---

Labour Care Guide (LCG) in Nepal — A Detailed Guide

Background & Context

• FWD / NHTC (National Health Training Centre)
• NESOG (Nepal Society of Obstetricians and Gynaecologists)
• MIDSON (Midwifery Society of Nepal)
• WHO Nepal, UNICEF Nepal, NHEICC

---

Why the LCG Replaces the Old Partograph

• Utilization and correct completion rates as low as 31% and 3% respectively in developing countries
• Did not account for individual variability in labour progress
• Did not promote woman-centred or shared decision-making
• Lacked quality-of-care monitoring elements

---

Structure of the Nepal LCG — Sections

Section 1 — Identity Information & Admission Details

• Name, age, parity, hospital ID
• Date and time of admission
• Labour onset: Spontaneous vs. induced
• Active labour diagnosis (confirmed at ≥5 cm cervical dilatation + regular contractions)
• Membrane status: Intact / ruptured (with date and time of rupture)
• Risk factors: Pre-existing conditions (chronic hypertension), obstetric conditions (pre-eclampsia, anaemia, previous stillbirth), advanced maternal age, adolescent pregnancy, preterm labour, grand multiparity

---

Section 2 — Supportive Care

---

Section 3 — Fetal Monitoring (Labour Progress: Fetal)

• FHR auscultation by Pinard fetal stethoscope is included (not only electronic monitoring), making it applicable to peripheral health posts
• If FHR <110 or ≥160 bpm → early referral from peripheral birthing centres without complication management teams

---

Section 4 — Labour Progress: Cervical Dilatation & Descent

• Active phase starts at ≥5 cm (updated from the old ≥4 cm threshold)
• No fixed alert or action lines drawn across all women
• If dilatation is <1 cm/hour over 4 hours, clinical review and decision-making are prompted
• Assessment is based on trend over time, not a single measurement

• 5/5 = fully above brim
• 0/5 = fully engaged / at outlet

• 0 = no moulding (normal)
• • = bones touching
• ++ = bones overlapping but reducible (monitor closely; early referral from peripheral centres per Nepal protocol)
• +++ = fixed overlap (obstructed labour — urgent referral)

---

Section 5 — Maternal Monitoring

• BP may be measured in sitting or left lateral posture (adapted for field conditions)
• SBP alert thresholds: <80 (shock) and ≥140 (pre-eclampsia/hypertension) — follow SBA/SHP protocol on breach

---

Section 6 — Medications & IV Fluids

• All medications recorded with dose, route, time
• Oxytocin use is specifically monitored — the LCG aims to reduce unnecessary oxytocin augmentation
• IV fluid: If given during labour, the amount must be documented (Nepal-specific addition)
• Analgesia and other interventions recorded

---

Section 7 — Shared Decision-Making

• Documents discussions between the woman and care provider
• Records woman's preferences, concerns, and consent
• Supports women-centred care and dignity in childbirth
• Interventions must be explained and agreed upon — not done without consent

---

Section 8 — Second Stage of Labour

• Onset of second stage (full dilatation) recorded
• Duration monitored — alerts prompted if second stage is prolonged:
  • Primigravida: active pushing >1 hour without progress → clinical review
  • Multigravida: active pushing >30 minutes without progress → review
• FHR continues to be recorded every 15 minutes in second stage
• Maternal pushing efforts, position, and progress documented

---

Section 9 — Care of the Newborn (Immediate)

• Time of delivery
• APGAR score at 1 and 5 minutes
• Initiation of early breastfeeding (within 1 hour)
• Skin-to-skin contact immediately after birth
• Cord clamping: delayed (1–3 minutes) unless resuscitation needed
• Newborn temperature management

---

Section 10 — Third Stage Management

• Time of placenta delivery
• Active Management of Third Stage of Labour (AMTSL):
  • Oxytocin 10 IU IM (within 1 minute of birth)
  • Uterine massage (gentle) after placenta delivery
  • Controlled cord traction
• Blood loss estimation
• Any complications (PPH, retained placenta)

---

Key Clinical Thresholds — Quick Reference (Nepal LCG)

---

Nepal-Specific Adaptations (Summary)

1. Pinard stethoscope accepted for FHR auscultation (not just electronic CTG)
2. Peripheral centre referral triggered by FHR <110 or ≥160 if no complication management team present
3. BP posture flexibility — sitting or left lateral position accepted
4. SBP alert thresholds aligned with SBA/SHP protocols: <80 and ≥140 mmHg
5. IV fluid volume documentation mandatory when fluids are given
6. Moulding referral protocol — early peripheral referral on moulding ++ (not waiting for +++)
7. Oxytocin documentation to reduce inappropriate augmentation
8. Fiscal year 2081 BS marks official rollout — training via NHTC, SBA/SHP programmes, midwifery schools

---

Implementation Pathway

District/Municipal Level
      ↓
Health Post / PHCC / Primary Hospital (SBA/SHP trained)
      ↓
LCG used from admission → active labour → delivery → third stage → newborn care
      ↓
Alert triggers → Referral to Secondary/Tertiary Centre
      ↓
Documentation → Audit & Quality Improvement

---

Comparison: Old Partograph vs. Nepal LCG

---

Evidence Base

---

Summary

• Admission assessment with risk factor identification
• Fetal monitoring (FHR, liquor, moulding, descent)
• Labour progress (cervical dilatation — individualized, no rigid action lines)
• Maternal vitals (BP with Nepal-specific alert thresholds)
• Supportive care (companion, mobility, oral fluids, pain relief)
• Medications and oxytocin documentation
• Shared decision-making with the woman
• Newborn care and third stage management
• Referral pathways adapted for Nepal's multi-tier health system