Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting women to make decisions about their care is particularly important during the intrapartum period. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance and the 2015 Montgomery ruling.

1.1 Information for women with existing medical conditions

1.1.1 Clarify with women with existing medical conditions whether and how they would like their birth companion(s) involved in discussions about care during labour and birth. Review this regularly.

1.1.2 Offer pregnant women with medical conditions and their birth companion(s) information about intrapartum care. This should include:

1.1.3 Offer information about intrapartum care in consultations before conception, if possible, and as early as possible during pregnancy. Allow extra time to discuss with the woman how her medical condition may affect her care.

1.1.4 Information about intrapartum care should be offered to women with medical conditions by a member of the multidisciplinary team (see recommendation 1.2.2).

1.1.5 If a pregnant woman with a medical condition has not had any antenatal care (see section 1.18), give her information about intrapartum care at her first contact with healthcare services during pregnancy.

NICE has published a guideline on diabetes in pregnancy.

To find out why the committee made the recommendations on information for women with existing medical conditions and how they might affect practice, see rationale and impact.

1.2 Planning for intrapartum care with women with existing medical conditions – involving a multidisciplinary team

1.2.1 A multidisciplinary team led by a named healthcare professional should involve a pregnant woman with a medical condition in preparing an individualised plan for intrapartum care. The plan should be:

  • formulated by following the principles of shared decision making outlined in the NICE guideline on patient experience in adult NHS services

  • reviewed with the woman and her birth companion(s) as early as possible throughout pregnancy and on admission for birth

  • updated with the woman if her medical condition changes during pregnancy

  • shared with the woman's GP and teams providing her antenatal and intrapartum care.

1.2.2 For pregnant women with a medical condition, the multidisciplinary team may include, as appropriate:

  • a midwife

  • an obstetrician

  • an obstetric anaesthetist

  • an obstetric physician or clinician with expertise in caring for pregnant women with the medical condition

  • a clinician with expertise in the medical condition

  • a specialty surgeon

  • a critical care specialist

  • a neonatologist

  • the woman's GP

  • allied health professionals.

To find out why the committee made the recommendations on planning for intrapartum care involving a multidisciplinary team and how they might affect practice, see rationale and impact.

1.3 Heart disease

Risk assessment for women with heart disease

1.3.1 Risk assessment for women with heart disease should follow the principles of multidisciplinary team working (outlined in recommendation 1.2.1). Include a cardiologist with expertise in managing heart disease in pregnant women in the multidisciplinary team discussions.

1.3.2 For women with heart disease diagnosed in the intrapartum period, urgent multidisciplinary discussions are needed to ensure that the woman is offered the same level of care as a woman with an existing diagnosis of heart disease and, where possible, that her preferences are taken into account.

1.3.3 Be aware that some women with heart disease are at low risk[1] of complications and their care should be in line with the NICE guideline on intrapartum care for healthy women and babies, whereas others need individualised specialist care.

1.3.4 For women with heart disease, reassess intrapartum risk regularly during pregnancy and the intrapartum period using all of the following:

  • comprehensive clinical assessment, including history and physical examination

  • the modified World Health Organization (WHO) classification of risk[1]

  • New York Heart Association (NYHA) functional class[2].

1.3.5 Offer the same investigations to pregnant women with heart disease as to women who are not pregnant. Review the results and act on them without delay.

To find out why the committee made the recommendations on risk assessment for women with heart disease and how they might affect practice, see rationale and impact.

Management of anticoagulation for women with mechanical heart valves

1.3.6 When pregnancy is confirmed:

  • involve women with mechanical heart valves in multidisciplinary discussion of plans for anticoagulation during the intrapartum period (see recommendations 1.2.1 and 1.2.2)

  • consider including a haematologist in the multidisciplinary discussion

  • explain to women that they will need individualised anticoagulation depending on their current treatment.

1.3.7 For women with mechanical heart valves who are taking warfarin in the third trimester, switch anticoagulation to low-molecular-weight heparin by 36+0 weeks of pregnancy or 2 weeks before planned birth (if this is earlier than 36+0 weeks). In hospital, consider doing this by:

  • stopping warfarin, and 24 hours later, starting low-molecular-weight heparin using a twice-daily regimen at a dose based on the most recent weight available

  • increasing the dose of low-molecular-weight heparin according to anti‑Xa levels; this should be done by:

    • checking anti‑Xa levels each day 3 to 4 hours after a dose of low-molecular-weight heparin, aiming for a peak anti‑Xa level between 1.0 and 1.2 IU/ml

    • checking that the anti‑Xa level before a dose of low-molecular-weight heparin (trough level) is above 0.6 IU/ml

  • rechecking anti‑Xa level weekly once the target anti‑Xa level is achieved.

1.3.8 For women with mechanical heart valves, stop therapeutic low-molecular-weight heparin 24 hours before a planned caesarean section and consider:

  • aiming to perform the caesarean section as near to 24 hours after stopping low-molecular-weight heparin as possible and no later than 30 hours after stopping or

  • switching to intravenous unfractionated heparin (aiming for an activated partial thromboplastin time [aPTT] of at least twice control), then 4 to 6 hours before caesarean section, stopping intravenous unfractionated heparin.

1.3.9 For women with mechanical heart valves who are having an induction of labour, a senior obstetrician should be involved in:

  • deciding when to stop low-molecular-weight heparin or intravenous unfractionated heparin in order to:

    • minimise the risk of maternal haemorrhage or valve thrombosis

    • enable the option of regional analgesia

  • reviewing the progress of labour and:

    • the need for low-molecular-weight heparin every 12 hours, aiming for birth as close to 12 hours from the last injection as possible or

    • the need for unfractionated heparin, aiming for birth as close to 4 to 6 hours after stopping the infusion.

1.3.10 For women with mechanical heart valves who are taking warfarin and who present in established labour:

  • check the international normalised ratio (INR) immediately and consult a haematologist

  • do not give anticoagulation until the woman has had an assessment by an obstetrician, which should happen within 2 hours

  • carry out a senior review (including at least a senior obstetrician, haematologist and a consultant obstetric anaesthetist) to discuss the mode of birth most likely to give the lowest risk of bleeding for the woman and the baby

  • consider reversal of anticoagulation.

1.3.11 For women with mechanical heart valves, carry out a postpartum review, involving at least a senior obstetrician and anaesthetist, of the risk of haemorrhage and valve thrombosis within 3 to 4 hours of birth. Aim to restart therapeutic low-molecular-weight heparin or unfractionated heparin 4 to 6 hours after birth.

1.3.12 For women with mechanical heart valves at high risk of peripartum haemorrhage, consider the following options until hourly review indicates that therapeutic anticoagulation can be re-established:

  • prophylactic low-molecular-weight heparin or

  • no low-molecular-weight heparin.

1.3.13 For women with mechanical heart valves, consider delaying restarting warfarin until at least 7 days after birth and arrange specialist follow‑up as outlined in the multidisciplinary care plan (see recommendation 1.3.6).

To find out why the committee made the recommendations on management of anticoagulation for women with mechanical heart valves, and how they might affect practice, see rationale and impact.

Mode of birth for women with heart disease

1.3.14 Develop an individualised birth plan with the woman with heart disease covering all 3 stages of labour following multidisciplinary discussion (outlined in recommendation 1.2.1). Consider including a cardiologist with expertise in managing heart disease in pregnant women in the multidisciplinary team discussions.

1.3.15 Throughout pregnancy, manage pulmonary arterial hypertension in consultation with a specialist pulmonary hypertension centre.

1.3.16 Offer planned birth (induction of labour or caesarean section) for women with mechanical heart valves.

1.3.17 Consider planned caesarean section for women with:

  • any disease of the aorta assessed as high risk

  • pulmonary arterial hypertension

  • NYHA class III or IV heart disease.

    Explain the benefits and risks of caesarean section. If the woman chooses not to have a caesarean section, explain the benefits and risks of an assisted second stage of labour compared with active pushing alone.

1.3.18 For women with heart disease who have a planned caesarean section, develop an individualised emergency care plan with the woman in case she presents in early labour, with new symptoms or with obstetric complications.

To find out why the committee made the recommendations on mode of birth for women with heart disease and how they might affect practice, see rationale and impact.

Fluid management for women with heart disease

1.3.19 During pregnancy, plan the management of fluid balance during the intrapartum period for women with heart disease with the multidisciplinary team (outlined in recommendation 1.2.2). Include a cardiologist with expertise in managing heart disease in pregnant women. Multidisciplinary discussion should include:

  • how the condition affects fluid balance

  • optimum fluid balance and how this might be achieved

  • plans for risk assessment and monitoring.

1.3.20 Identify women with heart disease for whom fluid balance is critical to cardiac function. These include women with:

  • severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)

  • hypertrophic cardiomyopathy

  • cardiomyopathy with systolic ventricular dysfunction

  • pulmonary arterial hypertension

  • Fontan circulation and other univentricular circulations

  • NYHA class IV heart disease.

1.3.21 For women with heart disease in whom fluid balance is critical for optimal cardiac function, offer tailored monitoring and clinical review during the intrapartum period, and consider escalation as follows:

  • hourly monitoring of fluid input and output (with at least 4‑hourly assessment by a senior clinician), blood pressure, pulse, respiratory rate and oxygen saturation

  • continuous electrocardiogram (ECG) and pulse oximetry with interpretation by trained staff

  • continuous intra-arterial blood pressure monitoring

  • cardiac output monitoring with non-invasive techniques, or serial echocardiography by trained staff.

    Advise women who need intensive monitoring that this may have to be carried out in an intensive care unit where the necessary equipment and expertise is available.

1.3.22 Offer standard fluid management during the intrapartum period for women with modified WHO 1 and NYHA class I heart disease.

1.3.23 Consider standard fluid management during the intrapartum period for women with modified WHO 2 to 3, or NYHA class II to III heart disease after a multidisciplinary discussion (outlined in recommendation 1.2.1).

To find out why the committee made the recommendations on fluid management for women with heart disease and how they might affect practice, see rationale and impact.

Diagnosis and management of heart failure for all women in the intrapartum period

These recommendations cover the diagnosis and management of heart failure for all women in the intrapartum period. This includes women with existing heart disease, and women with no existing heart disease who develop symptoms and signs of heart failure.

1.3.24 Take a cardiac-specific history and suspect heart failure if there is not another likely cause of any of the following symptoms:

  • breathlessness when lying down (ruling out aortocaval compression) or at rest

  • unexplained cough, particularly when lying down or which produces frothy pink sputum

  • paroxysmal nocturnal dyspnoea – being woken from sleep by severe breathlessness and coughing, which may produce pink frothy sputum and is improved by moving to an upright position

  • palpitation (awareness of persistent fast heart rate at rest).

1.3.25 Consider heart failure in the intrapartum period if there are any of the following signs:

  • pale, sweaty, agitated with cool peripheries

  • heart rate persistently greater than 110 beats per minute at rest

  • respiratory rate persistently greater than 20 breaths per minute at rest

  • hypotension (systolic blood pressure less than 100 mmHg)

  • oxygen saturation less than 95% on air

  • elevated jugular venous pressure

  • added murmur or heart sound

  • reduced air entry, basal crackles or wheeze, on listening to the chest.

1.3.26 If any of the symptoms or signs in recommendations 1.3.24 and 1.3.25 suggest heart failure, a senior clinician should review the woman's condition without delay.

1.3.27 When there is a clinical suspicion of heart failure in any woman in the intrapartum period:

  • establish peripheral venous access

  • measure urea and electrolytes, and perform a full blood count

  • measure arterial blood gases

  • perform an ECG

  • perform a chest X‑ray.

1.3.28 If clinical suspicion of heart failure in the intrapartum period cannot be ruled out by the investigations in recommendation 1.3.27, arrange:

  • review by a cardiologist (with interim review by a healthcare professional with expertise in this area if a cardiologist is not immediately available)

  • a transthoracic echocardiogram by a trained technician or cardiologist

  • measurement of N‑terminal pro‑brain natriuretic peptide (NT‑proBNP) levels.

1.3.29 Consider early birth for women with heart failure due to cardiomyopathy, depending on the severity of the condition and how well the condition has responded to treatment.

1.3.30 Optimise treatment for heart failure as soon as possible after birth even if the woman is breastfeeding.

1.3.31 If clinical suspicion of heart failure persists after birth, consider the continued involvement of a cardiologist.

To find out why the committee made the recommendations on diagnosis and management of heart failure in the intrapartum period and how they might affect practice, see rationale and impact.

Anaesthesia and analgesia for women with heart disease

1.3.32 During pregnancy, prepare a plan for managing anaesthesia and analgesia for women with heart disease involving a multidisciplinary team and the woman (outlined in recommendation 1.2.1). Consider including a haematologist for women on an anticoagulation regimen.

1.3.33 Consider offering the same information about anaesthesia and analgesia in labour to women with modified WHO 1 or modified WHO 2 heart disease as described in the NICE guideline on intrapartum care for healthy women and babies.

1.3.34 Consider regional anaesthesia for women with modified WHO 3 and modified WHO 4 heart disease, unless this is contraindicated.

1.3.35 Consider collaborative working in the intrapartum period between an obstetric anaesthetist and a cardiac anaesthetist for women with modified WHO 3 and modified WHO 4 heart disease.

1.3.36 When using regional anaesthesia for women with heart disease, aim to preserve cardiovascular stability by, for example, using a sequential combined spinal–epidural technique.

1.3.37 Offer intrapartum monitoring of the heart and circulation to all women with modified WHO 3 and modified WHO 4 heart disease; this will usually include continuous invasive intra-arterial pressure monitoring and may include central venous pressure monitoring and advanced cardiac output monitoring.

1.3.38 Offer low-dose regional analgesia to women with modified WHO 3 or modified WHO 4 heart disease because this is less likely to cause cardiac instability during labour and birth.

1.3.39 Consider regional analgesia for women who have been on low-molecular-weight heparin and who have not had a prophylactic dose for at least 12 hours, or a therapeutic dose for at least 24 hours.

1.3.40 For women taking low-molecular-weight heparin:

  • wait 12 hours after a prophylactic dose before siting an epidural, or removing an epidural catheter

  • wait 24 hours after a therapeutic dose before siting an epidural or spinal, or removing an epidural catheter

  • after siting an epidural or a spinal, or removing an epidural catheter, wait 4 hours before administering a further dose of low-molecular-weight heparin

  • do not administer therapeutic dose low-molecular-weight heparin while an epidural catheter is in place.

To find out why the committee made the recommendations on anaesthesia and analgesia for women with heart disease and how they might affect practice, see rationale and impact.

Management of the third stage of labour for women with heart disease

1.3.41 During pregnancy, prepare an individualised plan for managing the third stage of labour for women with heart disease, involving a multidisciplinary team and the woman (outlined in recommendation 1.2.1). Consider including a cardiologist with expertise in managing heart disease in pregnant women.

1.3.42 Treat women with modified WHO 1 heart disease as low risk and consider the full range of care options for healthy women in the third stage of labour described in the NICE guideline on intrapartum care for healthy women and babies.

1.3.43 Advise active management of the third stage of labour for women with modified WHO 2 heart disease, in line with the NICE guideline on intrapartum care for healthy women and babies.

1.3.44 Consider management of the third stage of labour for women with modified WHO 3 or modified WHO 4 heart disease[1] according to table 1.

Table 1 Management of the third stage of labour for women with modified WHO 3 or modified WHO 4 heart disease

Condition

First-line uterotonic

Second-line uterotonics

Drugs to avoid because of potential harm

Significant aortopathy

Marfan syndrome and Loeys–Dietz with aortic dilatation >40 mm.

Bicuspid aortopathy and aortic dilatation >45 mm.

Previous aortic dissection.

Turner syndrome and aortic size index >25 cm/m2.

Oxytocin.

Misoprostol.

Carboprost.

Ergometrine (because of risk of hypertension-induced aortic dissection or rupture).

Limited or fixed low cardiac output, or preload-dependent circulation

Severe systemic ventricular dysfunction (ejection fraction <30%).

Severe valvular stenosis.

Hypertrophic cardiomyopathy with diastolic dysfunction or significant outflow tract obstruction.

Fontan circulation.

Cyanotic heart disease.

Slow infusion of oxytocin to avoid sudden haemodynamic change.

Misoprostol.

Carboprost.

Long-acting oxytocin analogues and ergometrine (because of risk of hypertension-induced heart failure).

Pulmonary arterial hypertension.

Oxytocin.

Misoprostol.

Ergometrine, carboprost and long-acting oxytocin analogues (because of risk of worsening pulmonary hypertension).

Coronary artery disease.

Oxytocin.

Misoprostol.

Ergometrine (because of risk of coronary ischaemia).

To find out why the committee made the recommendations on management of the third stage of labour for women with heart disease how they might affect practice, see rationale and impact.

1.4 Asthma

Analgesia for women with asthma

1.4.1 Offer women with asthma the same options for pain relief during labour as women without asthma, including:

  • Entonox (50% nitrous oxide plus 50% oxygen)

  • intravenous and intramuscular opioids

  • epidural

  • combined spinal–epidural analgesia.

To find out why the committee made the recommendation on pain relief during labour for women with asthma and how it might affect practice, see rationale and impact.

Prostaglandins for women with asthma

1.4.2 Do not offer prostaglandin F2 alpha (carboprost) to women with asthma because of the risk of bronchospasm.

1.4.3 Consider prostaglandin E1 or prostaglandin E2 as options for inducing labour in women with asthma because there is no evidence that they worsen asthma.

1.4.4 Consider prostaglandin E1 as an option for treating postpartum haemorrhage in women with asthma because there is no evidence it worsens asthma.

To find out why the committee made the recommendations on prostaglandins for women with asthma and how they might affect practice, see rationale and impact.

1.5 Long-term systemic steroids

Steroid replacement regimens

1.5.1 Be aware that maternal corticosteroids given antenatally for fetal lung maturation should not affect the advice given in recommendations 1.5.2 to 1.5.4.

1.5.2 For women planning a vaginal birth who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks):

  • continue their regular oral steroids and

  • when they are in established first stage of labour, add intravenous or intramuscular hydrocortisone and consider a minimum dose of 50 mg every 6 hours until 6 hours after the baby is born.

1.5.3 For women having a planned or emergency caesarean section who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks):

  • continue their regular oral steroids and

  • give intravenous hydrocortisone when starting anaesthesia; the dose will depend on whether the woman has received hydrocortisone in labour, for example:

    • consider giving 50 mg if she has had hydrocortisone in labour

    • consider giving 100 mg if she has not had hydrocortisone in labour

  • give a further dose of hydrocortisone 6 hours after the baby is born (for example, 50 mg intravenously or intramuscularly).

1.5.4 Do not offer supplemental hydrocortisone in the intrapartum period to women taking inhaled or topical steroids.

To find out why the committee made the recommendations on steroid replacement for women on long-term steroids and how they might affect practice, see rationale and impact.

1.6 Bleeding disorders

Regional anaesthesia and analgesia for women with bleeding disorders

1.6.1 Discuss the balance of benefits and risks of regional analgesia and anaesthesia with women with bleeding disorders.

1.6.2 When considering regional analgesia and anaesthesia for women with bleeding disorders, take into account:

  • the overall risk of bleeding and opportunity for corrective treatment

  • therapeutic and prophylactic anticoagulation

  • the risk of bleeding associated with the technique to be used

  • the difficulty of needle siting or insertion

  • the comparative risks associated with no analgesia or non-regional analgesia

  • the comparative risks of general anaesthesia.

To find out why the committee made the recommendations on regional anaesthesia and analgesia for women with bleeding disorders and how they might affect practice, see rationale and impact.

Modifying the birth plan according to platelet count or function

1.6.3 For woman with known immune thrombocytopenic purpura, before admission for birth:

  • plan birth in an obstetric-led unit with a neonatal unit that routinely provides high-dependency care

  • plan as if the baby will be at risk of bleeding irrespective of the woman's platelet count

  • consider monitoring maternal platelet count weekly from 36 weeks, and if the platelet count is below 50:

    • discuss and agree a plan for intrapartum care with the multidisciplinary team, including a haematologist

  • consider giving steroids or intravenous immunoglobulin to raise the maternal platelet count.

1.6.4 For women with known immune thrombocytopenic purpura, on admission for birth:

  • measure maternal platelet count

  • manage intrapartum care according to table 2.

1.6.5 For women with known or suspected immune thrombocytopenic purpura, take the following precautions to reduce the risk of bleeding for the baby:

  • inform the neonatal team of the imminent birth of a baby at risk

  • do not carry out fetal blood sampling

  • use fetal scalp electrodes with caution

  • do not use ventouse

  • use mid-cavity or rotational forceps with caution

  • bear in mind that a caesarean section may not protect the baby from bleeding

  • measure the platelet count in the umbilical cord blood at birth.

1.6.6 Modify the birth plan based on maternal platelet count, using table 2 as a guide, for women with:

  • gestational thrombocytopenia (without pre-eclampsia and HELLP syndrome, and otherwise well)

  • an uncertain diagnosis of immune thrombocytopenic purpura.

Table 2 Modifying the birth plan according to maternal platelet count in women with immune thrombocytopenic purpura or gestational thrombocytopenia

Maternal platelet count

Maternal care

Fetal and neonatal care

Platelet count above 80×10 9 /l

Treat the woman as healthy for the purpose of considering regional analgesia and anaesthesia.

If the woman has ITP or suspected ITP, assume the baby is at risk of bleeding and take precautions as outlined in recommendation 1.6.5.

If the woman has gestational thrombocytopenia, assume the baby has a normal risk of bleeding.

Platelet count 50 to 80×10 9 /l

Before considering regional analgesia and anaesthesia, take into account:

  • clinical history

  • the woman's preferences

  • anaesthetic expertise.

Platelet count below 50×10 9 /l

Avoid regional analgesia and anaesthesia under most circumstances.

Abbreviation: ITP, immune thrombocytopenic purpura.

To find out why the committee made the recommendations on modifying the birth plan according to platelet count or function and how they might affect practice, see rationale and impact.

Management of the third stage of labour for women with bleeding disorders

1.6.7 Be aware that women with bleeding disorders are at increased risk of primary and secondary postpartum haemorrhage.

1.6.8 Offer active management rather than physiological management of the third stage of labour for women with bleeding disorders, in line with the NICE guideline on intrapartum care for healthy women and babies.

1.6.9 For women with bleeding disorders, avoid giving uterotonics by intramuscular injection.

1.6.10 Offer individualised postpartum care, as discussed with a senior haematologist, for women with bleeding disorders, to include:

  • measurement of blood loss

  • monitoring obstetric complications

  • monitoring haematological parameters.

1.6.11 Be aware that non-steroidal anti-inflammatory drugs can add to the risk of bleeding.

1.6.12 Before discharge from hospital, inform women with bleeding disorders of the risk of secondary bleeding postpartum and how to access care.

To find out why the committee made the recommendations on managing the third stage of labour for women with bleeding disorders and how they might affect practice, see rationale and impact.

1.7 Subarachnoid haemorrhage or arteriovenous malformation of the brain

Mode of birth and management of the second stage of labour for women with subarachnoid haemorrhage or arteriovenous malformation of the brain

1.7.1 Involve the multidisciplinary team in risk assessment for women with a cerebrovascular malformation or a history of intracranial bleeding. Include the woman in care planning and a clinician with expertise in managing neurovascular conditions in pregnant women.

Care for women with cerebrovascular malformation at low risk of intracranial bleeding

1.7.2 Classify the risk of intrapartum intracranial bleeding as low if a woman has:

  • a fully treated cerebrovascular malformation or

  • intracranial bleeding of unknown cause following investigation, which occurred more than 2 years ago.

1.7.3 For women with a cerebrovascular malformation at low risk of intracranial bleeding, base decisions on the mode of birth on the woman's preference and obstetric indications.

1.7.4 For women with a cerebrovascular malformation at low risk of intracranial bleeding, manage the second stage of labour based on the woman's preference and obstetric indications.

Care for women with cerebrovascular malformation at high risk of intracranial bleeding

1.7.5 Classify the risk of intrapartum intracranial bleeding as high if a woman has:

  • an untreated or partially treated cerebrovascular malformation that has bled previously

  • a large aneurysm (7 mm or more) or an aneurysm with other high-risk features as defined by a neuroradiologist

  • a complex arteriovenous malformation

  • cavernoma with high-risk features

  • intracranial bleeding within the past 2 years.

1.7.6 Consider caesarean section for women who are at high risk of cerebral haemorrhage, after a full discussion with the woman of the benefits and risks of all the options.

1.7.7 For women at high risk of cerebral haemorrhage who prefer to aim for a vaginal birth or are in the second stage of labour:

  • offer regional analgesia and

  • explain the benefits and risks of an assisted second stage of labour compared with active pushing alone.

1.7.8 For women who present for the first time in labour with a history of cerebrovascular malformation or intracranial bleeding and unknown risk of intracranial bleeding, manage as high risk and follow recommendations 1.7.6 and 1.7.7.

1.7.9 Do not withhold regional analgesia or anaesthesia from women with an isolated cerebrovascular malformation unless they have a genetic predisposition to multiple vascular malformations or unknown genetic history.

To find out why the committee made the recommendations on care of women at risk of intracranial bleeding and how they might affect practice, see rationale and impact.

1.8 Acute kidney injury or chronic kidney disease

Fluid management for women with kidney disease

1.8.1 During pregnancy, involve the multidisciplinary team in risk assessment for women with kidney disease. Include a clinician with expertise in managing renal conditions in pregnant women.

1.8.2 Ensure that women with chronic kidney disease stage 4 or 5 before pregnancy or women with progressive or active kidney disease are cared for in the intrapartum period by a midwife, obstetrician and obstetric anaesthetist with input from a clinician with expertise in managing renal conditions in pregnant women.

1.8.3 Ensure that a clinician with expertise in managing renal conditions in pregnant women is available for consultation during the intrapartum period for women with chronic kidney disease stage 4 or 5 before pregnancy or women with progressive or active kidney disease.

1.8.4 Manage acute kidney injury secondary to pre-eclampsia in line with the NICE guideline on hypertension in pregnancy.

1.8.5 For women with chronic kidney disease with or without pre-eclampsia, monitor fluid balance in the intrapartum period. Measure heart rate hourly and the following at least every 4 hours:

  • blood pressure

  • respiratory rate with chest auscultation

  • fluid output and fluid intake

  • oxygen saturation.

    After each assessment, develop an individualised plan for managing fluid balance, which may involve additional monitoring techniques, with the aim of maintaining normal fluid volume to reduce the risks of acute kidney injury and pulmonary oedema.

1.8.6 Assess renal function at least every 24 hours during the intrapartum period in all women with chronic kidney disease because prolonged labour may lead to dehydration and acute kidney injury.

1.8.7 For women with acute kidney injury:

  • identify and correct the cause of the acute kidney injury

  • measure heart rate hourly and monitor fluid balance in the intrapartum period by assessing the following at least every 4 hours:

    • blood pressure

    • respiratory rate and chest auscultation

    • fluid output and fluid intake

    • oxygen saturation

  • develop an individualised plan for managing fluid balance, which may involve additional monitoring techniques, with the aim of maintaining normal fluid volume and avoiding both dehydration and pulmonary oedema

  • consider giving a single small bolus of fluid (for example, 250 ml) as crystalloid if the woman is dehydrated and review the fluid status and urine output within an hour of giving the first fluid bolus and before considering giving a second

  • continue to monitor fluid balance and renal function until the acute kidney injury has recovered.

1.8.8 Do not offer nephrotoxic drugs (for example, non-steroidal anti-inflammatory drugs) in the intrapartum period to women with kidney disease.

1.8.9 For all women with kidney disease during pregnancy:

  • monitor the following at least every 4 hours for at least 24 hours after the birth:

    • heart rate and blood pressure

    • respiratory rate and chest auscultation

    • fluid output and fluid intake

    • oxygen saturation

  • ensure postpartum assessment of renal function and follow‑up for women with persistent kidney disease.

To find out why the committee made the recommendations on fluid management for women with kidney disease and how they might affect practice, see rationale and impact.

Timing and mode of birth for women with kidney disease

1.8.10 As early as possible during pregnancy, plan intrapartum care for women with kidney disease due to lupus nephritis, vasculitis or glomerulonephritis with the woman and a clinician with expertise in managing renal conditions in pregnant women.

1.8.11 As early as possible during pregnancy, plan intrapartum care for women with a kidney transplant with the woman, a clinician with expertise in managing renal conditions in pregnant women and a kidney transplant surgeon.

1.8.12 For women with chronic kidney disease stage 1, stable renal function and non-nephrotic-range proteinuria (urine protein:creatinine ratio less than 300 mg/mmol), base decisions on timing and mode of birth on the woman's preference and obstetric indications.

1.8.13 Consider planned birth by 40+0 weeks of pregnancy for women with:

  • chronic kidney disease stage 1 and nephrotic-range proteinuria (urine protein:creatinine ratio greater than 300 mg/mmol) or

  • chronic kidney disease stage 2 to 4 with stable renal function.

1.8.14 For women with chronic kidney disease stage 5 or deteriorating stage 3b and stage 4, before 34+0 weeks of pregnancy, discuss the option of dialysis with the woman and the multidisciplinary team in an effort to prolong the pregnancy to at least 34+0 weeks.

1.8.15 For women with chronic kidney disease stage 5 or deteriorating stage 3b and stage 4, after 34+0 weeks of pregnancy, discuss the option of planned birth with the woman and the multidisciplinary team and consider birth no later than 38+0 weeks.

1.8.16 For all women with kidney disease, including those with a kidney transplant, base decisions on mode of birth on the woman's preference and obstetric indications.

To find out why the committee made the recommendations on timing and mode of birth for women with kidney disease and how they might affect practice, see rationale and impact.

1.9 Obesity

Assessing fetal presentation early in labour for women with a BMI over 30

1.9.1 Consider ultrasound scanning at the start of established labour if the baby's presentation is uncertain for women with a BMI over 30 kg/m2 at the booking appointment, particularly those with a BMI over 35 kg/m2.

To find out why the committee made the recommendation on assessing fetal presentation early in labour for women with a BMI over 30 kg/m2 and how it might affect practice, see rationale and impact.

Fetal monitoring for women with a BMI over 30

1.9.2 Base intrapartum fetal monitoring on the woman's preference and obstetric indications (including no antenatal care), in line with the NICE guideline on intrapartum care for healthy women and babies, for women with a BMI over 30 kg/m2 at the booking appointment and no medical complications.

To find out why the committee made the recommendation on fetal monitoring for women with a BMI over 30 kg/m2 and how it might affect practice, see rationale and impact.

Position in labour for women with a BMI over 30

1.9.3 For women with a BMI over 30 kg/m2 at the booking appointment, carry out a risk assessment in the third trimester. When developing the birth plan with the woman, take into account:

  • the woman's preference

  • the woman's mobility

  • comorbidities

  • the woman's current or most recent weight.

1.9.4 For women with a BMI over 30 kg/m2 at the booking appointment and reduced mobility in the third trimester, consider advising the lateral position in the second stage of labour.

1.9.5 For women with a BMI over 30 kg/m2 at the booking appointment and adequate mobility, provide care in the second stage of labour in line with the NICE guideline on intrapartum care for healthy women and babies.

To find out why the committee made the recommendations on position during the second stage of labour for women with a BMI over 30 kg/m2 and how they might affect practice, see rationale and impact.

Equipment needs for women in labour with a BMI over 30

1.9.6 All obstetric units should have 'birthing beds' able to take a safe working load of 250 kg.

1.9.7 Carry out a risk assessment to ensure that essential equipment, in a size-appropriate form, is available for the intrapartum care of women with a BMI over 30 kg/m2 at the booking appointment, including:

  • surgical, obstetric and anaesthetic equipment

  • blood pressure cuffs

  • operating theatre tables

  • lifting and lateral transfer equipment

  • anti-embolism stockings

  • wheelchairs

  • monitoring and measuring equipment.

1.9.8 For women with a BMI over 50 kg/m2 at the booking appointment, offer referral to an obstetric unit with suitable equipment and expertise as early as possible in pregnancy, if this is not available in their current unit.

To find out why the committee made the recommendations on equipment needs for women in labour with a BMI over 30 kg/m2 and how they might affect practice, see rationale and impact.

1.10 Information for women with obstetric complications or no antenatal care

1.10.1 Follow the recommendations on communication in the NICE guideline on intrapartum care for healthy women and babies for women in labour with obstetric complications or no antenatal care.

1.10.2 Recognise that women in labour with obstetric complications or no antenatal care:

  • may be more anxious than other women in labour and

  • are likely to have a better experience of labour and birth if they receive information about the benefits and risks of options for their care and are fully involved in decision making.

1.10.3 Provide information about care in labour and mode of birth, which:

  • is personalised to the woman's circumstances and needs

  • uses local and national figures where possible

  • expresses benefits and risks in a way that the woman can understand

  • is presented as recommended in the NICE guideline on patient experience in adult NHS services.

1.10.4 Recognise that individual views about risk vary, and support a woman's decision making and choices.

1.10.5 Clarify with women with obstetric complications or no antenatal care whether and how they would like their birth companion(s) involved in discussions about care during labour and birth. Review this regularly.

1.10.6 Involve the woman in planning her care by asking about her preferences and expectations for labour and birth. Take account of previous discussions, planning, decisions and choices, and keep the woman and her birth companion(s) fully informed.

To find out why the committee made the recommendations on information for women with obstetric complications or no antenatal care and how they might affect practice, see rationale and impact.

1.11 Risk assessment for women with obstetric complications or no antenatal care

1.11.1 Take account of symptoms reported and concerns expressed by women in labour with any of the following:

  • pyrexia

  • sepsis

  • intrapartum haemorrhage

  • breech presentation

  • suspected small-for-gestational-age baby

  • suspected large-for-gestational-age baby

  • previous caesarean section

  • labour after 42 weeks of pregnancy

  • no antenatal care.

1.11.2 Ensure that a healthcare professional with skills and experience in managing obstetric complications reviews and assesses the condition of a woman with any of the complications in recommendation 1.11.1, including any observations recorded, and escalates care as needed.

1.11.3 Take account of the whole clinical picture when discussing options for care with the woman during the intrapartum period.

1.11.4 Carry out and record maternal observations (pulse, blood pressure, temperature and urine output), as recommended in the NICE guideline on intrapartum care for healthy women and babies and shown in table 3, for women in labour with any of the following and no other reasons for concern:

  • breech presentation

  • suspected small-for-gestational-age baby

  • suspected large-for-gestational-age baby

  • previous caesarean section

  • labour after 42 weeks of pregnancy

  • no antenatal care.

Table 3 Routine maternal observations for women in labour with breech presentation, suspected small- or large-for-gestational-age baby, previous caesarean section, onset of labour after 42 weeks or no antenatal care, and no other reasons for concern

Frequency of maternal observations 1

Pulse

Blood pressure

Respiratory rate

Temperature

Level of consciousness (AVPU)

Oxygen saturation

Urine

Hourly

4‑hourly, and hourly in the second stage

Not required routinely

4‑hourly

Not required routinely

Not required routinely

Record output

1 The frequency of observations should be adjusted if necessary based on the level of clinical concern.

Abbreviation: AVPU, alert, voice, pain, unresponsive.

1.11.5 For women in labour with fever, a temperature of 38°C or above on a single reading or 37.5°C or above on 2 consecutive readings (1 hour apart), carry out maternal observations as shown in table 4.

1.11.6 For women in labour with sepsis or suspected sepsis, carry out maternal observations as shown in table 4.

1.11.7 For women with intrapartum haemorrhage, continuously monitor vaginal blood loss and carry out maternal observations as shown in table 4.

Table 4 Routine maternal observations for women in labour with fever, suspected sepsis, sepsis or intrapartum haemorrhage

Complication

Frequency of maternal observations 1

Pulse

Blood pressure

Respiratory rate

Temperature

Level of consciousness (AVPU)

Oxygen saturation

Urine

Fever

Hourly

4-hourly, and hourly in the second stage

4-hourly

Hourly

Hourly

4-hourly

Record output

Suspected sepsis – concern insufficient for antibiotic treatment

Hourly

4-hourly, and hourly in the second stage

4-hourly

Hourly

Hourly

4-hourly

Record output

Sepsis or suspected sepsis – on antibiotic treatment

Continuous, or at least every 30 minutes

Continuous, or at least every 30 minutes

Continuous, or at least every 30 minutes

Hourly

Every 30 minutes

Continuous, or at least every 30 minutes

Record output, hourly if catheterised

Intrapartum haemorrhage

At least hourly

At least 4-hourly, and at least hourly in the second stage

At least 4-hourly

At least 4-hourly

Hourly

At least 4-hourly

Record output, hourly if catheterised

1 The frequency of observations should be adjusted if necessary based on the level of clinical concern.

Abbreviation: AVPU, alert, voice, pain, unresponsive.

To find out why the committee made the recommendations on risk assessment for women with obstetric complications or no antenatal care and how they might affect practice, see rationale and impact.

1.12 Pyrexia

Use of antipyretics for women in labour with a fever

1.12.1 Consider paracetamol for women in labour with a fever, a temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings (1 hour apart).

1.12.2 Be aware that paracetamol is not a treatment for sepsis and should not delay investigation if sepsis is suspected.

To find out why the committee made the recommendations on use of antipyretics for women in labour with a fever and how they might affect practice, see rationale and impact.

Fetal blood sampling for women in labour with a fever

1.12.3 For women in labour with a fever, a temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings (1 hour apart), follow the recommendations 1.13.17 to 1.13.21 on fetal blood sampling for women with suspected sepsis.

To find out why the committee made the recommendation on fetal blood sampling for women in labour with a fever and how it might affect practice, see rationale and impact.

1.13 Sepsis

Mode of birth for women with sepsis or suspected sepsis

Recognising sepsis

1.13.1 Follow the NICE guideline on sepsis for the recognition of sepsis in pregnant women.

1.13.2 Take into account the normal physiological changes in labour when thinking about the possibility of sepsis, for example, increased maternal pulse rate.

1.13.3 Recognise that women in labour with sepsis (see the NICE guideline on sepsis) are at higher risk of severe illness or death.

Multidisciplinary review for women in labour with suspected sepsis

1.13.4 For women in labour with suspected sepsis, ensure ongoing multidisciplinary review from a team with a named lead, including:

  • a senior obstetrician

  • a senior obstetric anaesthetist

  • a senior midwife

  • a labour ward coordinator.

Multidisciplinary review for women in labour with sepsis

1.13.5 For women in labour with sepsis, ensure ongoing multidisciplinary review from a team with a named lead, including:

  • a senior obstetrician

  • a senior obstetric anaesthetist

  • a senior neonatologist

  • a senior microbiologist

  • a senior midwife

  • a labour ward coordinator.

1.13.6 Include a senior intensivist (critical care specialist), if a woman in labour with sepsis has any of the following signs of organ dysfunction:

  • altered consciousness

  • hypotension (systolic blood pressure less than 90 mmHg)

  • reduced urine output (less than 0.5 ml/kg per hour)

  • need for 40% oxygen to maintain oxygen saturation above 92%

  • tympanic temperature of less than 36°C.

Planning intrapartum care for women with sepsis or suspected sepsis

1.13.7 For women with sepsis or suspected sepsis in the intrapartum period:

  • agree a clear multidisciplinary care plan with the woman

  • document the agreed plan

  • review the plan regularly, taking account of the whole clinical picture, including response to treatment.

1.13.8 Involve the woman with sepsis or suspected sepsis and her birth companion(s) in shared decision making about her care, including the following options:

  • induction of labour

  • continuing labour

  • augmenting labour

  • instrumental birth

  • caesarean section.

1.13.9 When discussing timing and mode of birth with a woman with sepsis or suspected sepsis, take into account the woman's preferences, concerns and expectations, and the whole clinical picture, including:

  • the source and severity of sepsis, if known

  • weeks of pregnancy

  • fetal wellbeing

  • stage and progress of labour

  • parity

  • response to treatment.

1.13.10 If the source of sepsis is thought to be the genital tract, expedite the birth.

To find out why the committee made the recommendations on mode of birth for women with sepsis or suspected sepsis and how they might affect practice, see rationale and impact.

Anaesthesia and analgesia for women in labour with sepsis or suspected sepsis

Anaesthesia for women in labour with sepsis and signs of organ dysfunction

1.13.11 For women in labour with sepsis and any signs of organ dysfunction (see recommendation 1.13.6), regional anaesthesia should only be used with caution and advice from a consultant obstetric anaesthetist, and with a senior anaesthetist present.

To find out why the committee made the recommendation on anaesthesia for women in labour with sepsis and signs of organ dysfunction and how it might affect practice, see rationale and impact.

Analgesia for women in labour with sepsis or suspected sepsis

1.13.12 For women in labour with sepsis and any signs of organ dysfunction (see recommendation 1.13.6), regional analgesia should only be used with caution and advice from a consultant obstetric anaesthetist.

1.13.13 For women in labour with suspected sepsis where concern is insufficient for antibiotic treatment, consider the birthing pool as a form of analgesia only after discussion with a senior midwife and a senior obstetrician.

1.13.14 For women in labour who need antibiotics for suspected sepsis (see the NICE guideline on sepsis), start the antibiotics before inserting the needle for regional analgesia.

1.13.15 For women in labour with suspected sepsis, carry out a multidisciplinary review of options for pain relief at least every 4 hours.

1.13.16 If there are concerns about providing a woman's choice of regional analgesia, this should be discussed with the consultant obstetric anaesthetist.

To find out why the committee made the recommendations on analgesia for women in labour with sepsis or suspected sepsis and how they might affect practice, see rationale and impact.

Fetal monitoring for women in labour with sepsis or suspected sepsis

1.13.17 Advise continuous cardiotocography during labour for:

1.13.18 Explain to the woman and her birth companion(s) what fetal blood sampling involves and the uncertainty of the significance of the results, and support her decision to accept or decline testing.

1.13.19 Be aware that for women in labour with sepsis or suspected sepsis, fetal blood sample results may be falsely reassuring, and always discuss with a consultant obstetrician:

1.13.20 For women in labour with sepsis or suspected sepsis and an abnormal cardiotocograph trace, think about the whole clinical picture and take account of the following before performing any fetal blood sampling and when interpreting the results:

  • the woman's preferences

  • stage and progress of labour

  • parity

  • likelihood of chorioamnionitis.

1.13.21 If sepsis continues to be suspected, only repeat fetal blood sampling with caution and in discussion with a consultant obstetrician.

To find out why the committee made the recommendations on fetal monitoring for women in labour with sepsis or suspected sepsis and how they might affect practice, see rationale and impact.

Antimicrobial treatment for women in labour with sepsis or suspected sepsis

1.13.22 For women in labour with sepsis or suspected sepsis:

  • Take into account the whole clinical picture when thinking about antimicrobial treatment.

  • Document the rationale for any decision to start antimicrobial treatment and the choice of antimicrobial.

  • Take specimens for microbiological culture, including blood cultures, before starting antimicrobials in line with the NICE guideline on sepsis.

1.13.23 For women in labour with sepsis or suspected sepsis and a clear source of infection, use existing local antimicrobial guidance when offering an antimicrobial. [This recommendation is adapted from the NICE guideline on sepsis.]

1.13.24 For women in labour with sepsis or suspected sepsis and an unclear source of infection, offer a broad-spectrum intravenous antimicrobial from the agreed local formulary and in line with local (where available) or national guidelines. [This recommendation is adapted from the NICE guideline on sepsis.]

1.13.25 Explain to the woman in labour with sepsis or suspected sepsis and her birth companion(s):

  • there is no evidence to support the use of one broad-spectrum antimicrobial over another

  • the choice of antimicrobial will be guided by local antimicrobial guidelines.

To find out why the committee made the recommendations on antimicrobial treatment for women in labour with sepsis or suspected sepsis and how they might affect practice, see rationale and impact.

Care for women with sepsis or suspected sepsis immediately after the birth

1.13.26 For women with sepsis or suspected sepsis, ensure that there is ongoing multidisciplinary review (see recommendations 1.13.4 to 1.13.6) in the first 24 hours after the birth. This should include a discussion about the need for:

  • microbiological specimens for culture

  • antimicrobial treatment

  • increased frequency of monitoring

  • an enhanced level of care and monitoring

  • further investigations such as imaging

  • support to enable the woman to feed her baby as she chooses (including keeping the woman and baby together wherever possible and maintaining skin-to-skin contact)

  • additional support for the woman and her family.

To find out why the committee made the recommendation on care for women with sepsis or suspected sepsis immediately after the birth and how it might affect practice, see rationale and impact.

1.14 Intrapartum haemorrhage

Management of intrapartum haemorrhage

1.14.1 If there are signs of shock in a woman with intrapartum haemorrhage, proceed with immediate resuscitation.

1.14.2 The maternity service and ambulance service should have strategies in place to respond quickly and appropriately if a woman has an intrapartum haemorrhage in any setting. [This recommendation is adapted from the NICE guideline on intrapartum care for healthy women and babies.]

1.14.3 If a woman in labour has any vaginal blood loss other than a 'show', transfer her to obstetric-led care, in line with the NICE guideline on intrapartum care for healthy women and babies.

1.14.4 If a woman in labour has any vaginal blood loss other than a 'show', explain to her and her birth companion(s) what is happening.

1.14.5 If a woman in labour has any vaginal blood loss other than a 'show':

  • Take a history of the bleeding, asking about:

    • any associated symptoms, including pain

    • any specific concerns the woman may have

    • any previous uterine surgery.

  • Check previous scans for placental position.

  • Assess the volume of blood loss and characteristics of the blood, such as colour, and presence of clots or amniotic fluid.

  • Carry out a physical examination, including:

    • vital signs

    • abdominal palpation

    • speculum examination

    • vaginal examination if placenta praevia has been excluded

    • fetal heart auscultation.

  • Start continuous cardiotocography.

  • Take a blood sample to determine full blood count and blood group.

1.14.6 Think about the possible causes of bleeding, for example:

  • placental abruption

  • placenta praevia

  • uterine rupture

  • vasa praevia.

    Recognise that in many cases, no cause will be identifiable.

1.14.7 If a woman in labour has any vaginal blood loss other than a 'show', agree a multidisciplinary care plan with the woman and document the plan. Include the following in plans for multidisciplinary care:

  • a senior obstetrician

  • a senior obstetric anaesthetist

  • a senior midwife

  • a labour ward coordinator.

1.14.8 If a woman has intrapartum bleeding and her condition is stable, management should include:

  • establishing venous access

  • maternal monitoring (see recommendation 1.11.7 and table 4)

  • monitoring the fetal heart rate with continuous cardiotocography.

1.14.9 If a woman with intrapartum bleeding has a large blood loss or her condition causes concern, management should be in line with recommendation 1.14.8 and also include:

  • giving intravenous fluids urgently

  • taking blood for full blood count and cross-matching

  • seeking medical advice from a more experienced healthcare professional.

    Management may also include:

    • triggering the local major haemorrhage protocol

    • taking blood for clotting studies and blood gases

    • use of amniotomy or oxytocin

    • expediting the birth.

1.14.10 If a woman in labour has vaginal blood loss typical of a 'show', follow the NICE guideline on intrapartum care for healthy women and babies.

To find out why the committee made the recommendations on management of intrapartum haemorrhage and how they might affect practice, see rationale and impact.

1.15 Breech presenting in labour

Mode of birth for women presenting with a breech position in labour

1.15.1 Discuss with women in labour with breech presentation the possible benefits and risks of vaginal birth and caesarean section, including:

  • an increase in the chance of serious medical problems for the woman with caesarean section

  • an increase in the chance of serious medical problems for the baby with vaginal birth

  • what it might mean for them and the baby if such problems did occur.

1.15.2 Explain to women in labour with breech presentation that any benefit of caesarean section in reducing the chance of serious medical problems for the baby may be greater in early labour.

1.15.3 Offer women in labour with breech presentation a choice between continuing labour and caesarean section.

1.15.4 Assess progress of labour in line with the NICE guideline on intrapartum care for healthy women and babies.

To find out why the committee made the recommendations on mode of birth for women presenting with a breech position in labour and how they might affect practice, see rationale and impact.

1.16 Small-for-gestational-age baby

Fetal monitoring in labour for babies suspected to be small for gestational age

1.16.1 Discuss with a woman whose baby is suspected to be small for gestational age:

  • the chance of serious medical problems for her baby

  • what it might mean for her and her baby if such problems did occur.

1.16.2 When discussing risk, explain that when a baby is suspected to be small for gestational age:

  • it is sometimes difficult to be certain the suspicion is correct until the baby is born

  • the chance of serious medical problems for the baby is greater with:

    • growth restriction

    • additional risk factors, such as preterm birth

    • complications during labour or birth.

1.16.3 Offer continuous cardiotocography to women whose babies are suspected to be small for gestational age after a full discussion of the benefits and risks (see recommendations 1.16.1 and 1.16.2). Respect the woman's decision if she declines continuous cardiotocography.

To find out why the committee made the recommendations on fetal monitoring in labour for babies suspected to be small for gestational age and how they might affect practice, see rationale and impact.

1.17 Large-for-gestational-age baby

Mode of birth for babies suspected to be large for gestational age

1.17.1 Explain to women in labour whose babies are suspected to be large for gestational age that:

  • it is sometimes difficult to be certain the suspicion is correct until the baby is born

  • when making decisions about mode of birth (for example, vaginal birth or caesarean section), this uncertainty needs to be taken into account.

1.17.2 Discuss with women in labour whose babies are suspected to be large for gestational age the possible benefits and risks of vaginal birth and caesarean section, including:

  • a higher chance of maternal medical problems such as infection with emergency caesarean section

  • a higher chance of shoulder dystocia and brachial plexus injury with vaginal birth

  • a higher chance of instrumental birth and perineal trauma with vaginal birth.

    Explain to the woman and her birth companion(s) what it might mean for her and her baby if such problems did occur.

1.17.3 Offer women in labour whose babies are suspected to be large for gestational age a choice between continuing labour, including augmented labour, and caesarean section.

To find out why the committee made the recommendations on mode of birth for babies suspected to be large for gestational age and how they might affect practice, see rationale and impact.

1.18 No antenatal care

Risk assessment and management of labour for women with no antenatal care

1.18.1 For women who have had no antenatal care, be aware of the particular importance of following the recommendations on establishing rapport and treating with respect in the NICE guideline on intrapartum care for healthy women and babies.

1.18.2 Provide obstetric-led intrapartum care for women who have had no antenatal care, and alert the neonatal team and, if relevant, the anaesthetic team. If the woman presents to a midwifery unit, arrange urgent transfer to an obstetric-led unit if appropriate.

1.18.3 For a woman with no antenatal care who has difficulty understanding, speaking and reading English, provide an interpreter (who may be a link worker or advocate and should not be a member of her family, her legal guardian or her partner), who can communicate with her in her preferred language. [This recommendation is adapted from the NICE guideline on pregnancy and complex social factors.]

1.18.4 If possible, take a full medical, psychological and social history from women who have had no antenatal care.

  • Try to find out why there has been no care during pregnancy.

  • Ask the woman who, if anyone, she would like to support her as her birth companion(s) during labour.

  • Explore sensitively any possible vulnerability or safeguarding concerns, including:

    • young maternal age

    • maternal mental health

    • maternal learning disability

    • maternal substance misuse

    • domestic or sexual abuse

    • homelessness

    • human trafficking

    • undocumented migrant status

    • female genital mutilation

    • the woman or family members being known to children's services or social services.

1.18.5 Carry out an obstetric and general medical examination of a woman with no antenatal care as soon as possible. This should include the initial assessment described in the NICE guideline on intrapartum care for healthy women and babies.

1.18.6 Carry out an assessment of the unborn baby, including ultrasound if possible, to determine:

  • viability

  • the presentation

  • an estimate of gestational age

  • the possibility of multiple pregnancy

  • the placental site.

1.18.7 Offer women who have had no antenatal care, tests for:

  • anaemia (full blood count)

  • haemoglobinopathies

  • blood group and rhesus D status

  • atypical red cell alloantibodies

  • random blood glucose

  • asymptomatic bacteriuria

  • HIV, hepatitis B and syphilis.

1.18.8 Offer rapid HIV testing to women thought to be at high risk of infection, which might include:

  • recent migrants from countries with high rates of HIV infection

  • women who misuse substances intravenously

  • suspected sexual abuse.

1.18.9 Explain to a woman who has had no antenatal care why and when information about her pregnancy may need to be shared with other agencies. [This recommendation is adapted from the NICE guideline on pregnancy and complex social factors.]

1.18.10 Contact the woman's GP and, if appropriate, other health or social care professionals for more information about the woman's history and to plan ongoing care.

1.18.11 If there are safeguarding concerns, refer the woman to safeguarding services, document the referral and inform healthcare professionals such as the GP, health visitor and paediatric teams, and social care professionals (see the NICE guidelines on pregnancy and complex social factors, child maltreatment and child abuse and neglect).

1.18.12 Follow the recommendations in the NICE guideline on intrapartum care for healthy women and babies when no medical conditions or obstetric complications are identified in women who present in labour with no antenatal care.

To find out why the committee made the recommendations on risk assessment and management of labour for women with no antenatal care and how they might affect practice, see rationale and impact.

1.19 Previous caesarean section

Management of the first and second stages of labour for women with a previous caesarean section

1.19.1 Do not routinely insert an intravenous cannula for women in labour who have had a previous caesarean section.

1.19.2 Explain to women in labour who have had a previous caesarean section that:

  • a vaginal birth is associated with a small chance of uterine rupture

  • an emergency caesarean section may mean a higher chance of:

    • heavy bleeding needing a blood transfusion

    • infection, for example, intrauterine infection

    • a longer hospital stay

    • complications in a future pregnancy, for example, placenta praevia and placenta accreta (see the NICE guideline on caesarean section).

1.19.3 Explain to women in labour who have had a previous caesarean section that there is little evidence of a difference in outcomes for the baby between a vaginal birth or another caesarean section.

1.19.4 Explain to women who have had a previous caesarean section that they are likely to have a lower chance of complications in labour if they have also had a previous vaginal birth.

1.19.5 When discussing oxytocin for delay in the first or second stage of labour, explain to women who have had a previous caesarean section that this:

  • increases the chance of uterine rupture

  • reduces the chance of another caesarean section

  • increases the chance of an instrumental birth.

1.19.6 Offer continuous cardiotocography to women with a previous caesarean section if using oxytocin for delay in the first or second stage of labour.

1.19.7 Support informed choice of a full range of options for pain relief for women who have had a previous caesarean section, including labour and birth in water.

1.19.8 Explain to women in labour who have had a previous caesarean section that regional analgesia is associated with:

  • a reduced chance of another caesarean section

  • an increased chance of an instrumental birth.

1.19.9 Do not routinely offer amniotomy to women in labour who have had a previous caesarean section.

1.19.10 Offer continuous cardiotocography to women with a previous caesarean section if performing amniotomy.

1.19.11 For women who have had a previous caesarean section, be aware of the particular importance of following the recommendations from the NICE guideline on intrapartum care for healthy women and babies on:

  • food and drink in labour

  • controlling gastric acidity

  • position in labour, including the latent first stage, and birth.

To find out why the committee made the recommendations on management of the first and second stages of labour for women with a previous caesarean section and how they might affect practice, see rationale and impact.

1.20 Labour after 42 weeks of pregnancy

Fetal and maternal monitoring for women in labour after 42 weeks of pregnancy

1.20.1 Offer continuous cardiotocography to women in labour after 42 weeks of pregnancy after a full discussion of the benefits and risks to the woman and her baby. Respect the woman's decision if she declines continuous cardiotocography.

To find out why the committee made the recommendation on fetal and maternal monitoring for women in labour after 42 weeks of pregnancy and how it might affect practice, see rationale and impact.

Terms used in this guideline

Chronic kidney disease stages

Classified according to estimated glomerular filtration rate (eGFR) measured before pregnancy. See glomerular filtration rate (GFR) categories in table 1 in the NICE guideline on chronic kidney disease in adults.

Intrapartum period

The intrapartum period is from the onset of labour (spontaneous or induced) to 24 hours after birth.

Mechanical heart valves

A mechanical heart valve refers to a prosthetic heart valve that requires long-term anticoagulation to prevent heart valve thrombosis. This is different from a bioprosthetic heart valve, which does not need long-term anticoagulation.

Regional anaesthesia

Regional anaesthesia includes spinal, epidural and combined spinal–epidural techniques.

Regional analgesia

Regional analgesia includes spinal, epidural and combined spinal–epidural techniques.



[1] Defined according to the modified World Health Organization classification of maternal cardiovascular risk (European Society of Cardiology 2018).

[2] See American Heart Association's information about classes of heart failure.

  • National Institute for Health and Care Excellence (NICE)