Rationale and impact
- Antenatal education about labour
- Planning place of birth
- Care throughout labour in all birth settings
- Transfer of care and changing place of birth
- Attitudes to pain and pain relief in childbirth
- Care and observations for women with regional analgesia
- Assessment of women in the first stage of labour
- Measuring fetal heart rate as part of the initial assessment
- Ongoing assessment during the first stage of labour
- Presence of meconium
- Delay in the first stage
- Assessment of women during the second stage of labour
- Birth with forceps or ventouse in delayed second stage
- Risk factors for postpartum haemorrhage
- Initial assessment of the newborn baby
- Optimal positioning during skin-to-skin contact
- Additional monitoring for babies exposed to antidepressants in utero
- Care of the woman after birth
- Impact of BMI on choice of place of birth
- Initial assessment of women reporting prelabour rupture of membranes
- Sterile water injections
- Remifentanil patient-controlled analgesia
- Programmed intermittent epidural bolus
- Use of oxytocin in the first or second stage of labour
- Position for birth
- Pushing techniques
- Interventions to reduce perineal trauma
- Prophylactic antibiotics for birth with forceps or ventouse
- Management of the third stage of labour
- Position of the baby during cord clamping
- Management of postpartum haemorrhage
These sections briefly explain why the committee made the recommendations and how they might affect practice.
The committee were aware that the increased focus on supported decision making during labour meant that there were a number of points during labour where women were asked to make decisions on their care (for example, type of analgesia, use of oxytocin, perineal care, and active or physiological management of the third stage). The committee agreed that it would therefore be helpful if discussions of some of these options could begin during pregnancy, when women would have more time to think about their options.
The committee were aware that resources were available on the NICE and NHS websites that could help women and healthcare professionals when discussing place of birth, so they added a cross reference to these resources.
Based on stakeholder feedback, the committee added an additional overarching recommendation to emphasise that women should be given all the information they need to make a supported decision and consent should always be obtained.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to update the sections on communication and to bring them more in line with current NICE style and terminology and to increase the emphasis on supported decision making. The committee therefore added this new recommendation as these aspects of communication were not previously covered in the guideline. Based on stakeholder feedback, the use of healthcare passports for people with learning disabilities or autism has been included.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to clarify the existing wording on the criteria that necessitate an emergency or urgent transfer to obstetric care. The committee therefore added this new recommendation as this aspect of transfer was not previously covered in the guideline.
Based on stakeholder feedback, the committee added a new recommendation to advise that experiences and reporting of pain may vary and this should be taken into consideration to avoid diagnostic overshadowing.
Based on their knowledge and experience, the committee were aware that women with an epidural in situ may not know that they can still mobilise, or may be discouraged from mobilising, but that they can do this safely with assistance. They therefore added a recommendation to state this. Based on stakeholder feedback, the need for the midwife to be trained was added.
The committee were aware that the guideline recommended a vaginal examination be carried out at a number of different timepoints but did not specify what should be assessed as part of this vaginal examination. Based on their knowledge and experience, the committee therefore added a recommendation with these details.
The detail about fetal monitoring has been removed from this guideline as it is now contained in a separate NICE guideline, so a cross-reference was added to explain this.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to update recommendations on monitoring of urine output and fluid balance during labour. The committee therefore added this new recommendation as this aspect of care was not previously covered in the guideline.
The committee added this recommendation on meconium to the existing recommendations on the presence of meconium to ensure consistency with the advice given in the NICE guideline on fetal monitoring in labour.
The committee were aware that there may be uncertainty about the need to transfer for amniotomy. Based on their knowledge and experience, the committee were aware that amniotomy could be safely carried out in midwife-led settings and so made a recommendation to state this.
Instead of repeating the list of observations for the second stage of labour, the committee chose to make a new recommendation, cross-referring to the first stage list and the NICE guideline on fetal monitoring in labour.
