Intrapartum care

1.3.1 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]

1.3.2 Advise women that additional resources to help them plan their place of birth are available on the tools and resources page for this guideline and the NHS website. [2023]

1.3.3 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:

1.3.4 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]

1.3.5 Discuss with women the following information, including local statistics, about all local birth settings, and update them if this changes during their pregnancy:

Source: Birthplace in England research study, 2011.

1.3.6 Advise women that, in general, the higher their body mass index (BMI) at booking (and particularly with a BMI above 35 kg/m²), the greater the likelihood of complications, so this may be something they wish to think about when planning their place of birth. Discuss with them that:

1.3.7 Using tables 2 and 3, explain to low-risk multiparous women that:

Sources: Birthplace in England research study, 2011; Outcomes of planned home births and planned hospital births in low-risk women in Norway between 1990 and 2007 (Blix et al. 2012).

For obstetric unit transfer to an obstetric unit, the 10 cases noted in table 2 are the estimated transfer rate from one obstetric unit to a different obstetric unit owing to lack of capacity or expertise. For regional anaesthesia, Blix et al. reported epidural analgesia and the Birthplace in England study reported spinal or epidural analgesia.

Source: Birthplace in England research study, 2011.

Serious medical problems were combined in table 3: 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.

1.3.8 Using tables 4 and 5, explain to low-risk nulliparous women that:

Sources: Birthplace in England research study, 2011; Outcomes of planned home births and planned hospital births in low-risk women in Norway between 1990 and 2007 (Blix et al. 2012).

For obstetric unit transfer to an obstetric unit, the 10 cases noted in table 4 are the estimated transfer rate from one obstetric unit to a different obstetric unit owing to lack of capacity or expertise. For regional anaesthesia, Blix et al. reported epidural analgesia and the Birthplace in England study reported spinal or epidural analgesia.

Source: Birthplace in England research study, 2011.

Serious medical problems were combined in table 5: 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.

1.3.9 Use tables 6 to 9 as part of an assessment for a woman choosing her planned place of birth:

1.3.10 If further discussion is wanted by either the midwife or the woman about the choice of planned place of birth, arrange this with an appropriately trained senior or consultant midwife and/or a senior or consultant obstetrician if there are obstetric issues. [2014, amended 2023]

1.3.11 When discussing the woman's choice of place of birth with her, do not disclose personal views or judgements about her choices. [2014]

1.4.5 Maternity services should:

1.4.6 Do not leave a woman in established labour on her own except for short periods or at the woman's request. [2007]

1.4.7 For guidance on ensuring continuity of care, see recommendation 1.4.1 in the NICE guideline on patient experience in adult NHS services. [2016]

1.4.8 When giving a woman (and her birth companions) information about care during labour:

1.4.9 Treat all women in labour with kindness, dignity and respect. [2007, amended 2023]

1.4.10 Ensure that the woman is empowered, informed and central to making decisions about her care, and recognise that the way in which care is given is key to this. Support the woman so she:

1.4.11 To establish communication with the woman:

1.4.12 Encourage and help the woman to move and adopt whatever positions she finds most comfortable throughout labour, except lying flat on her back. [2007, amended 2023]

1.4.13 Encourage the woman to have support from birth companion(s) of her choice. [2007]

1.4.14 Tap water may be used if cleansing is needed before vaginal examination. [2007]

1.4.15 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]

1.4.16 Selection of personal protective equipment for healthcare professionals must be based on an assessment of the risk of exposure to blood and/or bodily fluids, non-intact skin or mucous membranes. Standard infection control procedures to prevent transmission of recognised and unrecognised infections must be followed. See NHS England's national infection prevention and control manual. [2007, amended 2023]

1.6.1 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]

1.6.2 Take into account that every woman's experience of pain is unique and may be expressed in different ways, both verbally and non-verbally. In particular, this may vary because of:

1.6.3 Advise women that breathing exercises, having a shower or bath, and massage may reduce pain during the latent first stage of labour. [2014, amended 2023]

1.6.4 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, support her choice. [2014, amended 2023]

1.6.5 If a woman chooses to use breathing and relaxation techniques in labour, support her choice. [2007]

1.6.6 If a woman chooses to use massage techniques in labour that have been taught to birth companions, support her choice. [2007]

1.6.7 Advise women who wish to use transcutaneous electrical nerve stimulation (TENS) that:

1.6.8 Do not offer acupuncture, acupressure or hypnosis during labour. If a woman wants to use any of these techniques, support her choice. [2007, amended 2023]

