intrapartum care

Issue date: September 2007

Intrapartum care

Care of healthy women and their babies duringchildbirth

Quick reference guide

NICE clinical guideline 55Developed by the National Collaborating Centre for Women’s and Children’s Health

Intrapartum care

National Institute for Health and Clinical ExcellenceMidCity Place71 High HolbornLondonWC1V 6NA

www.nice.org.uk

ISBN 1-84629-471-1

© National Institute for Health and ClinicalExcellence, 2007. All rights reserved. This materialmay be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercialpurposes, is allowed without the express writtenpermission of the Institute.

This guidance is written in the following contextNICE clinical guidelines are recommendations about the treatment and care of people with specificdiseases and conditions in the NHS in England and Wales.

This guidance represents the view of the Institute, which was arrived at after careful considerationof the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individualresponsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.

Woman- and baby-centred careWomen and their families should always be treated with kindness, respect and dignity. Goodcommunication is essential, supported by evidence-based information, to allow women to reachinformed decisions about their care. The views, beliefs and values of the woman, her partner and herfamily in relation to her care and that of her baby should be sought and respected at all times.

IntroductionBirth is a life-changing event and the care given to women during labour has the potential to affectthem both physically and emotionally in the short and longer term.

About 600,000 women give birth in England and Wales each year. Most of these women are healthyand have a ‘normal’ labour. The guideline emphasises that birth is not a medical event but a ‘normal’process and as such clinical intervention should not be offered or advised where labour is progressingnormally. The focus is on the care that every woman and baby should receive with clear adviceprovided for any additional care that may be needed. It aims to ensure the standard of care acrossthe NHS is consistent and of high quality.

Quick reference guideNICE clinical guideline 55

Intrapartum care Contents

3

Contents

Introduction 2

Woman- and baby-centred care 2

Key priorities for implementation 4

Communication 6

Normal labour and birth 7

Coping with pain 10

Complications 12

Planning place of birth 21

Clinical governance 24

Registries 25

Implementation tools 26

Further information 27

AbbreviationsBP blood pressure

CS caesarean section

EFM electronic fetal monitoring

FBS fetal blood sampling

FHR fetal heart rate

IM intramuscular

IU international unit

IV intravenous

NSAIDs non-steroidal anti-inflammatory drugs

PROM prelabour rupture of the membranes

NICE clinical guideline 55 Quick reference guide4

Intrapartum care Key priorities for implementation

Key priorities for implementation

Communication ● All women in labour should be treated with respect and should be in control of and involved in

what is happening to them, and the way in which care is given is key to this. To facilitate this,healthcare professionals and other caregivers should establish a rapport with the labouringwoman, asking her about her wants and expectations for labour, being aware of the importanceof tone and demeanour, and of the actual words they use. This information should be used tosupport and guide her through her labour.

Support in labour● A woman in established labour should receive supportive one-to-one care.

● A woman in established labour should not be left on her own except for short periods or at thewoman’s request.

Normal labour● Clinical intervention should not be offered or advised where labour is progressing normally and

the woman and baby are well.

Planning place of birth ● Women should be offered the choice of planning birth at home, in a midwife-led unit or in an

obstetric unit. Women should be informed:– That giving birth is generally very safe for both the woman and her baby. – That the available information on planning place of birth is not of good quality, but suggests

that among women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth, with less intervention. We do not have enough information about the possible risks to either the woman or her baby relating to planned place of birth.

– That the obstetric unit provides direct access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia.

– Of locally available services, the likelihood of being transferred into the obstetric unit and the time this may take.

– That if something does go unexpectedly seriously wrong during labour at home or in a midwife-led unit, the outcome for the woman and baby could be worse than if they were in the obstetric unit with access to specialised care.

– That if she has a pre-existing medical condition or has had a previous complicated birth that makes her at higher risk of developing complications during her next birth, she should be advised to give birth in an obstetric unit (see pages 21–23).

● Clinical governance structures should be implemented in all places of birth (see pages 24–25).


Intrapartum care

5

Key priorities for implementation

Coping with pain● The opportunity to labour in water is recommended for pain relief.

● Before choosing epidural analgesia, women should be informed about the risks and benefits, and the implications for their labour.

Perineal care● If genital trauma is identified following birth, further systematic assessment should be carried out,

including a rectal examination.

Delay in the first stage ● When delay in the established first stage of labour is confirmed in nulliparous women, advice

should be sought from an obstetrician and the use of oxytocin should be considered. The womanshould be informed that the use of oxytocin following spontaneous or artificial rupture of themembranes will bring forward her time of birth but will not influence the mode of birth or other outcomes.

Instrumental birth● Instrumental birth is an operative procedure that should be undertaken with tested effective

anaesthesia.


