Maternity pathway and schedule of care: clinical guidance and schedule

4. Intrapartum Pathway

Refer to NICE Guidelines: Overview | Intrapartum care | Guidance | NICE Overview | Intrapartum care for women with existing medical conditions or obstetric complications and their babies | Guidance | NICE

Principles of Intrapartum Care:

1. Respectful maternity care: refers to care organised for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, is trauma informed, and enables informed choice and continuous support during labour and childbirth.

2. Effective Communication: between maternity care providers ,women in labour and birth partners, using simple and culturally acceptable methods. This may require the support of interpretation services.

3. Companionship during labour and childbirth: A companion(s) of choice is recommended for all women throughout labour and childbirth.

4. Continuity of care: Midwife-led continuity-of-care models, in which the primary midwife, buddy midwife or member of the team supports a woman supports a woman throughout the antenatal, intrapartum and postnatal continuum. The buddy midwife supports the primary midwife, providing cover for annual, and other, leave.

Points to consider for intrapartum care in any setting:

• The woman is the expert in her maternity care and should be provided with unbiased information, based on the best available evidence, in order that she can make decisions that are right for her and her baby. Time should always be given, where possible, for women to choose or decline care
• A full assessment will include the pregnancy history and any antenatal factors which relate to intrapartum care, the current situation, stage and progress in labour
• Where the wider perinatal team is involved in care, there is an open and honest team culture and joined-up decision making, with everyone’s contribution equally valued
• Discuss birth preferences on admission and review document throughout labour
• Discuss options for fetal monitoring
• Birth environment - relaxed, private, safe, comfortable
• One to one support from a midwife
• Birthing partner(s) present (where desired)
• Facility to eat and drink in labour according to guidelines
• Range of pain-relief
• Any intervention should be carefully considered and discussed and informed maternal consent obtained
• Upright positions that facilitate labour progress should be encouraged
• Women in the expulsive stage of 2nd stage of labour should be encouraged and supported to follow their own urge to push
• Techniques to reduce perineal trauma are recommended, based on a woman’s preferences and available options
• All birth choices should be accommodated where possible in all birth settings, including when birth takes place in a theatre setting

The third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes.

Physiological management of the third stage involves a package of care which includes all of these components:

• no routine use of oxytocic drugs
• no clamping of the cord until at least pulsation has ceased (unless clinically indicated)
• birth of the placenta by maternal effort
• offer skin to skin contact
• Assess Maternal Early Warning Score (MEWS) and blood loss
• Inspect placenta and membranes are complete

Active management of the third stage involves a package of care which includes all of these components:

• routine use of oxytocic drugs
• delayed cord clamping and cutting of the cord prior to controlled cord traction (unless clinically indicated)
• controlled cord traction
• offer skin to skin contact
• Assess Maternal Early Warning Score (MEWS) and blood loss
• Inspect placenta and membranes are complete

Woman may choose to accept all or only parts of this package of care.

The third stage of labour is diagnosed as prolonged if not completed within 60 minutes of the birth of the baby with physiological management and 30 minutes with active management.

Continual assessment will take place throughout labour and birth, anticipating potential changes in care that may be recommended.

Birthing women and their partners should be involved in discussions and kept informed throughout. Include information about transfer processes for mother and baby if required.

Labour and birth are dynamic, all care decisions should be made and documented in partnership with the woman.