1.6.9 Support the playing of music of the woman's choice in labour. [2007]

1.6.10 Offer the woman the opportunity to labour in water for pain relief. [2007]

1.6.11 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]

1.6.12 Keep baths and birthing pools clean using a protocol agreed with the local microbiology department or infection control guidance and, in the case of birthing pools, in accordance with the manufacturer's guidelines. [2007, amended 2023]

1.6.13 Consider intracutaneous or subcutaneous sterile water injections as a pain relief option for women in labour with back pain. These injections can be given by a midwife trained in the use of sterile water injections. [2023]

1.6.14 Explain to the woman that sterile water injections can provide relief of back pain from 10 minutes after the injection for up to 3 hours, but there can be an initial stinging sensation. [2023]

1.6.15 If the woman chooses to have sterile water injections, give these at 4 different injection points around the Rhombus of Michaelis, using doses of 0.1 ml intracutaneously or 0.5 ml subcutaneously at each injection point. [2023]

1.6.16 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]

1.6.17 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 (for example, drowsiness, nausea and vomiting) and her baby (for example, short-term respiratory depression and drowsiness, which may last several days and may make it more difficult to breastfeed). [2007, amended 2023]

1.6.18 If an intravenous or intramuscular opioid is used, also administer an antiemetic. [2007]

1.6.19 Women should not enter water (a birthing pool or bath) within 2 hours of opioid administration or if they feel drowsy. [2007]

1.6.20 Consider intravenous remifentanil patient-controlled analgesia (PCA), at 40 micrograms per bolus with a 2‑minute lockout period, as an option for women who want ongoing pain relief during labour and birth.

In September 2023, this was an off-label use of remifentanil. See NICE's information on prescribing medicines. [2023]

1.6.21 Only use remifentanil PCA in obstetric units because of the risk of respiratory depression in women that may need anaesthetic support. [2023]

1.6.22 Discuss the risks and benefits of remifentanil PCA with the woman and help them make a supported decision about its use. Explain that, with 40 micrograms of remifentanil compared with intramuscular pethidine:

1.6.23 When using remifentanil PCA, ensure that:

1.8.1 For the purposes of this guideline, use the following definitions of labour:

1.8.2 If a woman in labour contacts her midwife or maternity unit for advice, carry out an assessment of labour by telephone triage and determine whether a face-to-face assessment is needed. [2014, amended 2023]

1.8.3 Carry out a face-to-face early assessment of labour either:

1.8.4 Include the following in any early or triage assessment of labour:

1.8.5 The triage midwife should document the guidance that she gives to the woman. [2014]

1.8.6 If a woman seeks advice or attends a midwifery-led unit or obstetric unit with painful contractions, but is not in established labour:

1.8.7 When performing an initial assessment of a woman in labour, listen to her story and support her preferences and her emotional and psychological needs. [2014, amended 2023]

1.8.8 Carry out an initial assessment to determine if midwifery-led care in any setting is suitable for the woman, irrespective of any previous plan including consultant-led care. This assessment should comprise the following:

1.8.9 When conducting a vaginal examination:

1.8.10 When performing a vaginal examination, determine:

1.8.11 Transfer the woman to obstetric-led care, following the general principles for transfer of care described in section 1.5, if any of the following are observed on initial assessment, taking into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect:

1.8.12 If any of the factors in recommendation 1.8.11 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 woman and the coordinating midwife. [2014, amended 2023]

1.8.13 Offer auscultation of the fetal heart rate at first contact with a woman in suspected or established labour, and at each further assessment. [2017, amended 2023]

1.8.14 For advice on the choice and method of fetal monitoring during labour, including risk assessment and indications for continuous cardiotocography, see the NICE guideline on fetal monitoring in labour. [2023]

1.8.15 Do not routinely offer proton pump inhibitors to low-risk women. [2007, amended 2023]

1.8.16 Consider proton pump inhibitors (for example, omeprazole) for women who receive opioids, or who have or develop risk factors that make a caesarean birth more likely. [2007, amended 2023]

1.8.17 Inform the woman that she can drink during labour when she is thirsty, but there is no benefit to drinking more than normal. Isotonic drinks may be more beneficial than water. [2007, amended 2023]

1.8.18 Inform the woman that she can eat a light diet in established labour unless she has received opioids or she develops risk factors that make a caesarean birth more likely. [2007, amended 2023]

