Give the woman the following information, including local statistics, about all local birth settings: If further discussion is wanted by either the midwife or the woman about the choice of planned place of birth, arrange this with a consultant midwife or supervisor of midwives, and/or a consultant obstetrician if there are obstetric issues. If the woman appears to be in established labour, offer a vaginal examination. [new 2014], Palpate the maternal pulse to differentiate between maternal heart rate and fetal heart rate. Register for free. The priority research recommendations were selected in a similar way. These structures should include, as a minimum, midwifery (including a supervisor of midwives), obstetric, anaesthetic and neonatal expertise, and adequately supported user representation. Assess progress, which should include the woman's behaviour, the effectiveness of pushing and the baby's wellbeing, taking into account the baby's position and station at the onset of the second stage. [2007], After diagnosis of full dilatation in a woman with regional analgesia, agree a plan with the woman in order to ensure that birth will have occurred within 4 hours regardless of parity. Controlled cord traction after signs of separation of the placenta. To facilitate this, establish a rapport with the woman, ask her about her wants and expectations for labour, and be aware of the importance of tone and demeanour, and of the actual words used. Ergometrine (intramuscular, or cautiously intravenously), Combined oxytocin and ergometrine (intramuscular). 2Anonymous (1994) World Health Organization partograph in management of labour. The management of hypertensive disorders during pregnancy (NICE clinical guideline 107)]). [new 2014], If the baseline fetal heart rate is between 100 and 109 beats/minute or above 160 beats/minute and there is 1 other non-reassuring feature on the cardiotocograph, start conservative measures (see 'Conservative Measures') to improve fetal wellbeing. Established first stage of labour – when: There is progressive cervical dilatation from 4 cm. [2007], In normally progressing labour, do not perform amniotomy routinely. Define intrapartum. Where possible, dichotomous outcomes were presented as relative risks or odds ratios (ORs) with 95% confidence intervals (CIs), and continuous outcomes were presented as mean differences with 95% CIs or standard deviations (SDs). Perform these observations at 1 and 2 hours of age and then 2-hourly until 12 hours of age. See all programmes; Acknowledgements Introduction About Bettercare Why decentralised learning? [2007], The choice of instrument depends on a balance of clinical circumstance and practitioner experience. [new 2014], If a woman at low risk of postpartum haemorrhage requests physiological management of the third stage, support her in her choice. Intrapartum care for women with existing medical conditions Intrapartum care for women with obstetric complications Looked-after babies, children and young people People’s experience in adult social care services Pregnancy and complex social factors: service provision [2007]. [2007], If an intravenous or intramuscular opioid is used, also administer an antiemetic. In weighing up the risks and benefits of a comprehensive risk assessment at first contact, the group recognised that there are some potential harms, i.e., the small risk of infection from performing a vaginal examination, and the potential risk of making the woman anxious if the documentation takes too long. Recognise that a woman may experience painful contractions without cervical change, and although she is described as not being in labour, she may well think of herself as being 'in labour' by her own definition, Offer her individualised support, and analgesia if needed. Use this information to support and guide her through her labour. Ask how the woman is feeling and whether there is anything in particular she is worried about. The likelihood of being cared for in labour by a familiar midwife, The likelihood of receiving one-to-one care throughout labour (not necessarily being cared for by the same midwife for the whole of labour), Access to medical staff (obstetric, anaesthetic and neonatal), Access to pain relief, including birthing pools, Entonox, other drugs and regional analgesia. Intrapartum Care and Recommended Interventions to Prevent Perinatal HIV Transmission for Women with HIV, Based on Maternal HIV RNA Levels at the Time of Delivery All women with HIV should be receiving antiretroviral therapy (ART) or initiate ART in pregnancy as early as possible to suppress HIV RNA to undetectable levels (<50 copies/mL). We provide highly specialized care and monitoring to pregnant women with a variety of medical conditions. Take this into account when reviewing the whole clinical picture (see 'Overall Care'). [new 2014], Use the fetal heart rate response after fetal scalp stimulation during a vaginal examination to elicit information about fetal wellbeing if fetal blood sampling is unsuccessful or contraindicated. However, it was also associated with significantly higher adverse outcomes (nausea, vomiting and dizziness). The GDG considered maternal side effects and noted that rates of nausea, vomiting and hypertension were all higher in women allocated to receive active management. Intrapartum care (NICE clinical guideline 190) This guideline offers evidence-based advice on the care of women and their babies during labour and immediately after the birth. Disadvantages of cardiotocography (CTG) use include the increased likelihood that women may be left alone, mobility may be reduced, and women may be more frightened as