Intrapartum care Communication

Communication● Greet the woman with a smile and a personal welcome. Establish her language needs, introduce

yourself and explain your role in her care.

● Maintain a calm and confident approach to reassure the woman that all is going well.

● Knock and wait before entering her room.

● Ask how she is feeling.

● If the woman has a written birth plan, read and discuss it with her.

● Assess her knowledge of strategies for coping with pain and provide balanced information to find out which available approaches are acceptable to her.

● Encourage the woman to adapt the environment to meet her individual needs.

● Ask her permission before all procedures and observations.

● Show the woman and her birth partner how to summon help; she may do so as often as she needsto. When leaving the room, let her know when you will return.

● Involve the woman in any handover of care to another professional.


Intrapartum care Normal labour and birth

7

Normal labour and birth

Care throughout labourAsk the woman about her wants and expectations for labour

Don’t intervene if labour is progressing normally

Tell the women that first labour lasts on average 8 hours and secondlabour lasts on average 5 hours

Ensure supportive one-to-one care

Do not leave the woman on her own

Encourage involvement of birth partner(s)

Encourage the woman to mobilise and adopt comfortable positions

Take routine hygiene measures

Do not give H2-receptor antagonists or antacids routinely to low-riskwomen

For coping with pain, see pages 10–11

Initial assessment Listen to the woman. Ask about vaginal loss and contractions

Review clinical records

Check temperature, pulse, BP, urinalysis

Observe contractions, fetal heart rate (FHR)

Palpate abdomen

Offer vaginal exam


Women not in established labourIf initial assessment normal, offerindividualised support and encouragethese women to remain at/return home

For prelabour rupture, see page 14

First stage of labourUse a partogram once labour is established

If a partogram action line is used, this should be a 4-hour action line

Every 15 min after a contraction: check FHR

Every 30 min: document frequency of contractions

Every hour: check pulse

Every 4 hours: check BP, temperature and offer vaginal exam

Regularly: check frequency of bladder emptying

Consider the woman’s emotional and psychological needs


Concerns Indications for electronic fetal monitoring(EFM) in low-risk women, e.g. significantmeconium-stained liquor, abnormal FHR,maternal pyrexia, fresh bleeding; see pages 17–18

� diastolic BP (over 90 mmHg) or � systolic BP (over 140 mmHg) twice, 30 min apart

Uncertainty about the presence of a fetalheartbeat

Suspected delayNulliparous: < 2 cm dilatation in 4 hours

Parous: < 2 cm dilatation in 4 hours orslowing in progress

See page 12

OB

see top of page 8

Vaginal exam Tap water may be used for cleansingprior to exam

Ensure exam is really necessary

Ensure consent, privacy, dignity andcomfort

Explain reason for the exam and what’sinvolved

Explain findings sensitively

Key:

OB seek obstetrician advice (transfer toobstetric unit if appropriate)

HT healthcare professional trained inoperative vaginal birth



see top of page 9

Episiotomy /Carry out episiotomy only when there is: ● clinical need such as instrumental birth ● suspected fetal compromise

Do not offer routinely following previous third- or fourth-degree trauma

Use mediolateral technique (between 45° and 60° toright side, originating at vaginal fourchette)

Use tested effective analgesia

Birth

Key:



OB HT

Second stage of labourEvery 5 min after a contraction: check FHR

Every 30 min: document frequency of contractions

Every hour: check BP, pulse, offer vaginal exam

Every 4 hours: check temperature

Regularly: check frequency of bladder emptying

Assess progress, including fetal position and station

If woman has full dilatation but no urge to push, assess after 1 hour

Discourage the woman from lying supine/semi-supine

Consider the woman’s position, hydration and pain-relief needs. Provide support and encouragement


Concerns Indications for EFM in low-risk women, e.g. meconium-stained liquor,abnormal FHR, maternal pyrexia, freshbleeding, oxytocin for augmentation,see pages 17–18

Nulliparous: consider oxytocin, with offer of regional analgesia, ifcontractions inadequate at onset of second stage

DelayNulliparous: active second stage 2 hours

Parous: active second stage 1 hour

See page 13

OB

Perineal careCarry out systematic assessment of any trauma, including a rectal examination,sensitively. Explain assessment to the woman and confirm analgesia is effective.Document extent and findings

Lithotomy, if required, only to be used for assessment and repair

First-degree trauma: suture skin unless well opposed

Second-degree trauma: suture vaginal wall and muscle for all second-degreetears. Suture skin unless well opposed

