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Labour Care Guide (LCG) Nepal — Detailed Summary
Background & Context
Nepal's Family Welfare Division (FWD), Department of Health Services (DOHS) has adopted the WHO Labour Care Guide (LCG) as the national standard tool for intrapartum monitoring, formalised through the National Facilitation Guide for Intrapartum Care Program Implementation 2081 (2024/25). This replaces the traditional partograph, which failed to demonstrate significant clinical benefit in trials.
Nepal's maternal mortality burden is concentrated during the intrapartum period — the guide aims to directly address this by standardising monitoring, promoting respectful care, and triggering timely clinical action.
What Is the Labour Care Guide?
The LCG is a single-page, time-based monitoring tool covering the active first stage and second stage of labour. Unlike the partograph, it:
- Integrates fetal, maternal, and supportive care parameters in one document
- Promotes person-centred, respectful care (companion of choice, pain relief, position)
- Includes an explicit "Alert" column — any abnormal observation triggers immediate escalation
- Supports shared decision-making between provider and woman
- If labour extends beyond 12 hours, a new LCG is started
Structure: LCG Nepal Sections
The LCG Nepal is organised into 8 numbered sections:
Section 1 — Patient Identification & Admission Details
- Name, age, parity
- Labour onset (spontaneous or induced)
- Date/time of active labour diagnosis
- Date/time of rupture of membranes
- Risk factors (e.g., history of stillbirth, anaemia)
- Hospital ID
Section 2 — Supportive Care (Recorded Hourly)
| Parameter | Alert Criteria |
|---|---|
| Companion | Y (Yes) / N (No) — alert if absent when desired |
| Pain relief | Y / N — document if provided |
| Oral fluids | Y / N / D (Declined) |
| Posture | SP (Supine), MO (Mobile), LT (Left lateral), etc. |
Nepal adaptation: Support for the woman's choice of position including left lateral, squatting, kneeling, and standing supported by companion is explicitly included.
Section 3 — Fetal Well-being (Recorded Hourly)
| Parameter | Alert Criteria |
|---|---|
| FHR (Fetal Heart Rate) | < 110 or ≥ 160 bpm |
| FHR decelerations | L (Late), V (Variable), N (None) |
| Amniotic fluid | M+++ (Thick meconium), B (Blood) = Alert |
| Fetal position | P (Posterior), T (Transverse) = Alert |
| Caput succedaneum | +++ = Alert |
| Moulding | +++ = Alert |
Nepal adaptation: FHR auscultation by Pinard fetal stethoscope is included as an accepted method. If FHR is < 110 or ≥ 160, early referral from peripheral birthing centres lacking complication management capacity is mandated.
Section 4 — Maternal Well-being (Recorded Every 4 Hours)
| Parameter | Alert Criteria |
|---|---|
| Pulse | < 60 or ≥ 120 bpm |
| Systolic BP | < 80 or ≥ 140 mmHg |
| Diastolic BP | ≥ 90 mmHg |
| Temperature | < 35.0°C or ≥ 37.5°C |
| Urine | P++ (Protein), A++ (Acetonuria) |
Nepal adaptations:
- BP measurement in sitting or left lateral posture is acceptable
- SBP alert thresholds: < 80 or ≥ 140 — escalate to senior provider and follow SBA/SHP protocol
- If IV fluids are given during labour, the volume administered must be documented
Section 5 — Labour Progress (Recorded Every 4 Hours in Active First Stage)
| Parameter | Alert Criteria |
|---|---|
| Contractions per 10 min | ≤ 2 or > 5 |
| Duration of contractions | < 20 sec or > 60 sec |
| Cervical dilatation | Plot 'X'; Alert triggered when lag time for current dilatation is exceeded with no progress |
| Fetal head descent | Monitored alongside cervical dilatation |
The LCG uses a time-based horizontal axis and a vertical reference values axis — deviation from normal triggers alert action. Unlike the partograph's action/alert line system, the LCG uses contextual time-lag alerts.
In the second stage, 'P' is inserted to indicate when pushing begins (cervical dilatation assessment ends).
Section 6 — Medications & IV Fluids
- Documents all medications given during labour (oxytocin, antibiotics, antihypertensives, etc.)
- Records IV fluid type, rate, and total volume (Nepal-specific addition)
- Tracks speed of oxytocin infusion
Section 7 — Decision-Making & Actions
- Records clinical decisions and actions taken in response to alerts
- Documents who was alerted (nurse/midwife/doctor)
- Supports audit trail for quality improvement
Section 8 — Birth Outcome
After delivery, documents:
- Maternal condition post-delivery
- Blood loss
- Placenta delivery and completeness
- Birth outcome (live birth, stillbirth, Apgar-equivalent assessment)
Key Nepal-Specific Adaptations
- Pinard stethoscope accepted for FHR auscultation (resource-appropriate)
- Peripheral referral protocol: FHR < 110 or ≥ 160 triggers early referral from health posts/birthing centres
- BP positioning: Sitting or left lateral posture both acceptable
- IV fluid volume recording made mandatory
- SBA/SHP protocol linkage for emergency BP thresholds
- Safe Birth Checklist integrated alongside LCG in the second training-of-trainers (ToT) round
- Lead organisation: FWD/DOHS, with collaboration from NHTC, NESOG, MIDSON, WHO, UNICEF, NHEICC
Implementation Framework (7 Actions)
| Action | Description |
|---|---|
| 1 | Establish leadership (facility/district level) |
| 2 | Conduct situation analysis |
| 3 | Take ownership and create an implementation roadmap |
| 4 | Ensure essential infrastructure |
| 5 | Build capacity (Training of Trainers → cascade training) |
| 6 | Continuously monitor and evaluate (LCG quality/coverage assessment, audit of severe events, overall impact assessment) |
| 7 | Refine strategies for sustainable scale-up using PDSA cycles |
Objectives of Nepal's LCG Programme
- Guide monitoring and documentation of maternal and fetal well-being and labour progress
- Enable health personnel to provide supportive, respectful care during labour
- Assist prompt identification of emerging complications to trigger rapid action
- Prevent unnecessary medical interventions (episiotomy, augmentation, caesarean)
- Promote shared decision-making between woman and provider
- Support continuous intrapartum quality improvement including audit
Target Audience
- Skilled health personnel (SHPs, SBAs, nurses, midwives, doctors)
- Health facility managers
- Programme managers and policymakers
- Trainers and teaching institutions
- Both public and private sectors
Alert System — How It Works
Any parameter meeting an alert criterion (circled in red on the form) mandates:
- Immediate notification of the nurse/midwife or doctor
- Assessment and action recorded in Section 7
- Escalation/referral if at a facility without complication management capacity
This "monitor-to-action" framework is the core operational principle distinguishing the LCG from passive documentation tools like the partograph.
Key reference: National Facilitation Guide for Intrapartum Care Program Implementation 2081, Family Welfare Division, DOHS, Nepal (2024/25) | WHO LCG User's Manual | WHO LCG Implementation Resource Package (September 2025)
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