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@MedicalBooksStore Obstetric Guidelines 2017-2019 PDF
@MedicalBooksStore Obstetric Guidelines 2017-2019 PDF
@MedicalBooksStore Obstetric Guidelines 2017-2019 PDF
Guidelines
2017-19
The Bedside Clinical Guidelines Partnership
in association with the
GUIDELINES
Anaemia in pregnancy 14
Antepartum haemorrhage (APH) including placental abruption 18
Bladder care 22
Caesarean section 26
Cardiopulmonary resuscitation of the newborn 29
Care of the newborn at delivery 35
Cell salvage NEW 41
Collapse (including amniotic fluid embolism) 43
Delay in labour 48
Diabetes – Antenatal care 50
Diabetes – Labour 54
Diabetes – Screening for gestational diabetes 57
Diminished fetal movements (DFM) 58
Eclampsia 61
Electronic fetal monitoring (EFM) – Antenatal NEW 62
Electronic fetal monitoring (EFM) – Labour 66
Epidural analgesia 72
Episiotomy 78
Extreme prematurity (<24 weeks’ gestation) 80
Fetal abnormality – Antenatal detection 85
Fetal blood sampling 87
Fetal loss – see Perinatal bereavement
General anaesthesia and failed intubation 91
Genital herpes 95
Group B streptococcal disease 97
Hepatitis 99
High dependency care 102
HIV positive women 106
Home birth 109
Hypertension in pregnancy 112
Induction of labour 119
Infant feeding 124
Intermittent auscultation 136
Labour management (including clinical risk assessment) 138
Latent phase of labour 142
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CONTENTS • 2/2
Maternal death 144
Maternal transfer (including in-utero transfer) 146
Meconium stained liquor 150
Medical termination of pregnancy for fetal abnormality and fetocide 152
Mental health in pregnancy NEW 154
Morbidly adherent placenta 166
Multiple pregnancy 168
Neurological deficits after regional anaesthesia or analgesia 171
Normal laboratory values in pregnancy 175
Obese mother (care of) 176
Operative vaginal delivery 180
Oxytocin 183
Perinatal bereavement (previously Fetal loss) 185
Perineal trauma suturing (tears and episiotomy) 192
Postpartum haemorrhage (PPH) 195
Pregnant woman with a non-obstetric problem (management of) 201
Pre-labour rupture of membranes (PROM) at term 202
Preterm labour 204
Recovery 210
Refusing blood and blood products 213
Remifentanil patient controlled analgesia (PCA) use in labour NEW 217
Retained placenta 219
Routine postnatal care of women and babies 221
Sepsis 232
Severe pre-eclampsia 237
Shoulder dystocia 245
Stem cell banking 249
Substance misuse 251
Third and fourth degree perineal tears - OASIS (obstetric anal sphincter injuries) 255
Third stage labour 257
Transcervical catheter induction 258
Umbilical cord prolapse 260
Umbilical cord sampling 263
Uterine rupture 264
Vaginal birth after caesarean section (VBAC) 266
Vaginal breech delivery 268
VTE – Deep venous thrombosis 271
VTE – Pulmonary embolism 274
VTE – Thromboprophylaxis 277
Waterbirth 282
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ACKNOWLEDGEMENTS • 1/1
We would like to thank the following for their assistance in producing this edition of
the Obstetric Guidelines on behalf of the Bedside Clinical Guidelines Partnership and
Staffordshire, Shropshire & Black Country Newborn and Maternity Network
SANDS
Pharmacist (Stillbirth and Neonatal Death Society)
Nicola Staton Nathalya Kennedy
Cheryl Titherly
Microbiology
Seema Desai
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COMMONLY USED ABBREVIATIONS • 1/3
A CVS Chorionic villus sampling
AAGBI Association of Anaesthetists of CX Cervix
Great Britain and Ireland CXR Chest X-ray
ABG Arterial blood gases
ACEI Angiotensin-converting enzyme D
inhibitor DAS Difficult Airway Society
AFE Amniotic fluid embolism DFM Diminished fetal movements
AFP Alpha-fetoprotein DIC Disseminated intravascular
ALS Advanced life support coagulation
AN Antenatal DNA Did not attend
ANC Antenatal clinic DoH Department of Health
ANNP Advanced neonatal nurse DVT Deep venous thrombosis
practitioner
APH Antepartum haemorrhage E
ARB Angiotensin II receptor blockers EAS External anal sphincter
ARM Artificial rupture of membranes EBL Estimated blood loss
ECG Electrocardiography
B ECV External cephalic version
BBA Born before arrival EDD Expected date of delivery
BCG Bacilli calmette-guerin EFM Electronic fetal monitoring
BD Twice daily (BIS Die) EGC Emergency gynaecology clinic
BLS Basic life support ELLSCS Elective lower segment
BMI Body mass index caesarean section
BO Bowels opened EMLSCS Emergency lower segment
BP Blood pressure caesarean section
BPM Beats per minute EPU Early pregnancy unit
ERPC Evaluation of retained products
of conception
C
ETT Endotracheal tube
CBD Catheter bag drainage
Ceph Cephalic
F
CESDI Confidential enquiry into
stillbirths and deaths in infancy FBC Full blood count
CMACE Centre for Maternal and Child FBS Fetal blood sampling
Enquiries FHR Fetal heart rate
CEMACH See CMACE FSE Fetal scalp electrode
CMW Community midwife
CPR Cardio-pulmonary resuscitation G
CRP C reactive protein GBS Group B streptococcus
CS Caesarean section GCS Glasgow coma scale
CSU Catheter specimen of urine G Gravida
CVA Cerebrovascular accident GTN Glycerol trinitrate
CVP Central venous pressure GTT Glucose tolerance test
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COMMONLY USED ABBREVIATIONS • 2/3
H M
Hb Haemoglobin MAC Minimum alveolar concentration
HBIG Hepatitis B immunoglobulin MAP Mean arterial pressure
HBV Hepatitis B virus MAU Maternal assessment unit
Hcg Human chorionic gonadotrophin MBC Midwife birth centre
HCV Hepatitis C virus MEOWS See MEWS
HDC High dependency care MEWS Maternity Early Warning Scoring
HDU High dependency unit MgSO4 Magnesium sulphate
HELLP Haemolysis, elevated liver MROP Manual removal of placenta
enzymes and low platelet count MSSU Midstream sample of urine
H/O History of
HVS High vaginal swab N
NAD No abnormality detected
I NEWS Neonatal early warning score
IAP Intrapartum antibiotic prophylaxis NICE National Institute for Health and
IAS Internal anal sphincter Care Excellence
ICS Intra-operative cell salvage NICU Neonatal intensive care unit
NIPE Neonatal and infant physical
INR International normalised ratio
examination
IOL Induction of labour
NLS Neonatal life support
IPPV Intermittent positive pressure NNU Neonatal unit
ventilation
ITP Idiopathic thrombocytopenic O
purpura
OAA Obstetric Anaesthetists’
IUD Intrauterine death Association
IUGR Intrauterine growth restriction OASIS Obstetric anal sphincter injuries
IUT Intrauterine transfer ODP Operating department practitioner
IV Intravenous OGTT Oral glucose tolerance test
IVI Intravenous infusion
P
P Parity
J
PCEA Patient-controlled epidural
JVP Jugular venous pressure
anaesthesia
PE Pulmonary embolism
L
PEA Pulseless electrical activity
LFT Liver function tests
PET Pre-eclamptic toxaemia
LGA Large for gestational age
PIH Pregnancy induced hypertension
LMA Laryngeal mask airway PM Post mortem
LMP Last menstrual period PN Postnatal
LMWH Low molecular weight heparin PPH Postpartum haemorrhage
LSCS Lower segment caesarean PR Per rectum
section
PROM Pre-labour rupture of membranes
LVS Low vaginal swab
PV Per vagina
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COMMONLY USED ABBREVIATIONS • 3/3
Q V
QDS Four times daily VBAC Vaginal birth after caesarean
section
R VE Vaginal examination
RCM Royal College of Midwives VF Ventricular fibrillation
RCOG Royal College of Obstetricians VIP Visual infusion phlebitis
and Gynaecologists VTE Venous thromboembolism
RCT Randomised controlled trial vWD von Willebrand disease
Rh Rhesus
RM Registered midwife
RTC Road traffic collision
S
SAD Supraglottic airway device
SGA Small for gestational age
SNRI Serotonin norepinephrine
reuptake inhibitor
SROM Spontaneous rupture of
membranes
SSRI Selective serotonin
reuptake inhibitor
ST Specialist trainee
SVD Spontaneous vaginal delivery
T
TAP Transversus abdominis plane
TEDS Thromboembolic deterrent
stockings
TENS transcutaneous electrical nerve
stimulation
TIVA Total intravenous anaesthesia
TOP Termination of pregnancy
U
U&E Urea and electrolytes
UKOSS UK Obstetric Surveillance Survey
USS Ultrasound scan
UTI Urinary tract infection
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PREFACE • 1/2
This is the fourth edition of the Obstetric guidelines. It has been compiled as an
aide-memoire for all staff concerned with obstetric management, towards a more
uniform standard of care across the Staffordshire, Shropshire & Black Country and
Southern West Midlands Newborn and Maternity Networks’ hospitals.
The Staffordshire, Shropshire & Black Country and Southern West Midlands
Newborn and Maternity Networks and the Bedside Clinical Guidelines Partnership
have provided the logistical, financial and editorial expertise to produce these
guidelines.
These guidelines have been drafted with reference to published medical
literature and amended after extensive consultation. Wherever possible, the
recommendations made are evidence based. Where no clear evidence has been
identified from published literature the advice given represents a consensus of the
expert authors and their peers and is based on their practical experience.
No guideline will apply to every patient, even where the diagnosis is clear-cut;
there will always be exceptions. These guidelines are not intended as a substitute
for logical thought and must be tempered by clinical judgement in the individual
patient and advice from senior colleagues.
Supporting information
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PREFACE • 2/2
Treatment
Level Treatment harms Prognosis Diagnosis
benefits
Systematic review of Systematic review of Systematic review Systematic
randomized trials or randomized trials, of inception review of cross
n-of-1 trials systematic review of nested cohort studies sectional studies
case-control studies, n-of-1 with consistently
1 trial with the patient you are applied reference
raising the question about, standard and
or observational study with blinding
dramatic effect
Randomized trial or Individual randomized Inception cohort Individual cross
observational study trial or (exceptionally) studies sectional studies
with dramatic effect observational study with with consistently
2
dramatic effect applied reference
standard and
blinding
Non-randomized Non-randomized Cohort study or Non-consecutive
controlled cohort/ controlled cohort/follow-up control arm of studies, or studies
follow-up study study provided there are randomized trial without
3
sufficient numbers to rule consistently
out a common harm applied reference
standards
Case-series, case- Case-series, case-control, Case-series or Case-control
control studies, or or historically controlled case-control studies, or poor or
4 historically con- studies studies, or poor non-independent
trolled studies quality prognostic reference
cohort study standard
Mechanism-based Mechanism-based n/a Mechanism-based
5
reasoning reasoning reasoning
Excerpt from: OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Oxford
Centre for Evidence-Based Medicine. 2011. http://www.cebm.net/index.aspx?o=5653
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COMMUNICATION AND DOCUMENTATION • 1/1
COMMUNICATION
l Ensure information given to woman is l Maintain knowledge and develop your
presented in a way she can understand abilities in team-based communication,
keeping in mind the reliance placed on
l Maintain effective and appropriate your communication and recording of
communication with your colleagues information
DOCUMENTATION
l Record all discussions and actions l Ensure any justifiable alteration to your
relating to woman’s care, including own or other healthcare professional’s
discussions where she has not been documentation is clearly attributed to a
directly involved named person with an identifiable role.
l Ensure all entries in healthcare Original entry and alteration must be
records are clear, accurate, legible and clear, legible and auditable
contemporaneous and attributed to a l Healthcare record must include details
named person with an identifiable role of assessments, reviews, treatment
l Do not include: and evidence of arrangements for
future and continuing care, including
l unnecessary abbreviations or jargon information given to woman
l meaningless phrases
l irrelevant or offensive speculation
l irrelevant personal opinions regarding
the woman
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GUIDELINES
These guidelines are advisory, NOT mandatory
ANAEMIA IN PREGNANCY • 1/4
l Vitamin B12 deficiency
INTRODUCTION
l Hb variants
l In normal pregnancy, maternal plasma
l Other causes
volume increases by up to 50%, red
cell mass gradually increases by l exclude chronic illness [e.g. recurrent
approximately 20% and haemoglobin urinary tract infection (UTI), chronic
(Hb) concentration drops. This normal inflammatory bowel disease]
physiological response may resemble l women born outside the UK or with a
iron deficiency anaemia history of foreign travel
l Do not give routine iron and folic l consider less common causes (e.g.
acid supplementation until anaemia chronic infections and parasitic
diagnosed (using pregnant ranges) infections)
l Other groups may have an increased l Check serum ferritin, serum iron and
risk based on dietary or cultural factors. total iron binding capacity (TIBC)
Assess on an individual basis saturation. Iron deficiency indicated by:
l ferritin level of <15 micrograms/L
Causes of anaemia in l serum iron level of <12 micromoles/L
pregnancy l TIBC saturation of <15%
l Iron deficiency
l Folic acid deficiency
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ANAEMIA IN PREGNANCY • 2/4
l Counsel woman to take oral iron
TREATMENT
supplements correctly
Advice to women with anaemia l on an empty stomach
l 1 hr before meals
Life-style
l with a source of vitamin C (ascorbic
l Avoid alcohol acid) e.g. orange juice/meat
l Stop smoking l avoid taking tablets with tea/eggs/
coffee/milk – may reduce absorption
Dietary advice l other medications/antacids should not
be taken at the same time
l Animal protein – well cooked red meat
(avoid pre-cooked chilled meat, and
Side effects
liver)
l Eggs l Advise woman that iron supplements
may cause:
l Milk
l gastrointestinal upset with nausea and
l Increase vitamin C to aid iron
epigastric pain
absorption (fresh orange juice, citrus
fruits) l Where there is a history of constipation,
use osmotic laxative
l Leafy green vegetables (not
over-cooked)
Monitoring
l If concerns regarding compliance
with dietary advice, give vitamin C as l Check Hb 4 weeks after starting
ascorbic acid 50 mg/day therapy
l an increase of 8 g/L/week is usual
TREATMENT OF IRON irrespective of the route of iron
DEFICIENCY ANAEMIA administration
Aim of treatment
Response to treatment
l Hb should rise by 20 g/L over 3–4
l Check compliance
weeks
l If not tolerant, try alternative
Elemental iron preparations
l If inadequate response (<32 g/L)
l Give up to 100–200 mg elemental iron
using 1 of the following preparations: l check iron studies, B12 and folate
levels and refer to named consultant’s
l ferrous sulphate 200 mg 8–12 hrly antenatal clinic for next available
(contains 65 mg elemental iron per appointment where IV iron therapy will
200 mg tablet) be considered – see Flowchart
l ferrous fumarate tablet 210 mg l In consultation with a haematologist,
8–12-hrly (contains 65–70 mg consider erythropoietin
elemental iron per 210 mg tablet) or
oral solution 10 mL/280 mg 12-hrly
MACROCYTIC ANAEMIA
(contains 90 mg elemental iron per
10 mL/280 mg)
Definition
l sodium feredetate 10 mL 8-hrly
(contains 27.5 mg elemental iron per l Hb value and red cell numbers are
5 mL dose) reduced but MCV is increased
l If these products are not tolerated, l In pregnancy an MCV >96 fl is
seek pharmacy advice regarded as abnormal
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ANAEMIA IN PREGNANCY • 3/4
Diet
l Folic rich foods:
l leafy green vegetables (over boiling will
destroy folic acid)
l chickpeas
l bananas
l citrus fruit
l avocado
l mushrooms
l asparagus
l bread and cereals fortified with folic
acid
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ANAEMIA IN PREGNANCY • 4/4
Anaemia Hb <105
l Oral iron
See Elemental iron
Hb >105
Hb <105
Consider stopping
oral iron or consider
maintenance dose
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ANTEPARTUM HAEMORRHAGE (APH)
(including placental abruption) • 1/4
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ANTEPARTUM HAEMORRHAGE (APH)
(including placental abruption) • 3/4
l Central venous pressure (CVP) line/
Caesarean section
arterial line may be inserted by
anaesthetic team to monitor fluid l With significant bleeding, consultant
balance and aid resuscitation obstetrician will deliver by caesarean
l In coagulopathy or massive section or directly supervise a middle
transfusion, seek advice from grade obstetrician (ST3–7 or equivalent
consultant haematologist, who will e.g. staff grade, clinical fellow)
arrange blood and blood products and l Crossmatch 4 units of blood and have
correct clotting factor deficiencies ready in delivery suite blood bank,
preferably before delivery achieved or,
Post-operative/ if available, group-specific blood
post-delivery care l Obtain informed consent
l Transfer woman to delivery suite high l Discuss possibility of hysterectomy
dependency area
l Set up cell saver if used locally
l If ventilation necessary, transfer
to acute Trust ITU – see Maternal Women with a previous caesarean
transfer guideline section and anterior placenta praevia
are at high risk of placenta accreta
PLACENTA PRAEVIA and should be managed by consultant
obstetrician and anaesthetist
Definition
Choice of anaesthesia
l Placenta wholly or partially inserted in
lower segment of uterus l Decided by anaesthetist and
woman – usually spinal but, in
Major or complete haemodynamically unstable woman,
general anaesthesia may be indicated
l Placenta encroaching on cervical
opening (determined by ultrasound Post-operative infusion
scan)
l Commence oxytocin infusion as per
l deliver by caesarean section local practice
Minor or partial PLACENTA ABRUPTION
l Placenta not encroaching on cervical
Definition
opening
l Accidental haemorrhage due to partial
Management of bleeding or complete separation of normally
situated placenta
l Woman to remain on delivery suite
l Bleeding may be concealed or visible
l Crossmatch minimum of 2 units of
blood to delivery suite blood bank Risk factors
urgently
l Trauma
Conservative management l Hypertensive disease or pre-eclampsia
l Administer corticosteroids (if indicated) l Previous abruption
to assist fetal lung maturity l High parity
l In a significant bleed, on-call consultant l Twin gestation
obstetrician will discuss plan of care for
l Polyhydramnios
conservative management or delivery
with mother and document in maternal l Smoking
healthcare record l Prolonged rupture of membranes
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ANTEPARTUM HAEMORRHAGE (APH)
(including placental abruption) • 4/4
Management
Dependent on severity
of bleed
l If minor APH, midwife will monitor:
l amount of vaginal blood loss
l abdominal tenderness
l pain
l vital signs
l If active bleeding, monitor fetus with
continuous EFM
Conservative management
l Administer corticosteroids (if indicated)
to assist fetal lung maturity
l If bleeding continues, consultant
obstetrician/middle grade obstetrician
(ST3–7 or equivalent e.g. staff grade,
clinical fellow) will consider delivery,
possibly by induction
EXTRAPLACENTAL BLEEDING
l Coagulation defects (e.g. von
Willebrand’s disease), cervical polyps,
cervical ectropion, cervical infection,
cervical carcinoma, ruptured vulval
varices and infection
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BLADDER CARE • 1/4
l document response in medical history
BACKGROUND
section of maternal healthcare record
l Childbirth has the potential to cause l if problem highlighted, refer to
long-term damage to the pelvic floor, appropriate healthcare professional
affecting bladder or bowel function (e.g. physiotherapist, urotherapist or
l Most women have the urge to void consultant obstetrician) for plan of action
≤6 hr postpartum l Ensure MSSU sent to rule out UTI
l 10–15% of women experience voiding l Discuss:
dysfunction to some degree and for
l pelvic floor and urethral sphincter exercise
some time following delivery
l diet to prevent constipation
l 5% have significant and longer lasting
dysfunction
Third trimester antenatal visit
l this may lead to bladder over-distension
and overflow incontinence with long-term l It is good practice to ask again if woman
significant bladder dysfunction has ever experienced problems with
bowel or bladder function. Women are
BLADDER DYSFUNCTION often reluctant to disclose symptoms
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BLADDER CARE • 2/4
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BLADDER CARE • 4/4
UNABLE VOID
TO VOID <150–200 mL
l No further
l Catheterise Measure and measurements
EITHER VOID
with size 12 record volume required
≥150–200 mL
Foley using of next 2 voids l Document time
sterile single and volume of
use lubricant void
and measure BOTH VOIDS
residual volume <150–200 mL
l If residual
volume
≤150–200 mL,
remove catheter
and review
as per routine
postnatal checks
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CAESAREAN SECTION • 1/3
INTRODUCTION
Caesarean section can be life-saving or can prevent serious morbidity to mother and fetus
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CAESAREAN SECTION • 2/3
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CAESAREAN SECTION • 3/3
Anaesthetist
l Transfers woman to recovery room
l Ensures appropriate antibiotic
prophylaxis/analgesia/
thromboprophylaxis prescribed
according to local policy
l Hands over to midwife/recovery nurse
Midwife/recovery nurse
l Recovery observations as per local
practice
l Initiates skin-to-skin contact
l Completes appropriate documentation
IMMEDIATE/24 HR
POST-OPERATIVE CARE
l See Routine postnatal care of women
and babies guideline and refer to local
guidelines
l post anaesthetic care within the
maternity unit
l postnatal care within the maternity unit
l Observations required
l Administer subcuticular LMWH
l Remove urinary catheter according to
local practice
l see Bladder care guideline
l Wound dressing to remain undisturbed
for 48 hr–5 days (dependent on local
practice)
l women with BMI >40 (>35 with
comorbidities) use a negative pressure
wound dressing – left in place for 7
days (if local practice)
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CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 1/6
l Check equipment daily, and before
IMMEDIATE TREATMENT
resuscitation
l Follow Resuscitation Council UK Airway
Guidelines www.resus.org.uk
l Keep head in neutral position
DRY AND COVER l Use T-piece and soft round face mask,
extending from nasal bridge to chin
l Cord clamping – see Cord clamping
l Give 5 inflation breaths, sustaining
below
inflation pressure (Table 1) for 2–3 sec
l ≥28 weeks’ gestation, dry baby, for each breath
remove wet towels and cover baby
l Give PEEP of 5 cm H2O
with dry towels
l Begin inflation breaths in air
l <28 weeks’ gestation, do not dry body
but place baby in plastic bag feet first,
Table 1: Inflation pressure (avoid using
dry head only and put on hat
pressure higher than recommended)
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CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 2/6
Breathing
l Most babies have a good heart rate
after birth and establish breathing by
90 sec
l if not breathing adequately give 5
inflation breaths, preferably using air
at pressures in Table 1
l Heart rate should rapidly increase as
oxygenated blood reaches heart
l If baby is floppy with slow heart rate l Increase inspired oxygen concentration
and there is chest movement, start every 30 sec by 30% e.g. 30–60–90%
cardiac compressions with ventilation depending on response – see
breaths immediately after inflation Saturation chart
breaths
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CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 3/6
Chest compression
l Use if heart rate approximately <60 beats/min (do not try to count accurately as this
will waste time)
Start chest compression only after successful inflation of lungs
Figure 1
Figure 2
Pictures taken from NLS manual and Resuscitation Council (UK) and reproduced with their permission
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CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 4/6
l Recommence cardiac compressions
Ideal hold (Figure 1/Figure 2)
and ventilation breaths ratio 3:1 after
l Circle chest with both hands so that each drug administration and re-assess
thumbs can press on the sternum just after 30 sec
below an imaginary line joining the l If no heart rate increase, progress to
nipples with fingers over baby’s spine next drug
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2015–17
CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 6/6
Newborn
support life support algorithm
algorithm
Dry baby
Birth
Remove wet towels and cover
AT
Start clock or note time
Assess 30
tone, breathing and heart rate sec
ALL
If gasping or not breathing
Open airway 60
Give 5 inflation breaths sec
Consider SpO2 monitoring
STAGES
Re-assess
If no increase in heart rate, look
for chest movement
ASK:
If chest not moving
Re-check head position Acceptable
Consider 2-person airway Pre-ductal SpO2
control and other airway
manoeuvres 2 min 60%
Repeat inflation breaths
3 min 70%
Consider SpO2 monitoring
Look for a response 4 min 80%
5 min 85%
10 min 90%
Noincrease
No increaseininheart
heartrate
rate–
Look for
Look for chest
chest movement
movement
DO
When chest moving
If heart rate not detectable or
slow (<60/min),
start chest compressions
3 compressions to each breath YOU
NEED
Re-assess heart rate
Every 30 sec
If heart rate not detectable or
slow (<60/min), consider
HELP?
venous access and drugs
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CARE OF THE NEWBORN AT DELIVERY • 1/6
l Encourage first breast feed within 1 hr
INTRAPARTUM PREPARATION
and skin-to-skin contact for ≥1 hr
l Identify risk factors that may l Avoid performing routine postnatal
affect immediate care and devise procedures during first hour after
management plan birth unless requested by mother or
l Ensure delivery room warm treatment necessary for wellbeing of
baby
l Check resuscitation equipment
l Identify babies at increased risk of
l Pre-warm towels
hypothermia (<37 weeks or small for
l Summon multidisciplinary team dates) and hypoglycaemia (<37 weeks
members necessary for delivery and or <2.5 kg, infants of diabetic mothers)
inform of risk factors
Registration and identification
IMMEDIATE CARE
l Register and identify baby and mother
At delivery as soon as possible. See Registration
and identification
l If baby does not require immediate
resuscitation, clamp cord after 1 min THERMOREGULATION AND
l if local practice, document time cord is MANAGEMENT
clamped
l If immediate resuscitation is required Baby’s temperature in normal room
following assessment, clamp cord as environment should be 37ºC
soon as possible l Encourage uninterrupted skin-to-skin
l ≥28 weeks’ gestation, dry baby, contact with mother (or partner if
remove wet towels and cover baby appropriate)
with dry towels l document offer and whether accepted
l <28 weeks’ gestation, do not dry body by mother in intrapartum record. If
but place baby in plastic bag feet first, declined or not done, note reasons
dry head only and put on hat l Check baby’s initial axillary
l Assess wellbeing and, if necessary, temperature using digital thermometer
resuscitate – see Cardiopulmonary while cradled by mother/partner
resuscitation of the newborn (ideally 1–2 hr following birth). Record
guideline in intrapartum record
l Assess Apgar score at 1 and 5 min as l If temperature ≥36.4°C, do not recheck
a minimum. Document in intrapartum axilla temperature unless:
record l specific risk factors e.g. small for dates,
l If Apgar score at birth ≤5, continue preterm, maternal pyrexia during
to assess and record every 5 min. labour, group B streptococcus (GBS),
Document any appropriate action taken pre-labour spontaneous rupture of
until score is ≥6 or baby is transferred membranes (PROM) – see Group B
to neonatal care streptococcal disease guideline and
l If baby delivered in poor condition Pre-labour rupture of membranes
or risk factors identified during (PROM) guideline
intrapartum period: l baby unwell
l double clamp cord and take cord l Use digital thermometer and record
blood for paired cord samples – see subsequent temperature checks in
Umbilical cord sampling guideline postnatal record
l inform neonatal team of abnormal
results e.g. pH level <7
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CARE OF THE NEWBORN AT DELIVERY • 2/6
l Keep warm and encourage to feed
Hypothermia
as soon as possible. They will suck
l Although babies are able to maintain well, settle between feeds and
stable body temperature, their ability will not require monitoring – see
to stay warm may be overwhelmed Hypoglycaemia guideline in the
by extremes of environmental Staffordshire, Shropshire & Black
temperatures and influenced by Country Newborn and Maternity
gestational age Network Neonatal guidelines (if used
locally)
l A newborn is more likely to develop
hypothermia because of large surface
area per unit of body weight Symptoms and signs
Close observation by healthcare l Signs of hypoglycaemia may require
providers can often prevent neonatal further investigation including possible
hypothermia admission to neonatal unit
l Blood glucose <2.6 mmol/L and any of
the following symptoms:
Temperature <36.4ºC in an
otherwise well baby l apnoeic/cyanotic episodes
l irritability
l Apply hat to prevent further heat loss
l hypotonia
l Encourage continued skin-to-skin
l poor responsiveness
contact with covering blanket
l seizures
l Initiate early feeding
l Observe for general wellbeing Management
l Recheck temperature ≤1 hr
l See Hypoglycaemia guideline in the
l If temperature remains <36.4°C,
Staffordshire, Shropshire & Black
consider heated cot and further
Country Newborn and Maternity
investigations – follow local protocol
Network Neonatal guidelines (if used
locally)
Temperature ≥38ºC
INITIAL CARE AND FIRST
Temperature ≥38°C is abnormal and
requires urgent attention.
