Observations and Checks in Labour

The schedule

NICE's intrapartum guideline sets out what should be recorded during the established first stage of labour, and it is a short and specific list:

• half-hourly documentation of the frequency of contractions;
• hourly pulse;
• four-hourly temperature, blood pressure and respiratory rate;
• a four-hourly vaginal examination offered, or sooner in response to your wishes or if there is concern about progress.

Bladder care is reviewed at least every four hours as well, covering how often you are passing urine and whether you can feel your bladder. Your baby's heart rate is listened to on its own schedule, set by NICE's separate guideline on fetal monitoring in labour.

Alongside all of that, NICE asks for "an hourly risk assessment of the woman and her baby". That is the quiet one — a structured hourly look at whether anything has changed, rather than a single measurement.

Why a pulse and a blood pressure matter in labour

They are the cheapest early warning available. A rising pulse can be the first sign of blood loss, infection, dehydration or pain that is not being managed. A rising blood pressure can be the first sign of pre-eclampsia developing in labour. A temperature can be the first sign of infection in you or your baby. None of these announce themselves.

NICE's own list of what should prompt a move to obstetric-led care is built almost entirely out of these observations, which is why they are taken seriously even in a low-risk labour in a birth centre.

The thresholds that change your care

NICE publishes the actual numbers, which is unusual and useful. On the hourly risk assessment, transfer to obstetric-led care is recommended if any of the following are observed:

• a pulse over 120 beats a minute on two occasions 15 to 30 minutes apart;
• a single reading of diastolic blood pressure of 110 mmHg or more, or systolic of 160 mmHg or more;
• diastolic of 90 mmHg or more, or systolic of 140 mmHg or more, on two consecutive readings taken 15 to 30 minutes apart;
• a reading of 2+ protein on urinalysis together with a single raised blood pressure reading;
• a respiratory rate below 9 or above 21 breaths a minute on two occasions 15 to 30 minutes apart;
• a temperature of 38°C or above on a single reading, or 37.5°C or above on two consecutive occasions an hour apart;
• fresh red bleeding or blood-stained fluid;
• the new appearance of meconium;
• pain that differs from the pain normally associated with contractions;
• confirmed delay in the first stage of labour;
• a request by the woman for regional analgesia;
• an obstetric emergency.

NICE adds a caution that is easy to skip: "multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect". Two borderline findings together can matter more than either alone.

The list closes with a sentence that keeps the decision with you: "If none of these are observed, continue with midwifery-led care unless the woman requests transfer."

The chart it all goes on

NICE: "Use a pictorial record of labour (partogram) once labour is established." A partogram is a single sheet or screen where the observations are plotted against time, so that a pattern is visible at a glance rather than buried in prose.

The World Health Organization has published a successor tool, the Labour Care Guide, described as "a tool that aims to support good-quality, evidence-based, respectful care during labour and childbirth, irrespective of the setting or level of health care", with a user's manual for the staff using it. UK units generally use a partogram or an electronic equivalent; the principle is identical.

You are entitled to look at your own chart and to have it explained. It is your record.

Your baby's heartbeat

This is a separate decision with its own guideline. NICE asks that auscultation of the fetal heart rate be offered at first contact with a woman in suspected or established labour, and at each further assessment. Whether that continues as intermittent listening or becomes continuous electronic monitoring depends on a risk assessment set out in NICE's fetal monitoring guideline.

The HSE describes the equipment plainly for Irish units: a handheld doppler, which is waterproof and can be used in a pool; a Pinard stethoscope, "shaped like a small trumpet"; or a CTG machine.

Fluids in and fluids out

A more recent addition to NICE's guideline covers fluid balance. Teams are asked to monitor and record it if you are receiving intravenous fluids or an oxytocin infusion, if there are concerns about how much you are drinking, or if there are concerns about output such as being unable to pass urine, or vomiting.

NICE also names a specific threshold: if there is a positive fluid balance of 1.5 litres or more, or clinical concern, the team should explain that you may be developing hyponatraemia, request an obstetric review and offer a blood test to check your sodium level.

If you have an existing medical condition

NICE has a separate guideline for intrapartum care where a woman has an existing medical condition or an obstetric complication, and it adds condition-specific observations on top of the standard set — more frequent blood pressure recording, blood glucose monitoring, or additional anaesthetic review, depending on the condition. If you have been told your observations will be more frequent than the standard schedule, that guideline is usually the reason.

What you can ask, and what you can decline

Observations are offers like everything else, and NICE asks that they be explained before they happen and consented to. In practice most women accept them because they are quick and non-invasive; but you can ask for them to be timed between contractions, ask what a reading was and what it means, and ask why a particular observation is being done more often than the schedule.

The single most useful question when something is being repeated is: what would make you act on this? The answer is usually one of the numbers above, and knowing it turns a worrying repeat measurement into a process you can follow.