Recurring concern

Incomplete NICE intrapartum care guidance

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First reported 9 Nov 2021•Latest report 5 Nov 2025

Definition

What this concern includes

Includes omissions, ambiguities or inadequate definitions within NICE guidance specifically governing intrapartum care, including guidance affecting maternal or fetal risk assessment and mode-of-delivery decisions.

Not included

Excludes guidance concerning pregnancy, childbirth or neonatal care that is not specifically part of NICE intrapartum care guidance.
Excludes failures to implement, disseminate or follow otherwise adequate guidance where the unsafe condition is not an incompleteness or ambiguity in the NICE guidance itself.
Excludes local clinical practice, training or documentation deficiencies unless they directly identify an omission or ambiguity in the named NICE intrapartum care guidance.
Excludes general maternity risk-assessment deficiencies that do not concern the completeness or clarity of NICE intrapartum care guidance.

Reports: 3
Individual concerns: 4
Date range: 2021–2025
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

National Institute for Health and Care Excellence3

Department of Health and Social Care1

NHS England1

Nursing and Midwifery Council1

Royal College of Midwives1

Royal College of Obstetricians and Gynaecologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

5 Nov2025
Manchester North
Concerns raised1
1. Omission of maternal death risk from intrapartum guidance
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Engage with NICE to amend intrapartum guidance to reflect the risk of maternal death.
  Stated by Department of Health and Social CareStated planned
2. Action
  Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.
  Stated by Nursing and Midwifery CouncilStated planned
3. Action
  Support NICE’s ongoing work to develop evidence-based guidance covering maternity care, including home-birth-relevant aspects.
  Stated by Royal College of Obstetricians and GynaecologistsStated planned
Respondent positions 3
1. Position
  Trusts are responsible for ensuring maternity care is delivered in line with Nursing and Midwifery Council standards.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  NICE is best positioned to address the absence of guidance on maternal death risk in intrapartum care guidance.
  Stated by Royal College of Obstetricians and GynaecologistsRedirects responsibility
2. Position
  NICE is responsible for redeveloping guidance to address maternal risk explicitly.
  Stated by Royal College of MidwivesRedirects responsibility
AI-generated summary

Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Omission of maternal death risk from intrapartum guidance
Wider context from the report
“5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Engage with NICE to amend intrapartum guidance to reflect the risk of maternal death.

Verbatim wording from the response
“You have raised an important issue relating to the ethical responsibility and proportionality of offering, and women choosing, a homebirth. It is an incredibly personal choice for women about how they wish to give birth and they have a legal right to choose what healthcare they need. I want to acknowledge that women can choose an unsupported homebirth if they wish which carries a greater risk to the women and the baby. I agree that we need to consider this matter closely and will discuss with NHS England what further guidance is needed to better support Trusts manage these finely balanced situations. My officials will also engage with NICE to amend their intrapartum guidance to reflect the risk of maternal death.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.

Verbatim wording from the response
“As the professional regulator for midwives in the UK, the NMC plans to play an active role in the group in line with our regulatory role. More specifically, we propose to take the following actions in response to the matters of concern detailed in your report as follows:”

Source location
Response from Nursing & Midwifery Council
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support NICE’s ongoing work to develop evidence-based guidance covering maternity care, including home-birth-relevant aspects.

Verbatim wording from the response
“in an obstetric led unit. This guideline covers the general principles of care for women in all birth settings. The guideline provides advice regarding fetal monitoring in labour which is relevant to birth at home as well as in hospital settings, and links to the NICE Guideline on fetal monitoring in labour (2022)². The guideline also provides advice on care of the perineum to minimise the chance of perineal trauma as well as advice on the management of the third stage of labour (including “active management” of the third stage), initial assessment and management of post-partum haemorrhage and when to consider transfer to obstetric care) which is relevant to birth in any setting. Lastly the guideline covers resuscitation of the newborn including the training required for healthcare professionals, the need for emergency referral pathways and facilities for transfer.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Trusts are responsible for ensuring maternity care is delivered in line with Nursing and Midwifery Council standards.

Verbatim wording from the response
“I wholeheartedly agree that all risks throughout pregnancy, particularly the risk of death to both the mother and baby, must be discussed sensitively and fully with women. Whilst this is important for every woman regardless of the level of risk associated with the pregnancy, it is even more critical for women who identified as high risk. I am deeply sorry that for Jennifer, this did not happen, and we must ensure this does not happen again. The Nursing and Midwifery Council has guidance for midwives to support informed decision making, principles for supporting women’s choices throughout their maternity care and for outside of hours care. It is the responsibility of Trusts to ensure care is delivered in line with these standards.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE is best positioned to address the absence of guidance on maternal death risk in intrapartum care guidance.

Verbatim wording from the response
“5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE is responsible for redeveloping guidance to address maternal risk explicitly.

Verbatim wording from the response
“5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother.”

