People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Show
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. 1.1 Place of birthChoosing planned place of birthWomen at low risk of complications1.1.1 Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for both the woman and her baby. [2014] 1.1.2 Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth:
1.1.3 Using table 1 and table 2, explain to low‑risk multiparous women that:
Table 1Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low‑risk multiparous women (sources: Birthplace 2011; Blix et al. 2012)
* Figures from Birthplace 2011 and Blix et al. 2012 (all other figures from Birthplace 2011). ** Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise. *** Blix reported epidural analgesia and Birthplace reported spinal or epidural analgesia. Table 2Outcomes for the baby for each planned place of birth: low‑risk multiparous women (source: Birthplace 2011)
* Serious medical problems were combined in the study: neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, together accounting for 75% of the total. 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). For the frequency of these events (how often any of them actually occurred), see appendix A. 1.1.4 Using table 3 and table 4, explain to low‑risk nulliparous women that:
Table 3Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low‑risk nulliparous women (sources: Birthplace 2011; Blix et al. 2012)
* Figures from Birthplace 2011 and Blix et al. 2012 (all other figures from Birthplace 2011). ** Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise. *** Blix reported epidural analgesia and Birthplace reported spinal or epidural analgesia. Table 4Outcomes for the baby for each planned place of birth: low‑risk nulliparous women (source: Birthplace 2011)
* Serious medical problems were combined in the study: neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, together accounting for 75% of the total. 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. For the frequency of these events (how often any of them actually occurred), see appendix A. 1.1.5 Ensure that all healthcare professionals involved in the care of pregnant women are familiar with the types and frequencies of serious medical problems that can affect babies (see appendix A), in order to be able to provide this information to women if they request it. [2014] 1.1.6 Commissioners and providers (this can also include networks of providers) should ensure that all 4 birth settings are available to all women (in the local area or in a neighbouring area). [2014] 1.1.7 Give the woman the following information, including local statistics, about all local birth settings:
Table 5Primary reasons for transfer to an obstetric unit (source: Birthplace 2011)
* Main reason for transfer to an obstetric unit for each woman (there may be more than 1 reason). 1.1.8 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. [2014] 1.1.9 When discussing the woman's choice of place of birth with her, do not disclose personal views or judgements about her choices. [2014] Medical conditions and other factors that may affect planned place of birth1.1.10 Use tables 6, 7, 8 and 9 as part of an assessment for a woman choosing her planned place of birth:
Table 6Medical conditions indicating increased risk suggesting planned birth at an obstetric unit
Table 7Other factors indicating increased risk suggesting planned birth at an obstetric unit
Table 8Medical conditions indicating individual assessment when planning place of birth
Table 9Other factors indicating individual assessment when planning place of birth
Women's experience in all birth settings1.1.11 For all women giving birth in all birth settings, follow the principles in the NICE guideline on patient experience in adult NHS services. [2014] 1.1.12 Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought. [2014] 1.1.13 Senior staff should demonstrate, through their own words and behaviour, appropriate ways of relating to and talking about women and their birth companion(s), and of talking about birth and the choices to be made when giving birth. [2014] One‑to‑one care in all birth settings1.1.14 Maternity services should:
Service organisation and clinical governance1.1.15 Ensure that all women giving birth have timely access to an obstetric unit if they need transfer of care for medical reasons or because they request regional analgesia. [2014] 1.1.16 Commissioners and providers (this can also include networks of providers) should ensure that there are:
1.1.17 Commissioners and providers (this can also include networks of providers) should ensure that there are multidisciplinary clinical governance structures in place to enable the oversight of all birth settings. These structures should include, as a minimum, midwifery (including a supervisor of midwives), obstetric, anaesthetic and neonatal expertise, and adequately supported user representation. [2014] 1.2 Care throughout labourCommunication1.2.1 Treat all women in labour with respect. Ensure that the woman is in control of and involved in what is happening to her, and recognise that the way in which care is given is key to this. 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. Use this information to support and guide her through her labour. [2007] 1.2.2 To establish communication with the woman:
Mobilisation1.2.3 Encourage and help the woman to move and adopt whatever positions she finds most comfortable throughout labour. [2007] Support1.2.4 Encourage the woman to have support from birth companion(s) of her choice. [2007] Hygiene measures1.2.5 Tap water may be used if cleansing is required before vaginal examination. [2007] 1.2.6 Routine hygiene measures taken by staff caring for women in labour, including standard hand hygiene and single‑use non‑sterile gloves, are appropriate to reduce cross‑contamination between women, babies and healthcare professionals. [2007] 1.2.7 Selection of protective equipment must be based on an assessment of the risk of transmission of microorganisms to the woman, and the risk of contamination of the healthcare worker's clothing and skin by women's blood, body fluids, secretions or excretions. This is in accordance with the following health and
safety legislation (current at the time NICE's guideline on healthcare-associated infections was published [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations
2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and Social Care Act 2008). [2007, amended 2014] 1.3 Latent first stage of labourDefinitions of the latent and established first stages of labour1.3.1 For the purposes of this guideline, use the following definitions of labour:
Education and early assessment1.3.2 Give all nulliparous women information antenatally about:
