Care during labour and birth

• Health Services and practitioners are governed by State and national frameworks and standards for practice (Appendix 1.)
• Health services should provide planned care to pregnant women using a risk management approach that establishes when advice, referral, or transfer is required. This is to ensure that the right care is offered in the right place, at the right time and aligns with the Capability Framework for Victorian Maternity and Newborn Services. 
• If the level of care that is required falls outside the capability of the health service, then consultation, referral and transfer processes need to be enacted, taking into consideration geographical boundaries, weather and road conditions.  
• Consultation with the State’s Paediatric, Infant and Perinatal Emergency Retrieval service (PIPER) should occur if emergency referral or retrieval is required. Contact PIPER - Ph 1300 137 650. www.rch.org.au/piper

• Planning for labour and birth is a continuous process, commencing at the beginning of pregnancy. It aims to ensure the woman is an active participant in making informed choices and decisions that are in the best interest of her and her baby. 
• Evidence has shown that women who receive continuous support during labour, are more likely to give birth spontaneously, use less pain medications, have shorter labours and are more satisfied.1,2 
• The woman may be anxious or feeling vulnerable. This can be reduced by open communication, active listening and compassionate care. Simple measures such as introducing yourself and others, gaining consent for procedures, being respectful and maintaining the woman’s dignity will assist in minimising fears.

Care providers must be aware of and sympathetic to all people within our diverse global community, including but not exclusive to race, sexual orientation, sexual identity, or those linguistically or cognitively challenged. 

Personal behaviours, attitudes and beliefs have the potential to adversely affect the quality of care and the safety of a woman. Therefore, respectful communication together with non-judgmental care is paramount to optimise the woman’s labour and birth experience.

Aboriginal and Torres Strait Islander families

There remains an ongoing gap in maternal and neonatal morbidity and mortality for Aboriginal mothers and babies. Cultural competence is an essential component of care and underpins effective cultural communication and cultural safety.

• Offer to connect the woman with the Aboriginal Hospital Liaison Officer (AHLO) or equivalent, if this service is available. 
• Explore whether a woman has other cultural services supporting her in pregnancy for example, Koori Maternity Service, and what birth planning has been discussed. 
• Aboriginal and Torres Strait Islander women and families may use different terminology to describe their bodies or labour processes.
• For Aboriginal and Torres Strait Islander women and families, birth is women’s business, and they may prefer female care providers.
• For more information on culturally competent care, please refer to the Maternity and Newborn Services User Guide.

Women of non-English speaking background or with communication difficulties

Do not use family members or friends to interpret, as this can involve breaches of confidentiality, conflict of interest and possible legal liability. Use a telephone interpreter service or onsite interpreter for all interpreting. 

• While there is insufficient high-level evidence, a good practice telephone record tool has been developed to guide practice and can be found here: Telephone record tool
• All advice is individualised according to the woman’s circumstances.
• Consider the woman’s distance from hospital and how this may affect her ability to attend, the ideal timing of her attendance and her safety while she is travelling. If the level of care that is required falls outside the capability level of the health service then consultation, referral and transfer processes need to be considered, taking into account geographical boundaries and road conditions and the full clinical picture.  

Initial assessment

When a woman attends for assessment, it is important to gather information such as her medical and obstetric history, perform observations and possibly offer a vaginal examination (VE) to assess progress in labour and evaluate her needs. Care providers should:
Introduce themselves and their role to the woman and her support team.