they hear changes in the fetal heart rate. The criteria used in moving from evidence to recommendations were as follows: In areas where no substantial clinical research evidence was identified, the GDG considered other evidence-based guidelines and consensus statements or used their collective experience to identify good practice. *By signing up I agree to the privacy terms listed here. Women's satisfaction with maternity service is often associated with the quality of intrapartum care, as the nature of the support given during labour and childbirth is reflective of a positive birth experience. Ensure that her wishes are respected and her informed consent is obtained. A NICE pathway titled and "Intrapartum Care Overview" is available from the National Institute for Health and Care Excellence (NICE) Web site. The initial dose of local anaesthetic plus opioid is essentially a test dose, so administer cautiously to ensure that inadvertent intrathecal injection has not occurred. Recommendation Wording in Guideline Updates. [new 2014]. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. [new 2014], If there are no signs of infection in the woman, do not give antibiotics to either the woman or the baby, even if the membranes have been ruptured for over 24 hours. [2007], The Woman's Position and Pushing in the Second Stage, Discourage the woman from lying supine or semi-supine in the second stage of labour and encourage her to adopt any other position that she finds most comfortable. [2007], If a woman chooses to use massage techniques in labour that have been taught to birth companions, support her in this choice. If the woman has a written birth plan, read and discuss it with her. Electronic copies: Available from the, Intrapartum care: care of healthy women and their babies during childbirth. Fresh vaginal bleeding that develops in labour. There is a small chance that it will not be possible to obtain a blood sample (especially if the cervix is less than 4 cm dilated). [2007]. [2007], Establish epidural analgesia with a low-concentration local anaesthetic and opioid solution with, for example, 10–15 ml of 0.0625%–0.1% bupivacaine with 1–2 micrograms per ml fentanyl. Follow recommendations under 'Retained Placenta' on managing a retained placenta. (See 'Measuring Fetal Heartbeat.') Study efficiently. [new 2014], Give ongoing consideration to the woman's emotional and psychological needs, including her desire for pain relief. introitus - a mouth-like opening. Second degree – injury to the perineal muscles but not the anal sphincter. Follow the general principles for transfer of care described in 'General Principles for Transfer of Care.' Ask the woman how she is, and about her wishes, expectations and any concerns she has, Ask the woman about the baby's movements, including any changes, Give information about what the woman can expect in the latent first stage of labour and how to work with any pain she experiences, Give information about what to expect when she accesses care, Agree a plan of care with the woman, including guidance about who she should contact next and when. Show the woman and her birth companion(s) how to summon help and reassure her that she may do so whenever and as often as she needs to. Advise women with risk factors for postpartum haemorrhage to give birth in an obstetric unit, where more emergency treatment options are available. Transfer of care refers to the transfer between midwifery-led care and obstetric-led care. The health economics justification in areas of the guideline where the use of National Health Service (NHS) resources (interventions) was considered was based on GDG consensus in relation to the likely cost effectiveness implications of the recommendations. World Health Organization Maternal Health and Safe Motherhood Programme. Clear local pathways for the continued care of women who are transferred from one setting to another, including: If the nearest obstetric or neonatal unit is closed to admissions or the local midwifery-led unit is full. When referring to pharmacological treatments, the guideline will normally make recommendations within the licensed indications. The absence of accelerations in an otherwise normal cardiotocograph trace does not indicate acidosis. Unlimited Access to Thousands of Summaries, Personalized Content Recommendations and Alerts, Access Saved Content on All Mobile Devices. [new 2014], Use the classification of fetal blood sample results shown in Table 12 in the original guideline document. Changes in the strength, duration and frequency of uterine contractions. Intrapartum Care. Offer vaginal examination and then offer amniotomy if the membranes are intact. Electronic copies: Available from the, Intrapartum care: care of healthy women and their babies during childbirth. However, these misjudgements are made less likely if the assessment is carried out systematically following clear guidelines with thresholds for transfer. Record the following observations for a woman in the third stage of labour: If there is postpartum haemorrhage, a retained placenta or maternal collapse, or any other concerns about the woman's wellbeing: Active and Physiological Management of the Third Stage, Explain to the woman antenatally about what to expect with each package of care for managing the third stage of labour and the benefits and risks associated with each. Advise low-risk multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit. Interpretation of cardiotocograph traces table. London (UK): National Institute for Health and Care Excellence; 2014 Dec. 363 p. (Clinical guideline; no. This NGC summary was completed by ECRI Institute