1.3.3 Offer all nulliparous women antenatal education about the signs of labour, consisting of:
1.3.4 Consider an early assessment of labour by telephone triage provided by a dedicated triage midwife for all women. [2014] 1.3.5 Consider a face‑to‑face early assessment of labour for all low‑risk nulliparous women, either:
1.3.6 Include the following in any early or triage assessment of labour:
1.3.7 The triage midwife should document the guidance that she gives to the woman. [2014] 1.3.8 If a woman seeks advice or attends a midwifery‑led unit or obstetric unit with painful contractions, but is not in established labour:
Pain relief1.3.9 Advise the woman and her birth companion(s) that breathing exercises, immersion in water and massage may reduce pain during the latent first stage of labour. (See also the recommendation on timing of regional analgesia.) [2014] 1.3.10 Do not offer or advise aromatherapy, yoga or acupressure for pain relief during the latent first stage of labour. If a woman wants to use any of these techniques, respect her wishes. [2014] 1.4 Initial assessment1.4.1 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. [2014] 1.4.2 Carry out an initial assessment to determine if midwifery‑led care in any setting is suitable for the woman, irrespective of any previous plan. The assessment should comprise the following:
1.4.3 Transfer the woman to obstetric‑led care, following the section on the general principles for transfer of care, if any of the following are observed on initial assessment:
1.4.4 If any of the factors in recommendation 1.4.3 are observed but birth is imminent, assess whether birth in the current location is preferable to transferring the woman to an obstetric unit and discuss this with the coordinating midwife. [2014] 1.4.5 When conducting a vaginal examination:
Measuring fetal heart rate as part of initial assessment1.4.6 Offer auscultation of the fetal heart rate at first contact with a woman in suspected or established labour, and at each further assessment:
1.4.7 Be aware that for women at low risk of complications there is insufficient evidence about whether cardiotocography as part of the initial assessment either improves outcomes or results in harm for women and their babies, compared with intermittent auscultation alone. [2017] 1.4.8 If a woman at low risk of complications requests cardiotocography as part of the initial assessment:
1.4.9 Offer continuous cardiotocography if any of the risk factors listed in recommendation 1.4.3 in the section on initial assessment are identified on initial assessment, and explain to the woman why this is being offered. (See also the section on monitoring during labour for further guidance on fetal monitoring.) [2017] 1.4.10 Offer cardiotocography if intermittent auscultation indicates possible fetal heart rate abnormalities, and explain to the woman why this is being offered. If the trace is normal (see table 11 in the section on interpretation of cardiotocograph traces) after 20 minutes, return to intermittent auscultation unless the woman asks to stay on continuous cardiotocography. [2017] 1.4.11 If fetal death is suspected despite the presence of an apparently recorded fetal heart rate, offer real-time ultrasound assessment to check fetal viability. [2017] 1.5 Ongoing assessment1.5.1 Transfer the woman to obstetric‑led care (following the general principles for transfer of care) if any of the following are observed at any point, unless the risks of transfer outweigh the benefits:
Presence of meconium1.5.2 As part of ongoing assessment, document the presence or absence of significant meconium. This is defined as dark green or black amniotic fluid that is thick or tenacious, or any meconium‑stained amniotic fluid containing lumps of meconium. [2014] 1.5.3 If significant meconium is present, ensure that:
1.5.4 If significant meconium is present, transfer the woman to obstetric‑led care provided that it is safe to do so and the birth is unlikely to occur before transfer is completed. Follow the general principles for transfer of care described in section 1.6. [2014] 1.6 General principles for transfer of careTransfer of care refers to the transfer between midwifery‑led care and obstetric‑led care. This may or may not involve transport from one location to another. Women who are receiving midwifery‑led care in an obstetric unit can have their care transferred to obstetric‑led care without being moved. 1.6.1 Base any decisions about transfer of care on clinical findings, and discuss the options with the woman and her birth companion(s). [2014] 1.6.2 If contemplating transfer of care:
1.6.3 When arranging transfer of care, the midwife attending the labour should contact the ambulance service (if appropriate) and the coordinating midwife in the obstetric unit. The coordinating midwife should then alert the relevant healthcare professionals (obstetric, anaesthetic and neonatal). [2014] 1.6.4 When arranging transfer from one location to another, ensure the following:
1.6.5 If a woman is transferred to an obstetric unit after the birth (see the section on care of the woman after birth), ensure that her baby goes with her. [2014] 1.7 Care in established labourSupport in labour1.7.1 Provide a woman in established labour with supportive one‑to‑one care. [2007] 1.7.2 Do not leave a woman in established labour on her own except for short periods or at the woman's request. [2007] Controlling gastric acidity1.7.4 Do not offer either H2‑receptor antagonists or antacids routinely to low‑risk women. [2007] 1.7.5 Either H2‑receptor antagonists or antacids should be considered for women who receive opioids or who have or develop risk factors that make a general anaesthetic more likely. [2007] 1.7.6 Inform the woman that she may drink during established labour and that isotonic drinks may be more beneficial than water. [2007] 1.7.7 Inform the woman that she may eat a light diet in established labour unless she has received opioids or she develops risk factors that make a general anaesthetic more likely. [2007] 1.8 Pain relief in labour: non‑regionalAttitudes to pain and pain relief in childbirth1.8.1 Healthcare professionals should think about how their own values and beliefs inform their attitude to coping with pain in labour and ensure their care supports the woman's choice. [2007] Pain‑relieving strategies1.8.2 If a woman chooses to use breathing and relaxation techniques in labour, support her in this choice. [2007] 1.8.3 If a woman chooses to use massage techniques in labour that have been taught to birth companions, support her in this choice. [2007] 1.8.4 Offer the woman the opportunity to labour in water for pain relief. [2007] 1.8.5 For women labouring in water, monitor the temperature of the woman and the water hourly to ensure that the woman is