Intrapartum care

Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for both the woman and her baby. [2014]

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

Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth:

• Advise low-risk multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is associated with a lower rate of interventions and the outcome for the baby is no different compared with an obstetric unit.

• Advise low-risk nulliparous women that planning to give birth in a midwifery-led unit (freestanding or alongside) is associated with a lower rate of interventions and the outcome for the baby is no different compared with an obstetric unit. Explain that if they plan birth at home, there is a small increase in the risk of an adverse outcome for the baby. [2014, amended 2023]

Ensure that all healthcare professionals involved in the care of pregnant women are familiar with the types and frequencies of serious medical problems that can affect babies (see appendix A), in order to be able to provide this information to women if they request it. [2014]

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

• access to midwives, including:

  • the likelihood of being cared for in labour by a familiar midwife

  • the likelihood of receiving one-to-one care throughout labour (not necessarily being cared for by the same midwife for the whole of labour)

• access to medical staff (obstetric, anaesthetic and neonatal)

• availability of birthing pools

• access to pain relief, including Entonox (a 50:50 mixture of oxygen and nitrous oxide) and medicines (for example, pethidine, diamorphine, patient-controlled analgesia and regional analgesia)

• the likelihood of being transferred to an obstetric unit (if this is not the woman's chosen place of birth), the reasons why this might happen, the time it may take, the delay in obstetric or neonatal care this may cause, and how her birth companion will travel; refer to table 1 if no local data is available.
  
  More information on transfer to an obstetric unit for different groups of women is included in table 2 and table 4. [2014, amended 2023]

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

• these complications include unplanned caesarean birth, postpartum haemorrhage, transfer from home to an obstetric unit, stillbirth, neonatal death or the baby needing neonatal care

• the risk of complications may depend on whether the woman is nulliparous or multiparous, but in general the risks of complications are higher for nulliparous women with an increased BMI compared with multiparous women with an increased BMI

• in the event of complications arising, advanced care can generally be given more quickly in an obstetric unit or an alongside midwifery unit than at home or in a freestanding midwifery unit.
  
  For more detail on the risks associated with increased BMI in different places of birth, see appendix B. [2023]

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

• planning birth at home or in a freestanding midwifery unit is associated with a higher rate of spontaneous vaginal birth than planning birth in an alongside midwifery unit, and these 3 settings are associated with higher rates of spontaneous vaginal birth than planning birth in an obstetric unit

• planning birth in an obstetric unit is associated with a higher rate of interventions, such as vaginal birth with forceps or ventouse, unplanned caesarean birth and episiotomy, compared with planning birth in other settings

• there are no differences in outcomes for the baby associated with planning birth in any setting. [2014, amended 2023]

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

• planning birth at home or in a freestanding midwifery unit is associated with a higher rate of spontaneous vaginal birth than planning birth in an alongside midwifery unit, and these 3 settings are associated with higher rates of spontaneous vaginal birth than planning birth in an obstetric unit

• planning birth in an obstetric unit is associated with a higher rate of interventions, such as vaginal birth with forceps or ventouse, unplanned caesarean birth and episiotomy, compared with planning birth in other settings

• there are no differences in outcomes for the baby associated with planning birth in an alongside midwifery unit, a freestanding midwifery unit or an obstetric unit

• planning birth at home is associated with an overall small increase in the risk of a baby having a serious medical problem (about 4 more per 1,000 births) compared with planning birth in other settings. [2014, amended 2023]

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

• tables 6 and 7 show medical conditions or other situations in which there is increased risk for the woman or baby during or shortly after labour, where care in an obstetric unit would be expected to reduce this risk

• the factors listed in tables 8 and 9 are not reasons in themselves for advising birth within an obstetric unit, but indicate that further consideration of birth setting may be needed

• discuss these risks and the additional care that can be provided in the obstetric unit with the woman so that she can make an informed choice about planned place of birth. [2007, amended 2014]

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

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

Maternity services should:

• provide a model of care that supports one-to-one care in labour for all women and

• benchmark services and identify overstaffing or understaffing by using workforce planning models and/or woman-to-midwife ratios. [2014]

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

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

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

• use clear, plain language and confirm with the woman that they have understood the information

• tailor the content and delivery of information to the needs and preferences of the woman

• ensure that the woman is empowered to make a supported decision with her healthcare team, which may include:

  • using reliable interpreting services when needed (for example, for languages other than English, British Sign Language, or Makaton)

  • using interpreters who are independent of the woman (rather than, for example, a family member or friend)

  • using culturally sensitive language

  • adapting communication when necessary, for example, by using healthcare passports for people with learning disabilities or autism. [2023]

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

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

• can continue to make decisions about her care

• feels confident that her care team is there to assist her

• understands that she can accept or decline care that is offered, can change her mind, and that decisions she makes will not affect how care is provided to her.
  