Use continuous non-locked technique for suturing vaginal wall and muscle

Use continuous subcuticular technique for suturing skin

Offer rectal NSAIDs following perineal repair


Concerns Refer if uncertain ofnature/extent of trauma

Third- or fourth-degreetrauma



9

Third stage of labourObserve physical health

Check vaginal loss

Active management: oxytocin (10 IU IM), early cord clamping/cutting andcontrolled cord traction; advise that this reduces risk of haemorrhage andshortens third stage

Physiological management: if requested by low-risk woman. No oxytocin/noearly cord clamping; delivery by maternal effort. Do not pull cord or palpateuterus

Concerns Retained placenta

Active management: > 30 min

Physiological management: > 1 hour

See page 16

Care after birthWoman: observe general physical condition, colour, respiration, how she feels;check temperature, pulse, BP, uterine contractions, lochia, bladder voiding.Examine cord, placenta and membranes. Assess maternalemotional/psychological condition

Baby: record Apgar score at 1 and 5 min; keep warm

Encourage skin-to-skin contact between woman and baby as soon as possible

Don’t separate the woman and baby in the first hour

Initiate breastfeeding within the first hour

After 1 hour, record baby’s head circumference, body temperature and weight

Concerns Suspected postpartumhaemorrhage: take emergencyaction, see page 20

Basic resuscitation of newbornbabies should be started withair, see page 19

OB

OB

OB


Intrapartum care Coping with pain

Coping with pain

Supporting women● Consider your attitude to coping with pain in labour and ensure your care supports the woman’s

choice.

● Offer support and encouragement.

● Encourage her to ask for analgesia at any point during labour.

Pain-relieving strategies● Encourage labouring in water to reduce pain.

● Support women’s use of breathing/relaxation techniques, massage, music.

● Acupuncture, acupressure and hypnosis should not be provided, but do not prevent women if theywish to use these.

● Do not offer transcutaneous electrical nerve stimulation (TENS) to women in established labour.

Inhalation analgesia and opioids● Ensure access to Entonox and opioids such as pethidine or diamorphine. Explain that:

– they provide limited pain relief– Entonox may make the woman feel nauseous and light-headed– opioids may cause drowsiness, nausea and vomiting in the woman– opioids may cause short-term respiratory depression and drowsiness for several days in the baby – opioids may interfere with breastfeeding.

● Provide antiemetic if opioids used.

● No birthing pool or bath within 2 hours of opioids or if drowsy.

Before choosing epidural● Inform women that epidural:

– is only available in obstetric units – provides more effective pain relief than opioids– is associated with a longer second stage of labour and an increased chance of vaginal

instrumental birth– is not associated with long-term backache– is not associated with a longer first stage of labour or an increased chance of caesarean birth– is accompanied by a more intensive level of monitoring and IV access– large amounts of epidural opioid may cause short-term respiratory problems in the baby and

make the baby drowsy.See page 11.


Intrapartum care Coping with pain

11

Regional analgesia Regional analgesia is only available in obstetric units, administered by an anaesthetist.

Provide for all women who request regional analgesia(including those in severe pain in latent first stage) after

discussion, see page 10

Secure IV access Preloading/maintenance fluid infusion not

needed routinely

Fully dilated: delay pushing for at least 1 hour, unless baby’s head is visible orwoman has urge to push

Birth should take place within 4 hours

Establishment/after each bolus: measure BPevery 5 min for 15 min; provide continuousEFM for 30 min (see pages 17–18)

After 30 min: call anaesthetist if the womanis still in pain

Every hour: check level of sensory block

No routine use of oxytocin in the secondstage

Encourage and help the woman to adoptany comfortable upright position

Epidural or combined spinal–epidural analgesia isrecommended

Use low-concentration anaesthetic and opioid forestablishing and maintaining epidural

Do not use high concentrations of localanaesthetics routinely

Use combined spinal–epidural analgesia(bupivacaine and fentanyl) for rapid relief

Continue epidural until after completion of thethird stage and any perineal repair


Intrapartum care Complications

Complications

Delay in the first stage

Definition of delay in the first stage

Consider also:• descent and rotation of the fetal head • changes in strength, duration and

frequency of uterine contractions• station and position of presenting part• woman’s emotional state

Parous: < 2 cmdilatation in 4 hours ora slowing in progress

AmniotomyExplain procedure andthat it:● will shorten labour

by about an hour● may make

contractions stronger and more painful

OxytocinExplain that oxytocinwill bring forwardtime of birth but notinfluence mode ofbirth, will increasefrequency andstrength ofcontractions andcontinuous EFM willbe necessary, seepages 17–18

Offer epidural beforestarting oxytocin, seepage 11

Oxytocin increments > every 30 min;increase until 4–5 contractions in 10 min

Nulliparous: consider oxytocin followingspontaneous or artificialrupture of membranes If oxytocin used advisecontinuous EFM, see pages 17–18