comfortable and not becoming pyrexial. The temperature of the water should not be above 37.5°C. [2007] 1.8.6 Keep baths and birthing pools clean using a protocol agreed with the microbiology department and, in the case of birthing pools, in accordance with the manufacturer's guidelines. [2007] 1.8.7 Do not use injected water papules. [2007] 1.8.8 Do not offer acupuncture, acupressure or hypnosis, but do not prevent women who wish to use these techniques from doing so. [2007] 1.8.9 Support the playing of music of the woman's choice in labour. [2007] Non‑pharmacological analgesia1.8.10 Do not offer transcutaneous electrical nerve stimulation (TENS) to women in established labour. [2007] Inhalational analgesia1.8.11 Ensure that Entonox (a 50:50 mixture of oxygen and nitrous oxide) is available in all birth settings as it may reduce pain in labour, but inform the woman that it may make her feel nauseous and light‑headed. [2007] Intravenous and intramuscular opioids1.8.12 Ensure that pethidine, diamorphine or other opioids are available in all birth settings. Inform the woman that these will provide limited pain relief during labour and may have significant side effects for both her (drowsiness, nausea and vomiting) and her baby (short‑term respiratory depression and drowsiness which may last several days). [2007] 1.8.13 Inform the woman that pethidine, diamorphine or other opioids may interfere with breastfeeding. [2007] 1.8.14 If an intravenous or intramuscular opioid is used, also administer an antiemetic. [2007] 1.8.15 Women should not enter water (a birthing pool or bath) within 2 hours of opioid administration or if they feel drowsy. [2007] 1.9 Pain relief in labour: regional analgesiaInformation about regional analgesia1.9.1 If a woman is contemplating regional analgesia, talk with her about the risks and benefits and the implications for her labour, including the arrangements and time involved for transfer of care to an obstetric unit if she is at home or in a midwifery unit (follow the general principles for transfer of care). [2007, amended 2014] 1.9.2 Provide information about epidural analgesia, including the following:
Timing of regional analgesia1.9.3 If a woman in labour asks for regional analgesia, comply with her request. This includes women in severe pain in the latent first stage of labour. [2007] Care and observations for women with regional analgesia1.9.4 Always secure intravenous access before starting regional analgesia. [2007] 1.9.5 Preloading and maintenance fluid infusion need not be administered routinely before establishing low‑dose epidural analgesia and combined spinal–epidural analgesia. [2007] 1.9.6 Undertake the following additional observations for women with regional analgesia:
1.9.7 Encourage women with regional analgesia to move and adopt whatever upright positions they find comfortable throughout labour. [2007] 1.9.8 Once established, continue regional analgesia until after completion of the third stage of labour and any necessary perineal repair. [2007] 1.9.9 Upon confirmation of full cervical dilatation in a woman with regional analgesia, unless the woman has an urge to push or the baby's head is visible, pushing should be delayed for at least 1 hour and longer if the woman wishes, after which actively encourage her to push during contractions. [2007] 1.9.10 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. [2007] 1.9.11 Do not routinely use oxytocin in the second stage of labour for women with regional analgesia. [2007] 1.9.12 Perform continuous cardiotocography for at least 30 minutes during establishment of regional analgesia and after administration of each further bolus of 10 ml or more. [2007, amended 2014] Establishing and maintaining regional analgesia1.9.13 Use either epidural or combined spinal–epidural analgesia for establishing regional analgesia in labour. [2007] 1.9.14 If rapid analgesia is required, use combined spinal–epidural analgesia. [2007] 1.9.15 Establish combined spinal–epidural analgesia with bupivacaine and fentanyl. [2007] 1.9.16 Establish epidural analgesia with a low‑concentration local anaesthetic and opioid solution with, for example, 10 to 15 ml of 0.0625 to 0.1% bupivacaine with 1 to 2 micrograms per ml fentanyl. 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. [2007] 1.9.17 Use low‑concentration local anaesthetic and opioid solutions (0.0625 to 0.1% bupivacaine or equivalent combined with 2.0 micrograms per ml fentanyl) for maintaining epidural analgesia in labour. [2007] 1.9.18 Do not use high concentrations of local anaesthetic solutions (0.25% or above of bupivacaine or equivalent) routinely for either establishing or maintaining epidural analgesia. [2007] 1.9.19 Either patient‑controlled epidural analgesia or intermittent bolus given by healthcare professionals are the preferred modes of administration for maintenance of epidural analgesia. [2007] 1.10 Monitoring during labourMeasuring fetal heart rate1.10.1 Do not offer cardiotocography to women at low risk of complications in established labour. [2017] 1.10.2 Offer intermittent auscultation of the fetal heart rate to women at low risk of complications in established first stage of labour:
1.10.3 If there is a rising baseline fetal heart rate or decelerations are suspected on intermittent auscultation, actions should include:
1.10.4 Advise continuous cardiotocography if any of the following risk factors are present at initial assessment (see the section on initial assessment) or arise during labour:
1.10.5 Do not offer continuous cardiotocography to women who have non-significant meconium if there are no other risk factors. [2017] 1.10.6 Do not regard amniotomy alone for suspected delay in the established first stage of labour as an indication to start continuous cardiotocography. [2007, amended 2014]
1.10.7 Address any concerns that the woman has about continuous cardiotocography, and give her and her birth companion(s) the following information:
1.10.8 If continuous cardiotocography has been started because of concerns arising from intermittent auscultation, but the trace is normal (see table 11) after 20 minutes, return to intermittent auscultation unless the woman asks to stay on continuous cardiotocography (see recommendation 1.4.8 in the section on measuring fetal heart rate as part of initial assessment). [2017] Telemetry1.10.9 Offer telemetry to any woman who needs continuous cardiotocography during labour. [2014] Box 1Interpreting cardiotocograph trace features, including accelerationsOverall care
Principles for intrapartum CTG trace interpretation
Accelerations The presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy. Table 10Description of cardiotocograph trace features