• Establish the reason for her presentation.
• Assess the woman’s emotional and psychological needs/state.
• Ask about: 
  • fetal movements in the past 24 hours
  • vaginal loss: record colour, volume, odour of any liquor or show, bleeding
  • time of onset of contractions - frequency, strength, duration, resting tone
  • antenatal events and complications.
• Review pregnancy care record and note the woman’s:
  • parity and gestation
  • Group B Streptococcus (GBS) status (see GBS management eHandbook topic)
  • pathology and imaging results including placenta location
  • allergies
  • significant antenatal events and/or complications
  • medical/surgical history
  • check and record the woman’s temperature, respiratory rate (RR), blood pressure (BP) and heart rate (HR).
• Perform a urinalysis, predominately for ketones, glucose and protein.
• Palpate the abdomen to assess:
  • fetal size for gestational age and document symphyseal-fundal height
  • confirm lie, presentation and position of the fetus (if unsure of presentation, escalate immediately to senior clinicians and consider bedside ultrasound scan for confirmation)
  • station and descent of the presenting part into the pelvis.
• Fetal Heart rate (see fetal surveillance below) 
• Stay with the woman, observe and palpate her contractions and fetal movements for a minimum of 20 minutes. This is an opportunity to offer reassurance to the woman and her support team. 
• If appropriate and indicated offer the woman a vaginal examination (VE), gain her consent and document the findings. Be mindful that a VE can be painful and confronting for some women. Maintain her dignity, privacy and be respectful.
• Consult and refer with appropriately skilled clinician when deviations from normal are noted.

• The routine use of admission Cardiotocograph (CTG) or continuous electronic fetal monitoring (CEFM) during all stages of labour for low risk women, is not recommended as there is insufficient evidence to support this practice.3,4 
• Fetal surveillance should be as per the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Intrapartum Fetal Surveillance guideline.
• If CEFM is not indicated, intermittent auscultation (IA) of the fetal heart rate (FHR) in labour should occur toward the end of the contraction and continue for at least 30-60 seconds after the contraction has finished.
• Ensure the maternal heart rate is recorded and differentiated from the fetal heart rate.
• Reassess the need for CEFM throughout labour and birth as risk factors may appear such as maternal fever, prolonged labour, bleeding or an abnormal fetal heart rate on IA.
• If there is difficulty auscultating the fetal heart OR obtaining an adequate fetal heart rate tracing at any time in labour, the fetal heart rate should be monitored using a scalp electrode.

During all stages of labour, provide both physical and psychological comfort and support, while ensuring the woman’s privacy and dignity are always protected. 

Encourage the woman to keep hydrated, eat a light diet, mobilise and adopt upright positions where possible, as these are associated with a reduction in the duration of the first stage of labour.5  If the woman is supine, use a wedge under her right hip.

Where possible, honour labour and births plans, discuss options for pain relief and support the woman’s choice for comfort and coping strategies.

Maintain accurate, factual and contemporaneous documentation. 

Latent phase (early labour)

Early or latent phase of labour is typically characterised by painful contractions, some degree of cervical effacement and cervical dilatation. The literature states cervical dilatation is typically less than 4-6cm.3 For purposes of this guideline the WHO 2018 definition will be accepted as dilation up to 5cm for first and subsequent labour. Some women may believe they are in active labour and may find this phase confusing and exhausting. Care providers should be aware of and acknowledge this, offering reassurance and support.

• Support the woman to return home until labour establishes, providing she feels safe and confident to do so and according to her individual needs, wishes and circumstances.
• Reassure the women that she can return to hospital at any time if she is anxious or unable to manage her pain.

Discuss:

• what to expect in the latent phase and how to recognise established labour 
• recognition of ruptured membranes, normal and abnormal vaginal loss.

Advise the woman:

• to rest if feeling tired, take light meals and keep hydrated
• that mobilising may help contractions to establish
• about comfort and pain management strategies
• If the woman chooses to return home, ensure she is aware of when to call or re-present to the hospital
• Encourage the woman to attend if early labour exceeds: 
  • 20 hours (primip) 
  • 14 hours (multip)
• Document an agreed, ongoing management plan in the woman’s medical record.
   

Note: Cervical dilatation should not be the sole determinant of safety to return home or admission for ongoing care. An assessment of contractions and the woman’s behaviour and wishes are important considerations

Active first stage of labour

Active labour is traditionally defined as commencing between 4cm and 5cm of cervical dilatation, although increasing evidence suggests that some women may not be in active labour before 6cm dilation.6 For the purpose of this guideline the World Health Organisation 2018 3 active labour definition will be recommended for practice as a period of time characterised by regular painful uterine contractions, a substantial degree of cervical effacement and more rapid cervical dilatation from 5cm until full dilation. 

Expected progress

• Duration of the first stage may be up to: 
  • 12 hours for nulliparous women
  • 10 hours for multiparous women.
     
