MANAGEMENT OF LABOUR

Stages of labour.
1st stage.
It is divided into latent phase, active phase and transition
Latent phase

Cervix dilates from 0 to 3-4cm

Cervical canal shortens from 3cm to .05cm long (cervical effacement)
Latent phase - Lasts 6 12 hours

Active phase of 1st stage

Begins when cervix is 3 4cm dilated

Cervix undergoes more rapid dilatation
There is presence of rhythmic contractions
Ends when cervix is fully dilated
Active phase of first stage lasts 7.7 hours in first time mothers, but can go up to
17.5hours

Transition phase

Cervix is 8cm dilated to full dilatation.

2nd stage

Begins from full cervical dilatation

Ends when baby is born
Transition phase - 5.6 hours in multiparous mothers but can go up to 13.8 hours

3rd stage

Separation and expulsion of placenta and membranes

Involves control of bleeding
Lasts from birth of a baby until placenta and membranes have been expelled.

INITIAL ASSESSMENT AND CARE

The initial assessment will include details of when labour started, whether membranes have
ruptured, frequency and strength of the contractions.
The midwife should remember that the woman will be very conscious of her body and
therefore be unable to pay attention or respond while experiencing a contraction.
Thought should be given to the social circumstances, particularly the care of other children
and whether a birthing partner is available and has been contacted.
PAST HISTORY
Of particular relevance at onset of labour are;

Birth plan
Parity and age
Character and outcome of previous labours
Weights and outcomes of previous babies.
If she has attended any special of clinic
Any known problems social or physical
Blood results including rhesus isoimmunization and hemoglobin

Birth plan
This is a written document by the pregnant woman in discussion with her midwife
showing the kind of birth she would like.

The partner is frequently involved in this

forward planning, which should be a flexible proposal that can be reviewed and revised
during labour. (DOH,1993).
The midwives should explore if the following issues have been included in the birth plan

The womans chosen birth companion

Her choice of clothes in labour
Pain relief methods
Position during labour and birth
Type of third stage management natural /active
Time when the umbilical cord should be cut
Whether to do skin to skin contact after birth and whether to breast feed the baby.

The midwife should offer to explain anything the woman /her partner wishes to know and
document all their requests.
PHYSICAL EXAMINATION OF THE MOTHER
Prior to touching the woman, a sound explanation of the proposed examination and their
significance should be given.
Verbal consent should be obtained and recorded in the notes.
The woman as then asked to empty her bladder and a specimen of urine is tested for proteins
glucose and ketoses.
Her temperature is taken. Pulse rate is counted; blood pressure is also taken and recorded.
The womans hands and feet are examined for signs of Odema.
A detailed abdominal examination should be carried out and recorded. Initial observations
form a basis for further examinations carried out through labour. Abdominal examinations
may be repeated at intervals in order to assess the decent of the fetal head. This is measured
by the number of fifths palpable above the pelvic brim and should be recorded on the
patograph.

Vaginal examination

A virginal examination should always be preceded by an abdominal examination, an

explanation and the obtaining of verbal consent from the woman.
The womans bladder should be empted as the head may be displaced by a full bladder as
well as being very uncomfortable for the woman.

Indications for VE

To certain whether the fore water, have ruptured, or to rapture them artificially.
To exclude cord prolapsed after rapture of fore water, especially if there is an ill-fitting

presenting part or fetal heart rate changes.

Assess progress or delay in labour
Confirm full dilatation of the cervix.
Confirm the axis of the fetus and preventative of the 2 nd twin in multiple pregnancy.
And if necessary in order to rapture the 2nd amniotic sac.

It is not recommended to do a VE if there is frank bleeding in pregnancy.

Method
-

Ensure aseptic technique

Explain the procedure and allow the woman to ask questions.
Ask the woman to lie on her back
Ensure dignity and privacy during examination

Findings
Inspection
-

The midwife should observe the labia for any sign of vericosities, edema or valval warts or

sores.
Should note whether the perineum is scarred from a previous tear or episiotomy,

scurrying from female genital mutilation.

The midwife should note any bleeding from the vaginal orifice if membranes have
ruptured, the color and odour of any amniotic fluid should be noted. Offensive liquor
suggests infection and green fluid indicates the presence of meconium, which may be a
sign of fetal compromise or post maturity.

