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Intrapartum Care NICEGuidance PDF
Intrapartum Care NICEGuidance PDF
Intrapartum care
Care of healthy women and their babies during childbirth
Developed by the National Collaborating Centre for Womens and Childrens Health
Contents
Introduction ......................................................................................................5
Woman- and baby-centred care.......................................................................6
Key priorities for implementation......................................................................7
1
Guidance ..................................................................................................9
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.11
Meconium-stained liquor..................................................................42
1.12
1.13
1.14
1.15
1.16
Implementation .......................................................................................57
4.1
4.2
4.3
5.2
5.3
Introduction
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.
This guideline covers the care of healthy women in labour at term
(3742 weeks). About 600,000 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. Most women (about two thirds) go into labour spontaneously. The
majority of women giving birth in the UK therefore fall under the scope of this
guideline.
This guideline does not cover the care of women with suspected or confirmed
preterm labour; women with an intrauterine death of their baby; women with
coexisting severe morbidities such as pre-eclampsia or diabetes; women who
have multiple pregnancies; or women with intrauterine growth retardation of
the unborn baby.
This guideline provides an update of The use of electronic fetal monitoring:
The use and interpretation of cardiotocography in intrapartum fetal
surveillance (Inherited clinical guideline C) issued in 2001. Inherited clinical
guideline C will be withdrawn upon publication of this new guideline.
Guidance
The following guidance is based on the best available evidence. The full
guideline (www.nice.org.uk/CG055fullguideline) gives details of the methods
and the evidence used to develop the guidance (see section 5 for details).
1.1
1.1.1
1.1.2
10
11
1.1.3
1.1.4
1.1.5
1.1.6
12
Medical condition
Confirmed cardiac disease
Hypertensive disorders
Respiratory
Haematological
Infective
Immune
Endocrine
Hyperthyroidism
Diabetes
Renal
Neurological
Epilepsy
Myasthenia gravis
Previous cerebrovascular accident
Gastrointestinal
Psychiatric
13
Additional information
Unexplained stillbirth/neonatal death or previous death related to intrapartum
difficulty
Previous baby with neonatal encephalopathy
Pre-eclampsia requiring preterm birth
Placental abruption with adverse outcome
Eclampsia
Uterine rupture
Primary postpartum haemorrhage requiring additional treatment or blood
transfusion
Retained placenta requiring manual removal in theatre
Caesarean section
Shoulder dystocia
Current pregnancy
Multiple birth
Placenta praevia
Pre-eclampsia or pregnancy-induced hypertension
Preterm labour or preterm prelabour rupture of membranes
Placental abruption
Anaemia haemoglobin less than 8.5 g/dl at onset of labour
Confirmed intrauterine death
Induction of labour
Substance misuse
Alcohol dependency requiring assessment or treatment
Onset of gestational diabetes
Malpresentation breech or transverse lie
Body mass index at booking of greater than 35 kg/m2
Recurrent antepartum haemorrhage
Fetal indications
Small for gestational age in this pregnancy (less than fifth centile or reduced
growth velocity on ultrasound)
Abnormal fetal heart rate (FHR)/Doppler studies
Ultrasound diagnosis of oligo-/polyhydramnios
Previous
gynaecological history
Myomectomy
Hysterotomy
14
Medical condition
Cardiovascular
Haematological
Infective
Immune
Endocrine
Skeletal/neurological
Spinal abnormalities
Previous fractured pelvis
Neurological deficits
Gastrointestinal
Additional information
Previous complications
Current pregnancy
Fetal indications
Fetal abnormality
Previous
gynaecological history
15
1.2
1.2.1
1.3
Communication
1.3.1
16
rapport with the labouring woman, asking her about her wants and
expectations for labour, being aware of the importance of tone and
demeanour, and of the actual words they use. This information
should be used to support and guide her through her labour.
1.3.2
17
Mobilisation
1.3.3
Support in labour
1.3.4
1.3.5
1.3.6
1.3.7
1.3.9
1.3.10
1.3.11
Women may eat a light diet in established labour unless they have
received opioids or they develop risk factors that make a general
anaesthetic more likely.
Hygiene measures
1.3.12
18
1.3.13
1.3.14
1.4
Pain-relieving strategies
1.4.2
1.4.3
1.4.4
1.4.5
19
1.4.6
1.4.7
1.4.8
1.4.9
Non-pharmacological analgesia
1.4.10
Inhalational analgesia
1.4.11
1.4.13
1.4.14
20
1.4.15
1.5
1.5.2
21
1.5.5
1.5.6
1.5.7
1.5.8
1.5.9
1.5.10
1.5.11
22
1.5.12
1.5.14
1.5.15
1.5.16
It is recommended that epidural analgesia is established with a lowconcentration local anaesthetic and opioid solution with, for
example, 1015 ml of 0.06250.1% bupivacaine with
12 micrograms per ml fentanyl. The initial dose of local
anaesthetic plus opioid is essentially a test dose and as such
should be administered cautiously to ensure that inadvertent
intrathecal injection has not occurred.
