Intrapartum care w medical conditions Flashcards
Heart disease assessment
- Hx and examination
- Modified WHO classification
- NYHA class
Mechanical valves anti-coag AN
- Discuss anti-coag- switch to LMWH
- If taking warfarin- change to LMWH at 36w
- Stop warfarin, 24h later start LMWH- BD doses by wt
- Check anti Xa levels (Peak- 1-1.2, pre-dose >0.6) and ajust dose
AN care- heart disease
- Joint care
- Plan for MOD- including emergency plan if pt presents in labour w booked CS
- Plan fluid balance
MOD plan
Consider CS for:
- Mechanical valves
- Aortic disease
- Pulmonary HTN
- NYHA class III or IV
Labour w anti-coag
- Decide when to stop LMWH
- Think about heparin
- Reassess need for LMWH every 12h
Warfarin in labour
- Check INR
- Contact heam cons
- Obs rv in 2h and discuss MOD + anti coag
PN plan for mechanical valves
- PN obs +anaesthetic rv in 3-4h after birth
- Aim to restart LMWH at 4-6h PN
Warfarin PN
- Consider delaying restart to 7 days PN
Close fluid balance in labour
- Esp if class IV NYHA, Fontan circulation, Pulmonary arterial HTN, cardiomyopathy, severe Lsided stenosis
- Hourly input output
- Cont ECG + sats
- Arterial BP monitoring
Heart failur symptoms
- SOB when lying down
- unexplained cough w pink sputum
- Paroxysmal nocturnal dyspnoea
- Palpitations
HF signs
- HR>110
- RR >20
- Hypotension
- Sats <95%
- Elevated JVP
- Murmur
- Red air entry/crackles
HF mx
- Cannula
- Bloods- FBC, U+E, ABG, BNP
- ECG
- CXR
- ECHO
- Cardio rv
Anaesthetic for heart disease
- WHO 1/2- Normal advise
- WHO 3/4- Regional unless contraindicated
- Lower dose - less cardiac instability
- Arterial BP monitoring
LMWH + regional
- Wait 12h after prophylactic dose
- Wait 24h after treatment dose
- Once regional removed, wait 4h to give LMWH
3rd stage w heart disease
- First line- oxytocin
- 2nd line- Misoprostol/carboprost
Women w asthma - care
- Same AN care
- Avoid carboprost in PPH due to bronchospasm
Steroids in Asthma
If on 5mg or > for >3w:
- Labour:
Give 50mg IM hydrocortisone every 6h from first stage to 6h PN - CS:
100mg hydrocortisone IV
or 50mg if had in labour
ITP care in labour
- Deliver on LW
- Check plt on admission in labour
Plt count and mx
Plt >80- treat as normal
Plt 50-80- Consider regional, rv hx
Plts <50- GA, avoid regional
ITP- baby care
- Treat as it has a bleeding risk
- No ventouse/FBS/FSE
- No mid cavity/rotational forceps
- Check plts in cord blood
ITP risks in labour
- Inc risk of PPH
- Active 3rd stage - give IV not IM drugs
Sub-arch bleed/AV malformations MOD
- MDT discussion
Sub-arch bleed/AV malformations Low risk if
- Fully treated AV mal
- ICB of unknown cause >2years ago
Sub-arch bleed/AV malformations high risk if
- Complex/ Untreated/partially rx AV malformation
- Large aneursym 7mm>
- Cavernoma
- ICB in last 2 years
Offer CS
Sub-arch bleed/AV malformations if decline CS/ in 2nd stage
- Offer regional anaesthetic
- Offer assisted birth vs active pushing
CKD/AKI mx in labour
- Mat HR every 1h
- Every 4h- BP, RR +chest sounds, fluid balance, Sats
- U+E every 24h
Monitor all obs +fluid balance every 4h till 24h PN
Timing of delivery
- CKD stage 1, stable U+E and PCR <300mg - obs discussion
- CKD S1 + PCR>300 or CKD 2-4 w stable U+E- IOL at 40w
- CKD 5 or 3b/4 w unstable U+E- Delivery at or < 34w, latest by 38w
- Kidney transplant- MDT discussion