1ST Stage Management

Labour, the culmination of pregnancy, is an event with great psychological, social and
emotional meaning for the mother and her family.
In addition, many women experience steers and physical pain. The mid wife as well as all
other supporters should display tact and sensitivity, respect the needs of the individual and
provide an environment with in which each woman can labour and give birth with dignity, in
a way that she chooses, having been given all the information necessary to make decisions.

Communication and environment

The midwife should give full and unbiased information about labour and associated
outcomes to the laboring woman so that she is able to make informed decisions. Her choice
should be supported.
The midwife should be able to provide an environment that allows the laboring woman to
ensure various positions in labour.
The labour ward staff should ensure good communication with women, and doctors. Good
communication here includes non verbal communication written birth plans and involving
the whole team in decision making. Good communication ensures smooth labour and good
labour outcomes.
Emotional support
This is done through skillful assessment of a woman, expressing confidence and care as well
as being an advocate for the laboring women.
The midwife should display non judgmental attitude, ensuring the woman is accepted
whatever her reactions to labour may be.
Women who feel in control of their own bodies, who retain control of their behaviors and who
feel they have an active part in decision making have a more satisfactory birth experience.
(Wallence et al 1995)
The woman should be allowed to have a companion of her choice. The midwife should be
able to give direct support to the companion.
Consent and information giving
The laboring woman has the right or refuse as accept treatment. Therefore she should be
empowered with complete information and her autonomy protected.
Midwives must provide support by giving information that ensures the woman understands
events, feels free to question and is aware of how labour is progressing. Permission (verbal)
must be sought before any procedure/examinations are made. Feedbacks should be given
after examination and the woman should be reinforcement in making further decisions about
her care.
Prevention of infections
Hospitals are notorious sources of infections which can be resistant to antibiotic treatment.

The midwife must wash her hands before and after examining the mother and wear gloves
when handling used sanitary pads, blood stained linen or body fluids.

Women with

hepatitis, HIV, gastro enteritis should be given specialized care.

Early identification of prolonged labour should be done because its associated with
infection and hemorrhage.

Invasive procedures should be minimized as an intact skin provides an excellent barrier

to organisms
The fetal membranes should be kept intact unless there is a positive indication for their

rapture that would outweigh the advantage of their protective functions (dements 2001).
Minimize vaginal examinations.

Position and mobility.

Women should be encouraged to adopt upright position during labour.

This significantly

reduces pain and the risk of perineal trauma.

Women should be encouraged to give birth in a position they find most comfortable.

There is evidence that if the mother lies flat on her back then the venacava is compressed
resulting in hypotension. This can lead to reduced placental perfusion and diminished fetal
oxygenation. (Kurtz et al 1982)
Dorsal positions may be convenient for the midwives access and a clear view of the perineum
but the mothers weight on her sacrum directs the coccyx forward reducing the pelvic outlet.
Recommended positions in labour

Squatting, kneeling or standing.

There is an average increase of 1cm in the

transverse diameter & 2cm increase in the anteroposteriror diameter of pelvic outlet

when squatting is adopted. (There is 28% increase in area of outlet).

Lateral position Assistant is required to support the right side.
Up right positions Associated with less discomfort and less backache, fewer
abdominal birth and less perineal tear or vaginal trauma and valval oedema.

Fetal monitoring
Many methods of fetal monitoring are available e.g. electronic fetal monitoring EFM, CTG but
intermittent auscultation with a pinard stethoscope or a hand held droppler device should be
the monitoring of choice.
Nutrition
The vigorous muscle contractions of the uterus during labour demand a continuous supply
of glucose, if this is not obtained from the diet, the body will start to metabolize protein and
fat stores in the effort to provide glucose. (Gluconeogenesis) without which uterine muscle
inertia will occur.
This relatively inefficient method of producing glucose results in occurrence of Ketoacidosis.
It is recommended that low fat foods such as toast, breakfast cereal, yoghurt, fruit juice, tea,
plain biscuits, be given during labour.
Bladder care:
The woman should be encouraged to empty her bladder 1 2 hours during labour. Also a
sound of water can trigger micturition reflex.
If the woman is on IV fluids urine output should be monitored and urine volume measured.
Urine in the bladder is a non compressible mass which may interfere with descent of the
presenting part or reduce the capacity of the uterus to contract, increasing the risk of PPH
The midwife should provide privacy and ensure maximum comfort by placing a bed pan on
the stool or chair or encourage the women to squat on the bed.
Observations
Mother
Reaction to labour.