Parous: ● abdominal palpation● vaginal exam before making decision about the useof oxytocinIf oxytocin used advise continuousEFM, see pages 17–18

Progress < 1 cm: diagnose delayOffer support and effective pain relief Offer continuous EFM, see pages 17–18

If membranes intact: advise amniotomy.Advise repeat vaginal exam 2 hourslater

Vaginal exam 4 hours after starting oxytocin in established labour

Progress < 2 cm: consider CS1

Progress > 2 cm: vaginal exam 4-hourly

Progress > 1 cm:return to page 7,first stage

Progress > 1 cm: returnto page 7, first stage

Progress < 1 cm

If membranesruptured

Nulliparous: < 2 cmdilatation in 4 hours

Delay suspected: consider amniotomy if membranes intact Whether membranes ruptured or intact, advise vaginal exam 2 hours later

1 See ‘Caesarean section’ (NICE clinical guideline 13).

OB

OB

OB

OB



13

Delay in the second stage

Diagnosis of delay in the second stage

Consider instrumental birth if concern aboutfetal wellbeing or for prolonged second stage

Advise CS if vaginal birth not possible

Birth expected to take place within 3 hours ofstart of active second stage for nulliparouswomen and within 2 hours for parous women

Good progress:return to page 8,second stage

Instrumental birth Choice of instrument depends on balance ofclinical circumstance and practitioner experience

Use tested effective anaesthesia

If declined or if concern about fetalcompromise, use pudendal block with localanaesthetic to perineum

Birth: return topage 9, thirdstage

Nulliparous: delay suspected ifinadequate progress after 1 hour ofactive second stage

Offer vaginal exam; advise amniotomy ifmembranes intact

Offer support and encouragement andconsider analgesia/anaesthesia

Birth within 1 hour:return to page 9,third stage

No birth within nexthour (total active secondstage = 2 hours)

Assessment and ongoing review every 15–30 min by obstetrician Do not start oxytocin

Parous: active secondstage = 1 hour

OB

HTHT

HT

Key:





Prelabour rupture of the membranes (PROM) at term

2 Care of women who have their labour induced is covered by ’Induction of labour’ (NICE inherited clinical guideline D).

Suspected PROM PROM certain history

No speculum examOffer speculum examAvoid digital vaginal examin absence of contractions

Normalprogress: returnto page 7, first

stage

If membranesintact advisewoman to

return home PROM – care of the womanAdvise woman that:● risk of serious neonatal infection is 1% rather than 0.5%● 60% will go into labour within 24 hours● induction of labour is appropriate after 24 hours No antibiotics for woman or baby without signs of infection If evidence of infection, prescribe full course of broad-spectrum antibiotics

PROM – care of the babyIf no signs of infection do not give antibiotics to the baby

For baby with possible sepsis or born to a woman with evidence ofchorioamnionitis: immediately refer to neonatal care

Observe asymptomatic term babies (PROM > 24 hours) for the first 12 hours at 1 hour, 2 hours then 2-hourly for 10 hours:

● general wellbeing● chest movements and nasal flare● skin colour (test capillary refill)● feeding● muscle tone● temperature● heart rate and respiration

No blood, cerebrospinal fluid and/or surface culture tests for asymptomatic baby

Woman to inform immediately of any concerns about the baby in first 5 days

Until induction or if the woman chooses expectant managementbeyond 24 hoursDo not offer lower vaginal swabs and maternal C-reactive protein

Advise the woman to record her temperature every 4 hours duringwaking hours and to report immediately any change in the colour orsmell of her vaginal loss

Inform her that bathing or showering are not associated with an increasein infection, but that having sexual intercourse may be

Assess fetal movement and heart rate at initial contact and then every 24 hours following membrane rupture while the woman is not in labour

Advise the woman to report immediately any decrease in fetal movements

PROM > 24 hoursInduction of labour2

Transfer/access toneonatal care

Stay in hospital at least 12 hours after birth sothe baby can be observed



15

Meconium-stained liquor

Light meconium-stained liquor Significant meconium-stained liquorDark green or black amniotic fluid that is thick or tenacious, or any meconium-stained fluid containing lumps ofmeconium

FBS available in labour and advancedneonatal life support available for birth

Do not suction nasopharynx andoropharynx before birth of the shouldersand trunk

Suction upper airways only ifthick/tenacious meconium in oropharynx

Advise continuous EFM, see pages 17–18Consider continuous EFM based on riskassessment: stage of labour, volume ofliquor, parity, FHR, transfer pathway; see pages 17–18

Baby in good condition1 and 2 hours, observe: ● general wellbeing● chest movements and nasal flare● skin colour (test capillary refill)● feeding● muscle tone● temperature● heart rate and respiration

