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Intrapartum care

About

What is covered

This interactive flowchart 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 interactive flowchart.
The flowchart 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 interactive flowchart

27 February 2017 Intrapartum care (NICE quality standard 105) updated.
20 February 2017 Recommendations on fetal monitoring in initial assessment, fetal monitoring and fetal blood sampling amended in line with the update of NICE guideline CG190 on intrapartum care for healthy women and babies.
15 November 2016 Recommendation on continuity of care in service organisation amended in line with the update of NICE guideline CG190 on intrapartum care for healthy women and babies.
9 December 2015 Intrapartum care (NICE quality standard 105) added.
2 December 2014 Major update on publication of intrapartum care for healthy women and babies (NICE clinical guideline CG190).

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on the care of healthy women and their babies during childbirth in an interactive flowchart

What is covered

This interactive flowchart 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 interactive flowchart.
The flowchart 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 interactive flowchart

27 February 2017 Intrapartum care (NICE quality standard 105) updated.
20 February 2017 Recommendations on fetal monitoring in initial assessment, fetal monitoring and fetal blood sampling amended in line with the update of NICE guideline CG190 on intrapartum care for healthy women and babies.
15 November 2016 Recommendation on continuity of care in service organisation amended in line with the update of NICE guideline CG190 on intrapartum care for healthy women and babies.
9 December 2015 Intrapartum care (NICE quality standard 105) added.
2 December 2014 Major update on publication of intrapartum care for healthy women and babies (NICE clinical guideline CG190).

Sources

NICE guidance and other sources used to create this interactive flowchart.
Intrapartum care for healthy women and babies (2014 updated 2017) NICE guideline CG190
Ultrasound-guided catheterisation of the epidural space (2008) NICE interventional procedures guidance 249
Intrapartum care (2015 updated 2017) NICE quality standard 105
Episcissors-60 for guided mediolateral episiotomy (2015) NICE medtech innovation briefing 33
The Epidrum for aiding access to the epidural space (2015) NICE medtech innovation briefing 23

Quality standards

Intrapartum care

These quality statements are taken from the intrapartum care quality standard. The quality standard defines clinical best practice for intrapartum care and should be read in full.

Quality statements

Choosing birth setting

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women at low risk of complications during labour are given the choice of all 4 birth settings and information about local birth outcomes.

Rationale

Women at low risk of complications during labour and birth need information that is specific to their local or neighbouring area about safety and outcomes for women and babies in the different birth settings. This information will help women to make informed choices about where to have their baby.

Quality measures

Structure
a) Evidence of local arrangements to provide women at low risk of complications with a choice of all 4 birth settings.
Data source: Local data collection.
b) Evidence of local arrangements to provide women at low risk of complications with local information about birth outcomes.
Data source: Local data collection.
Process
a) Proportion of women at low risk of complications with a recorded discussion at their antenatal booking appointment of their preferred choice of birth setting.
Numerator – The number in the denominator with a recorded discussion at their antenatal booking appointment of their preferred choice of birth setting.
Denominator – The number of women at low risk of complications attending an antenatal booking appointment.
Data source: Local data collection.
b) Proportion of women at low risk of complications with a recorded discussion at their antenatal booking appointment about local birth outcomes.
Numerator – The number in the denominator with a recorded discussion at their antenatal booking appointment about local birth outcomes.
Denominator – The number of women at low risk of complications attending an antenatal booking appointment.
Outcome
Maternal experience and satisfaction with place of birth.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (community, primary and secondary care services) raise awareness of maternity pathways and ensure that systems and tools are in place to offer women at low risk of complications a choice of all 4 birth settings and local information about birth outcomes to support them to make informed decisions about where to have their baby.
Healthcare professionals provide women at low risk of complications with local information about birth outcomes and rates of transfer to an obstetric unit for all birth settings, and support them to make informed decisions about where to have their baby. Healthcare professionals can adapt and use NICE's choosing place of birth resource for midwives to do this.
Commissioners (clinical commissioning groups) commission maternity services to ensure that all 4 birth settings are available in the local or a neighbouring area to women at low risk of complications. Commissioners also ensure that services provide local information about outcomes for women and babies and rates of transfer to an obstetric unit for all birth settings to support women to make informed decisions about where to have their baby. Commissioners coordinate collection of outcome data in local and neighbouring areas to help service providers and healthcare professionals giving information to women. Commissioners can refer to the costing statement for the guideline on intrapartum care for healthy women and babies for more information about the likely resource impact of this quality statement, which will depend on local circumstances.

