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The NICE guidelines recommend that all women receive antenatal education about labour, including information on what to expect during the first stage of labour, how to manage pain, and how to contact their midwifery care team in an emergency. Women should also be offered education on the signs of labour, including how to differentiate between Braxton Hicks contractions and active labour contractions, and the expected frequency and duration of contractions. Additionally, women should discuss their preferences and choices for care during labour and birth as early as possible in their pregnancy, and record these choices. Commissioners and providers should ensure that all four birth settings are available to all women, and that there are robust protocols in place for transfer of care between settings. Finally, low-risk women should be advised that giving birth is generally very safe for both the woman and her baby.
Low-risk nulliparous women should be advised that planning to give birth in a midwifery-led unit (freestanding or alongside) is associated with a lower rate of interventions and no difference in outcome for the baby compared to an obstetric unit. However, if they plan to give birth at home, there is a small increase in the risk of adverse outcomes for the baby. Healthcare professionals should be familiar with serious medical problems that can affect babies and discuss local statistics and information about all local birth settings with women, including access to midwives, medical staff, birthing pools, and pain relief. Women with a higher BMI at booking have a greater likelihood of complications, including unplanned caesarean birth, postpartum haemorrhage, transfer from home to an obstetric unit, stillbirth, neonatal death, or the baby needing neonatal care. Advanced care can generally be given more quickly in an obstetric unit or an alongside midwifery unit than at home or in a freestanding midwifery unit in the event of complications arising.
The Birthplace in England research study found that planning birth at home or in a freestanding midwifery unit is associated with a higher rate of spontaneous vaginal birth than planning birth in an alongside midwifery unit, and these 3 settings are associated with higher rates of spontaneous vaginal birth than planning birth in an obstetric unit. Planning birth in an obstetric unit is associated with a higher rate of interventions, such as vaginal birth with forceps or ventouse, unplanned caesarean birth and episiotomy, compared with planning birth in other settings. However, there are no differences in outcomes for the baby associated with planning birth in any setting. Planning birth at home is associated with an overall small increase in the risk of a baby having a serious medical problem (about 4 more per 1,000 births) compared with planning birth in other settings.
The study found that neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, accounting for 75% of the total, while stillbirths after the start of care in labour and death of the baby in the first week of life accounted for 13% of the events. Fractured humerus and clavicle were uncommon outcomes, less than 4% of adverse events. Tables 6 and 7 show medical conditions or other situations in which there is an increased risk for the woman or baby during or shortly after labour, where care in an obstetric unit would be expected to reduce this risk. The factors listed in tables 8 and 9 are not reasons in themselves for advising birth within an obstetric unit, but indicate that further consideration of birth setting may be needed.
When planning the place of birth, factors such as previous complications, current pregnancy, and maternal health should be taken into account. If further discussion is needed, an appropriately trained senior or consultant midwife and/or obstetrician should be involved. During labour, all staff should ensure that the woman is in control, listened to, and cared for with compassion. One-to-one care should be provided, and communication should be clear and tailored to the woman’s needs and preferences. All women in labour should be treated with kindness, dignity, and respect.
Effective communication and support are crucial in providing care to women during labour. Healthcare professionals should establish a rapport with the woman, ask about her preferences and expectations, and respect her decisions regarding care. Encouraging the woman to move and adopt comfortable positions, having support from a birth companion, and following appropriate hygiene measures are also important. In the event of a transfer of care, decisions should be based on clinical findings and discussed with the woman and her birth companion(s), and transfers should be carried out as soon as possible with appropriate communication between healthcare professionals.
When transferring a woman in labour, it is important to ensure she is comfortable and covered appropriately, and that communication and companionship are maintained. Healthcare professionals should consider their own attitudes towards pain relief and support the woman’s choice. Breathing exercises, showering, and massage may reduce pain during the latent first stage of labour, but aromatherapy, yoga, and acupressure should not be offered. TENS devices are not provided by the NHS, but can be used if the woman chooses. Acupuncture, acupressure, and hypnosis should not be offered, but if the woman wants to use them, her choice should be supported. Women should be offered the opportunity to labour in water for pain relief, but the temperature should be monitored and kept below 37.5°C. Sterile water injections can be considered for back pain relief during labour.
The guidelines recommend various options for pain relief during labor, including inhalational analgesia, pharmacological analgesia, and regional analgesia. Entonox, a 50:50 mixture of oxygen and nitrous oxide, is recommended for pain relief, but may cause nausea and light-headedness. Opioids such as pethidine and diamorphine are also available, but may have significant side effects for both the mother and baby. Remifentanil patient-controlled analgesia (PCA) is an option for ongoing pain relief, but should only be used in obstetric units due to the risk of respiratory depression. If a woman requests regional analgesia, the benefits and risks should be discussed, and intravenous access should be secured before starting.