Review by a neonatologist if baby’scondition causes concern at any time

Baby in good condition1 hour, 2 hours then 2-hourly until 12 hoursold, observe: ● general wellbeing● chest movements and

nasal flare● skin colour (test

capillary refill)● feeding● muscle tone● temperature● heart rate and

respiration

Baby has depressedvital signs Laryngoscopy andsuction under directvision by a healthcareprofessional trained inadvanced neonatal lifesupport

OB

Key:





Retained placenta

Diagnosis of delay in the third stage

> 30 min after birth with activemanagement (see page 9)

Secure IV access

> 1 hour after birth with physiologicalmanagement (see page 9)

Revert to activemanagement: give 10 IU

oxytocin IM and applycontrolled cord traction

Placenta delivered: return topage 9, care after birth

Use analgesia or anaesthesiafor assessment

If woman reports inadequatepain relief, stop assessmentand address this need

Use effective regional orgeneral anaesthesia for manualremoval of the placenta

Placenta delivered:return to page 9,care after birth

Oxytocin not effectivewithin 30 min

Oxytocin effective

OB

Key:



OxytocinInjection of 20 IU in 20 ml of saline into the umbilicalvein, proximal cord clamping

No IV oxytocin infusion



17

Continuous EFM

Continuous EFM

Inform that EFM will restrict woman’smobilityEvery hour take documented systematicassessment based on tables 1 and 2,page 18

Normal trace with oxytocinContinue oxytocin until 4 or 5contractions every 10 min. Reduce if more than 5 in 10 min

If uterine hypercontractility,consider 0.25 mgterbutaline subcutaneously4

Fetal death suspected withrecordable trace

Real-time ultrasoundassessment

Acute compromise(deceleration > 3 min)

Other risk factors present3

Previous CSPre-eclampsiaPregnancy > 42 weeksPROM > 24 hoursInduced labourDiabetesAntepartum haemorrhageOther maternal medical diseaseFetal growth restrictionPrematurityOligohydramniosAbnormal Doppler artery velocimetryMultiple pregnanciesBreech presentation

Maternal factors that maycontribute to an abnormal trace3

Woman’s position: advise her toadopt left-lateral position Woman is hypotensiveWoman has just had a vaginal examWoman has just emptied her bladderor bowelWoman has been vomiting or had avasovagal episodeWoman has just had regionalanalgesia sited or topped up

With oxytocin Suspicious trace: review;continue to increase oxytocin till 4 or5 contractions every 10 minPathological trace: stop oxytocin; fullassessment by obstetrician beforerecommencing

Meconium-stained liquor(see page 15)

FHR less than110 or greaterthan 160 bpm;decelerations

after acontraction

Maternalpyrexia

(38.0°C onceor 37.5°C

twice 2 hoursapart)

Fresh bleedingin labour

Abnormal trace

Pathologicaltrace

FBS, see page 19.If result

abnormal

Woman’s request( not necessary)

Oxytocin foraugmentation

3 These factors (risk factors for women outside the scope of this guideline and maternal factors that may contribute to anabnormal trace) are from ‘Electronic fetal monitoring’ (NICE inherited guideline C) which this guideline updates and replaces.4 At the time of publication (September 2007), terbutaline did not have UK marketing authorisation for this indication. Informedconsent should be obtained and documented.

Key:

low-risk women

Urgent birth

OB

OB

OB

OB



EFM: definitions and classifications

Table 1 Definition of normal, suspicious and pathological FHR traces

Category Definition

Normal All four features are classified as reassuring

Suspicious One feature classified as non-reassuring and the remaining features classified as reassuring

Pathological Two or more features classified as non-reassuring or one or more classified as abnormal

Table 2 Classification of FHR trace features

Feature Baseline Variability Decelerations Accelerations(bpm) (bpm)

Reassuring 110–160 ≥ 5 None Present

Non-reassuring 100–109 < 5 for Typical variable decelerations The absence of161–180 40–90 min with over 50% of contractions, accelerations with

for over 90 min otherwise normalSingle prolonged deceleration trace is of uncertainfor up to 3 min significance

Abnormal < 100 < 5 for 90 min Either atypical variable> 180 decelerations with over 50% ofSinusoidal contractions or late decelerations,pattern both for over 30 min≥ 10 min Single prolonged deceleration for

more than 3 min

Record-keeping ● Check date/time clock on EFM machine.

● Label FHR traces with mother’s name, date and hospital number.

● Sign trace and record date, time and mode of birth.

● Note events, e.g. vaginal exam, FBS, epidural siting on trace.

● Store traces securely.

Risk management ● Consider the time taken for instrumental vaginal birth and CS when making decisions about fetal

wellbeing.