• Progress may include:
  • cervical dilatation
  • cervical effacement
  • descent of the presenting part (confirmed by abdominal or vaginal examination)
  • increasing strength and duration of contractions.
     

The use of amniotomy to check liquor colour or for prevention of delay in labour in an otherwise uncomplicated pregnancy and labour, is not recommended.3

Active first stage of labour flowchart - quick reference guide

Maternal observations

• Every 30 minutes: 
  • palpate uterine activity for 10 minutes and document frequency, strength and length of contractions, being mindful of sufficient uterine rest between contractions (60-90 seconds minimum).
  • check and document maternal pulse/heart rate (HR). If continuous EFM is being used ensure maternal pulse is differentiated from fetal heart rate and it is documented on the CTG.
  • check vaginal loss – liquor, blood.
• Every 2 hours (and prior to each vaginal examination): abdominal palpation.
• Every 2-3 hours encourage bladder emptying and consider urinalysis.
• Every 4 hours, or more frequently as indicated, check: 
  • blood pressure (BP) 
  • temperature
  • respiratory rate (RR) 
  • Offer a vaginal examination to assess labour progress. Vaginal examination may also be indicated prior to administration of a narcotic, siting of an epidural for analgesia, to confirm full cervical dilatation (if in doubt) or in response to the woman’s wishes – however it is important to note that vaginal examinations more frequently than every four hours could potentially increase the risk of infection for both the mother and baby.7
• When there are concerns regarding abnormal observations, the progress of labour or the fetal heart rate, escalate according to local policy, while offering reassurance and using honest but positive language. 

Indications for consultation or escalation during the first stage of labour:

Active first stage of labour flowchart - quick reference guide
National Midwifery Guidelines for Consultation and Referral

The second stage of labour is from full cervical dilatation (10cm) to the birth of the baby. When the 2nd stage of labour is suspected or confirmed, ensure other clinicians required to attend the birth are made aware. Provide supportive care to the woman as she transitions to the 2nd stage. 

Preparation for the 2nd stage of labour

• Ensure all equipment required for birth and neonatal resuscitation is in the room and checked prior to the 2nd stage. Explain to the woman and her support people why any equipment or extra clinicians may be required in the room to help relieve any anxiety.
• Ensure appropriate clinicians are present for the birth, based on maternal or neonatal risk factors.
• Many women worry about opening their bowels in the 2nd stage: Reassure them that this can be a normal occurrence that many women experience.
• Discuss the birthing process with the woman including perineal care and measures that may be taken to reduce the risk of a 3rd and 4th degree tear. See below ‘Perineal care’.
• Discuss and confirm the management of 3rd stage with the woman.

Expected progress

• Birth would be expected to be completed: (combined passive and active stages of birth) 
  • within three hours from the start of the 2nd stage for nulliparous women
  • within two hours from the start of the 2nd stage for multiparous women.
• Passive descent for up to one hour may be appropriate for women who have NO urge to push, or for those who have an epidural in situ or a high presenting part.
• Passive descent is NOT appropriate for women who have an urge to push, or an abnormal CTG.
• Retrospective documentation should be completed as soon as possible after birth, if contemporaneous notes are not possible.

Maternal and fetal observations

Second stage is a time where the maternal heart rate is often mistaken for the fetal heart rate. Ensure the maternal pulse is differentiated from the fetal one and that both are documented.

Fetal

If continuous fetal monitoring is not being used:

• Not actively pushing: Auscultate the fetal heart rate every 15 minutes.
• Actively pushing: Auscultate the fetal heart rate every 5 minutes or after every contraction.

Maternal

Every 15 minutes:

• If continuous monitoring is being used, document maternal pulse on the CTG

Every 30 minutes:

• palpate uterine activity for 10 minutes and document frequency of contractions, strength and length and uterine rest time.

Every hour: 

• Blood pressure
• Temperature
• Respiratory rate
• Abdominal palpation.

Second stage of labour flowchart - quick reference guide

Bladder care

An in/out catheter is appropriate if the woman: 

• Has not passed urine for 2-3 hours
• has difficulty passing urine
• has a palpable bladder
• Deflate the Indwelling Catheter (IDC) balloon, if applicable.

