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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.
Care throughout labour
Care throughout labour
Care throughout labour
Ask 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 second labour lasts on average 5 hours.
Ensure supportive one-to-one care is provided.
Do not leave the woman on her own.
Encourage the involvement of birth partner(s).
Encourage the woman to mobilise and adopt comfortable positions.
Team midwifery is not recommended.
Communication
See communication.
Hygiene measures
Take routine hygiene measures.
See 'Infection control' (NICE clinical guideline 2) for more information on hygiene measures.
Controlling gastric acidity
Do not give H2-receptor antagonists or antacids routinely to low-risk women.
Consider H2-receptor antagonists or antacids for women who receive opioids or who have or develop risk factors that make a general anaesthetic more likely.
Women may drink during established labour. Isotonic drinks may be more beneficial than water.
Women may eat a light diet in established labour unless they have received opioids or develop risk factors that make a general anaesthetic more likely.
For coping with pain
See coping with pain.
Vaginal exam
Tap water may be used for cleansing prior to exam.
Ensure the exam is really necessary.
Be aware that for many women vaginal examinations can be very distressing.
Ensure the woman's consent, privacy, dignity and comfort.
Explain the reason for the exam and what's involved.
Explain the findings and their impact sensitively.
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-nodeCoping with pain
View the 'Coping with pain during labour and birth' pathInitial assessment
Initial assessment
Initial assessment
Listen to the woman. Ask about vaginal loss and contractions.
Review clinical records.
Check temperature, pulse, blood pressure and urinalysis.
Observe contractions and FHR.
Palpate the woman's abdomen.
Offer vaginal exam (see care throughout labour).
Do not use admission cardiotocography in low-risk pregnancy.
For coping with pain
See coping with pain.
Women not in established labour
If the initial assessment is normal, offer individualised support and encourage women who are not in established first stage of labour to remain at/return home.
For prelabour rupture
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeFirst stage of labour
First stage of labour
First stage of labour
Use 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 (use intermittent auscultation by Doppler ultrasound or Pinard stethoscope).
Every 30 min: document frequency of contractions.
Every hour: check pulse.
Every 4 hours: check blood pressure, temperature and offer vaginal exam (see care throughout labour).
Regularly: check frequency of bladder emptying.
Consider the woman's emotional and psychological needs.
Interventions that should not be used routinely
Do not routinely:
- use verbal assessment with a numerical pain score
- offer active management of labour
- perform amniotomy in normally progressing labour
- use combined early amniotomy with use of oxytocin.
For coping with pain
See coping with pain.
Concerns
Seek obstetrician advice (transfer to obstetric unit if appropriate) for the following concerns.
Indications for EFM in low-risk women, e.g. significant meconium-stained liquor, abnormal FHR, maternal pyrexia, fresh bleeding; see continuous EFM.
Raised diastolic blood pressure (over 90 mmHg) or raised systolic blood pressure (over 140 mmHg) twice, 30 min apart.
Uncertainty about the presence of a fetal heartbeat.
Suspected delay
Nulliparous: < 2 cm dilatation in 4 hours.
Parous: < 2 cm dilatation in 4 hours or slowing in progress.
See delay in the first stage of labour for further information.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSecond stage of labour
Second stage of labour
Second stage of labour
Every 5 min after a contraction: check FHR.
Every 30 min: document frequency of contractions.
Every hour: check blood pressure, pulse and offer vaginal exam (see care throughout labour).
Every 4 hours: check temperature.
Regularly: check frequency of bladder emptying.
Assess progress, including fetal position and station.
If the 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.
Inform the woman that she should be guided by her own urge to push. Assistance such as support, change of position, emptying the bladder and encouragement can be used.
Perineal trauma
Prior discussions
Inform women with a history of severe perineal trauma that their risk of repeat severe perineal trauma is not increased. Discussions about future mode of birth should encompass current symptoms, the degree of trauma, success of the repair, psychological effects, risk of recurrence and management of her labour.
Inform women with infibulated genital mutilation of the risks of difficulty with vaginal examination, catheterisation and application of fetal scalp electrodes. They should also be informed of the risks of delay in the second stage and spontaneous laceration together with the need for an anterior episiotomy and the possible need for defibulation in labour.
Reducing perineal trauma
Either the 'hands on' (guarding the perineum and flexing the baby's head) or the 'hands poised' (with hands off the perineum and baby's head but in readiness) technique can be used in spontaneous birth.
Do not perform perineal massage.
Do not use lidocaine spray.
For coping with pain
See coping with pain.
Concerns
Seek obstetrician advice (transfer to obstetric unit if appropriate) for the following concerns.
Indications for EFM in low-risk women, e.g. meconium-stained liquor, abnormal FHR, maternal pyrexia, fresh bleeding, oxytocin for augmentation, see continuous EFM.
Nulliparous: consider oxytocin, with the offer of regional analgesia, if contractions are inadequate at onset of second stage.
Delay
Nulliparous: if the active second stage of labour has lasted 2 hours.
Parous: if the active second stage of labour has lasted 1 hour.