For women with regional analgesia, encourage them to adopt comfortable positions throughout labour except lying flat on their back. Women with an epidural can mobilize with assistance if they have sufficient leg strength and sensation, but their legs may feel heavier than usual. Regional analgesia should be continued until after completion of the third stage of labour and any necessary perineal repair. Pushing may be delayed for up to 2 hours for nulliparous women after confirmation of full cervical dilatation, unless the woman has an urge to push or the baby’s head is visible. Continuous cardiotocography should be performed for at least 30 minutes during establishment of regional analgesia and after administration of each further bolus of 10 ml or more. Use either epidural or combined spinal-epidural analgesia for establishing regional analgesia in labour, and if rapid analgesia is needed, use combined spinal-epidural analgesia. Use low-concentration local anaesthetic and opioid solutions for maintaining epidural analgesia in labour, and do not use high concentrations of local anaesthetic solutions routinely. For women with suspected rupture of membranes after 37+0 weeks, advise them to contact their midwife or maternity unit for an initial triage assessment over the phone with a midwife.
For women presenting with prelabour rupture of the membranes at term, it is recommended to offer a speculum examination if it is uncertain whether the membranes have ruptured, but to avoid digital vaginal examination in the absence of contractions. Intrapartum antibiotics are recommended in some situations, and women should be advised that the risk of serious neonatal infection is 1%, rather than 0.5% for women with intact membranes, and may increase over time. Women should be offered a choice of expectant management for up to 24 hours or induction of labour as soon as possible, and if expectant management is chosen, induction of labour should be offered if labour has not started naturally after approximately 24 hours. Fetal movement and heart rate should be assessed at initial contact and then every 24 hours after rupture of the membranes while the woman is not in labour, and women should be advised to report immediately any decrease in fetal movements. The latent first stage of labour is defined as a period of time when there are contractions and some cervical change, including cervical position, consistency, effacement and dilatation up to 4 cm, while the established first stage of labour is when there are regular contractions and progressive cervical dilatation from 4 cm. If a woman in labour contacts her midwife or maternity unit for advice, an assessment of labour should be carried out by telephone triage to determine whether a face-to-face assessment is needed.
During early or triage assessment of labour, midwives should ask the woman about her wishes, expectations, and any concerns she has, as well as the baby’s movements and any changes. They should provide information about what to expect during the latent first stage of labour and how to manage pain, and agree on a plan of care with the woman. The triage midwife should document the guidance given to the woman. If a woman seeks advice or attends a midwifery-led unit or obstetric unit with painful contractions but is not in established labour, midwives should recognize that a woman may experience painful contractions without cervical change and offer her individualized support and analgesia if needed. During an initial assessment of a woman in labour, midwives should listen to her story and support her preferences and emotional and psychological needs. They should also carry out an initial assessment to determine if midwifery-led care in any setting is suitable for the woman, irrespective of any previous plan, including consultant-led care. This assessment should comprise maternal and unborn baby factors, and if the woman appears to be in established labour, a vaginal examination should be offered. When performing a vaginal examination, midwives should ensure the woman’s informed consent, privacy, dignity, and comfort, and advise the woman that she can decline the examination before it starts or ask to stop at any stage during the examination. Midwives should also determine the station and position of the presenting part, the presence or absence of caput or moulding, cervical effacement, cervical dilatation, and the presence or absence of membranes. If necessary, the woman should be transferred to obstetric-led care following the general principles for transfer of care.
This section outlines various factors that should be considered during the initial assessment and ongoing assessment of a woman in labour. These include blood pressure readings, respiratory rate, temperature, presence of meconium or bleeding, fetal presentation, and fetal heart rate monitoring. The guidelines also provide recommendations for controlling gastric acidity, eating and drinking during labour, and ongoing assessments during the first stage of labour. If any risks are observed, the woman should be transferred to obstetric-led care unless the risks of transfer outweigh the benefits. During the first stage of labor, healthcare professionals should monitor the woman for various signs of complications, including raised blood pressure, abnormal respiratory rate, high temperature, bleeding, meconium, and pain that differs from normal contractions. They should also monitor the unborn baby for non-cephalic presentation, head position, suspected growth restriction or macrosomia, and changes in fetal heart rate pattern. Bladder care should be reviewed every 4 hours, and ongoing consideration should be given to the woman’s emotional and psychological needs. If meconium is present, healthcare professionals should consider transfer to obstetric-led care and discuss the risks with the woman. The length of established first stage of labor varies between women, and interventions should not be performed routinely if labor is progressing normally and the woman and baby are well.
