Key points of New NICE Recommendations: Guidelines for Intrapartum Care

The new NICE Guidelines for Intrapartum Care were released today in the UK.


The NICE Guidelines are evidence based recommendations on care practices for healthy women in healthy pregnancy; the majority of pregnancies.


You can read the full NICE Guidelines here: http://guidance.nice.org.uk/CG/WaveR/109/Consultation/DraftGuidance/pdf/English


AIMS Ireland committee are just going through the full guidelines the past hour or two...and to be frank.... the HSE should be MORTIFIED with the services they offer to women in Ireland. Irish maternity services fail every recommendation. Women and babies in Ireland deserve better. Women and babies in Ireland deserve the NICE level of care.


A taste of some of the key recommendations.


Care, Respect, Support of women & their Choices


Lets start with the opening line: "Giving birth is a life-changing event, and the care that a woman receives during labour has the potential to affect her both physically and emotionally in the short and longer term. Good communication, support and compassion from staff, whilst having her wishes respected, can contribute to making birth a positive experience for the woman and those accompanying her."


"Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion. [new 2014] [16]"




Place of Birth


"Advise low-risk multiparous women to plan to give birth at home or in a midwifery-led unit (freestanding or alongside). Explain that this is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit. [new 2014] [3]"


"Advise low-risk nulliparous women to plan to give birth in a midwifery-led unit (freestanding or alongside). Explain that this is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit, but if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby. [new 2014] [4] "

"Commissioners and providersa should ensure that all 4 birth settings are available to all women (in the local area or in a neighbouring area). [new 2014] [8] "


"Explain to the woman that she may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support her in her choice of setting wherever she chooses to give birth. [new 2014] "


"planning birth in an obstetric unit is associated with a higher rate of interventions, such as instrumental vaginal birth, caesarean section 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. [new 2014]"

In Ireland: The HSE determines the criteria for women's eligibility to midwife-led units and homebirth. There is no individual assessment based on current pregnancy/health or history. Women who do not meet HSE eligibility, cannot access this care option, regardless of her personal decision or informed choice.


Ireland has very limited midwife-led care options - the large majority of women have no midwife led unit or homebirth options in their region. There are NO freestanding birth centres in Ireland.

Recommendations for staff - treatment of women/personal perceptions & beliefs

"When performing an initial assessment of a woman in labour, listen to her story and take into account her emotional and psychological needs."

"Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion. [new 2014]"

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


"Treat all women in labour with respect. Ensure that the woman is in control of and involved in what is happening to her, and recognise that the way in which care is given is key to this. To facilitate this, establish a rapport with the woman, ask her about her wants and expectations for labour, and be aware of the importance of tone and demeanour, and of the actual words used. Use this information to support and guide her through her labour. [2007]"


"Encourage the woman to adapt the environment to meet her individual needs."


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


"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."


Clinical Governance

"maternity services should provide a model of care that supports one-to-one care in labour"

"Ensure that there are clear local pathways for the continued care of women who are transferred from one setting to another, including where this involves crossing provider boundaries. These pathways should include arrangements for occasions when the nearest obstetric or neonatal unit is closed to admissions or when the local midwifery-led unit is full. [new 2014] "


"Base any decisions about transfer of care on clinical findings, not on the birth setting."

Latent Labour


"If a woman seeks advice or attends a midwifery-led or obstetric-led unit with painful contractions, but is not in established labour: recognise that some women experience pain without cervical change, and although these women are described as not being in labour, they may well think of themselves being ‘in labour’ by their own definition"


"When performing an initial assessment of a woman in labour, listen to her story and take into account her emotional and psychological needs."
"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. Take the woman’s wishes into account. "


Vaginal Examinations

"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 "

CTG


"Do not perform cardiotocography on admission for low-risk women in suspected or established labour in any birth setting unless the initial assessment indicates there is a risk factor for, or actual, fetal acidosis (see recommendations 45 and 46). [new 2014] [54] "


"Do not make any decision about a woman’s care in labour on the basis of cardiotocography findings alone. [new 2014] [109] "

If continous CTG is needed - " remain with the woman in order to continue providing one-to-one support"

"Offer continuous cardiotocography if intermittent auscultation indicates possible fetal heart rate abnormalities, and explain to the woman why this is necessary. Remove the cardiotocograph if the trace is normal after 20 minutes. (See also section 1.10 on fetal monitoring)."

 "ensure that the focus of care remains on the woman rather than the cardiotocograph trace."

Labour

"Encourage women with regional analgesia (epidural) to move and adopt whatever upright positions they find comfortable throughout labour. [2007]"

"Upon confirmation of full cervical dilatation in a woman with regional analgesia, unless the woman has an urge to push or the baby’s head is visible, pushing should be delayed for at least 1 hour and longer if the woman wishes, after which actively encourage her to push during contractions. "


"After diagnosis of full dilatation in a woman with regional analgesia, agree a plan with the woman in order to ensure that birth will have occurred within 4 hours regardless of parity".


"Do not routinely use oxytocin in the second stage of labour for women with regional analgesia."


"Offer intermittent auscultation of the fetal heart rate to low-risk women in established first stage of labour in all birth settings"


"If continuous cardiotocography has been used because of concerns arising from intermittent auscultation but there are no concerning features on the cardiotocograph trace after 20 minutes, remove the cardiotocograph and return to intermittent auscultation."


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


"Do not routinely offer the package known as active management of labour (one-to-one continuous support; strict definition of established labour; early routine amniotomy; routine 2-hourly vaginal examination; oxytocin if labour becomes slow)."

"In normally progressing labour, do not perform amniotomy routinely."

"An obstetrician should assess a woman with confirmed delay in the second stage (after transfer to obstetric care if she is at home or in a midwifery unit, following the general principles for transfer of care described in section 1.6), but do not start oxytocin."

Birth

"Discourage the woman from lying supine or semi-supine in the second stage of labour and encourage her to adopt any other position that she finds most comfortable. "


"Inform the woman that in the second stage she should be guided by her own urge to push".


"Do not carry out a routine episiotomy during spontaneous vaginal birth. "


"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. "


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


"Diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth with modified active management or within 60 minutes of the birth with physiological management. Follow recommendations 1.14.17 to 1.14.24 on managing a retained placenta. "


"For modified active management, administer 10 IU of oxytocin by intramuscular injection with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is
clamped and cut. Use oxytocin as it is associated with fewer side
effects than oxytocin plus ergometrine"


Cord Clamping


"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 heartbeat below 60 beats/minute that is not getting faster."

"If the woman requests that the cord is clamped and cut later than 5 minutes, support her in her choice. [new 2014] [234] "


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


"Encourage women to have skin-to-skin contact with their babies as soon as possible after the birth."