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Intrapartum Care

NICE guideline [NG235] Intrapartum Care. Last updated: Jun 2025.

Background Information

Stage   NICE definition
First stage Latent From:
  • Presence of contraction, and
  • Cervical dilation up to 4 cm (and some other cervical change)
Active (established labour) From:
  • 4cm cervical dilation, and
  • Regular painful contractions

To: full dilation (10 cm)
Second stage  
  • From: full dilation (10 cm) with active / involuntary pushing
  • To: delivery of the baby
or starts when baby is visible
Third stage  
  • From: delivery of the baby
  • To: delivery of the placenta
 

It is worth noting that various organisations have different definitions of the active (established) phase of labour:

  • NICE definition: 4-10 cm
  • WHO definition: 5-10 cm
  • ACOG definition: 6-10 cm

Place of Birth

Common birth settings in the UK are:
 

Setting Definition Who provides care? Access to obstetric care?
Home Women give birth at home Midwives only No immediate access
Freestanding midwifery unit (FMU) Separate birth centre, not on a hospital site
Alongside midwifery unit (AMU) Birth centre on same hospital site as the obstetric unit Rapid access if needed
Obstetric unit Hospital labour ward Midwives and obstetricians
 

Advise the following birth settings:

  • Nulliparous women = midwifery unit (FMU / AMU)
  • Multiparous women = home / midwifery unit (FMU / AMU)
 

Advise that for low-risk women:

  • Birth at home / freestanding midwifery unit is associated with higher rates of spontaneous vaginal birth
  • Birth in an obstetric unit is associated with higher rates of interventions (e.g. forceps, ventouse, unplanned Caesarean birth, episiotomy)
  • There are no differences in outcomes for the baby associated with planning birth in any setting

If at increased risk → suggest planned birth at obstetric unit
 

Disease area Medical condition

Cardiovascular

  • Confirmed cardiac disease

  • Hypertensive disorders

Respiratory

  • Asthma requiring an increase in treatment or hospital treatment

  • Cystic fibrosis

Haematological

  • Haemoglobinopathies, such as sickle-cell disease, beta-thalassaemia major

  • History of thromboembolic disorders

  • Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×109/litre

  • Von Willebrand's disease

  • Bleeding disorder in the woman or unborn baby

  • Atypical antibodies which carry a risk of haemolytic disease of the newborn

Endocrine

  • Hyperthyroidism

  • Diabetes needing medication

Infective

  • Hepatitis B or C with abnormal liver function tests

  • Toxoplasmosis – women receiving treatment

  • Current active infection of chicken pox, rubella or genital herpes in the woman or baby

  • Tuberculosis under treatment

Immune

  • Systemic lupus erythematosus

  • Scleroderma

Renal

  • Abnormal renal function

  • Renal disease requiring supervision by a renal specialist

Neurological

  • Epilepsy

  • Myasthenia gravis

  • Previous cerebrovascular accident

Gastrointestinal

Liver disease associated with current abnormal liver function tests

Psychiatric

Psychiatric disorder requiring current inpatient care
 

Factor Additional information

Previous complications

  • Unexplained stillbirth or neonatal death, or previous death related to intrapartum difficulty

  • Previous baby with neonatal encephalopathy

  • Pre-eclampsia requiring preterm birth

  • Placental abruption with adverse outcome

  • Eclampsia

  • Uterine rupture

  • Primary postpartum haemorrhage requiring additional treatment or blood transfusion

  • Caesarean birth

  • Shoulder dystocia

Current pregnancy

  • Multiple birth

  • Placenta praevia

  • Pre-eclampsia or pregnancy-induced hypertension

  • Preterm labour or preterm prelabour rupture of membranes

  • Placental abruption

  • Anaemia – haemoglobin less than 85 g/litre at onset of labour

  • Confirmed intrauterine death

  • Substance misuse

  • Alcohol dependency requiring assessment or treatment

  • Gestational diabetes needing medication

  • Malpresentation – breech or transverse lie

  • Recurrent antepartum haemorrhage

  • Small for gestational age in this pregnancy (less than third centile or reduced growth velocity on ultrasound as defined in the NHS Saving babies lives version 3)