● Keep FHR traces for 25 years; where possible store electronically.

● If the baby may suffer developmental delay, photocopy and store FHR traces indefinitely.

● Use tracer systems if FHR traces stored separately from women’s records.

● Take paired cord blood gases only when concerned about the baby either in labour or immediatelyfollowing birth.

● Ensure an additional clamp for double-clamping is available at all birth settings.



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Neonatal resuscitation ● Start basic resuscitation of newborn babies with air.

● Use oxygen for babies who do not respond.

● Attend a neonatal resuscitation course at least once a year5.

5 Consistent with the algorithm adopted in the ‘Newborn life support course’ developed by the Resuscitation Council (UK),available from www.resus.org.uk/siteindx.htm

Fetal blood sampling (FBS)

FBS

FBS

Woman in left-lateralposition

Normal pH ≥ 7.25

BorderlinepH 7.21–7.24

AbnormalpH ≤ 7.20

Repeat FBSwithin 1 hour if

FHR traceremains

pathological

Repeat FBSwithin 30 min if

FHR traceremains

pathological

Urgent birth

Urgent birth

Third FBSnecessary

Normal pH ≥ 7.25

FHR trace unchanged and FBS resultstable; defer third/further FBS unlessadditional abnormalities develop on

the trace

BorderlinepH 7.21–7.24

AbnormalpH ≤ 7.20

OB

OB

OB

Key:





Postpartum haemorrhage

Risk factors for postpartum haemorrhage

Antenatal risk factors for which women should be advised to givebirth in an obstetric unit:● previous retained placenta or postpartum haemorrhage● maternal haemoglobin level below 8.5 g/dl at onset of labour● increased body mass index● 4 or more previous babies● antepartum haemorrhage● overdistention or abnormalities of the uterus● low-lying placenta● woman 35 years or older

Risk factors in labour:● induction● prolonged first, second or third stage of labour● oxytocin use● precipitate labour● operative birth or CS

Have strategies in place to respond quicklyand appropriately to a postpartumhaemorrhage Highlight risk factors in the notesPlan and discuss care

Uterotonic options:● repeat bolus of oxytocin (IV)● ergometrine (IM/cautiously IV)● IM oxytocin with ergometrine (Syntometrine)● misoprostol6● oxytocin infusion (Syntocinon)● carboprost (IM)

Additional treatment options:● tranexamic acid (IV)● rFactor VIIa on advice from haematologist6

Managing postpartum haemorrhage

6 At the time of publication (September 2007), misoprostol and rFactor VIIa did not have UK marketing authorisation for thisindication. Informed consent should be obtained and documented; however, if this is not possible, follow the Department ofHealth guidelines ‘Reference guide to consent for examination or treatment’ (2001) (available from www.dh.gov.uk). It may beappropriate to get consent in the antenatal period.

Immediate treatment: ● call for help ● uterine massage● IV fluids

OB

Key:




Intrapartum care Planning place of birth

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Planning place of birthFirst, see recommendation on planning place of birth in the key priorities for implementationon page 4.

Tables 3 and 4 show medical conditions or situations in which there is increased risk for the woman orbaby during or shortly after labour, where care in an obstetric unit would be expected to reduce this risk.

The factors listed in tables 5 and 6 are not reasons in themselves for advising birth within an obstetricunit but indicate that further consideration of birth setting may be required.

These risks and the additional care that can be provided in the obstetric unit should be discussed withthe woman so that she can make an informed choice about place of birth.

Table 3 Medical conditions indicating increased risk suggesting planned birth at an obstetric unit

Disease area Medical condition

Cardiovascular Confirmed cardiac diseaseHypertensive disorders

Respiratory Asthma requiring an increase in treatment or hospital treatmentCystic fibrosis

Haematological Haemoglobinopathies – sickle-cell disease, beta-thalassaemia majorHistory of thromboembolic disordersImmune thrombocytopenia purpura or other platelet disorder or platelet count below 100,000Von Willebrand’s diseaseBleeding disorder in the woman or unborn babyAtypical antibodies which carry a risk of haemolytic disease of the newborn

Infective Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommendedHepatitis B/C with abnormal liver function testsCarrier of/infected with HIVToxoplasmosis – women receiving treatmentCurrent active infection of chicken pox/rubella/genital herpes in the woman or babyTuberculosis under treatment

Immune Systemic lupus erythematosusScleroderma

Endocrine HyperthyroidismDiabetes

Renal Abnormal renal functionRenal disease requiring supervision by a renal specialist

Neurological EpilepsyMyasthenia gravisPrevious cerebrovascular accident

Gastrointestinal Liver disease associated with current abnormal liver function tests