  To ensure this happens, establish a rapport with the woman, ask her about her wants and expectations for labour, and be aware of the importance of both tone and demeanour and the actual words used. Use this information to support her and guide her care through her labour. [2007, amended 2023]

To establish communication with the woman:

• greet her and her birth companion(s) with a smile and a personal welcome, introduce yourself and explain your role in her care

• ask her what she wants to be called

• maintain a calm, confident and professional approach

• respect the woman's personal space, privacy and dignity, and ask others to do the same (for example, knock and wait before entering the woman's room)

• ask how the woman is feeling and whether there is anything in particular she would like to discuss or if she has any concerns

• discuss the woman's labour and birth preferences, and review and discuss any written birth plan

• ensure the woman is aware of pain relief options, and provide both the opportunity to discuss these options and give information if she requests it to establish what her choices are

• encourage the woman to adapt the environment to meet her individual needs

• explain all procedures and observations before they take place and ask for consent for them, focusing on the woman rather than the technology or the documentation

• show the woman and her birth companion(s) how to summon help, and reassure her that she can do so whenever and as often as she needs to

• when leaving the room, let her know when you will return

• involve the woman in any handover of care to another professional, either when additional expertise has been brought in or at the end of a shift – this should occur in the room, when appropriate, with the woman at the centre of the handover discussion. [2007, amended 2023]

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

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

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

Routine hygiene measures taken by staff caring for women in labour, including standard hand hygiene and single-use, non-sterile gloves, are appropriate to reduce cross-contamination between women, babies and healthcare professionals. [2007]

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

Healthcare professionals should think about how their own values and beliefs inform their attitude to coping with pain in labour and ensure their care supports the woman's choice. [2007]

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

• their cultural background and beliefs

• their socioeconomic status

• any neurodiverse conditions they may have. [2023]

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

Do not offer or advise aromatherapy, yoga or acupressure for pain relief during the latent first stage of labour. If a woman wants to use any of these techniques, support her choice. [2014, amended 2023]

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

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

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

• TENS devices are not provided by the NHS, but if a woman wants to use TENS to manage her comfort during labour, support her choice

• there is very little evidence of its effectiveness in established labour, but no evidence of harm

• other forms of pain relief can be used alongside TENS if needed by the woman. [2007, amended 2023]

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

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

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

For women labouring in water, monitor the temperature of the woman and the water hourly to ensure that the woman is comfortable and not becoming pyrexial. The temperature of the water should not be above 37.5°C. [2007]

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

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

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

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

Ensure that Entonox (a 50:50 mixture of oxygen and nitrous oxide) is available in all birth settings as it may reduce pain in labour, but inform the woman that it may make her feel nauseous and light-headed. [2007]

Ensure that pethidine, diamorphine or other opioids are available in all birth settings. Inform the woman that these will provide limited pain relief during labour and may have significant side effects for both her (for example, drowsiness, nausea and vomiting) and her baby (for example, short-term respiratory depression and drowsiness, which may last several days and may make it more difficult to breastfeed). [2007, amended 2023]

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

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

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

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

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

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

• they are less likely to need an epidural or have a birth using forceps or ventouse if using remifentanil PCA

• they are more likely to have a spontaneous vaginal birth or need supplemental oxygen when using remifentanil PCA.
  
  For more detail on the risks and benefits associated with the use of remifentanil, see appendix C. [2023]

When using remifentanil PCA, ensure that:

• there is the continuous presence of a midwife trained in the care of women receiving remifentanil PCA (one-to-one care)

• there is continuous cardiotocography monitoring if there are other risk factors

• there is continuous monitoring of respiratory function (observation of breathing and pulse oximetry)

• units have clear guidelines on responding to respiratory depression

• supplemental oxygen is immediately available

• immediate anaesthetic support is available in case of respiratory depression. [2023]

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

• latent first stage of labour is a period of time, not necessarily continuous, when:

  • there are contractions and

  • there is some cervical change, including cervical position, consistency, effacement and dilatation up to 4 cm

• established first stage of labour is when:

  • there are regular contractions and

  • there is progressive cervical dilatation from 4 cm. [2007, amended 2023]

