Introduction

The Intrapartum Care NICE Guidelines were issued in September 2007. They cover the care of healthy women in labour at term (37 - 42 weeks). They update the Electronic Fetal Monitoring Guidelines issued in May 2001 and partially update the Induction of Labour Guidelines issued in June 2001.

The new NICE Guidelines are an essential part of any risk management strategy. When defending obstetric compensation claims, NHS Trusts will also need to demonstrate that their health professionals complied. The full NICE Guidelines are over 60 pages long and can be found on the NICE website (CG55). We have set out a summary of the key points below for you to review against your own procedures:

Planning place of birth

Women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit. Women should be advised of the risks and benefits associated with giving birth at home, in a midwife led unit and in an obstetric unit.

A woman who has a pre-existing medical condition or has had a previous complicated birth that makes her at higher risk of developing complications during her next birth, should be advised to give birth in an obstetric unit.

The Guidelines prescribe that Clinical governance structures should be implemented in all places of birth, summarised below:

		Multi-disciplinary clinical governance structures (e.g. the Labour Ward Forum) should be in place to enable the oversight of all places of birth. As a minimum these structures should include midwifery expertise (ideally from a supervisor), obstetric, anaesthetic and neonatal expertise.
		Rotating staff between obstetric and midwifery led units should be encouraged.
		Midwives should be able to inform or seek advice from a supervisor of midwives when caring for a woman who may have high risk factors but does not wish to labour in an obstetric unit.
		If the midwife or the woman seeks obstetric opinion on the appropriate place of birth, this should be from a Consultant.
		All Healthcare Professionals should document discussions with the woman about her chosen place of birth in the hand-held maternity notes.
		Risk assessment in the antenatal period and when labour commences should be subject to continuous audit
		Monthly figures of numbers of women booked for, admitted to, transferred from and given birth in each place of birth should be audited and include maternal and neonatal outcomes.
		The clinical governance group should be responsible for detailed root cause analysis of any serious maternal and neonatal adverse outcomes and consider any near misses. Data must be submitted for the National Registries for either intrapartum related perinatal mortality or neonatal encephalopathy.

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Communication throughout labour

		All women should be treated with respect and should be in control of and involved in what is happening to them.
		Healthcare Professionals should establish communication with the labouring woman and should read and discuss a written birth plan with her.
		A woman in established labour should receive supportive one to one care and a woman in established labour should not be left on her own except for short periods or at the woman’s request.
		Team midwifery is not recommended.

Regional Analgesia

The Guidelines provide that women should be informed about the risks and benefits of regional analgesia and the implications for their labour.

It is important to advise women that regional analgesia is associated with a longer second stage of labour and an increased chance of instrumental birth, but that it is not associated with a longer first stage of labour or an increased chance of caesarean birth. Women should be informed that modern epidurals contain opioids which cross the placenta and in large doses may cause short-term respiratory depression and make the baby drowsy.

When dealing with consent issues, Claimant solicitors will no doubt be looking for evidence in the notes that women were counselled appropriately and so, as ever, it is important that healthcare professionals document their discussions with the patient.

The Guidelines also provide that women in labour should not be denied regional analgesia (including women in severe pain in the later first stage of labour).

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First Stage of Labour

The Guidelines define the established first stage of labour is as when there are regular painful contractions and there is progressive cervical dilation from 4cm.

Delay in the established first stage is defined as cervical dilation of less than 2cm in four hours for first labours and cervical dilation of less than 2cm in four hours or a slowing in the progress of labour for second or subsequent labours. This is helpful guidance as previously, most of the literature supported the argument that slow progress was less than 1 cm per hour.

A diagnosis of delay should take into consideration the descent and rotation of the fetal head and changes in the strength, duration and frequency of contractions.

The use of admission CTG monitoring in low risk pregnancy is not recommended in any birth setting.

Where delay in the established first stage is suspected the following should be considered: parity, cervical dilation and rate of change, uterine contractions, station and position of presenting part, the woman’s emotional state and referral to the appropriate Healthcare Professionals.

Amniotomy should be considered for all women with intact membranes. A vaginal examination (VE) should be performed two hours later and, if at that stage, progress is less than 1cm, a diagnosis of delay is made.

In nulliparous women, advice should be sought from an obstetrician and the use of oxytocin should be considered. They should also be seen by an obstetrician.

A VE should be performed four hours after commencing oxytocin in established labour. If there is less than 2cm progress after four hours of oxytocin, further obstetric review is required to consider a caesarean. If there is 2cm or more progress, VE’s should be advised four-hourly.

If a partogram action line is used this should be a four hour action line. The fetal heart rate should be checked every 15 minutes after a contraction. The frequency of contractions should be documented every 30 minutes. The pulse should be checked every hour, BP and temperature every four hours and a VE offered. The frequency of bladder emptying should also be checked regularly.