1.5.17
1.5.18
1.5.19
23
1.6
1.6.1
1.6.2
In all stages of labour, women who have left the normal care
pathway due to the development of complications can return to it
if/when the complication is resolved.
24
1.6.7
25
1.6.9
1.6.11
1.6.12
26
1.6.13
1.6.14
1.6.15
1.6.17
1.6.18
27
1.6.20
1.6.21
1.6.22
1.6.23
Changing from intermittent auscultation to continuous EFM in lowrisk women should be advised for the following reasons:
significant meconium-stained liquor, and this change should also
be considered for light meconium-stained liquor (see
recommendations 1.11.1 and 1.11.2)
abnormal FHR detected by intermittent auscultation (less than
110 beats per minute [bpm]; greater than 160 bpm; any
decelerations after a contraction)
maternal pyrexia (defined as 38.0C once or 37.5C on two
occasions 2 hours apart)
fresh bleeding developing in labour
oxytocin use for augmentation
the womans request.
1.6.24
28
1.7
Duration and definition of delay in the second stage (see section 1.14)
1.7.2
Nulliparous women:
Birth would be expected to take place within 3 hours of the start
of the active second stage in most women.
A diagnosis of delay in the active second stage should be made
when it has lasted 2 hours and women should be referred to a
healthcare professional trained to undertake an operative
vaginal birth if birth is not imminent.
1.7.3
Parous women:
Birth would be expected to take place within 2 hours of the start
of the active second stage in most women.
A diagnosis of delay in the active second stage should be made
when it has lasted 1 hour and women should be referred to a
healthcare professional trained to undertake an operative
vaginal birth if birth is not imminent.
29
1.7.4
30
1.7.8
1.7.9
1.7.11
Either the hands on (guarding the perineum and flexing the babys
head) or the hands poised (with hands off the perineum and
babys head but in readiness) technique can be used to facilitate
spontaneous birth.
1.7.12
1.7.13
1.7.14
31
1.7.16
1.7.17
1.7.18
1.7.19
1.7.20
32
Water birth
1.7.21
1.8
33
1.8.5
1.8.6
1.8.7
1.8.8
Pulling the cord or palpating the uterus should only be carried out
after administration of oxytocin as part of active management.
1.8.9
At the time of publication (September 2007), oxytocin did not have UK marketing
authorisation for this indication. Informed consent should be obtained and documented.
34
1.9
1.9.2
1.9.3
1.9.4
1.9.5
Separation of a woman and her baby within the first hour of the
birth for routine postnatal procedures, for example weighing,
measuring and bathing, should be avoided unless these measures
are requested by the woman, or are necessary for the immediate
care of the baby4.
1.9.6
1.9.7
1.9.8
Recommendations relating to immediate postnatal care (within 2 hours of birth) have been
extracted from Routine postnatal care of women and their babies (NICE clinical guideline
37). Please see NICE clinical guideline 37 for further guidance on care after birth.
35
1.9.9
Perineal care
1.9.11
1.9.12
36
1.9.14
1.9.15
1.9.16
1.9.17
1.9.18
37
1.9.19
1.9.20
1.9.21
1.9.22
1.9.23
If the woman reports inadequate pain relief at any point this should
immediately be addressed.
1.9.24
1.9.25
1.9.26
If the skin is opposed following suturing of the muscle in seconddegree trauma, there is no need to suture it.
1.9.27
1.9.28
Perineal repair should be undertaken using a continuous nonlocked suturing technique for the vaginal wall and muscle layer.
1.9.29
38
1.9.30
1.9.31
1.10
1.10.1
1.10.2
39
1.10.4
1.10.5
1.10.6
Care of women who have their labour induced is covered by Induction of labour (Inherited
clinical guideline D).
40
1.10.8
1.10.9
1.10.10
1.10.11
1.10.12
41
1.11
Meconium-stained liquor
1.11.2
1.11.3
1.11.5
1.11.6
The upper airways should only be suctioned if the baby has thick or
tenacious meconium present in the oropharynx.
1.11.7
1.11.8
42
general wellbeing
chest movements and nasal flare
skin colour including perfusion, by testing capillary refill
feeding
muscle tone
temperature
heart rate and respiration.
1.11.9
1.12
This guideline updates and replaces The use of electronic fetal monitoring: The use and
interpretation of cardiotocography in intrapartum fetal surveillance (Inherited clinical guideline
C), issued in 2001.
