Intrapartum careImplementing NICE guidance

2nd edition March 2012

NICE clinical guideline 55

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.

What this presentation covers

Background

Scope

Key priorities for implementation

Costs and savings

NHS Evidence andNICE Pathway

Find out more

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

Key priorities for implementation

Communication

Labour

Perineal care

Planning place of birth

Clinical governance structures

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

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

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

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

Perineal careIf 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

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

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.

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

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

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

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

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

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

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

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

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

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

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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