Intrapartum care

Short Text

Care of healthy women and their babies during childbirth

Introduction

This pathway covers the care of healthy women in labour at term (37–42 weeks).
Birth is a life-changing event and the care given to women during labour has the potential to affect them 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 healthy and have a 'normal' labour. The pathway 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 progressing normally. The focus is on the care that every woman and baby should receive with clear advice provided for any additional care that may be needed. It aims to ensure the standard of care across the NHS is consistent and of high quality.
NICE is updating the clinical guideline on intrapartum care.

Source guidance

The NICE guidance that was used to create the pathway.
Intrapartum care. NICE clinical guideline 55 (2007)
Ultrasound-guided catheterisation of the epidural space. NICE interventional procedure guidance 249 (2008)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on the following topics.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

6 November 2013 Minor maintenance updates
21 September 2013 Minor maintenance updates
8 February 2013 Minor maintenance updates

Supporting information

Explain procedure and that it:
  • will shorten labour by about an hour
  • may make contractions stronger and more painful.
Do not start continuous EFM for amniotomy alone.

Glossary

A package of care including one-to-one continuous support, strict definition of established labour, early routine amniotomy, routine 2-hourly vaginal examination, oxytocin if labour becomes slow.
A package of care which includes all of these three components:
  • routine use of uterotonic drugs
  • early clamping and cutting of the cord
  • controlled cord traction.
Onset of the active second stage:
  • the baby is visible
  • expulsive contractions with a finding of full dilatation of the cervix or other signs of full dilatation of the cervix
  • active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
Caesarean section.
Electronic fetal monitoring.
Regular painful contractions and progressive cervical dilatation from 4 cm.
Fetal blood sampling.
Fetal heart rate.
Injury to skin only.
Injury to the perineum involving the anal sphincter complex (external and internal anal sphincter) and anal epithelium.
Intramuscular.
International unit.
Intravenous.
A period of time, not necessarily continuous, when:
  • there are painful contractions, and
  • there is some cervical change, including cervical effacement and dilatation up to 4 cm.
Non-steroidal anti-inflammatory drugs.
The finding of full dilatation of the cervix prior to or in the absence of involuntary expulsive contractions.
A package of care which includes all of these three components:
  • no routine use of uterotonic drugs
  • no clamping of the cord until pulsation has ceased
  • delivery of the placenta by maternal effort.
Prelabour rupture of the membranes.
Injury to the perineal muscles but not the anal sphincter.
A group of midwives providing care and taking shared responsibility for a group of women from the antenatal, through intrapartum to the postnatal period.
Injury to the perineum involving the anal sphincter complex:
  • 3a – less than 50% of external anal sphincter thickness torn
  • 3b – more than 50% of external anal sphincter thickness torn
  • 3c – internal anal sphincter torn.
The time from the birth of the baby to the expulsion of the placenta and membranes.

Communication

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 (see coping with pain in this pathway).
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 needs to. When leaving the room, let her know when you will return.
Involve the woman in any handover of care to another professional.
NICE has written information for the public explaining the guidance on intrapartum care.

Implementation tools

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Source guidance

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Clinical governance and registries

Clinical governance and registries

Clinical governance and registries

Clinical 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 a minimum, 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 maintain equivalent competency and experience.
Clear referral pathways should be in place to enable midwives to inform or seek advice from a supervisor of midwives when caring for a woman who may have risk factors but does not wish to labour in an obstetric unit.
If an obstetric opinion is sought by either the midwife or the woman on the appropriate place of birth, 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 (see the antenatal care pathway for more information on planning a place of birth).
In all places of birth, risk assessment in the antenatal period and when labour commences should be subject 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 serious maternal or neonatal adverse outcomes (for example, intrapartum-related perinatal death or seizures in 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 or neonatal encephalopathy once these are in existence (see Registries below).

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 they have transferred. These pathways should include arrangements for times when the nearest obstetric or neonatal unit is closed to admissions.
If the emergency is such that transfer is not possible, open access must be given on-site for any appropriate 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 not occur. Audit should include time taken to see an obstetrician or neonatologist and the time from admission 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.

Implementation tools

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Source guidance

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Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: November 2011 Last updated: November 2013

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