43
Definition
Normal
Suspicious
An FHR trace with one feature classified as non-reassuring and the remaining features
classified as reassuring
Pathological
An FHR trace with two or more features classified as non-reassuring or one or more
classified as abnormal
44
Accelerations
Reassuring
110160
None
Present
Nonreassuring
100109
161180
< 5 for
4090 minutes
Typical variable
decelerations with over 50%
of contractions, occurring for
over 90 minutes
Single prolonged
deceleration for up to
3 minutes
The absence of
accelerations with
otherwise normal
trace is of uncertain
significance
Abnormal
< 100
> 180
Sinusoidal
pattern
10 minutes
If repeated accelerations are present with reduced variability, the FHR trace should be regarded as
reassuring.
True early uniform decelerations are rare and benign, and therefore they are not significant.
If a bradycardia occurs in the baby for more than 3 minutes, urgent medical aid should be sought
and preparations should be made to urgently expedite the birth of the baby, classified as a category
1 birth. This could include moving the woman to theatre if the fetal heart has not recovered by
9 minutes. If the fetal heart recovers within 9 minutes the decision to deliver should be reconsidered
in conjunction with the woman if reasonable.
A tachycardia in the baby of 160180 bpm, where accelerations are present and no other adverse
features appear, should not be regarded as suspicious. However, an increase in the baseline heart
rate, even within the normal range, with other non-reassuring or abnormal features should increase
concern.
1.12.3
1.12.4
1.12.5
45
1.12.6
1.12.7
1.12.8
1.12.10
1.12.11
At the time of publication (September 2007), terbutaline did not have UK marketing
authorisation for this indication. Informed consent should be obtained and documented.
46
1.12.12
1.12.13
1.12.14
Fetal blood samples should be taken with the woman in the leftlateral position.
1.12.15
Interpretation
7.25
7.217.24
7.20
These results should be interpreted taking into account the previous pH measurement, the rate of
progress in labour and the clinical features of the woman and baby.
1.12.16
1.12.17
1.12.18
1.12.19
47
1.12.20
If the FHR trace remains unchanged and the FBS result is stable
after the second test, a third/further sample may be deferred unless
additional abnormalities develop on the trace.
1.12.21
1.12.22
Clinicians should take into account the time that it will take to
achieve birth by both instrumental vaginal birth and caesarean
section when making decisions regarding concern over fetal
wellbeing during labour.
1.12.24
FHR traces should be kept for 25 years and, where possible, stored
electronically.
1.12.25
1.12.26
1.12.27
1.12.28
48
1.12.29
1.13
1.13.2
49
it will shorten her labour by about an hour and may increase the
strength and pain of her contractions.
1.13.3
1.13.4
1.13.5
1.13.6
1.13.7
All women with delay in the established first stage of labour should
be offered support and effective pain relief.
1.13.8
1.13.9
50
1.13.11
1.13.12
1.13.13
1.14
Parous women:
51
1.14.2
1.14.3
1.14.4
1.14.6
On rare occasions, the womans need for help in the second stage
may be an indication to assist by offering instrumental birth when
supportive care has not helped.
1.14.7
1.14.8
1.14.9
52
1.14.10
1.14.11
1.15
1.15.2
1.15.3
1.15.4
Emergency referral pathways for both the woman and the baby
should be developed and implemented for all birth settings.
1.16
8
9
53
1.16.2
1.16.3
1.16.4
1.16.5
1.16.6
54
low-lying placenta
maternal age (35 years or older).
Risk factors in labour:
induction
prolonged first, second or third stage of labour
oxytocin use
precipitate labour
operative birth or caesarean section.
1.16.8
1.16.9
1.16.11
55
1.16.12
1.16.13
1.16.14
1.16.15
NICE guidelines are developed in accordance with a scope that defines what
the guideline will and will not cover. The scope of this guideline is available
from www.nice.org.uk/page.aspx?o=243361
The guideline is intended to develop guidance for healthy women and their
babies in labour. Therefore the following were excluded from the scope:
Women or their babies in suspected or confirmed preterm labour (before
37 weeks gestation); women with an intrauterine fetal death; women with
coexisting severe morbidities such as pre-eclampsia or diabetes; women
10
At the time of publication (September 2007), misoprostol and rFactor VIIa did not have UK
marketing authorisation for this indication. Informed consent should be obtained and
documented; however, if this is not possible, follow the Department of Health guidelines
Reference guide to consent for examination or treatment (2001) (available from
www.dh.gov.uk). It may be appropriate to get consent in the antenatal period.
56
Implementation
57
Research recommendations
4.1
4.2
Wellbeing of women
58
4.3
5.1
Full guideline
The full guideline, Intrapartum care: care of healthy women and their babies
during childbirth, contains details of the methods and evidence used to
develop the guideline. It is published by the National Collaborating Centre for
Womens and Childrens Health, and is available from www.ncc-wch.org.uk,
NICE clinical guideline 55 intrapartum care
59
5.2
5.3
A version of this guideline for healthy women during childbirth and their carers
(Understanding NICE guidance) is available from
www.nice.org.uk/CG055publicinfo
For printed copies, phone the NHS Response Line on 0870 1555 455 (quote
reference number N1327).
60
61
62
63
64
65