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Intrapartum care
Short Text
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)
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 topic.
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 someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their 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.
Updates to this pathway
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.
Woman in the first stage of labour
Woman in the first stage of labour
Definition of delay in the first stage
Definition of delay in the first stage
Definition of delay in the first stage
A diagnosis of delay in the established first stage of labour needs to take into consideration all aspects of progress in labour and should include:
- nulliparous: < 2 cm dilatation in 4 hours.
- parous: < 2 cm dilatation in 4 hours or a slowing in progress.
- descent and rotation of the fetal head
- changes in the strength, duration and frequency of uterine contractions.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSuspected delay
Suspected delay
Suspected delay
If delay in the established first stage of labour is suspected, consider:
- parity
- cervical dilatation and rate of change
- uterine contractions
- station and position of presenting part
- the woman's emotional state
- referral to the appropriate healthcare professional.
Offer support, hydration, and appropriate and effective pain relief.
Amniotomy
Consider amniotomy if membranes intact.
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.
Vaginal examination
Whether membranes ruptured or intact, advise vaginal exam 2 hours later.
If progress > 1 cm, see the first stage in normal labour and birth.
If progress < 1 cm, see diagnosis of delay.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDiagnosis of delay
Diagnosis of delay
Diagnosis of delay
Diagnose delay if progress < 1 cm on vaginal exam 2 hours after delay is suspected.
Seek obstetrician advice (transfer to obstetric unit if appropriate).
Offer support and effective pain relief.
Offer continuous EFM.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeMembranes intact
Membranes intact
Membranes intact
Amniotomy
If membranes intact: advise amniotomy.
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.
Vaginal exam
Advise repeat vaginal exam 2 hours later.
If progress > 1 cm, see the first stage in normal labour and birth.
If progress < 1 cm see considering and using oxytocin.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeConsidering and using oxytocin
Considering and using oxytocin
Considering and using oxytocin
Nulliparous woman
Seek advice from an obstetrician.
Consider oxytocin following spontaneous or artificial rupture of membranes.
If oxytocin used advise continuous EFM.
Parous woman
Women should be seen by an obstetrician who should make a full assessment, including:
- abdominal palpation
- vaginal exam
before making decision about the use of oxytocin.
If oxytocin used advise continuous EFM.
Using oxytocin
Explain that oxytocin will bring forward time of birth but not influence mode of birth, will increase frequency and strength of contractions and continuous EFM will be necessary.
Offer epidural before starting oxytocin, see regional analgesia during labour and birth.
Oxytocin increments > every 30 min; increase until 4–5 contractions in 10 min.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAssessing progress
Assessing progress
Assessing progress
Vaginal examination 4 hours after starting oxytocin in established labour.
Progress > 2 cm or more: vaginal exam 4-hourly.
Progress < 2 cm: further obstetric review to consider caesarean section. For more information see the caesarean section pathway .
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
- Normal labour and birth
- Coping with pain during labour and birth
- Regional analgesia during labour and birth
- Intrapartum complications
- Monitoring babies during complicated labour
- Continuous electronic fetal monitoring
- Fetal blood sampling
- Prelabour rupture of the membranes at term
- Meconium-stained liquor
- Delay in the first stage of labour
- Delay in the second stage of labour
- Retained placenta
- Postpartum haemorrhage
Pathway created: November 2011 Last updated: February 2013
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