Stakeholders at consultation advised that there were no recommendations on the action to be taken if a women declined a birth with forceps or ventouse. Based on their knowledge and experience, the committee therefore added this recommendation to outline the options in this scenario.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to update recommendations on medications which may increase the risk of postpartum haemorrhage. The committee therefore added this new recommendation to alert healthcare professionals to the Medicines and Healthcare products Regulatory Agency (MHRA) warning about SSRI and SNRI antidepressants increasing the risk.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to update recommendations on the use of the Apgar score for non-white babies. The committee therefore added this new recommendation to explain how the skin colour assessment of the Apgar score should be carried out.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to update recommendations on skin-to-skin contact to include information on safe positioning and monitoring. The committee therefore added this new recommendation to ensure safety for the airway during skin-to-skin contact.
The committee were aware of an MHRA warning relating to the risk of persistent pulmonary hypertension or withdrawal symptoms in babies whose mothers had taken SSRI or SNRI antidepressants during pregnancy, so they added a recommendation to alert people to this.
As part of the editorial updates planned for this guideline (see supplement 3), the committee were asked to update recommendations on monitoring of women with regional analgesia in light of updated guidelines from the Association of Anaesthetists and the Obstetric Anaesthetists' Association. The committee therefore added this new recommendation to ensure motor function was checked appropriately.
There was some evidence of increased risks for women with a body mass index (BMI) of 25 to 29.9 kg/m2, 30 to 35 kg/m2 and greater than 35 kg/m2, compared with women with a lower BMI. Some of the increased risks were dependent on whether the woman was nulliparous or multiparous, and the evidence was from a number of different planned birth settings. The increased risks included increased rates of transfer from home to an obstetric unit, increased rates of unplanned caesarean birth, increased risks of postpartum haemorrhage and increased rates of neonatal admission, stillbirth or neonatal death. As the increased risks were reported across a variety of different planned places of birth (home, freestanding and alongside midwifery-led units, and obstetric units) the committee were unable to determine if the differences in risks for women of different BMIs were the same in all planned places of birth, but agreed that the information showed a trend for increased risk as BMI increased across a number of settings and should be made available to women to assist with their decision making about place of birth.
The information on risks will help women make an informed, personal choice about their place of birth, and may result in more women at lower BMIs choosing to give birth at home or in a midwifery-led unit.
No evidence was identified for this review, so the committee used their knowledge and experience to define the factors which may indicate that a woman with prelabour rupture of the membranes requires an immediate in‑person clinical review. For other women without these factors, the committee agreed, based on their knowledge and experience, that an in-person review within 12 hours would ensure review within a safe time period, but would not put undue pressure on the woman to attend urgently.
Based on their knowledge and experience, the committee also amended the recommendations on actions to be taken when a woman presents with prelabour rupture of the membranes at term to align with the recommendations in the NICE guidelines on inducing labour and neonatal infection.
The recommendations will reduce variation in practice and for some units may mean women are reviewed a few hours earlier than is currently the case.
There was evidence for the benefits of sterile water injections for back pain in labour, and some evidence that women found it a satisfactory treatment that they would use again. However, the committee were concerned about the quality of the evidence and chose only to recommend sterile water injections as an option for back pain.
There was evidence that both intracutaneous and subcutaneous sterile water injections were effective, and that while there was a greater quantity of evidence for intracutaneous administration, there was no difference between the effectiveness of the 2 types of injection. Based on their own knowledge and experience, the committee were aware that sterile water injections could lead to a stinging sensation when administered, but there was evidence that pain relief was apparent 10 minutes after the injection and could last up to 3 hours. A variety of doses were found to be effective. However, several studies used doses of 0.1 ml for intracutaneous administration or 0.5 ml for subcutaneous administration, usually injected into 4 sites in the Rhombus of Michaelis, so the committee recommended these doses.
The evidence showed that use of sterile injected water did not increase the risk of unplanned caesarean birth, birth with forceps or ventouse, use of rescue analgesia or neonatal unit admission.
The recommendations may lead to increased use of sterile water injections for back pain in labour and will increase the number of treatment options available to women. As this is an inexpensive intervention, there is not expected to be a resource impact for the NHS.
There was some evidence that using remifentanil patient-controlled analgesia (PCA), when compared with intramuscular opioids, reduced the use of epidural analgesia, reduced birth with forceps or ventouse and increased vaginal birth, without causing any neonatal harms (such as neonatal respiratory depression or neonatal unit admission). Because of concerns over the quality and heterogeneity of this evidence, the committee agreed that they could not make a stronger recommendation about the use of remifentanil PCA.
