situ
  • Abdominal prep; theatre gown, anti-embolism stockings
  • Antacid prophylaxis: sodium citrate 30 mL PO + ranitidine IV
  • Brief patient: what to expect under spinal anaesthesia

Intraoperative Nursing Considerations

  • Uterine displacement: left lateral tilt 15° until delivery (manual or wedge) — prevents aortocaval compression under spinal
  • Monitor: BP every 1–2 min until baby delivered; SpO2; ECG
  • Spinal hypotension: phenylephrine infusion first-line (vasopressor); IV crystalloid bolus
  • Blood loss measurement: weigh swabs + suction contents
  • Instrument/swab counts: at opening, before uterine closure, before skin closure
  • Scrub nurse role: sterile field maintenance, instrument passing, counting, assisting with retraction

Skin-to-Skin in Theatre

Skin-to-skin contact in theatre immediately post-delivery is evidence-based (improves breastfeeding initiation, bonding, neonatal thermoregulation). GCC practice: increasingly supported in private hospitals. Requires: baby vigorous, no immediate neonatal concern, mother's agreement, staff support for positioning and monitoring during closure.

Active Management of Third Stage (AMTSL)

Components (WHO Recommendation)

  1. Oxytocin 10 units IM within 1 minute of birth of baby (into outer thigh)
  2. Wait for signs of placental separation
  3. Controlled cord traction (CCT) with counter-traction on uterine fundus (Brandt-Andrews technique)
  4. Uterine massage after placenta delivered (if uterus not well contracted)
AMTSL reduces PPH by ~60% compared to physiological management. Oxytocin alone is as effective as the full package — focus on early oxytocin administration.

Signs of Placental Separation

  • Uterus becomes globular and rises in abdomen
  • Gush of blood from vagina
  • Cord lengthens at introitus
  • Uterus no longer retracted when cord held — Brandt-Andrews sign positive

Physiological (Expectant) Management

  • No oxytocin; no CCT; await spontaneous expulsion
  • May take up to 60 minutes
  • Higher blood loss (average ~250 mL vs ~175 mL with AMTSL)
  • Appropriate only if patient requests and no risk factors for PPH

Retained Placenta

Definition: Placenta not delivered within 30 min (AMTSL) or 60 min (physiological management).

Actions: IV access + bloods; empty bladder; attempt oxytocin IV; consider manual removal of placenta (MRP) under anaesthesia; consent, theatre preparation, blood products available

Placental Examination

Maternal Surface

  • 15–20 cotyledons fitting together like a jigsaw — ensure completeness
  • Dark red, velvety surface
  • Missing cotyledon = retained placental tissue → risk of PPH and infection
  • Note: calcification (normal at term), infarcts, clot on surface

Fetal Surface

  • Smooth, shiny, covered by amnion
  • Cord insertion: central (normal), eccentric, marginal (battledore) or velamentous (risk of vasa praevia)
  • Check for succenturiate lobe (accessory lobe — risk of retained tissue)

Umbilical Cord

  • Normal length: ≥30 cm (average 50–60 cm)
  • Normal: 2 arteries + 1 vein (cut cross-section shows 3 vessels)
  • Single umbilical artery (SUA): associated with renal/cardiac anomalies
  • Wharton's jelly surrounds vessels — provides protection
  • Colour: white/blue-grey; twisting (spiral) normal
  • Nuchal cord (around neck): document; if tight → double clamp and cut before body delivery
Always document: placenta weight, membrane completeness, cord vessels, any anomalies. If doubt about completeness → USS + obstetric review.

Immediate Postpartum Observations

Monitoring Protocol (First Hour)

ObservationFrequency (1st hour)Normal Range
BP & PulseEvery 15 min × 4SBP 90–140; PR 60–100
Respiratory rateEvery 15 min × 412–20 breaths/min
TemperatureAt 1 hour36.0–37.5°C
Uterine fundusEvery 15 minFirm, midline, at umbilicus
LochiaEvery 15 minRubra; soaking <1 pad/15 min
Perineum30 min & 1 hourNo haematoma; minimal oedema
BladderAt 1 hour; 4 hours post-deliveryVoid ≥150 mL within 6 h

PPH Recognition & HAEMOSTASIS

PPH Definition:
Primary PPH: Blood loss >500 mL within 24 h of vaginal delivery; >1000 mL after LSCS.
Severe PPH: >1000 mL vaginal; >1500 mL LSCS.