When diagnosing delay in the established first stage of labor, assess cervical dilation, descent and rotation of the baby’s head, and changes in the strength, duration, and frequency of uterine contractions. If delay is suspected, discuss findings and options with the woman and offer support and effective pain relief. Advise a vaginal examination 2 hours later and consider amniotomy for all women with intact membranes. After amniotomy, advise a repeat vaginal examination 2 hours later. If there is no progress, diagnose delay and transfer the woman to obstetric-led care. An obstetrician should offer a full assessment for all women with confirmed delay, including consideration of oxytocin. Discuss the use of oxytocin with the woman and offer an epidural before oxytocin is started or if requested later. Use oxytocin with caution and discontinue immediately if the cardiotocography is pathological.
During the first stage of labor, if oxytocin is restarted, the timing of the next vaginal examination should be based on a clinical assessment of the woman and her individual circumstances. In the second stage of labor, observations of the woman and baby should continue, and the frequency of fetal monitoring should increase. Vaginal examinations should be offered hourly in the active second stage, and progress should be assessed, including the woman’s behavior, the effectiveness of pushing, and the baby’s wellbeing. The woman’s position during the second stage of labor is important, and women should be advised to avoid lying flat on their back and to use any other position they find comfortable to give birth.
Advice for women with an epidural during childbirth includes directed pushing and delayed directed pushing to reduce the likelihood of unplanned caesarean birth and the need for forceps or ventouse. If pushing is ineffective, strategies such as support, position changes, and bladder emptying should be offered. Techniques to reduce perineal trauma, such as warm compresses and perineal massage, should be discussed with the woman and her preferences supported. Routine episiotomy should not be carried out, and women with a history of severe perineal trauma should be informed that their risk of repeat trauma is not increased. There is insufficient evidence to support or discourage giving birth in water. The active second stage of labor for nulliparous women without an epidural is expected to last up to 3 hours, and if birth is not imminent after 2 hours of pushing, a senior review and decision on place and mode of birth should be made.
The duration of the active second stage of labor varies depending on whether the woman is nulliparous or multiparous and whether she has an epidural. For a multiparous woman without an epidural, birth is expected to take place within 2 hours of the start of the active second stage, and after 30 minutes of active pushing, progress should be reassessed. If there are no signs of progress after 1 hour of pushing, the woman should be referred for senior review. If there is delay in the second stage of labor, support and sensitive encouragement should be provided, and if the decision is made to transfer the woman to obstetric-led care, an obstetrician should carry out an in-person assessment before contemplating the use of oxytocin. If the birth needs to be expedited, a risk assessment should be carried out.
The guidelines recommend offering birth with forceps or ventouse if there is concern about the baby’s wellbeing, a prolonged second stage, or if the woman requests assistance. If a woman declines, her remaining options should be discussed, and she should be advised that her choices may be limited by clinical safety or degree of urgency. The choice of instrument should be based on a balance of clinical circumstance and practitioner experience, and pain relief options should be discussed. After birth with forceps or ventouse, a single dose of intravenous co-amoxiclav should be offered within 6 hours after cord clamping.
The third stage of labour is defined as the time from the birth of the baby to the expulsion of the placenta and membranes, and active management involves routine use of uterotonic drugs, cord clamping and cutting, and controlled cord traction. Physiological management involves no routine use of uterotonic drugs, no clamping of the cord until pulsation has stopped, and delivery of the placenta spontaneously or by maternal effort. Observations should be recorded for the woman’s general physical condition and vaginal blood loss, and if there are concerns about her wellbeing, frequent observations should be carried out and she should be transferred to obstetric-led care. The different options for managing the third stage of labour should be discussed with the woman antenatally, during her initial assessment, and in labour.
Active management of the third stage of labor is associated with a lower risk of postpartum hemorrhage, blood transfusion, need for further uterotonics, and postpartum anemia, but a higher risk of side effects such as nausea and vomiting, headache, hypertension, and readmission for bleeding. Women who request physiological management should have their level of risk discussed with them so they can make an informed decision, and their choice should be documented in their records. For women who choose active management, oxytocin plus ergometrine may be more effective than oxytocin alone at reducing the risk of postpartum hemorrhage, but is more likely to lead to nausea and vomiting. Carbetocin should be offered by slow intravenous injection for the prevention of postpartum hemorrhage in women who have had a cesarean birth.