Pushing

• The woman should be advised that in 2nd stage she should be guided by her own urge to push, while listening to guidance from her care provider to ensure a slow, controlled birth of the baby’s head is facilitated.
• Directed pushing and breath holding should be avoided3, but guidance is appropriate if requested by the woman or if pushing is ineffective. Discourage uncontrolled, explosive pushing that could lead to severe perineal trauma.
• Care providers should be aware that when the woman is squatting, standing, using the toilet or using a birth stool, that visualising and supporting the perineum is more difficult in these positions.
• To provide positive feedback regarding progress, offer a mirror to guide pushing efforts or touching the fetal head as it descends. Note: this may not be acceptable to all women and if possible, should be discussed prior to the 2nd stage. 
• Do not use fundal pressure.

Perineal care

• Offer all women warm perineal compresses at the commencement of perineal stretching as recommended by Women’s Healthcare Australasia (WHA).8
• Water temperature 38-44°C
• Replace water entirely every 15 minutes
• After application, check skin colour for signs of excessive heat.
  • Warm compresses can be used with caution for women with epidurals: check the temperature with her on her upper body.
• Document all perineal observations and interventions, including:
  • oedema
  • blanching
  • visible scar tissue
  • use of warm compresses.8

Hands on technique is recommended.8 

• support the perineum. 
• apply light counter-pressure on the fetal head. 
• if the shoulders do not deliver spontaneously, apply gentle traction to release the anterior shoulder.
• allow the posterior shoulder to be released, following the curve of Carus.
• When birth is imminent, call for the 2nd clinician: Two clinicians are required in order to provide optimal care for mother and baby.
• Routine checking for nuchal cord is not recommended.
• Routine clamping and cutting of the nuchal cord is not recommended.
• Place the baby skin to skin with the mother immediately following birth, if appropriate.
• Delayed cord clamping (not earlier that 1 minute after birth) is recommended, if appropriate.

Episiotomy

• Do not perform a routine episiotomy.
• Only perform episiotomy with the woman’s verbal consent.
• Episiotomy is recommended for all women having their first vaginal birth requiring forceps or ventouse assisted birth, to reduce the risk of 3rd and 4th degree perineal tears.8
• Episiotomy may be indicated for, but not limited to:
  • suspected or confirmed fetal compromise
  • delayed second stage
  • where a severe perineal tear is judged to be imminent (‘button-holing’, significant blanching).
• When an episiotomy is indicated, it should be performed:
  • at crowning of the fetal head.
  • using a medio-lateral incision, at a minimum 60 degree angle from the posterior fourchette.8
• Ensure effective analgesia (e.g. perineal infiltration, effective epidural) before cutting an episiotomy, except in an emergency, for example due to acute fetal compromise.

Suggested role of the 2nd clinician at birth:

• Support the woman, her birth partner and the accoucheur as required.
• Re-check the neonatal resuscitation equipment.
• Check the oxytocic in preparation for the 3rd stage. Administer the oxytocic as required, within one minute of birth and complete documentation.
• Note the time of birth.
• Take responsibility for care of the newborn from birth. (Unless paediatric care is commenced) and initiate resuscitation if required. Document Apgar scores. 
• Attach baby identification labels.
• If required, assist in collecting cord blood gas for analysis (as indicated by local guidelines) and collect cord blood for Resus (Rh) negative women. 

For indications for consultation or escalation during the 2nd stage:

National Midwifery Guidelines for Consultation and Referral 
Second stage of labour flowchart - quick reference guide

The third stage of labour is from the birth of the baby until the birth of placenta and membranes and control of bleeding.9  Recognise that this time is also one where the mother and her support team are getting to know the baby. Maintain a private, calming environment. Be sensitive to the woman’s emotional and psychological needs and encourage the woman to focus on the process of birthing the placenta and avoid distractions.

Women should be provided with information on the benefits and harms of both active and physiological third stage management during the antenatal period and the woman’s informed choice and decisions should be supported. If a woman requests physiological third stage management, document a plan for indications for initiation of active management.

Active Management 

Active management of the 3rd stage is recommended, to reduce the risk of postpartum haemorrhage.10 Interventions are designed to facilitate the delivery of the placenta, by increasing uterine contractions and to prevent primary postpartum haemorrhage by minimising uterine atony.

• Confirm the woman’s consent for active management. 
• Give a uterotonic agent: Oxytocin (Syntocinon) 10iu IM/IV is recommended.10  Oxytocin/ergometrine (Syntometrine) may be used but should be avoided for women with hypertension. Clinicians and women should be aware that ergometrine may cause a brief, temporary reduction in lactation. 
• Wait one to three minutes after birth of the baby or for cord pulsation to cease and then clamp and cut the umbilical cord. Early Umbilical cord clamping (less than 1 minute after birth) is not recommended unless the neonate requires resuscitation. Even then, per WHO guidelines, if the provider has experience providing effective positive-pressure ventilation without cutting the cord, ventilation can be initiated with the cord intact to allow for delayed cord clamping.1
• Clamp the cord before 5 minutes in order to perform controlled cord traction (CCT).1, 10, 12 
• CCT is recommended as it is associated with fewer manual removals, shorter third stage and lower intensity of pain.13
• Perform CCT while ‘guarding the uterus’ when signs of separation occur which include:
  • the uterus rises in the abdomen
  • the uterus becomes firmer. 
  • a trickle or gush of blood is observed from the vagina
  • observe for lengthening of the cord
  • cord does not retract with suprapubic pressure.
• After the expulsion of the placenta and careful removal of the membranes, check the fundus for uterine tone and perform fundal massage if active bleeding is evident.
• Never apply CCT without applying counter pressure to the uterus (guarding). Do not encourage maternal effort in conjunction with CCT. If releasing downward pressure on cord, this must be done before relaxing counter pressure of the uterus.
• Immediately following birth of the placenta assess uterine tone and monitor blood loss (ongoing).
• Active third stage should be completed within 30 minutes of birth.1  Escalate in a timely manner and if placenta is retained, prepare for manual removal of placenta in theatre.

If excessive bleeding is observed, initiate emergency postpartum haemorrhage (PPH) response management immediately. Refer to our Postpartum haemorrhage eHandbook page.

Physiological management (also referred to as expectant management)

The birth of the placenta and membranes are expelled by maternal effort and without using uterotonic agents or controlled cord traction. 

• Physiological 3rd stage is not appropriate for women with an increased risk of PPH such as augmentation, past history of PPH see PPH eHandbook topic. 
• Physiological 3rd stage should ideally be undertaken by clinicians experienced in physiological management. 
• Do not manage physiological third stage in water.
• Leave the cord intact until pulsation has ceased or the placenta is birthed.
• Encourage skin-to-skin contact and assist breastfeeding.
• Encourage upright maternal position, as gravity may help to expel the placenta.
• Observe for signs of separation (see signs of separation in Active Management).
• Do not use CCT, the placenta births spontaneously by maternal effort. Adapting an upright position may help to facilitate gravity expulsion of the placenta.
• If the placenta is visible at introitus a “lift out” is appropriate.
• Recommend intervention with oxytocin if bleeding needs to be controlled.10 
• Physiological third stage should be completed within one hour of birth.1 Escalate in a timely manner and if the placenta is retained, prepare for manual removal of placenta in theatre. 

Examination of the placenta and blood collection

• Examine the placenta, membranes and cord for completeness and deviations from normal. 
• The woman may request to take her placenta home according to personal wishes and/or cultural beliefs. Provide information relevant to the circumstances and respect her decisions.
• For women with Rh negative blood groups collect cord blood to test the blood group and direct antiglobulin (Coombs) of the baby. Ensure maternal Kleihauer / flow cytometry is collected and results are followed up and acted upon.
• If fetal compromise was suspected, consider collecting cord blood lactates to perform umbilical blood gas analysis. Follow local guidelines.
• Send the placenta for histopathological examination for the following indications: 
  • neonatal hypoxic ischaemic encephalopathy (HIE)
  • small for gestational age or growth restriction
  • antepartum haemorrhage 
  • suspected chorioamnionitis 
  • diabetes (Gestational, type1 and type 2)
  • preeclampsia 
  • macroscopic placental abnormalities
  • infants admitted to neonatal intensive care
  • infants failing to respond to resuscitation
  • spontaneous preterm labour and birth
  • planned delivery for fetal compromise
  • severe cardiorespiratory depression at birth including resuscitated stillborn babies
  • signs consistent with congenital infection
  • hydropic infants
  • suspected severe anaemia
  • suspected or known major congenital abnormalities
  • other circumstances where a liveborn infant dies shortly after birth.

