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Intrapartum care overview

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Intrapartum care HAI

About

What is covered

This pathway covers the care of healthy women who go into labour at term (37–42 weeks). About 700,000 women give birth in England and Wales each year, of whom about 40% are having their first baby. Most of these women are healthy and have a straightforward pregnancy. Almost 90% of women will give birth to a single baby after 37 weeks of pregnancy, with the baby presenting head first. About two thirds of women go into labour spontaneously. Therefore most women giving birth in England and Wales are covered by this pathway.
The pathway is intended to cover the care of healthy women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications. In addition, recommendations are included that address the care of women who start labour as 'low risk' but who go on to develop complications. These include the care of women with prelabour rupture of membranes at term, care of the woman and baby when meconium is present, indications for continuous cardiotocography, interpretation of cardiotocography traces, and management of retained placenta and postpartum haemorrhage.

Updates

Updates to this pathway

2 December 2014 Major update on publication of the intrapartum care guideline CG190.

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.

Short Text

Care of healthy women and their babies during childbirth

What is covered

This pathway covers the care of healthy women who go into labour at term (37–42 weeks). About 700,000 women give birth in England and Wales each year, of whom about 40% are having their first baby. Most of these women are healthy and have a straightforward pregnancy. Almost 90% of women will give birth to a single baby after 37 weeks of pregnancy, with the baby presenting head first. About two thirds of women go into labour spontaneously. Therefore most women giving birth in England and Wales are covered by this pathway.
The pathway is intended to cover the care of healthy women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications. In addition, recommendations are included that address the care of women who start labour as 'low risk' but who go on to develop complications. These include the care of women with prelabour rupture of membranes at term, care of the woman and baby when meconium is present, indications for continuous cardiotocography, interpretation of cardiotocography traces, and management of retained placenta and postpartum haemorrhage.

Updates

Updates to this pathway

2 December 2014 Major update on publication of the intrapartum care guideline CG190.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Intrapartum care (2014) NICE guideline CG190
Ultrasound-guided catheterisation of the epidural space (2008) NICE interventional procedure guidance 249

Quality standards

Quality statements

Effective interventions library

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.

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 each of the following topics.

Pathway information

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.