* Regard the following as concerning characteristics of variable decelerations: lasting more than 60 seconds; reduced baseline variability within the deceleration; failure to return to baseline; biphasic (W) shape; no shouldering. ** Although a baseline fetal heart rate between 100 and 109 beats/minute is a non-reassuring feature, continue usual care if there is normal baseline variability and no variable or late decelerations. Table 11Management based on interpretation of cardiotocograph traces
Abbreviation: CTG, cardiotocography. * If there are any concerns about the baby's wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s): encourage the woman to mobilise or adopt an alternative position (and to avoid being supine); offer intravenous fluids if the woman is hypotensive; reduce contraction frequency by reducing or stopping oxytocin if it is being used and/or offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg). Overall care1.10.11 When a woman is having continuous cardiotocography:
1.10.12 When reviewing the cardiotocograph trace, assess and document contractions and all 4 features of fetal heart rate:
1.10.13 Do not make any decision about a woman's care in labour on the basis of cardiotocography findings alone, but also take into account:
1.10.14 Supplement ongoing care with a documented systematic assessment of the condition of the woman and unborn baby (including any cardiotocography findings) every hour. If there are concerns about cardiotocography findings, undertake this assessment more frequently. [2017] Baseline fetal heart rate1.10.15 Use the following categorisations for baseline fetal heart rate:
1.10.16 Take the following into account when assessing baseline fetal heart rate:
Baseline variability1.10.17 Use the following categorisations for fetal heart rate baseline variability:
1.10.18 Take the following into account when assessing fetal heart rate baseline variability:
Decelerations1.10.19 When describing decelerations in fetal heart rate, specify:
1.10.20 Describe decelerations as 'early', 'variable' or 'late'. Do not use the terms 'typical' and 'atypical' because they can cause confusion. [2017] 1.10.21 Use the following categorisations for decelerations in fetal heart rate:
1.10.22 Regard the following as concerning characteristics of variable decelerations:
1.10.23 If variable decelerations with no concerning characteristics (see recommendation 1.10.22) are observed:
1.10.24 Take the following into account when assessing decelerations in fetal heart rate:
1.10.25 Take into account that the longer and later the individual decelerations, the higher the risk of fetal acidosis (particularly if the decelerations are accompanied by tachycardia or reduced baseline variability). [2017] Accelerations1.10.26 Take the following into account when assessing accelerations in fetal heart rate:
Categorisation of traces1.10.27 Categorise cardiotocography traces as follows:
Management1.10.28 If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low. [2017] 1.10.29 If there is an acute bradycardia, or a single prolonged deceleration for 3 minutes or more:
1.10.30 If the cardiotocograph trace is categorised as pathological (see the recommendation on categorisation of traces):
1.10.31 If the cardiotocograph trace is still pathological after implementing conservative measures:
1.10.32 If the cardiotocograph trace is categorised as suspicious (see the recommendation on categorisation of traces):
1.10.33 If the cardiotocograph trace is categorised as normal (see the recommendation on categorisation of traces):
Conservative measures1.10.34 If there are any concerns about the baby's wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s):
1.10.35 Inform a senior midwife or an obstetrician whenever conservative measures are implemented. [2017] Intrauterine resuscitation1.10.36 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). [2014] 1.10.37 Do not offer amnioinfusion for intrauterine fetal resuscitation. [2014] Fetal scalp stimulation1.10.38 If the cardiotocograph trace is pathological (see the recommendation on categorisation of traces), offer digital fetal scalp stimulation. If this leads to an acceleration in fetal heart rate, only continue with fetal blood sampling if the cardiotocograph trace is still pathological. [2017] 1.10.39 If digital fetal scalp stimulation (during vaginal examination) leads to an acceleration in fetal heart rate, regard this as a sign that the baby is healthy. Take this into account when reviewing the whole clinical picture. [2017] Fetal blood sampling1.10.40 Do not carry out fetal blood sampling if:
1.10.41 Be aware that for women with sepsis or significant meconium (see the section on presence of meconium), fetal blood sample results may be falsely reassuring, and always discuss with a consultant obstetrician:
1.10.42 Before carrying out or repeating fetal blood sampling, start conservative measures and offer digital fetal scalp stimulation (see the sections on conservative measures and fetal scalp stimulation). Only continue with fetal blood sampling if the cardiotocograph trace remains pathological (see categorisation of traces). [2017] 1.10.43 When considering fetal blood sampling, take into account the woman's preferences and the whole clinical picture. [2017] 1.10.44 When considering fetal blood sampling, explain the following to the woman and her birth companion(s):
1.10.45 Do not take a fetal blood sample during or immediately after a prolonged deceleration. [2017] 1.10.46 Take fetal blood samples with the woman in the left-lateral position. [2017] 1.10.47 Use either pH or lactate when interpreting fetal blood sample results. [2017] 1.10.48 Use the following classifications for fetal blood sample results:
1.10.49 Interpret fetal blood sample results taking into account:
1.10.50 If the fetal blood sample result is abnormal:
1.10.51 If the fetal blood sample result is borderline and there are no accelerations in response to fetal scalp stimulation, consider taking a second fetal blood sample no more than 30 minutes later if this is still indicated by the cardiotocograph trace. [2017] 1.10.52 If the fetal blood sample result is normal and there are no accelerations in response to fetal scalp stimulation, consider taking a second fetal blood sample no more than 1 hour later if this is still indicated by the cardiotocograph trace. [2017] 1.10.53 Discuss with a consultant obstetrician if a third fetal blood sample is thought to be needed. [2017] When a fetal blood sample cannot be obtained1.10.54 If fetal blood sampling is attempted and a sample cannot be obtained, but the associated fetal scalp stimulation results in a fetal heart rate acceleration, decide whether to continue the labour or expedite the birth in light of the clinical circumstances and in discussion with the woman and a senior obstetrician. [2017] 1.10.55 If fetal blood sampling is attempted but a sample cannot be obtained and there has been no improvement in the cardiotocograph trace, expedite the birth (see the section on expediting birth). [2017] Record keeping1.10.56 To ensure accurate record keeping for cardiotocography:
