Intrapartum care–updated summary of NICE guidance
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj.p2885 (Published 29 January 2024) Cite this as: BMJ 2024;384:p2885
This article has a correction. Please see:
- Rebecca Blackburn, technical analyst1,
- Agnesa Mehmeti, technical analyst1,
- Samantha Russell, patient representative2,
- Frances Rivers, consultant midwife3,
- Margaret Blott, consultant obstetrician and lead for obstetrics4
- On behalf of the guideline committee
- 1National Institute for Health and Care Excellence, London, UK
- 2Patient author
- 3Kingston Hospital NHS Foundation Trust, UK
- 4The Royal Free London NHS Foundation Trust, UK
- Correspondence to R Blackburn Rebecca.Blackburn{at}nice.org.uk
What you need to know
Consider a woman’s body mass index when planning place of birth, as the chance of needing interventions in labour varies across different BMI ranges
Remifentanil patient controlled analgesia and programmed intermittent epidural boluses are now recommended as pain relief options for women during labour; consider sterile water injections for back pain
Warm compresses or massage during the second stage of labour may prevent serious perineal tears and can be considered if appropriate for and acceptable to the woman
In 2021, there were around 650 000 births in England and Wales.1 Most of these births were the result of a straightforward pregnancy, where labour occurred spontaneously at term (37-42 weeks) and the woman gave birth to a single baby without complications. The advice and care that women receive around where to plan their place of birth, pain relief during labour, and management of labour affect their overall experience, and could impact both their mental and physical health and the health of their babies.
The National Institute for Health and Care Excellence (NICE) first published guidelines on intrapartum care for healthy women and babies in 2014, and these were updated in 2017. This article summarises a selection of new and updated recommendations, and focuses on those where new evidence has emerged that has led to a change in advice and recommendations involving shared decision making between the woman and the healthcare professional.
The recommendations included in this summary use the terms “woman” or “mother” throughout; however, they apply also to people who do not identify as women but who are pregnant or have given birth.
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline development group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. Evidence certainty is based on GRADE criteria.
GRADE Working Group grades of evidence
High certainty—we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty—we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty—our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty—we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
Place of birth and body mass index
The recommendations below are new in the 2023 update of this guideline. Before this recommendation was introduced, information on the impact of body mass index (BMI) to guide a woman’s choice of place of birth was limited.
Choosing place of birth is an important part of a woman’s birth plan. Parity, obstetric history, and medical or obstetric conditions need to be considered as they might affect a woman’s decision and appropriateness for place of birth. The evidence in this review relates to how BMI impacts on a woman’s choice regarding place of birth. Most of the evidence comes from two different cohorts of women: those within a BMI range of 18.5-24.9 kg/m22 and those within other BMI ranges.3456 Evidence was available for all birth settings, including home, freestanding midwifery units, alongside midwifery units, and obstetric units. Most of the evidence showed that the risk of interventions and complications increased with higher BMI ranges, and the risk differed depending on parity.
Advise women that, in general, the higher their BMI at booking (and particularly with a BMI above 35 kg/m2) the greater the likelihood of complications, and therefore this may be something they wish to think about when planning their place of birth. Discuss with them that:
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; in general, the risk is higher for nulliparous women with an increased BMI compared with multiparous women with an increased BMI
In the event of complications, 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.
[Recommendations based on high to very low quality evidence]
Pain relief during labour
Multiple pain relief options are available to women in labour (box 1). Unless contraindicated, women can often choose their preferred method of pain relief (non-pharmacological or pharmacological) depending on the level required and the mode of administration. Providing the woman with options aims to ensure that giving birth is a positive experience. This updated guideline has added new recommendations on remifentanil patient controlled analgesia (PCA) and programmed intermittent epidural bolus for pain relief during labour, and sterile water injections for relief of back pain during labour.
Therapies for pain relief during labour
Non-pharmacological
Breathing exercises
Massage
Relaxation techniques
Having a bath or shower
Labouring in water
Sterile water injections (for back pain)
Pharmacological
Inhalation analgesia
Pharmacological analgesia (remifentanil PCA, pethidine, diamorphine, or other opioids)
Regional analgesia
Remifentanil patient controlled analgesia
Remifentanil has a short duration of action (less than 10 minutes) and is metabolised by neonates; therefore it can be used in obstetric PCA. Patient controlled infusions of intravenous analgesia, such as remifentanil PCA, can offer some benefits compared with intramuscular administration of opioids, including reduced anaesthetist re-attendance and reduced labour pain. A review of the evidence, which comprised four randomised controlled trials and one retrospective cohort study, compared various doses of intravenous remifentanil PCA with intramuscular pethidine or intramuscular diamorphine, and showed a reduction in instrumental birth, reduced subsequent use of epidural analgesia, and an increase in spontaneous vaginal birth. Because of the low quality of the study and high heterogeneity, the committee advised that remifentanil PCA should be “considered,” rather than strongly recommended, as an option for pain relief.