EXAMINATION BY MIDWIFE
Notify neonatal team who will First hour of birth
undertake full assessment, including
physical examination l If baby appears unwell or has
symptoms of hypoglycaemia, attempt
l If baby appears unwell, or not to feed and refer to neonatal team
maintaining own temperature, refer to
l Explain feeding cues to mother and
neonatologist
offer help initiating first feed [see
l If problems identified, continue to Breastfeeding guideline in the
observe baby until resolved. Document Staffordshire, Shropshire & Black
all management in postnatal records, Country Newborn and Maternity Network
including discussions with parents Neonatal guidelines (if used locally)]
l Document first feed in intrapartum
HYPOGLYCAEMIA record, include:
l Unless unwell, babies do not become l feeding method
hypoglycaemic even if feeding is l time feed started
delayed
l duration of feed
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CARE OF THE NEWBORN AT DELIVERY • 3/6
l If problems identified, continue to
Ears
observe until resolved and document
management in postnatal record – l Canal patency
including discussions with parents
l Position in relation to level of eyes
l Once skin-to-skin contact ceased,
l Tags or pits
further assess newborn. Include:
l birth weight Nose
l head circumference
l Patent nares
l initial examination
l Accessory skin tags
l Document all findings and discussions
in intrapartum record
Mouth
EXAMINATION l Use torch to check:
l To identify major physical l palate intact
abnormalities/problems l signs of ‘tongue-tie’ (defined by NICE
as an inability to extend the tongue
Consent and preparation beyond tip of lower incisors)
l Inform parents and obtain consent l presence of any teeth
l Keep baby warm and examine in quiet
environment – ideally with parents
Neck
present l Run fingers down neck towards trunk
to check for abnormal swelling or
Procedure webbing
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CARE OF THE NEWBORN AT DELIVERY • 4/6
Chest Abnormalities
l With baby supine, check presence of l If baby unwell e.g. respiratory distress
nipples and normal chest movement or has a major abnormality e.g.
l look for abnormal breathing e.g. flaring spina bifida, inform neonatal team
of nostrils, sub or intercostal recession, immediately
grunting, raised respiratory rate. If l note other minor abnormalities and
present, seek neonatal review inform neonatal team next working
day for prompt referral to appropriate
Anus clinician e.g. medical, surgical,
orthopaedic etc.
l Presence and normality of appearance,
l If abnormalities (or deviations from
position and patency
the norm) detected, inform parents
and record findings and discussion in
Cord stump intrapartum record
l Examine to confirm presence of 3 l If in doubt, discuss with delivery suite
vessels. If only 2 identified, neonatal co-ordinator immediately
junior doctor must review and l If community birth, community midwife
document will arrange admission to hospital for
mother and baby
External genitalia
(to determine sex) VITAMIN K
Male Prophylaxis
l Gently examine scrotum with thumb l Vitamin K (Konakion® MM Paediatric)
and forefinger. Check for descended as a single dose (see Table below for
testes and note any hydrocele dosage schedule)
l Penis – check position of urethra and l avoid IV administration for prophylaxis
exclude hypospadias as it does not provide the same
sustained protection as IM
Female
l See Vitamin K guideline in
l Separate labia to confirm presence of Staffordshire, Shropshire & Black
vaginal and urethral orifices Country Newborn and Maternity
Network Neonatal guidelines (if used
l Examine perineum to detect sinuses
locally)
If evidence of ambiguous genitalia,
avoid gender assignment before
expert evaluation to avoid
confirmation of wrong sex.
Ask consultant neonatologist to
discuss with parents as soon as
possible.
Always use the term ‘baby’ and avoid
using ‘he’, ‘she’ or, most importantly,
‘it’
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CARE OF THE NEWBORN AT DELIVERY • 5/6
Prophylaxis dosage
Konakion® MM Paediatric
Healthy babies of ≥36 weeks First line
l 1 mg IM at birth or soon after
Second line
l 2 mg oral at birth, then
l 2 mg oral at 4–7 days, then
l 2 mg oral at 1 month if exclusively
breastfed
Term babies at special risk
l Instrumental delivery, caesarean section 1 mg IM at birth or soon after
l Maternal treatment with enzyme-inducing
anticonvulsants (carbamazepine, pheno-
barbital, phenytoin), rifampicin or warfarin Do not offer oral vitamin K
l Requiring admission to neonatal
intensive care unit (NICU)
l Babies with cholestatic disease where
oral absorption likely to be impaired
Preterm babies <36 weeks but ≥2500 g 1 mg IM at birth or soon after
All babies <2500 g 400 microgram/kg (0.04 mL/kg) IM shortly
after birth (maximum dose 1 mg)
Do not exceed this parenteral dose
The frequency of further doses should
depend on coagulation status
Babies who have or may have Factor VIII Give orally unless results of Factor assays
or Factor IX deficiency or other coagula- normal
tion deficiency
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CARE OF THE NEWBORN AT DELIVERY • 6/6
Baby
l As soon as possible after delivery
secure 2 wristbands to baby. These
must contain the following information:
l mother’s last name
l baby’s date of birth
l time of birth
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CELL SALVAGE • 1/2
INTRODUCTION Collection
l Has a place in massive haemorrhage l Unless excessive blood loss
to reduce incidence and complications anticipated set up only the collection
of homologous blood transfusions element
l use endorsed by CEMACH, OAA, l processing part to be opened only
AAGBI and NICE when sufficient blood has been
collected
INDICATIONS FOR USE l Use 2-sucker technique to reduce
amniotic fluid contamination
l Placenta praevia/abruption
l in certain circumstances i.e. placenta
l Placenta accreta/percreta
praevia, may be appropriate to
l Classical incision commence cell salvage before delivery
l Maternal bleeding disorders or taking l Use large bore sucker with low vacuum
anticoagulants pressure of 150 mmHg
l Laparotomy following postpartum l in cases of heavy bleeding pressure
haemorrhage (PPH) may need to be increased to
l Women who refuse blood transfusion 300 mmHg
l Emergency situations where there l Gently wash swabs in isotonic sodium
is difficulty with crossmatching – chloride 0.9% in sterile bowl and
antibodies and blood not available process fluid
Discontinue cell saver if
CONTRAINDICATIONS contamination of the field by
l Contamination of surgical field substances not licensed for IV use/
bowel contents
l Malignancy
Do not suck blood from vaginal
l Homogenous sickle cell disease wounds and swabs
Remove obvious meconium
PREREQUISITES
Presence of urine is not a
l Informed consent is required from contraindication
woman before use
l outline procedure and theoretical risks
of amniotic embolism and haemolytic Processing
disease in future pregnancies l Wash collected blood in sodium
l provide information leaflet to woman; if chloride 0.9% and centrifuge
available locally l Label salvaged blood immediately
l may not be possible in emergency l Use within 6 hr of completion of
l Decision to use cell saver should be processing
made by senior clinicians l Use leucocyte depletion filter and
l All persons operating cell salvage standard blood giving set to reinfuse
machine to be trained in its use blood
l Stop transfusion if hypotension occurs
PROCEDURE OF COLLECTION
l For rapid transfusions filter may be
AND PROCESSING removed (at clinician’s discretion) as
l 2 disposable parts a last resort (e.g. women who decline
blood products)
l collection
l processing
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CELL SALVAGE • 2/2
SPECIAL CIRCUMSTANCES
Jehovah’s Witness
l To maintain continuity all parts of circuit
must be primed by sodium chloride
0.9% and attached to a dedicated
cannula
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COLLAPSE (Including amniotic fluid embolism) • 1/5
Use this guideline for antenatal and l Ensure arrest team can gain immediate
postnatal collapse access to maternity unit
l Station someone (e.g. healthcare
CAUSES assistant, student etc.) at delivery suite
door, to open door and direct team to
l Haemorrhage – see Antepartum
woman
haemorrhage and Postpartum
haemorrhage guidelines l Collect cardiac arrest trolleys and
defibrillator
l Pulmonary embolus
l Concealed haemorrhage (e.g. broad Woman
ligament haematoma, hepatic rupture)
l Amniotic fluid embolus l Avoid aortocaval compression
>20 weeks’ gestation
l Myocardial infarction
l Manually displace the uterus
l Aortic dissection
l An anaesthetist should protect the
l Peripartum cardiomyopathy airway as soon as possible with a
l Rheumatic mitral stenosis cuffed endotracheal tube
l Sepsis l Do not consider the baby in this
l Intracranial haemorrhage emergency
l Total spinal block (see Epidural l If resuscitative attempts to revive
analgesia guideline) >20 weeks’ gestation woman
have failed after 4 min, perform an
l Local anaesthetic or magnesium
immediate caesarean section to
toxicity
improve the chances of successful
l Hypoglycaemia maternal resuscitation. Do this
l Eclampsia (see Eclampsia guideline wherever the arrest has occurred
and Severe pre-eclampsia guideline) without further preparation as she will
l Anaphylaxis (follow local guideline for need to deliver within minutes, and
anaphylaxis) there will not be time for preparation or
transfer to theatre
CARDIAC OR RESPIRATORY l Caesarean section is of no benefit to
ARREST women <20 weeks’ gestation
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COLLAPSE (Including amniotic fluid embolism) • 2/5
l Obtain arterial blood gases and
Organise
consider arterial line insertion
l Bleep consultant obstetrician, on-call l Check capillary blood glucose
obstetric anaesthetist, junior doctor
l Arrange portable chest X-ray,
and middle grade obstetrician (ST3–7
particularly if oxygen saturation
or equivalent e.g. staff grade, clinical
reduced or central venous catheter
fellow) – follow local practice
inserted owing to risk of pneumothorax
l Summon as many staff as possible and
l 12-lead ECG – particularly important if
allocate specific tasks, e.g:
any form of cardiac disease suspected
l taking observations
l ECG must be reviewed by a doctor
l recording events and their competent in ECG interpretation
management, with times
l communication History and examination
l runner for samples and equipment l Obtain history from those present
l support for family before collapse occurred
l Examine woman to try to identify most
Observations likely cause of collapse
l Commence HDU chart and observe:
IV access and fluids
l pulse
l blood pressure – at least every 15 min l Commence IV fluids
l respiratory rate l Unless cardiopulmonary function is
rapidly restored, consider a central
l pulse oximetry
venous catheter
l If possible, transfer woman to room
where HDU care can be provided
Investigations
l Insert ≥1 large IV cannula
l Take blood for:
l FBC
l clotting studies including fibrin
degradation products
l crossmatch 2 units of blood
l blood cultures
l U&Es and glucose
l LFTs
l Troponin T or Troponin I [(whichever is
used locally) (a marker for myocardial
infarction)]
It is the responsibility of person
obtaining sample to complete
blood bottles and forms
Send bloods urgently to laboratory
with healthcare assistant or porter
Phone laboratory to request
results urgently
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COLLAPSE (Including amniotic fluid embolism) • 3/5
FURTHER TREATMENT
l Further treatment is dependent on diagnosis
Diagnosis Treatment
Pulmonary embolism See VTE – Pulmonary embolism guideline
Concealed haemorrhage See Antepartum haemorrhage and Postpartum haem-
orrhage guidelines
Amniotic fluid embolism See Amniotic fluid embolism below
Myocardial infarction
Aortic dissection
Seek advice from cardiologist
Peripartum cardiomyopathy
Rheumatic mitral stenosis
Sepsis See Sepsis guideline
Intracranial haemorrhage Seek advice from physician
Total spinal block Call consultant anaesthetist – See Epidural
analgesia guideline
Toxicity Call consultant anaesthetist – See Epidural analgesia
guideline, Eclampsia guideline or Severe eclampsia guideline
Hypoglycaemia IV glucose – see Diabetes guidelines
Eclampsia See Eclampsia guideline
Anaphylaxis Give adrenaline 500 microgram (0.5 mL of 1:1000
solution) IM into midpoint of anterolateral aspect of thigh
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COLLAPSE (Including amniotic fluid embolism) • 4/5
TREATMENT
As above, plus:
l If necessary, deliver immediately –
ideally vaginally. If not possible, by
caesarean section under general
anaesthetic
l Insert second large bore (16 G) IV
cannula and prepare to manage
massive obstetric haemorrhage (see
Postpartum haemorrhage guideline)
l Consider early insertion of central
venous catheter and arterial line
l Discuss need for blood products
(including fresh frozen plasma
to correct DIC) with consultant
haematologist, without waiting for
blood results
l Woman will require circulatory support,
which can include inotropes, with
invasive monitoring
l Transfer to critical care unit
l Report all cases of suspected or
proven amniotic fluid embolism,
whether fatal or not to National
amniotic fluid embolism register via
UKOSS (UK obstetric surveillance
system)
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Collapse 201719
Open airway
Look for signs of life
100% supplemental O2
CPR 30:2 Intubate early
Until defibrillator/monitor attached Insert 2 IV cannulae
(wide bore)
If no response to CPR
after 4 min, proceed to
delivery/perimortem
caesarean section
Assess
rhythm
Shockable Non-shockable
(VF/pulseless VT) (PEA/asystole)
1 shock Return of
150–360 J biphasic or spontaneous
360 J monophasic circulation
Immediate post-cardiac
arrest treatment
Immediately resume Immediately resume
CPR for 2 min • Use ABCDE approach CPR for 2 min
Minimise interruptions • Controlled oxygenation Minimise interruptions
and ventilation
• 12-lead ECG
• Treat precipitating cause
During CPR: • Temperature Reversible causes:
• Ensure high-quality CPR: rate, control/therapeutic • Hypoxia
depth, recoil hypothermia • Hypovolaemia
• Plan actions before interrupting • Hypo-
CPR /hyperkalaemia/metabolic
• Give oxygen • Hypothermia
• Consider advanced airway and • Thrombosis – coronary or
capnography pulmonary
• Continuous chest compressions • Tamponade – cardiac
when advanced airway in place • Toxins
• Vascular access (intravenous, • Tension pneumothorax
intraosseous)
• Give adrenaline every 3–5 min
• Correct reversible causes
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DELAY IN LABOUR • 1/2
See also:
Before commencing oxytocin,
l Labour management guideline middle grade obstetrician (ST3–7 or
l Latent phase of labour guideline equivalent e.g. staff grade, clinical
fellow) must review parous woman.
DELAY IN FIRST STAGE If previous caesarean section,
discuss use of oxytocin with
l Cervical dilatation <2 cm in 4 hr in first obstetric consultant.
labours Perform at least an abdominal
l Cervical dilatation <2 cm in 4 hr, palpation
or slowing in progress of labour for Repeat vaginal examination may also
second or subsequent labours be appropriate
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DIABETES – ANTENATAL CARE • 3/4
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DIABETES – ANTENATAL CARE • 4/4
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DIABETES – LABOUR • 1/3
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DIABETES – LABOUR • 3/3
Gestational diabetes
l Ensure blood glucose measurements
returning to normal ≥4 tests in first
24 hr – fasting and 1 hr post meals
l Arrange postnatal GTT or fasting blood
glucose at 6–13 weeks according to
local Trust policy
l At 6 week assessment:
l inform woman of risk of developing
type 2 diabetes later in life and
preventative measures i.e. diet,
exercise and ideal weight
l recommend annual screening for diabetes
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DIABETES – SCREENING FOR GESTATIONAL DIABETES • 1/1
INTRODUCTION
Optimisation of glycaemic control and advice on preparation for pregnancy have been
shown to improve pregnancy outcomes in type 1 and 2 women
How FOLLOW-UP
l Use 75 g 2-hr OGTT to test for l Offer women with diagnosis of
gestational diabetes gestational diabetes a review with
l Screen positive the joint diabetes and antenatal clinic
within 1 week
l fasting plasma glucose concentration
≥5.6 mmol/L or l Inform primary healthcare team when
woman diagnosed with gestational
l 2 hr plasma glucose concentrations diabetes
≥7.8 mmol/L
l See Diabetes – Antenatal care
guideline
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DIMINISHED FETAL MOVEMENTS (DFM) • 1/3
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DIMINISHED FETAL MOVEMENTS (DFM) • 2/3
l If symphysis fundal height reduced for
Second episode DFM
dates, arrange growth scan (unless
performed in previous 2 weeks) l EFM trace, ideally computerised (if
l If adequate EFM trace cannot be available)
obtained despite midwife sitting with l EFM trace normal:
woman, seek middle grade obstetrician l reassure, allow home and advise to
(ST3–7 or equivalent e.g. staff grade, return again if concerned about fetal
clinical fellow) opinion movements and expect to be contacted
for growth scan
>28 weeks’ gestation l arrange growth scan (unless performed
in previous 2 weeks), liquor volume
First episode DFM and umbilical artery Doppler
l EFM trace, ideally computerised (if l >28 weeks’ gestation, women with
available) second episode of DFM within 1 month
l Assess symphysis fundal height of first DFM:
l refer to their consultant’s next antenatal
l if symphysis fundal height reduced for
clinic
dates, arrange growth scan (unless
performed in previous 2 weeks) l EFM trace non-reassuring or
abnormal:
l EFM trace normal with fetal
movement felt and no risk factors l inform middle grade obstetrician
(see Risk factors below) for fetal (ST3–7 or equivalent e.g. staff grade,
growth restriction (FGR)/stillbirth clinical fellow) urgently
identified: l FBC and group and save
l reassure, allow home and advise to l consider cannulation
return again if concerned about fetal l transfer to delivery suite
movements
l EFM trace normal with persistent Risk factors
DFM and/or risk factor (see Risk
l Known FGR
factors below) for FGR/stillbirth
identified: l Hypertension
l reassure, allow home and advise to l Diabetes
return again if concerned about fetal l Extremes of maternal age
movements and expect to be contacted l Primiparity
for growth scan l Smoking
l arrange growth scan (unless performed l Placental insufficiency
in previous 2 weeks)
l Congenital malformation
l manage any abnormalities found l Obesity
l EFM trace non-reassuring or l Racial/ethnic factors
abnormal:
l Poor past obstetric history (e.g. FGR
l inform middle grade obstetrician and stillbirth)
(ST3–7 or equivalent e.g. staff grade,
l Genetic factors
clinical fellow) urgently
l Issues with access to care
l consider cannulation
l FBC and group and save Management plan in labour
l transfer to delivery suite
l Continuous EFM in labour
l If admitted with ruptured membranes or
suspected early labour, EFM
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DIMINISHED FETAL MOVEMENTS (DFM) • 3/3
INABILITY TO IDENTIFY
FETAL HEART
l Ultrasound scan (ideally in maternity
scan department)
l If out-of-hours, performed by middle
grade obstetrician (ST3–7 or equivalent
e.g. staff grade, clinical fellow) or
consultant competent to use portable
labour ward ultrasound machine
l If scan identifies fetal death (second
trained operator to confirm this),
inform on-call consultant obstetrician.
It is unlikely that woman will need
immediate delivery – see Perinatal
bereavement guideline
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ECLAMPSIA • 1/1
Eclamptic seizures are often self-limiting. l If repeated seizures not responding
See also – Severe pre-eclampsia to magnesium sulphate, consultant
guideline obstetrician and anaesthetist decide
on use of diazepam 5–10 mg or
RESUSCITATION AND
thiopentone, together with intubation
STABILISATION and transfer to intensive care
l Airway, Breathing, Circulation and l consider CT scan to exclude other
lateral tilt causes
l Do not leave woman alone. Call for l Blood pressure control – see Severe
help from senior midwife, middle grade pre-eclampsia guideline
obstetrician (ST3–7 or equivalent e.g.
staff grade, clinical fellow) and inform Post seizure
consultant obstetrician and consultant
anaesthetist to attend as soon as possible l Once seizure ended, auscultate lungs
l During convulsion, consider personal and commence continuous oxygen
safety and aim to prevent maternal saturation monitoring
injury l Transfer to an area where high
l as soon as possible, position woman in dependency care can be provided with
recovery position and administer 15 L full HDU monitoring
oxygen via close-fitting face mask l Monitor consciousness level and
l Attach pulse oximeter and automatic document on HDU chart
blood pressure monitor l Full neurological assessment following
l As soon as is safely possible, site two seizure to rule out localising signs of
16 gauge (grey) Venflons™ alternative causes e.g. intracranial
haemorrhage
l Insert Foley indwelling catheter, and
monitor urine output hourly with strict l If pregnant, perform EFM
fluid restriction l Once woman stabilised, plan to deliver
INVESTIGATIONS Delivery
l Obtain blood and send urgently for: l See Severe pre-eclampsia guideline
l FBC Eclampsia is nearly always an
l clotting studies indication for rapid delivery
l U&E regardless of gestation
l LFT Woman’s condition will always take
priority over fetal condition
l urates
l group and save
POSTNATAL CARE
l Consider arterial blood gases
l HDU care for minimum of first 24 hr as
TREATMENT for severe pre-eclampsia
Classification
Table 1: Categories and definition of FHR traces
Category Definition
Normal All 4 features classified as reassuring
Suspicious 1 feature is non-reassuring
Pathological ≥2 non-reassuring features or ≥1 abnormal feature
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ELECTRONIC FETAL MONITORING (EFM) – ANTENATAL • 3/4
l While an abnormal 60 min STV is a
Dawes-Redman criteria not met
significant risk indicator, a normal STV
l If insufficient evidence of normality does not necessarily mean there is no
Dawes-Redman criteria will not be met risk of mortality or morbidity
l Continue CTG monitoring for 60 min l Consider gestational age, recording
duration and clinical indication
l at 60 min discontinue CTG; reason for
not meeting criteria may be on CTG l Normality is determined by a number
printout of Dawes-Redman criteria, with the
minimum duration of trace set at
l Woman to be reviewed by middle
10 min
grade obstetrician (ST3–7 or equivalent
e.g. staff grade, clinical fellow) l if criteria not met ≤60 min, end trace
with the conclusion that normality has
l Action dependent on the STV and/or
not been demonstrated
reason
l STV value
STV l thresholds only valid when measured
l STV is recorded on the CTG when over the full period of 60 min. Always
Dawes-Redman criteria is not met; this interpret results in the context of
is the best predictor of fetal wellbeing perceived fetal problem:
RECORDING AND
DOCUMENTATION
l Machine: set speed 1 cm/min, set date
and time, ensure identification, ensure
adequate quality of FHR and uterine
contraction recordings and improve
quality with necessary adjustment
l if there are artefacts, change machine
l ensure setting in multiple pregnancy
l Ensure the following are recorded on
EFM trace:
l date, time and signature of midwife at
commencement of trace
l maternal details: label name, hospital
number, pulse rate, date and time
l fetal heart rate: auscultation
l events: note any events on trace
during monitoring e.g vaginal
examination, FBS
l opinion: add comment on EFM
trace e.g. ‘normal’, ‘suspicious’,
‘pathological’ with date time and
signature
l completion: sign again, enter name,
date, time and mode of delivery
l Storage: follow local practice for
storing trace
l Document plan in maternal healthcare
record
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ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 1/6
l Abnormal FHR on auscultation:
AIM
l baseline abnormality <110 bpm >160
Recognition and prevention of potential bpm, decelerations after a contraction
fetal acidosis in labour
l Postmaturity (>42+0 weeks’ gestation)
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ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 2/6
l Take into account the woman’s MATERNAL CHOICE FOR FETAL
preferences, any antenatal and
MONITORING
intrapartum risk factors, current
wellbeing of the woman and unborn l Respect the woman’s choice of fetal
baby and progress of labour monitoring
l Ensure focus of care remains on the l Explain risks and benefits of fetal
woman rather than CTG trace monitoring in labour
l Remain with the woman in order to l Clearly document discussion and
continue providing one-to-one support explanation of risks and benefits in
l Talk to the woman and her birth maternal healthcare record
companion(s) about what is happening
and take her preferences into account
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ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 3/6
Table 1: Description of CTG trace features
Baseline Variability
Description Deceleration Acceleration
(bpm) (bpm)
Reassuring l 110–160 l 5–25 l None/early l Present
l Variable decelerations without any l Record
concerning characteristics for <90 min accelerations
if heard
Non- l 100–109 l <5 for l Variable decelerations with no
reassuring or 30–50 min concerning characteristics for ≥90 min
l 161–180 or l Variable decelerations with any
l >25 for concerning characteristics in <50%
15–25 min of contractions for ≥30 min
l Variable decelerations with any l Absence of
accelerations
concerning characteristics in >50%
of contractions for <30 min or on an
otherwise
l Late decelerations in >50% of normal
contractions for <30 min with no CTG trace
maternal or fetal clinical risk factors does not
(e.g. vaginal bleeding or significant indicate
meconium) fetal
Abnormal l <100 l <5 for l Variable decelerations with any acidosis
or >50 min concerning characteristics in >50%
l >180 or of contractions for 30 min or
l >25 for l Late decelerations for 30 min
>25 min l Act sooner than 30 min if any
or maternal/fetal clinical risk factors
l Sinusoidal (e.g. vaginal bleeding/significant
meconium) or
l Acute bradycardia, or single
prolonged deceleration lasting ≥3 min
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ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 6/6
RECORDING AND
DOCUMENTATION
l Machine: set speed 1 cm/min, set date
and time, ensure identification, ensure
adequate quality of FHR and uterine
contraction recordings and improve
quality with necessary adjustment
l if there are artefacts, change machine
l ensure setting in multiple pregnancy
mode
l Ensure the following are recorded on
EFM trace:
l date, time and signature of midwife at
commencement of trace
l maternal: label name, hospital number,
pulse rate, date and time
l fetal: auscultation
l events: note any events on trace
during monitoring e.g. vaginal
examination, FBS
l opinion: add comment on CTG trace
e.g. normal, suspicious, or pathological
with date time and signature
l completion: sign again, enter name,
date, time and mode of delivery
l Storage: follow local practice for
storing trace
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EPIDURAL ANALGESIA • 1/6
l Raised intracranial pressure
INTRODUCTION
l Inadequately trained or competency
Epidural analgesia is the most effective assessed staff
method of pain relief in labour. If epidural
analgesia is available on a 24 hr basis, Anticoagulant therapy
time from informing anaesthetist until he/
she is able to attend should ideally not l Do not insert epidural:
exceed 30 min. Discuss the following l for ≥12 hr after last prophylactic dose
risks and benefits with the mother: l for ≥24 hr after last therapeutic dose
l Reduced neonatal respiratory
depression (repeat doses of IM opioids) Relative
l Improved uteroplacental blood flow in Discuss with consultant
the compromised fetus
obstetric anaesthetist
l Assists with controlled birth (e.g.
