1.14.2 The maternity service and ambulance service should have strategies in place to respond quickly and appropriately if a woman has an intrapartum haemorrhage in any setting. 1.13.17 Advise continuous cardiotocography during labour for: women with confirmed sepsisin line with recommendation 1.10.4 in the NICE guideline on intrapartum care for healthy women and babies. You can access the Intrapartum management of pre-eclampsia tutorial for just £48.00 inc VAT. To find out why the committee made the recommendations on modifying the birth plan according to platelet count or function and how they might affect practice, see rationale and impact. 1.3.39 Consider regional analgesia for women who have been on low-molecular-weight heparin and who have not had a prophylactic dose for at least 12 hours, or a therapeutic dose for at least 24 hours.

consider giving steroids or intravenous immunoglobulin to raise the maternal platelet count. 1.1.5 If a pregnant woman with a medical condition has not had any antenatal care (see section 1.18), give her information about intrapartum care at her first contact with healthcare services during pregnancy. 1.8.14 For women with chronic kidney disease stage 5 or deteriorating stage 3b and stage 4, before 34+0 weeks of pregnancy, discuss the option of dialysis with the woman and the multidisciplinary team in an effort to prolong the pregnancy to at least 34+0 weeks. To find out why the committee made the recommendation on fetal and maternal monitoring for women in labour after 42 weeks of pregnancy and how it might affect practice, see rationale and impact. 1.7.6 Consider caesarean section for women who are at high risk of cerebral haemorrhage, after a full discussion with the woman of the benefits and risks of all the options.

To find out why the committee made the recommendations on information for women with existing medical conditions and how they might affect practice, see rationale and impact. If the woman has gestational thrombocytopenia, assume the baby has a normal risk of bleeding. Regional anaesthesia includes spinal, epidural and combined spinal–epidural techniques. Avoid regional analgesia and anaesthesia under most circumstances. To find out why the committee made the recommendations on mode of birth for babies suspected to be large for gestational age and how they might affect practice, see rationale and impact. To find out why the committee made the recommendations on risk assessment and management of labour for women with no antenatal care and how they might affect practice, see rationale and impact. Gynaecologists, describe the physiology of intrapartum complications in women with pre-eclampsia, assess when a woman with pre-eclampsia requires delivery, confidently devise a care plan for women with pre-eclampsia in labour and delivery in order to minimise risk. To find out why the committee made the recommendation on care for women with sepsis or suspected sepsis immediately after the birth and how it might affect practice, see rationale and impact. 1.9.6 All obstetric units should have 'birthing beds' able to take a safe working load of 250 kg. Bicuspid aortopathy and aortic dilatation >45 mm. 1.3.27 1.3.33 Consider offering the same information about anaesthesia and analgesia in labour to women with modified WHO 1 or modified WHO 2 heart disease as described in the NICE guideline on intrapartum care for healthy women and babies.

To find out why the committee made the recommendations on management of the third stage of labour for women with heart disease how they might affect practice, see rationale and impact. For women who present for the first time in labour with a history of cerebrovascular malformation or intracranial bleeding and unknown risk of intracranial bleeding, manage as high risk and follow recommendations 1.7.6 and 1.7.7. 1.3.23 Consider standard fluid management during the intrapartum period for women with modified WHO 2 to 3, or NYHA class II to III heart disease after a multidisciplinary discussion (outlined in recommendation 1.2.1). 1.17.2 Discuss with women in labour whose babies are suspected to be large for gestational age the possible benefits and risks of vaginal birth and caesarean section, including: a higher chance of maternal medical problems such as infection with emergency caesarean section, a higher chance of shoulder dystocia and brachial plexus injury with vaginal birth. shared with the woman's GP and teams providing her antenatal and intrapartum care. To find out why the committee made the recommendations on risk assessment for women with heart disease and how they might affect practice, see rationale and impact. 1.14.10 If a woman in labour has vaginal blood loss typical of a 'show', follow the NICE guideline on intrapartum care for healthy women and babies.
1.1.1 Clarify with women with existing medical conditions whether and how they would like their birth companion(s) involved in discussions about care during labour and birth. The intrapartum period is from the onset of labour (spontaneous or induced) to 24 hours after birth. is presented as recommended in the NICE guideline on patient experience in adult NHS services.