As the evidence included studies which had used different doses of remifentanil, the committee based their recommendations on the dose used in the most recent and larger studies, which was the same dose as that already used in clinical practice.
There was evidence that intravenous remifentanil PCA led to an increase in maternal respiratory depression, and together with their knowledge and experience, the committee defined the appropriate settings, monitoring and safety procedures that should be in place for its use.
The recommendations will increase the use of intravenous remifentanil PCA, and this will have resource implications but will be offset by reduced use of rescue analgesia (including epidurals) and is a cost-effective use of NHS resources.
There was some evidence from different combinations of local anaesthetics and opioids that programmed intermittent epidural bolus (PIEB) used to maintain epidural analgesia led to reduced anaesthetist reattendance, reduced motor block, reduced labour pain, reduced duration of the second stage of labour, reduced caesarean birth and improved women's experience of labour, compared with other methods of maintaining epidural analgesia such as continuous epidural infusion, or patient-controlled epidural. There was conflicting evidence for the effects of PIEB on the rate of birth with forceps or ventouse, with evidence for both of an increased and decreased rate. As the evidence was limited, the committee agreed to recommend PIEB as an alternative option to epidural bolus administered by a healthcare professional or patient-controlled.
As PIEB is suggested as an alternative option to other methods of maintaining epidural analgesia, the resource impact is likely to be minimal. Most epidural pumps can already provide either patient-controlled or programmed intermittent boluses, so units would not need to purchase new pumps to implement these recommendations. There may be a reduction in staff time to administer the boluses and reduced anaesthetist reattendance.
There was no evidence about altering the dose of intravenous oxytocin, so the committee amended the recommendations from the previous version of the guideline. They based the changes on the summary of product characteristics for oxytocin and their knowledge and experience of the potential harms that may arise from hyperstimulation if oxytocin is administered at too high a dose or the dose is increased too rapidly.
There was no evidence for the optimum dose at which oxytocin should be restarted if stopped because of an abnormality in the cardiotocography, so the committee were unable to make recommendations about the dose to be used, but advised the decision should be based on the woman's previous dose and the full clinical picture.
Based on their knowledge and experience, the committee made recommendations to advise that the use of oxytocin, including whether to stop or restart it, should always be discussed with the woman and a supported decision should be made about its use. They also added a recommendation based on their knowledge and experience to advise cautious use of intravenous fluids and monitoring of fluid balance to limit the likelihood of fluid overload and hyponatremia.
As there was no evidence available, the committee made recommendations for research on restarting oxytocin and oxytocin in the first stage of labour.
The recommendations may reduce variation in current practice.
For women with an epidural in situ, there was a statistically significant increase in spontaneous vaginal births for nulliparous women who were in the left or right lateral recumbent positions (lying on their side) compared with upright positions during the second stage of labour. This did not meet the pre-specified minimally important difference but the committee agreed women should be informed of this result so they could take this into account when deciding on their position. There was evidence of no difference for any other outcomes for women who adopted an upright or a recumbent position for birth, although the committee agreed that the definitions of these positions differed between studies, and the lack of clarification around semi-recumbent positions may have confounded some of the results. Based on this evidence and their knowledge and experience, the committee were aware that women with an epidural in situ may need more assistance to mobilise and find a comfortable position, and may choose to lie on their side but could adopt another position if more comfortable.
For women with no epidural in situ, there was some evidence for the benefits of an upright position on fetal heart rate abnormalities, episiotomy rates and women's experience of birth.
For all women, the committee were aware of the risks of women lying flat on their backs from aortocaval compression and for women with an epidural in situ, exacerbation of epidural-induced hypotension.
The recommendations will reduce variation in practice.
There was evidence for pushing techniques for women both with and without an epidural in place, and as the action of an epidural can affect a woman's urge and ability to push, the committee made recommendations for these 2 groups separately.
For women without an epidural, there was evidence that spontaneous pushing and directed pushing while exhaling may reduce the length of the second stage of labour, but that there was otherwise no difference for any outcomes so the committee could not recommend one technique over another.