breech or multiple pregnancy) l Neurological disorders (spinal bifida
occulta)
l Can be used as regional anaesthesia if
required l Significant cardiac disease
l Anatomical deformity or back surgery
If delay anticipated l Haemorrhage, hypovolaemia
l Review necessity of epidural: purely PREPARATION
analgesic or medical indication
l If only for analgesia, midwife to Patient
discuss alternative form of pain relief
(remifentanil PCA) with the woman until l Explain technique, and risks and benefits
epidural service is available l Provide information leaflet if available
locally
l Document ‘exceptional circumstances’,
cause of delay and discussion with l Obtain and document verbal consent
woman in maternal healthcare record. l Obtain IV access
Involve on-call consultant anaesthetist
in the discussion Investigations
l In pre-eclamptic women, check FBC. If
INDICATIONS
platelet count <100,000 – APPT, INR
l Maternal request l Intra-uterine death >1 week: detailed
l Obstetric indications (e.g. coagulation profile, including D-dimer
pre-eclampsia, breech, multiple and fibrinogen levels
pregnancies, prolonged labour) l In septic woman: FBC and CRP
l Medical indication (CVS and respiratory
diseases, etc.) Equipment
l Morbid obesity l Oxygen and suction available
l Epidural trolley with:
CONTRAINDICATIONS
l epidural pack (16 G/18 G Tuohy
needle) or 19 G/23 G catheter
Absolute
l yellow epidural infusion lines labelled
l Patient refusal with yellow label from pack
l Local or systemic sepsis l sterile gown, gloves, hat and mask
l Known hypersensitivity to local l chlorhexidine skin preparation 0.5%
anaesthetic drugs l Use specific epidural pumps with
l Coagulopathy – see Investigations locking ability
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EPIDURAL ANALGESIA • 2/6
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EPIDURAL ANALGESIA • 3/6
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EPIDURAL ANAESTHESIA • 5/6
l Provide information leaflet (if available
Pruritus
locally)
l If of sufficient severity to warrant l Ensure details recorded in audit book
treatment, administer one dose of or according to local practice
naloxone 40 microgram IV
l Offer postnatal anaesthetic clinic
l Alternatively, consider chlorpheniramine appointment if available locally
(Piriton®) 4 mg oral or 10 mg IM
l Notify GP
Immediate management
l Stop injecting drug
l Commence resuscitation, all principles
of basic and advanced life support
apply
l Summon help immediately including
anaesthetist if not present
l If lateral tilt of 15–30° cannot be
applied, manually displace uterus
l Give benzodiazepine, thiopental or
propofol in small incremental doses to
control seizures
l Bag-mask ventilate with 100% oxygen
before intubation
l Perform caesarean section
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EPISIOTOMY • 1/2
DEFINITION PROCEDURE
A surgical incision of the perineum to This procedure must only be
increase the diameter of the vulval outlet performed by appropriately trained
during childbirth to facilitate delivery but practitioners or under direct
minimise harm to mother and baby supervision of a mentor
Perform mediolateral episiotomy only
Mediolateral episiotomy
l Cut starts at centre of the vaginal
fourchette and directed to the right side
at an angle of 60° to the vertical axis
(see diagram below) Centre of
fourchette
INDICATIONS
The list below is not exhaustive – use
clinical judgement on an individual basis
l Fetal distress Position and preparation of
l Maternal reason to expedite delivery woman
(e.g. pre-eclampsia/eclampsia)
l Place in comfortable legs-open position
l Rigid perineum preventing delivery l Cleanse perineal area using aseptic
l Instrumental delivery (particularly technique
forceps) l Place index and middle fingers into vagina
l Occipitoposterior position (OP) between presenting part and perineum
l Shoulder dystocia l Insert needle fully into perineal tissue
l Breech presentation starting at centre of fourchette and
direct it midway between ischial
tuberosity and anus (protect fetal head)
Equipment
l Draw back plunger of syringe before
l Sterile or tap water to clean area before injecting 5–10 mL lidocaine 1% slowly
procedure as needle is withdrawn
l 1 x 10 mL syringe
Episiotomy incision
l 1 x 22 gauge (green) infiltration needle
l 10 mL lidocaine 1% l Insert middle and index fingers into
vagina and gently pull perineum away
l Mayo episiotomy scissors from fetal part to protect fetal head
l Perform incision when presenting part
Consent has distended perineum
l Reassure woman and partner l Insert open scissors between 2 fingers
l Explain procedure and indications and make incision in 1 single straight
cut to minimise damage and allow/
l Obtain and record consent facilitate optimal realignment
l begin at the centre of the fourchette
and extend 4 cm in a right mediolateral
direction midway between the ischial
tuberosity and anus, ideally at a 60°
angle to vertical axis
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EPISIOTOMY • 2/2
COMPLICATIONS
A: B: C:
Suturing
See Third and fourth degree perineal tears – OASIS guideline and Perineal trauma
suturing (tears and episiotomy) guideline
Pain management
See Perineal trauma suturing (tears and episiotomy) guideline
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EXTREME PREMATURITY (<28 WEEKS’ GESTATION) • 1/5
INTRODUCTION
l Management of babies born at the threshold of viability presents some of the most
testing ethical and clinical problems
l If it seems likely that delivery will occur at an extremely premature gestation, there
may be a variable amount of time to counsel and prepare woman and partner for the
outcome
l Unless circumstances dictate otherwise, senior staff should always be involved
l Document all information given to parents in the maternal healthcare record
Table 1
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EXTREME PREMATURITY (<28 WEEKS’ GESTATION) • 2/5
l as a minimum, a middle grade
OBSTETRIC RESPONSIBILITIES
obstetrician (ST3–7 or equivalent e.g.
Calculating gestational age staff grade, clinical fellow) must discuss
with parents whether to deliver or
l Management of extreme prematurity continue labour without monitoring
depends on gestation. Knowledge l document discussion and decision in
of precise gestation is important, maternal healthcare record
preferably calculated from an
ultrasound scan at 9–14 weeks Antenatal steroids
l Dating scans are accurate within 1
week below 14 weeks. However, even l Decision to give betamethasone to
at 20 weeks they are accurate to within improve fetal lung maturity <24 weeks’
one-and-a-half weeks gestation must be discussed with
consultant obstetrician
l If only late ultrasound scan is available,
use best estimate gestation to
determine management MAGNESIUM SULPHATE
l If estimated gestation is ≥23 weeks l Magnesium sulphate protects
and fetal heart is audible before premature babies’ brains from cerebral
delivery, a neonatologist experienced in palsy. Consider for all babies
resuscitation to attend birth <30 weeks’ gestation likely to deliver in
≤24 hr regardless of mode of delivery
Counselling l Can be given to women with multiple
pregnancy and irrespective of whether
l Middle grade obstetrician (ST3–7 or
steroids have been given
equivalent e.g. staff grade, clinical
fellow) or consultant to provide l ideally, commence infusion 4 hr before
patient information leaflet (if available) delivery, but there may still be benefit if
and counsel mother addressing the given <4 hr before delivery but do not
following questions: delay delivery in time-critical situations
e.g. fetal distress
l how sick is baby now
l administration may be impractical
l how sick is baby likely to be at birth
when delivery is imminent. Consultant
l is baby likely to die or survive obstetrician will decide whether to
l Use EPICure data (see Tables 2 and 3) administer
l Discuss the role of operative delivery
(risks and benefits) and the use of fetal Side effects
monitoring with woman and family and l Inform woman about the possibility of
take their views into account side effects. The most common are:
Electronic fetal monitoring l facial flushing
(EFM) l nausea and vomiting
l sweating
l Perform EFM only if it has been agreed
with parents after discussion that an l Tachycardia and hypotension have also
emergency CS would be performed for been observed
a pathological EFM l The effect may be more pronounced
l It is often difficult to monitor a fetus when magnesium sulphate is given
<28 weeks’ gestation with calcium channel blockers e.g.
nifedipine
l If an adequate trace cannot be
obtained, baby’s wellbeing is not being
monitored
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EXTREME PREMATURITY (<28 WEEKS’ GESTATION) • 5/5
COMMUNICATION WITH l When completing the certificate, the
doctor prints his/her name after the
PARENTS
signature and records their GMC
l Dependent upon labour timescales number
etc., a second counselling session may l If it is not possible for a doctor to see
be useful baby before he/she dies, document
l Following discussion, parents should be this clearly in the healthcare record.
aware of the options, their risks, benefits Doctor should see baby as soon as
and the implications of alternatives possible after death
l Reinforce verbal information by l In some areas, all deaths must be
providing printed leaflets (if available). discussed with the coroner’s office.
Give details of support services Check your local coroner’s requirements
available e.g. bereavement counselling before issuing death certificate and
and BLISS information (http://www. requesting post mortem consent
bliss.org.uk/shop)
l When talking to parents, survival Definition of signs of life
outcomes may need to be modified
l It is extremely important to distinguish
in light of clinical information available
between involuntary, physiological
see Table 3
movements and signs of life
l The RCOG states that ‘conveying
l A live birth is delivery of a baby,
the concept that fetal death is not
regardless of duration of pregnancy,
the worst outcome, and that severe
which, after delivery, breathes or
neonatal morbidity and maternal and
shows any other evidence of life, such
fertility morbidity are also important
as beating of the heart, pulsation
considerations to the woman and
of umbilical cord, or any definite
her partner, must be conducted with
movement of voluntary muscles,
kindness and sensitivity’
whether or not umbilical cord has been
l Doctor counselling parents should not cut or placenta delivered
impose his/her cultural or religious
l observed movement, such as a jerk of a
convictions on those whose beliefs
limb or occasional gasp, are involuntary,
may differ. When a doctor’s beliefs
physiological movements and not
prevent the disclosure of all available
necessarily signs of life or viability
management options, he/she has a
duty to refer woman to a colleague l in these circumstances, explanations
should be given to parents by a senior
l If there is a difference of opinion between
member of staff and registration as a
clinical staff and parents regarding
neonatal death is not necessary
management, seek second opinion
l Where signs of life are evident at
CERTIFYING NEONATAL DEATH birth, inform parents that their baby
may continue to show such signs
l Baby must be seen by a doctor while for minutes or even hours following
alive (if possible). This does not have to delivery and reassure them that baby
be a neonatologist will be treated with respect and dignity
l Doctor who saw baby before death l Give parents the opportunity to keep
issues a medical certificate certifying baby with them until he/she dies
death. The certificate must always be l Baby must then be registered as a
issued even if baby lived for only a few neonatal death
minutes
l Once a baby is born alive he/she
l Neonatal death certificates can only be acquires the same legal status as any
issued by a doctor. Midwives do not other human being and is owed a duty
certify neonatal deaths of care
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FETAL ABNORMALITY – ANTENATAL DETECTION • 1/2
l If woman does not wish to be informed
INTRODUCTION
of any fetal abnormalities, give her the
l Prenatal screening for fetal opportunity to decline anomaly scanning
abnormalities using second trimester but to have a scan to determine placental
ultrasound scan and maternal serum site and fetal growth
screening is offered routinely in the UK
l Routine second trimester ultrasound ABNORMALITY DETECTED
scans increase detection rate for fetal l Sonographer performing ultrasound
abnormalities compared to scans examination must report findings to
offered on a selective basis only woman and document the discussion
l Abnormalities may be detected on l Inform woman and her partner in
an ultrasound scan at any stage of descriptive but not diagnostic terms
pregnancy
l sensitivity of detection is determined If there is doubt about a diagnosis
by severity and type of abnormality. or a scan feature, refer woman to
More severe abnormalities and those appropriate expert, giving reason for
developing earlier have a higher referral
detection rate
l false positive rates from ultrasound Referral
scanning are <1%
l Within 1 working day, refer to consultant
SECOND TRIMESTER obstetrician with fetal medicine expertise
ANOMALY SCANNING l Fetal medicine consultant will re-scan
within 5 days and explain findings to
l To identify fetal conditions associated woman and her partner
with high morbidity and long-term
disability l it may be necessary to repeat
information. Written information and
l Performed between 18–23 weeks’ diagrams can be helpful
gestation
l When major fetal abnormalities are
Ultrasound imaging must only be identified, give parents the Antenatal
performed by person fully trained Results and Choices (ARC) booklet (if
in its use and qualified in detection used locally)
of fetal abnormality using this l It may be appropriate for consultant
technique with expertise in fetal medicine to offer
fetal karyotyping by amniocentesis or
Before scan chorionic villus sampling
l Refer confirmed fetal abnormalities in
l Ensure ultrasound equipment is of ongoing pregnancies to neonatologist
appropriate standard and in working
order l Feticide is recommended for termination
of pregnancy >22 weeks’ gestation,
l Check woman’s identity which is associated with increased
l Inform woman of nature and purpose difficulty in managing a woman who
of the screening proposed and discuss elects termination later than this stage
the limitations of ultrasound scanning l More complex cases may benefit
in detecting fetal abnormality i.e. from referral to a tertiary centre e.g. to
sensitivity of detection is only 76% even obtain access for magnetic resonance
for life-threatening abnormalities (MR) imaging or to receive antenatal
l Treat woman sympathetically and counselling from neonatal surgeon
address anxieties or concerns l Complete notification to the regional
congenital anomaly register
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FETAL ABNORMALITY - ANTENATAL DETECTION • 2/2
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FETAL BLOOD SAMPLING • 1/4
BACKGROUND CONTRAINDICATIONS
l Fetal blood sample (FBS) is a sample Absolute
of blood taken using aseptic technique
from the presenting part of the fetus l Acute fetal compromise (e.g. prolonged
in-utero deceleration): FBS should not be
undertaken and baby delivered urgently
l Fetal pH can identify fetal hypoxemia
and acidosis l Maternal infection e.g. HIV [viral load
>50 copies/mL not taking highly active
l when the fetus is hypoxemic, antiretroviral therapy (HAART)], hepatitis
metabolism changes from aerobic to viruses or herpes simplex virus. FBS
anaerobic, producing lactic acid and increases risk of transmission to baby
a subsequent drop in pH, providing a
l Group B streptococcus carrier status
measure of the degree of hypoxaemia
does not preclude FBS
l Electronic fetal monitoring (EFM) l Fetal bleeding disorders e.g. haemophilia
without supporting FBS in suspected
fetal distress in labour is associated l Prematurity (<34 weeks’ gestation)
with significant increase in caesarean l Face presentation
delivery, with no apparent improvement
in neonatal outcome (see Electronic Cautions with maternal
fetal monitoring guideline) bleeding disorders
l Sampling acceptable:
INDICATIONS
l type 1 von Willebrand disease (vWD)
l Consider fetal pH: l idiopathic thrombocytopenic purpura
(ITP) – providing previous children did
l with abnormal EFM, FBS can be helpful
not have low platelet count immediately
in planning further management and
following birth
can be performed in first and second
stage of labour l If vWD or ITP in first pregnancy/previous
children born with thrombocytopenia,
l if CTG is classified as abnormal, but do not undertake FBS without
urgent intervention is not required, discussion with consultant obstetrician
confirmation of fetal wellbeing to be and consultant haematologist
obtained through FBS where possible,
along with conservative measures (see
Relative
below)
l Gestation 34–36+6 weeks
Do not undertake FBS where there
is clear evidence of acute fetal l Maternal pyrexia >38°C
compromise. Make preparations for l Suspected/confirmed intrauterine sepsis
urgent birth l Discuss with consultant obstetrician
Assess and manage each woman
individually and, where there is FBS NOT POSSIBLE
cause for concern, seek advice from
on-call consultant obstetrician l If FBS necessary but cannot be
obtained due to technical difficulties or
l Take 2 samples, to ensure reliability of contraindications consider delivery –
result. Remember an FBS only reflects discuss with consultant obstetrician
the condition of the fetus at the time of l Urgency to deliver should take into
sampling account:
l severity of CTG abnormality
l relevant maternal factors
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FETAL BLOOD SAMPLING • 2/4
l Avoid leaving woman alone while
PREPARATION
sample is processed, especially if her
Equipment legs are on supports
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FETAL BLOOD SAMPLING • 3/4
INTERPRETATION OF RESULT
l Interpret results taking into account:
l previous lactate/pH measurement
l rate of progress of labour
l maternal/fetal clinical features
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FETAL BLOOD SAMPLING • 4/4
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GENERAL ANAESTHESIA AND FAILED INTUBATION • 1/4
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GENERAL ANAESTHESIA AND FAILED INTUBATION • 2/4
l Use atracurium or rocuronium after
INDUCTION
suxamethonium wears off
l Keep noise to minimum during induction l Maintain anaesthesia with oxygen and
l Establish full monitoring air or oxygen and nitrous oxide (usually
l pulse oximeter 50% N2O pre- and 67% post-delivery),
with an inhalational agent (isoflurane/
l non-invasive BP
sevoflurane) to keep a MAC of ≥1
l ECG
l Remember the possibility of patient
l capnography and airway gas monitoring
awareness at all times
l airway pressure
l Confirm sodium citrate and ranitidine AFTER DELIVERY
have been given, if not, consider
ranitidine 50 mg IV slowly after induction l After cord clamped, give opioid – e.g.
fentanyl 100 microgram and morphine
l Establish free-running IV infusion with a
10 mg. Alternatively, if epidural in situ,
16 G (or larger) cannula
top-up with local anaesthetic and
l Position woman supine on table with a epidural opioid
20–30° head up and 15° left lateral tilt
l At end of surgery, and if not
l In morbidly obese use ramped up
contraindicated, give 100 mg
position – align external auditory
diclofenac rectally
meatus with supra-sternal notch
l Perform TAP blocks at the end of
l Remove oral piercings and hair bands
surgery for post-operative pain relief
l Give appropriate antibiotics –
l Extubate woman awake in left lateral
according to local practice
position in theatre
Pre-oxygenation l Obese women may benefit from
waking up in upright position
l Consider attaching nasal cannulae
5 L/min before pre-oxygenation Transfer to recovery room
l Pre-oxygenate for 3 min with 100%
l Transfer to recovery room for ≥30 min
oxygen >10 L/min via close-fitting face
mask l See Recovery guideline
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• Follow-up for potential complications: oedema, bleeding, tracheal and esophageal
perforation, pneumothorax and aspiration
• Inform GP and woman in writing
GENERAL ANAESTHESIA AND FAILED INTUBATION •
• In complex cases offer anaesthetic outpatient appointment
4/4
Flowchart: Failed
Flowchart: failed intubation
intubation algorithmalgorithm
Pre-induction preparation
Fail
Success
Algorithm 2 Declare failed intubation Is it essential to proceed
Can’t Call for help with surgery?
intubate Maintain oxygenation
Can ventilate Supraglottic device
(2 attempts only) NO YES
Success
Wake Proceed
with
surgery
Declare can’t intubate can’t
Algorithm 3 ventilate
Can’t intubate Give 100% oxygen
Can’t ventilate Exclude laryngospasm
Ensure neuromuscular
blockage
Front of neck access
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GENITAL HERPES • 1/2
Neonatal herpes is a rare (1.65/10,000
Antiretroviral therapy
in the UK) but serious disease with a
significant mortality l Women with a history of recurrent
herpes may reduce the risk of active
Causes lesions at time of delivery by taking
oral aciclovir for the last 4 weeks of
Herpes simplex virus type 1 (HSV-1) or pregnancy. Refer them to GUM for
herpes simplex virus type 2 (HSV-2) further discussion
l If woman develops primary infection
Transmission before or earlier in pregnancy,
Transmission of virus from mother to prophylactic oral aciclovir is not
fetus occurs mostly by direct contact recommended in the last 4 weeks of
with virus in the genital tract during birth, pregnancy
although cases of transplacental infection
and postnatal transmission have been DELIVERY
reported
Mode of delivery
Maternal infection l If woman develops her first episode of
May be primary or recurrent active herpes >28 weeks’ gestation or
≤6 weeks of the onset of labour, offer
delivery by caesarean section (CS)
Primary infection
l If an attack occurs in the third trimester
l Risks are greatest in the third trimester, that is thought to be primary, send
particularly ≤6 weeks of delivery, swab and blood for HSV antibodies
as viral shedding may persist and
l if the virus types on swab and blood
baby is likely to be born before the
match the attack is recurrent – advise
development of protective maternal
against CS
antibodies
l There is no indication to deliver a
Recurrent infection woman by CS because of a history of
genital herpes before pregnancy or
l Is associated with a very low risk of earlier in pregnancy
neonatal herpes l Advise women with active recurrent
l Recurrent herpes at the time of delivery herpes lesions at the onset of labour
causes localised forms of neonatal that the risk of neonatal herpes is
herpes only very small and that CS is not routinely
recommended
ANTENATAL DIAGNOSIS AND
MANAGEMENT Care in labour
l Refer women who present with lesions Primary infection
that are thought to be herpes to
genitourinary medicine (GUM). Make it l If woman refuses delivery by CS,
clear the woman is pregnant avoid fetal scalp electrodes, fetal
l GUM clinic will arrange screening for blood sampling and, where possible,
other sexually transmitted infections instrumental delivery to minimise risk of
vertical transmission
l Active herpes is painful and analgesia
with lidocaine 2% gel may be required l Inform neonatologists during labour
l Ask directly whether woman can pass l Give aciclovir, 5 mg/kg (350 mg for a
urine. It is not unusual for an indwelling 70 kg woman) IV 8-hrly over 60 min
catheter to be required
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GENITAL HERPES • 2/2
l Give woman aciclovir 5 mg/kg IV 8-hrly
Recurrent infection
over 60 min
l Women with active recurrent genital l If woman has recurrent genital herpes
herpes and confirmed rupture of and has preterm pre-labour rupture of
membranes – augment labour as soon membranes <34 weeks, give aciclovir
as possible 400 mg oral 8-hrly
l In women with active recurrent
genital herpes, avoid invasive Care of neonate
procedures during labour and inform
neonatologists l Encourage breastfeeding unless
woman has herpetic lesions around
nipple
Preterm labour
l Advise woman and family about good
l If woman has primary genital herpes hand hygiene
and delivery is induced, deliver by CS
l Those with oral herpetic lesions (cold
l If managing conservatively give sores) should not kiss neonate
betamethasone for neonatal lung
function
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GROUP B STREPTOCOCCAL DISEASE • 2/2
Observations
l If antibiotics indicated but not given or
received an inadequate dose of IAP,
observe baby for 12–24 hr after birth on
postnatal ward with regular assessment
of:
l general wellbeing
l feeding
l heart rate
l respiratory rate
l temperature
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HEPATITIS • 1/3
l Hepatitis B infection is not an indication
HEPATITIS B
for CS as there is insufficient evidence
Introduction that it reduces mother-to-child
transmission
Hepatitis B is a blood borne viral infection l If unbooked or untested woman accepts
affecting the liver. It is caused by the testing, send sample for antenatal
hepatitis B virus (HBV) transferred in screening to microbiology urgently
blood or body fluid (notify microbiologist on duty/on-call
via switchboard) to allow immunisation
Principles of isolation within 24 hr of delivery if required
l Body fluids are regarded as infectious l If woman requires in-utero transfer,
material. Take appropriate infection immunoglobulin (if indicated) must
control precautions in line with local accompany her
Trust policy
Postnatal care
Antenatal care l For all newborns, check antenatal
l As part of antenatal care, provide screening results for mother’s tests
all women with information on, and l If antenatal testing not done (e.g.
access to, HBV screening concealed pregnancy) request urgent
l If mother positive for HBV: maternal hepatitis B virus surface
antigen (HBsAg) test and other
l review in consultant-led antenatal clinic, infection screening bloods (HIV and
where an individualised management syphilis) – see HIV positive women
plan will be drawn up guideline
l alert neonatal team and inform l Wash baby immediately following birth
Public Health team and GP of plan to and cleanse oropharynx and nasal
immunise cavities of all visible maternal blood
l Arrange for prophylaxis and secretions by gentle wiping
l for multiple pregnancy arrange dose l Encourage and support breastfeeding
for each baby (unless mother also HIV +ve) but do
l Refer women with HBV infection to not allow mother to donate milk as the
a consultant with expertise in liver virus has been detected in breast milk
disease for further assessment l Inform postnatal ward baby will require
immunisation
Communication
IMMEDIATE POSTNATAL
l Give mother information about
TREATMENT OF BABY
hepatitis B, modes of transmission and
prevention of spread Immunisation
l Obtain parental consent for
immunisation l Some babies require hepatitis B
immunoglobulin (HBIG) as well as
immunisation
Intrapartum care
l Order immunoglobulin [HBIG
l When an HBsAg positive mother antenatally if required (see Table)],
arrives in labour or for CS, inform depending on mother’s antigen status
on-call neonatal team l Immunise baby of HBsAg positive
l Avoid fetal scalp sampling and fetal mother as follows, depending on other
scalp electrodes hepatitis B markers in mother during
pregnancy:
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HEPATITIS • 2/3
Vaccine Immunoglobulin
Maternal status required by (HBIG)
baby required by baby
HBsAg positive, HBeAg positive Y Y
HBsAg positive, HBeAg negative, Y Y
HBe antibody (anti-HBe) negative
HBsAg positive where e markers have not Y Y
been determined
Acute hepatitis B during pregnancy Y Y
HBsAg positive and baby <1.5 kg Y Y
HBsAg positive, anti-HBe negative Y N
HBsAg positive and >106 iu/mL Hepatitis B Y Y
DNA in antenatal sample
Other high risk group (e.g. HIV) Y N
l Give low birth weight and premature l HBIG 200 units additionally IM in
babies full neonatal dose of hepatitis B opposite thigh to that of the hepatitis
vaccine B vaccine soon after birth and no later
l Give HBIG and hepatitis B vaccine to than 24 hr simultaneously with vaccine
babies with birth weight <1.5 kg born to babies of highly infectious mothers
to mother with hepatitis B, regardless (see Table above)
of mother’s HBeAg status l 3 further doses of hepatitis B vaccine
will be given according to local policy
l obtain HBIG from regional virus
at aged 1 month, 2 months and 1 yr
laboratory service or local microbiology
as applicable How
l Give hepatitis B vaccine to HIV
l Use 2 separate injection sites for hepatitis
exposed/infected neonates
B vaccine and HBIG, in anterolateral
aspect of the thighs (not buttocks)
When
l Give hepatitis B vaccine IM, except
l Give first immunisation +/- HBIG within in bleeding disorder where it may be
24 hr of delivery on postnatal ward. given deep subcutaneously
Check that arrangements are in place Dose regimen for infants of
for further immunisations and follow-up
mothers with hepatitis B
to be provided in the community or
by paediatrician – see Hepatitis B l Vaccine is given at 0, 1, 2 and 12 months
and C guideline in the Staffordshire, l Book hospital outpatient appointment
Shropshire & Black Country Newborn for 12 months for testing for HBsAg
and Maternity Network Neonatal l see the Staffordshire, Shropshire &
guidelines (if used locally) Black Country Newborn and Maternity
Network Neonatal Hepatitis B and C
What guideline (if used locally)
l Hepatitis B vaccine, 0.5 mL IM. Relationship to other
Caution: brands have different immunisations
doses [e.g. engerix-B® 10 microgram
l No need to delay BCG following HBIG
(recommended), HBVaxPro Paediatric®
5 microgram] l Hepatitis B vaccine may be given with
other vaccines, but use separate site.