1.8.19 Record the following observations during the first stage of labour:

1.8.20 Carry out an hourly risk assessment of the woman and her baby, and if any of the following risks have developed, transfer the woman to obstetric-led care (following the general principles for transfer of care described in section 1.5), unless the risks of transfer outweigh the benefits. Take into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect:

1.8.21 Do not routinely use verbal assessment using a numerical pain score. [2007]

1.8.22 Use a pictorial record of labour (partogram) once labour is established. [2007, amended 2023]

1.8.23 Review bladder care for women at least every 4 hours. This should include:

1.8.24 Give ongoing consideration to the woman's emotional and psychological needs, including her desire for pain relief. [2007]

1.8.25 Encourage the woman to say if she needs more analgesia at any point during labour. [2007]

1.8.26 As part of ongoing assessment, document the presence or absence of meconium. [2014, amended 2023]

1.8.27 If meconium is present, consider the character of the meconium and discuss the option of transfer to obstetric-led care with the woman. Explain that meconium:

1.8.28 If the woman wishes to be transferred, 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 1.5. Take into account that the presence of other risk factors (in addition to meconium) may increase the urgency of the transfer. [2014, amended 2023]

1.8.29 Be aware that meconium is more common after full term but should still trigger a full risk assessment and discussion with the woman about the option of transfer to obstetric-led care. [2023]

1.8.30 Inform women that, while the length of established first stage of labour varies between women:

1.8.31 Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well. [2007]

1.8.32 In all stages of labour, women who have left the normal care pathway because of the development of complications can return to it if or when the complication is resolved. [2007]

1.8.33 Do not routinely perform amniotomy in normally progressing labour. [2007]

1.8.34 Do not routinely use combined early amniotomy with use of oxytocin. [2007]

1.8.35 If delay in the established first stage is suspected, take the following into account:

1.8.36 If delay in the established first stage is suspected, assess all aspects of progress in labour when diagnosing delay, including:

1.8.37 If delay in the established first stage of labour is suspected, discuss the findings (see recommendation 1.8.36) and the options available with the woman, and support her decision. [2007, amended 2023]

1.8.38 Offer all women with delay in the established first stage of labour support and effective pain relief. [2007]

1.8.39 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]

1.8.40 If delay in the established first stage of labour is diagnosed, consider amniotomy for all women with intact membranes, after explanation of the procedure and advice that it will shorten labour by about an hour and may increase the strength and pain of contractions. [2007, amended 2023]

1.8.41 Do not advise transfer to obstetric-led care for amniotomy alone. [2023]

1.8.42 After amniotomy, advise the woman to have a repeat vaginal examination 2 hours later. [2007, amended 2023]

1.8.43 If there is no progress 2 hours after the amniotomy, diagnose delay and transfer the woman to obstetric-led care. Follow the general principles for transfer of care described in section 1.5. Take into account that the presence of other risk factors (in addition to delay) may increase the urgency of the transfer. [2014, amended 2023]

1.8.44 For all women with confirmed delay in the established first stage of labour, an obstetrician should offer a full assessment. The obstetric review should include abdominal palpation and vaginal examination and consideration of oxytocin. [2007, amended 2023]

1.8.45 Discuss the use of oxytocin with the woman and make a decision with her about its use. Explain that:

1.8.46 Offer the woman an epidural before oxytocin is started or if she requests it later. [2007, amended 2023]

1.8.47 When starting intravenous oxytocin in the first stage of labour:

1.8.48 If oxytocin is used in the first stage of labour, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 3 to 4 contractions in 10 minutes. [2023]

1.8.49 Use oxytocin in labour with caution. If the woman has contractions more frequently than 4 in 10 minutes, reduce or stop the oxytocin until the woman is having 4 or fewer contractions in 10 minutes. [2023]

1.8.50 Oxytocin must be discontinued immediately if the cardiotocography is pathological, and urgent obstetrician or senior midwife review sought. See the NICE guideline on fetal monitoring in labour. [2023]

1.8.51 Consider restarting oxytocin in the first stage of labour if:

1.8.52 Advise the woman to have a vaginal examination 4 hours after the oxytocin infusion has led to regular contractions in established labour:

1.8.53 If oxytocin is restarted in the first stage of labour, base the timing of the next vaginal examination on a clinical assessment of the woman and her individual circumstances. [2023]