Consider intravenous remifentanil PCA 40 μg per bolus with a two 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).8
Use remifentanil PCA in obstetric units only because of the risk of respiratory depression.
Discuss the risks and benefits of remifentanil PCA with women and help them to make a supported decision about its use. Explain that, with 40 μg of remifentanil compared with intramuscular pethidine:
They are less likely to need an epidural or have a birth using forceps or ventouse
They are more likely to have a spontaneous vaginal birth
They are more likelyto need supplemental oxygen.
When using remifentanil PCA, ensure that:
A midwife trained in the care of women receiving remifentanil PCA (one-to-one care) is available continuously
Continuous cardiotocography monitoring is available if the woman has other risk factors
Continuous monitoring of respiratory function (observation of breathing and pulse oximetry) is available
Units have clear guidelines on responding to respiratory depression
Supplemental oxygen is available
Immediate anaesthetic support is available in case of respiratory depression.
[Recommendations based moderate to low quality evidence]
Programmed intermittent epidural bolus
Before this update, no recommendation referenced the use of programmed intermittent epidural bolus for the maintenance of epidural analgesia. Conventionally, analgesia given via epidural injection is maintained by either continuous epidural infusion through a pump, intermittent boluses administered by a healthcare professional, or patient controlled epidural analgesia. More recently, epidural pumps have been designed to deliver a programmed intermittent epidural bolus. Evidence reviewed on the use of programmed intermittent epidural bolus for maintenance of epidural analgesia comprised data from 23 randomised controlled trials, most of which compared various combinations of programmed intermittent epidural bolus with either patient controlled epidural analgesia or continuous epidural infusion. Some evidence showed that, compared with other methods of maintaining epidural analgesia, programmed intermittent epidural bolus resulted in reduced anaesthetist re-attendance and reduced length of second stage of labour and labour pain.3 Additionally, programmed intermittent epidural bolus led to an improvement in women’s experience of labour.
Use patient controlled epidural analgesia, programmed intermittent epidural bolus, or intermittent bolus given by a trained healthcare professional for maintaining epidural analgesia.
[Recommendations based on high to very low quality evidence]
Relief of back pain during labour
Sterile water injections, which involve injection of a small volume of water into the woman’s lower lumbar spine and sacrum, can be administered by a trained midwife and are available in all birth settings for back pain. Although the exact mechanism of action remains unclear, it is thought that sterile water injections relieve back pain by referring it to the site of injection.7 The procedure is inexpensive and easy to administer. A review of the evidence comprising data from 17 randomised controlled trials assessed sterile water injections administered intracutaneously and subcutaneously specifically to target back pain. Although a greater number of studies looked at intracutaneous administration, both methods were found to be equally effective. The evidence review also showed that sterile water injections did not lead to an increase in instrumental or caesarean births.
Consider intracutaneous or subcutaneous sterile water injections as a pain relief option for women in labour with back pain. These injections can be administered by a midwife trained in the use of sterile water injections.
Explain to women that sterile water injections can provide relief of back pain from 10 minutes after the injection for up to three hours, but can lead to an initial stinging sensation.
If the woman chooses to have sterile water injections, give these at four different injection points around the rhombus of Michaelis, using doses of 0.1 mL intracutaneously or 0.5 mL subcutaneously at each injection point.
[Recommendations based on high to very low quality evidence]
Management of the second stage of labour—perineal care
These recommendations are new to the 2023 update of this guideline. Before they were added, limited information was available on the choices for interventions in the second stage to reduce perineal trauma. Vaginal birth may be associated with tears to the perineum of varying severity. Techniques that can be used to protect the perineum and reduce the risk and severity of tears include warm compress application and perineal massage. A review of the evidence comprising nine randomised controlled trials showed that use of a warm compress resulted in a reduction in third and fourth degree perineal tears, urinary incontinence, and postpartum perineal pain.9 Evidence also showed that massage with lubricant reduced the rate of third and fourth degree perineal tears in a mixed population of nulliparous and multiparous women.
Recommendations made as a result of this review were:
Discuss with women their preferences for techniques to reduce perineal trauma during birth, and support their choices
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
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.