If same limb used, give vaccines
>2.5 cm apart
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HEPATITIS • 3/3
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HIGH DEPENDENCY CARE • 2/4
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HIGH DEPENDENCY CARE • 3/4
l Clinical decisions should be made by l If possible keep baby with mother
consultant obstetrician in conjunction l if not, ensure good communication with
with anaesthetist and midwife NNU
l consult specialist relevant to woman’s l promote breast feeding, collection of
specific condition early (need for this colostrum for baby
identified by triennial reports)
l advice from other disciplines should be MONITORING
preferably from consultant or ≥middle
grade obstetrician (ST3–7 or equivalent Observations
e.g. staff grade, clinical fellow)
l Consultant obstetrician and consultant l Undertake observations at frequency
anaesthetist review all women according to guidance for the
receiving level 2 care at least twice underlying diagnosis and document in
daily, and women receiving level 1 care appropriate charts:
at least once a day l temperature
l Inform obstetric and anaesthetic l pulse
consultants early of any changes in l respiratory rate
clinical condition
l oxygen saturations
l Perform detailed handover between
clinicians at the end of each shift l blood pressure
l fluid balance
ON COMMENCEMENT OF HIGH l consciousness level
DEPENDENCY CARE l blood results/arterial gas results
l Formulate a management plan to
include as a minimum: CONSIDERATIONS FOR
l frequency of observations and type of TRANSFER TO CRITICAL
monitoring required CARE AREA
l fluid balance
l When woman requires:
l VTE risk assessment, fit TED stockings
l level 3 critical care or respiratory
unless contraindicated, and analgesia
support
l Pressure injury prevention (Bromage
l level 2 critical care which cannot be
score)
provided on delivery suite
l Monitoring of infusion sites (VIP score)
l level 2 critical care of >1 organ/system
l Treatment of specific condition e.g.
antibiotics, anti-hypertensives l level 2 critical care currently but at a
significant risk of deterioration
l Clearly document handover to and
from maternal critical care l Start intensive care when it is
needed with early involvement of
l Use and complete all HDU
ICU consultant. Do not delay until
documentation
admission to CCU
l Provide and document the following
information given to woman and her Decision to transfer woman to
family: critical care area must be made
l reason for high dependency care by consultant obstetrician and
consultant anaesthetist after
l explanation of procedures, drugs and
discussion with intensive care
care given
specialists
l Duty of candour if required by
consultant in charge of case
l complete incident report
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HIGH DEPENDENCY CARE • 4/4
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HIV POSITIVE WOMEN • 1/3
Check latest version of individualised
MODE OF DELIVERY
maternal care plan
l Women known to be HIV positive will
TESTING have been counselled antenatally and
a plan made for mode of delivery and
l Recommend HIV testing to all pregnant care on delivery suite
women as a routine part of antenatal
screening l Normal vaginal delivery is now
recommended for women:
l if HIV testing declined, offer counselling
by HIV specialist (if available) l with a viral load of <50 copies/mL who
have been treated antenatally with
l do not test without consent, explore highly active antiviral therapy (HAART)
reasons for refusal, promote testing to
improve maternal health and reduce l who are elite controllers (have a viral
vertical transmission and document load of <50 copies/mL untreated)
discussion and who have been on zidovudine
monotherapy (zidovudine IV in labour
l Check HIV test result in notes at every is not required)
visit; if no result available, recommend
retesting. If not done early in l For women with a viral load of
pregnancy, offer at 28 weeks’ gestation 50–400 copies/mL who have been
treated antenatally with HAART,
l If in labour and no HIV test result, consider pre-labour caesarean section
request urgent testing with consent (CS), taking into account:
l actual viral load
ANTENATAL CARE
l trajectory of viral load
l Ensure consultant-led antenatal care in l length of time on treatment
conjunction with HIV physician and, if
available, HIV specialist nurses l adherence issues
l Amniocentesis or chorionic villus l obstetric factors
sampling should only be performed l woman’s views
with antiviral cover l Pre-labour CS is advised for women
l Advise mother not to breastfeed and with:
ensure she has formula and steriliser l a viral load of >50 copies/mL who were
l Ensure stock of zidovudine IV and not taking HAART, including women on
zidovudine, lamivudine and nevirapine zidovudine monotherapy
oral suspensions on labour ward l a viral load of >400 copies/mL for
l See woman’s individualised HIV care those who were taking HAART
plan l women with an unknown viral load
l untreated women
During pregnancy
l Arrange pre-labour CS at 38–39 weeks’
l If an HIV positive woman becomes gestation
acutely unwell in pregnancy liaise with
HIV physicians INTRAVENOUS ZIDOVUDINE
l If a woman taking antiretrovirals FOR DELIVERY
presents with GI upset, fatigue,
fever and breathlessness, check Indications
lactate levels; if raised do not give l Women with a viral load
antiretrovirals and inform HIV team >1,000 copies/mL
l Untreated women with an unknown
viral load
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HIV POSITIVE WOMEN • 2/3
l Women on zidovudine monotherapy.
PRETERM DELIVERY
An alternative for these women is to
continue their oral regime <34 weeks’ gestation
l There is no evidence that intrapartum
zidovudine IV is beneficial for women l In threatened preterm labour or if baby
taking HAART with a viral load of has absent/reversed umbilical artery
<1,000 copies/mL end diastolic flow, if mother’s viral load
>50 copies/mL, administer nevirapine
Medication 200 mg oral once to mother to load
baby who will be unable to take oral
l Start zidovudine IV 4 hr before elective medication after birth
CS (or for as long as possible before l give nevirapine >2 hr before birth if
emergency CS): possible
l prepare an infusion of 2 mg/mL in l Discuss with HIV consultant the use of
glucose 5% double dose tenofovir +/- raltegravir to
l run 1 mL/kg/hr for first hour (for a 70 kg reduce risk of vertical transmission
woman this is 70 mL/hr) l Continue mother’s current antiviral
l after 1 hr, reduce rate to 0.5 mL/kg/hr therapy
(for a 70 kg woman this is 35 mL/hr) l If preterm pre-labour rupture of
l use actual body weight even if >100 kg membranes occurs, on-call consultant
l Stop infusion after cord is clamped obstetrician will weigh the risk of
prematurity and vertical transmission.
Most recent viral load can be helpful
VAGINAL DELIVERY
l if conservative management is chosen
l Manage women with careful infection give erythromycin
control procedures
l There is no contraindication to steroids
l In women for whom intrapartum for mother to reduce risk of RDS in baby
zidovudine IV is indicated, see
Intravenous zidovudine for delivery TERM RUPTURE OF
above. It may be necessary to contact MEMBRANES
on-call pharmacist to ensure adequate
supply of zidovudine l In all cases of term pre-labour
spontaneous rupture of the membranes,
l If pre-labour rupture of membranes
expedite delivery following woman’s
occurs at term, or in any gestation
individual HIV care plan for birth
>34 weeks, commence oxytocin
without delay – see Oxytocin guideline l If indicated in individual care plan,
prepare for CS as soon as the
l If labour is progressing normally, avoid
zidovudine infusion is commenced
amniotomy
at initial rate. Do not wait to complete
l Be vigilant for pyrexia in labour and before delivering baby
have low threshold for antibiotic
l If pre-labour rupture of membranes
therapy
occurs after 34 weeks’ gestation
l Continue oral HAART medication expedite delivery
throughout labour
l Fetal blood sampling and fetal scalp
electrodes are not contraindicated for
woman with viral load <50 copies/mL
taking HAART
l If instrumental delivery required, prefer
low cavity forceps to Ventouse
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HIV POSITIVE WOMEN • 3/3
AFTER DELIVERY
Mother
l Advise woman not to breastfeed
l Prescribe cabergoline 1 mg single
dose first day postpartum to all
mothers to inhibit lactation
l maternal hypertension is a
contraindication
l On postnatal ward, follow infection
control procedures
l woman may need a side ward
l Follow mother’s individualised HIV
care plan with regard to discontinuing
antivirals
l Ensure woman has follow-up with her
HIV physician and team in 2 weeks
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HOME BIRTH • 1/3
l 34–36 weeks’ gestation:
COMMUNICATION WITH WOMAN
l carry out risk assessment and discuss
l Inform woman that: home birth arrangements/birth plan
l giving birth is generally very safe for l 36–37 weeks’ gestation:
both her and her baby
l check and arrange delivery of home
l there is a higher likelihood of a normal birth equipment to woman’s home
birth with less intervention among
l Women must be informed of possible
women who plan to give birth at home
complications during labour and
l there are rare events that, if occurring delivery which may necessitate transfer
at home, may have worse outcome for to hospital via ambulance
mother and baby than if occurring in
l midwife must document in detail that
hospital
discussion has taken place
Midwives undertaking home births If, at any time, woman’s risk category
must be competent in obstetric and changes, appropriate referral must
neonatal emergencies and must be made
attend annual mandatory training
Pethidine
Referral for home birth
l Follow local policy for making pethidine
l On confirmation of pregnancy, woman available
can either refer herself to a community l Midwife checks and administers the
midwife who is attached to a GP injection of pethidine according to NMC
surgery, or ask GP to refer her standards for medicines management
(2008) and NMC Rules and Standards
MANAGEMENT PLAN (2012)
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HOME BIRTH • 3/3
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HYPERTENSION IN PREGNANCY • 1/7
Hypertensive disorders during pregnancy occur in women with pre-existing primary or
secondary chronic hypertension, and in women who develop new-onset hypertension
in the second half of pregnancy (gestational hypertension)
If occurring with significant proteinuria it is termed pre-eclampsia – see
Eclampsia and Severe pre-eclampsia guidelines
Degrees of hypertension
Mild Moderate Severe
Systolic BP 140–149 mmHg Systolic BP 150–159 mmHg Systolic BP ≥160 mmHg
Diastolic BP 90–99 mmHg Diastolic BP 100–109 mmHg Diastolic BP ≥110 mmHg
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HYPERTENSION IN PREGNANCY • 2/7
l Stop angiotensin-converting enzyme
SYMPTOMS AND SIGNS
inhibitors (ACEI) and/or angiotensin
l Advise woman to report any of the II receptor blockers (ARBs) within 2
following to a healthcare professional: days of notification of pregnancy and
offer alternative medication
l headache
l ACEI and ARB carry an increased risk
l visual disturbance (blurring or flashing)
of congenital abnormalities
l pain below ribs
l Limited evidence shows no increased
l sudden swelling of face, hands or feet risk of congenital abnormalities with
l vomiting other antihypertensive treatments but
discuss with healthcare professional
INVESTIGATIONS responsible for managing the
hypertension
l BP and urinalysis on each visit to a
l The antihypertensive medications
healthcare professional
commenced/used in pregnancy are
methyldopa, labetalol and nifedipine
TREATMENT
l Avoid anaemia – see Anaemia in
Antihypertensive treatment and pregnancy guideline
prenatal counselling
l Base antihypertensive treatment on
pre-existing treatment, medication
side-effect profile and risk of
teratogenicity
Intrapartum care
Mild or moderate hypertension Severe hypertension
(BP ≤159/109 mmHg) (BP ≥160/110 mmHg)
l Continue antenatal antihypertensive l Continue antenatal antihypertensive
treatment treatment
l Measure BP hourly l Measure BP continuously
l See Epidural analgesia guideline – l If BP controlled <150 mmHg systolic,
Investigations do not routinely limit duration of second
l If BP stable <150 mmHg systolic, do stage
not routinely limit duration of second l If BP does not respond to initial
stage treatment, advise operative birth
l Measure BP:
Postnatal care
l daily for first 2 days after birth
Antihypertensive treatment l at least once 3–5 days after birth
l Continue antenatal antihypertensive l as clinically indicated if
treatment antihypertensive treatment changed
l If methyldopa was used during l Maintain BP at 140/90 mmHg
pregnancy, stop within 2 days of birth l See Breastfeeding advice for women
due to risk of depression taking antihypertensive medication
l If no antenatal antihypertensive below
treatment was required, commence
antihypertensive treatment only if BP
≥150/100 mmHg
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HYPERTENSION IN PREGNANCY • 3/7
l ACEI other than enalapril and captopril
Follow-up care
l Assess clinical wellbeing of baby,
l At transfer to community care, ensure especially adequacy of feeding, at least
care plan in place, including: daily for first 2 days after delivery
l who will provide follow-up care
(including medical review if required) CHRONIC HYPERTENSION
l frequency of blood pressure monitoring Antihypertensive treatment
l thresholds for reducing or stopping
treatment l See Antihypertensive treatment and
prenatal counselling above
l indications for referral to primary care
l In uncomplicated chronic hypertension,
for blood pressure review
maintain blood pressure at
l If antihypertensive treatment is to <150/100 mmHg
be continued, offer medical review 2 l In target-organ damage secondary
weeks after transfer to community care to chronic hypertension (e.g. kidney
l Offer medical review at 6–8 week disease), maintain BP at
postnatal GP review <140/90 mmHg
l If antihypertensive treatment is to be l Refer pregnant women with secondary
continued after the 6–8 week postnatal chronic hypertension to a specialist in
review, offer a specialist assessment of hypertensive disorders
hypertension
Aspirin therapy
Breastfeeding advice for l 75 mg daily from 12 weeks until delivery
women taking antihypertensive
medication Antenatal care
l If breastfeeding or expressing milk, l Consultant obstetrician as lead
avoid diuretic treatment professional
l Inform woman the following l Plan additional antenatal consultations
antihypertensive drugs have no known according to individual needs of
adverse effects on babies receiving woman and baby
breast milk:
l labetalol
Fetal monitoring
l nifedipine l At 28–30 and 32–34 weeks perform:
l enalapril l ultrasound for fetal growth and
amniotic fluid volume assessment
l captopril
l umbilical artery Doppler velocimetry
l atenolol l If results normal, do not repeat >34
l metoprolol weeks unless clinically indicated
l Inform woman that there is insufficient l If fetal activity abnormal, perform
evidence regarding the safety of babies electronic fetal monitoring – see
receiving breast milk where mother is Electronic fetal monitoring (EFM)
receiving: guideline
l ARBs
l amlodipine
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HYPERTENSION IN PREGNANCY • 5/7
Fetal monitoring
Mild or moderate hypertension Severe hypertension
(BP 140/90–159/109 mmHg) (BP ≥160/110 mmHg)
l If diagnosis confirmed before l At diagnosis, if conservative management
34 weeks, perform: planned, perform:
l ultrasound for fetal growth and l ultrasound for fetal growth, amniotic fluid
amniotic fluid volume assessment volume assessment and umbilical artery
Doppler velocimetry (not >2 weekly)
l umbilical artery Doppler
velocimetry l EFM
l Do not repeat more than weekly if all fetal
l If results normal, do not repeat after
monitoring normal
34 weeks
l Repeat EFM if any of the following:
l If fetal activity abnormal:
l change in fetal movement reported by woman
l EFM l vaginal bleeding
l abdominal pain
l deterioration in maternal condition
l If results of any fetal monitoring abnormal,
inform consultant obstetrician
Intrapartum care
l Mild and moderate hypertension
(140/90–159/109 mmHg)
l See Intrapartum care above
Postnatal care
l See Postnatal care above
Haematological and
biochemical monitoring
l In women who have pre-eclampsia with
mild or moderate hypertension, or after
step-down from critical care:
l measure platelet count, LFT and
serum creatinine 48–72 hr after birth or
step-down
l if results are normal at 48–72 hr, do not
repeat platelet count, transaminases or
serum creatinine measurement
l If biochemical and haematological
indices are improving but stay within
the abnormal range in women with
pre-eclampsia who have given birth,
repeat platelet count, LFT and serum
creatinine measurement as clinically
indicated and at postnatal review
(6–8 weeks after birth)
l If biochemical and haematological
indices are not improving relative to
pregnancy ranges in women with
pre-eclampsia who have given birth,
repeat platelet count, LFT and serum
creatinine measurement as clinically
indicated
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INDUCTION OF LABOUR • 1/5
l History of precipitate labour
DEFINITION
l routine induction of labour to avoid
Artificially initiated uterine contractions unattended birth not recommended
leading to progressive dilatation and
l Macrosomia – in the absence of other
effacement of the cervix and delivery of baby.
indications, other than healthcare
Includes women with intact membranes
suspicion is not an indication for
and those with spontaneous rupture of
induction
membranes but who are not in labour
INDICATIONS PREGNANCY
>42 WEEKS’ GESTATION
Prevention of prolonged
pregnancy (term plus 10–14 days) l Advise women choosing to continue
pregnancy >42 weeks, despite
l Ultrasound at <20 weeks to confirm adequate explanation of risks, to
gestation reduces induction for closely monitor fetal movement pattern
perceived post-term pregnancy
l Refer to obstetric consultant for plan of
l In uncomplicated pregnancies, offer care
induction of labour between term plus
l ultrasound estimation of maximum
7–14 days
amniotic pool depth
l Pre-labour rupture of membranes
(>37 weeks’ gestation) – see l umbilical artery Doppler study
Pre-labour rupture of membranes l electronic fetal monitoring (EFM)
(PROM) at term guideline
l Intrauterine fetal death – see Perinatal METHODS OF INDUCTION
bereavement guideline OF LABOUR
Other (this list is not exhaustive) Membrane sweeping
l Diabetes l Before considering other methods
l Hypertension for induction, offer membrane sweep
l Fetal growth restriction (FGR) according to local practice. This has
been shown to increase probability of
l Antepartum haemorrhage (APH)
labour starting naturally within 48 hr
l Multiple pregnancy
l May be carried out in woman’s home,
l Cholestasis antenatal clinic or hospital
l Previous stillbirth
l Offer nulliparous membrane sweep at
l Breech presentation 40 and 41 weeks
l Previous caesarean section (CS) l Offer parous women membrane sweep
at 41 weeks
Maternal request <41 weeks’
gestation l If labour does not start spontaneously
additional membrane sweeps may be
l Do not offer routinely at maternal offered
request alone Membrane sweep not recommended
l Consider when compelling if membranes have ruptured
psychological or social reasons
>40 weeks. Refer to a consultant clinic
Midwife/doctor will:
CONTRAINDICATIONS
l Provide full explanation of procedure
l Severe FGR with confirmed fetal l Obtain and record consent
compromise (requires LSCS)
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INDUCTION OF LABOUR • 2/5
l Inform woman that membrane sweeping l In nulliparous or multiparous women
is not associated with an increase in with ruptured membranes regardless
maternal or neonatal infection but the of cervical status, prostaglandin
procedure can result in increased levels or oxytocin are equally effective in
of discomfort and bleeding induction of labour
l Provide ‘Induction of labour’ leaflet (if
available locally)
Midwife/doctor will:
l Ensure woman has relevant contact l Provide full explanation of procedure,
telephone numbers including associated risks of
hyperstimulation
MEDICAL INDUCTION
l Obtain and record consent
OF LABOUR
l In nulliparous or multiparous
women with intact membranes with
unfavourable cervix, use prostaglandin
in preference to oxytocin unless
specific clinical contraindications
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INDUCTION OF LABOUR • 4/5
l Obtain and review full history, confirm
gestation and reason for induction and
ANTENATAL MANAGEMENT
carry out: OF PLANNED INDUCTION
OF LABOUR
l abdominal examination to determine
lie and fifths of the head palpable in the (HIGH-RISK PREGNANCIES)
abdomen l Consultant obstetrician will be lead
l fetal heart assessment professional for all cases
l Give woman information regarding l Obstetric medical staff will decide
discomfort associated with procedure place of induction (routine antenatal
and pain relief options wards are not appropriate in certain
l Explain there is no association with circumstances e.g. vaginal birth after
an increase in maternal or neonatal CS)
infection or bleeding l Obstetric medical staff will determine
l Obtain consent and document frequency of maternal
and fetal observations required over
l Perform external EFM for 20 min to
and above those for low-risk pregnancy
confirm fetal wellbeing
l Discuss plan of care with all high-risk
l Assess cervix using Bishop’s score and
women to decide timing and method of
record findings
induction of labour
l Administer prostaglandin as per local
l Provide ‘Induction of labour’
guidance
information leaflet (if available locally)
l Advise woman to remain recumbent for
l Follow procedure in Low-risk
30–60 min
pregnancies
l Provided initial monitoring on
admission is within normal parameters, INDUCTION OF LABOUR WITH
reassess fetal wellbeing: A PREVIOUS CS
l EFM trace of 20 min once contractions
have commenced l The decision to induce a woman with
a previous CS should be made by an
l discontinue EFM after 20 min providing obstetric consultant following a vaginal
fetal heart remains within normal examination. Vaginal examination
parameters is useful in determining method of
l If, at any time throughout the induction
procedure, fetal heart rate is outside l Offer membrane sweeping
normal parameters, continue EFM
and inform middle grade obstetrician l Discuss risks of induction of labour with
(ST3–7 or equivalent e.g. staff grade, woman (e.g. failed induction/repeat
clinical fellow) or consultant CS, scar rupture) and document in
maternal healthcare record
l Encourage woman to mobilise freely,
eat and drink normally, and consider l risk of scar rupture is approximately
using non-pharmacological pain relief/ doubled with ARM and oxytocin and
simple analgesia increased five-fold with prostaglandin. If
both oxytocin and prostaglandin used
Uterine hypercontractility with risk is further increased 9–15 times
prostaglandin l With a relatively low modified Bishop’s
score, consider proceeding directly to
l In the presence of abnormal fetal ARM or use of transcervical catheter
heart rate patterns and uterine induction – see Transcervical catheter
hypercontractility, consider induction guideline
administration of subcutaneous
l Discuss and document individualised
terbutaline 250 microgram
management plan using local proforma
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INDUCTION OF LABOUR • 5/5
l For women with a previous CS
undergoing induction, insert cannula
and take blood for FBC and group and
save
l Inform obstetric anaesthetic middle
grade (ST3–7 or equivalent e.g. staff
grade, clinical fellow)
l EFM continuously from onset of even
mild contractions or any pain until
delivery
l If only indication for induction is
post-term pregnancy, consider
monitoring fetal wellbeing >42 weeks’
gestation
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INFANT FEEDING • 1/12
l Never interrupt skin-to-skin contact
INTRODUCTION
to perform routine procedures (e.g.
l Unless otherwise stated, this guideline weighing baby)
applies to healthy term infants l Where condition of mother or baby
l Where expressed breast milk (EBM) is requires medical intervention, this
mentioned, it refers to mother’s own will take precedence over immediate
EBM skin-to-skin contact
l commence contact once condition of
ANTENATAL PERIOD mother and baby stable
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INFANT FEEDING • 2/12
l When baby showing feeding cues, offer
Breastfed babies
assistance to breastfeed
l Unless it is necessary, for clinical l Early and frequent breastfeeding has
reasons, to separate mother and baby, many benefits including:
mother has primary responsibility l enhances milk supply – the more milk
for baby’s care on postnatal areas. removed from the breast, the more milk
Baby will remain with mother 24 hr/ the mother will produce
day to allow her to recognise feeding
l reduces incidence of physiological
cues (see Responsive feeding) and
jaundice
encourage night-time breastfeeds/
formula feeds l Inform mother that it is acceptable
to wake baby for feeding if her
Do not routinely separate mother and breasts become overfull. Explain the
baby at night whether formula-fed, importance of night-time feeding for
breastfed or delivered by CS milk production
l If mother requests separation from l Length of individual feeds will vary
baby for ‘settling’ by staff, explain considerably. The length of the feed is
the benefits of staying close to baby determined by the rate of milk transfer
and document decision and length from mother to baby. Encourage
of separation in maternal healthcare mother to allow baby to empty the first
record. Return baby to mother as soon breast before offering the second
as baby settles l Babies who are not removed from
the breast but allowed to finish a feed
RESPONSIVE FEEDING spontaneously are more likely to
take the high fat hind milk which will
l Encourage woman to breastfeed not encourage satisfaction and weight gain
only for nutrition, but for comfort and
calming of baby, or if woman has full Formula-fed babies
breasts or needs to rest
l Ensure mother understands the nature l After explaining the avoidance of ‘over
of feeding cues, the importance of feeding’, encourage mothers to feed in
quick response (rather than waiting the same way taking amounts of milk
until baby cries) and is aware of normal that the baby wishes at each feed, and
feeding patterns, including cluster allowing baby to ‘pace’ the feed
feeding and ‘growth spurts’. This is l ensure number of feeders are limited
applicable to breast and formula-fed
babies BREASTFEEDING
l Unless, clinically inappropriate, l Human milk is important in establishing
encourage responsive feeding, enteral nutrition
allowing baby to feed for as long
l To promote optimum health benefits,
and as often as he/she wants. Where
babies should be breastfed exclusively
clinical procedures are necessary, they
until aged 6 months and should
should not interfere with this process
continue to breastfeed until aged 2 yr
l Observation of the sleepy baby (for
l Frequent feeds during the initial period
either method of feeding) is important
will help prevent breast engorgement
to ensure vital signs such as colour,
and encourage a good milk supply
respiration rate, heart rate and
temperature are stable and that there l Midwife or skilled support worker to be
are no signs of hypoglycaemia available during mother’s hospital stay
to assist with breastfeeding
l support should also be available to
mothers who choose to deliver at home
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INFANT FEEDING • 4/12
Assessment of breastfeeding
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INFANT FEEDING • 6/12
l Encourage skin-to-skin contact l Recent cytotoxic chemotherapy
between mother and baby (see l Certain medications – see https://toxnet.