The immediate postpartum period is a time of physiological adaptation and this is an opportunity to facilitate mother-baby and family bonding. Continuous ongoing support and observation of the mother and baby is required.

Care of the mother

• Uninterrupted skin-to-skin contact between mother and baby should be encouraged for at least the first hour after birth, or until after the first feed.
• Explain the importance of positioning the baby to maintain a patent airway.
• Ensure warmth of both mother and baby.
• Encourage mother to eat, drink and rest.
• Observe, discuss and document the woman’s initial emotional and psychological response to labour and birth.
• Ensure mother is supported and has access to a call bell if the midwife is not present.
• Encourage the woman’s support team to remain with her, if the midwife needs to leave the room at any stage in the immediate postpartum period.
• Provide adequate education to the woman and her support team as appropriate, including information about life threatening conditions.
• Discuss perineal care, pain relief, hygiene, normal lochia, escalating concerns and normal newborn behaviour. 

Observations

• There is a lack of high-level evidence to support recommendations for frequency and timing of postnatal observations of the mother.
• Frequency and timing of observations should be performed according to organisational guidelines and modified according to clinical circumstances if required. Ensure observations are documented appropriately.
• Escalate any abnormal observations to the medical team.

Recommended maternal observations for the first four hours: 

Perineal care

• Fully explain the need to examine the woman’s perineum and gain her consent.
• Perineal examination needs to:
  • be performed by an experienced clinician and reviewed by a second experienced clinician.8
  • any perineal trauma to be graded and documented according to RCOG grading guideline.
  • include a rectal examination, with the woman’s consent, performed by an experienced clinician for all women who have had a vaginal birth, including those with an intact perineum.1, 8, 14
  • ensure privacy and promote comfort (adequate pain relief) during assessment and repair of any perineal trauma.
• Prompt repair of an episiotomy or perineal lacerations is required to minimise blood loss and the risk of infection.
• Document time of assessment and repair. 
• Apply ice packs for 10-20 minutes after perineal assessment/repair. Offer ice no more frequently than every two hours, for up to 72 hours after birth.
• Offer ongoing analgesia as required.
   

Bladder care

• Assist the woman to mobilise to the bathroom and encourage her to empty her bladder within 2 hours of birth. Document time of the first void.
• The amount and the frequency of urine passed should be documented for six hours.3
• Encourage adequate fluid intake.
• Advise the woman that her first void post-birth may be more comfortable if passed in the shower.
• Enquire about and document any reports of decreased sensation to void or other concerns. 
• If the woman is unable to void, assess if her bladder is palpable and escalate as required. Follow local guidance.

• Undertake newborn support/care as required, as per neonatal flow chart. Also see Neonatal eHandbook topic Neonatal resuscitation. Consider consultation or referral if neonatal resuscitation is required, or the baby exhibits any deviations from normal.
• Maintain warmth by drying the baby with prewarmed towels and immediate skin to skin contact following birth to maintain thermoregulation.
• Explain the importance of positioning the baby to maintain a patent airway.
• Assess and record Apgar scores at 1, 5 minutes (and 10 minutes when indicated). Breathing, heart rate (HR), colour, reflex irritability, tone.

Observations

• Provide close, continuous care.
• Ensure adequate lighting for observation of newborn colour.
• Observe: Position and patency of airway, respiratory effort and rate, colour, heart rate and temperature.
• Routine observations as per Neonatal eHandbook topic or local guidelines, recorded on a ‘Track and Trigger Chart’ such as ViCTOR Birth Suite/Postnatal escalating as appropriate.

Infant feeding

• Encourage, support and promote breastfeeding as the feeding option of choice for infants.15, 16
• Support the woman’s choice of newborn feeding.
• Promote skin-to-skin contact.
• Encourage & support the initiation of newborn feeding within the first hour of birth.
• Observe initial feed and offer assistance as required.
   