1.9.1 For the purposes of this guideline, use the following definitions of labour:

1.9.2 Continue with observations of the woman and baby, and assessment of risk as described for the first stage of labour (see recommendations 1.8.19 and 1.8.20), but be aware that the frequency of fetal monitoring should increase. See the NICE guideline on fetal monitoring in labour. [2023]

1.9.3 Offer a vaginal examination (see recommendations 1.8.9 and 1.8.10) hourly in the active second stage, or in response to the woman's wishes (after abdominal palpation and assessment of vaginal loss). To assess progress, the vaginal examination should include:

1.9.4 During the second stage of labour:

1.9.5 Advise a woman with an epidural in place during the second stage of labour that:

1.9.6 Advise a woman without an epidural in place during the second stage of labour that:

1.9.7 Advise women without an epidural in place that:

1.9.8 If full dilatation of the cervix has been confirmed in a woman without an epidural in place, but she does not get an urge to push, offer to carry out further assessment after 1 hour. [2007]

1.9.9 Advise nulliparous women with an epidural that:

1.9.10 Advise multiparous women with an epidural that:

1.9.11 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]

1.9.12 Discuss the woman's preferences for techniques to reduce perineal trauma during birth and support her choices. [2023]

1.9.13 Once the presenting part distends the perineum in the second stage of labour, offer to apply a warm wet compress to the perineum and continue this until birth. Check the temperature of the compress is comfortable for the woman. [2023]

1.9.14 Consider massage of the perineum with a water-soluble lubricant in the second stage of labour, if perineal massage is acceptable to the woman and she prefers this to a warm compress. [2023]

1.9.15 Do not offer lidocaine spray to reduce pain in the second stage of labour. [2007]

1.9.16 Do not carry out a routine episiotomy during spontaneous vaginal birth. [2007]

1.9.17 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]

1.9.18 Do not offer episiotomy routinely at vaginal birth after previous third- or fourth-degree trauma. [2007]

1.9.19 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:

1.9.20 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 possible need for defibulation in labour. [2007, amended 2023]

1.9.21 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]

1.9.22 Perform an episiotomy if there is a clinical need, such as birth with forceps or ventouse or suspected fetal compromise. [2007]

1.9.23 Provide tested, effective analgesia before carrying out an episiotomy, except in an emergency because of acute fetal compromise. [2007]

1.9.24 Inform women that there is insufficient high-quality evidence to either support or discourage giving birth in water. [2007]

1.9.25 For a nulliparous woman without an epidural:

1.9.26 For a multiparous woman without an epidural:

1.9.27 For a nulliparous woman with an epidural:

1.9.28 For a multiparous woman with an epidural:

1.9.29 If there is delay in the second stage of labour (see the section on the duration of the active second stage), or if the woman is excessively distressed, provide support and sensitive encouragement and ask her if she needs analgesia or anaesthesia. [2007, amended 2023]

1.9.30 If there is delay in the second stage of labour and the decision is made to transfer the woman to obstetric-led care, follow the general principles for transfer of care described in section 1.5. Take into account that the presence of other risk factors (in addition to delay) may increase the urgency of the transfer. [2014, amended 2023]

1.9.31 An obstetrician should carry out an in-person assessment of a woman with confirmed delay in the second stage after transfer to obstetric-led care before contemplating the use of oxytocin. This should include:

1.9.32 If the decision is made to start oxytocin in the second stage of labour, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 3 to 4 contractions in 10 minutes (see recommendation 1.8.48). [2023]

1.9.33 After initial obstetric assessment of a woman with delay in the second stage, maintain ongoing obstetric review every 15 to 30 minutes. [2007]

1.9.34 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. The assessment should include:

1.9.35 Talk with the woman and her birth companion(s) about why the birth needs to be expedited and what the options are. [2014]

1.9.36 Inform the team about the degree of urgency. [2014]

1.9.37 Record the time at which the decision to expedite the birth is made. [2014]

1.9.38 Offer birth with forceps or ventouse if there is concern about the baby's wellbeing, there is a prolonged second stage or the woman requests assistance. [2007, amended 2023]

1.9.39 If a woman declines a birth with forceps or ventouse:

1.9.40 Base the choice of instrument on a balance of clinical circumstance and practitioner experience. [2007, amended 2023]

1.9.41 Discuss pain relief options for birth with forceps or ventouse. The option used should be based on the woman's preference and the clinical situation. [2007, amended 2023]

1.9.42 Ensure the level of pain relief is acceptable to the woman before using forceps or ventouse during birth. [2007, amended 2023]

