Intrapartum Care for Healthy Women and Babies

Key Recommendations

• Low-risk women should be offered choice of birth setting: home, freestanding midwifery unit (FMU), alongside midwifery unit (AMU), or obstetric unit
• Multiparous low-risk women: FMU or home birth associated with similar outcomes to obstetric unit with fewer interventions
• Nulliparous low-risk women: slightly higher transfer rate from home; AMU/FMU are suitable options
• Continuous support in labour is recommended for all women

Birth Setting and Risk Assessment

• Risk assessment at every contact: booking, 36-week appointment, onset of labour, throughout labour
• Transfer criteria from non-obstetric unit: meconium, abnormal CTG, delay in labour, request for epidural, maternal pyrexia, fresh vaginal bleeding, malpresentation

CTG Interpretation (NICE Classification)

Features Assessed

• Baseline rate: normal 110-160 bpm
• Variability: normal ≥5 bpm; reduced <5 bpm for ≥30 but <50 min (non-reassuring) or ≥50 min (abnormal)
• Decelerations: early (normal), variable (non-reassuring if atypical features), late (abnormal)
• Accelerations: present = reassuring; absence alone is not significant

Classification

• Normal CTG: all 4 features reassuring — continue monitoring
• Suspicious CTG: 1 non-reassuring feature — conservative measures, increase monitoring
• Pathological CTG: 2 or more non-reassuring features, or 1 or more abnormal features — urgent review, fetal blood sampling or delivery
• Need for urgent intervention: acute bradycardia (<100 bpm for ≥3 min), prolonged deceleration

Indications for Continuous CTG

• Previous caesarean section
• Pre-eclampsia
• Post-term (>42 weeks)
• Prolonged rupture of membranes (>24 hours)
• Induced or augmented labour
• Epidural analgesia
• Meconium-stained liquor
• Abnormal fetal heart rate on intermittent auscultation
• Maternal pyrexia
• Vaginal bleeding in labour
• Multiple pregnancy

First Stage of Labour

• Latent phase: painful contractions with cervical change up to 4cm — can be managed at home or in low-risk setting
• Active first stage: regular contractions with progressive cervical dilatation from 4cm
• Expected progress: approximately 0.5cm/hour (but individual variation is normal)
• Delay in first stage: <2cm in 4 hours — consider amniotomy if membranes intact, then oxytocin augmentation
• 4-hourly vaginal examinations in active labour

Second Stage of Labour

• Passive second stage: full dilatation before involuntary expulsive contractions
• Active second stage: active maternal effort/pushing
• Duration guidance:
  • Nulliparous: up to 2 hours active pushing (3 hours with epidural) before considering intervention
  • Multiparous: up to 1 hour active pushing (2 hours with epidural)
• Directed pushing in active second stage; passive descent if epidural and no urge

Third Stage of Labour

• Active management (recommended): prophylactic uterotonic (oxytocin 10 IU IM), controlled cord traction, early cord clamping only if concern about PPH
• Physiological management: no uterotonic, spontaneous cord separation, maternal effort for placental delivery
• Active management reduces risk of PPH by approximately 60%
• Delayed cord clamping: wait at least 1 minute (up to 5 minutes) before clamping if no concern about neonatal or maternal compromise — improves neonatal iron stores and reduces IVH risk in preterm infants

Pain Relief in Labour

• Non-pharmacological: water immersion, breathing techniques, TENS, positioning, massage
• Entonox (50% N2O + 50% O2): self-administered, rapid onset, no fetal effects
• Pethidine/diamorphine: IM opioids; may cause neonatal respiratory depression (naloxone available)
• Epidural: most effective form of pain relief; associated with longer second stage, increased instrumental delivery rate, NOT associated with increased caesarean rate

Important Facts for MRCOG

• Normal CTG baseline: 110-160 bpm; normal variability: ≥5 bpm
• Pathological CTG: 2+ non-reassuring features or 1+ abnormal feature
• Delay in first stage: <2cm in 4 hours
• Active management of 3rd stage reduces PPH by 60%
• Delayed cord clamping (≥1 minute) is now recommended
• Epidural does NOT increase caesarean section rate (common exam misconception)
• All women should have documented risk assessment at every stage

Source: NICE CG190 (2023)

Read the original on nice.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2023

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).