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

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

• at home (regardless of planned place of birth) or

• in her planned place of birth (midwifery-led unit or obstetric unit), comprising one-to-one midwifery care for at least 1 hour. [2014, amended 2023]

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

• ask the woman how she is, and about her wishes, expectations and any concerns she has

• ask the woman about the baby's movements, including any changes

• give information about what the woman can expect in the latent first stage of labour and how to work with any pain she experiences

• give information about what to expect when she accesses care

• agree a plan of care with the woman, including guidance about who she should contact next and when

• provide guidance and support to the woman's birth companion(s). [2014]

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

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

• recognise that a woman may experience painful contractions without cervical change and offer her individualised support and analgesia if needed

• encourage her to remain at or return home, unless doing so leads to a significant risk that she could give birth without a midwife present or become distressed. [2014, amended 2023]

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

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

• maternal factors:

  • review and discuss the antenatal notes (including all antenatal screening results)

  • review the personalised care plan

  • review if there are any antenatal or intrapartum risk factors for fetal hypoxia (see the NICE guideline on fetal monitoring in labour)

  • ask her about the length, strength and frequency of her contractions

  • ask her about any pain she is experiencing and discuss her options for pain relief

  • record her pulse, blood pressure, temperature and respiratory rate, and carry out urinalysis

  • record if she has had any vaginal loss

  • check if she needs intrapartum antibiotics for group B streptococcus prophylaxis and, if so, that these are available in her chosen place of birth if needed (see the section on intrapartum antibiotics in NICE's guideline on neonatal infection)

• observations of the unborn baby:

  • ask the woman about the baby's movements in the last 24 hours

  • palpate the woman's abdomen to determine the fundal height, the baby's lie, presentation, position, engagement of the presenting part, and frequency and duration of contractions

• auscultate the fetal heart rate for a minimum of 1 minute immediately after a contraction; palpate the woman's pulse to differentiate between the heartbeats of the woman and the baby

• if there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment, but is not always necessary

• if the woman appears to be in established labour, offer a vaginal examination. [2014, amended 2023]

When conducting a vaginal examination:

• be sure that the examination is necessary and will add important information to the decision-making process

• recognise that a vaginal examination can be very distressing for a woman, especially if she is already in pain, highly anxious and in an unfamiliar environment

• explain the reason for the examination and what will be involved

• ensure the woman's informed consent, privacy, dignity and comfort

• explain sensitively the findings of the examination and any impact on the birth plan to the woman and her birth companion(s)

• advise the woman that she can decline the examination before it starts, or ask to stop at any stage during the examination. [2014, amended 2023]

When performing a vaginal examination, determine:

• the station of the presenting part

• the position of the presenting part

• the presence or absence of caput or moulding

• cervical effacement

• cervical dilatation

• presence or absence of membranes. [2023]

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

• observations of the woman:

  • pulse over 120 beats a minute on 2 occasions 15 to 30 minutes apart

  • a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more

  • either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 15 to 30 minutes apart

  • respiratory rate of less than 9 or more than 21 breaths per minute on 2 occasions 15 to 30 minutes apart

  • a reading of 2+ of protein on urinalysis and a single reading of either raised diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure (140 mmHg or more)

  • temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings 1 hour apart; for advice about intrapartum antibiotics, see the section on intrapartum antibiotics in NICE's guideline on neonatal infection

  • fresh red bleeding or blood-stained liquor

  • rupture of membranes more than 24 hours before the onset of established labour

  • the presence of meconium (see the section on the presence of meconium)

  • pain reported by the woman that differs from the pain normally associated with contractions

  • any risk factors recorded in the woman's notes that indicate the need for obstetric-led care

• observations of the unborn baby:

  • non-cephalic fetal presentation

  • high (4/5 to 5/5 palpable) or free-floating head in a nulliparous woman

  • suspected or diagnosed small for gestational age

  • diagnosed fetal growth restriction

  • diagnosis of oligohydramnios or anhydramnios on ultrasound

  • concerns about fetal monitoring, as described in the NICE guideline on fetal monitoring in labour

  • reduced fetal movements in the last 24 hours reported by the woman

  • cord presentation.
    
    If none of these are observed, continue with midwifery-led care unless the woman requests transfer. [2014, amended 2023]

If any of the factors in recommendation 1.8.11 are observed but birth is imminent, assess whether birth in the current location is preferable to transferring the woman to an obstetric unit and discuss this with the woman and the coordinating midwife. [2014, amended 2023]

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

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

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

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

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

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

Record the following observations during the first stage of labour:

• half-hourly documentation of frequency of contractions

• hourly pulse

• 4‑hourly temperature, blood pressure and respiratory rate

• offer a 4‑hourly vaginal examination (see recommendations 1.8.9 and 1.8.10), or in response to the woman's wishes if there is concern about progress (after abdominal palpation and assessment of vaginal loss). [2007]

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

• observations of the woman:

  • pulse over 120 beats/minute on 2 occasions 15 to 30 minutes apart

  • a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more

  • either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 15 to 30 minutes apart

  • a reading of 2+ of protein on urinalysis and a single reading of either raised diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure (140 mmHg or more)

  • respiratory rate of less than 9 or more than 21 breaths per minute on 2 occasions 15 to 30 minutes apart

  • temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart; for advice on intrapartum antibiotics, see the section on intrapartum antibiotics in NICE's guideline on neonatal infection

  • fresh red bleeding or blood-stained liquor

  • the new appearance of meconium (see the section on the presence of meconium)

  • pain reported by the woman that differs from the pain normally associated with contractions

  • confirmed delay in the first stage of labour

  • request by the woman for additional pain relief using regional analgesia

  • obstetric emergency, including antepartum haemorrhage, cord prolapse, maternal seizure or collapse, or a need for advanced neonatal resuscitation

• observations of the unborn baby:

  • any non-cephalic presentation, including cord presentation

  • high (4/5 to 5/5 palpable) or free-floating head in a nulliparous woman

  • suspected fetal growth restriction or macrosomia

  • suspected anhydramnios or polyhydramnios

  • any changes in the fetal heart rate pattern (see the NICE guideline on fetal monitoring in labour)
    
    If none of these are observed, continue with midwifery-led care unless the woman requests transfer. [2014, amended 2023]

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

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

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

• frequency of passing urine and bladder sensation

• fluid balance monitoring if sensation is abnormal or absent, if there is an inability to pass urine, or the woman is receiving intravenous fluids (including oxytocin)

• offering to insert a catheter if there are any ongoing concerns over the woman's ability to pass urine. [2023]

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

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

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

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

• may increase the risk to the baby

• means that continuous cardiotocography monitoring may be advised (see the NICE guideline on fetal monitoring in labour)

• may mean that healthcare professionals trained in advanced neonatal life support are needed as soon as the baby is born. [2014, amended 2023]

If the woman wishes to be transferred, provided that it is safe to do so and the birth is unlikely to occur before transfer is completed, follow the general principles for transfer of care described in section 1.5. Take into account that the presence of other risk factors (in addition to meconium) may increase the urgency of the transfer. [2014, amended 2023]

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

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

• first labours last on average 8 hours and are unlikely to last over 18 hours

• second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours. [2007]

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

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

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

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

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

• parity

• cervical dilatation and rate of change

• uterine contractions

• station and position of presenting part.
  
  Offer the woman support, hydration, and appropriate and effective pain relief. [2007, amended 2023]

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

• cervical dilatation of less than 2 cm in 4 hours for first labours

• cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours

• descent and rotation of the baby's head

• changes in the strength, duration and frequency of uterine contractions. [2007]

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

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

Advise all women with suspected delay in the established first stage of labour to have a vaginal examination 2 hours later, and diagnose delay if progress is less than 1 cm. [2007]

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

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

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

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

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

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

• her choice to start, stop or restart the oxytocin will be supported

• using oxytocin after spontaneous or artificial rupture of the membranes will bring forward the time of birth but will not influence the mode of birth or neonatal outcomes

• oxytocin will increase the frequency and strength of contractions and that its use will mean that her contractions and her baby's heartbeat will be monitored continuously using cardiotocography; see the NICE guideline on fetal monitoring in labour

• oxytocin can cause hyperstimulation, which may increase the chance of transient fetal hypoxia, and if hyperstimulation occurs the dose will be reduced or stopped. [2007, amended 2023]

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

When starting intravenous oxytocin in the first stage of labour:

• do not start separate intravenous fluids without a clinical indication (for example, the woman is not drinking, is dehydrated, or is hypotensive)

• monitor fluid balance. [2023]

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

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

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

Consider restarting oxytocin in the first stage of labour if:

• obstetric review has been carried out and the cardiotocography is no longer pathological

• the woman agrees that it can be restarted.
  
  Base the dose when restarting on a full clinical assessment, taking into consideration the previous dose. [2023]

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

• if cervical dilatation has increased by less than 2 cm after 4 hours of oxytocin, further obstetric review is needed to assess whether a caesarean birth is advisable

• if cervical dilatation has increased by 2 cm or more, advise 4‑hourly vaginal examinations. [2007, amended 2023]

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

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

• passive second stage of labour: when there is full dilatation of the cervix (determined by either vaginal examination or noting other external signs of full dilatation) before or in the absence of involuntary or active pushing

• the passive second stage of labour may be up to 2 hours when a woman with an epidural in place has been advised to delay pushing (see recommendations 1.9.7 to 1.9.10)

• onset of the active second stage of labour is when:

  • the baby is visible or

  • there is involuntary or active pushing with full dilatation of the cervix. [2007, amended 2023]

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

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

• position of the head

• descent

• caput and moulding. [2007, amended 2023]

During the second stage of labour:

• continue to take the woman's emotional and psychological needs into account

• assess progress, which should include the woman's behaviour, the effectiveness of pushing and the baby's wellbeing, taking into account the baby's position and station at the onset of the second stage; these factors will assist in deciding the timing of further vaginal examinations and any need for transfer to obstetric-led care

• assess the frequency, strength and duration of contractions

• perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least 1 minute, at least every 5 minutes. Palpate the woman's pulse every 5 minutes to differentiate between the 2 heartbeats; see the NICE guideline on fetal monitoring in labour

• ongoing consideration should be given to the woman's position, hydration, coping strategies and pain relief throughout the second stage. [2007, amended 2023]

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

• lying flat on her back can lead to a decrease in blood pressure and may reduce placental blood flow

• lying on her side may increase the chance of a spontaneous vaginal birth, but she can use any other position she finds comfortable to give birth, including upright positions. [2023]

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

• lying flat on her back can lead to a decrease in blood pressure and may reduce placental blood flow

• she can use any other position she finds comfortable to give birth

• upright positions and keeping mobile may be beneficial (as they may reduce fetal heart rate abnormalities, episiotomy rates and improve her birthing experience). [2023]

Advise women without an epidural in place that:

• spontaneous pushing may shorten the second stage of labour compared with directed pushing

• if directed pushing is used, pushing while exhaling may shorten the active second stage of labour for multiparous women. [2023]

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

Advise nulliparous women with an epidural that:

• directed pushing rather than spontaneous pushing may reduce the likelihood of having an unplanned caesarean birth

• delayed directed pushing (up to 2 hours after full dilatation) may shorten the active second stage of labour. [2023]

Advise multiparous women with an epidural that:

• delayed directed pushing (by 1 hour after full dilatation) may reduce the likelihood of needing birth with forceps or ventouse

• delayed directed pushing (by 1 hour after full dilatation) may shorten the active second stage of labour. [2023]

If pushing is ineffective or if requested by the woman, offer strategies to assist birth, such as support, change of position, emptying of the bladder and encouragement. [2007]

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

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

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

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

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

Inform any woman with a history of severe perineal trauma that her risk of repeat severe perineal trauma is not increased in a subsequent birth, compared with women having their first baby. [2007]

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

In order for a woman who has had previous third- or fourth-degree trauma to make an informed choice, talk with her about the future mode of birth, encompassing:

• current urgency or incontinence symptoms

• the degree of previous trauma

• risk of recurrence

• the success of the repair undertaken

• the psychological effect of the previous trauma

• management of her labour. [2007]

Inform any woman with infibulated genital mutilation of the risks of difficulty with vaginal examination, catheterisation and application of fetal scalp electrodes. Inform her of the risks of delay in the second stage and spontaneous laceration together with the possible need for defibulation in labour. [2007, amended 2023]

If an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy. [2007]

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

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

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

For a nulliparous woman without an epidural:

• birth would be expected to take place within 3 hours of the start of the active second stage in most women

• after 1 hour of active pushing, reassess the clinical picture, including progress, contractions, and maternal and fetal wellbeing:

  • if there are signs of progress (in terms of rotation or descent of the presenting part), encourage the woman to continue pushing

  • if there are no signs of progress, offer vaginal examination and consider amniotomy if the membranes are intact; if there is still no progress, diagnose delay and escalate for senior review

• if birth is not imminent after 2 hours of pushing, refer the woman for a senior review and a decision on place and mode of birth. [2007, amended 2023]

For a multiparous woman without an epidural:

• birth would be expected to take place within 2 hours of the start of the active second stage in most women

• after 30 minutes of active pushing, reassess clinical picture, including progress, contractions, and maternal and fetal wellbeing:

  • if there are signs of progress (in terms of rotation or descent of the presenting part), encourage the woman to continue pushing

  • if there are no signs of progress, offer vaginal examination and consider amniotomy if the membranes are intact; if there is still no progress, diagnose delay and escalate for senior review

• if birth is not imminent after 1 hour of pushing, refer the woman for senior review and decision on place and mode of birth. [2007, amended 2023]

For a nulliparous woman with an epidural:

• birth would be expected to take place within 3 hours of the start of the active second stage in most women, but be aware that these women may have had a passive stage of up to 2 hours after full dilatation before commencing active pushing (see recommendation 1.9.9)

• after 1 hour of active pushing, reassess the clinical picture, including progress, contractions, and maternal and fetal wellbeing:

  • if there are signs of progress (in terms of rotation or descent of the presenting part), encourage the woman to continue pushing

  • if there are no signs of progress, offer vaginal examination and consider amniotomy if the membranes are intact; if there is still no progress, diagnose delay and escalate for senior review

• if birth is not imminent after 2 hours of pushing, refer the woman for a senior review and decision on place and mode of birth. [2007, amended 2023]

For a multiparous woman with an epidural:

• birth would be expected to take place within 2 hours of the start of the active second stage in most women, but be aware that these women may have had a passive stage of up to 1 hour after full dilatation before commencing active pushing (see recommendation 1.9.10)

• after 30 minutes of active pushing, reassess clinical picture, including progress, contractions, and maternal and fetal wellbeing:

  • if there are signs of progress (in terms of rotation or descent of the presenting part), encourage the woman to continue pushing

  • if there are no signs of progress, offer vaginal examination and consider amniotomy if the membranes are intact; if there is still no progress, diagnose delay and escalate for senior review

• if birth is not imminent after 1 hour of pushing, refer the woman for a senior review and decision on place and mode of birth. [2007, amended 2023]

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

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

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

• assessment and confirmation of fetal wellbeing (including presentation, position and heart rate)

• differentiation between the fetal and maternal heart rates

• confirmation that there are no signs of obstructed labour

• confirmation that contractions are infrequent or ineffective. [2014, amended 2023]

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

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

If the birth needs to be expedited for maternal or fetal reasons, assess both the risk to the baby and the safety of the woman. The assessment should include:

• the degree of urgency

• clinical findings on abdominal and vaginal examination

• the mode of birth (and whether to use forceps or ventouse if indicated)

• anticipated degree of difficulty, including the likelihood of success if birth with forceps or ventouse is attempted

• location

• any time that may be needed for transfer to obstetric-led care

• the need for additional analgesia or anaesthesia

• the woman's preferences. [2014]

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

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

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

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

If a woman declines a birth with forceps or ventouse:

• discuss her remaining options (vaginal birth, caesarean birth or reconsidering her decision about forceps or ventouse)

• advise her that her choices may be limited by clinical safety or degree of urgency (for example, if a caesarean birth is no longer an option because the baby's head is too low in the pelvis)

• support her decision. [2023]

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

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

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

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

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

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

• the third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes

• active management of the third stage involves a package of care comprising the following components:

  • routine use of uterotonic drugs

  • cord clamping and cutting of the cord (see recommendation 1.10.14)

  • controlled cord traction after signs of separation of the placenta

• physiological management of the third stage involves a package of care that includes the following components:

  • no routine use of uterotonic drugs

  • no clamping of the cord until pulsation has stopped, or after delivery of the placenta

  • delivery of the placenta spontaneously or by maternal effort. [2014, amended 2023]

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

• her general physical condition, as shown by her colour, respiration and her own report of how she feels

• vaginal blood loss. [2014]

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

• carry out frequent observations to assess whether resuscitation is needed

• transfer her to obstetric-led care; follow the general principles for transfer of care described in section 1.5, taking into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect. [2014, amended 2023]

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

• the different options for managing the third stage of labour, and what to expect with each option

• the benefits and risks associated with active and physiological management of the third stage (see tables 10 and 11). [2023]

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

If a woman requests physiological management of the third stage:

• discuss her level of risk so she can make an informed decision and

• support her in her choice. [2014, amended 2023]

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

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

• oxytocin plus ergometrine may be more effective than oxytocin alone at reducing the risk of postpartum haemorrhage

• oxytocin plus ergometrine is advised if there are risk factors which could increase the risk of postpartum haemorrhage

• oxytocin plus ergometrine is more likely to lead to nausea and vomiting compared with oxytocin alone

• oxytocin plus ergometrine is contraindicated in women with severe hypertension, pre-eclampsia, eclampsia, or severe cardiac, hepatic or renal disease. [2023]

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

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

If oxytocin is used, administer it by:

• intramuscular injection or

• slow intravenous injection over 3 to 5 minutes for women who have received oxytocin during labour. [2023]

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

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

• do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heart rate below 60 beats a minute that is not getting faster

• clamp the cord before 5 minutes in order to perform controlled cord traction as part of active management

• if the woman requests that the cord is clamped and cut later than 5 minutes, support her choice. [2014, amended 2023]

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

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

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

• haemorrhage

• the placenta is not delivered within 1 hour of the birth of the baby. [2014]

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

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

Diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management. Follow the recommendations on managing a retained placenta. [2014]

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

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

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

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

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

• offer a vaginal examination to assess the need to undertake manual removal of the placenta

• explain that this assessment can be painful and advise her to have analgesia. [2014]

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

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

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

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

When assessing the colour element of the Apgar score:

• assess central oxygenation by looking inside the mouth at the mucous membranes and tongue

• assess peripheral oxygenation by looking at the colour of the nail beds. [2023]

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

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

• follow recommendations on neonatal resuscitation and

• take paired cord-blood samples for blood gas analysis, after double-clamping the cord using 2 clamps.
  
  Continue to evaluate and record the baby's condition until it is improved and stable. [2014]

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

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

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

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

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

Avoid separating the woman and her baby within the first hour of the birth for routine postnatal procedures, for example, weighing, measuring and bathing, unless these measures are requested by the woman or are necessary for the immediate care of the baby. [2007]

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

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

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

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

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

Ensure that any examination or treatment of the baby is undertaken with the consent of the parents and either in their presence or, if this is not possible, with their knowledge. [2007]

In the first minutes after birth, evaluate the condition of the baby (specifically respiration, heart rate and tone) in order to determine whether resuscitation is needed according to nationally accredited guidelines on neonatal resuscitation. [2014]

All relevant healthcare professionals caring for women during birth should attend annually a course in neonatal resuscitation that is consistent with nationally accredited guidelines on neonatal resuscitation. [2014]

In all birth settings:

• bear in mind that it will be necessary to call for help if the baby needs resuscitation, and plan accordingly

• ensure that there are facilities for resuscitation, and for transferring the baby to another location if necessary

• develop emergency referral pathways for both the woman and the baby, and implement these if necessary. [2014]

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

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

Throughout an emergency situation in which the baby needs resuscitation, allocate a member of the healthcare team to talk with, and offer support to, the woman and any birth companion(s). [2014]

In the presence of any degree of meconium:

• do not suction the baby's upper airways (nasopharynx and oropharynx) before birth of the shoulders and trunk

• do not suction the baby's upper airways (nasopharynx and oropharynx) if the baby has normal respiration, heart rate and tone

• do not intubate if the baby has normal respiration, heart rate and tone. [2014]

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

If there has been significant meconium and the baby is healthy, closely observe the baby within a unit with immediate access to a neonatologist. Perform these observations at 1 and 2 hours old and then 2‑hourly until 12 hours old. [2014]

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

If any of the following are observed after any degree of meconium, ask a neonatologist to assess the baby. Transfer both the woman and baby if they are at home or in a freestanding midwifery unit. Follow the general principles for transfer of care described in section 1.5, taking into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect:

• respiratory rate above 60 breaths per minute

• the presence of grunting

• heart rate below 100 or above 160 beats per minute

• capillary refill time above 3 seconds

• body temperature of 38°C or above, or 37.5°C on 2 occasions 15 to 30 minutes apart

• oxygen saturation below 95% (measuring oxygen saturation is optional after non-significant meconium)

• presence of central cyanosis, confirmed by pulse oximetry if available. [2014, amended 2023]

Explain the findings to the woman, and inform her about what to look out for and who to talk to if she has any concerns. [2014]

Closely observe any baby born to a woman with prelabour rupture of the membranes (more than 24 hours before the onset of established labour) at term for the first 12 hours of life (at 1, 2, 6 and 12 hours) in all settings. Include assessment of:

• temperature

• heart rate

• respiratory rate

• presence of respiratory grunting

• significant subcostal recession

• presence of nasal flare

• presence of central cyanosis, confirmed by pulse oximetry if available

• skin perfusion assessed by capillary refill

• floppiness

• concerns about general wellbeing and feeding.
  