  • Abnormal fetal heart rate, umbilical or fetal doppler studies

  • Ultrasound diagnosis of oligo- or polyhydramnios

Previous gynaecological history

  • Myomectomy

  • Hysterotomy
 

Pain Relief During Labour

Non-pharmacological options can be roughly categorised into 4 main categories.

  • Breathing exercises, having a shower or bath, massage may reduce pain during latent stage of labour

  • Offer the women the choice to labour in water for pain relief 
    • Monitor temperature of the women and water hourly 
    • Water temperature should not exceed 37.5°C

NICE states NOT to offer the following, but support the woman's choice if they wishes to:
  • Aromatherapy
  • Yoga
  • Acupressure
  • Acupuncture
  • Acupressure
  • Hypnosis

NICE states to support the woman's choice if they chooses to use the following during labour:
  • Breathing and relaxation techniques
  • Massage techniques 

NICE recommendation on transcutaneous electrical nerve stimulation (TENS):
  • Not provided by the NHS
  • Supports the woman's choice if she wants to use TENS during labour
  • Very little evidence of its effectiveness but no evidence of harm
  • Other forms of pain relief can be used alongside TENS

NICE recommends to consider intracutaneous / subcutaneous sterile water injections as a pain relief option for back pain in labour.

Explain that:
  • Sterile water injections can provide back pain relief from 10 minutes after the injection for up to 3 hours
  • 4 injections to be given around the lower back

Entonox (50:50 mix of oxygen and nitrous oxide) can be used to reduce pain in labour


Possible side effects:
  • Nausea
  • Light-headed

Pethidine, diamorphine (usually given IM) and other opioids can be used, but inform the woman that:

  • They provide limited pain relief during labour
  • May have significant side effects (both mother and baby)
    • Mother: drowsiness, nausea, vomiting
    • Baby: short-term respiratory depression, drowsiness, difficulty breastfeeding

Consider IV remifentanil PCAPatient-controlled analgesia for those who want ongoing pain relief:
  • Only use in obstetric units due to risk of respiratory depression and only under one-to-one care

Only available in obstetric unit
  • Epidural anaesthesia (allow continuous infusion) - most common
  • Spinal anaesthesia (one-off)

Some important information about epidural anaesthesia:
  • Prolongs second stage of labour 
  • Increased chance of birth with forceps / ventouse
  • Requires more intensive level of monitoring during labour

 Important side effects of spinal anaesthesia:
  • Higher risk of hypotension
  • Risk of post-dural puncture headache
 
 

Regional analgesia provides more effective pain relief than opioids

Assessment During Labour

The observations can be categorised by their frequency:
 
Frequency of observation Observation
Every 15 min Intermittent auscultation
  • After a contraction (wait for a contraction to finish, then listen)
  • Auscultate for at least 1 min
Every 30 min Contraction frequency
Every 1 hour Pulse (maternal)
Every 4 hours Temperature
Blood pressure
Respiratory rate
Vaginal examination - assess for:
  • Bishop score components
  • Presence or absence of caput / moulding
  • Presence or absence of membranes
 

Red flags for transfer to obstetric-led care:

  • Maternal observations
    • Pre-eclampsia concerns
      • 1 reading of BP >160/110 mmHg
      • 1 reading of BP >140/90 mmHg and 2+ protein on urinalysis
      • 2 consecutive readings of BP >140/90 mmHg
    • Pulse >120 bpm on 2 occasions 15-30 min apart
    • Respiratory rate <9 or >21 /min on 2 occasions 15-30 min apart
    • Pyrexia (single reading of ≥38°C or 2 consecutive readings of ≥37.5°C 1 hour apart)
    • New appearance of meconium
    • Fresh vaginal bleeding or blood-stained liquor
    • Pain differs from normal contraction pain
    • Woman requesting regional analgesia
    • Confirmed delay in 1st stage of labour
    • Obstetric emergency, including antepartum haemorrhage, cord prolapse, maternal seizure or collapse, or a need for advanced neonatal resuscitation
 