Psychiatric Psychiatric disorder requiring current inpatient care



Table 4 Other factors indicating increased risk suggesting planned birth at an obstetric unit

Factor Additional information

Previous Unexplained stillbirth/neonatal death or previous death related to intrapartum difficultycomplications Previous baby with neonatal encephalopathy

Pre-eclampsia requiring preterm birthPlacental abruption with adverse outcomeEclampsiaUterine rupturePrimary postpartum haemorrhage requiring additional treatment or blood transfusionRetained placenta requiring manual removal in theatreCaesarean sectionShoulder dystocia

Current pregnancy Multiple birthPlacenta praeviaPre-eclampsia or pregnancy-induced hypertensionPreterm labour or preterm prelabour rupture of membranesPlacental abruptionAnaemia – haemoglobin less than 8.5 g/dl at onset of labourConfirmed intrauterine deathInduction of labourSubstance misuseAlcohol dependency requiring assessment or treatmentOnset of gestational diabetesMalpresentation – breech or transverse lieBody mass index at booking of greater than 35 kg/m2

Recurrent antepartum haemorrhage

Fetal indications Small for gestational age in this pregnancy (less than fifth centile or reduced growth velocity on ultrasound)Abnormal fetal heart rate (FHR)/Doppler studiesUltrasound diagnosis of oligo-/polyhydramnios

Previous Myomectomygynaecological Hysterotomyhistory



23

Table 5 Medical conditions indicating individual assessment when planning place of birth

Disease area Medical condition

Cardiovascular Cardiac disease without intrapartum implications

Haematological Atypical antibodies not putting the baby at risk of haemolytic diseaseSickle-cell traitThalassaemia traitAnaemia – haemoglobin 8.5–10.5 g/dl at onset of labour

Infective Hepatitis B/C with normal liver function tests

Immune Non-specific connective tissue disorders

Endocrine Unstable hypothyroidism such that a change in treatment is required

Skeletal/ Spinal abnormalitiesneurological Previous fractured pelvis

Neurological deficits

Gastrointestinal Liver disease without current abnormal liver functionCrohn’s diseaseUlcerative colitis

Table 6 Other factors indicating individual assessment when planning place of birth

Factor Additional information

Previous Stillbirth/neonatal death with a known non-recurrent causecomplications Pre-eclampsia developing at term

Placental abruption with good outcomeHistory of previous baby more than 4.5 kgExtensive vaginal, cervical, or third- or fourth-degree perineal traumaPrevious term baby with jaundice requiring exchange transfusion

Current pregnancy Antepartum bleeding of unknown origin (single episode after 24 weeks of gestation)Body mass index at booking of 30–34 kg/m2

Blood pressure of 140 mmHg systolic or 90 mmHg diastolic on two occasionsClinical or ultrasound suspicion of macrosomiaPara 6 or moreRecreational drug useUnder current outpatient psychiatric careAge over 40 at booking

Fetal indications Fetal abnormality

Previous Major gynaecological surgerygynaecological Cone biopsy or large loop excision of the transformation zone (LLETZ)history Fibroids


Intrapartum care Clinical governance

Clinical governanceClinical governance in all settings● Multidisciplinary clinical governance structures, of which the Labour Ward Forum is an example,

should be in place to enable the oversight of all places of birth. These structures should include, as aminimum, midwifery (ideally a supervisor of midwives), obstetric, anaesthetic and neonatal expertise,and adequately supported user representation.

● Rotating staff between obstetric and midwife-led units should be encouraged in order to maintainequivalent competency and experience.

● Clear referral pathways should be in place to enable midwives to inform or seek advice from asupervisor of midwives when caring for a woman who may have risk factors but does not wish tolabour in an obstetric unit.

● If an obstetric opinion is sought by either the midwife or the woman on the appropriate place ofbirth, this should be obtained from a consultant obstetrician.

● All healthcare professionals should document discussions with the woman about her chosen place of birth in the hand-held maternity notes.

● In all places of birth, risk assessment in the antenatal period and when labour commences should besubject to continuous audit.

● Monthly figures of numbers of women booked for, being admitted to, being transferred from and giving birth in each place of birth should be audited. This should include maternal and neonatal outcomes.

● The clinical governance group should be responsible for detailed root-cause analysis of any seriousmaternal or neonatal adverse outcomes (for example, intrapartum-related perinatal death or seizuresin the neonatal period) and consider any ‘near misses’ identified through risk-management systems.The Confidential Enquiry into Maternal and Child Health and the National Patient Safety Agency’s‘Seven steps to patient safety’ provide a framework for meeting clinical governance and risk-management targets.

● Data must be submitted to the national registries for either intrapartum-related perinatal mortality orneonatal encephalopathy once these are in existence.