cardiac output monitoring with non-invasive techniques, or serial echocardiography by trained staff.Advise women who need intensive monitoring that this may have to be carried out in an intensive care unit where the necessary equipment and expertise is available. Royal College of Obstetricians and To find out why the committee made the recommendations on timing and mode of birth for women with kidney disease and how they might affect practice, see rationale and impact. UK prices shown, other nationalities may qualify for reduced prices. 1.4.1 Offer women with asthma the same options for pain relief during labour as women without asthma, including: Entonox (50% nitrous oxide plus 50% oxygen). review the plan regularly, taking account of the whole clinical picture, including response to treatment. To find out why the committee made the recommendations on regional anaesthesia and analgesia for women with bleeding disorders and how they might affect practice, see rationale and impact. 1.3.22 Offer standard fluid management during the intrapartum period for women with modified WHO 1 and NYHA class I heart disease.

an increased chance of an instrumental birth. To find out why the committee made the recommendation on fetal monitoring for women with a BMI over 30 kg/m2 and how it might affect practice, see rationale and impact. rechecking anti‑Xa level weekly once the target anti‑Xa level is achieved. 1.8.5 For women with chronic kidney disease with or without pre-eclampsia, monitor fluid balance in the intrapartum period.

In hospital, consider doing this by: stopping warfarin, and 24 hours later, starting low-molecular-weight heparin using a twice-daily regimen at a dose based on the most recent weight available. an uncertain diagnosis of immune thrombocytopenic purpura. Review the results and act on them without delay. 1.17.1 Explain to women in labour whose babies are suspected to be large for gestational age that: when making decisions about mode of birth (for example, vaginal birth or caesarean section), this uncertainty needs to be taken into account. 1.7.1 Involve the multidisciplinary team in risk assessment for women with a cerebrovascular malformation or a history of intracranial bleeding. 1.3.18 For women with heart disease who have a planned caesarean section, develop an individualised emergency care plan with the woman in case she presents in early labour, with new symptoms or with obstetric complications. 1.8.4 Manage acute kidney injury secondary to pre-eclampsia in line with the NICE guideline on hypertension in pregnancy. 1.13.26 For women with sepsis or suspected sepsis, ensure that there is ongoing multidisciplinary review (see recommendations 1.13.4 to 1.13.6) in the first 24 hours after the birth. 1.18.5 Carry out an obstetric and general medical examination of a woman with no antenatal care as soon as possible. 1.8.16 For all women with kidney disease, including those with a kidney transplant, base decisions on mode of birth on the woman's preference and obstetric indications. 1.18.2 Provide obstetric-led intrapartum care for women who have had no antenatal care, and alert the neonatal team and, if relevant, the anaesthetic team. monitoring the fetal heart rate with continuous cardiotocography. additional support for the woman and her family. 1.14.1 If there are signs of shock in a woman with intrapartum haemorrhage, proceed with immediate resuscitation. Take specimens for microbiological culture, including blood cultures, before starting antimicrobials in line with the NICE guideline on sepsis. the chance of serious medical problems for the baby is greater with: additional risk factors, such as preterm birth. 1.11.3 Take account of the whole clinical picture when discussing options for care with the woman during the intrapartum period. To find out why the committee made the recommendation on anaesthesia for women in labour with sepsis and signs of organ dysfunction and how it might affect practice, see rationale and impact. To find out why the committee made the recommendations on prostaglandins for women with asthma and how they might affect practice, see rationale and impact. 1.19.6 For guidance on continuous cardiotocography in labour for women with a previous caesarean section, see NICE's guideline on caesarean section. 1.1.4 Information about intrapartum care should be offered to women with medical conditions by a member of the multidisciplinary team (see recommendation 1.2.2). 1.6.10 Offer individualised postpartum care, as discussed with a senior haematologist, for women with bleeding disorders, to include: 1.6.11 Be aware that non-steroidal anti-inflammatory drugs can add to the risk of bleeding. switching to intravenous unfractionated heparin (aiming for an activated partial thromboplastin time [aPTT] of at least twice control), then 4 to 6 hours before caesarean section, stopping intravenous unfractionated heparin.

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