4 Ts (Causes): Tone (80%) · Trauma · Tissue · Thrombin
HAEMOSTASIS Algorithm:
H – Ask for Help
A – Assess (ABC), IV access ×2, bloods
E – Establish aetiology (4 Ts)
M – Massage uterus, bimanual compression
O – Oxytocin infusion (40 units in 500 mL NS over 4 h)
S – Shift to theatre if not responding
T – Tamponade (intrauterine balloon)
A – Apply compression sutures (B-Lynch)
S – Systematic pelvic devascularisation
I – Interventional radiology
S – Subtotal/total hysterectomy (last resort)

PPH Risk Stratifier

Select Risk Factors to Calculate PPH Risk

Antenatal Risk Factors

Intrapartum Risk Factors

Caesarean Section Rates in GCC

Regional Data (Approximate)

CountryLSCS RateNotable Factors
UAE~50%High private sector utilisation; cultural preference; medicolegal culture
Qatar~45%High-volume centralised units; growing maternal request CS
Saudi Arabia~40%Large tertiary centres; VBAC rates declining
Kuwait / Bahrain~35–40%Mix of public/private; cultural factors similar
Oman~25%Lower rates; stronger midwifery-led model in some regions
WHO target: ≤15% caesarean rate. GCC rates significantly exceed this. Nurse advocacy for informed choice and vaginal birth where safe is important.

Driving Factors

  • Cultural demand: Perception of CS as safer/more modern; patient request increasing
  • Medicolegal pressure: Obstetricians in private sector may prefer CS to reduce litigation risk
  • Fear of pain: Limited access to or preference for epidural may drive CS request
  • Previous CS: Repeat CS cycle — once a CS, always a CS perception
  • Consanguinity: Higher congenital anomaly rates may increase complex deliveries

VBAC in GCC

Vaginal Birth After Caesarean (VBAC): success rate 60–80% when appropriately selected. Declining in GCC despite evidence of safety. Risk of uterine rupture ~0.5%. Requires: continuous CTG, IV access, theatre availability within 30 min, clear patient counselling and informed consent.

Gender Preferences & Cultural Birth Practices

Healthcare Provider Preferences

  • Female midwife or female obstetrician strongly preferred by most GCC patients
  • Male healthcare providers (doctors, nurses): consent must be explicitly obtained and documented
  • In emergencies — patient safety overrides preference, but this must be communicated sensitively
  • Mixed-gender rooms: not acceptable; ensure private female-only wards where possible
  • Privacy during examinations: chaperone always present; expose minimally

Family Presence

  • Husband commonly present during labour in UAE and Qatar private hospitals
  • Saudi public hospitals: traditionally more restricted — policies vary by institution
  • Other female family members (mother, sister) may be requested — accommodate where possible
  • Large family gatherings in the waiting room common — manage respectfully

Cultural & Religious Practices at Birth

  • Azan (call to prayer): Father or family member whispers azan in right ear of newborn — facilitate this immediately after birth
  • Quranic recitation: Patient or family may recite Quran aloud or via phone during labour — support and do not interrupt
  • Tahneek: Rubbing date or honey on the palate of the newborn (traditional) — educate re: aspiration risk in preterm; document if performed
  • Cord burial: Some families request the placenta/cord for burial — check hospital policy; many GCC hospitals accommodate this
  • Naming ceremony: May occur at bedside shortly after birth — privacy important
  • Fasting women: Muslim women may not eat during Ramadan — ensure IV access, monitor hydration; most scholars permit not fasting during labour
Cultural competency is a core nursing skill in GCC. Asking "Is there anything important to you or your family that we should know about for your birth?" opens dialogue and builds trust.

Leading Maternity Units in GCC

UAE

Latifa Hospital, Dubai
Level III NICU; high-volume; training centre; ~10,000 births/year

Corniche Hospital, Abu Dhabi
Largest maternity unit in UAE; Abu Dhabi Health Services; Level III

Al Wasl Hospital, Dubai
Major public maternity unit; complex cases

Qatar & Saudi Arabia

Women's Hospital, Doha (HMC)
Qatar's main tertiary maternity centre; Level III NICU; MFM unit

KFMC (King Fahad Medical City), Riyadh
Major academic centre; complex obstetric cases; subspecialty MFM

King Abdullah Specialist Children's Hospital, Riyadh
Level IV NICU; extreme preterm care

Epidural Uptake Trends

  • Rapidly increasing in UAE private hospitals (Dubai/Abu Dhabi)
  • Qatar: available in HMC system; uptake growing
  • Saudi Arabia: available in major centres; less uniform access in regional hospitals
  • 24/7 obstetric anaesthesia: mandatory in Level II+ units across GCC
  • Nurse anaesthetists: role varies — MDs primarily administer in most GCC countries
GCC nurses: advocate for adequate pain relief access as a patient right, regardless of cultural norms about pain in labour.

Practice MCQs — Labour & Delivery (10 Questions)

0/10

Practice complete — review any incorrect answers above