1.10.57 Individual units should develop a system for recording relevant intrapartum events (for example, vaginal examination, fetal blood sampling and siting of an epidural) in standard notes and/or on the cardiotocograph trace. [2014] 1.10.58 Keep cardiotocograph traces for 25 years and, if possible, store them electronically. [2007, amended 2014] 1.10.59 In cases where there is concern that the baby may experience developmental delay, photocopy cardiotocograph traces and store them indefinitely in case of possible adverse outcomes. [2007, amended 2014] 1.10.60 Ensure that tracer systems are available for all cardiotocograph traces if stored separately from the woman's records. [2007, amended 2014] 1.10.61 Develop tracer systems to ensure that cardiotocograph traces removed for any purpose (such as risk management or for teaching purposes) can always be located. [2007, amended 2014] 1.11 Prelabour rupture of membranes at term1.11.1 Do not carry out a speculum examination if it is certain that the membranes have ruptured. [2007] 1.11.2 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. Avoid digital vaginal examination in the absence of contractions. [2007] 1.11.3 Advise women presenting with prelabour rupture of the membranes at term that:
1.11.4 Until the induction is started or if expectant management beyond 24 hours is chosen by the woman:
1.11.5 Assess fetal movement and heart rate at initial contact and then every 24 hours after rupture of the membranes while the woman is not in labour, and advise the woman to report immediately any decrease in fetal movements. [2007] 1.11.6 If labour has not started 24 hours after rupture of the membranes, advise the woman to give birth where there is access to neonatal services and to stay in hospital for at least 12 hours after the birth. [2007] 1.12 First stage of labourSee the recommendation on definitions of the latent and established first stages of labour. 1.12.1 Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well. [2007] 1.12.2 In all stages of labour, women who have left the normal care pathway because of the development of complications can return to it if/when the complication is resolved. [2007] Duration of the first stage1.12.3 Inform women that, while the length of established first stage of labour varies between women:
Observations during the established first stage1.12.4 Do not routinely use verbal assessment using a numerical pain score. [2007] 1.12.5 Use a pictorial record of labour (partogram) once labour is established. [2007] 1.12.6 Where the partogram includes an action line, use the World Health Organization (WHO) recommendation of a 4‑hour action line (the WHO partograph in management of labour, published in 1994 as part of the Maternal Health and Safe Motherhood Programme. Lancet 343: 1399 to 404). [2007] See also the WHO Multicountry Survey on Maternal and Newborn Health. 1.12.7 Record the following observations during the first stage of labour:
1.12.8 Give ongoing consideration to the woman's emotional and psychological needs, including her desire for pain relief. [2007] 1.12.9 Encourage the woman to communicate her need for analgesia at any point during labour. [2007] Possible routine interventions in the first stage1.12.10 Do not routinely offer the package known as active management of labour (one‑to‑one continuous support; strict definition of established labour; early routine amniotomy; routine 2‑hourly vaginal examination; oxytocin if labour becomes slow). [2007] 1.12.11 In normally progressing labour, do not perform amniotomy routinely. [2007] 1.12.12 Do not use combined early amniotomy with use of oxytocin routinely. [2007] Delay in the first stage1.12.13 If delay in the established first stage is suspected, take the following into account:
1.12.14 If delay in the established first stage is suspected, assess all aspects of progress in labour when diagnosing delay, including:
1.12.15 If delay in the established first stage of labour is suspected, amniotomy should be considered for all women with intact membranes, after explanation of the procedure and advice that it will shorten her labour by about an hour and may increase the strength and pain of her contractions. [2007] 1.12.16 Whether or not a woman has agreed to an amniotomy, advise all women with suspected delay in the established first stage of labour to have a vaginal examination 2 hours later, and diagnose delay if progress is less than 1 cm. [2007] 1.12.17 For women with intact membranes in whom delay in the established first stage of labour is confirmed, advise the woman to have an amniotomy, and to have a repeat vaginal examination 2 hours later whether her membranes are ruptured or intact. [2007] 1.12.18 For all women with confirmed delay in the established first stage of labour:
1.12.19 For a multiparous woman with confirmed delay in the established first stage of labour, an obstetrician should perform a full assessment, including abdominal palpation and vaginal examination, before a decision is made about using oxytocin. [2007] 1.12.20 Offer all women with delay in the established first stage of labour support and effective pain relief. [2007] 1.12.21 Inform the woman that oxytocin will increase the frequency and strength of her contractions and that its use will mean that her baby should be monitored continuously. Offer the woman an epidural before oxytocin is started. [2007] 1.12.22 If oxytocin is used, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 4 to 5 contractions in 10 minutes. (See also recommendation 1.10.4 in the section on measuring fetal heart rate.) [2007] 1.12.23 Advise the woman to have a vaginal examination 4 hours after starting oxytocin in established labour:
1.13 Second stage of labourDefinition of the second stage1.13.1 For the purposes of this guideline, use the following definitions of labour:
Observations during the second stage1.13.2 Carry out the following observations in the second stage of labour, record all observations on the partogram and assess whether transfer of care may be needed (see the recommendation on ongoing assessment). [2007, amended 2014]:
Duration of the second stage and definition of delay1.13.3 For a nulliparous woman:
1.13.4 For a multiparous woman:
1.13.5 For a nulliparous woman, suspect delay if progress (in terms of rotation and/or descent of the presenting part) is inadequate after 1 hour of active second stage. Offer vaginal examination and then offer amniotomy if the membranes are intact. [2007, amended 2014] 1.13.6 For a multiparous woman, suspect delay if progress (in terms of rotation and/or descent of the presenting part) is inadequate after 30 minutes of active second stage. Offer vaginal examination and then offer amniotomy if the membranes are intact. [2014] 1.13.7 If full dilatation of the cervix has been confirmed in a woman without regional analgesia, but she does not get an urge to push, carry out further assessment after 1 hour. [2007] Oxytocin in the second stage1.13.8 Consideration should be given to the use of oxytocin, with the offer of regional analgesia, for nulliparous women if contractions are inadequate at the onset of the second stage. [2007] The woman's position and pushing in the second stage1.13.9 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] 1.13.10 Inform the woman that in the second stage she should be guided by her own urge to push. [2007] 1.13.11 If pushing is ineffective or if requested by the woman, offer strategies to assist birth, such as support, change of position, emptying of the bladder and encouragement. [2007] Intrapartum interventions to reduce perineal trauma1.13.12 Do not perform perineal massage in the second stage of labour. [2007] 1.13.13 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 to facilitate spontaneous birth. [2007] 1.13.14 Do not offer lidocaine spray to reduce pain in the second stage of labour. [2007] 1.13.15 Do not carry out a routine episiotomy during spontaneous vaginal birth. [2007] 1.13.16 Inform any woman with a history of severe perineal trauma that her risk of repeat severe perineal trauma is not increased in a subsequent birth, compared with women having their first baby. [2007] 1.13.17 Do not offer episiotomy routinely at vaginal birth after previous third‑ or fourth‑degree trauma. [2007] 1.13.18 In order for a woman who has had previous third- or fourth‑degree trauma to make an informed choice, talk with her about the future mode of birth, encompassing:
1.13.19 Inform any woman with infibulated genital mutilation of the risks of difficulty with vaginal examination, catheterisation and application of fetal scalp electrodes. Inform her 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. [2007] 1.13.20 If an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy. [2007] 1.13.21 Perform an episiotomy if there is a clinical need, such as instrumental birth or suspected fetal compromise. [2007] 1.13.22 Provide tested effective analgesia before carrying out an episiotomy, except in an emergency because of acute fetal compromise. [2007] Water birth1.13.23 Inform women that there is insufficient high‑quality evidence to either support or discourage giving birth in water. [2007] Delay in the second stage1.13.24 If there is delay in the second stage of labour, or if the woman is excessively distressed, support and sensitive encouragement and the woman's need for analgesia/anaesthesia are particularly important. [2007] 1.13.25 An obstetrician should assess a woman with confirmed delay in the second stage (after transfer to obstetric‑led care, following the general principles for transfer of care) before contemplating the use of oxytocin. [2014] 1.13.26 After initial obstetric assessment of a woman with delay in the second stage, maintain ongoing obstetric review every 15 to 30 minutes. [2007] Instrumental birth and delayed second stage1.13.27 Think about offering instrumental birth if there is concern about the baby's wellbeing or there is a prolonged second stage. [2007] 1.13.28 Recognise that, on rare occasions, the woman's need for help in the second stage may be an indication to assist by offering instrumental birth when supportive care has not helped. [2007] 1.13.29 The choice of instrument depends on a balance of clinical circumstance and practitioner experience. [2007] 1.13.30 Because instrumental birth is an operative procedure, advise the woman to have tested effective anaesthesia. [2007] 1.13.31 If a woman declines anaesthesia, offer a pudendal block combined with local anaesthetic to the perineum during instrumental birth. [2007] 1.13.32 If there is concern about fetal compromise, offer either tested effective anaesthesia or, if time does not allow this, a pudendal block combined with local anaesthetic to the perineum during instrumental birth. [2007] 1.13.33 Advise the woman to have a caesarean section if vaginal birth is not possible (see the NICE guideline on caesarean birth). [2007] . Expediting birth1.13.34 If the birth needs to be expedited for maternal or fetal reasons, assess both the risk to the baby and the safety of the woman. Assessments should include:
1.13.35 Talk with the woman and her birth companion(s) about why the birth needs to be expedited and what the options are. [2014] 1.13.36 Inform the team about the degree of urgency. [2014] 1.13.37 Record the time at which the decision to expedite the birth is made. [2014] 1.14 Third stage of labour1.14.1 Recognise that the time immediately after the birth is when the woman and her birth companion(s) are meeting and getting to know the baby. Ensure that any care or interventions are sensitive to this and minimise separation or disruption of the mother and baby. [2014] Definition of the third stage1.14.2 For the purposes of this guideline, use the following definitions:
Prolonged third stage1.14.3 Diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management. Follow the recommendations on managing retained placenta. [2014] Observations in the third stage1.14.4 Record the following observations for a woman in the third stage of labour:
1.14.5 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 stage1.14.6 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. [2014] 1.14.7 Explain to the woman that active management:
1.14.8 Explain to the woman that physiological management:
1.14.9 Discuss again with the woman at the initial assessment in labour (see the section on initial assessment) about the different options for managing the third stage and ways of supporting her during delivery of the placenta, and ask if she has any preferences. [2014] 1.14.10 Advise the woman to have active management of the third stage, because it is associated with a lower risk of a postpartum haemorrhage and/or blood transfusion. [2014] 1.14.11 If a woman at low risk of postpartum haemorrhage requests physiological management of the third stage, support her in her choice. [2014] 1.14.12 Document in the records the decision that is agreed with the woman about management of the third stage. [2014] 1.14.13 For active management, administer 10 IU of oxytocin by intramuscular injection with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is clamped and cut. Use oxytocin as it is associated with fewer side effects than oxytocin plus ergometrine. [2014] 1.14.14 After administering oxytocin, clamp and cut the cord.