Non-urgent care

• Minimise mother and baby separation within the first hour of birth to perform: 
• Weight, length & head circumference
• Administration of phytomenadione (Vitamin K, Konakion)
• Administration of Hepatitis B vaccine (and immunoglobulin where required).

For indications for consultation/escalation during immediate postpartum care, see the National Midwifery Guidelines for Consultation and Referral (2015).

Maternity and newborn care should be provided in accordance with the following statewide and national frameworks, standards and guidelines:

• Australian College of Midwives (ACM) National Midwifery Guidelines for Consultation and Referral  
• Australian National Breastfeeding Strategy: 2017 and beyond  
• Capability framework for Victorian maternity and newborn services   
• Department of Health funding policy 
• National Perinatal Mental Health Clinical Practice Guideline  
• National Safety and Quality Health Service Standards  
• National Strategic Approach to Maternity Services (NSAMS)  
• Nursing and Midwifery Board of Australia (NMBA) Midwife Standards for Practice  
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Standards of maternity care  
• Victorian Clinical governance framework

Audit and performance improvement

All maternity services should have processes in place for: 

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Potential auditable standards include:

• adherence to standards of care
• Low Apgar rates
• 3rd and 4th degree tear rates
• LUSC

Peer review and consultation process

This guideline has been developed by an expert working group of clinicians and consumer representatives. It is endorsed by our Insight and Governance committees, who were not involved during the development process.

1. National Institute for Health and Clinical Excellence. Intrapartum care for healthy women and babies Clinical guideline [CG190] Published date: December 2014 Last update: February 2017 
2. Bohren MA, Hofmeyr G, Sakala C, Fukazawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.:CD003766. DOI: 10.1002/14651858.CD003766.pub6. 
3. WHO recommendations: Intrapartum care for a positive childbirth experience, Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA-3.0 IGO {Internet} (cited Oct 2019).
4. Royal Australia and New Zealand College of Obstetricians and Gynaecology (RANZCOG), Intrapartum Fetal Surveillance: Clinical Guideline – Third Edition 2014 {internet} (cited Oct 2019). 
5. Lawrence A, Lewis L, Homeyr GJ, Styles C. Maternal positions and mobility during first stage of labour. Cochrane Database of Systematic reviews {Internet} 2013 (cited Sep 2019) Issue 10 Art No. CD003934 DOI:10.1002/14651858.CD003934.pub4.
6. American College of Obstetricians and gynaecologists, Society of Maternal Fetal Medicine, Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of primary caesarean delivery, American Journal of Obstetrics and Gynaecology 2014 (reaffirmed 2019): 210(3):179-93.
7. WHO recommendations for prevention and treatment of maternal peripartum infections Geneva: World Health Organisation; 2015 {Internet} (cited Oct 2019) 
8. Women’s Healthcare Australasia. The how to guide: WHA CEC Perineal Protection Bundle, Aug 2019 [Internet} (cited Oct 2019). 
9. Sleep, J Physiology and management of the third stage of labour, in Myles’ Textbook for Midwives, Bennett BR., Brown LK. Editor 1993, Churchill Livingstone: London, UK p.216-29.
10. WHO recommendations for the prevention and treatment of Postpartum Haemorrhage. Geneva: World Health Organization; 2012 {Internet} (cited Oct 2019). 
11. WHO Guidelines on basic newborn resuscitation 2012: Geneva: World Health Organization; 2012 {Internet} (cited Oct 2019).
12. Neoresus. Neonatal Resuscitation: Specific treatment recommendations (ILCOR 2015) The Victorian Newborn Resuscitation project. 
13. Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR), 2013, BMJ; 346 doi: https://doi.org/10.1136/bmj.f1541 
14. Royal College of Obstetricians and Gynaecologists, The Management of third and fourth degree perineal tears Green top guideline No.29 June 2015.
15. National Health and Medicine Research Council,  Infant Feeding Guidelines: Information for health workers. Canberra: National Health and Medical Research Council. 2012. 
16. WHO: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018 Implementation guidance, Geneva: World Health Organization {internet} (cited Oct 2019)