Intrapartum care

The NICE guideline on intrapartum care published in September 2023 updated and replaced the former guideline CG190 published in 2014. The guideline update helps women to make an informed choice about where to have their baby and about their care in labour. It also aims to reduce variation in aspects of care. The guideline update was partially revised in December 2024 and June 2025 in the areas of uterotonics for postpartum haemorrhage and maternal hyponatraemia.

Maternal hyponatraemia (June 2025 update)

The June 2025 update introduces recommendations covering maternal hyponatremia and strengthens some existing recommendations to emphasise awareness of fluid intake during labour.

We expect that the resource impact of this update:

• for any single guideline recommendation in England will be less than £1 million per year (or approximately £1,800 per 100,000 population, based on a population for England of 57.1 million people) and
• for implementing the whole guideline in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 57.1 million people).

This is because the updates to existing recommendations and new recommendations are not expected to have significant resource implications at a national level. However, some of the guideline areas and recommendations may represent a change to current local practice. These are:

Recommendation 1.8.27 outlines situations where fluid balance should be monitored. This will in some cases lead to a change in practice with increased use of fluid balance monitoring in labour. The best way to prevent hyponatraemia is to monitor fluid balance by recording the volume of fluid intake (oral and intravenous) and output (primarily urine) in a chart. Fluid balance monitoring will likely be undertaken by a midwife.

Recommendation 1.8.28 advises on what to do in cases of a positive fluid balance of 1500 ml or more, or if there are clinical concerns. This may lead to a small increase in the need for blood tests or transfers to an obstetric setting, but the benefits of preventing adverse outcomes from hyponatraemia are likely to outweigh this.

The guideline update may also serve to increase general awareness of maternal hyponatraemia and the associated risks. Savings will arise from preventing and recognising the condition and maternity and neonatal units should benefit from the avoidance of adverse outcomes which sometimes lead to maternal or neonatal severe morbidity or death.

Uterotonics for postpartum haemorrhage (December 2024 update)

The December 2024 update removes carbetocin as an option for treating women who experience a postpartum haemorrhage and require a post second-line treatment from the option on table 12. In addition to this change, clarification has been added to this part of the guideline in recognition that not all suggested treatments are available in all settings. Where this is the case, an alternative treatment of a repeat dose of ergometrine or the combination of oxytocin and ergometrine may be given.

The change in recommendation in the use of carbetocin may result in an additional cost, but this will need to be determined at a local level. The impact of the recommendations will depend on the number of women who experience a postpartum haemorrhage and need additional, post second-line treatment and are currently treated with carbetocin. Carbetocin is more expensive than misoprostol and similar in price to a single dose of carboprost. Carboprost may be used up to 8 doses whereas carbetocin is limited to a single dose. 

The cost per 100 mg pre-filled syringe of carbetocin is £17.64, the cost per ampule of carboprost is £18.20 and misoprostol costs £0.67 for an 800 mg dose (BNF - November 2024). 

Intrapartum care for healthy women and babies (September 2023 update)

We expect that the resource impact of the September 2023 update:

• for any single guideline recommendation in England will be less than £1 million per year (or approximately £1,800 per 100,000 population, based on a population for England of 56.6 million people) and
• for implementing the whole guideline in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 56.6 million people).

This is because the overall incremental cost of treatment is low and any cost is likely to be offset by savings and benefits. However, some of the guideline areas and recommendations may represent a change to current local practice. These are:

Remifentanil patient-controlled analgesia (recommendations 1.6.20 to 1.6.23)

The recommendations to consider remifentanil may increase the use of intravenous remifentanil PCA, and this will have resource implications such as increased monitoring which will require the presence of a qualified midwife or other suitably qualified person to be available at all times, but this is likely to be offset by reduced use of rescue analgesia (including epidurals).

Management of the third stage of labour (recommendations 1.10.11 to 1.10.13)

The recommendation 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.

Intrapartum care services are commissioned by integrated care boards. Providers are NHS Hospital trusts.