Supporting information

Give ongoing consideration to the woman's emotional and psychological needs, including her desire for pain relief.
Encourage the woman to communicate her need for analgesia at any point during labour.
Do not carry out a routine episiotomy during spontaneous vaginal birth.
Do not offer episiotomy routinely at vaginal birth after previous third- or fourth-degree trauma.
Overall care
  • Do not make any decision about a woman's care in labour on the basis of cardiotocography (CTG) findings alone.
  • Take into account any antenatal and intrapartum risk factors, the current wellbeing of the woman and unborn baby, and the progress of labour when interpreting the CTG trace.
  • Remain with the woman at all times in order to continue providing one-to-one support.
  • Ensure that the focus of care remains on the woman rather than the CTG trace.
  • Make a documented systematic assessment of the condition of the woman and the unborn baby (including CTG findings) hourly, or more frequently if there are concerns.
Principles for intrapartum CTG trace interpretation
  • When reviewing the CTG trace, assess and document all 4 features (baseline fetal heart rate, baseline variability, presence or absence of decelerations, presence of accelerations).
  • It is not possible to categorise or interpret every CTG trace. Senior obstetric input is important in these cases.
Accelerations
  • The presence of fetal heart rate accelerations is generally a sign that the unborn baby is healthy.
  • If a fetal blood sample is indicated and the sample cannot be obtained, but the associated scalp stimulation results in fetal heart rate accelerations, decide whether to continue the labour or expedite the birth in light of the clinical circumstances and in discussion with the woman.
Description
Feature
Baseline (beats/ minute)
Baseline variability (beats/ minute)
Decelerations
Normal/ reassuring
100–160
5 or more
None or early
Non-reassuring
161–180
Less than 5 for 30–90 minutes
Variable decelerations:
  • dropping from baseline by 60 beats/minute or less and taking 60 seconds or less to recover
  • present for over 90 minutes
  • occurring with over 50% of contractions.
OR
Variable decelerations:
  • dropping from baseline by more than 60 beats/minute or taking over 60 seconds to recover
  • present for up to 30 minutes
  • occurring with over 50% of contractions.
OR
Late decelerations:
  • present for up to 30 minutes
  • occurring with over 50% of contractions.
Abnormal
Above 180 or below 100
Less than 5 for over 90 minutes
Non-reassuring variable decelerations (see row above):
  • still observed 30 minutes after starting conservative measures
  • occurring with over 50% of contractions.
OR
Late decelerations:
  • present for over 30 minutes
  • do not improve with conservative measures
  • occurring with over 50% of contractions.
OR
Bradycardia or a single prolonged deceleration lasting 3 minutes or more.
Abbreviation: CTG, cardiotocography.
Category
Definition
Interpretation
Management
CTG is normal/ reassuring
All 3 features are normal/reassuring
Normal CTG, no non-reassuring or abnormal features, healthy fetus
  • Continue CTG and normal care.
  • If CTG was started because of concerns arising from intermittent auscultation, remove CTG after 20 minutes if there are no non-reassuring or abnormal features and no ongoing risk factors.
CTG is non-reassuring and suggests need for conservative measures
1 non-reassuring feature
AND
2 normal/ reassuring features
Combination of features that may be associated with increased risk of fetal acidosis; if accelerations are present, acidosis is unlikely
  • Think about possible underlying causes.
  • If the baseline fetal heart rate is over 160 beats/minute, check the woman's temperature and pulse. If either are raised, offer fluids and paracetamol.
  • Start 1 or more conservative measures:
    • encourage the woman to mobilise or adopt a left-lateral position, and in particular to avoid being supine
    • offer oral or intravenous fluids
    • reduce contraction frequency by stopping oxytocin if being used and/or offering tocolysis.
  • Inform coordinating midwife and obstetrician.
CTG is abnormal and indicates need for conservative measures AND further testing
1 abnormal feature
OR
2 non-reassuring features
Combination of features that is more likely to be associated with fetal acidosis
  • Think about possible underlying causes.
  • If the baseline fetal heart rate is over 180 beats/minute, check the woman's temperature and pulse. If either are raised, offer fluids and paracetamol.
  • Start 1 or more conservative measures (see 'CTG is non-reassuring…' row for details).
  • Inform coordinating midwife and obstetrician.
  • Offer to take a fetal blood sample (for lactate or pH) after implementing conservative measures, or expedite birth if a fetal blood sample cannot be obtained and no accelerations are seen as a result of scalp stimulation.
  • Take action sooner than 30 minutes if late decelerations are accompanied by tachycardia and/or reduced baseline variability.
  • Inform the consultant obstetrician if any fetal blood sample result is abnormal.
  • Discuss with the consultant obstetrician if a fetal blood sample cannot be obtained or a third fetal blood sample is thought to be needed.
CTG is abnormal and indicates need for urgent intervention
Bradycardia or a single prolonged deceleration with baseline below 100 beats/minute, persisting for 3 minutes or more*
An abnormal feature that is very likely to be associated with current fetal acidosis or imminent rapid development of fetal acidosis
  • Start 1 or more conservative measures (see 'CTG is non-reassuring…' row for details).
  • Inform coordinating midwife.
  • Urgently seek obstetric help.
  • Make preparations for urgent birth.
  • Expedite birth if persists for 9 minutes.
  • If heart rate recovers before 9 minutes, reassess decision to expedite birth in discussion with the woman.
Abbreviation: CTG, cardiotocography.
  • A stable baseline value of 90–99 beats/minute with normal baseline variability (having confirmed that this is not the maternal heart rate) may be a normal variation; obtain a senior obstetric opinion if uncertain.
Lactate (mmol/l)
pH
Interpretation
≤ 4.1
≥ 7.25
Normal
4.2–4.8
7.21–7.24
Borderline
≥ 4.9
≤ 7.20
Abnormal
Active management of the third stage involves a package of care comprising the following components:
  • routine use of uterotonic drugs
  • deferred clamping and cutting of the cord
  • controlled cord traction after signs of separation of the placenta.
Physiological management of the third stage involves a package of care that includes the following components:
  • no routine use of uterotonic drugs
  • no clamping of the cord until pulsation has stopped
  • delivery of the placenta by maternal effort.
Explain to the woman that active management :
  • shortens the third stage compared with physiological management
  • is associated with nausea and vomiting in about 100 in 1000 women
  • is associated with an approximate risk of 13 in 1000 of a haemorrhage of more than 1 litre
  • is associated with an approximate risk of 14 in 1000 of a blood transfusion.
Explain to the woman that physiological management:
  • is associated with nausea and vomiting in about 50 in 1000 women
  • is associated with an approximate risk of 29 in 1000 of a haemorrhage of more than 1 litre
  • is associated with an approximate risk of 40 in 1000 of a blood transfusion.

Glossary

Home, freestanding midwifery unit, alongside midwifery unit and obstetric unit.
In accordance with current health and safety legislation (at the time of publication of NICE clinical guideline 139 [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and Social Care Act 2008.
The transfer between midwifery-led care and obstetric-led care. This may or may not involve transport from one location to another. Women who are receiving midwifery-led care in an obstetric unit can have their care transferred to obstetric-led care without being moved.

Paths in this pathway

Pathway created: November 2011 Last updated: December 2014

© NICE 2014

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