Women vary in their reactions to labour. Some see contractions as a life giving force.
Others may feel them as pain and resist them.
There may be feelings of apprehension, fear and worry incase the woman does not
conform to the social expectations of her culture.
She may experience anxiety in case child birth is painful and have concerns about her
ability to control pain (Niven 1992).
As labour progresses, she may feel less confident in her ability to cope with the rent less
nature of contractions that control her body.
The midwife should skillfully observe advice and assist her by giving one-on-one care.
A clear and accurate understanding of info-helps the woman gain courage.
Understanding of the methods of pain relief increases the mothers feelings of being in
control of her labour.
Pulse rate
The pulse rate is a good indicator of the general physical condition of a woman.
The midwife should monitor and record pulses rate every 1 2 hours during early labour and
every 30 minutes when labour is more advanced.
A rate more than 100 beats per minute may indicate anxiety, pain, infection, ketosis or
haemorrhage
Temp:
Maternal body temp should be monitored and recorded every 4 hours. Pyrexia may indicate
infection or ketosis or use of epidural analgesia.
Blood Pressure.
BP must be measured 2 4 hours unless its abnormal in which case it may be repeated
frequently depending on the situation.
Pre-eclampsia or essential HT during pregnancy may further alleviate BP.
Urinalysis
Urine passed should be tested for glucose, ketones and proteins.
-

Ketones in urine indicate starvation/maternal distress

Glucose indicates diabetes
Trace of proteins may indicate a contaminant following rapture of membrane, or UTI
Significant proteinuria indicates pre-eclampsia

Fluid balance
A record should be kept of all urine passed to ensure that the bladder is being emptied. If an
intravenous infusion is in progress, the fluids administered must be recorded accurately. It
is particularly important to note how much fluid remains if the bag is changed when only
partially used.
Abdominal examination

The initial abdominal examination is carried out when the midwife first examines the mother.
This should be repeated at intervals throughout labour in order to assess the length,
strength and frequency of contractions and the descent of the presenting part.
Contractions
The frequency, length and strength of contractions should be noted. When the uterine
contraction begins, it is painless for a number of seconds and painless again at the end.
The midwife when feeling for contractions is aware of the beginning before the woman feels it.
This knowledge can be utilized when giving inhalation analgesia or using other copying
mechanisms.
The uterus should always feel softer between contractions. Contractions which are unduly
long or very strong and in quick succession give cause for concern as fetal hypoxia may
develop.
Hyper stimulation should be considered if oxytocin is being infused. It should be stopped if
fetal compromise or hyper stimulation is apparent.
Descent of the presenting part.
During the 1st stage of labour descent should be assessed by abdominal palpation.

It is

usual to describe the level in terms of the fifths of the head which can still be palpated above
the brim.
In the prime parous woman, the fetal head is usually engaged before the labour begins. If
this is not the case, the level of the head must be estimated frequently by abdominal
palpation in order to observe whether the head will pass through the brim with the aid of
good contractions.
When the head is engaged, the occipital protuberance can be felt only with difficulty from
above but the sinciput may be palpable owing to increased flexion of the head, until the
occipital reaches the pelvic floor and rotates forwards.
Vaginal examination and progress in labour.
Vaginal examinations should be minimized as possible. Indications for V.E include;
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Effacement and dilation of the cervix.

Descent, flexion and rotation of fetal head.

All examinations should be recorded.

Effacement and dilatation of the cervix
In normal labour the prime parous cervix effaces before dilating, whereas in the parous
woman these two events often occur simultaneous.

The latent phase of labour usually

defined as up to 3 4 cm dilated. Use of a patograph starts after the latent phase of 1 st

stage of labour.

Descent.
When assessed vaginally, the level of station of the presenting part is estimated in relation to
the Ischia spines, which are flexed points at the outlet of the bony pelvis.
During normal labour the head descents progressively. The midwife must be aware, while
estimating whether the head is lower than previously marked. Moulding or a large carput
will give a false impression of the level of the fetal head.
Flexion
In vertex presentations, progress depends partly on increased flexion. When the head is
driven down on the pelvic floor it encounters resistance; the level principle causes the
anterior part of the need to flex because there is less counter pressure.
The midwife assesses flexion by the position of the sutures and fountanelles. If the head is
fully flexed, the posterior fontanelle becomes almost central. If the head is deflexed both
anterior and posterior fontanelles may be palpable.
Rotation
Rotation is assessed by noting changes in the position of the fetus between one examination
and the next.