Skin-to-skin contact) nlm.nih.gov/newtoxnet/lactmed.htm
l Encourage responsive feeding from l Active herpes on breast
birth (see Responsive feeding)
l Assist mother to initiate breastfeeding Medical indications when
formula supplementation may
Artificial teats, dummies and be necessary:
nipple shields
l Each baby and situation will be
l Discourage the use of artificial individually assessed. Indications include:
teats or dummies to breastfeeding l low birth weight <1500 g
babies during the establishment of
l metabolic disorders e.g.
breastfeeding. If a breastfed baby
galactosaemia, maple syrup urine
seems unsettled, it is more important
disease, phenylketonuria (PKU)
to assess carefully and, if necessary,
improve mother’s feeding technique l very preterm e.g. <32 weeks’ gestation
l If parents wish to use teats, dummies or l at risk of hypoglycaemia e.g. preterm,
nipple shields, advise that dummies may small for gestational age, intrapartum
have a detrimental effect on breastfeeding stress, illness or maternal diabetes
and lactation. Document discussion and – if blood glucose fails to respond
parent(s) decision in postnatal record to optimal breastfeeding in spite of
l If baby requires additional fluids, give frequent effective suckling
these by cup rather than by bottle l persistent faltering growth/significant
to avoid nipple/teat confusion and weight loss/hypernatraemia
encourage baby to develop correct l breast abscess where there is pus
tongue technique. Offering bottles coming from the nipple
may encourage baby to develop a l See Breastfeeding guideline and
preference for a teat Abstinence syndrome guideline in
l Nipple shields are not recommended the Staffordshire, Shropshire & Black
except in extreme circumstances Country Newborn and Maternity Network
and then only for as short a time as Neonatal guidelines (if used locally)
possible. If used, mother must be
l When breastfeeding is temporarily
supervised by a skilled practitioner
delayed or interrupted, assist mother in
and given assistance to discontinue
establishing and maintaining lactation
use as soon as possible. Explain
e.g. through manual or hand pump
the disadvantages to mother before
expression of milk, in preparation for
commencing use, which may include:
resumption of breastfeeding
l nipple soreness caused by incorrect
positioning and attachment Documentation
l difficulty in improving positioning and
attachment l Record the following in maternal
healthcare record:
l reduced milk transfer to baby
l discussions with parent(s) and
l increased risk of mastitis and breast
informed consent obtained
abscess
l reason for administering supplements,
SUPPLEMENTATION whether for clinical reasons or parents’
request
Medical indications for l supplements used
formula supplementation: l Complete appropriate formula audit
l HIV positive mother – see HIV positive form and send to breastfeeding
women guideline co-ordinator
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INFANT FEEDING • 7/12
Baby has breastfed l low-risk babies can mobilise alternative
fuels like ketones as an energy source
at delivery
in the presence of low glucose
≤6 hr of birth l Encourage mother to express milk
8 times in 24 hr, (including during
l Offer assistance with second the night) and give colostrum, when
breastfeed and document available, via cup or syringe or by
l If baby sleeping or unwilling to feed, try direct expression into baby’s mouth
again in 2 hr, or earlier if baby shows l Stop monitoring temperature,
signs of hunger/wakefulness respirations, heart rate and muscle
tone once baby is feeding regularly
Baby has not fed since birth and neonatal/midwifery staff are happy
with progress
At 4 hr
l Use feeding chart to assess whether
l Check heart rate, temperature, feeding is established for a minimum of
respiration rate, tone, colour and 24 hr
baby’s general appearance again. If l Observe a breastfeed to ensure correct
baby appears well and is still reluctant positioning and attachment and take a
to feed, gently stimulate by: thorough breastfeeding history
l unwrapping l Complete feeding assessment sticker
l resuming skin-to-skin contact in woman’s hand held notes
l gentle massage Reluctance to feed may be the only
l tempt at the breast sign of a sick baby. Consider the
l Encourage mother to hand-express possibility of septicaemia or inborn
colostrum and give via cup/syringe errors of metabolism. Careful clinical
(use of a breast pump is unlikely to surveillance is key to management
obtain any colostrum)
l Review baby 2-hrly and repeat above Amount not increasing
process until baby has successfully l If, after 12 hr, amount of colostrum only
breastfed ‘droplets’, support mother and attempt
l Document all care given on a feeding to allay anxiety, which is helpful in
chart establishing colostrum/milk flow by the
natural release of oxytocin
Baby not taken feed by 12 hr l Increase expressing frequency from 8
l If baby refuses to breastfeed, is unable to 10–12 times in 24 hr to ensure more
to cup feed, or no colostrum available, stimulation of breasts and increased
midwife to assess baby to determine amounts given to baby
whether neonatal referral necessary l explain carefully to mother the rationale
l Midwife/neonatologist and mother will for temporarily increasing expressing
formulate an individualised care plan frequency
l If baby will not accept cup or l Ensure mother is hand-expressing and
small syringe feeds, partnership using the pump effectively and safely
decision-making with neonatal medical l All colostrum expressed must be given
colleagues is recommended to establish to baby
why and agree management plan. l Observe breastfeeding attempts and
Explain suggested care plan to mother encourage skin-to-skin contact as
l If baby is otherwise well and clinical much as possible in a dimly lit quiet
signs are stable, blood glucose testing environment
is not routinely required
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INFANT FEEDING • 8/12
l Complete feed chart until breastfeeding l Continue to express and cup feed
established and record baby’s urine colostrum frequently
and stool output. Report any deviations l Maintain feed chart until breastfeeding
from normal to neonatal medical staff established
l Record plan (agreed with mother,
Breastfed baby ‘sleepy’ or
midwife and neonatal team) in maternal
‘reluctant to feed’ in second healthcare record/neonatal notes
24 hr of life
l Review progress with mother 12-hrly,
l Refer to the neonatal team for ensuring baby has at least 8–12 feeds
assessment in this time period
l Ensure there are no anatomical l Observe wet and dirty nappies
reasons preventing breastfeeding l Consider biological nurturing positions
attachment e.g. cleft palate/tongue tie/
mother’s breast or nipple anatomy
Assessment of output
l Keep baby close to mother –
skin-to-skin contact l At each postnatal visit, enquire about
babies output, together with ongoing
l Provide emotional reassurance and
monitoring by mother
support for mother
l inadequate output (less than that
l Ensure mother understands feeding
specified – see Table below) triggers
cues and is trying at every opportunity
weight assessment and implementation
to breastfeed
of appropriate management plan
l Observe and assess a full breastfeed,
l The following findings are ‘reassuring’
and offer breastfeeding support where
in a breastfed baby. Any deviation from
necessary
this should trigger further assessment
l Avoid teats and dummies
Day 7–28
Age Day 1–2 Day 3–4 Day 5–6 and
beyond
Urine ≥1–2 ≥3
≥6
Number of wet Urates may be Nappies feel ≥5
Heavy
nappies per day present* heavier
Stools ≥1 ≥2 ≥2 ≥2
Number per Dark Change in Yellow At least size
day, colour, green/black colour May be of £2
consistency ‘tarlike’ and consistency quite coin, yellow
(meconium) – brown/green/ watery and watery,
yellow
‘seedy’
becoming looser
appearance
(‘changing stool’)
* Urates are normal bladder discharges in the first few days but persistent urates may
indicate insufficient milk intake
l After 28 days, baby will establish own frequency of passing stools – may pass
several per day or have several days’ gap between
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INFANT FEEDING • 9/12
l always wash hands before removing
FORMULA FEEDING
equipment from the steriliser
Early postnatal period l make a fresh solution every 24 hr
l rinse equipment with cool boiled water
l Encourage mother to hold baby in a
(optional)
calm environment as soon as possible
after delivery – see Skin-to-skin contact
Formula milk preparation/storage
l Explain how mother may obtain help
with feeding while in hospital l Discuss with parent(s) and give leaflets
l Ensure mother is supported with on bottle feeding (if available locally)
feeding until she feels confident l Demonstrate technique in early
l Document formula feeding progress and postnatal period before discharge
all information given on the feeding care home and, if necessary, again in the
plan, and maternal healthcare record home environment. Document in
maternal healthcare record
Sterilising equipment l Wash, rinse and dry hands thoroughly
l Use a clean work surface
l Equipment that is used to store formula
or feed an infant must be kept very clean l Use boiled tap water that has been left
to cool for a few minutes (<30 min – it
l Discuss with parents and offer the
should still be >70°C) – to reduce the
following information:
risk of growth of bacteria found in infant
l wash milk-related feeding equipment formula powder
thoroughly in hot soapy water, using a
l Remind parents not to use bottled
clean brush, inside and out (especially
water due to variable mineral content
the rim) before sterilising, until baby
aged 1 yr l Make up a fresh bottle for each feed,
following preparation instructions on tin
l rinse well in clean water after washing
l check equipment regularly for signs of Storing prepared formula milk
deterioration. If any doubt, throw away increases the risk of bacterial
growth (powdered infant formula
is not sterile)
Technique
l If using cold water sterilisation, rinse
l Boiling (saucepan) – all equipment
feeding equipment with cooled boiled
must be under the water level of the
water (not water straight from tap), or
pan, with no air bubbles trapped inside
shake solution off well
l Do not allow the pan to boil dry
l Fill bottle to required mark – always
l Boil for ≥10 min water first before powder
l Keep pan covered with a lid until l Add powder using only the scoop
equipment is used provided with the tin – level off with
l Steam or microwave sterilisers – a plastic knife or spatula (1 scoop of
follow manufacturer’s instructions powder to 30 mL of water)
l Chemical sterilisation (tablets or fluid) l Place the disc, teat and cap onto
– follow manufacturer’s instructions bottle, and shake well until all powder
l ensure all equipment is under the has dissolved
fluid – with no trapped air bubbles – a l To cool the milk, hold bottle, with cap
plunger or plate can be used to keep covering teat, under cold running
items under water water, or stand in jug of cold water
l leave submersed for ≥30 min or as per l Remind parents to check temperature of
manufacturer’s instructions feed on inner wrist before giving to baby
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INFANT FEEDING • 10/12
l After feeding, throw away any unused
Feeding away from home
milk
l Freshly prepared powdered formula l It is safest to carry a measured amount
milk will keep for 2 hr at room of milk powder in a small clean and dry
temperature, after which time, discard container, a flask of hot water that has
been boiled and an empty sterilised
How to bottle-feed feeding bottle
l Hold baby upright with head supported l Bottle must be cooled before feeding
in a comfortable neutral position (twisted l If the above is not possible, the feed can
neck makes swallowing difficult) be prepared at home and cooled at rear
l To start the feed, brush the teat against of fridge. Take out of fridge before leaving
baby’s lips. Baby will open mouth with home and carry in a cool bag with an
tongue down, which helps draw the ice pack. Use within 4 hr or, if destination
teat in reached within 4 hr, store at rear of fridge
l Keep teat full of milk, to avoid intake of l Never store feeds for >24 hr. It is
air always safer to make up a fresh bottle
l Hold bottle horizontal to the ground, l Ready-to-drink, formula milk is an
tilting just enough to ensure baby is alternative
taking milk Formula-fed baby who is
l Babies feed in bursts of sucking with reluctant to feed
short pauses. In this position the milk
will stop flowing when baby pauses – l Encourage skin-to-skin contact to
allowing baby to rest stimulate feeding cue
l There should be bubbles in the bottle l Offer frequent opportunities to feed
as baby feeds, if not, break the suction l If unwilling to suck from teat – try cup
– you should see bubbles rushing back feeding
into the remaining milk
l small volumes in first 2 days is normal
l Babies may need short breaks during
l Clinically assess baby at 12 hr
the feed and may need to be winded
(colour, tone, behaviour, temperature,
l Discuss responsive feeding – babies respiration, heart rate). If concerns,
may take different amounts at different seek neonatal team assessment
times – and the tin provides a guide only
l If baby not waking for feeds or sucking
l Advise parents not to try to give more milk eagerly at the bottle by 36–48 hr,
at 1 feed in the hope baby will go longer request neonatal team assessment
before needing another feed. If baby is
given more milk than necessary, he/she is l Alternative feeding methods may be
likely to gain too much weight, or be sick required based on clinical indication
l Discuss feeding cues with parents so DISCHARGE AND FOLLOW-UP
that they can recognise when their
baby is hungry and encourage parents Before discharge home
to stay close to baby in order to
recognise these cues Rooming in
l Encourage parents to hold baby close
for feeding, offering eye contact. l Explain and encourage parent(s) to
Skin-to-skin contact can be enjoyed stay close to baby, sharing the same
bedroom at night for first 6 months of
l As with breastfeeding, bottle feeding is a
life
social interaction, not just for delivering
nutrition. Aim to keep number of people l Ensure parent(s) are aware of the
feeding baby to a minimum appropriate age for introducing
complimentary foods
l Never leave baby alone with a bottle
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INFANT FEEDING • 11/12
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INFANT
InfantFEEDING
feeding 201719• 12/12
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INTERMITTENT AUSCULTATION • 1/2
DEFINITION Fetal
l The interval monitoring of fetal heart l Intrauterine growth restriction/abnormal
using Doppler ultrasound or Pinard to Doppler
assess fetal wellbeing in labour l Macrosomia
l Prematurity <37 weeks’ gestation
Who
l Oligohydramnios/polyhydramnios
l Advise low-risk women to have l Multiple pregnancy
baby’s heart monitored by intermittent
auscultation l Abnormal presentation
l Risk factors below indicate the woman l High (4/5–5/5 palpable) or free floating
is not low-risk head in nulliparous woman
l If risk factors present or structured l Iso-immunisation
intermittent auscultation not possible, l Non-reassuring antenatal EFM
use continuous electronic fetal l Reduced fetal movements in last 24 hr
monitoring (EFM) – see Electronic
l Abnormality on auscultation (abnormal
fetal monitoring guideline
baseline, decelerations)
Contraindications
How
Maternal l Start intermittent auscultation as
l Previous caesarean section/uterine soon as established labour has been
scar diagnosed
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INTERMITTENT AUSCULTATION • 2/2
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LABOUR MANAGEMENT
(including clinical risk assessment) • 1/4
DEFINITION
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LABOUR MANAGEMENT
(including clinical risk assessment) • 2/4
l examination
Fetal wellbeing
l observations
l Auscultate fetal heart rate (FHR) for a
l current complaint
minimum of 1 full minute immediately
after a contraction Identified risks
l Ask about fetal movements in last 24 hr
l To minimise risk to mother and baby,
l Palpate maternal pulse rate to instigate a management plan for each
differentiate between maternal and FHR risk identified
l If there is a clinical indication, perform l If risk is such that midwifery-led care
electronic fetal monitoring (EFM) – see is no longer appropriate, discuss with
Electronic fetal monitoring guideline middle grade obstetrician (ST3–7 or
equivalent e.g. staff grade, clinical fellow)
Blood and blood products
and transfer care to obstetric team
l If not already done, ask woman if she l Advice for management can also be
is prepared to accept blood or blood obtained from resident anaesthetist
products – see Refusing blood and
blood products guideline Assess risk status continuously and
change management plan accordingly
Thromboembolism
Documentation and handover
l Carry out VTE risk assessment using
local protocol l Document risk assessment clearly in
maternal healthcare record
Communication and l Ensure thorough face-to-face verbal
documentation handover between midwives and
document (including identified risks) using
l Document findings of assessments
appropriate structured handover tool
l Discuss findings, birth plan and
l Repeat risk assessment at handover
analgesia with woman/and her partner
of care from each midwifery shift and
CLINICAL RISK ASSESSMENT document any supplementary risks
identified
l Must be performed in all women by a
midwife in all clinical settings, whether FIRST STAGE OF LABOUR
in maternity unit or at home
Observations and
l Once labour diagnosed, complete
intrapartum risk assessment and
assessment during first stage
devise individualised management plan l As a minimum, perform and document
l If an obstetrician is involved in the following on partogram at frequencies
woman’s care, he/she should repeat indicated, unless other clinical reasons to
risk assessment document more frequently:
l temperature: 4-hrly
Full risk assessment
l blood pressure: 4-hrly
l Determine level of risk based on: l maternal pulse: hourly
l medical comorbidity l abdominal palpation followed by
l anaesthetic history vaginal assessment: 4-hrly
l previous obstetric history l frequency of contractions: every 30 min
l lifestyle history l frequency of bladder emptying (test
and measure amount voided) – see
l any concerns with this pregnancy e.g.
Bladder care guideline
IUGR
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LABOUR MANAGEMENT
(including clinical risk assessment) • 3/4
l If not EFM, auscultate fetal heart
Position and mobility
rate for ≥1 full minute every 15 min
following a contraction l An upright position during labour
l If FHR abnormality suspected, palpate facilitates efficient uterine contractions,
maternal pulse to differentiate – see shortens latent phase and reduces
Electronic fetal monitoring guideline need for analgesia
l Once in established labour, complete l Encourage mobilisation
partogram l Allow woman to adopt a position she is
l VE: 4-hrly comfortable with
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LABOUR MANAGEMENT
(including clinical risk assessment) • 4/4
Fetal observations
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LATENT PHASE OF LABOUR • 1/2
l if contact is from woman’s support
INTRODUCTION
person, advise him/her that it would be
l Latent phase of labour is a normal more appropriate for midwife to speak
process during which dynamic to the woman directly
physiological and emotional changes l In order that advice and reassurance
(unique to each woman) occur. It is can be based on individual need,
vital that healthcare professionals obtain a detailed history
caring for women in the latent phase
l Document discussions, information
of labour appreciate this physical and
and advice given
psychological process
l retain a record for future reference if
l This guideline is applicable to women
woman makes contact again regarding
expecting a vaginal birth 37–42 weeks’
her labour
gestation
l Midwife must exercise professional
DEFINITION judgement when diagnosing latent
phase of labour
l Onset of short, mild, irregular
contractions that soften, efface and Action
begin to dilate the cervix from 0–4 cm.
Average duration is poorly understood l If appropriate, encourage woman to
stay at home and continue normal daily
ANTENATAL ADVICE activities, light diet and plenty of fluids,
ideally with company, but to make
l Midwife will discuss process of further contact if her needs change or
latent phase of labour with woman she requires midwife support
in antenatal period <37 weeks’ l Advise about pain relief strategies (see
gestation, providing her with a realistic below)
understanding of what to expect
l On the third telephone assessment
l Include this topic in parent education made by a midwife, arrange for woman
classes and, if available locally, provide to attend maternity unit for full maternal
woman with an information leaflet and fetal assessment and plan of care
l Provide woman and her birth partner(s) After 3 telephone assessments,
with information about the type of midwife must see woman
support available during the latent
phase of labour
l When developing birth plan, discuss Assessment on admission
coping strategies, as anxiety can l See Labour management guideline
impact on the effectiveness of other
l Midwife should undertake a full
relaxation techniques
assessment, taking into consideration
the woman’s reactions to the
MANAGEMENT physiological and emotional changes
Telephone assessment
Vaginal examination
l Most women who feel they are in
labour make their first contact with l Following discussion with woman,
midwife by telephone, in order to seek consider need for vaginal examination
help and advice. This first contact is l if, after examination, it is decided
an important initial assessment, and woman is not in active labour,
it is preferable for a midwife to speak encourage her to go home with advice
directly with the woman about when and who to contact
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LATENT PHASE OF LABOUR • 2/2
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MATERNAL DEATH • 1/2
BACKGROUND Equipment
l Safe transfer or retrieval of a woman from l Ensure accompanying equipment
one clinical care setting to another to functioning with charged batteries
provide care in specialist area or centre l Supply sufficient drugs and fluids for
l Transfers may be made for maternal entire journey
or neonatal reasons and can occur at l Secure lines (e.g. IV, CVP, urinary
any stage of antenatal, intrapartum or catheter)
postnatal period
l It may be necessary to transfer between Woman
community and hospital or from one
hospital to another (e.g. where specific l Explain reason for transfer to woman
maternal/neonatal facilities are required) and partner and document discussion
in healthcare record
This guideline covers l Obtain and record consent (where able)
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MATERNAL TRANSFER
(INCLUDING IN-UTERO TRANSFER) • 4/4
Procedure
l Ensure ongoing consideration of
maternal and fetal condition throughout
the transfer process, looking for
any deterioration in maternal/fetal
wellbeing. Follow your local Trust
in-utero transfer guideline
l It is good practice to ensure woman
receives appropriate follow-up
POSTNATAL TRANSFER
l If transferring woman alone postnatally,
midwife will discharge baby to the care
of woman’s partner/relatives
l If unable to discharge baby to family,
arrange care as per local policy (e.g. as
lodger on special care baby unit)
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MECONIUM STAINED LIQUOR • 1/2
l Take umbilical cord sample – see
BACKGROUND
Umbilical cord sampling guideline
l Meconium stained liquor occurs in l Report meconium change from light to
10–20% of deliveries, increasing to over significant to middle grade obstetrician
30% after 42 weeks’ gestation (ST3–7 or equivalent e.g. staff grade,
l Meconium aspiration syndrome clinical fellow)
occurs in 2–5% of babies born through
meconium stained liquor
RESUSCITATION OF BABIES
BORN FROM MECONIUM
l Significant meconium at onset of
STAINED LIQUOR
labour carries the worst prognosis and
is associated with five to seven-fold Ensure resuscitation equipment is
increased risk of perinatal death checked and ready for use before
delivery
DEFINITION
In the presence of any degree
Significant of meconium:
l Dark green or black amniotic fluid that l Do not suction baby’s upper airways:
is thick or tenacious or any meconium l before birth of shoulders and trunk
stained amniotic fluid containing lumps l if baby has normal respiration, heart
of meconium rate and tone
l Do not intubate if baby has normal
Light respiration, heart rate and tone
l Staining of lesser severity l Tracheal intubation should not be
routine in presence of meconium,
MANAGEMENT and should only be performed for
suspected tracheal obstruction
l Unless birth imminent, transfer l Emphasis should be on initiating lung
from low-risk setting to care of an inflation within first minute of life in
obstetrician as per local protocol non-breathing or ineffectively breathing
l If woman is not in labour and thick infants, and this should not be delayed
meconium is present, arrange l If baby does not have normal
induction of labour respiration, heart rate and tone, follow
l Continuous electronic fetal monitoring nationally accredited guidelines on
(EFM) is advised for women with neonatal resuscitation, including early
significant meconium stained liquor – laryngoscopy and suction under direct
see Electronic fetal monitoring (EFM) vision
- Labour guideline l Obtain arterial and venous cord blood
to assess pH and blood gases – see
In labour Umbilical cord sampling guideline.
Record values in maternal healthcare
l Whatever the degree or time of passage record and, if local practice, in neonatal
of meconium, fetal risks are increased notes
l Document the presence or absence of l In the presence of significant meconium,
significant meconium or light with other fetal risk factors:
l If fetal heart rate abnormalities also l ensure that neonatologist/advanced
present, perform fetal blood sampling – nurse practitioner is available at birth
see Fetal blood sampling guideline l if baby is floppy and apnoeic and born
through thick particulate meconium it
l When delivery imminent, call neonatal
is reasonable to inspect oropharynx
team according to local practice
rapidly to remove potential obstructions
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MECONIUM STAINED LIQUOR • 2/2
Active baby
l If baby crying and active at birth:
l dry and cover to avoid hypothermia
l do not aspirate airways
l neonatologist does not inspect larynx
or aspirate trachea (unnecessary
intubation and lower airway suction
does more harm than good)
Floppy baby
l If baby floppy, pale and makes no
immediate respiratory effort at birth, call
neonatal team (if not already present)
and commence neonatal resuscitation
– see Cardiopulmonary resuscitation
of the newborn guideline (Airway) or
follow local guidance
Postnatal observations
l For any baby delivered with a history
of significant meconium, perform the
following observations at aged 1 and
2 hr and then 2-hrly until aged 12 hr
or as per local policy. Document in
neonatal observations chart:
l general wellbeing
l chest movement and nasal flare
l skin colour including perfusion by
capillary refill
l feeding
l muscle tone
l temperature
l heart rate and respiration
l If light meconium staining occurred,
observations for baby as above at aged
1 and 2 hr and document in neonatal
observations chart
l If baby’s condition causes concern at
any time, review by neonatologist
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MEDICAL TERMINATION OF PREGNANCY FOR FETAL
ABNORMALITY AND FETOCIDE • 1/2
l Provide contact telephone numbers
PROCEDURE
with instructions to call if she has any
l Obtain written informed consent, concerns while at home. Give patient
together with written agreement of 2 information leaflet, if available locally
certified medical practitioners who have
signed HSA1 form (Abortion Act 1967 Further drug regimen
revised 1991)
l No more than 24–72 hr after initial
l Guidance from Royal College of dose of mifepristone 200 mg oral, give
Obstetricians and Gynaecologists misoprostol:
on termination of pregnancy for fetal
abnormality stresses that a legal l <27 weeks’ gestation: 100 microgram
abortion ‘must not be allowed to result vaginally 6-hrly – maximum 4 doses
in a live birth’. Therefore, method of l ≥27 weeks’ gestation:
termination of pregnancy >21 weeks, 25–50 microgram vaginally 4-hrly –
should ensure fetus is born dead maximum 6 doses
l Where termination is planned >21+6 In previous caesarean section
weeks for abnormalities that are not (CS) or uterine surgery, where the
lethal, consultant in fetal medicine must cavity has been breached (e.g.
discuss fetocide with woman myomectomy, uterine perforation)
l If woman refuses fetocide, document use 25–50 microgram dosage
clearly in maternal health care records
that it has been offered and declined
Side effects/complications
l Inform women that even before cut off associated with misoprostol
of 21+6 weeks there is a chance the
baby may show signs of life l Pyrexia
l this does not mean the baby will l Diarrhoea
survive l Retained placenta
l the baby then needs to be registered l Hypovolaemic shock
as a neonatal death
l Ruptured uterus
Pre-termination assessment
l Carried out by trained staff who will
provide counselling and support
l Obtain informed consent
l Perform ultrasound scan immediately
before procedure to confirm presence
of fetal abnormalities and select
suitable site for needle entry
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MENTAL HEALTH IN PREGNANCY • 1/12
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MENTAL HEALTH IN PREGNANCY • 2/12
l If she has violent thoughts, plans, PREVENTION, DETECTION AND
images or impulses keep her and
INITIAL MANAGEMENT
her baby/children safe – see Acute
concerns below l Women at increased risk of postnatal
l Times of high suicide risk: mental illness are those who:
l conclusion safeguarding meetings l develop mental health problems during
this pregnancy
l removal of baby
l have previous history of postnatal
depression
Acute concerns
l with severe and enduring mental illness
l If the woman is at risk of harming herself/
others, ensure she is accompanied and At booking
kept in a safe environment
l In hospital: may be appropriate to call All women
police and/or hospital security staff,
particularly if: l Ask about mental health problems
using standard questions e.g. do you
l large number of people to control have a history of:
l area needs to be cordoned off l past/present mental illness?
l In community: call police, who will take l previous treatment/inpatient care?
woman to a place of safety and request
police surgeon to assess mental health l family history in first degree relative?
l Under common law it is reasonable l Consider asking about anxiety using
to use reasonable force to prevent a the 2-item Generalized Anxiety Disorder
person harming themselves, e.g. trying scale (GAD-2). Over the last 2 weeks,
to jump out of window how often have you been bothered by:
l Doctors can apply section 5(ii) of the l feeling nervous, anxious or on edge?