  • Fetal observations
    • Non-cephalic presentation (including cord presentation)
    • High (4/5 to 5/5 palpable) or free-floating head in a nulliparous woman
    • Suspected fetal growth restriction or macrosomia
    • Suspected anhydramnios or polyhydramnios
    • Any changes in the fetal heart rate pattern
 
 
If none of these are observed, continue with midwifery-led care unless the woman requests transfer.

Similar to observations in 1st stage of labour but increased frequency of the following:
  • Intermittent auscultation every 5 min
    • After a contraction (wait for a contraction to finish, then listen)
    • Auscultate for at least 1 min
 
  • Vaginal examination every 1 hour to assess:
    • Head position
    • Descent
    • Caput and moulding

Otherwise the same as 1st stage of labour, assess:
  • Contraction (frequency, strength, duration) 
  • Pulse every 1 hour
  • Temperature, blood pressure, respiratory rate every 4 hours

Delayed 1st and 2nd Stage Labour Guidelines

  • Nulliparous: average 8 hours and mostly <18 hours
  • Multiparous: average 5 hours and mostly <12 hours


Offer suspected cases a vaginal examination 2 hours later → diagnose delayed 1st stage labour

 

NICE also recommends to take other factors apart from cervical dilation rate into account:

  • Parity
  • Changes to uterine contractions (strength, duration, frequency)
  • Station and position of presenting part
  • Descent and rotation of baby's head

Consider amniotomy (for artificial ROM) for women with intact membrane:

  • Repeat vaginal examination 2 hours later

If no progress 2 hours after later:
  • Transfer woman to obstetric-led care
  • Consider oxytocin (after obstetric review) and offer epidural before starting 


 


Requiring amniotomy alone is not an indication for transfer to obstetric-led care.

If oxytocin is used during labour, reduce or stop it if contractions are more frequently than 4 in 10 min

Normal durations of 2nd stage labour depends on more factors, including parity and use of epidural:
  • Nulliparous
    • No epidural:  within 3 hours
    • With epidural: within 3 hours (but may have a passive stage of up to 2 hours)
 
  • Multiparous
    • No epidural: 2 hours
    • With epidural: 2 hours (but may have a passive stage of up to 1 hours)
 

Anything beyond the normal duration quoted above, should be consdiered as delayed

Consider amniotomy (for artificial ROM) for women with intact membrane:


If no progress after 1 hour (multiparous) / 2 hours (nulliparous) of pushing:
  • Refer for senior review and decision on place and mdoe of birth
  • Consider oxytocin (after obstetric review) 
 

Offer birth with forceps / ventouse if:
  • Concern about baby wellbeing (e.g. abnormal cardiotography)
  • Prolonged second stage labour
  • Woman requests assistance 
 

If woman declines forceps or ventouse, other optiosn include:

  • Vaginal birth
  • Caesarean birth
  • Reconsidering about forceps or ventouse

Third Stage Labour Guidelines

Timing depends on whether active or physiological management:
  • Active management: >30 min
  • Physiological management: >60 min

Active management:
  • Routine use of uterotonic drugs (e.g. oxytocin)
  • Cord clamping and cutting
  • Controlled cord traction after signs of separation of the placenta

Physiological management:
  • No routine use of uterotonic drugs
  • No clamping of the cord until pulsation has stopped, or after delivery of the placenta
  • Delivery of placenta spontaneously or by maternal effort 

References

Author: Adams Lau
Reviewer:
Last edited: 06/07/25