1.9.43 Offer women who have had a birth with forceps or ventouse a single dose of intravenous co-amoxiclav (or a locally agreed alternative for women who are allergic to penicillin) within 6 hours after cord clamping. [2023]

1.9.44 Advise the woman to have a caesarean birth if vaginal birth is not possible. See the NICE guideline on caesarean birth. [2007]

1.10.2 For the purposes of this guideline, use the following definitions:

1.10.3 Record the following observations for a woman in the third stage of labour:

1.10.4 If there is postpartum haemorrhage, a retained placenta or maternal collapse, or any other concerns about the woman's wellbeing:

1.10.5 Discuss with the woman antenatally, during her initial assessment and in labour:

1.10.6 Advise women that active management of the third stage of labour is associated with a lower risk of a postpartum haemorrhage or blood transfusion. [2014]

1.10.7 If a woman requests physiological management of the third stage:

1.10.8 Document in her records the decision that is agreed with the woman about management of the third stage. [2014]

1.10.9 For a woman who is having a vaginal birth and has chosen to have an active third stage, discuss the choice of uterotonic for active management. Include that:

1.10.10 Offer antiemetics (for example, cyclizine) to women having oxytocin plus ergometrine. [2023]

1.10.11 For active management after vaginal birth, administer 10 units of oxytocin (by intramuscular injection), 5 units of oxytocin (by intravenous injection, see recommendation 1.10.12) or 5 units of oxytocin plus 500 micrograms of ergometrine (by intramuscular injection) immediately after the birth of the baby and before the cord is clamped and cut. [2023]

1.10.12 If oxytocin is used, administer it by:

1.10.13 For women who have had a caesarean birth, offer carbetocin by slow intravenous injection for the prevention of postpartum haemorrhage. [2023]

1.10.14 After administering the uterotonic, clamp and cut the cord, but:

1.10.15 After cutting the cord, perform controlled cord traction as part of active management only after administration of oxytocin and signs of separation of the placenta. [2014, amended 2023]

1.10.16 Record the timing of cord clamping in both active and physiological management. [2014]

1.10.17 Advise a change from physiological management to active management if either of the following occur:

1.10.18 Offer a change from physiological management to active management if the woman wants to shorten the third stage. [2014]

1.10.19 Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage of labour. [2014]

1.10.20 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 a retained placenta. [2014]

1.10.21 Secure intravenous access if the placenta is retained, and explain to the woman why this is needed. [2014]

1.10.22 Do not use umbilical vein agents if the placenta is retained. [2014]

1.10.23 Do not use intravenous oxytocic agents routinely to deliver a retained placenta. [2014]

1.10.24 Give intravenous oxytocic agents if the placenta is retained and the woman is bleeding excessively. [2014]

1.10.25 If the placenta is retained and there is concern about the woman's condition:

1.10.26 If the woman reports inadequate analgesia during the assessment, stop the examination and address this immediately. [2014]

1.10.27 If the placenta is retained and the woman is not already in an obstetric unit, arrange transfer. Follow the general principles for transfer of care described in section 1.5, taking into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect. [2014, amended 2023]

1.10.28 Do not carry out uterine exploration or manual removal of the placenta without an anaesthetic. [2014]

1.11.1 Record the Apgar score routinely at 1 minute and 5 minutes for all births. [2007]

1.11.2 When assessing the colour element of the Apgar score:

1.11.3 Record the time from birth to the onset of regular respirations. [2014]

1.11.4 If the baby is born in poor condition (for example, with abnormal breathing, heart rate or tone):

1.11.5 Do not take paired cord-blood samples (for blood gas analysis) routinely. [2014]

1.11.6 Ensure that a second clamp to allow double-clamping of the cord is available in all birth settings. [2014]

1.11.7 Encourage women to have skin-to-skin contact with their babies as soon as possible after the birth. If the woman is not well enough, encourage her birth companion to have skin-to-skin contact instead. [2007, amended 2023]

1.11.8 In order to keep the baby warm, dry and cover them with a warm, dry blanket or towel while maintaining skin-to-skin contact with the woman. [2007]

1.11.9 Prioritise optimal baby airway positioning, ensuring the head is supported so the airway does not become obstructed during skin-to-skin contact and explain to the woman and her birth companion(s) how to maintain the baby's airway. [2023]