What the quality statement means for women and their companions

Women at low risk of having problems during labour and birth have a choice of 4 places where they can have their baby – at home, in a midwife-led unit that is either next to a hospital obstetric unit or in a different place, or in an obstetric unit (‘labour ward’). To help women make an informed choice, they are given information by their midwife about birth outcomes and rates of transfer to an obstetric unit for their local or neighbouring area. Birth outcomes are things like the chances of needing a ventouse or forceps birth, caesarean section or episiotomy, and the risk of serious medical problems for the baby.

Source guidance

Definitions of terms used in this quality statement

4 birth settings
The 4 settings where a woman at low risk of complications may choose to have her baby are: at home, in a freestanding midwifery unit, in an alongside midwifery unit and in an obstetric unit.
[Intrapartum care for healthy women and babies (NICE guideline CG190) recommendation 1.1.2]
Birth outcomes
Outcomes for women for each planned place of birth include rates of spontaneous vaginal birth, transfer to obstetric unit, obstetric intervention and delivering a baby with or without serious medical problems.
[Adapted from intrapartum care for healthy women and babies (NICE guideline CG190) recommendation 1.1.3]

One-to-one care

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women in established labour have one-to-one care and support from an assigned midwife.

Rationale

One-to-one care will increase the likelihood of the woman having a ‘normal’ vaginal birth without interventions, and will contribute to reducing both the length of labour and the number of operative deliveries. Care will not necessarily be given by the same midwife for the whole labour.

Quality measures

Structure
Evidence of midwifery staff available to provide one-to-one care to women in established labour in each birth setting.
Data source: Local data collection.
Process
Midwifery staffing levels as in the NICE guideline on safe midwifery staffing for maternity settings.
Numerator – The number of women in the denominator who receive one-to-one care from an assigned midwife during established labour.
Denominator – The number of women in established labour in a time period.
Data source: Local data collection.
Outcome
a) Neonatal morbidity.
Data source: Local data collection.
b) Maternal morbidity.
Data source: Local data collection.
c) Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) ensure that recommended midwifery staffing ratios are maintained so that women in established labour have one-to-one care and support from an assigned midwife.
Healthcare professionals (assigned midwives) give one-to-one care to each woman in established labour and are solely dedicated to the care of that woman.
Commissioners (clinical commissioning groups) commission services that have systems in place to maintain recommended midwifery staffing ratios, so that women in established labour have one-to-one care and support from an assigned midwife. Commissioners can refer to the costing statement for the guideline on intrapartum care for healthy women and babies for more information about the likely resource impact of this quality statement, which will depend on local circumstances.

What the quality statement means for women and their companions

A woman in labour is cared for by a midwife who is looking after just her – this is called ‘one-to-one care’. She might not have the same midwife for the whole of labour. One-to-one care aims to ensure that the woman has a good experience of care and reduces the likelihood of problems for her and her baby.

Source guidance

Definitions of terms used in this quality statement

Established labour
Labour is established when:
  • there are regular painful contractions and
  • there is progressive cervical dilatation from 4 cm.
[Intrapartum care for healthy women and babies (NICE guideline CG190) recommendation 1.3.1]

Cardiotocography and the initial assessment of a woman in labour

This statement has been removed. For more details see update information in the intrapartum care quality standard.

Stopping cardiotocography

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

Rationale

Cardiotocography is offered to women if intermittent auscultation indicates possible fetal heart rate abnormalities. However, cardiotocography that is started for this reason should be stopped if the trace is normal for 20 minutes, because it restricts the woman’s movement and can cause labour to slow down. This can lead to a cascade of interventions that may result in adverse birth outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that women at low risk of complications having cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Data source: Local data collection.
Process
Proportion of women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Numerator – The number in the denominator who have the cardiotocograph removed.
Denominator – The number of women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation and who have a normal trace for 20 minutes.
Data source: Local data collection.
Outcome
Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners.

Service providers (for freestanding midwifery units, alongside midwifery units and obstetric units) have evidence of local arrangements to ensure that protocols are in place so that women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Healthcare professionals (midwives and obstetricians) remove the cardiotocograph if the trace is normal for 20 minutes for women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

What the quality statement means for women and their companions

Women who are at low risk of problems during labour, but who have electronic monitoring because of possible concerns about the baby's heartbeat, are taken off the monitor if the baby’s heartbeat is normal for 20 minutes.

Source guidance

Definitions of terms used in this quality statement

Normal cardiotocograph trace
A normal trace has the following normal/reassuring features:
  • baseline fetal heart rate of 100 to 160 beats per minute and
  • baseline variability of 5 beats per minute or more and
  • no or early decelerations.
[Intrapartum care for healthy women and babies (NICE guideline CG190) table 10]

Interventions during labour

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women at low risk of complications are not offered amniotomy or oxytocin if labour is progressing normally.

Rationale

For women at low risk of complications, amniotomy and oxytocin do not reduce the incidence of caesarean section, increase the incidence of spontaneous vaginal births or contribute to improved neonatal outcomes. They are therefore unnecessary for women at low risk of complications if labour is progressing normally.

Quality measures

Structure
Evidence of local arrangements to ensure that women at low risk of complications who are in labour that is progressing normally do not have amniotomy or oxytocin.
Data source: Local data collection.
Process
Proportion of women at low risk of complications whose labour is progressing normally who do not have amniotomy or oxytocin.
Numerator – The number in the denominator who do not have amniotomy or oxytocin.
Denominator – The number of women at low risk of complications whose labour is progressing normally.
Data source: Local data collection.
Outcome
a) The number of women in labour that is progressing normally having amniotomy or oxytocin.
Data source: Local data collection.
b) Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) have protocols in place to ensure that women at low risk of complications whose labour is progressing normally are not offered amniotomy or oxytocin.
Healthcare professionals (midwives and obstetricians) do not offer amniotomy or oxytocin to women at low risk of complications whose labour is progressing normally.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women at low risk of complications whose labour is progressing normally are not offered amniotomy or oxytocin.

What the quality statement means for women and their companions

Women who are at low risk of having problems and whose labour is progressing normally are not offered amniotomy (having their waters broken) or oxytocin (a medicine given through a drip that speeds up labour).

Source guidance

Definitions of terms used in this quality statement

Normal labour and normal progression of labour
The NICE full guideline on intrapartum care for healthy women and babies adopts the World Health Organization definition of a normal labour: ‘labour is normal when it is spontaneous in onset, low risk at the start and remaining so throughout labour and birth. The baby is born spontaneously and in the vertex position between 37–42 completed weeks of pregnancy. After birth woman and baby are in good condition’.

Delayed cord clamping

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women do not have the cord clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.

Rationale

The benefits of delayed cord clamping include higher haemoglobin concentrations, a decreased risk of iron deficiency and greater vascular stability in babies. If they wish, women can ask healthcare professionals to wait longer to clamp the cord.

Quality measures

Structure
Evidence of local arrangements to ensure that midwives and obstetricians do not clamp the cord earlier than 1 minute after the birth unless there is a concern about cord integrity or the baby’s heartbeat.
Data source: Local data collection.
Process
a) Proportion of cords clamped earlier than 1 minute after the birth where there is not a concern about cord integrity or the baby’s heartbeat.
Numerator – The number in the denominator where the cord is clamped after 1 minute after the birth.
Denominator – The number of babies born where there is no concern about cord integrity or the baby’s heartbeat.
b) Proportion of cords clamped earlier than 1 minute where there is a concern about cord integrity or the baby’s heartbeat.
Numerator – The number in the denominator where the cord is clamped earlier than 1 minute after the birth.
Denominator – the number of babies born where there is a concern about cord integrity or the baby’s heartbeat.
Data source: Local data collection.
Outcome
Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) have protocols in place to ensure that the cord is not clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Healthcare professionals (midwives and obstetricians) do not clamp the cord earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that the cord is not clamped earlier than 1 minute after the birth unless there is a concern about cord integrity or the baby’s heartbeat.

What the quality statement means for women and their companions

Women who have just given birth do not have the cord clamped for at least 1 minute after the birth unless there are concerns about the baby. This is to allow more blood to reach the baby and may help to prevent anaemia.

Source guidance

Definitions of terms used in this quality statement

Cord integrity
Concerns would arise over cord integrity if the cord was damaged in any way, if it had snapped during delivery or if there was bleeding to the cord. Definitions of cord integrity are not limited to those stated here.
[Expert opinion]
Concern about the baby’s heartbeat
Concern would arise if, after delivery, the baby has a heartbeat below 60 beats/minute that is not getting faster.
[Adapted from Intrapartum care for healthy women and babies (NICE guideline CG190), recommendation 1.14.14]

Skin-to-skin contact

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women have skin-to-skin contact with their babies after the birth.

Rationale

Skin-to-skin contact with babies soon after birth has been shown to promote the initiation of breastfeeding and protect against the negative effects of mother–baby separation.

Quality measures

Structure
Evidence of local arrangements to ensure that midwives and obstetricians encourage women to have skin-to-skin contact with their babies after the birth.
Data source: Local data collection.
Process
Proportion of women with a record of having skin-to-skin contact with their babies after the birthIt is important that this happens as soon as possible, but timescales should be determined locally, depending on the setting and whether the baby and mother are stable..
Numerator – The number in the denominator where there is a record of the woman having skin-to-skin contact with the baby.
Denominator – The number of babies born.
Data source: Local data collection.
Outcome
Women’s satisfaction with the support received to have skin-to-skin contact with their babies after the birth.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) have protocols in place for midwives and obstetricians to encourage women to have skin-to-skin contact with their babies as soon as possible after the birth.
Healthcare professionals (midwives and obstetricians) encourage women to have skin-to-skin contact with their babies as soon as possible after the birth.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women are encouraged to have skin-to-skin contact with their babies as soon as possible after the birth.

What the quality statement means for women and their companions

Women are encouraged to have skin-to-skin contact with their babies as soon as possible after the birth.

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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.