The sutures and fontanelles are palpated in order to determine position.

Findings can be compared with findings of earlier abdominal examinations.

THE FETAL MONITORING
Fetal condition during labour can be assessed by obtaining information about the fetal heart
rate and patterns, the PH of fetal blood and amniotic fluid.
Fetal heart
-

Use

-Pinard stethoscope
-Hand held Doppler device
-Electronic fetal monitoring (EFM)

Intermittent monitoring
This term is used when the fetal heart is osculated at intervals using a pinards stethoscope.
The rate of the fetal heart should be counted over a complete minute in order to listen to the
beat-to-beat variation.
Normal rate is 110 160 b/m
Rate more than 160 tachycardia
Rate less than 110 bradycardia
Either may be indicative of fetal compromise due to a number of causes
EFM is indicated if decelerations are heard in the 1 st stage of labour with a pinards
stethoscope or droppler.
Fetal blood sampling (FBS)

Facilities that use electronic fetal monitoring should have 24 hours access to fetal blood
sampling faculties when the fetal heart rate patterns is suspicious or pathological and fetal
acidosis is suspected, then FBs should always be carried out (Vice 2001). Fetal blood sample
result of 7.25 or below should be repeated usually within 30 minutes to an hour. A FBs below
7.20 is indicative of immediate delivery of the baby.
Amniotic fluid
Amniotic fluid escapes from the uterus continuously following rapture of membranes. This
fluid should normally remain clear. If the fetus becomes hypoxic, meconium may be passed
as hypoxia causes relaxation of the anal sphincter. The amniotic fluid becomes green as a
result of meconium staining.
Amniotic fluid that is muddy yellow colour or only slightly green may signify a previous event
from which the fetus has recovered, but is common and of no significance in post dates
babies.
If bleach is presenting and is compacted in the pelvis, the fetus may pass meconium because
of the compression of the abdomen; a fetus presenting by the bleach is also prone to fetal
compromise and may pass meconium as a result of hypoxia.
In rare cases of a fetus that is severely affected by rhesus isoimmunization, the amniotic fluid
may be golden yellow owing to an exess bilirubin.
Bleeding of sudden onset at the time of rapture of membranes may be the result of raptured
vasaprevia and is an acute emergency.
Fetal compromise:
If the fetus suffers as a result of an intrapartum event resulting in 0xygen deprivations then
the following signs may be present.
-

Fetal tachycardia
A pathological (poor) FBS result
Fetal Brady cardiac or severe change in fetal heart rate or decelerations related to uterine

contractions as both.
Passage of meconium stained amniotic fluid.

Management of fetal compromise midwife

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Call appropriately trained obstetrician

If oxytocin is being administered, it should be stopped and the woman placed in a

favorable position usually on the left side.

In case of maternal 0 2 lack, such as eclampsia or shock due to ante partum hemorrhage,

02 may be given via a face mask.

A doctor may take a fetal blood sample of fetal blood for testing and arrangements should

be made for this or delivery will be expected depending on the clinical situation.
If in 1st stage of labour, prepare for caesarean section.
If in 2nd stage of labour forceps delivery or ventouse extraction may be performance.

In all cases of delivery following indications an expedite delivery, the presence of

pediatrician or appropriately trained practitioner in desirable pain management in
labour.

2ND STAGE OF LABOUR MANAGEMENT

Latent Phase Descent and rotation occurs

Active phase Descent with urge to push.
The 2nd stage of labour is confirmed with full cervical dilation on vaginal examination
Progression from the 1st to 2nd stage of labour is not always clinically apparent; several of
the signs are presumptive.

These signs and presumptive differential diagnosis include.

Expulsive uterine contraction.

Although it is the usual sign that the cervix is fully dilated. It is possible for a woman to
feel a strong desire to push before full dilatation occurs.
The midwife needs to work with each individual woman to make sure they dont push
prematurely.

Rapture of the fore waters: This may occur at any time during labour.
Dilatation and gaping of the anus: Deep engagement of the presenting part may produce

this sign during the latter part of first stage.

