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This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) for healthcare professionals caring for women during labour and birth.1 It defines the care that women who are at low risk of complications in labour at term should expect to receive, and therefore it relates to most women giving birth in the United Kingdom.
NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
A woman's desire for and choice of pain relief during labour are influenced by many factors, including her expectations, the complexity of her labour, and the severity of her pain. Flexible expectations and being prepared for labour may influence her psychological wellbeing after birth, as may good communication with the healthcare team.
Provide clear definitions, referral points, and actions for the recognition and management of delay in both the first and second stages of labour.
If genital trauma is identified after birth, further detailed systematic assessment should be carried out to identify accurately the extent of the trauma and ensure appropriate repair. This should include:
The new guideline contains changes in recommendations for women at term whose membranes rupture before the onset of labour.
Including place of birth in the guideline is politically and professionally sensitive, but collecting safety data should now be a matter of priority, so that women can be more adequately informed of the advantages and disadvantages of each place of birth. To support this, the guideline recommends the collection, audit, and oversight of maternal and neonatal mortality and serious morbidity data relating to each place of birth and the development of clear pathways for referral to the obstetric unit should that be required.
These events are rare so the guideline also recommends the establishment of national surveillance of this information, which should include a national registry of all deaths resulting from events occurring during labour at term, and of neonatal encephalopathy.
Barriers to implementation are complex and varied, and some recommendations seem more expensive than others to implement. For example, adopting the recommendation for women to labour in water may require changes in service provision if maternity units do not have sufficient baths or pools; it will also require support and possible additional training for midwives and other healthcare professionals, as well as for the women themselves. However, if maternity units are prepared to embrace change and to implement such recommendations health outcomes will improve, as will clarity and consistency of care.
NICE has developed tools to help organisations implement the guidance (see www.nice.org.uk?page.aspx?0=tools).
This latest guideline presents the most comprehensive and up to date systematic review and analysis of the evidence on the intrapartum care of healthy women and their babies. Although this is the first guideline of its type to consider the cost effectiveness of the various options, it was not possible to formulate recommendations on this owing to lack of data.
The guideline was developed according to standard methods for NICE guidelines (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Women's and Children's Health. The collaborating centre convened a development group of clinicians and patient representatives to oversee the work and help to develop the recommendations.
The group conducted an extensive systematic review of the literature, assessed the quality of the literature, and used a combined meta-analysis approach to compare the effectiveness of the various interventions. Where possible, an economic model was developed to ascertain the most cost effective strategies.
The guideline went through an external consultation with stakeholders. The development group assessed the comments, re-analysed the data where necessary, and modified the guideline.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG055) or the website of the National Collaborating Centre for Women's and Children's Health.
The guideline will be updated as needed. Information about the progress of any update will be posted on the NICE website. NICE hopes to audit the uptake of the guideline and provide the data in any future update.
Future updates of the guideline will be produced as part of the NICE guideline development programme, and information about the progress of any update will be posted on the NICE website.2
Prospective research should be undertaken to assess clinical outcomes, including safety and qualitative data on women's experiences of birth in all settings, for all places of birth so that comparisons can be made. Studies should also investigate the components that significantly affect a woman's satisfaction with her birth experience, including psychological outcomes, and a robust method of assessing women's satisfaction should be developed. Finally, studies should also investigate the effectiveness of strategies to increase the likelihood of spontaneous vaginal birth when delay in the first stage of labour is diagnosed.
The guideline development group comprises Sara Kenyon, Tony Ducker, Simon Grant, Gill Gyte (resigned June 2007), Jayne Jempson, Carolyn Markham, Geraldine O'Sullivan, Julia Sanders, Maureen Treadwell, Derek Tuffnell, Marina Wells, Steve Walkinshaw, and eight staff from the National Collaborating Centre for Women's and Children's Health (Martin Whittle, Martin Dougherty, Rintaro Mori, Roz Ullman, Paul Jacklin, Peny Retsa, Debbie Pledge, Samantha Vahidi).
Contributors: All authors contributed to reviewing the evidence and writing and correcting the article. SK wrote the paper, which was commented on by the other authors.
Funding: The National Collaborating Centre for Women's and Children's Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: None declared.