Description of cardiotocograph trace features

Overall care
  • Make a documented systematic assessment of the condition of the woman and unborn baby (including cardiotocography findings) hourly, or more frequently if there are concerns.
  • Do not make any decision about a woman's care in labour on the basis of cardiotocography findings alone.
  • Take into account the woman's preferences, any antenatal and intrapartum risk factors, the current wellbeing of the woman and unborn baby and the progress of labour.
  • Ensure that the focus of care remains on the woman rather than the cardiotocography trace.
  • Remain with the woman in order to continue providing one-to-one support.
  • Talk to the woman and her birth companion(s) about what is happening and take her preferences into account.
Principles for intrapartum cardiotocography trace interpretation
  • When reviewing the cardiotocography trace, assess and document contractions and all 4 features of fetal heart rate: baseline rate; baseline variability; presence or absence of decelerations (and concerning characteristics of variable decelerations* if present); presence of accelerations.
  • If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low.
  • If it is difficult to categorise or interpret a cardiotocography trace, obtain a review by a senior midwife or a senior obstetrician.
Accelerations
  • The presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy.
Description
Feature
Baseline (beats/ minute)
Baseline variability (beats/ minute)
Decelerations
Reassuring
110 to 160*
5 to 25
None or early
Variable decelerations with no concerning characteristics* for less than 90 minutes
Non-reassuring
100 to 109†
OR
161 to 180
Less than 5 for 30 to 50 minutes
OR
More than 25 for up to 15 to 25 minutes
Variable decelerations with no concerning characteristics* for 90 minutes or more
OR
Variable decelerations with any concerning characteristics* in up to 50% of contractions for 30 minutes or more
OR
Variable decelerations with any concerning characteristics* in over 50% of contractions for less than 30 minutes
OR
Late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium
Abnormal
Below 100
OR
Above 180
Less than 5 for more than 50 minutes
OR
More than 25 for more than 30 minutes
OR
Sinusoidal
Variable decelerations with any concerning characteristics* in over 50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors [see above])
OR
Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors)
OR
Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more
* Regard the following as concerning characteristics of variable decelerations: lasting more than 60 seconds; reduced baseline variability within the deceleration; failure to return to baseline; biphasic (W) shape; no shouldering.
† Although a baseline fetal heart rate between 100 and 109 beats/minute is a non-reassuring feature, continue usual care if there is normal baseline variability and no variable or late decelerations.

Management based on interpretation of cardiotocograph traces

Category
Definition
Management
Normal
All features are reassuring
  • Continue cardiotocography (unless it was started because of concerns arising from intermittent auscultation and there are no ongoing risk factors) and usual care
  • Talk to the woman and her birth companion(s) about what is happening
Suspicious
1 non-reassuring feature
AND
2 normal/reassuring features
  • Correct any underlying causes, such as hypotension or uterine hyperstimulation
  • Perform a full set of maternal observations
  • Start 1 or more conservative measures*
  • Inform an obstetrician or the senior midwife
  • Document a plan for reviewing the whole clinical picture and the cardiotocography findings
  • Talk to the woman and her birth companion(s) about what is happening and take her preferences into account
Pathological
1 abnormal feature
OR
2 non-reassuring features
  • Obtain a review by an obstetrician and a senior midwife
  • Exclude acute events (for example, cord prolapse, suspected placental abruption or suspected uterine rupture)
  • Correct any underlying causes, such as hypotension or uterine hyperstimulation
  • Start 1 or more conservative measures*
  • Talk to the woman and her birth companion(s) about what is happening and take her preferences into account
  • If the cardiotocograph trace is still pathological after implementing conservative measures
    • obtain a further review by an obstetrician and a senior midwife
    • offer digital scalp stimulation and document the outcome
  • If the cardiotocograph trace is still pathological after fetal scalp stimulation:
    • consider fetal blood sampling
    • consider expediting the birth
    • take the woman's preferences into account.
Need for urgent intervention
Acute bradycardia, or a single prolonged deceleration for 3 minutes or more
  • Urgently seek obstetric help
  • If there has been an acute event (for example, cord prolapse, suspected placental abruption or suspected uterine rupture), expedite the birth
  • Correct any underlying causes, such as hypotension or uterine hyperstimulation
  • Start 1 or more conservative measures*
  • Make preparations for an urgent birth
  • Talk to the woman and her birth companion(s) about what is happening and take her preferences into account
  • Expedite the birth if the acute bradycardia persists for 9 minutes
  • If the fetal heart rate recovers at any time up to 9 minutes, reassess any decision to expedite the birth, in discussion with the woman
* If there are any concerns about the baby's wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s): encourage the woman to mobilise or adopt an alternative position (and to avoid being supine); offer intravenous fluids if the woman is hypotensive; reduce contraction frequency by reducing or stopping oxytocin if it is being used and/or offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg).
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
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: June 2017

© NICE 2017

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