Intrapartum care

1. Intrapartum care Implementing NICE guidance 2nd edition March 2012 NICE clinical guideline 55

2. Guideline review • Guideline issue date: 2007 • First review year: 2011 • 2011 review recommendation • The guideline should be updated. • Consultation on the update scope closed in November 2011. No publication date has yet been confirmed.

3. What this presentation covers • Background • Scope • Key priorities for implementation • Costs and savings • NHS Evidence and • NICE Pathway • Find out more

4. Background • About 600,000 births in England and Wales per year • Most women are healthy and have a straightforward pregnancy • Birth is a life-changing event • Care in labour affects women physically and emotionally in the short and longer term

5. Key priorities for implementation • Communication • Labour • Perineal care • Planning place of birth • Clinical governance structures

6. Communication • Women should be treated with respect • Women should be in control of and involved in their labour • Establish a rapport to help the woman identify her wants and expectations • Use this information to support and guide the woman through labour and birth

7. Labour (1) • A woman in established labour should receive supportive one-to-one care • A woman in established labour should not be left on her own • Do not offer or advise medical intervention if: • the woman and her baby are well • labour is progressing normally

8. Labour (2) • Labouring in water is recommended for pain relief • Inform the woman of the risks and benefits of an epidural and the implications for labour

9. Delayed labour andinstrumental birth • If a nulliparous woman has confirmed delay in the first stage: • seek advice from an obstetrician • consider using oxytocin • discuss potential outcomes • Use tested effective anaesthesia for instrumental birth

10. Perineal care • If genital trauma is identified, carry out a systematic assessment: • explain what will be done and why • make sure adequate anaesthesia is in place • perform a rectal examination • record findings

11. Place of birth • Women should be: • offered choices: birth at home, in a midwife-led unit or in an obstetric unit • informed of the potential risks and benefits of each birth setting • Document discussions about place of birth in the maternity notes

12. Clinical governance structures • A multidisciplinary group (such as the Labour Ward Forum) should be responsible for the collection and audit of maternal and neonatal outcomes relating to each place of birth.

13. Governance issues • Identification of risk in the antenatal period • Recognising risk and appropriate transfer • Data collection and audit related to transfer • Root-cause analysis • Audit • National surveillance schemes

14. Identification of risk in the antenatal period • Establish clear pathways for midwives to seek advice from a supervisor of midwives when women with risk factors choose not to labour in an obstetric unit • If a midwife or a woman seeks advice about appropriate place of birth, a consultant obstetrician should provide this advice • Document discussions about place of birth in maternity notes

15. Recognising risk and appropriate transfer • Establish clear pathways, guidelines and processes for transfer • Develop clear pathways and guidelines for continued care of women following transfer • When transfer is not possible because of emergency, provide open access to all staff who need it • Encourage staff rotation between obstetric and midwife-led units

16. Data collection and audit: transfer • Carry out continuous audit of reasons for and speed of transfer • Include: • when transfer was indicated but did not occur • the time taken to see an obstetrician or neonatologist • the time from admission to birth once transferred

17. Root-cause analysis • Undertake detailed root-cause analysis of any serious maternal or neonatal outcomes • Consider ‘near misses’ identified through risk-management systems • Use CEMACH and NPSA frameworks for clinical governance and risk-management targets

18. Audit • For each place of birth, carry out monthly audit: • numbers of women booking for, admitted to, transferred from and giving birth there • include data on maternal and neonatal outcomes • Risk assessment should be continuously audited • Submit audit data to national registries once these are in existence

19. National surveillance • These should be established: • a national surveillance scheme of all places of birth • national registries of causes of all intrapartum-related deaths over 37 weeks • a definition and national registry of neonatal encephalopathy

20. Costs and savings • The following recommendations were identified in the costing work but were not found to have significant resource impact: • maintaining epidural analgesia • training in perineal / genital assessment • rectal non-steroid anti-inflammatory drugs • prelabour rupture of the membranes Costing information correct at Sept. 2007. This was not updated for 2nd edition

21. NICE Pathway • The NICE Intrapartum care Pathway covers the care of healthy women in labour at term (37–42 weeks) Click here to go to NICE Pathways website

22. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects of maternity care Click here to go to the NHS Evidence website

23. Find out more • Visit www.nice.org.uk/guidance/CG55 for: • the NICE guideline • the full guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing statement • audit support

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