on May 28, 2010. [new 2014], When performing an initial assessment of a woman in labour, listen to her story and take into account her preferences and her emotional and psychological needs. If any of the following are observed after any degree of meconium, ask a neonatologist to assess the baby (transfer both the woman and baby if they are at home or in a freestanding midwifery unit, following the general principles for transfer of care described in 'General Principles for Transfer of Care'): Explain the findings to the woman, and inform her about what to look out for and who to talk to if she has any concerns. [2007]. A third fetal blood sample is thought to be needed. Delivery refers to the actual birth. Look it up now! [new 2014]. Any estimate of effect is very uncertain. Intrapartum care (NICE clinical guideline 190) This guideline offers evidence-based advice on the care of women and their babies during labour and immediately after the birth. The GDG prioritised a number of review questions where it was thought that economic considerations would be particularly important in formulating recommendations. If a sample cannot be obtained, a caesarean section or instrumental birth (forceps or ventouse) may be needed because otherwise it is not possible to find out how well the baby is coping. For studies evaluating the accuracy of a diagnostic test, sensitivity, specificity and likelihood ratios for positive and negative test results (LR+ and LR–, respectively), were calculated or quoted where possible (see Table 4 in the full version of the guideline). [2007, amended 2014]. [2007]. Intrapartum Care and Recommended Interventions to Prevent Perinatal HIV Transmission for Women with HIV, Based on Maternal HIV RNA Levels at the Time of Delivery All women with HIV should be receiving antiretroviral therapy (ART) or initiate ART in pregnancy as early as possible to suppress HIV RNA to undetectable levels (<50 copies/mL). ... Intrapartum Pain Management. [new 2014], As part of ongoing assessment, document the presence or absence of significant meconium. [2007], If it is uncertain whether prelabour rupture of the membranes has occurred, offer the woman a speculum examination to determine whether the membranes have ruptured. Planning birth at home is associated with an overall small increase (about 4 more per 1000 births) in the risk of a baby having a serious medical problem compared with planning birth in other settings. Clinical audit tool - initial assessment. For issues of prognosis, the highest possible level of evidence is a controlled observational study (a cohort study or case–control study), and a body of evidence based on such studies would have an initial quality rating of low, which might be downgraded to very low or upgraded to moderate or high, depending on the factors listed above. [new 2014], If there has been non-significant meconium, observe the baby at 1 and 2 hours of age in all birth settings. National Collaborating Centre for Women's and Children's Health. Fetal assessment and monitoring during labour: Electrocardiogram (ECG) analysis with continuous electronic fetal monitoring (EFM) compared with continuous EFM alone, Management of the third stage of labour: management of retained placenta, Medical management of postpartum haemorrhage, Intrapartum care provided in different birth settings, Interventions during the latent (early) phase of labour, Pain-relieving strategies that can be used at home without support from a health care professional, Appropriate staffing configuration of midwives on labour ward to support one-to-one continuous care during labour, Intrapartum care: care of healthy women and their babies during childbirth. [2014], If the fetal blood sample result is borderline, offer repeat sampling no more than 30 minutes later if this is still indicated by the cardiotocograph trace, or sooner if additional non-reassuring or abnormal features are seen. [2007], If a woman chooses to use breathing and relaxation techniques in labour, support her in this choice. intrapartum period: in obstetrics, the period from the onset of labor to the end of the third stage of labor. During establishment of regional analgesia or after further boluses (10 ml or more of low-dose solutions), measure blood pressure every 5 minutes for 15 minutes. The section on intrapartum care is particularly noteworthy for the general practitioner because it contains detailed instructions concerning the delivery of women in their own homes. In the presence of any degree of meconium: If there has been significant meconium (see 'Presence of Meconium') and the baby does not have normal respiration, heart rate and tone, follow nationally accredited guidelines on neonatal resuscitation, including early laryngoscopy and suction under direct vision. This does not apply to any recommendations ending [2007] (see 'Update information' above for details about how recommendations are labelled). [new 2014], When a Fetal Blood Sample Cannot Be Obtained, 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 consultant obstetrician and the woman. Define perineal or genital trauma caused by either tearing or episiotomy as follows: Perform the initial examination gently and with sensitivity. This guideline covers the care of healthy women in labour at term (37–42 weeks of gestation). [2007], Do not offer lidocaine spray to reduce pain in the second stage of labour. Do not use maternal facial oxygen therapy for intrauterine fetal resuscitation, because it may harm the baby (but it can be used where it is administered for maternal indications such as hypoxia or as part of preoxygenation before a potential anaesthetic).