Mental Health Act (1983) to detain l not being able to stop or control
woman for ≤72 hr worrying?
l If woman is suffering from mental l Document responses in woman’s
illness/lacks capacity physical restraint healthcare record
can be used l If history of previous mental health
l must be proportionate to situation problems established see below
l large bean bag/pillow is ideal
History of severe postnatal
l If the woman is risk to herself/
depression/psychosis
others consider rapid sedation (e.g.
haloperidol 10 mg IM) l Midwife to obtain mental illness history/
l contact obstetric anaesthetist for advice relevant social information from GP
record
l if rapid sedation administered observe
woman for several hours for respiratory l do not rely on the woman’s history
depression, most appropriately alone
achieved where enhanced maternity l Women who have suffered puerperal
care is provided. Monitoring: psychosis have a 50% risk of
– oxygen saturation recurrence
– BP l should be cared for by local perinatal
mental health service or
– ECG
l booked under care of consultant
– RR
obstetrician with an interest in mental
– conscious level and airway assessment health disorders or
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MENTAL HEALTH IN PREGNANCY • 3/12
l receive consultant-led care supported l At each postnatal contact ask women
by an appropriate midwife or midwifery about their emotional wellbeing,
team support systems and coping strategies
l If woman currently under care of l use above questions
community mental health team, refer to l encourage women and their families
named care co-ordinator – otherwise, to tell midwife about changes in mood/
refer to relevant community mental emotional state/behaviour
health team to plan postnatal care
l Recognise that women with a mental
health problem may be unwilling to
History of less severe
disclose/discuss their problem because
postnatal depression of:
l Discuss with woman, partner and l fear of stigma
family:
l negative perceptions of them as a
l recognition of symptoms of depression mother
l need to contact GP early l fear that their baby might be taken into
l Encourage: care
l gentle exercise l Avoidance may be associated with
l resting when necessary mental health problem or related to
drug/alcohol dependence
l obtaining help with baby care
l If concern about woman’s mental
l talking to someone about feelings and health, refer to GP/mental health
access to social support networks service for further management
l Consider enhanced schedule of visits
in first 2 weeks Treatment
l 50% of women who become psychotic
do so by day 7, and 75% by day 16 Women at increased risk of suicide are
characteristically white, older women
Detecting current concerns who may be socially advantaged
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MENTAL HEALTH IN PREGNANCY • 6/12
l Use minimal effective dose of drug with l Possibility of sudden onset of symptoms
best evidence base particularly in early puerperium
l If possible avoid polytherapy
When a woman with mental
l If woman has mental health problems
and been under sole care of GP, ask GP illness decides to stop
to review need to continue medication medication discuss:
l Direct communication between mental l Her reasons
health services and obstetric services is l Possibility of:
essential for some women
l restarting
l When talking to the woman about her
medication, explain all women are at l switching to another medication
risk of having a baby with a congenital l psychological intervention
abnormality l Increasing level of monitoring and
l 2–4 in 100 in general population – support
describe risk simply: e.g. 1 in 100 l Ensure she knows risk to herself and
rather than 1% and 1 in 4, not 25 in 100 the fetus/baby of stopping medication
l if possible give written information and l Risk of discontinuation symptoms in
use visual aids woman and baby with most tricyclic
l See Common mental health drugs antidepressants, selective serotonin
and pregnancy below reuptake inhibitor (SSRI) and serotonin
l Complete neonatal alert if required norepinephrine reuptake inhibitor
(SNRI)
l Strongly advise anomaly scan if required
l If a woman has taken medication Eating disorders
with known teratogenic risk in the first
trimester: l Most women with eating disorders
improve during pregnancy but may
l confirm gestation
relapse/develop postnatal depressive
l sensitively explain that stopping symptoms
medication may not remove risk to baby
l Perform GTT at 26–28 weeks’
l offer detailed ultrasound with fetal gestation, due to increased risk of
medicine consultant gestational diabetes
l explain risk to baby if she continues the
medication, balancing against risk of Child protection
discontinuing – see Deciding whether
to stop medication l If concerns about unborn child’s
wellbeing, follow routine safeguarding
Deciding whether to stop procedures
medication l Have a low threshold for referring
women with schizophrenia for
l Severity of mental health problem safeguarding of their unborn child
l Likely benefit treatment options l Some women avoid maternity care
l Previous response to treatment because of concerns about removal
l Background risk of harm to woman, of their child. Extra vigilance and
fetus and baby with no treatment support is required around time of case
conferences and afterwards, especially
l Risk to mental health and parenting
if recommendation is for removal of the
with no treatment
child
l What might happen if medication is
stopped abruptly
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MENTAL HEALTH IN PREGNANCY • 7/12
l For complex cases, community mental
Missed appointments
health team will, after discussion with
l If woman with severe and enduring the woman and partner, forward mental
mental health problems misses health joint care plan
appointment: l If direct discussion between obstetric
l make contact to ensure she is well and community mental health teams
required, to include:
l if concerned about her mental health,
contact named mental health care l non-routine action required on admission
co-ordinator (identified on booking in labour and before discharge
letter) by phone, to allow earlier l crisis plan
follow-up by community mental health
l early relapse signs
team
l schedule of monitoring in community
Smoking l roles of professional; who co-ordinates
plan and agrees outcomes with woman
l Offer smoking cessation
l Co-ordinator must ensure:
l success rates equal to those for
l interventions occur promptly
general population
l effective information sharing
Physical symptoms l Share specific plan for delivery with
woman, her family, community midwife,
Women with mental health problems mental health team (in particular
can have serious physical illness. Do named care co-ordinator) and hospital
not assume that all symptoms are obstetric team
attributable to a mental health disorder l clearly display plan in woman’s
healthcare record
Childhood sex abuse l Inform GP of planned postnatal mental
health support
l See Sensitive practice below
l Obstetric team to inform relevant
l If woman discloses a history of sexual
community mental health team
abuse, a careful birth plan is required
consultant secretary when woman
l When discussing labour, it is important delivers, to allow plan to be
to carefully explain: implemented
l what a vaginal examination is and why
it is necessary Contraception
l not all women will achieve normal l Attempt to establish plan for postnatal
vaginal delivery and operative delivery contraception during pregnancy
may be necessary
l discuss various methods of analgesia Breastfeeding and neonatal care
Individual management plan for l Encourage women with a mental health
delivery and puerperium problem to breastfeed, unless they are
taking carbamezepine, clonazepam or
l Devise clear individual management
lithium. Valproate is not recommended
plan for pregnancy, labour and
to treat a mental health problem in
immediate postnatal period
women of child bearing potential
l for most women this happens at birth
l Support each woman in her choice of
planning antenatal appointment
feeding method
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MENTAL HEALTH IN PREGNANCY • 8/12
l When assessing risks and benefits of
antidepressants take into account:
l limited data about the safety of these
drugs
l risk of switching from a previously
effective medication
l When assessing risks and benefits of
antipsychotic medication, take into
account:
l limited data on the safety of these
medications
l level of antipsychotic medication in
breast milk depends on drug
l extra caution may be required with
premature, small or sick infant
l If necessary seek advice from
pharmacist, infant feeding specialist
midwife or local perinatal mental health
service
l If the woman takes psychotropic
medication while breastfeeding,
monitor baby for adverse effects
l Discuss risk of maternal sedation with
the woman
l advise women receiving mental health
medication not to share bed with baby
Postnatal care
l Community mental health team to
arrange enhanced support in postnatal
period
l At each postnatal contact, ask woman
about her emotional wellbeing, support
systems and coping strategies
l Encourage woman and family to inform
midwife about changes in mood/
emotional state/behaviour
l If concerns community midwife will
contact named care co-ordinator
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Table 2 (contact pharmacy for information for drugs not included) cont.
St John’s wort
l Neonatal colic, lethargy and Avoid if possible
difficult breastfeeding Neonatal alert
l Uterotonic activity
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Table 2 (contact pharmacy for information for drugs not included) cont.
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MENTAL HEALTH IN PREGNANCY • 12/12
SENSITIVE PRACTICE
l A disproportionate number of women
with mental health problems have
suffered childhood sexual abuse
l Treat all women with the highest
standards of care
l Give woman as much sense of
safety/control/respect as possible. In
particular:
l ask her choice of name
l do not use endearments e.g. love,
dear, good girl
l do not ask intrusive questions about
her past
l avoid touch – respect personal space
l obtain history before asking her to
remove any clothing
l explain relevance of enquiries
l ensure privacy for dressing/undressing
and ask permission to re-enter
l offer a cover for modesty
l ensure she understands she can
ask you to slow down/pause during
physical examination
l ask if she is comfortable and ready to
continue when moving from one part of
body to next
l be aware of body language indicating
discomfort
l before moving to another part of body,
tell the woman and explain why
l ensure doors are closed and no one
enters room
l avoid delay – be prepared e.g. have all
equipment ready
l explain equipment used
l do not assume because consent is
given at 1 assessment it will be given
for another
l see the woman fully dressed after each
appointment to reinforce that you see
her as a whole person
l monitor her body language and
sympathetically address apparent
discrepancies between verbal and
non-verbal responses
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MORBIDLY ADHERENT PLACENTA • 1/2
l Discuss the risk of hysterectomy
DEFINITION
l Re-check haemoglobin >32 weeks’
l Placenta adheres to or invades the gestation and, if anaemic, prescribe
myometrium oral iron
l Refer woman to an obstetric anaesthetist
Increased incidence
l If placenta is located over a previous Advice to woman
scar
l If appropriate, inform woman and
l With increasing number of caesarean her partner about the risk of major
sections (CS) haemorrhage and advise to:
l Following myomectomy l avoid sexual intercourse for the
l If previous manual removal of placenta remainder of the pregnancy
from the same placental site l contact maternity triage to attend
Morbidly adherent placenta carries hospital immediately if any vaginal
an increased risk of mortality due to blood loss, contractions, pain or
massive obstetric haemorrhage at suprapubic period-like aches
delivery l ensure someone available at home who
can help and take to hospital if necessary
ANTENATAL CARE
ELECTIVE DELIVERY
l Advise ultrasound scan at 20 weeks’
gestation to determine placental site l Schedule elective CS at 36–37 weeks’
l if scan reveals a low or anterior gestation
placenta with a history of previous CS, l Give antenatal steroids to reduce risk
further ultrasound scan at 32 weeks’ of respiratory distress syndrome
gestation to identify distance from
l Multidisciplinary planning involving
lower edge of the placenta to cervical
consultant obstetrician, consultant
os and determine whether the placenta
anaesthetist and haematologist
overlies the old scar
l Ensure 4–6 units of packed red blood
l report signs of invasion of the scar by
cells available in delivery suite blood
placental tissue
fridge on morning of procedure and
l a colour-flow Doppler ultrasound senior haematologist available for
scan performed by an experienced advice
sonographer is the first line diagnostic
l Experienced neonatologist to be
test
present at birth
l Where the placenta lies over the old
l A scan on morning of procedure may
scar, or in placenta praevia, consultant
be useful in mapping placental site
obstetrician will discuss with woman
(and her partner if appropriate) l Where there is high probability of a
and plan antenatal care including morbidly adherent placenta it may
further imaging and multidisciplinary be appropriate to liaise with an
preparation and delivery interventional radiologist if available
locally
l MRI scan, arranged with a consultant
radiologist, can aid diagnosis and l may be appropriate to insert balloons
clarify depth of invasion in the femoral arteries before
procedure as a prophylactic measure
l Since up to 40% of cases are likely to
for inflation in the event of postpartum
require emergency delivery, place a
haemorrhage. Particularly appropriate
clear care plan in woman’s healthcare
for women who will not consent to a
record and hand-held notes
blood transfusion
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MORBIDLY ADHERENT PLACENTA • 2/2
l Set up cell salvage if used routinely, or l there is reduced need for transfusion
arrange a perfusionist to facilitate cell if no attempt is made to remove the
salvage if required placenta both before hysterectomy and
l Ensure local availability of enhanced before leaving placenta in situ
maternity care after surgery l If plan of care is to manage the
placenta in situ conservatively, unclamp
Consent the cord and drain the placenta of
blood before tying off and dividing the
l Must be taken by a consultant cord as close to its insertion into the
obstetrician who will discuss blood placenta as surgically practicable
transfusion, hysterectomy, admission
l Close the uterus in the routine way or
to critical care and the possibility of
proceed directly to hysterectomy
leaving the placenta in place. It will
include routine consent for CS l If the placenta separates, partially
adherent portion(s) can be left in place.
l If placenta left in situ – pregnancies
Heavy blood loss can occur – see
have been reported after this approach
Postpartum haemorrhage guideline
but so have cases of delayed
haemorrhage and hysterectomy
Postnatal care
Procedure l Provide enhanced maternity care after
delivery. Do not transfer to postnatal
l Consultant obstetric anaesthetist will
ward for ≥2 hr after delivery
determine and administer type of
anaesthetic l Regularly assess uterine fundus
and observe carefully for signs of
l Consultant obstetrician must perform
haemorrhage. Where a placenta totally
CS
covering the cervical os is left in situ, it
l It may be appropriate to open the lower can conceal bleeding within the uterine
segment of the uterus, thus leaving cavity. In this situation, woman should
a lower segment scar only. However, remain on delivery suite for 24 hr
it may be appropriate to access the
uterine cavity deliberately avoiding Management when placenta left
the placenta. This requires knowledge in situ postnatally
of the limits of the placental site. This
approach allows an assessment of l Carries risk of infection and
placental adherence without heavy delayed haemorrhage. Ensure
bleeding before a definitive decision is woman understands the need for
made a commitment to hospital visits for
l If the placenta separates, the operation clinical checks, blood tests and
continues as normal possibly imaging
RISKS Communication
Multiple pregnancy is associated with l Discuss plan of care with parents
higher risks of adverse outcomes for l Provide psychological support and,
mother and babies where possible, written information and
contact details of multiple pregnancy
Maternal support groups
l Miscarriage
Plan of care (in addition to
l Anaemia routine antenatal care)
l Placenta praevia
l Undertake FBC at 20–24 weeks’
l Hypertensive disorders gestation and have low threshold for
l Haemorrhage iron and folic acid supplementation
l Operative delivery l Offer first trimester combined Down
l Postnatal illness syndrome screening
l Maternal mortality associated with l Offer second trimester screening with
multiple births is 2.5 x that for singleton appropriate counselling
births l At each antenatal examination
>24 weeks’ gestation, confirm
Fetal/baby presence of 2 fetal hearts using Pinard
stethoscope, sonic aid or ultrasound
l Small for gestational age scan
l Congenital malformation l If woman has ≥1 of the following
l Cerebral palsy (4 x higher) hypertension risk factors, advise to take
l Birth asphyxia higher for second twin, 75 mg of aspirin daily from 12 weeks
usually occurs after delivery of first twin until birth:
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MULTIPLE PREGNANCY • 3/3
l Insert IV cannula and flush l Continuous electronic fetal monitoring
l Take blood for FBC and group and l Determine presentation and lie
save l Monitor vaginal loss
l Review obstetric records, fetal l Perform abdominal palpation to
presentation and plan for delivery determine presentation. At the same
l discuss plan of care with parents and time, perform a vaginal examination –
document in maternal healthcare record preferably by middle grade obstetrician
l While respecting woman’s choice, (ST3–7 or equivalent e.g. staff grade,
encourage her to use epidural analgesia clinical fellow) or consultant to allow
to facilitate delivery in the event of internal interventions, if appropriate, without
manoeuvres or urgent instrumental repeat examination
delivery becoming necessary l where second twin was not cephalic
l If oxytocin required to accelerate in first stage of labour, it may be
labour [prescribed by middle grade appropriate to deliver the woman
obstetrician (ST3–7 or equivalent e.g. in lithotomy to allow rapid vaginal
staff grade, clinical fellow) or consultant examination of second twin and
only], use with caution perform interventions as required
l Stabilise second twin as longitudinal lie
Second stage of labour l Prepare ultrasound machine in case
required to confirm position of second
Ensure twin
l Experienced obstetric consultant, l If necessary, perform external cephalic
middle grade obstetrician (ST3–7 or version
equivalent e.g. staff grade, clinical l If necessary, perform internal podalic
fellow), neonatology team and midwives version and breech extraction before
are present in room at delivery cervix can shrink
l Appropriate equipment, including: l If any delay in resumption of effective
l ultrasound machine uterine contractions, start oxytocin
infusion according to local practice at
l resuscitation equipment
maximum rate
l Anaesthetist and theatre team on
l If vertex or breech in pelvis, perform
standby on labour ward
artificial rupture of membranes at peak
l In the case of CS, 1 midwife per baby of contraction
is designated to receive the babies
l After delivery of second twin, place 2
l Oxytocin as per local practice clamps on umbilical cord
l If all normal, midwife will carry out
delivery, otherwise middle grade Active management of third
obstetrician (ST3–7 or equivalent e.g. stage of labour
staff grade, clinical fellow) or consultant
will perform l Routine active management third
stage, see Third stage of labour
l Deliver twin 1 and place 1 clamp on guideline. In addition:
umbilical cord
l oxytocin infusion as per local practice
Delivery of second twin l cord gases
l because of risk of haemorrhage, avoid
l Aim to deliver second twin ≤30 min
too rapid transfer to postnatal ward
l risk for second twin increases steeply
as time passes from delivery of first
twin
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NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR
ANALGESIA • 1/4
l Reconsider the use of large volumes
INTRODUCTION
for epidurals in the presence of spinal
l Neurological deficits after regional stenosis
anaesthesia or analgesia: l Chlorhexidine 0.5% in alcohol spray is
l can be temporary or permanent the skin preparation of choice
l have a variety aetiologies; caused l single spray is adequate
directly/indirectly l allow to dry completely
l Advise women about the risks, l do not splash chlorhexidine on spinal
including neurological deficit, before or epidural needles
administrating regional anaesthesia or
l If, on performing central nerve blockade
analgesia
(CNB), there are recurrent, persistent,
bilateral or severe symptoms of
PRE-EXISTING NEUROLOGICAL dysaesthesia, reconsider further attempts
DEFICITS
l Prevent prolonged periods of
l May increase risk of new and hypotensive episodes to maintain
progressive post-operative neurological spinal cord perfusion
complications l Follow local guidance for regional
l Risk-benefit assessment to be carried blocks and regional anaesthesia for the
out in women with: anticoagulated woman
l pre-existing central nervous system l Avoid neuroaxial procedures in the
(CNS) disorders: e.g. multiple sclerosis septic woman (discuss with on-call
l diabetes mellitus consultant anaesthetist) or in the
presence of localised infection
l spinal stenosis or mass in spinal canal
l When topping up with heavy
l extremes of body habitus
concentration of local anaesthetic,
position the woman appropriately
EPIDURAL AND SPINAL
l obese – lateral tilt and ramped-up position
ANAESTHESIA AFTER MAJOR
SPINAL SURGERY l non-obese – shoulders raised
Red flags
l Unexpected dense motor block
l Markedly increasing motor block,
including unilateral block, motor block
that does not recede and recurrent
motor blockade
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NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR
ANALGESIA • 3/4
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NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR
ANALGESIA • 4/4
Yes
Yes
Switch epidural infusion off
Patient comfortable?
Reassess leg muscle strength
every 30 min
Yes
No
Yes
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NORMAL LABORATORY VALUES IN PREGNANCY • 1/1
MCV 80–100 fl
<380 µmol/L
Urates
If 350–380, registrar/consultant reviews notes
24 hr protein 0.3 g
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OBESE MOTHER (CARE OF) • 1/4
DEFINITION
l Body mass index (BMI) = weight in kg/height in metres squared (m2)
Obese >30.0
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OBESE MOTHER (CARE OF) • 2/4
ENVIRONMENT AND l Venous thromboembolism (VTE)
risk assessment and follow VTE
EQUIPMENT
thromboprophylaxis guideline
l Adequate doorway widths and thresholds
l Early booking visit to antenatal clinic to
l Theatre trolley and operating table able plan pregnancy
to take weight >180 kg
l Examination and ultrasound couch At booking
able to take weight >180 kg
l Delivery and ward bed able to take l Measure height and weight and
weight >180 kg calculate BMI for all women
l Moving equipment e.g. hover mattress l note interpregnancy weight change
or hoist l Record arm circumference (to ensure
l Large chairs without arms appropriate BP cuff used) in maternal
l Large wheelchairs healthcare record
l Calibrated weighing scale
Arm circumference
l Height measuring equipment Cuff range at midpoint
l Range of epidural and spinal needles, (cm)
including extra-long
Adult 27–34
l Appropriately sized thromboembolic
stockings Large adult 35–44
l Appropriately sized theatre gowns Adult thigh cuff 45–52
l Large blood pressure cuffs
l Assess VTE risk
MANAGEMENT BEFORE
l if low molecular weight heparin
CONCEPTION
indicated, give weight appropriate dose
l Offer pre-pregnancy counselling on
l Inform scan department of need
lifestyle, diet and smoking cessation
for appropriate couch and longer
l encourage women who wish to lose appointment time (if local practice)
weight to follow a weight reduction
programme and take regular exercise l Anticipate requirement for specific
≥2–3 months before pregnancy equipment during labour and document
in maternal healthcare record
l consider referral to dietitian
l consider referral to smoking cessation
Prophylaxis treatment
advisor (if available)
l Screen for diabetes l Advise vitamin D supplement (‘Healthy
l High dose folic acid 5 mg/day for Start’ vitamins)
3 months before conception l Severely obese women (BMI
l Record blood pressure >35 kg/m2) plus 1 additional risk factor
for hypertensive disease, prescribe
Obese women require the same
aspirin 75 mg/day from 12 weeks’
routine antenatal, intrapartum and
gestation
postnatal care as all other women
Discussion with woman
INITIAL ANTENATAL CARE l Explain significance of BMI to woman.
Provide advice on weight management,
l Refer for consultant-led care and advise
including lifestyle and diet
woman to give birth in a consultant-led
unit l where available, give written information
on diet and risk of obesity in pregnancy
l if woman requests home birth, inform
professional midwifery advocate (PMA)
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OBESE MOTHER (CARE OF) • 3/4
l Refer to dietitian and/or weight
Assessment
management programme according to
local protocol l Consider likelihood of difficult
l advise ≥30 min/day moderate physical intubation and airway management –
activity (e.g. walking, swimming, see General anaesthesia and failed
aqua-natal) on ≥5 days/week intubation guideline
l Refer for smoking cessation l Other comorbidities may impact on
anaesthesia:
l Advise breastfeeding
l hypertension
Communication l ischaemic heart disease
l respiratory distress
l Complete local alert form
l sleep apnoea
l Discuss with manual handling l diabetes
department to ensure appropriate
equipment available l assess difficult IV cannulation and
lumbar anatomy
l Inform senior delivery suite midwife
l Assess on individual basis and
to ensure availability of appropriate
according to local protocol
equipment – see Environment and
equipment
Management
l If mobility reduced, seek advice from
manual handling department l If anaesthetic or airway management
problems anticipated, ask anaesthetist
SUBSEQUENT ANTENATAL CARE to review who will:
l document plan of care clearly in
l Routine antenatal care and:
maternal healthcare record
l it may be appropriate to re-weigh
l discuss plan of care with woman
woman in third trimester
l serial ultrasound scan for fetal growth INTRAPARTUM CARE
l increased risk of gestational diabetes –
book GTT at 26–28 weeks’ gestation l Individual plan of care depending on
woman’s needs
l If admitted to hospital or other
intercurrent problems develop, repeat l Review antenatal anaesthetic
VTE risk assessment assessment and obstetric plan
l In third trimester with BMI >40 l Tissue viability assessment and manual
handling assessment for labour as per
l provide information about tissue
local practice
viability
l Notify duty anaesthetist and middle grade
l manual handling assessment
obstetrician (ST3–7 or equivalent e.g. staff
l Offer continued advice and support. grade, clinical fellow) of admission
Encourage weight gain to be kept to
l Cannulate using wide bore cannula
7–10 kg
(BMI >40)
ANAESTHETIC ASSESSMENT l Bloods for FBC and group and save
AND MANAGEMENT (BMI >40)
l Risk assessment for thromboembolism,
l If BMI >40 refer to anaesthetist (give document and follow plan
anaesthetics information leaflet if
available locally) l thromboembolic stockings (if local
practice)
l Early epidural may be required for
regional analgesia
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OBESE MOTHER (CARE OF) • 4/4
l a suction drain can be left above
Monitor
sheath, and interrupted sutures can be
l Fetal monitoring – see Electronic fetal used for skin
monitoring (EFM) guideline l Use correct equipment for patient
l where difficulty monitoring fetal heart with handling including theatre table and
EFM, apply fetal scalp electrode (FSE) bed – see Equipment
l If uncertainty about fetal presentation,
consider ultrasound scan POSTPARTUM CARE
l Monitor progress in labour closely. Be l If operative delivery, consider transfer
aware of increased risk of shoulder to high dependency area for immediate
dystocia and postpartum haemorrhage postnatal care – see High dependency
(BMI >40) care guideline
First and second stage l Thromboembolism risk assessment
immediately after delivery
of labour
l thromboprophylaxis – see VTE –
l Keep as mobile as possible Thromboprophylaxis guideline
l Maintain hydration l adequate analgesia to allow early
l Antacid (e.g. ranitidine) as per local policy mobilisation
l Pressure area care l thromboembolic stockings
l If instrumental delivery contemplated, l encourage good hydration
consider performing trial in theatre l If intrathecal opiates not used, consider
with an experienced obstetrician patient controlled analgesia (PCA)
(following usual discussion of risks and
l Obesity carries increased risk of
alternatives). Obesity is a recognised
postnatal wound and genital tract
predictor of abandoned trial, shoulder
infection. Encourage good hygiene and
dystocia and birth injury
monitor for signs of infection
Third stage of labour l If CS carried out, observe for wound
infection, wound dehiscence, DVT, PE
l Active management and chest infection
l Oxytocin infusion over 4 hr following
delivery to reduce risk of postpartum PLAN FOR DISCHARGE
haemorrhage l Continue to encourage healthy eating
l Care when putting woman in lithotomy and exercise, reinforcing benefits of a
to avoid tissue damage healthy BMI for future wellbeing and
subsequent pregnancies. Consider
Caesarean section (CS) dietitian referral
l Consider referral to physiotherapist
l If CS considered – seek advice
from consultant obstetrician and l Unless contraindicated, encourage
anaesthetist – see Caesarean section breastfeeding. Obese women have
guideline decreased rates of breastfeeding
(initiation and maintenance) but it can
l Administer antibiotic prophylaxis at
help with postnatal maternal weight
time of surgery
loss
l Due to risk of poor wound healing,
l Postnatal visiting schedule based on
especially if BMI >40, use delayed
individual needs
absorbable suture e.g. PDS for rectus
sheath closure l Offer family planning and contraceptive
advice
l close subcutaneous fat to prevent
wound infection and dehiscence
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OPERATIVE VAGINAL DELIVERY • 1/3
Fetal Other
l Presumed fetal compromise l After-coming head of the breech
developing in second stage
If fetal compromise suspected, CONTRAINDICATIONS
confirmation using fetal blood
l Vacuum extractor contraindicated with
sampling (FBS) is preferable before
a face presentation
a difficult instrumental delivery
l Avoid:
Maternal l use of vacuum <34 weeks’ gestation
because of preterm susceptibility
l Medical indications (e.g. cardiac
to cephalohaemtoma, intracranial
disease, cerebrovascular disease and
haemorrhage and neonatal jaundice
hypertension)
l metal cups <36 weeks’ gestation
l forceps/vacuum extraction deliveries
before full dilatation of cervix
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OPERATIVE VAGINAL DELIVERY • 2/3
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OPERATIVE VAGINAL DELIVERY • 3/3
DOCUMENTATION AFTERCARE
Clearly document in maternal l Perform local VTE risk assessment
healthcare record l Give regular analgesia. If no
contraindications, consider
l Informed consent obtained
paracetamol and diclofenac PR/
l Analgesia used ibuprofen PO
l Maternal bladder catheterised l Bladder management – see Bladder
l Use of instruments: care guideline