For nulliparous women with an epidural in place, there was some evidence that directed pushing may reduce the likelihood of an unplanned caesarean birth and for multiparous women, some evidence that delayed pushing may reduce the likelihood of a birth with forceps or ventouse. For both nulliparous and multiparous women with epidurals, there was evidence that delayed pushing may reduce the duration of the active second stage. For all other outcomes, there was no difference between spontaneous and directed, or immediate or delayed, so the committee could not recommend one technique over another.
The committee used the evidence to determine by how many hours pushing should be delayed by for nulliparous and multiparous women with epidurals in place.
The recommendations will reduce variation in practice.
There was evidence that warm compresses applied to the perineum during labour reduced the incidence of third- and fourth-degree tears, urinary incontinence and postpartum perineal pain. There was some evidence that massage with lubricant also reduced the incidence of third- and fourth-degree tears, and a comparison of warm compresses and massage with lubricant showed a reduction in episiotomy with warm compresses. Therefore, the committee recommended that massage with lubricant could be considered as an alternative, but that warm compresses should be used in preference where possible.
The evidence for 'hands on' and 'hands poised' was mixed and had limitations, with no difference between the techniques for many outcomes, and benefits and harms seen for both techniques for other outcomes. The committee could therefore not recommend one technique over another.
As there was a lack of evidence that allowed the committee to decide between 'hands on' and 'hands poised' care, and as there was no evidence for a technique called 'the Finnish grip', the committee made a recommendation for research on perineal care.
The recommendations will increase the use of warm compresses during labour and may increase the use of massage with lubricant. These are low-cost interventions and the long-term benefits of reducing third- and fourth-degree tears, urinary incontinence and pain are likely to make them cost effective.
There was good evidence that antibiotics administered within 6 hours reduced the risk of infection after birth with forceps or ventouse and did not cause any harms to the mother or baby. There was evidence for intravenous co-amoxiclav but the committee agreed, based on their experience, that in women who were allergic to penicillin, an alternative may be necessary.
As there was no evidence for oral antibiotics, the committee made a recommendation for research on prophylactic antibiotics for birth with forceps or ventouse.
The recommendation will increase the use of intravenous antibiotics after birth with forceps or ventouse. However, the benefits of preventing infections and on quality of life are likely to make this intervention cost effective, and the resource impact is likely to be mitigated by a reduction in the costs of treating women with postpartum infection.
There was evidence that active management had benefits compared with physiological management in terms of postpartum haemorrhage of 500 mL or more and 1,000 mL or more, anaemia, need for blood transfusion and need for additional uterotonics, but also harms in terms of increased side effects because of the use of uterotonics in active management. The committee were aware that some of the evidence was old and that methods for measuring blood and criteria for blood transfusion may have changed, which may impact the absolute rates of postpartum haemorrhage and blood transfusion quoted in the recommendations. However, they agreed that the increase in these risks with physiological management compared with active management still provided an indication to women of the difference in outcomes between the 2 management methods.
There was evidence of clinical effectiveness for some doses of oxytocin, oxytocin plus ergometrine, carbetocin and some doses of misoprostol at reducing postpartum haemorrhage more than 1,000 mL, the need for additional uterotonics, blood transfusions and mean blood loss, compared with placebo. The committee agreed that reduction in postpartum haemorrhage was the most important outcome for decision making. The committee considered the evidence stratified by women who had a vaginal birth and women who had a caesarean birth. For vaginal birth, the most effective uterotonics that the committee agreed were suitable for use in a wide variety of settings without causing unacceptable side effects were oxytocin plus ergometrine or oxytocin alone. The cost-effectiveness evidence showed that for women who had a vaginal birth, the most cost-effective options were oxytocin alone or oxytocin plus ergometrine to reduce postpartum haemorrhage more than 1,000 mL. Based on their knowledge and experience, the committee were aware that oxytocin plus ergometrine may lead to more nausea and vomiting (so should be prescribed with an antiemetic) and the treatment is also contraindicated in women with some comorbidities. They therefore recommended a choice of oxytocin or oxytocin plus ergometrine, but highlighted that women with risk factors for postpartum haemorrhage should be advised to have oxytocin plus ergometrine as the clinical evidence had shown it may be more effective. The committee considered the use of carbetocin but based on the evidence, did not consider that carbetocin was cost effective for the prevention of postpartum haemorrhage for women who had a vaginal birth.