Source location
Response from Royal College of Midwives
Page 5 · response
Published 7 November 2025
Open published response
8 Jul2025
South Wales Central
Concerns raised2
1. Lack of explicit guidance on analgesia levels during induction and labour
2. Lack of explicit guidance on supervision of women under analgesia
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Consider updating NG235 pain-relief guidance on combination therapies and required further monitoring.
  Stated by National Institute for Health and Care ExcellenceStated planned
2. Action
  Consider updating NG207 recommendations on the frequency of clinical assessments before active labour and during increasing pain relief.
  Stated by National Institute for Health and Care ExcellenceStated planned
AI-generated summary

Liliwen Iris THOMAS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Liliwen Iris THOMAS was delivered unattended in hospital after her mother, who had received analgesia, was not attended to or physically checked frequently enough for progression to active labour to be recognised. Liliwen was in a very poor condition and died later that day; the inquest identified concerns including the effects of analgesia, insufficient supervision, absence of resuscitation at birth, congenital infection and placental malperfusion. The report also identified that current NICE guidelines did not explicitly address analgesia levels and supervision.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of explicit guidance on analgesia levels during induction and labour
Wider context from the report
“(1) Liliwen’s mother was given unlimited Entonox, as well as routine doses of pethidine and codeine. The result was that she effectively became comatose for a period of time, during which she delivered Liliwen; (2) Cardiff & Vale Health Board have taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards and increased levels of supervision of mothers under analgesia; (3) They have seen an escalation in the numbers of women being transferred from the induction ward to the delivery suite as a consequence of reduced analgesia, which would otherwise have masked the transition to active labour; and (4) The current NICE guidelines on Induction of Labour and Intrapartum Care do not deal explicitly with analgesia levels and supervision. ”
Source location
Liliwen Iris THOMAS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of explicit guidance on supervision of women under analgesia
Wider context from the report
“(1) Liliwen’s mother was given unlimited Entonox, as well as routine doses of pethidine and codeine. The result was that she effectively became comatose for a period of time, during which she delivered Liliwen; (2) Cardiff & Vale Health Board have taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards and increased levels of supervision of mothers under analgesia; (3) They have seen an escalation in the numbers of women being transferred from the induction ward to the delivery suite as a consequence of reduced analgesia, which would otherwise have masked the transition to active labour; and (4) The current NICE guidelines on Induction of Labour and Intrapartum Care do not deal explicitly with analgesia levels and supervision. ”
Source location
Liliwen Iris THOMAS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consider updating NG235 pain-relief guidance on combination therapies and required further monitoring.

Verbatim wording from the response
“I can confirm that we will consider updating the recommendations in our guidelines on inducing labour (NG207) and intrapartum care (NG235) as a result of the issues raised in your report. This will include the following specific considerations:”

Source location
Response from NICE
Page 1 · response
Published 16 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consider updating NG207 recommendations on the frequency of clinical assessments before active labour and during increasing pain relief.

Verbatim wording from the response
“I can confirm that we will consider updating the recommendations in our guidelines on inducing labour (NG207) and intrapartum care (NG235) as a result of the issues raised in your report. This will include the following specific considerations:”

Source location
Response from NICE
Page 1 · response
Published 16 July 2025
Open published response
9 Nov2021
Buckinghamshire
Concerns raised1
1. Lack of a clear national definition of large-for-gestational-age babies
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  No further action is required because introducing a cutoff could convey inappropriate certainty or reassurance despite diagnostic uncertainty.
  Stated by National Institute for Health and Care ExcellenceNo action considered necessary
AI-generated summary

Mollie Daisy DIMMOCK · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mollie Daisy DIMMOCK died 34 minutes after delivery at Stoke Mandeville Hospital from perinatal asphyxia caused by hypoxia associated with umbilical cord compression during shoulder dystocia. The report identified uncertainty in national guidance because there is no definition of a large-for-gestational-age baby, creating variation in decisions about delivery mode and management of shoulder dystocia.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a clear national definition of large-for-gestational-age babies
Wider context from the report
“NICE Guidance NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies. Within this Guidance, whilst there is reference at paragraph 1.17 to guidance in respect mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby in the Guidance. There does not appear to be any national guidance or accepted definition of large-for-gestational-age such that application of the Guidance is open to interpretation and variation depending upon an NHS Trust's own policies and guidance, and, in turn, the interpretation of obstetricians and other clinicians advising potential parents in anticipation of delivery modes. It is clear that NG121 is intended to provide guidance in relation to many potential scenarios which may impact upon care and mode of delivery decisions. The uncertainty surrounding when section 1.17 of the Guidance should be relevant arises through the lack of a definition of a large-for-gestational-age baby. Application of section 1.17 of the Guidance includes consideration of shoulder dystocia and options for continuing labour or caesarean section relevant to both the life of the mother and the baby. ”
Source location
Mollie Daisy DIMMOCK · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No further action is required because introducing a cutoff could convey inappropriate certainty or reassurance despite diagnostic uncertainty.

Verbatim wording from the response
“We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.”

Source location
2021-0379-Response-from-NICE_Published
Page 1 · response
Published 16 November 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Omission of maternal death risk from intrapartum guidance

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised2

Lack of explicit guidance on analgesia levels during induction and labour

Lack of explicit guidance on supervision of women under analgesia

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Lack of a clear national definition of large-for-gestational-age babies

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Respondent positions 3

Actions described in response 2

Respondent positions 1