l number of pulls l Refer to local guidance on postnatal
l descent of head observations of the neonate
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OXYTOCIN • 1/2
INDICATIONS Monitoring
l Induction of labour after artificial l Monitor fetus by continuous electronic
rupture of membranes (ARM) fetal monitoring (EFM)
l Acceleration/stimulation of labour l if EFM non reassuring or abnormal,
after pre-labour rupture of membranes stop oxytocin until assessment by
(PROM) middle grade obstetrician (ST3–7 or
l prostaglandin induction may be equivalent e.g. staff grade, clinical
appropriate before this – see fellow)
Pre-labour rupture of membranes l Perform routine maternal observations
(PROM) guideline – pulse, blood pressure and
l Augmentation when rate of progress in temperature and record in partogram
labour is considered unsatisfactory – l Perform vaginal examination ≤6 hr
see Delay in labour guideline after start of oxytocin and record
l For prevention of postpartum planned timing of next vaginal
haemorrhage following delivery where examination
there is an increased risk of bleeding l Record individual management plan in
– see Postpartum haemorrhage intrapartum notes
guideline
OXYTOCIN REGIMEN
Assessment before oxytocin
l Administer oxytocin through an
l Before commencing oxytocin, midwife infusion pump or syringe driver using a
must confirm presentation is cephalic Y-connector. This acts as a non-return
and membranes are ruptured valve to minimise risk of oxytocin being
forced up into a second infusion and
Before commencing oxytocin on
flushed through later as a bolus
a multiparous woman for delay in
labour, an obstetrician of at least l Use local regimen for oxytocin
middle grade (ST3–7 or equivalent l Increase infusion rate at ≤30 min
e.g. staff grade, clinical fellow) status intervals and by no more than the
must personally assess woman and steps in the table, until contractions are
perform abdominal palpation and adequate
vaginal examination l There should be <4–5 contractions
every 10 min
l If previous caesarean section, the use
of oxytocin should be or have been l Once contractions established,
discussed with a consultant especially in a parous woman, it may
be possible and desirable to stop
Contraindications the infusion. Experience in the use of
oxytocin is to be valued – seek the
l Non-rupture of membranes advice of midwife co-ordinator and
l there are rare exceptions but these are middle grade obstetrician (ST3–7 or
consultant decision only equivalent e.g. staff grade, clinical
fellow) or consultant early
Do not commence oxytocin within
6 hr of administration of
prostaglandin gel or tablet or
≤30 min of removal of Propess
pessary to prevent hyperstimulation
– see Induction of labour guideline
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OXYTOCIN • 2/2
Suggested regimen
30 2
60 4
90 8
120 12
150 16
180 20
Hyperstimulation
l Stop oxytocin and call middle grade l Consultant obstetrician to decide
obstetrician (ST3–7 or equivalent e.g. whether and when to restart oxytocin
staff grade, clinical fellow)
l If stopping oxytocin does not correct
hyperstimulation, consider tocolysis
with terbutaline 250 microgram SC
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PERINATAL BEREAVEMENT • 1/7
INTRODUCTION Signs of life
l A parent’s relationship with their l A live birth is the delivery of a baby,
baby can begin long before birth. It is irrespective of duration of pregnancy,
possible for parents to grieve for babies which, after delivery, breathes or shows
who die before birth, who are born and, any other evidence of life, such as beating
for whatever reason, cannot survive of heart, pulsation of umbilical cord,
and where pregnancy is terminated or any definite movement of voluntary
owing to abnormality muscles, whether or not umbilical cord
l When a pregnancy ends or a baby has been cut or placenta attached
dies, for whatever reason, there are a l it is important to distinguish between
number of shared elements and needs involuntary, physiological movements
in the parents’ experience of loss. Some and signs of life. Observed movements
aspects of grief are individual and such as jerk of a limb, or occasional gasp
very private, but should be supported are not necessarily signs of life. Parents
by healthcare professionals. Aim to should be advised before birth, that this
support parents and facilitate, as far as may happen. In these circumstances
is possible, their individual needs explain formal registration of neonatal
l do not make assumptions about what death is not appropriate
each parent will feel, want or need l Required elements of care will depend
on circumstances of loss:
Treat parents and baby with respect,
sensitivity and dignity at all times. l termination of pregnancy for fetal anomaly
Inappropriate care can lead to l fetal loss <24 weeks’ gestation
immense dissatisfaction and
l stillbirth
additional trauma
l neonatal death
DEFINITIONS l Complete appropriate local checklist
for particular circumstance to ensure
Intrauterine death (IUD) no aspect of care is overlooked, even
if woman chooses to decline some
l The absence of cardiac activity before
management options
birth
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PERINATAL BEREAVEMENT • 5/7
Additional investigations
Investigation
l Blood for TORCH (toxoplasma, rubella, cytomegalovirus
and herpes simplex) and parvovirus
l VDRL Microbiology
l High vaginal swab for sexual health screen
l Endo-cervical swab for chlamydia
l U&E
l LFT
l Uric acid
l TFT Clinical biochemistry
l HbA1c and random glucose
l CRP
l Bile acids
l Group and save
l Lupus anticoagulant
l Thrombophilia screen
Haematology
l Clotting screen
l FBC
l Kleihauer
l Cardiolipin antibodies Immunology
l For women who have experienced late
Miscarriage
pregnancy loss, stillbirth or neonatal
death, carry out complete local list of l For a baby born <24 weeks’ gestation
blood tests and swabs showing no signs of life, midwife or
l Where pregnancy was medically doctor present at birth completes local
terminated owing to fetal anomaly, form to allow disposal of fetal remains
investigations should include at least: l If used locally, offer non-statutory
l FBC certificate to the parents to
acknowledge the death of the baby
l group and save
l swabs (as per local guidance) Stillbirth
CERTIFICATION l Doctor or midwife present at birth
completes a medical certificate of
l Failure to complete all certification stillbirth
carefully can result in delay registering
l A midwife or doctor who has examined
baby
the baby after birth can also complete
l Complete stillbirth and neonatal death the form but must be certain that the
certificates in black ink baby was not born alive
l Print name after signatures and include
GMC/PIN number
l Do not use abbreviations
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PERINEAL TRAUMA SUTURING (TEARS AND EPISIOTOMY) • 1/3
INTRODUCTION DEFINITION
l Perineal trauma may occur Anterior perineal trauma
spontaneously during vaginal birth or Injury to labia, anterior vagina, urethra or
by a surgical incision (episiotomy). It clitoris
is possible to have an episiotomy and
a spontaneous tear (for example, an Posterior perineal trauma
episiotomy may extend into a third Injury to posterior vaginal wall, perineal
degree tear) muscles or anal sphincters – may include
l >85% of women who have a vaginal disruption of the anal epithelium
birth will sustain some degree of Classification of perineal tears
perineal trauma and of these 60–70% Midwife/doctor must identify the extent
experience suturing of perineal trauma and document it
according to the agreed classification
Definition of spontaneous tears
First degree Second degree Obstetric anal sphincter injury
l Injury to skin only l Injury to perineum l Injury to perineum involving anal
involving perineal sphincter complex
muscles but not l 3a: <50% of external anal sphincter
involving anal (EAS) thickness torn
sphincter l 3b: >50% of EAS thickness torn
l 3c: EAS and internal anal sphincter
(IAS) torn
See also Third and fourth degree
perineal tears - OASIS guideline
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POSTPARTUM HAEMORRHAGE (PPH) • 1/6
PREVENTION
Table 1: Cause of haemorrhage (the 4 T’s)
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POSTPARTUM HAEMORRHAGE (PPH) • 2/6
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POSTPARTUM HAEMORRHAGE (PPH) • 3/6
l Transfuse crossmatched packed cells
Fluids and fluid balance
as soon as possible if required
l Give fluids – compound sodium l Use best available device to deliver
lactate (Hartmann’s) solution 1 L stat warmed fluids rapidly
l Follow with blood, colloid or crystalloid l do not use blood filter
as indicated by availability, blood loss
l In a dire emergency while awaiting
and woman’s haemodynamic state
crossmatched blood, consider
l Do not give >3.5 L clear fluids, ideally requesting type specific blood or O
warmed [up to 2 L compound sodium negative blood
lactate (Hartmann’s) solution and 1.5 L
l If red cell antibodies present, liaise
colloid] while waiting for blood
closely with blood bank
l Insert urinary catheter with hourly
l Fresh frozen plasma (FFP) usually
urinometer attached and maintain urine
required if 4 units of packed red cells
output >0.5 mL/kg/hr
are given
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POSTPARTUM HAEMORRHAGE (PPH) • 4/6
l If surgery to be carried out for major
Oxygen
PPH, it is usual to obtain consent for
l 15 L/min oxygen via face mask initially, hysterectomy
with woman lying flat l Involve consultant with greater
gynaecological surgical experience
Monitoring in complex cases. If available locally,
l Attach non-invasive blood pressure cuff consider contacting interventional
radiologist
l Monitor every 15 min and record on
MEOWS or HDU chart; act on promptly
Repeat blood tests
when there is deterioration in parameters
l BP l FBC
l pulse l APTT, PT (INR), fibrinogen
l SpO2 (maintain at >95%) l Ca2+
l respiratory rate l Blood gases including lactate
l urine output and fluid balance
Reassess
l core temperature
l State of haemorrhage and woman’s
Inform physiological state after initial
resuscitation
For massive obstetric haemorrhage,
use local trigger phrase to Central venous and
communicate the seriousness of the arterial lines
situation clearly
l If continuing haemorrhage (or
l Consultant obstetrician (who will haemorrhage >40 mL/kg), or need to
usually attend as soon as possible) go to theatre for second time, insert
l Consultant anaesthetist CVC and arterial lines (and monitor
l Theatre team (even if not immediately CVP and BP directly)
going to theatre) l Use early if cardiovascular system
l Haematology biomedical scientist compromised by disease
to allow them to prepare for major
haemorrhage Hypocalcaemia
l Haematologist if: l Suspect if massive (>10 units blood)
l blood products other than 4 units of transfusion with ongoing hypotension,
packed cells and 4 units of FFP are check Ca2+. Give calcium gluconate
required, or 10% 10–20 mL by IV infusion over 10
l if there is ongoing haemorrhage after min. Ensure ECG monitoring when
this has been given or administering calcium gluconate
l if clotting studies are abnormal
l Consider involving surgical colleagues
Support for woman
as required and family
l Ideally, midwife should remain with
Specific treatment woman and family throughout the
l For causes of haemorrhage (4 T’s) emergency situation
including surgery – see Tone (uterine
atony), Trauma, Tissue and Thrombin
below
l commonest cause is uterine atony
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POSTPARTUM HAEMORRHAGE (PPH) • 5/6
l ergometrine 250 microgram IM with an
POST-EVENT
antiemetic [contraindicated in pregnancy
l As soon as practically possible after induced hypertension (PIH) or other
a massive haemorrhage, consultant significant cardiovascular disease]
obstetrician should counsel woman and l carboprost (Hemabate®) 250 microgram
her family providing explanation and IM or intramyometrially (unlicensed)
significance of cause of haemorrhage – repeated up to every 15 min to
maximum of 2 mg (unusual to reach
Thromboprophylaxis maximum dose)
l These women are at increased risk of l misoprostol 800 microgram
thromboembolism, whilst being nursed sublingually or 1 mg PR, if used locally
in HDU, consider thromboembolic
stockings and other methods of Continuing bleeding
mechanical thromboprophylaxis
l If above measures fail to prevent
l Unless advised to be inappropriate by
ongoing or recurrent bleeding, suspect
consultant obstetrician/anaesthetist,
Trauma, Tissue (e.g. retained products
give LMWH regardless of mode of
of conception) or Thrombin (e.g. a
delivery once bleeding has settled
coagulopathy)
Non steroidal l If pharmacological measures fail
anti-inflammatory drugs to control bleeding, initiate surgery
sooner rather than later
l Contraindicated for ≤12 hr after
haemorrhage has settled and platelet l Consider surgical examination under
count and renal function are normal anaesthesia
l if woman haemodynamically stable,
Documentation use pre-existent regional (epidural)
anaesthesia
l Carefully document:
l if woman not stable or (dilutional)
l times coagulopathy present, use general
l drugs, fluids and blood products anaesthesia
administered l If bleeding still not controlled,
l personnel consider uterine cavity balloon
l use of trigger phrase tamponade, haemostatic brace suture,
hysterectomy, uterine artery ligation/
l Complete incident forms as required
embolisation by an interventional
radiologist
A TONE (UTERINE ATONY)
l A consultant obstetrician must be
Immediate management involved
l A second consultant opinion before
l Fundal massage, empty bladder and hysterectomy can be helpful, but
consider bimanual uterine massage hysterectomy should be performed
l Oxytocin – start oxytocin infusion. sooner rather than later
Use local regimen for postpartum via
volumetric pump B TRAUMA
l Remember to inspect vulva, vagina and
cervix for trauma/lacerations Inverted uterus
l Consider: l Degree of haemodynamic shock is
l a first or repeat dose of oxytocin 5 or often disproportionate to the volume of
10 units slow bolus IV or 10 units IM the haemorrhage
(unlicensed)
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POSTPARTUM HAEMORRHAGE (PPH) • 6/6
l Replace uterus as soon as possible
D THROMBIN
using manual, hydrostatic or surgical
methods Inherited coagulopathies
l Anticipate massive haemorrhage
l Several inherited conditions will
l Some women may experience a
give rise to excessive peripartum
vasovagal episode (hypotension and
haemorrhage if incorrectly managed
bradycardia) during uterine replacement
and not detected antenatally.
l Run an oxytocin infusion using local Seek advice from consultant
regimen for postpartum for ≥4 hr after haematologist at earliest opportunity
replacement (ideally antenatally) about the
investigation and treatment of these
Uterine rupture varied and uncommon conditions
l See Uterine rupture guideline
Acquired coagulopathies
Perineal trauma l Will often represent a form of
Disseminated Intravascular
l See Third and fourth degree Coagulation (DIC) and will usually
perineal tears – OASIS guideline and result in continuing or worsening
Perineal trauma suturing (tears and haemorrhage without blood product
episiotomy) guideline replacement therapy
l Suspect DIC in abruption, severe PIH,
Other
prolonged +/- infected retained fetus/
l Broad ligament haematoma products of conception, amniotic fluid
embolism or prolonged/untreated
l Extra genital bleeding e.g. sub capsular
hypovolaemic shock
liver rupture
l FBC, PT, INR, APTT, and APTTR in the
C TISSUE first instance in all those conditions
where there is a known associated
Retained placenta complication of DIC
l If platelet count <50 x 109/L or INR
l See Retained placenta guideline >1.6, check fibrinogen and fibrinogen
degradation products (FDP) levels
Placenta
l Give FFP, platelets, +/- cryoprecipitate
accreta/increta/percreta
as directed by investigations
l See Morbidly adherent placenta l Seek advice of consultant
guideline haematologist about treatment and
l If attempts are made to separate further investigations
adherent placenta (surgically/forcibly),
expect massive haemorrhage
l If expected or actual haemorrhage,
follow management plan for major
obstetric haemorrhage
l 1 option, after consultant review,
is to leave the placenta in situ and
monitor woman very closely for signs
of infection and bleeding in postnatal
period
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PREGNANT WOMAN WITH A NON-OBSTETRIC PROBLEM
(MANAGEMENT OF) • 1/1
l If the disease causes reduced mobility,
INTRODUCTION
consider VTE prophylaxis. Use local
l Assessment and management of obstetric VTE assessment tool
disease unrelated to the pregnancy are l Use early warning scoring system
altered by the pregnancy (MEWS) to help in the timely
l The need to consider 2 patients recognition, treatment and referral of
(mother plus fetus) may change women who have or are developing
treatment decisions critical conditions
l Anatomical and physiological changes
in pregnancy result in altered: Contact
l clinical features during CVS and l If ≥16 weeks’ gestation, contact
respiratory system and abdominal delivery suite co-ordinator, who will
examination advise which healthcare professional(s)
l biochemical and haematological values should review, if necessary after
l pharmacological management discussion with on-call obstetric middle
l response to any systemic pathology grade obstetrician (ST3–7 or equivalent
e.g. staff grade, clinical fellow)
l protocols for the management of
critical illness l If any severely ill pregnant woman is
admitted outside the maternity service:
AIM l contact on-call middle grade
l To ensure obstetrician/consultant obstetrician
l every pregnant woman admitted is l if she is critically ill, or likely to need
managed promptly urgent surgery, refer early to critical
care team and/or anaesthetist
l communication link is established
between admitting team and obstetric l By giving consideration to the
team so that the most appropriate care pregnancy and the fetus, maternity
can be delivered service providers can help with:
l assessment of maternal and fetal
ACTIONS wellbeing
Accident and emergency l investigations
l treatment
l Ask apparently pregnant woman
presenting to Emergency department l Be aware of the significance of
for any reason (irrelevant of gestation) hypertension and proteinuria in
if she has booked for maternity care pregnant women
l if not booked for maternity care, inform Radiological investigations are not
delivery suite co-ordinator, who can contraindicated during pregnancy
advise on appropriate follow-up and where there is a significant clinical
booking arrangements indication. Discuss with obstetric team
l In cases of trauma or vaginal bleeding
at any gestation, give consideration to
woman’s blood group and need for
Documentation
anti-D. If in doubt, discuss with on-call l Document all communication
middle grade obstetrician (ST3–7 or (including inter-departmental)
equivalent e.g. staff grade, clinical fellow) in maternal healthcare record,
highlighting pregnant or newly
Nursing delivered woman’s attendance or
l To prevent aortocaval compression, do admission to non-midwifery ward or
not nurse women in the second and department
third trimester in supine position
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PRE-LABOUR RUPTURE OF MEMBRANES (PROM) AT TERM • 1/2
l Rupture of membranes before onset of
Indications for immediate IOL
labour ≥37 weeks’ gestation
l majority of women will labour l Induce labour immediately if:
spontaneously within 24 hr of PROM l maternal pyrexia
l PROM is associated with an increased l fetal distress
risk of intrauterine infection
l significant meconium stained liquor
RECOGNITION AND l blood stained liquor
ASSESSMENT l requiring group B streptococcus
prophylaxis
History and examination l HIV positive mother
l Take a careful history l unstable presenting part
l Full antenatal assessment, including l maternal choice
fetal and maternal observations and
abdominal palpation to confirm fetal lie MANAGEMENT
and presentation
l Assess fetal wellbeing As time between rupture of
membranes and onset of labour
l Speculum examination and indicator
increases, so does the risk of
swab test (if used locally), or pad test
maternal and fetal infection
(if used locally) is only required if there
is doubt about whether membranes
have ruptured Expectant management
l If contractions absent, do not perform l Until IOL commenced or if woman
digital vaginal examination, unless chooses expectant management
result necessary to guide or alter beyond 24 hr, care can be inpatient or
management outpatient
l Electronic fetal monitoring (EFM) 24 hr l Advise women that:
after PROM or earlier if other indications
e.g. decreased fetal movement l the risk of serious neonatal infection is
1%, rather than 0.5% for women with
intact membranes
Assessment and indications
for immediate induction of l 60% of women with PROM will go into
labour (IOL) labour within 24 hr
l IOL is appropriate approximately 24 hr
l When forming management plan, after rupture of membranes
determine if immediate IOL is
necessary – see below l If labour not started after 24 hr
of ruptured membranes, arrange
l consider duration of ruptured induction
membranes
l Until induction is started, or if expectant
Risk factors for intrauterine management beyond 24 hr is chosen
by the woman:
infection
l assess fetal movement and heart rate
l Maternal group B streptococcus status at initial contact and then every 24 hr
l Presence of meconium in amniotic fluid l do not offer lower vaginal swabs and
l Increasing time from rupture measurement of maternal C-reactive
l Number of vaginal examinations protein
l Provide woman with information leaflet l Perform Neonatal Early Warning Score
before discharge home observations
l Include assessment of following – if
Evidence of infection in mother any abnormality or any of these are
observed, request assessment by a
l Prescribe broad spectrum antibiotics – neonatologist
as per local practice l temperature
l Babies born with symptoms of possible l heart rate
sepsis or to a woman with evidence
of chorioamnionitis, immediate l respiratory rate
referral to neonatologist (see Group B l presence of respiratory grunting
streptococcal disease guideline) l significant subcostal recession
l presence of nasal flare
Induction and delivery
l presence of central cyanosis,
l For women with previous caesarean confirmed by pulse oximetry if available
section (CS) – see Induction of labour l skin perfusion assessed by capillary refill
guideline
l floppiness, general wellbeing and
l Discuss with woman and explain feeding
procedure
l If there are no signs of infection in the
l Use either oxytocin or prostaglandin woman – see Sepsis guideline, do not
l On admission, perform digital vaginal give antibiotics to either her or baby,
examination using aseptic technique even if membranes have been ruptured
l if cervix unfavourable, use for over 24 hr
prostaglandin (see Induction of labour l If there is evidence of infection in the
guideline) – follow local practice woman, prescribe a full course of
l If local practice, consider antibiotic broad-spectrum intravenous antibiotics
prophylaxis to baby
l After 24 hr from membrane rupture l Refer baby with any symptom of
(if not already in established labour), possible sepsis, or born to woman
perform EFM with evidence of chorioamnionitis, to
neonatal care specialist immediately
l Perform EFM in labour
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PRETERM LABOUR • 1/6
l Palpate for contractions
INTRODUCTION
l note strength and frequency/
l Preterm birth is the most important tenderness
single determinant of adverse infant
l In all cases seek an underlying cause
outcome
e.g. placental abruption, infection
l preterm defined as delivery before 37
l >26 weeks’ gestation: perform CTG
completed weeks
l Perform speculum examination and 1 of
RISK FACTORS the following:
l fetal fibronectin test: avoid using gel
l Previous preterm birth with speculum – use only use sterile
l Infection/inflammation of genital tract water (see below)
l Cervical weakness l cervical length scanning: if cervical
l Uterine abnormality length is ≤15 mm, consider diagnosis
of preterm labour and offer treatment
l Substance abuse
l if extent of cervical dilatation cannot be
l Multiple pregnancy assessed: digital vaginal examination
l Polyhydramnios - to be performed by middle grade
l Bleeding/thrombosis obstetrician (ST3–7 or equivalent
l Early stress e.g. staff grade, clinical fellow) or
consultant only
l Low BMI
- only indicated if regular contractions
l Short conception cycle <1 yr are palpable
l Aged <17 and >35 yr - if pre-labour rupture of membranes
has occurred avoid digital vaginal
DIAGNOSIS AND ASSESSMENT examination
l Explain to woman: clinical assessment,
l All women with suspected preterm
available diagnostic tests, and how
labour/preterm ruptured membranes
these will be carried out
<34 weeks’ gestation to be assessed
by middle grade obstetrician (ST3–7 Test for preterm labour
or equivalent e.g. staff grade, clinical
fellow) or consultant l Follow manufacturer’s instructions
l Any woman <29 weeks’ gestation to l Only valid 23–35 weeks’ gestation
be seen by consultant obstetrician l To reduce the risk of false positive
within 24 hr of admission results use only water as lubricant for
l Confirm gestational age speculum examination
l Take thorough history l Take swab from posterior fornix before
any other vaginal/cervical swab or
l Record digital examination
l maternal temperature l Not indicated if evidence of membrane
l pulse rupture
l blood pressure l Do not use test if moderate/gross
l respiratory rate bleeding, or in women with suspected
placenta praevia or abruption
l MEOWS score
l If sexual intercourse has occurred in
l Perform abdominal palpation to the previous 24 hr, may be difficult to
determine presentation interpret
l if in doubt confirm using portable l Record result in hospital maternity care
ultrasound machine record
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PRETERM LABOUR • 2/6
Quantitative fibronectin results (if available locally)
% who will % who will
FFN value
deliver within 2 deliver Suggested management
ng/mL
weeks <34/40 weeks
0–9 <2 l Home routine follow-up
<2
10–49 5–15 l Home routine follow-up
50–199 5–15 10–15 l Admit
l Betamethasone
l Consultant-led care
200–499 30 30 l Admit
l Betamethasone with tocolysis
l MgSO4 if <30/40
l Consultant-led care
l Consider repeat FFN in ANC
≥500 50 75 l Admit
l Betamethasone with tocolysis
l MgSO4 if <30/40
l Consultant-led care
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RECOVERY • 1/3
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RECOVERY • 2/3
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RECOVERY • 3/3
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REFUSING BLOOD AND BLOOD PRODUCTS • 1/4
l Where a woman aged <16 yr refuses
GENERAL PRINCIPLES
blood products, seek urgent advice
Consent from Trust manager/director on-call.
Consider second opinion from
l Transfusion against a woman’s consultant obstetrician/anaesthetist/
expressed view is a gross physical haematologist
violation – follow your local Trust
Consent policy Unconscious/incapable woman
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REFUSING BLOOD AND BLOOD PRODUCTS • 2/4
l If high blood loss during caesarean
Refusal
section anticipated (e.g. placenta
l If woman does not wish to praevia), discuss at multidisciplinary
accept blood transfusions in any level and make appropriate
circumstances, ask her to complete arrangements e.g. cell salvage
an advance directive/decision to
this effect. Place 1 copy in maternal Reversal of decision
healthcare record and the other in main l If woman changes her decision in any
case notes way, complete a ‘Reversal of advance
l Complete a neonatal alert/maternal decision’ form (if available locally) and
alert form and any other alert system file in front of the Advance decision
used locally l The maternal alert form will be updated
l Refer her to consultant obstetrician and to reflect this reversal of decision. All
consultant anaesthetist forms will remain in woman’s healthcare
record and will not be removed even if a
Investigations and preparation reversal of advanced decision is made
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REFUSING BLOOD AND BLOOD PRODUCTS • 4/4
Hysterectomy
l Early recourse to surgery may be
necessary
DEATH
l See Maternal death guideline
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REMIFENTANIL PATIENT CONTROLLED ANALGESIA (PCA) USE
IN LABOUR • 1/2
WHEN TO CONTACT
ANAESTHETIST
l SpO2 <90% despite oxygen therapy
l Respiratory rate <10/min
l Sedation score >moderate or P or U
(see Sedation score below)
l Fetal heart rate <110 bpm
l Record every 5 min, record for 15 min
when started, then half hourly:
l non-invasive blood pressure amplifier
(NIBP)
l respiratory rate
l heart rate
l applies if and when program changed
l CTG monitoring
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RETAINED PLACENTA • 1/2
l See Third stage labour guideline l Manual removal of placenta (MROP)
l If placenta has not delivered or has takes priority over elective cases, even
shown no signs of separation 20 min if woman not actively bleeding
after administration of Syntometrine® or l obstetric junior doctor can undertake
oxytocin, prepare to treat promptly for this procedure under the direct
retained placenta after 30 min supervision of a middle grade
l If woman has requested a physiological obstetrician (ST3–7 or equivalent e.g.
third stage of labour and placenta staff grade, clinical fellow)
has not delivered or shown signs of l if blood loss increases or maternal
separation 60 min after birth, advise condition deteriorates, accelerate
woman to allow active management of transfer to theatre
the third stage l Use gauntlets to protect the operator
l While waiting for placenta to separate, l Midwife can accompany woman into
follow Management below theatre to support her throughout
Unnecessary delay increases risk of l Administer broad spectrum IV antibiotics
postpartum haemorrhage
l Following placenta removal, middle
grade obstetrician (ST3–7 or equivalent
MANAGEMENT e.g. staff grade, clinical fellow) must
ensure uterus is empty
l Observe for shock and excessive blood
loss l If placenta does not separate see
Morbidly adherent placenta guideline
l If the woman is located at a free
standing midwifery-led unit, transfer will l Run oxytocin infusion for 4 hr after
be necessary – see Maternal transfer removal of placenta
guideline l Following MROP, provide care on
l Prepare postnatal oxytocin infusion delivery suite ≥2 hr
if actively bleeding – see Oxytocin l Oral broad spectrum antibiotics for
guideline 5 days or as local practice
l Notify delivery suite co-ordinator that l In the case of postpartum haemorrhage
placenta has not delivered – see Postpartum haemorrhage
l Encourage skin-to-skin/baby to breast guideline
l Assist mother onto bed pan and
encourage to empty bladder Communication
l if unsuccessful, catheterise bladder l Ensure woman and her partner are fully
l Ensure mother is warm informed at all times
l Ensure large bore IV cannula in situ and l Obstetric middle grade obstetrician
take blood for FBC and group and save (ST3–7 or equivalent e.g. staff grade,
clinical fellow) will see woman the
l Unclamp cord at maternal end to allow
following day to answer questions,
blood to drain out of the placenta once
especially in view of the uniquely
baby is detached
penetrative nature of the procedure
l Middle grade obstetrician (ST3–7 or
l Inform woman of increased risk of
equivalent e.g. staff grade, clinical
placental retention in future pregnancy
fellow) will perform vaginal examination
and check placenta not detached in
vagina
Do not attempt to remove an
adherent placenta in delivery room
or without anaesthetic
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RETAINED PLACENTA • 2/2
Documentation
l Ensure clear and accurate
documentation, including:
l procedure used
l total estimated blood loss since
delivery
RETAINED PRODUCTS
l Where there is any concern about the
completeness of delivered placenta,
midwife must notify middle grade
obstetrician (ST3–7 or equivalent e.g.