For women who had a caesarean birth, there was evidence showing that the most effective uterotonics at reducing postpartum haemorrhage were misoprostol 600 to 800 micrograms and intravenous carbetocin. The committee considered that misoprostol was not a suitable agent for routine use because of the high incidence of nausea and vomiting, diarrhoea and abdominal pain it caused. The most cost-effective option appeared to be carbetocin, and the committee noted that carbetocin would be considered cost effective compared with oxytocin if a person would be willing to trade 17 days in full health to avoid having a postpartum haemorrhage equal to or greater than 1,000 mL. The committee agreed this was a reasonable trade off, so agreed to recommend carbetocin.
There was evidence that oxytocin given intravenously as part of active management of the third stage of labour had benefits when compared with intramuscular injection of oxytocin, as it helped reduce:
maternal admission to intensive care
the risk of primary and severe postpartum haemorrhage
the need for manual removal of placenta
the use of additional uterotonic drugs.
The committee investigated the outcomes stratified by intravenous infusion or intravenous bolus injection, and by whether the woman had received oxytocin during labour. They agreed that there was sufficient clinical evidence of the benefits and no evidence of harms compared with intramuscular oxytocin, in terms of side effects, to offer oxytocin administered by intravenous bolus injection to women in the third stage of labour. However, because of insufficient evidence of the benefits for women who have not had oxytocin during labour, the committee chose to make a recommendation offering intravenous bolus oxytocin only to women who have already had oxytocin during labour. The committee agreed that this would also improve the feasibility and acceptability of the recommendation, as these women would already have intravenous access in place.
The recommendations will reinforce current practice, which is to advise active management of the third stage of labour.
The recommendations will lead to increased use of oxytocin and ergometrine instead of oxytocin alone for women having a vaginal birth, and will increase the use of carbetocin instead of oxytocin for women having a caesarean birth, but both of these changes will be cost effective.
The recommendations will increase the administration of oxytocin by intravenous bolus injection for women in the third stage of labour who have already had oxytocin during labour, and this may have resource implications if an additional midwife is needed to assist with the intravenous administration.
There was only a very small amount of evidence, mostly of low or very low quality, which showed no difference or an unclear difference between holding the baby at the vaginal level, or abdominal or chest level. The committee did not therefore make any recommendations about the optimum position for the baby during cord clamping, but agreed that more data was needed, so made a recommendation for research on position of the baby during cord clamping.
There may currently be some variation in practice, with some babies held at vaginal level and some placed on the mother's abdomen or passed to her. This variation may continue in the short term as at present there is no evidence to suggest one technique is better or worse than the other.
There was good evidence that tranexamic acid reduced maternal death from bleeding compared with placebo, and some evidence that, when used in combination with oxytocin and ergometrine, it reduced blood loss volume and the need for additional surgical intervention, compared with oxytocin and ergometrine alone. There was no evidence for the benefits of oxytocin and ergometrine for the management of postpartum haemorrhage but based on their knowledge and experience, the committee knew these were effective so retained them in the guideline as treatment options. There was some evidence for the benefits of misoprostol, and carbetocin at reducing the need for additional surgical and pharmacological management, and evidence that carboprost reduced blood loss compared with oxytocin, so these were included as treatment options.
There was no evidence on the ideal sequencing of pharmacological treatments for postpartum haemorrhage, but the committee were aware that the choice of medication for the management of postpartum haemorrhage depended on uterotonics that had been received by the woman as part of active management, as a number of agents could not be repeated (for example, ergometrine and carbetocin).
As there was no evidence for the outcomes of breastfeeding or women's experience, the committee made a recommendation for research on management of postpartum haemorrhage.
Tranexamic acid was already recommended in the previous version of the guideline as an option for the treatment of postpartum haemorrhage, but these recommendations may increase its use and standardise practice across the NHS. Carbetocin was not previously recommended to treat postpartum haemorrhage so this may increase its use, but all other medicines were recommended in the previous version of the guideline so this is unlikely to change practice.