Anal cleft line: some midwifes have reported observing this line as a pigmented mark in
the cleft of the buttocks that creeps up the anal cleft as the labour progresses. (Hobbs

1998). The efficiency of this observation remains to be tested formally.

Appearance of the rhomboid of Michaelas. This phenomenon is sometimes noted when a
woman is in a position where the back is visible. It presents as a dome shaped curve in
the lower back, and is held to indicate the posterior displacement of the sacram and the

coccyx as the fetal occiput moves to the maternal sacral curve. (Sutton & Scott 1996).
Upper abdominal pressure and epidural analgesia.
It has been observed that women who have an epidural analgesia in situ after having a
sense of discomfort under the ribs as the fetus uncurls.
This tends to coincide with full cervical dilatation. The efficiency of these observations in

predicting the onset of the 2nd stage of labour remains to be researched.

Show: This is the loss of blood stained mucus, which often accompagns rapid dilatation
towards the end of first stage of labour.
It must be distinguished from frame fresh blood loss caused by partial separation of the

placenta or that caused by raptured vasa praevia.

Appearance of the presenting part; Although this is usually definite, it is important to
be aware that excessive moulding may result in formation of a large caput succedaneum,
which can protrude through the cervix prior to full dilatation.
It is important to be aware that very occasionally, the presenting part may be visible at
the perineum at the same time as a section of prolapsed undilated cervix.
This is more common in women of high parity. Similarly a breech presentation may be
visible when the cervix is only 7 8cm dilated.

The appearance of any of these signs may indicate that the stage of labour has been
reached.

Midwifery care
There are a number of dilemmas of practice relating to midwifery care during the 2 nd stage of
labour. The midwife needs to work tactful to overcome them as follows.

1. Care for the mother and caretaker:

As the birth of the baby becomes eminent, the mother and her caretaker may feel excited
and elated but at the same time anxious and frightened by the dramatic change in pace.
The midwifes calm approach and information about what is happening can ensure the
women about what is happening can ensure the women stays in control and confident of
her ability to birth her baby.
This is critical at the time of translation when a woman may feel a lack of control over
events, which can result in a sensation of panic.
Crucially it is at this point that the woman may request analgesia.
In this situation the relationship of trust the midwife has built up during the earlier
stages of labour will help to establish the mothers self confidence and trust. The midwife
may be able to help her overcome this transient phase with good midwifery support and
without utilizing analgesia.
2. Frequent explanation of events should continue as labour progresses.
3. The midwife should praise and congratulate the mother on her hard work, recognizing
that she is probably undertaking the most extreme physical activity she will ever
encounter.
4. The midwife should work hard to ensure that privacy and dignity are key components of
womans birth experience.
5. The midwife needs to support the woman with massage, with appropriate nutrition, and
with suggestions for changes of position and of scenery, tailored to each woman and her
labour.
Techniques such as use of complementary therefore and optimal fetal positioning are
helpful.
6. Leg cramps can be relieved by massaging the calf muscle, extending the leg and dorsiflexing the foot.
7. The midwife should also have regard to the well being of the womans partner and other
companions as possible and recognize that witnessing birth is emotionally taxing.
It is crucial to respect them and the meaning that this birth will have for them both on
that day and in future.

OBSERVATIONS DURING THE 2ND STAGE

-

Uterine contractions continuously assess the strength, length and frequency of

contractions. This is done by observing the maternal response and uterine palpation.
They are usually stronger and longer than during the 1 st stage, lasting up to one minute

with a longer resting phase between.

Decent, Rotation and flexion
The midwife performs a VE to confirm whether or not internal rotation of the head has
taken place, to assess the station of the presenting part, and to determine whether a
caput succedaneum has formed.
If the occiput was rotated interiorly, the head is well flexed, and caput succedaneum is
not excessive, then it is likely that progress will continue.
If there is evidence that either fetal or maternal condition is compromised, an

experienced obstetrician should be consulted.

Fetal condition
If membranes have ruptured, liquor amni is observed to ensure that it is clear.
Thin old meconium is not a sign of fetal compromise.
Thick fresh meconium consult an obstetrician
Maternal condition
The midwife observation includes an appraisal of the mothers ability to cope emotionally
as well as an assessment of her physical well being.
BP Monitored every hour
PulseEvery after 30 minutes.
Ensure maternal comfort
Sponge her body with a cool flannel because she may be hot and stick because of
exertions.
Apply iced water on her lips if dry. Her partner may help with these duties.
Bladder care. Ensure the bladder is emptied. This avoids trauma from compression as
the fetus descends into the pelvis.