1.11.10 Avoid separating the 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]

1.11.11 Encourage initiation of breastfeeding as soon as possible after the birth, ideally within 1 hour. [2007]

1.11.12 Record head circumference, and birth weight soon after the first hour following birth and plot on the centile chart. [2007, amended 2023]

1.11.13 Check the baby's body temperature is in the normal range. [2007, amended 2023]

1.11.14 Undertake an initial examination to detect any major physical abnormality and to identify any problems that need referral. [2007]

1.11.15 Undertake additional monitoring of the baby for women who have taken SSRI or SNRI antidepressants during pregnancy as these may result in a small increased risk of persistent pulmonary hypertension of the newborn or neonatal withdrawal symptoms. See the NICE guideline on antenatal and postnatal mental health and the MHRA advice on the use of SSRI and SNRI antidepressants in pregnancy. [2023]

1.11.16 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]

1.11.17 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]

1.11.18 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]

1.11.19 In all birth settings:

1.11.20 If a newborn baby needs basic resuscitation, start with air. [2014]

1.11.21 Minimise separation of the baby and mother, taking into account the clinical circumstances. [2014]

1.11.22 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]

1.11.23 In the presence of any degree of meconium:

1.11.24 If there has been any degree of meconium and the baby does not have normal respiration, heart rate and tone, follow nationally accredited guidelines on neonatal resuscitation. [2014, amended 2023]

1.11.25 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 old and then 2‑hourly until 12 hours old. [2014]

1.11.26 If there has been non-significant meconium, observe the baby at 1 and 2 hours old in all birth settings. [2014]

1.11.27 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. Follow the general principles for transfer of care described in section 1.5, taking into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect:

1.11.28 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]

1.11.29 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, 2, 6 and 12 hours) in all settings. Include assessment of:

1.11.30 If there are no signs of infection in the woman or in the baby, do not give antibiotics to either the woman or the baby, even if the membranes have been ruptured for over 24 hours. [2007, amended 2023]

1.11.31 If there is evidence of infection in the woman or in the baby, see the section on antibiotics for suspected early-onset infection in NICE's guideline on neonatal infection for advice on when to consider antibiotics. [2007, amended 2023]

1.11.32 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]

1.11.33 Do not perform blood, cerebrospinal fluid and/or surface culture tests in an asymptomatic baby. [2007]

1.11.34 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]

1.12.1 Carry out the following observations of the woman after birth:

1.12.2 Check that women who have had regional analgesia or anaesthesia can perform a straight leg raise by 4 hours after the last anaesthetic dose. If not, contact the obstetric anaesthetist for urgent review. [2023]

1.12.3 Define perineal or genital trauma caused by either tearing or episiotomy as follows:

1.12.4 Before assessing for genital trauma:

1.12.5 Offer all women systematic assessment, including a rectal examination, to exclude all genital tract trauma, including buttonhole tears. [2007, amended 2023]

1.12.6 Perform the initial examination gently and with sensitivity. It may be done in the immediate period after birth. [2007]

1.12.7 Include the following in a systematic assessment of genital trauma:

1.12.8 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]

1.12.9 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 described in section 1.5. [2007, amended 2014]

1.12.10 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 described in section 1.5) if the repair needs further surgical or anaesthetic expertise. [2007, amended 2014]

1.12.11 Document the systematic assessment and its results fully, possibly pictorially. [2007]

1.12.12 All relevant healthcare professionals should attend training in perineal/genital assessment and repair and ensure that they maintain these skills. [2007]

1.12.13 Undertake repair of the perineum as soon as possible to minimise the risk of infection and blood loss. [2007]

1.12.14 When carrying out perineal repair:

1.12.15 If the woman reports inadequate pain relief at any point, address this immediately. [2007]

1.12.16 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]

1.12.17 Advise the woman that in the case of second-degree trauma, the muscle should be sutured in order to improve healing. [2007]

1.12.18 If the skin is opposed after suturing of the muscle in second-degree trauma, there is no need to suture it. [2007]

1.12.19 If the skin does need suturing, use a continuous subcuticular technique. [2007]

1.12.20 Undertake perineal repair using a continuous non-locked suturing technique for the vaginal wall and muscle layer. [2007]

1.12.21 Use an absorbable synthetic suture material to suture the perineum. [2007]

1.12.22 Offer rectal non-steroidal anti-inflammatory drugs routinely after perineal repair of first- and second-degree trauma provided these drugs are not contraindicated. [2007]

1.12.23 Observe the following basic principles when performing perineal repairs: