Evidence
Surveillance decision
We propose to update the guideline on intrapartum care for healthy women and babies. The update will focus on risks associated with epidural, the woman's position in the second stage of labour, intrapartum interventions to reduce perineal trauma, risks associated with active management, route of administration of oxytocin during active management, delayed cord clamping and management of postpartum haemorrhage.
The following table gives an overview of how evidence identified in surveillance might affect each area of the guideline, including any proposed new areas.
|
Section of the guideline |
New evidence identified |
Impact |
|
Place of birth |
Yes |
No |
|
Care throughout labour |
Yes |
No |
|
Latent first stage of labour |
Yes |
No |
|
Initial assessment |
Yes |
No |
|
Ongoing assessment |
No |
No |
|
General principles for transfer of care |
No |
No |
|
Care in established labour |
Yes |
No |
|
Pain relief in labour: non-regional |
Yes |
No |
|
Yes |
Yes |
|
|
Monitoring during labour |
Yes |
No |
|
Pre-labour rupture of membranes at term |
No |
No |
|
First stage of labour |
Yes |
No |
|
Yes |
Yes |
|
|
Yes |
Yes |
|
|
Care of the newborn baby |
Yes |
No |
|
Care of the woman after birth |
Yes |
No |
|
Areas not covered in the guideline |
||
|
Use of ultrasound during instrumental delivery |
Yes |
No |
|
Routine antibiotic prophylaxis with episiotomy or perineal tears |
Yes |
No |
|
Prophylactic antibiotics for operative vaginal delivery |
Yes |
No |
|
Fundal pressure |
Yes |
No |
|
Tranexamic acid for the prevention of postpartum haemorrhage |
Yes |
No |
Reasons for the decision
This section provides a summary of the areas that will be updated and the reasons for the decision to update.
Pain relief in labour: regional analgesia
New evidence was identified on the risks associated with epidural. Findings suggest that there is no longer an association of epidural with more assisted vaginal birth, but it is associated with the following side effects: increased risk of hypotension, motor blockade, fever, urinary retention and oxytocin augmentation. This is not in line with recommendation 1.9.2 in the guideline, which currently states that there is an increased chance of vaginal instrumental birth with epidural and it does not mention the side effects listed in the new evidence. Taking into account the new evidence, it is proposed that the guideline should be updated in this area.
Second stage of labour
The woman's position and pushing during the second stage of labour
New evidence was identified on the mother's position during the second stage of labour. Currently, recommendation 1.13.9 in the guideline recommends discouraging the woman from lying supine or semi-supine in the second stage of labour and encouraging her to adopt any position that she finds comfortable. Two Cochrane reviews have been updated since the guideline was published, with results indicating that the optimal position of the woman during the second stage of labour is dependent on whether she has an epidural. For women without epidural, there was some indication that upright positions were associated with a reduction in episiotomies and fewer abnormal fetal heart rate problems. For women with epidural, findings suggest that upright positions significantly increase the chance of operative births (driven by an increase in caesarean sections). In light of the new evidence, it is proposed that the guideline section on maternal position in the second stage of labour is reviewed.
Intrapartum interventions to reduce perineal trauma
New evidence was identified on the effectiveness of different interventions to reduce perineal trauma in the second stage of labour. Results from a Cochrane review suggest that perineal massage may be associated with higher rates of intact perineum and fewer incidences of third- and fourth-degree tears. However no effect was found on perineal trauma requiring suturing or second-degree tears. Currently, recommendation 1.13.12 in the guideline states to not perform perineal massage in the second stage of labour. As the new evidence highlights some potential benefits to perineal massage, it is proposed that this recommendation is reviewed.
Third stage of labour
Route of administration of oxytocin during active management of the third stage of labour
Results from a large UK-based randomised controlled trial indicated that compared to the intramuscular route, intravenous administration of oxytocin (as part of active management) is associated with significantly lower rates of severe postpartum haemorrhage, the need for blood transfusion and admission to a high dependency unit. Currently, recommendation 1.14.13 in the guideline recommends intramuscular administration of oxytocin. Therefore it is proposed that this recommendation is reviewed considering the new findings.
Active management of the third stage of labour
Results from an updated Cochrane review indicated that there are some side effects associated with active management that are not mentioned in the guideline, these being: increased maternal diastolic blood pressure, after‐pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding. Currently, recommendation 1.14.7 in the guideline references nausea and vomiting but may need to be updated in view of the other side effects highlighted in the review.
Delayed cord clamping
New evidence suggests that volume of placental transfusion was similar in babies that were given straight to the mother compared to being held at vagina level for 2-minutes. The guideline does not currently make any recommendations on where the baby should be held during the delay in cord clamping. Further advice was sought from topic experts on what is standard practice in the UK. Feedback suggests that both practices are used, however it was noted that holding the baby at vagina level was difficult and may result in low compliance of delayed cord clamping. It was agreed that recommendations in this area would be beneficial and that the guideline should be updated in light of the new evidence.
Management of postpartum haemorrhage
Results from a Cochrane review found that tranexamic acid given 1 to 3 hours after birth may be effective at reducing risk of maternal death from bleeding, maternal deaths from all causes and blood loss of more than 500 ml. Currently, recommendation 1.14.34 in the guideline only recommends tranexamic acid as treatment for significant continuing postpartum haemorrhage, rather than as a first-line treatment. As the new evidence suggests that tranexamic acid is more effective when given as early as possible in the event of postpartum haemorrhage, it is proposed this area of the guideline is reviewed.
For further details and a summary of all evidence identified in surveillance, see appendix A.
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