Preparation for birth

-

Labour room should be warm and should have sufficient light so that the perineum is

clearly observed.
A clean area should be prepared to receive the baby and water proof covers provided to

protect the bed and floor.

Sterile cord damps, a plastic apron and sterile rubber gloves are placed to hand, others

sterile episiotomy scissors, warm swabbing solution, cotton wool and pads.
Uterotonic agent may be prepared in readiness for active management of third stage if
this is acceptable to woman or for use during an emergency.
The doze should be cross checked by another person, and it must be kept from any

neonatal drugs such as vitamin K to avoid risk of error.

A warm cot and clothes should be prepared for the baby.
Neonatal resuscitation equipment must be thoroughly checked and readily accessible
and should include potable or piped 02 equipment.

Episiotomy scissors
The following basic principles must be applied by every midwife.
Observation of progress
Prevention of infection
Emotional and physical comfort of the mother.
Anticipation of normal events.
Recognition of abnormal developments.

Birth of the head

-

The perineum is swabbed, clean pad applied under the woman to absorb feaces or any

fluids.
A pad is placed over the rectum to reduce risk of perineal trauma.
Midwife observes the progress of the fetus.
Also the midwife places her fingers lightly on the advancing head to prevent rapid

crowning and extension to reduce perineal laceration.

The head is born by extension as the face appears at the perineum.
The midwife checks if the cord is not around the babys neck.
If it is around the neck, two artery forceps are applied approximately 3cm a part and the
cord is cut between the clamps.

Birth of shoulders
-

Restitution and external rotation of the head is allowed to occur naturally.

Hands are placed on each side of the babys head over the ears and the gentle down ward

traction is applied to deliver the anterior shoulder.

Posterior shoulder is also delivered by an upward traction.
The rest of the body is delivered
Time of birth is noted.
The baby is dried and placed in the skin to skin position with the mother.
A warm cover is placed over the exposed areas of the baby to prevent cooling.
The cord is clamped after it has stopped pulsating (2-3) minutes following delivery.

Management of 3rd stage

-

Abdomen is palpated to rule out the 2nd baby.

10 I U of oxytocin is administered.
When the uterus has contracted
Wait until the strong contraction is palpable
Sometimes signs of placental separation may be observed before counter traction is

applied.
Once the uterus is found on palpation to be contracted,
One hand is placed above the level of public symphysis with the palm facing towards the

umblicus exerting pressure in an upward direction.

The other hand firmly grasping the cord, applied traction in a down ward and backward

direction if the line of the birth canal.

Avoid pulling with force.
The placenta is received /cupped in the hands to ease pressure on the friable membrane.
A gentle upward plus downward or twisting action will help to coax out membranes and

increase the chances of delivering them intact.

Placenta is immediately examined for completion.
The midwife checks if the uterus is well contracted and fresh blood was in minimal.
Vagina and perineum are carefully inspected for evidence of trauma /bleeding.
Woman is cleaned and clean pad applied.
Blood loss is then estimated. Normal < 300 mls.

Immediate care
-

Baby and mother remain in midwifes hand for an hour after delivery.
Careful observation of baby and mother is done.
Midwife assesses general condition of the baby
Observe cord for bleeding
Observe the skin color
Respirations
Temperature
Baby dried and wrapped in clean, dry towel so that body temperature is

maintained.
Full examination of baby is done in presence of parents.
Baby is breast fed.

Assessment of mother:-

BP, Temperature, Pulse, Resp.

Encouraged to pass urine
Uterine contraction checked

Records.
Complete and accurate account of labour is done
-

Documentation of drugs
Documentation of observations

Detailed examination of the placenta, membranes, cord with attention drawn to any

abnormalities.
Volume of blood loss is particularly important.
Signature of the midwife, and co-signatory (assistant)
Mother transferred to post natal ward after the observation and documentation has been

completed.
Post natal ward midwife should verify these details prior to transfer of mother and baby.
Midwife leaves details of her contact telephone.
Should parents feel any cause for concern they can contact the midwife.