The indications for continuous electronic fetal monitoring in low risk women are: significant meconium stained liquor, abnormal FHR, maternal pyrexia, fresh bleeding and also a woman’s request

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Second Stage of Labour

A diagnosis of delay in the active second stage should be made when the first stage has lasted two hours and women should be referred for operative vaginal birth. In parous women, a diagnosis of delay in the active second stage should be made when it has lasted one hour.

Instrumental birth should be considered if there is concern about fetal wellbeing or for a prolonged second stage. An episiotomy should only be carried out when there is a clinical need (such as an instrumental birth) or there is suspected fetal compromise. If a woman has full dilation but no urge to push, she should be assessed after one hour.

Third Stage of Labour

Third stage of labour is diagnosed as prolonged if not completed within 30 minutes of the birth of the baby with active management and 60 minutes with physiological management. Changing from physiological management to active management of the third stage is indicated in the case of haemorrhage, failure to deliver the placenta within one hour and/or the woman’s desire to artificially the shorten the third stage.

Apgar scores should be recorded at one and five minutes. Breast feeding should be initiated within the first hour and after one hour the baby’s head circumference, body temperature and weight should be recorded.

Intravenous access should always be secured in women with a retained placenta but intravenous infusion of oxytocin should not be used. Oxytocin injection into the umbilical vein is recommended, following by proximal clamping of the cord.

If the placenta is still retained 30 minutes after oxytocin injection, assessment should be offered with analgesia (or even anaesthesia). If manual removal is required, this must be carried out under effective regional or general anaesthesia.

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Risk Factors for Postpartum Haemorrhage

The Guidelines provide that antenatal risk factors include previous retained placenta or postpartum haemorrhage, maternal haemoglobin level below 8.5 G/DL at onset of labour, body mass index greater than 35kg/m2, parity 4 or more, antepartum haemorrhage, over-distension of the uterus, existing uterine abnormalities.

Risk factors in labour include induction, prolonged first, second or third stage of labour, oxytocin use, precipitate labour, operative birth or caesarean section.

Any risk factors should be highlighted in the notes and a care plan made. The unit should also have strategies in place in order to respond quickly and appropriately should a postpartum haemorrhage occur.

Immediate treatment for postpartum haemorrhage should include calling for appropriate help, uterine massage, IV fluids and uterotonics.

No particular uterotonic drug is recommended over another and no particular surgical procedure is recommended over another.

Changes to the Induction of Labour NICE Guidelines issued June 2001

Section 1.10 of the 2007 Intrapartum Care Guidelines, which deals with pre-labour rupture of the membranes at term, replaces Section 2 of the 2001 Induction of Labour Guidelines which relate to pre-labour rupture of the membranes.

The 2007 guidelines in respect of pre-labour rupture of the membranes at term can be summarised as follows:

		Women with an uncertain history of pre-labour rupture of the membranes should be offered a speculum examination (digital vaginal examination in the absence of contractions should be avoided).
		Women presenting with pre-labour rupture of the membranes at term should be informed that the risk of serious neonatal infection is 1% rather than 0.5% for women with intact membranes. Women should be informed that 60% of women with pre-labour rupture of the membranes will go into labour within 24 hours and induction is appropriate approximately 24 hours after rupture of the membranes. These discussions should be documented in the notes.
		Until the induction is commenced, lower vaginal swabs and maternal C-reactive protein should not be offered. Women should be advised to record their temperature every four hours and report any change in the colour or smell of their vaginal loss immediately. Women should be informed that having sexual intercourse increases the risk of infection.
		If there are no signs of infection, antibiotics should not be given to either the woman or the baby. If however there is evidence of infection in the woman, a full course of broad-spectrum intravenous antibiotics should be prescribed.
		Women should be asked to inform their Healthcare Professionals immediately of any concerns they have about the baby’s wellbeing in the first five days following birth, particularly in the first 12 hours.
		Blood, cerebrospinal fluid and/or surface culture tests should not be performed in a symptomatic baby.
		A symptomatic term baby is born to women with pre-labour rupture of the membranes (more than 24 hours before labour) and should be closely observed for the first 12 hours of life (at one hour, two hours and then two hourly for 10 hours).

Conclusion

The new NICE Guidelines must be reflected in your Trusts’ own protocols and disseminated. When defending obstetric compensation claims, Trusts will also need to demonstrate that their health professionals complied with the Guidelines. If there has been a departure from the Guidelines then this is not necessarily conclusive - this document is no more than a guide and should not be seen as a bible - but it is a strong indication to the Court of the recognised standards to be adhered to and the reasons for any departure should be robust and logical, ideally discussed with a senior clinician and the patient wherever possible, and always clearly documented in the notes.

Trusts should ensure that all relevant healthcare professionals are familiar with the new NICE Guidelines with the aim of improving patient safety. Claimant’s solicitors will no doubt scrutinise patient records alongside the Guidelines when formulating compensation claims if they do not.

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