1.14.15 After cutting the cord, use controlled cord traction. [2014] 1.14.16 Perform controlled cord traction as part of active management only after administration of oxytocin and signs of separation of the placenta. [2014] 1.14.17 Record the timing of cord clamping in both active and physiological management. [2014] 1.14.18 Advise a change from physiological management to active management if either of the following occur:
1.14.19 Offer a change from physiological management to active management if the woman wants to shorten the third stage. [2014] 1.14.20 Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage of labour. [2014] Retained placenta1.14.21 Secure intravenous access if the placenta is retained, and explain to the woman why this is needed. [2014] 1.14.22 Do not use umbilical vein agents if the placenta is retained. [2014] 1.14.23 Do not use intravenous oxytocic agents routinely to deliver a retained placenta. [2014] 1.14.24 Give intravenous oxytocic agents if the placenta is retained and the woman is bleeding excessively. [2014] 1.14.25 If the placenta is retained and there is concern about the woman's condition:
1.14.26 If the woman reports inadequate analgesia during the assessment, stop the examination and address this immediately. [2014] 1.14.27 If uterine exploration is necessary and the woman is not already in an obstetric unit, arrange urgent transfer (following the general principles for transfer of care). [2014] 1.14.28 Do not carry out uterine exploration or manual removal of the placenta without an anaesthetic. [2014] Postpartum haemorrhageRisk factors1.14.29 Advise women with risk factors for postpartum haemorrhage to give birth in an obstetric unit, where more emergency treatment options are available.
1.14.30 If a woman has risk factors for postpartum haemorrhage, highlight these in her notes, and make and discuss with her a care plan covering the third stage of labour. [2007] Management1.14.31 If a woman has a postpartum haemorrhage:
1.14.32 Administer a bolus of one of the following as first‑line treatment for postpartum haemorrhage:
1.14.33 Offer second‑line treatment for postpartum haemorrhage if needed. No particular uterotonic drug can be recommended over any other; options include:
1.14.34 Assess the need for adjuvant options for managing significant continuing postpartum haemorrhage, including:
1.14.35 Allocate a member of the healthcare team to stay with the woman and her birth companion(s), explain what is happening, answer any questions and offer support throughout the emergency situation. [2014] 1.14.36 If the haemorrhage continues:
1.14.37 Be aware that no particular surgical procedure can be recommended over any other for treating postpartum haemorrhage. [2014] 1.14.38 The maternity service and ambulance service should have strategies in place in order to respond quickly and appropriately if a woman has a postpartum haemorrhage in any setting. [2014] 1.15 Care of the newborn babyInitial assessment of the newborn baby and mother–baby bondingRecommendations 1.15.6, 1.15.8 and 1.15.9 have been adapted from NICE's guideline on postnatal care; refer to this guideline for more information on immediate postnatal care (within 2 hours of birth). 1.15.1 Record the Apgar score routinely at 1 and 5 minutes for all births. [2007] 1.15.2 Record the time from birth to the onset of regular respirations. [2014] 1.15.3 If the baby is born in poor condition (on the basis of abnormal breathing, heart rate or tone):
1.15.4 Do not take paired cord blood samples (for blood gas analysis) routinely. [2014] 1.15.5 Ensure that a second clamp to allow double‑clamping of the cord is available in all birth settings. [2014] 1.15.6 Encourage women to have skin‑to‑skin contact with their babies as soon as possible after the birth. [2007] 1.15.7 In order to keep the baby warm, dry and cover him or her with a warm, dry blanket or towel while maintaining skin‑to‑skin contact with the woman. [2007] 1.15.8 Avoid separation of a woman and her baby within the first hour of the birth for routine postnatal procedures, for example, weighing, measuring and bathing, unless these measures are requested by the woman, or are necessary for the immediate care of the baby. [2007] 1.15.9 Encourage initiation of breastfeeding as soon as possible after the birth, ideally within 1 hour. [2007] 1.15.10 Record head circumference, body temperature and birth weight soon after the first hour following birth. [2007] 1.15.11 Undertake an initial examination to detect any major physical abnormality and to identify any problems that require referral. [2007] 1.15.12 Ensure that any examination or treatment of the baby is undertaken with the consent of the parents and either in their presence or, if this is not possible, with their knowledge. [2007] Neonatal resuscitation1.15.13 In the first minutes after birth, evaluate the condition of the baby – specifically respiration, heart rate and tone – in order to determine whether resuscitation is needed according to nationally accredited guidelines on neonatal resuscitation. [2014] 1.15.14 All relevant healthcare professionals caring for women during birth should attend annually a course in neonatal resuscitation that is consistent with nationally accredited guidelines on neonatal resuscitation. [2014] 1.15.15 In all birth settings:
1.15.16 If a newborn baby needs basic resuscitation, start with air. [2014] 1.15.17 Minimise separation of the baby and mother, taking into account the clinical circumstances. [2014] 1.15.18 Throughout an emergency situation in which the baby needs resuscitation, allocate a member of the healthcare team to talk with, and offer support to, the woman and any birth companion(s). [2014] Care of babies in the presence of meconium1.15.19 In the presence of any degree of meconium:
1.15.20 If there has been significant meconium (see recommendation 1.5.2 in the section on 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. [2014] 1.15.21 If there has been significant meconium and the baby is healthy, closely observe the baby within a unit with immediate access to a neonatologist. Perform these observations at 1 and 2 hours of age and then 2‑hourly until 12 hours of age. [2014] 1.15.22 If there has been non‑significant meconium, observe the baby at 1 and 2 hours of age in all birth settings. [2014] 1.15.23 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):
1.15.24 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. [2014] Babies born to women with prelabour rupture of the membranes at term1.15.25 Closely observe any baby born to a woman with prelabour rupture of the membranes (more than 24 hours before the onset of established labour) at term for the first 12 hours of life (at 1 hour, 2 hours, 6 hours and 12 hours) in all settings. Include assessment of:
1.15.26 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] 1.15.27 If there is evidence of infection in the woman, prescribe a full course of broad‑spectrum intravenous antibiotics. [2007] 1.15.28 Advise women with prelabour rupture of the membranes to inform their healthcare professionals immediately of any concerns they have about their baby's wellbeing in the first 5 days after birth, particularly in the first 12 hours when the risk of infection is greatest. [2007] 1.15.29 Do not perform blood, cerebrospinal fluid and/or surface culture tests in an asymptomatic baby. [2007] 1.15.30 Refer a baby with any symptom of possible sepsis, or born to a woman who has evidence of chorioamnionitis, to a neonatal care specialist immediately. [2007] 1.16 Care of the woman after birthInitial assessment1.16.1 Carry out the following observations of the woman after birth:
Perineal care1.16.2 Define perineal or genital trauma caused by either tearing or episiotomy as follows:
1.16.3 Before assessing for genital trauma:
1.16.4 Perform the initial examination gently and with sensitivity. It may be done in the immediate period after birth. [2007] 1.16.5 If genital trauma is identified after birth, offer further systematic assessment, including a rectal examination. [2007] 1.16.6 Include the following in a systematic assessment of genital trauma:
1.16.7 Ensure that the timing of this systematic assessment does not interfere with mother–baby bonding unless the woman has bleeding that requires urgent attention. [2007] 1.16.8 Assist the woman to adopt a position that allows adequate visual assessment of the degree of trauma and for repair. Only maintain this position for as long as necessary for systematic assessment and repair. If it is not possible to adequately assess the trauma, transfer the woman (with her baby) to obstetric‑led care, following the general principles for transfer of care. [2007, amended 2014] 1.16.9 Seek advice from a more experienced midwife or obstetrician if there is uncertainty about the nature or extent of the trauma. Transfer the woman (with her baby) to obstetric‑led care (following the general principles for transfer of care) if the repair needs further surgical or anaesthetic expertise. [2007, amended 2014] 1.16.10 Document the systematic assessment and its results fully, possibly pictorially. [2007] 1.16.11 All relevant healthcare professionals should attend training in perineal/genital assessment and repair, and ensure that they maintain these skills. [2007] 1.16.12 Undertake repair of the perineum as soon as possible to minimise the risk of infection and blood loss. [2007] 1.16.13 When carrying out perineal repair:
1.16.14 If the woman reports inadequate pain relief at any point, address this immediately. [2007] 1.16.15 Advise the woman that in the case of first‑degree trauma, the wound should be sutured in order to improve healing, unless the skin edges are well opposed. [2007] 1.16.16 Advise the woman that in the case of second‑degree trauma, the muscle should be sutured in order to improve healing. [2007] 1.16.17 If the skin is opposed after suturing of the muscle in second‑degree trauma, there is no need to suture it. [2007] 1.16.18 If the skin does require suturing, use a continuous subcuticular technique. [2007] 1.16.19 Undertake perineal repair using a continuous non‑locked suturing technique for the vaginal wall and muscle layer. [2007] 1.16.20 Use an absorbable synthetic suture material to suture the perineum. [2007] 1.16.21 Offer rectal non‑steroidal anti‑inflammatory drugs routinely after perineal repair of first‑ and second‑degree trauma provided these drugs are not contraindicated. [2007] 1.16.22 Observe the following basic principles when performing perineal repairs:
What happens in the 2nd stage of labor?In the second stage of labor, your cervix is fully dilated and ready for childbirth. This stage is the most work for you because your provider wants you to start pushing your baby out. This stage can be as short as 20 minutes or as long as a few hours. It may be longer for first-time moms or if you've had an epidural.
What is the latent phase of labor?Early Labor (Latent Phase of Labor)
During the latent phase of labor, contractions are usually irregular (occurring every five to 20 minutes) and mild to moderately uncomfortable. The contractions may feel like gas pains, bad menstrual cramps, or back discomfort.
Which 2 of the following would indicate that a woman is in the second stage of labour?The second stage starts when your cervix is fully open (dilated) and the muscles of your womb are tightening and loosening to push the baby down and out. You may not feel an urge to push straightaway, which is called the passive second stage.
What are the two phases of second stage of labour?There are two phases of the second stage of labor, the passive stage and the active stage.
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