[Recommendations based on low to very low quality evidence]
Implementation
Discussions around BMI and place of birth may have resource implications, with more multiparous women with higher BMIs at booking giving birth at home or in a midwife led unit. Changing practice across different birth settings will take time to implement. Most midwives already have the necessary skills to make the changes recommended in these guidelines, although additional training may be required to administer sterile water injections as this will be a new procedure for some midwives. Similarly, techniques to reduce perineal tears (warm compress and massage) may require further training, but will provide additional options for women during the second stage of labour to reduce perineal trauma.
Increasing the use of intravenous remifentanil may lead to increased drug costs and more intensive staffing requirements for administration and monitoring. However, these may be offset, in part, by reduced need for rescue analgesia and lower overall costs of delivery. The resource implications of an increased use of programmed intermittent epidural bolus are likely to be minimal as most epidural pumps can already provide either patient controlled or programmed epidural bolus, meaning that birthing units would not need to purchase new pumps to implement recommendations.
Future research
What is the effectiveness of “hands on” (midwife’s hands used to put pressure on the baby’s head to flex the head and supportor “guard” the perineum); “hands poised” (midwife keeps hands poised but not touching the head or perineum); and “Finnish grip” (support of the posterior fourchette with one hand and cupping of the fetal head with the other to prevent the head coming out with great force as it progresses at crowning) in the second stage of labour for reducing perineal trauma and postnatal pain?
What is the most effective dosage at which oxytocin should be recommenced once stopped in labour because of an abnormal cardiotocography?
During delayed cord clamping, what is the optimum position for the baby in relation to the mother’s uterus?
Guidelines into practice
How do you discuss BMI in relation to choices about birth options with women who are planning to become pregnant?
What options do you discuss for pain relief during labour?
At what stage do you inform women of the different perineal techniques available, and do you note which are acceptable to them?
How patients were involved in the creation of this article
Committee members involved in this guideline update included lay members Samantha Russell and Sarah Beswick, who contributed to the formulation of the recommendations summarised here.
Further information on the guidance
This guidance was developed by the National Guideline Alliance in accordance with NICE guideline methodology (www.nice.org.uk/media/default/about/what-we-do/our-programmes/developing-nice-guidelines-the-manual.pdf). A guideline committee (GC) was established by the National Guideline Alliance, which incorporated healthcare and allied healthcare professionals (three consultant obstetricians, one consultant midwife, three community midwives, two consultant neonatal physicians, two obstetric anaesthetists, one general practitioner, one pharmacist) and two lay members.
The guideline is available at: https://www.nice.org.uk/guidance/ng235
The GC identified relevant review questions and collected and appraised clinical and cost effectiveness evidence. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes or themes rather than the quality of the study. The GC agreed recommendations for clinical practice based on the available evidence or, when evidence was not found, based on their experience and opinion using informal consensus methods.
The scope and the draft of the guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment; the GC took all comments into consideration when producing the final version of the guideline.
NICE will conduct regular reviews after publication of the guidance, to determine whether the evidence base has progressed significantly enough to alter the current guideline recommendations and require an update.
Footnotes
The members of the Guideline Committee were (shown alphabetically) Alena Chong, Aung Soe, Charlotte Huddy, Chimwemwe Kalumbi (vice chair), Cornelia Wiesender, Debbie Miller, Frances Rivers, Lisa Relton, Maggie Blott (topic adviser), Philip Barclay, Samantha Russell, Sarah Beswick, Sarah Fishburn (chair), Sophie McAllister.
Other co-opted members (shown alphabetically): Ashifa Trivedi and Sarah Griffiths.
Resigned members shown alphabetically: Debbie Miller.
Members of the NICE technical team were (shown alphabetically): Agnesa Mehmeti (technical analyst), Claire Maynard (systematic reviewer, until April 2022), Eva Gonzalez (senior systematic reviewer until January 2023), Georgina Winney (business administrator, from September 2021), Hayley Shaw (project manager), Hilary Eadon (guideline lead), Hannah Tebbs (health economist), Michael Maresh (clinical adviser), Paul Jacklin (health economist), Rebecca Blackburn (technical analyst), Stephanie Arnold (information scientist, from April 2022) and Timothy Reeves (information scientist, until March 2022).
Funding: No authors received specific funding from NICE to write this summary.
Contributors: All five authors confirm that they meet all four authorship criteria in the ICMJE uniform requirements. RB is the guarantor for this article. The views expressed in this publication are those of the authors and not necessarily those of NICE.
Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf)
The guideline authors’ full statements can be viewed at (https://www.nice.org.uk/guidance/ng235/documents/register-of-interests).
Provenance and peer review: commissioned; not externally peer reviewed.