After administering uterotonic, clamp and cut the cord, but do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heart rate below 60 beats a minute that is not getting faster. Controlled cord traction should be performed as part of active management only after administration of oxytocin and signs of separation of the placenta. The timing of cord clamping should be recorded in both active and physiological management. If there is haemorrhage or the placenta is not delivered within 1 hour of the birth of the baby, advise a change from physiological management to active management. Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage of labour. If the placenta is retained, secure intravenous access and do not use umbilical vein agents. If the placenta is retained and the woman is bleeding excessively, give intravenous oxytocic agents. Advise women with antenatal risk factors for postpartum haemorrhage to give birth in an obstetric unit. Continue to assess risk factors for postpartum haemorrhage during labour.
The excerpt provides guidelines for the management of postpartum hemorrhage, including the use of uterotonic drugs and tranexamic acid, as well as the importance of continuously assessing blood loss and the woman’s condition. The guidelines also recommend highlighting risk factors for postpartum hemorrhage in a woman’s notes and agreeing on a care plan for the third stage of labor. Additionally, the excerpt advises allocating a healthcare team member to stay with the woman and her birth companion(s) to offer support during the emergency situation. The Medicines and Healthcare products Regulatory Agency (MHRA) advice on the use of SSRI and SNRI antidepressants in the month before birth should also be taken into account as part of the bleeding and thrombotic risk assessment.
For postpartum haemorrhage, no particular surgical procedure is recommended over any other. Maternity and ambulance services should have strategies in place to respond quickly to postpartum haemorrhage. The Apgar score should be recorded at 1 and 5 minutes after birth, and the baby’s airway should be prioritized during skin-to-skin contact. Paired cord-blood samples should be taken for blood gas analysis if the baby is born in poor condition. Skin-to-skin contact should be encouraged as soon as possible after birth, and breastfeeding should be initiated within 1 hour. The baby’s head circumference and birth weight should be recorded and plotted on the centile chart, and any examination or treatment of the baby should be done with the consent of the parents. Neonatal resuscitation should be evaluated in the first minutes after birth.
When preparing for neonatal resuscitation, it is important to have facilities for resuscitation and emergency referral pathways in place. If a newborn baby needs basic resuscitation, start with air and minimise separation of the baby and mother. In the presence of any degree of meconium, do not suction the baby’s upper airways before birth of the shoulders and trunk, and do not intubate if the baby has normal respiration, heart rate, and tone. If there has been any degree of meconium and the baby does not have normal respiration, heart rate, and tone, follow nationally accredited guidelines on neonatal resuscitation. Closely observe any baby born to a woman with prelabour rupture of the membranes at term for the first 12 hours of life, and if any concerns arise, ask a neonatologist to assess the baby and transfer both the woman and baby if necessary. Do not perform blood, cerebrospinal fluid, and/or surface culture tests in an asymptomatic baby.
After birth, medical professionals should record the woman’s vital signs and transfer her to obstetric-led care if necessary. They should also check for uterine contraction and lochia, examine the placenta and membranes, and assess the woman’s emotional and psychological condition. If the woman has had regional analgesia or anaesthesia, they should check that she can perform a straight leg raise by 4 hours after the last anaesthetic dose. Perineal care should also be provided, including a systematic assessment of genital trauma, with a rectal examination to assess damage to the anal sphincter if necessary. All healthcare professionals should be trained in perineal/genital assessment and repair, and perineal repair should be carried out as soon as possible with effective analgesia.
The guidelines advise on the appropriate suturing techniques for first and second-degree perineal trauma, with continuous subcuticular and non-locked suturing techniques recommended. Rectal non-steroidal anti-inflammatory drugs are also recommended for pain relief after perineal repair. The guidelines also outline basic principles for performing perineal repairs, including using aseptic techniques, ensuring good lighting, and documenting an accurate account of the trauma and repair. Additionally, the guidelines recommend providing women with information about pain relief, diet, hygiene, pelvic floor exercises, and seeking advice or psychological support if needed. The committee also added recommendations for antenatal education about labour, planning place of birth, and emphasising the importance of obtaining consent from women.
The committee added a new recommendation to update the sections on communication and to bring them more in line with current NICE style and terminology and to increase the emphasis on supported decision making. The use of healthcare passports for people with learning disabilities or autism has been included. This recommendation reinforces best practice and is unlikely to have any resource impact.
The committee has made several recommendations regarding the assessment of women during the second stage of labour, birth with forceps or ventouse in delayed second stage, risk factors for postpartum haemorrhage, initial assessment of the newborn baby, optimal positioning during skin-to-skin contact, additional monitoring for babies exposed to antidepressants in utero, and care of the woman after birth. These recommendations reinforce best practice and are unlikely to have any resource impact.