  If any of these are observed, ask a neonatologist to assess the baby. Transfer both the woman and baby if they are at home or in a freestanding midwifery unit. Follow the general principles for transfer of care described in section 1.5 and take into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect. [2014, amended 2023]

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

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

Advise women with prelabour rupture of the membranes to inform their healthcare professionals immediately of any concerns they have about their baby's wellbeing in the first 5 days after birth, particularly in the first 12 hours when the risk of infection is greatest. [2007]

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

Refer a baby with any symptom of possible sepsis, or born to a woman who has evidence of chorioamnionitis, to a neonatal care specialist immediately. [2007]

Carry out the following observations of the woman after birth:

• record her temperature, pulse, blood pressure and respiratory rate. Transfer the woman (with her baby) to obstetric-led care if any of the relevant indications listed in recommendation 1.8.20 are met

• check uterine contraction and lochia

• examine the placenta and membranes: assess their condition, structure, cord vessels and completeness; transfer the woman (with her baby) to obstetric-led care if the placenta is incomplete

• make an early assessment of the woman's emotional and psychological condition in response to labour and birth; see the NICE guideline on postnatal care

• check for successful voiding of the bladder; if, after 6 hours, her bladder is palpable and she is unable to pass urine, advise catheterisation and consider transferring the woman (with her baby) to obstetric-led care.
  
  If transferring the woman to obstetric-led care, follow the general principles for transfer of care described in section 1.5 and take into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect. [2014, amended 2023]

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

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

• first degree – injury to skin only

• second degree – injury to the perineal muscles but not the anal sphincter

• third degree – injury to the perineum involving the anal sphincter complex:

  • 3a – less than 50% of external anal sphincter thickness torn

  • 3b – more than 50% of external anal sphincter thickness torn

  • 3c – internal anal sphincter torn

• fourth degree – injury to the perineum involving the anal sphincter complex (external and internal anal sphincter) and anal epithelium. [2007]

Before assessing for genital trauma:

• explain to the woman what is planned and why

• offer inhalational analgesia

• ensure good lighting

• position the woman so that she is comfortable and so that the genital structures can be seen clearly. [2007]

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

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

Include the following in a systematic assessment of genital trauma:

• further explanation of what is planned and why

• confirmation by the woman that tested effective local or regional analgesia is in place

• visual assessment of the extent of perineal trauma to include the structures involved, the apex of the injury and assessment of bleeding

• a rectal examination to assess whether there has been any damage to the external or internal anal sphincter if there is any suspicion that the perineal muscles are damaged. [2007]

Ensure that the timing of this systematic assessment does not interfere with mother–baby bonding unless the woman has bleeding that requires urgent attention. [2007]

Assist the woman to adopt a position that allows adequate visual assessment of the degree of trauma and for repair. Only maintain this position for as long as necessary for systematic assessment and repair. If it is not possible to adequately assess the trauma, transfer the woman (with her baby) to obstetric-led care, following the general principles for transfer of care described in section 1.5. [2007, amended 2014]

Seek advice from a more experienced midwife or obstetrician if there is uncertainty about the nature or extent of the trauma. Transfer the woman (with her baby) to obstetric-led care (following the general principles for transfer of care described in section 1.5) if the repair needs further surgical or anaesthetic expertise. [2007, amended 2014]

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

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

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

When carrying out perineal repair:

• ensure that tested effective analgesia is in place, using infiltration with up to 20 ml of 1% lidocaine or equivalent

• top up the epidural or insert a spinal anaesthetic if necessary. [2007]

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

Advise the woman that in the case of first-degree trauma, the wound should be sutured in order to improve healing, unless the skin edges are well opposed. [2007]

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

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

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

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

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

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

Observe the following basic principles when performing perineal repairs:

• repair perineal trauma using aseptic techniques

• check equipment and count swabs and needles before and after the procedure

• ensure good lighting is available to see and identify the structures involved

• ensure that trauma is repaired in the appropriate place with appropriate anaesthesia, according to the clinician's judgement

• ensure that good anatomical alignment of the wound is achieved and that consideration is given to the cosmetic results

• ensure that suture material has not been accidentally inserted through the rectal mucosa by carrying out a rectal examination after completing the repair

• after completion of the repair, document an accurate detailed account covering the extent of the trauma, the method of repair and the materials used

• give the woman information about the extent of the trauma, pain relief, diet, hygiene and the importance of learning to do pelvic floor exercises, what to expect as they recover, and where and when to seek advice or psychological support if needed. [2007, amended 2023]