Intrapartum care Clinical governance

25

Clinical governance for settings other than an obstetric unit● Clear pathways and guidelines on the indications for, and the process of transfer to, an obstetric unit

should be established. There should be no barriers to rapid transfer in an emergency.

● Clear pathways and guidelines should also be developed for the continued care of women once theyhave transferred. These pathways should include arrangements for times when the nearest obstetricor neonatal unit is closed to admissions.

● If the emergency is such that transfer is not possible, open access must be given on-site for anyappropriate staff to deal with whatever emergency has arisen.

● There should be continuous audit of the appropriateness of, the reason for and speed of transfer.Conversely, audit also needs to consider circumstances in which transfer was indicated but did notoccur. Audit should include time taken to see an obstetrician or neonatologist and the time fromadmission to birth.

Registries● The following should be established:

– a national surveillance scheme of all places of birth– national registries of causes of all intrapartum-related deaths over 37 weeks– a definition of neonatal encephalopathy– a national registry of neonatal encephalopathy.


Intrapartum care Implementation tools

Implementation toolsNICE has developed tools to help organisationsimplement this guidance (listed below). These are available on our website(www.nice.org.uk/CG055).

● Slides highlighting key messages for localdiscussion.

● Implementation advice on how to put theguidance into practice and national initiativeswhich support this locally.

● Costing statement.

● Audit criteria to monitor local practice.


Intrapartum care Further information

27

Further informationOrdering informationYou can download the following documents fromwww.nice.org.uk/CG055

● A quick reference guide (this document) – a summary of the recommendations forhealthcare professionals.

● The NICE guideline – all the recommendations.

● ‘Understanding NICE guidance’ – informationfor healthy women during childbirth and their carers.

● The full guideline – all the recommendations,details of how they were developed andsummaries of the evidence they were based on.

For printed copies of the quick reference guide or‘Understanding NICE guidance’, phone the NHSResponse Line on 0870 1555 455 and quote:

● N1326 (quick reference guide)

● N1327 (‘Understanding NICE guidance’).

Related NICE guidanceFor information about NICE guidance that hasbeen issued or is in development, see the website(www.nice.org.uk).

Published● Antenatal care: routine care for the healthy

pregnant woman. NICE clinical guideline 6(2003). Available from:www.nice.org.uk/CG006

● Postnatal care: routine postnatal care ofwomen and their babies. NICE clinical guideline37 (2006). Available from:www.nice.org.uk/CG037

● Antenatal and postnatal mental health: clinicalmanagement and service guidance. NICEclinical guideline 45 (2007). Available from:www.nice.org.uk/CG045

● Caesarean section. NICE clinical guideline 13(2004). Available from:www.nice.org.uk/CG013

● Infection control: prevention of healthcare-associated infection in primary and communitycare. NICE clinical guideline 2 (2003). Available from: www.nice.org.uk/CG002

● Induction of labour. Inherited clinical guideline D (2001). Available from:www.nice.org.uk/guidelineD

This guideline provides an update of ‘The use of electronic fetal monitoring: The use andinterpretation of cardiotocography in intrapartum fetal surveillance’ (Inherited clinical guideline C) issued in 2001.

Under development● Diabetes in pregnancy: management of

diabetes and its complications from pre-conception to the postnatal period. NICEclinical guideline (publication expected March 2008)

● Maternal and child nutrition: Guidance formidwives, health visitors, pharmacists andother primary care services to improve thenutrition of pregnant and breastfeedingmothers and children in low incomehouseholds. NICE public health programme(publication expected March 2008)

Updating the guidelineThis guideline will be updated as needed andinformation about the progress of any update will be posted on the NICE website(www.nice.org.uk/CG055).

About this bookletThis is a quick reference guide that summarises the recommendations NICE has made to the NHS inIntrapartum care (NICE clinical guideline 55).

Who should read this booklet?This quick reference guide is for midwifes, obstetricians and other staff who care for women and their babies during labour. It contains what you need to know to put the guideline’srecommendations into practice.

Who wrote the guideline?The guideline was developed by the National Collaborating Centre for Women’s and Children’s Health,which is based at the Royal College of Obstetricians and Gynaecologists. The Collaborating Centreworked with a group of healthcare professionals (including midwives and obstetricians), service users and technical staff, who reviewed the evidence and drafted the recommendations. Therecommendations were finalised after public consultation.

For more information on how NICE clinical guidelines are developed, go to www.nice.org.uk

Where can I get more information about the guideline?The NICE website has the recommendations in full, reviews of the evidence they are based on, asummary of the guideline for women and their families, and tools to support implementation (see pages 26–27 for more details).

National Institute for

Health and Clinical Excellence

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N1326 1P 100k Sep 07

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intrapartum care

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