NICE’s draft guideline on intrapartum care

In March 2014 the National Institute for Health and Care Excellence (NICE) released for consultation a draft of its updated guideline on intrapartum care.1 Publication of the final version is scheduled for October this year.

Although this update has involved a broad group of professionals and lay people (appointed through a transparent process of competitive interview), the “collective clinical experience” of obstetric practice came from just three obstetricians and two midwives. The guideline includes over 300 recommendations, and the evidence published with the full guideline will provide clinicians with a comprehensive, quality assessed resource of clinical trials and expert discussion. NICE has followed the suggested presentation of recommendations by the GRADE Working Group. However, we are concerned that using the terminology “strongly recommend,” “consider,” or “offer” for each point rather than the previous grading system (A to D) could make it more difficult to judge the level of evidence underpinning each recommendation without reading the full guideline. Most clinicians will not have the time to do this given that the complete guideline has increased from 305 to 805 pages, and this could lead them to misinterpret the strength of recommendations. Furthermore, the summary is 127 pages long, reducing its usefulness at the point of care.

Additionally, the length of both the full and the summary guideline may limit detailed review of the guidance by many clinicians and stakeholders. This is a vital step in the peer review process ensuring the validity of the work presented. We suggest that in future NICE should consider dividing its guidelines on intrapartum care into the first, second, and third stages of labour.

We congratulate the guideline development group on prioritising the holistic care of the labouring woman throughout the guideline (including women in the latent and early stages of labour). This will go some way to ensuring that women feel supported by the healthcare professionals looking after them and that they are empowered by their individual birthing experience.

We consider that the guideline’s greatest effect will be to support the normalisation of birth and in turn reduce unnecessary intervention. Drawing on the results of the Birthplace study,2 it recommends that all multiparous women with low risk pregnancies should deliver at home or in a midwifery led unit and all primiparous women with an uncomplicated pregnancy in a midwifery led unit. The risk table will help clinicians inform women and encourage shared decision making on the place of birth by providing data on safety and intervention rates.

The guideline comprehensively covers intrapartum fetal monitoring (both electronic fetal heart monitoring and intermittent auscultation). The continued emphasis on the safety of intermittent auscultation will help promote vaginal delivery.

The interpretation of electronic fetal heart monitoring was substantially reclassified in 2007,3 and this has again been changed, with the overall classification now categorised into five rather than three headings, without robust justification. This is likely to cause confusion, and there is no evidence that it will improve safety.

Recommendations regarding additional methods of assessing the fetus in labour are inconsistent. The evidence supporting fetal scalp stimulation and fetal electrocardiography4 is at least as good as, if not stronger than, that for fetal blood sampling.5 Despite this, the guideline development group recommends the use of fetal blood sampling based on collective clinical experience. This may reflect the difficulties of objectively assessing evidence in the light of accepted clinical practice. It is disappointing that the opportunity to critically assess and influence the use of fetal blood sampling in the UK has been missed.

When the 2007 guideline on intrapartum care was published, there was concern about the recommendation to accept an active second stage of up to 4 hours as normal. This recommendation remains. Despite many gynaecologists’ concerns that this would increase damage to the pelvic floor, little research has been published in the past five years on whether the guideline has affected the length of second stage, reduced operative delivery, or had adverse effects on the pelvic floor. The limited evaluation of guideline implementation is a concern.

The guideline development group has focused on the management of the third stage of labour and delayed cord clamping, a subject of longstanding controversy in both resource rich and resource poor countries. Data show that delayed cord clamping is safe, but the increased risk of jaundice requiring phototherapy should be balanced against the benefit of improved iron stores with potential positive benefit on neurological development. The “strong recommendation” to delay cord clamping for between 1 and 5 minutes after delivery is helpful as it clarifies the UK position, although from an international perspective it would seem that the jury is still out.6 7

Although NICE no longer insists that recommendations should be based on published clinical trials (grade 1+ evidence), care needs to be exercised over some of the recommendations in this draft guideline that are based on clinical experience (such as the use of fetal blood sampling). The paucity of data around intrapartum care needs attention from the specialty. Otherwise we are in danger of being awarded the Cochrane “wooden spoon” again.8