Intrapartum Care for women with medical conditions or obstetric complications & their babies NICE 2019 Flashcards
Described NYHA
Class 1
Class 2
Class 3
Class 4
Class 1 No Sx
Class 2 Sx at ordinary activity
Class 3 Sx at less than ordinary activity
Class 4 Sx at rest
Women with mechanical heart value who are taking warfarin in 3rd trimester, when to switch to LMWH
Switch by 36 weeks or 2 weeks before planned birth
Start LMWH after 24hrs, BD dosing
When to check anti-Xa levels? What should be the aim?
3-4 hours after LMWH
Aim 1.0-1.2
Check trough dose (before LMWH) >0.6
Once anti-Xa level is in target how often should it be checked?
1 x weekly
If mechanical heart valve when to stop therapeutic LMWH?
24 hours before planned CS, perform CS as close to 24 hours as possible, no later than 30 hours
Or switch to IV unfractioned heparin (stop 4-6 hours before CS)
If IOL and mechanical heart value, a senior obstetrician should be involved with:
- Decide when to stop IV unfractioned heparin to LMWH
- Reviewing progress of labour - 12 hours from LMWH, 4-6 hrs IV uheparin
If mechanical heart value on warfarin and present in labour>
Check INR, discuss with haemorrhage
Senior review (Obs, haem, anaesthetics)
Consider reversal
Post partim review for women with mechanical heart value
Assess within 3-4 hrs after birth by senior obs and anaesthetics
Aim restart LMWH/uheparin within 4-6 hours
When to restart warfarin in women with mechanical heart value postnatally?
At least 7 days after birth with specialist follow up
Offer planned CS to which women with cardiac conditions
High risk disease of aorta
PAH
NYHA class 3-4
Offer IOL or CS to mechanical heart value
For which women is fluid balance critical to heart function?
- severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)
- hypertrophic cardiomyopathy
- cardiomyopathy with systolic ventricular dysfunction
- pulmonary arterial hypertension
- Fontan circulation and other univentricular circulations
- NYHA class IV heart disease.
For women who fluid balance is critical what monitoring should be done?
Hourly fluid input/output
Cont ECG
Cont intra-arterial BP monitoring
Cardiac output monitoring with non-invasive techniques
What Sx may indicate heart failure if no other cause?
SOB lying flat/at rest
Unexplained cough, espieaclly lying flat/frothy pink
PND
Palpiatations
Consider heart failure in intraprtum period if:
pale, sweaty, agitated, cool peripheries
HR >110
RR >20
Low BP
O2 sats <95% RA
Elevated JVP
Added murmur or HS
reduced air entry, basal crackles/wheeze
What Ix if suspect heart failure?
IV cannula
Bloods FBC, U+E
ABG
ECG
CXR
If cannot be ruled out - ECHO and BNP
What considerations should be taken for regional anaesthesia WHO class 3-4
Involve anaesthetic
Consider regional
Preserve CV stability - sequential Combine spinal-epidural technique
Cont invasive intra-arterial pressure monitoring
For patients with significant aortopathy, what uterotonics can you give, what us contraindicated?
1st: Oxytocin
2: Miso and Carboprost
Avoid Ergo (hypertension induced aortic dissection or rupture)
For patients with low cardiac output , what uterotonics can you give, what us contraindicated?
EF < 30%, severe valvular stenosis, HCOM, fontan, cyanotic heart disease
- Slow infusion oxytocin (avoid haemodynamic change)
- Miso and carboprost
Avoid Long acting oxytocin analogues and erometrine
For patients with pulmonary arterial hypertension , what uterotonics can you give, what us contraindicated?
- Oxytocin
- Miso
Avoid: Ergo, carboprost and long acting oxytocin analogues
For patients with coronary artery disease , what uterotonics can you give, what us contraindicated?
- Oxytocin
- Miso
Avoid ergo
What uterotonic to avoid in parties with asthma?
Carboprost - prostaglandin F2 alpha, risk of bronchospasm
What amount of steroids is considered long term to cause adrenal insufficiency?
5mg preg OD for > 3 weeks
If on long term steroids, what should be done in labour?
Continue regular steroids and when established in labour IM hydrocortisone - minimum 50mg every 6 hours and 6 hours after baby born
If on long term steroids, what should be done for CS?
Continue regular +
IV hydrocortisone 50mg if had hydrocortisone in labour
IV 100mg if not had
Further dose 6 hours after delivery
Plan from 36 weeks in woman with ITP
Weekly bloods from 36 weeks
Deliver on LW
If <50 - discuss intrapartum plan with obs and haem, consider steroids and IVIG
Consider baby will be at risk of bleeding
Under what count is regional anaesthesia contraindicated, based on platelet counr
Contraindicated < 50
Consider 50-80, clinical Hx, woamsn preference, anaesthetic expertise
What plan should be in place for baby of mother with ITP?
Inform neonates
No FBS/ventose/mid-cavity or rotational forceps,
Measure platelet count in the umbilical cord @ birth
Is baby at risk in gestational thrombocytopenia?
No
What should be considered for women with bleeding disorders in 3rd stage
Do not give utertonics IM
Carefully monitor blood loss
No NSAIDs
How to classify women as low or high risk who have Hx intracranial bleeding or AV malformation?
Low risk: Fully treated CV malformation, intracranial bleeding of unknown cause >2 years ago
High risk: untreated or partially treated CV malfoamrtion that has bleed previously, aneurysm 7mm +, complex AV malformation, cavernous with high risk features, intracranial bleeding within the last 2 years
If low risk of bleeding
Mode of birth woman’s preference and obstetrics
If high risks of cerebral haemorrhage who prefer to aim for vaginal delivery or in the second stage of labour
Consider CS
Offer regional anaesthesia
Explained risk of assisted 2nd stage vs active pushing alone
Cor CKD 4-5 what should be the management in labour?
MDT - Obs, anaesthetis, MW, renal physician
HR hourly
At least 4 hourly: BP/RR/fluid output/O2 Sats
Individualised fluid plan to avoid AKI/pulmonary odeama
Assess renal function every 24 hrs
How to manage AKI
Identify and correct cause
HR hourly
At least 4 hourly: BP/RR/fluid output/O2 Sats
250mls fluid bolis and review fluid status
Monitor fluid balance and renal function
Avoid nephrotoxics
Consider planned delivery by 40 weeks for which renal disorders?
CKD stage 1, urine PCR >300
CKD 2-4 with stable renal function
When should women with CKD stage 5 or 3b/stage 4 that are deteriorating?
Before 34 weeks
Consider dialysis
Do not deliver after 38 weeks
when should critical care specialist be involved for a women with sepsis in labour
Altered consciousness
Hypotension
Reduced UO
40% oxygen to maintain sat>92%
temp <36
If someone who is unbooked in labour, what questions should you as, to investigate safeguarding?
- young maternal age
- maternal mental health
- maternal learning disability
- maternal substance misuse
- domestic or sexual abuse
- homelessness
- human trafficking
- undocumented migrant status
- female genital mutilation
- the woman or family members being known to children’s services or social services.
what Ix to do for unbooked pregnancy
Obstetric and general examination
USS
Booking bloods, random blood glucose, HIV/Hep B/syphilis
Escalate to safeguarding
Communicated with GP
CKD deficiency
Stage 1
Steg 2
Stage 3
Stage 4
Stage 5
St 1: Normal >90
St 2: Mild 60-90
St 3a: Mild - mod 45-59
St 3b Mod-severe 30-44
Stager 4 severe 15-29
Stage 5 <15
