Intrapartum care of healthy women and their babies: summary of updated NICE guidance



## Recommendations
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group's experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

## Choosing the planned place of birth
- Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for the woman and her baby. [Based on high to very low quality evidence from randomised controlled trials, observational studies, and the experience and opinion of the Guideline Development Group .]
- Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit (alongside an obstetric unit and not requiring ambulance transfer), or obstetric unit) and support them in their choice of setting, wherever that may be: -Advise low risk multiparous women that planning to give birth at home or in a midwifery led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit (tables 1 and 2)
-Advise low risk nulliparous women that planning to give birth in a midwifery led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit. However, if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby (tables 3 and 4). (New recommendation.) [Based on high to very low quality evidence from randomised controlled trials and observational studies and the experience and opinion of the GDG]
- Boxes 1 and 2 outline medical conditions and obstetric and gynaecological factors that indicate increased risk. Women with these conditions or factors should consider planned birth at an obstetric unit.

## The bottom line
- The care that a woman receives during labour can affect the woman herself (physically and emotionally) and the health of her baby in the short and longer term - Maternity services should provide a model of care that supports one-to-one care in labour
- Low risk mothers and babies do not benefit from birth in hospital obstetric units or from many previously "routine" but unindicated labour interventions
- Clinicians need to be familiar with the evidence and able to talk non-judgmentally to women about their choices - Healthcare service commissioners and providers should ensure that all four birth settings are available to all women (in the local area or in a neighbouring area

## Service organisation and clinical governance
- Commissioners and providers should ensure that there are: -Robust protocols in place for transfer of care between settings.
-Clear local pathways for the continued care of women who are transferred from one setting to another, including:
Where this involves crossing provider boundaries (institutional boundaries, whether geographical or policy related, should not impede care or endanger women)
Arrangements for occasions when the nearest obstetric or neonatal unit is closed to admissions or when the local midwifery led unit is full.

## (new recommendation.) [based on the experience and opinion of the gdg]

## Education and early assessment
- Consider early assessment of labour by telephone triage provided by a dedicated triage midwife for all women.

## (new recommendation.) [based on high to low quality evidence from randomised trials and the experience and opinion of the gdg]
- Consider a face-to-face early assessment of labour for all low risk nulliparous women, either: -At home (regardless of planned place of birth) or -In an assessment facility in her planned place of birth (midwifery led unit or obstetric unit), comprising one-to-one midwifery care for at least one hour. 

## Third stage of labour
For the purposes of this guideline, use the following definitions:
- The third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes.
- Active management of the third stage involves a package of care comprising the following three components:
-Routine use of uterotonic drugs -Deferred clamping and cutting of the cord -Controlled cord traction after signs of separation of the placenta.
- Physiological management of the third stage involves a package of care that includes the following three - After administering oxytocin, clamp and cut the cord: -Do not clamp the cord sooner than one minute after the birth of the baby unless there is concern about the integrity of the cord or the baby has a heartbeat of under 60 beats/min that is not getting faster -Clamp the cord before five minutes to perform controlled cord traction as part of active management -If the woman asks for the cord to be clamped and cut more than five minutes after birth, support her in her choice.

## Overcoming barriers
This guideline recommends that women should be given information and advice about all types of planned labour settings and be advised that all settings are available. Healthcare professionals may need to change the advice they give and the manner in which they deliver this. The provision of one-to-one care in all birth settings is recommended. This may not be happening at the moment because of shortages of midwives and budgets. The guideline also highlights the need for robust protocols regarding the transfer of care between settings when required (see for reasons for transfer).
The guidance on cardiotocography has also been updated to clarify when it is not indicated and recommendations are now better aligned with the predictive value of this technique. Early cord clamping is no longer recommended, and healthcare professionals may need to change practice and document when cord clamping has taken place. On the basis of the evidence, the recommendations set the limit of no earlier than one minute and no later than five minutes after birth in active management of the third stage of labour.

## Further information on the guidance
This update to the 2007 guidance was undertaken because of concern about possible variation of practice in labour in England and Wales (for example, variations in care during the latent first stage, fetal monitoring, and third stage practices). It also reflects new research on, for example, the timing of cord clamping and birth outcomes in England by parity and birth setting. The updated guideline emphasises women centred care, highlighting women's informed decision making and choice, as well as noting how the practices, demeanour, and attitudes of staff can influence the experience of women and their birth companions.

# Methods
This guidance was developed by the National Collaborating Centre for Women's and Children's Health in accordance with National Institute for Health and Care Excellence (NICE) guideline development methods (www.nice.org.uk/article/PMG6/chapter/1%20Introduction). A Guideline Development Group (GDG) was established by the National Collaborating Centre for Women's and Children's Health; it incorporated healthcare professionals (including midwives, obstetricians, a neonatologist, an anaesthetist, a healthcare service commissioner, and a general practitioner) and lay members. The GDG identified relevant clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions where possible. The draft guideline underwent a public consultation in which stakeholder organisations were invited to comment; the GDG took all comments into consideration when producing the final version of the guideline.
Four different versions of this guideline have been produced: a full version containing all the evidence, the process undertaken to develop the recommendations, and all the recommendations; a care pathway; a version containing a list of all the recommendations, known as the "NICE guideline"; and a version for the public (www.nice.org.uk/guidance/cg190/informationforpublic). All of these versions are available from the NICE website (www.nice.org.uk/CG190). Updates of the guideline will be produced as part of NICE's guideline development programme.

# Future research
- How does the provision of accurate, evidence based information affect women's decision making processes and choice of place of birth?
- What are the long term consequences for women and babies of planning birth in different settings?
- Does enhanced education specifically about the latent first stage of labour increase the number of nulliparous women who wait until they are in established labour before attending the obstetric or freestanding or alongside midwifery unit (or calling the midwife to a home birth), compared with women who do not receive this education?
- What is the most effective treatment for primary postpartum haemorrhage?
- For women who are assessed as being at low risk of complications at the start of labour, what are the natural frequencies of the avoidable harms that cardiotocography is intended to prevent? Does the use of cardiotocography in labours where complications develop confer a net benefit compared with intermittent auscultation? Babies with serious medical problems  *No of babies per 1000 births. Serious medical problems were combined. Neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, 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 events. Fractured humerus and clavicle were uncommon (<4% of adverse events).

# Tables
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[table] Table 1 |: Spontaneous vaginal birth, transfer to an obstetric unit, and obstetric interventions according to planned place of birth*: low risk multiparous women *Figures are instances (n) per 1000 multiparous women giving birth. Data from Birthplace in England Collaborative Group 3 and Blix and colleagues 4 (all other data from Birthplace in England Collaborative Group 3 only). Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise. The Birthplace in England Collaborative Group 3 reported spinal or epidural analgesia and Blix and colleagues reported epidural analgesia.*No of babies per 1000 births. Serious medical problems were combined. Neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, 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 events. Fractured humerus and clavicle were uncommon (<4% of adverse events). personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe [/table]
[table] Table 3|: Spontaneous vaginal birth, transfer to an obstetric unit, and obstetric interventions according to planned place of birth*: low risk nulliparous women *Figures are instances (n) per 1000 multiparous women giving birth. Figures from Birthplace in England Collaborative Group 3 and Blix and colleagues 4 (all other figures from Birthplace in England Collaborative Group 3 only). Estimated transfer rate from one obstetric unit to a different one owing to lack of capacity or expertise. The Birthplace in England Collaborative Group 3 reported spinal or epidural analgesia and Blix and colleagues reported epidural analgesia. For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe [/table]
[table] Table 4|: Outcomes for the baby for each planned place of birth: low-risk nulliparous women [/table]