The committee recommends that information on increased risks of postpartum haemorrhage and neonatal admission or death should be made available to women to assist with their decision making about place of birth. This may result in more women at lower BMIs choosing to give birth at home or in a midwifery-led unit. The committee also recommends that women with prelabour rupture of membranes should have an in-person review within 12 hours, and that sterile water injections should be used as an option for back pain in labour. Remifentanil patient-controlled analgesia may reduce the use of epidural analgesia and increase vaginal birth, but the committee could not make a stronger recommendation due to concerns over the quality and heterogeneity of the evidence.
The use of intravenous remifentanil PCA will increase due to the recommendations, which will have resource implications but will be cost-effective. Programmed intermittent epidural bolus (PIEB) is suggested as an alternative option to other methods of maintaining epidural analgesia, and the resource impact is likely to be minimal. The committee made recommendations for the use of oxytocin, including cautious use of intravenous fluids and monitoring of fluid balance to limit the likelihood of fluid overload and hyponatremia. For women with an epidural in situ, there was a statistically significant increase in spontaneous vaginal births for nulliparous women who were in the left or right lateral recumbent positions (lying on their side) compared with upright positions during the second stage of labour.
The committee made recommendations for pushing techniques for women with and without an epidural, with evidence suggesting that directed pushing may reduce the likelihood of an unplanned caesarean birth and delayed pushing may reduce the likelihood of a birth with forceps or ventouse. Warm compresses applied to the perineum during labor and massage with lubricant were found to reduce the incidence of third- and fourth-degree tears, and antibiotics administered within 6 hours after birth with forceps or ventouse were found to reduce the risk of infection. Active management of the third stage of labor was found to have benefits but also harms. The recommendations aim to reduce variation in practice and increase the use of low-cost interventions with long-term benefits.
The committee recommends the use of certain uterotonics to reduce postpartum haemorrhage, with oxytocin plus ergometrine or oxytocin alone being the most effective for vaginal births. Carbetocin is not considered cost-effective for vaginal births but is recommended for caesarean births. Intravenous bolus oxytocin is recommended for the third stage of labour for women who have already had oxytocin during labour, as it reduces the risk of postpartum haemorrhage and the need for additional uterotonic drugs. These recommendations will reinforce current practice and may lead to increased use of certain medications, with potential resource implications for intravenous administration.
The guideline covers the care of women who go into labour at term, with most women in England and Wales being covered by this guideline. There is no evidence to suggest one technique is better or worse than the other for the position of the baby during cord clamping, so there may be some variation in practice. Tranexamic acid was found to reduce maternal death from bleeding compared with placebo, and carbetocin was not previously recommended to treat postpartum haemorrhage, so this may increase its use. It is important for the woman to be given information and advice about all available settings when deciding where to have her baby, and to recognize when transfer of care from midwifery-led care to obstetric-led care is indicated due to complications.
The guideline covers the care of women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications, as well as recommendations for the care of women who start labour as low risk but who go on to develop complications. Appendix A provides a composite definition of ‘adverse outcome’ used in the Birthplace UK (2011) study, including stillbirth, death of the baby in the first week after birth, neonatal encephalopathy, meconium aspiration syndrome, and physical birth injuries. Appendix B shows how body mass index (BMI) may affect the rate of stillbirth, neonatal death, or the baby needing neonatal care for nulliparous and multiparous women with planned birth in an obstetric unit.
The tables provide information on how BMI affects various outcomes in pregnancy. Table B3 shows that women with a BMI over 35 have an increased rate of intrapartum and emergency caesarean birth, as well as postpartum haemorrhage. Table B4 shows that multiparous women with a BMI over 30 have an increased rate of transfer from home to an obstetric unit. Table B5 shows that women with a BMI over 25 have an increased rate of intrapartum caesarean birth, but no difference in stillbirth, neonatal death, or the need for neonatal care. Women with a BMI over 35 have an increased rate of intrapartum caesarean birth and a decreased rate of birth with forceps or ventouse.
The excerpt discusses the outcomes of using intravenous remifentanil patient-controlled analgesia (PCA) compared to intramuscular pethidine during childbirth. The table shows that women using intravenous remifentanil PCA are less likely to request epidural analgesia and have a birth with forceps or ventouse, but more likely to require supplemental oxygen and have reduced oxygen saturation. The data is based on a population of women of mixed ethnicity, and more information can be found in evidence review D.