See delay in the second stage for further information.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeEpisiotomy
Episiotomy
Episiotomy
Seek obstetrician advice / healthcare professional trained in operative vaginal birth.
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° to right side, originating at vaginal fourchette).
Use tested effective analgesia (see coping with pain).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeThird stage of labour
Third stage of labour
Third stage of labour
Observe physical health.
Check vaginal blood loss.
Active management of the third stage is recommended.
Active management includes: oxytocin (10 IU IM), early cord clamping/cutting and controlled cord traction (see information on off-label drug use below).
Advise that active management reduces risk of haemorrhage and shortens third stage.
Physiological management of the third stage should be supported if requested by low-risk women.
Physiological management involves: no oxytocin/no early cord clamping; delivery by maternal effort. Do not pull the cord or palpate the uterus.
Change from physiological management to active management in the case of:
- haemorrhage
- failure to deliver the placenta within 1 hour
- the woman's desire to artificially shorten the third stage.
Do not routinely use umbilical oxytocin infusion or prostaglandin.
Concerns
Seek obstetrician advice (transfer to obstetric unit if appropriate) for the following concerns.
Retained placenta if the third stage of labour is not completed after:
- > 30 min with active management or
- > 1 hour with physiological management.
See retained placenta for further information.
Off-label drug use
At the time this pathway was created (November 2011), oxytocin did not have UK marketing authorisation for this indication (active management of the third stage of labour). Informed consent should be obtained and documented.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeCare after birth
Care after birth
Care after birth
Woman
Observe the woman's general physical condition, colour, respiration and how she feels; check her temperature, pulse, blood pressure, uterine contractions, lochia and bladder voiding.
Examine the cord, placenta and membranes.
Assess maternal emotional/psychological condition.
Baby
Record Apgar score at 1 and 5 min; keep the baby warm.
If the baby is born in poor condition (Apgar score 5 or less at 1 minute), record time to the onset of regular respirations and double-clamp the cord to allow paired cord blood gases to be taken. Record Apgar score until the baby's condition is stable.
After 1 hour, record baby's head circumference, body temperature and weight.
Examine for major physical abnormalities and problems that require referral.
Any examination or treatment should be undertaken with the parents' consent and in their presence or, if this is not possible, with their knowledge.
See the Postnatal care pathway for more information on immediate postnatal care (within 2 hours of birth) of the baby, in particular encouraging skin-to-skin contact, avoiding separation of mother and baby, and initiating breastfeeding.
Concerns
Seek obstetrician advice (transfer to obstetric unit if appropriate) for the following concerns.
Suspected postpartum haemorrhage: take emergency action, see postpartum haemorrhage.
Basic resuscitation of newborn babies should be started with air, see neonatal resuscitation.
Postnatal care
For more information on care of the mother and baby after birth, see the postnatal care pathway.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePerineal care
Perineal care
Perineal care
Assessment
Perform the initial examination gently and with sensitivity. It may be done in the immediate period following birth.
If genital trauma is identified, carry out systematic assessment, which should include:
- visual assessment of the extent of perineal trauma to include the structures involved, the apex of the injury and assessment of bleeding
- a rectal examination to assess whether there has been any damage to the external or internal anal sphincter if there is any suspicion that the perineal muscles are damaged.
Explain the assessment to the woman; offer inhalational analgesia and confirm analgesia is effective; ensure good lighting and position the woman so that she is comfortable and the genital structures can be seen clearly.
The timing of this systematic assessment should not interfere with mother–infant bonding unless the woman has bleeding that requires urgent attention.
Document extent and findings.
Repair
When performing perineal repairs:
- Use aseptic techniques.
- Check equipment and count swabs and needles before and after the procedure.
- Ensure good lighting to see and identify the structures involved.
- Difficult trauma should be repaired by an experienced practitioner in theatre under regional or general anaesthesia. An indwelling catheter should be inserted for 24 hours to prevent urinary retention.
- Good anatomical alignment of the wound should be achieved, and consideration given to the cosmetic results.
- Carry out rectal examination after completing the repair to ensure that suture material has not been accidentally inserted through the rectal mucosa.
- Following completion of the repair, document an accurate detailed account covering the extent of the trauma, the method of repair and the materials used.
- Give the woman information on the extent of the trauma, pain relief, diet, hygiene and the importance of pelvic-floor exercises.
Undertake repair of the perineum as soon as possible to minimise the risk of infection and blood loss.
Use tested effective analgesia using infiltration with up to 20 ml of 1% lidocaine or equivalent, or topping up the epidural (spinal anaesthesia may be necessary). Immediately address inadequate pain relief.
Lithotomy, if required, is 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-degree tears. 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.
For coping with pain
See coping with pain.
Concerns
Seek obstetrician advice (transfer to obstetric unit if appropriate) for the following concerns.
Refer if uncertain of nature/extent of trauma.
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-nodeComplications
View the 'Intrapartum complications' pathPostnatal care pathway
View the 'postnatal care overview' pathPaths 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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