staff grade, clinical fellow) regardless of
mode of delivery
l Insert cannula, take blood for FBC and
group and save
l Where there is a confirmed incomplete
placenta, take woman to theatre for
evacuation of retained products as
above for a retained placenta
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 1/11
PRINCIPLES
l To encourage women to participate in planning postnatal care and to provide
information to enable them to make informed choices
l To provide woman with relevant and timely information to enable her to recognise
and respond to problems
l Identified lead professional will be responsible for co-ordinating care for woman and
baby in postnatal period, until they are discharged from midwifery care
Document all discussions in maternal healthcare record
POSTNATAL PERIOD
l A documented, individualised postnatal care plan to be developed with the woman
during antenatal period, or as soon as possible after birth. This should include:
l relevant factors from antenatal, intrapartum and immediate postnatal period
l details of healthcare professionals involved in care of her and baby
l plans for postnatal period
l review at each postnatal contact
EVERY POSTNATAL CONTACT
Maternal health Infant health
l Ascertain physical and emotional l Enquire about baby’s health
health and wellbeing l Provide information about:
l Offer woman opportunity to talk l promoting baby’s health and general
about her birth experience and to ask condition
questions about care received l recognising signs and symptoms of
l inform her about the debriefing service common health problems in newborns
and how/who to contact if required and how to contact healthcare
l Discuss vaginal loss and perineal professionals as soon as a problem is
healing suspected or in an emergency
l Look for signs and symptoms of mental l Advise woman to contact healthcare
health problems professionals if baby:
l Discuss coping strategies and support l becomes jaundiced (or is jaundiced
and it worsens)
l Encourage partner involvement
l passes pale stools
l Provide health promotion information
l Provide advice and support on infant
and how to recognise life-threatening
feeding
and common health problems – see
l discuss breastfeeding and document
Life-threatening conditions in women
any support required
and Common health problems in
women sections l Give information regarding local
support networks
l Confirm contact numbers (if woman
l Check healthcare record for previous
is at home and needs to report any
alerts
concerns)
l Women with physical, emotional, social
or educational needs – see Women
with multi-agency or multidisciplinary
needs section
l Be alert to signs of domestic abuse. If
concerned, follow local child protection
and domestic abuse guidance
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 2/11
l During inpatient episodes on delivery l It is the responsibility of allocated
suite/midwifery-led unit or postnatal midwife on postnatal ward to ensure it
ward, allocate woman and baby a is safe to accept woman and/baby onto
named midwife for each shift who ward
will undertake care, including care as l Ensure all allergies and sensitivities are
described in Every postnatal contact documented
above
l Check baby is wearing 2 name bands
l Midwives have direct access for referral containing woman’s hospital number.
to a consultant obstetrician at all times Check this against mother’s name
during the postnatal period if required band
l Assess general condition of baby
Women with multi-agency or
multidisciplinary needs l Check that a birth weight has been
performed and recorded in all relevant
l Named midwife will: documentation
l co-ordinate woman’s multi-agency and l Establish vitamin K has been
multidisciplinary needs administered and recorded
l liaise with named community midwife, l Determine chosen method of feeding
lead midwife for vulnerable women and and obtain details of initial feed on
appropriate agencies and healthcare delivery suite
professionals
l Commence Red child health record
l with woman’s knowledge and, where book
possible and safe to do so, ensure
appropriate agencies and healthcare Allocated midwife on
professionals are involved according to postnatal ward will:
local practice
l document outcomes of multi-agency or l See woman at each handover, review
multidisciplinary meetings in woman’s care plan and document in maternal
postnatal care plan healthcare record
See also the following guidelines: l See Every postnatal contact section
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 3/11
l Group B streptococcal disease Discharge home from delivery
guideline
suite/birth unit
l Pre-labour rupture of membranes
(PROM) at term guideline l Dependent upon individual
circumstances and preferences,
l Substance misuse guideline
woman may choose to go home
l local Transitional care guideline (if from delivery suite/birth unit or to be
available) admitted to postnatal ward
l Hypothermia guideline in the l For home birth, see Home birth
Staffordshire, Shropshire & Black guideline
Country Newborn and Maternity
Network Neonatal guidelines (if used If woman or baby not considered
locally) appropriate for early discharge
and woman insists on going home,
l Jaundice guideline in the Staffordshire,
complete a ‘Discharge against
Shropshire & Black Country Newborn
medical advice’ form
and Maternity Network Neonatal
guidelines (if used locally)
l Meconium stained liquor guideline
l local Administration of IV antibiotics
guideline, Admission to SCBU
guideline and Bed sharing policy (if
available)
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 5/11
l apply separate neonatal barcode label
Postnatal visiting
to each sheet of the card after checking
Community midwife will: details with parent(s)
l place specimen in correctly
l Visit woman at home on day following addressed envelope (use appropriate
discharge and offer ≥2 further addressograph label)
postnatal contacts (day of delivery is
l send to regional screening unit on day
day 0)
sample taken
l second contact: day 5, to weigh baby
l document according to local practice
and perform bloodspot test
l inform parent(s) that health visitor will
l third contact: on or after day 10, to
relay ‘normal’ results
weigh baby and transfer care to GP
and health visitor if appropriate l if any results abnormal or borderline,
parent(s) will be contacted directly
l date and venue to be agreed with
woman. Can be at home or clinic
Preterm baby
l Discuss individual social, clinical and (<36 weeks’ gestation)
emotional needs, taking into account
the views and beliefs of woman, her l If baby almost 36 weeks’ gestation,
partner and family sample may be postponed for a few
l See also Every postnatal contact days to prevent unnecessary repeat
section at beginning of guideline l Inform parent(s) baby will need a
repeat sample at 36 weeks corrected
Community team leader is age for congenital hypothyroidism and
responsible for ensuring all arrange to visit and repeat test at the
caseloads are picked up during appropriate time
periods of annual leave and/or
sickness
Newborn screening
l It is the midwife’s responsibility to:
l discuss newborn screening with
parents ≥1 day before being
performed
l provide national screening committee
leaflet ‘Screening tests for your baby’
l obtain consent and take sample on
day 5 (count date of birth as day 0).
See Bloodspot screening guideline
in the Staffordshire, Shropshire &
Black Country Newborn and Maternity
Network Neonatal guidelines (if used
locally)
l ensure sufficient neonatal barcode
labels available (if used locally) for
when test is taken
l complete request card after performing
test
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 6/11
First 24 hr following initial delivery assessment
Woman’s wellbeing Baby’s wellbeing and feeding
See also Every postnatal contact section
Midwife will: Midwife will:
l Give information related to physiological l Confirm and document urine passed
process of recovery in postnatal period
l Confirm meconium passed, if not,
l Discuss the following signs and
assess baby and seek medical
symptoms of life-threatening conditions
opinion
and how to contact their healthcare
professional or call for emergency help: l Ensure woman has received
l sudden profuse blood loss information regarding:
l offensive/excessive vaginal loss l bathing – advise that cleansing
l tender abdomen agents, lotions and medicated wipes
l fever are not recommended in first 6 weeks
l severe or persistent headache l keeping the umbilical cord clean and
l raised BP with other signs of pre-eclampsia dry (do not use antiseptic)
l chest pain and/or shortness of breath l cot safety
l unilateral calf pain/redness or swelling l parents aware of bed-sharing
l In first 6 hr following delivery, assess guidance from the Department of
and document BP (see Hypertension Health. The safest place for baby to
guideline) and first urine void (see sleep is in a cot in parents’ room for
Bladder care guideline) first six months
l Record maternal observations
l If offensive/excessive loss, abdominal
tenderness or fever, assess vaginal loss, Feeding
uterine involution and position l Observe a full feed and offer ongoing
l Offer assessment of the perineum to any feeding support
woman who suffered perineal trauma l Outline the benefits of colostrum
– see Episiotomy guideline, Perineal and breastfeeding (this information
trauma suturing (tears and episiotomy) should be culturally appropriate) –
guideline and Third and fourth degree see Breastfeeding guideline in the
tears – OASIS guideline Staffordshire, Shropshire & Black
l Ask about headache symptoms. If Country Newborn and Maternity
epidural or spinal used, advise woman to Network Neonatal guidelines (if used
report headache, particularly if occurring locally)
while sitting or standing
l If artificial feeding, see Infant
l Assess thrombosis risk – see VTE feeding guideline and Staffordshire,
guidelines and refer to obstetrician if Shropshire & Black Country Newborn
appropriate and Maternity Network Neonatal
l Give woman opportunity to discuss the Nutrition and enteral feeding
birth guideline (if used locally)
l Encourage gentle mobilisation
l Give information on mental wellbeing
l Update postnatal care plan Ensure all discussions/numbers
l Ensure all contact numbers are clearly given are clearly documented
documented in maternal healthcare
record and that woman and, if
appropriate, partner/family also aware
l Ensure all discussions clearly
documented in maternal healthcare record
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 7/11
Care in first week
Mother’s wellbeing Baby’s wellbeing and feeding
See also Every postnatal contact section
Midwife will: Midwife will:
l Ensure Rh–D negative woman is l Discuss all aspects of baby’s physical health
offered anti-D immunoglobulin and wellbeing with parent(s), including
within 72 hr of delivering an Rh-D continuous assessment of feeding
positive infant l Inform parent(s) a full examination of
l ≤3 days – discuss normal baby will be performed ≤72 hr of life and
patterns of emotional changes encourage them to be present. Provide full
in the postnatal period and that explanation including results of any tests
these usually resolve within l Review family health history and address
10–14 days parental concerns
l Discuss the importance of l Discuss neonatal screening
appropriate exercise, rest and
diet, including high fibre foods l Assess baby’s general condition. Healthy
and adequate fluid intake babies should have normal colour for their
ethnicity, maintain a stable body temperature
l If woman reports persistent and pass urine and stools at regular intervals
fatigue, and suffered a
postpartum haemorrhage, check l Assess feeding behaviour – see Infant
Hb feeding guideline and Breastfeeding,
Nutrition and enteral feeding and
l Offer information and Hypoglycaemia guidelines in the
reassurance on involuntary Staffordshire, Shropshire & Black Country
leakage of small amounts of urine Newborn and Maternity Network Neonatal
commonly experienced after birth guidelines (if used locally)
– see Bladder care guideline
l Look for signs and symptoms of baby
l Advise woman to report concerns becoming unwell e.g. excessive irritability,
about haemorrhoids, rectal pain tense, high temperature, sleepy or floppy
or bleeding, and if she has not
opened her bowels ≤3 days of l Assess parent(s) for emotional attachment
delivery or regained her normal and offer information and support in adjusting
pattern to their new parenting role
l Give perineal hygiene information l If any jaundice, record intensity, together with
baby’s hydration and alertness. If significantly
l Offer women with low-level or no jaundiced or unwell, inform medical staff and
immunity to rubella on antenatal arrange evaluation of serum bilirubin level –
screening an MMR vaccination see Jaundice guideline in the Staffordshire,
before discharge from maternity Shropshire & Black Country Newborn and
unit if possible. Can be given Maternity Network Neonatal guidelines (if
with anti-D injection, provided used locally)
separate syringe is used and
administered into different limb l provide parent(s) information on, reason
for and how to monitor jaundice (normally
l if not given simultaneously, give occurring around 3–4 days after birth)
MMR 3 months after anti-D
l Weigh baby once within first week of life. If
l advise woman to avoid problem identified, more frequent weighing
pregnancy for 1 month after may be necessary
receiving MMR, but breastfeeding
may continue l If weight loss not within normal limits, inform
parent(s) and take appropriate action
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 8/11
Care in first week cont.
Mother’s wellbeing Baby’s wellbeing and feeding
See also Every postnatal contact section
Midwife will: Midwife will:
l Discuss future methods of l If parent(s) concerned about baby’s skin,
contraception advise to contact a healthcare professional
l Look for changes in mood l Ensure bloodspot screening performed – see
and emotional state, signs and Newborn screening section and Bloodspot
symptoms of health problems. screening guideline in the Staffordshire,
Seek information from family/ Shropshire & Black Country Newborn and
partner if appropriate Maternity Network Neonatal guidelines (if
used locally)
l Observe for risks, signs and
l Explain bowel movement pattern in a normal
symptoms of domestic and child
neonate and inform parent(s) to seek advice
abuse and refer appropriately
from healthcare professional if concerned
l Update postnatal care plan using about baby’s bowel movements or urine
variances when required output
l Update postnatal care plan, including
variances where required and all discussions
with parent(s)
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 9/11
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 11/11
Wellbeing and care in first 2–8 weeks
Mother’s wellbeing Baby’s wellbeing and feeding
See also Every postnatal contact section
Midwife will: Midwife will:
l Ask woman about her physical, emotional l Assess baby’s feeding
and social wellbeing, and the wellbeing of
l Provide advice and support woman’s
her baby. Recognise symptoms that may
choice of feeding and document in
need discussion/action
postnatal plan
l Discuss resumption of sexual
intercourse and possible dyspareunia l Reinforce relevant safety issues
for all family members in the home
l Use routine screening questions for
environment and promote safety
postnatal depression (within 10–14 days)
education (e.g. safe sleeping). If
l Enquire about and give information on: parents choose to bed-share with baby,
l headache explain the increased risk of sudden
l perineal pain, discomfort, stinging, infant death syndrome if either parent:
offensive odour or dyspareunia smokes, has recently drunk alcohol,
l persistent fatigue taken medication or drugs that make
l backache them sleep more heavily, or is very tired
l constipation l Discourage use of a dummy
l haemorrhoids l Discuss smoking, including passive
l urinary or faecal incontinence smoking and access to cessation of
l urine retention (within 6 hr of birth) smoking programme for woman and
other family members if required
l Promote emotional attachment and
improved parenting skills l Be alert to signs and symptoms of child
l Provide information on local/national/ abuse. If there are concerns, follow
voluntary groups that provide support local child protection procedures
and guidance in the postnatal period l Document all discussions in maternal
l Discuss sudden infant death syndrome healthcare record and baby healthcare
with parents, in line with DoH guidance record (Red book)
l Update postnatal care plan using
variances when required. Document all
discussions
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SEPSIS • 3/5
MANAGEMENT OF Antibiotics
SEVERE SEPSIS
After obtaining urgent bloods,
Severe sepsis is an emergency. swabs and cultures, administer high
Involve consultant obstetrician at an dose broad spectrum IV antibiotics
early stage. immediately without waiting for
Consultant obstetrician will seek microbiology results
advice from other specialists
l Choice of antibiotic therapy depends
e.g. anaesthetist, haematologist,
on clinical suspicions and local flora
microbiologist and intensivist
and culture information (if available)
Key actions (from ‘Surviving sepsis’) l Treatment should include cover for:
l Gram negative and anaerobic
Tests Treatment organism
l FBC and blood l Broad spectrum l if likelihood of infection is high, Gram
cultures before antibiotics positive cover
antibiotics l IV fluids
l Measure serum l Oxygen
lactate
l Measure urine
output hourly
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SEPSIS • 4/5
FURTHER MANAGEMENT
l Remove source of infection
l closed-space infections need surgical
drainage including evacuation of
retained products of conception
l Consider VTE prophylaxis
l Consider delivery
l regional anaesthesia may be
contraindicated
l If woman already extremely ill,
deteriorates or does not improve,
consider additional or alternative IV
antibiotics – seek further early advice
from consultant microbiologist
l repeat microbiological specimens and
mark ‘urgent’
l In women with endometritis not
responding to antibiotics, consider
septic pelvic thrombosis
l In presence of uterine sepsis,
carefully counsel women requesting
conservative management about
maternal risks
l Necrotising fasciitis requires early
surgical intervention with fasciotomy
and aggressive antibiotic therapy
l If Group A streptococcus disease
suspected, inform neonatologists. If
confirmed, this is a notifiable disease
l Be prepared for haemorrhage from
uterine atony and DIC
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SEPSIS • 5/5
Sepsis/severe sepsis screening and management flowchart
Does woman have 2 of the following signs of infection?
l Temperature >38°C or <36°C
l Heart rate:
l >100 bpm (antenatal and intrapartum)
l >90 bpm (postnatal)
l Respiratory rate >20 bpm
l Acutely altered mental state
l WCC >12 OR <4 x 109/L (higher threshold in labour)
l Hyperglycaemia (blood glucose >7.7) in the absence of diabetes
Yes
Elicit history or signs of new infection or infective source and consult appropriate guideline
l Prolonged ruptured membranes or offensive smelling liquor
l Unexplained fetal tachycardia in the absence of a maternal tachycardia
l Recent delivery/offensive lochia
l Catheter or dysuria
l Line infection
l Headache with neck stiffness
l Endocarditis
l Breast redness and/or tenderness
l Fetal demise
l Sore throat/cough/sputum/chest pain
l Abdominal pain/distension/diarrhoea
l Cellulitis/wound infection/septic arthritis
l Other
No Yes
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SEVERE PRE-ECLAMPSIA • 1/8
DEFINITIONS
l Pre-eclampsia: pregnancy induced hypertension with significant proteinuria +/-
oedema affecting virtually any organ system in the body
l Severe pre-eclampsia: diastolic blood pressure >110 mmHg or systolic blood
pressure ≥160 mmHg on >2 occasions, with significant proteinuria
l Mild to moderate pre-eclampsia: BP <160/110 and proteinuria with ≥1 of
symptoms and signs listed below (see RECOGNITION AND ASSESSMENT below)
Maternal and fetal complications associated with severe pre-eclampsia
Maternal Fetal
l Eclampsia l Prematurity
l Placental abruption l Intrauterine growth restriction
l Severe hypertension l Acute fetal distress
l Risk of cerebral haemorrhage l Placental abruption
l Pulmonary oedema l Intrauterine death
l Renal failure l Respiratory distress syndrome
l Liver failure or ruptured liver
l Disseminated intravascular coagulation (DIC)
l HELLP syndrome
l Pulmonary haemorrhage
l Aspiration pneumonia
l Retinal detachment
l Circulatory collapse
l Maternal death
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SEVERE PRE-ECLAMPSIA • 4/8
Notes Diagnosis
l Epidural is a useful method of l Confirmed by:
controlling blood pressure and l fragmented red cells on blood film
providing analgesia but may be
l platelet count <100 x 109/L
contraindicated in low platelet count
l Elevated AST >75 IU/L significant and
l If oxytocin indicated for induction
>150 IU/L is associated with maternal
of labour or augmentation, give IV
morbidity
via syringe driver and administer a
reduced fluid regime l Severe hypertension is not always
a feature of HELLP syndrome and
Managing third stage of degree of severity rarely reflects overall
labour severity of the disease
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SEVERE PRE-ECLAMPSIA • 5/8
l If transferred to community – Common contraindications
measure BP every 1–2 days ≤2 weeks,
(see also current BNF)
until anti-hypertensive treatment
stopped and no hypertension. l Asthma
Medical team to include management l Cardiogenic shock
plan for monitoring on discharge
documentation l AV block
NIFEDIPINE HYDRALAZINE
l Calcium-channel blocker, relaxes l Direct acting vasodilator
vascular smooth muscle and dilates
coronary and peripheral arteries Contraindications
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SEVERE PRE-ECLAMPSIA • 7/8
Hydralazine regimen
Acute treatment Maintenance treatment
l Consider pre-loading with colloid l Where continuous IV doses required,
300 mL before administration consider insertion of arterial line in
l 5 mg by slow IV bolus diluted with discussion with anaesthetist
sodium chloride 0.9% 10 mL – can l 40 mg in sodium chloride 0.9% 40 mL via
be repeated after 20–30 min – some syringe driver e.g. 1000 microgram/mL
Trusts prefer to mix 20 mg in 20 mL solution
l Check BP every 5 min for 30 min or l Start infusion at 2 mL/hr
until stable at acceptable limit, then l Increase rate in 2 mL/hr increments to a
every 15 min for further 60 min maximum of 20 mL/hr
l If pulse >140, consider alternative
hypertensive drug
l If target BP reached, reduce infusion rate
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SEVERE PRE-ECLAMPSIA • 8/8
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SHOULDER DYSTOCIA • 1/4
DEFINITION MANAGEMENT
Prolonged head to body delivery time Immediate action
requiring additional obstetric manoeuvres
to release shoulders from behind l Sound emergency call bell/buzzer and
mother’s pubic bone or, less commonly, summon:
sacral promontory l delivery suite co-ordinator
l middle grade obstetrician (ST3–7 or
RISK FACTORS equivalent e.g. staff grade, clinical
l If identified, middle grade obstetrician fellow) or consultant
(ST3–7 or equivalent e.g. staff grade, l neonatal team member (as per local
clinical fellow) to be on delivery suite at practice)
delivery or l anaesthetist
l in delivery room for women with l theatre staff
previous shoulder dystocia
l Quickly tell mother what is happening,
l No evidence to suggest that prophylactic reassure her
McRoberts position will be of any benefit
l Nominate a member of staff to
before delivery of fetal head
document events
Antepartum
Position woman and traction
Maternal l Position mother with buttocks at end of
bed lying flat
l Maternal obesity – body mass index
>30 kg/m2 [see Obese mother (care l Mother’s legs flexed, abducted
of) guideline] and rotated outwards (McRoberts
manoeuvre) and attempt delivery using
l Excessive weight gain
routine axial traction
l Previous big baby
To reduce risk of brachial plexus
l Previous shoulder dystocia
injury, use axial traction only
l Maternal diabetes mellitus – even in
absence of fetal macrosomia l Instruct mother not to push as may
cause further impaction of the shoulders
Fetal l Do not apply fundal pressure (associated
l Suspected or confirmed fetal macrosomia with a high neonatal complication rate
and may result in uterine rupture)
l Post-dated pregnancy
Suprapubic pressure
Intrapartum
l If delivery not successful with McRoberts
l Prolonged first or second stage
manoeuvre alone, ask assistant to apply
l Oxytocic augmentation suprapubic pressure for 30 sec with heel
l Assisted delivery of hand over posterior aspect of shoulder
l Signs in second stage: – assistant must be aware of position
l difficulty with delivery of face and chin of fetal back to ensure pressure
applied in the right direction
l head remaining tightly applied to vulva
or even retracting (turtle-neck sign) l if continuous pressure not successful,
attempt a rocking movement as there is
l failure of restitution of fetal head
no clear difference in efficacy between
l failure of shoulders to descend continuous pressure and rocking
Notify middle grade obstetrician of movement
any second stage risk factors l if shoulder disimpacted, encourage
mother to push and attempt delivery
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l In all cases of shoulder dystocia, obtain l Baby appears well – transfer to
paired cord blood for gases – see postnatal ward with mother. Full
Umbilical cord sampling guideline neonatal assessment will take place,
l If baby well, encourage a period of and findings documented in maternal
skin-to-skin contact healthcare record, before discharge
from hospital
Documentation
Transfer to postnatal ward
l In all cases of shoulder dystocia,
regardless of outcome, midwife or l When transferring mother and baby to
doctor responsible for mother’s care postnatal ward, follow local practice
should: and ensure all events communicated to
postnatal ward midwives
l complete a shoulder dystocia
checklist and place 1 copy in maternal l Obstetrician involved in the shoulder
healthcare record dystocia will:
l record which shoulder was anterior at l visit woman and family on postnatal
delivery ward the following day to discuss
events in detail
l follow local adverse incident/near miss
reporting procedure l if appropriate speak to other
healthcare professionals involved e.g.
Communication with neonatologist or midwife
parents/family
Deterioration in baby’s condition
l Obstetrician and midwife must
discuss events with woman/family l If, at any time, midwifery staff in
and document discussion in maternal hospital or community detect
healthcare record deterioration in baby’s condition, refer
to neonatal team
Examination of baby
In hospital
l Neonatal team member who was
present at delivery will carry out a l Contact neonatal junior doctor and/or
detailed initial examination – see middle grade depending on severity of
Staffordshire, Shropshire & Black problem
Country Newborn and Maternity
Network Examination of the newborn In the community
guideline (if used locally), paying
particular attention to the arms for the l Contact woman’s GP/paediatric
presence of swelling, bruising, tone, assessment unit or A&E department
posture and movement. If concerns, depending on severity of problem
X-ray of affected side – arm and clavicle l For babies with a history of shoulder
l No movement noted – inform neonatal dystocia, follow local incident reporting
consultant on duty and refer to surgeons policy for re-admission
for review and investigation of possible
brachial plexus injury – see Staffordshire, DISCHARGE AND FOLLOW-UP
Shropshire & Black Country Newborn
l Neonatal staff will discuss ongoing care
and Maternity Network Upper limb birth
with parents/family before discharge
injuries guideline
l Some restricted movement noted
– refer to physiotherapy and arrange
outpatient follow-up
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SHOULDER DYSTOCIA • 4/4
McRoberts manoeuvre –
hyperflexion of legs ‘Knee-to-chest’ and abducted
Operator to
Deliver posterior arm and
decide which
shoulder
manoeuvre to
use first
REMEMBER – if With other internal rotary
one fails, try the Wood’s screw manoeuvre
manoeuvres
other method
Try symphysiotomy, or
If all above fail Zavenelli manoeuvre (rarely
cleidotomy and only as a
last resort)
Carefully examine
For trauma after delivery –
genital tract
beware PPH
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STEM CELL BANKING • 1/2
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STEM CELL BANKING • 2/2
NON-COMMERCIAL BLOOD
COLLECTION
l Umbilical cord blood may be collected
via a third party agreement with a
Human Tissue Authority licensed
establishment. Collection may have
been recommended where family
members have:
l haemoglobinopathies
l acute inherited disorders
l acute lymphoblastic leukaemia
l In general, those caring for the family
member with the haematological
disorder have provided third party
agreement for cord blood collection.
They also have the responsibility to
provide training and clear instructions
for staff
l The National Blood Service in
Birmingham (if involved) provides 2
collection packs containing instructions
and contact details. 1 pack is for
staff (most likely to be present when
collection occurs) to open and
familiarise themselves with before
delivery. Do not open the second pack
until cord blood collection is about to
be performed
l Store the cool packs in a refrigerator at
4°C until required – do not freeze
l In addition to the collection packs,
ensure the following equipment is
available:
l Spencer Wells clamps
l scissors
l swabs, spray and gauze for cord
disinfection before venepuncture
Collection
l See NHS Blood and Transplant Service
http://www.nhsbt.nhs.uk/
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SUBSTANCE MISUSE • 1/4
l Encourage women using opiates who
INTRODUCTION
are not already in a drug treatment
l Maternal drug use in pregnancy programme, to accept referral to
increases perinatal mortality and specialist services for:
morbidity with an increased risk of l a full assessment of substance usage
placental abruption, fetal growth
l drug screening (to confirm present usage)
restriction etc.
l ongoing counselling
l Many drugs (opiates, benzodiazepines)
can cause severe neonatal withdrawal l support in stabilising usage through
symptoms substitute prescribing (e.g. methadone)
l Substance misuse can lead to l thorough assessment of woman’s
poor maternal health e.g. infective social circumstances to decide
endocarditis, VTE and blood borne appropriate referral (e.g. social care
viruses and health planning)
l Record and discuss with community
ANTENATAL CARE midwife
l Refer woman to appropriate professionals
l Initial contact between woman
and maternity services is likely to Documentation and confidentiality
influence their subsequent uptake
of care. Non-judgmental care from l Be aware – although the maternal
maternity unit staff encourages regular hand-held record is marked ‘confidential’,
attendance, which in turn improves anything written can be read by others.
antenatal care, detection of fetal Before recording explicit details of
growth restriction, neonatal care, substance misuse in this record, ensure
communication between members of woman agrees to their inclusion
the multi-agency team, and discharge
planning Domestic abuse
l Whilst respecting privacy and
l Staff should be aware that substance
confidentiality, routinely record problem
misuse may be associated with current
drug or alcohol use at booking risk
or past experiences of abuse. Domestic
assessment
abuse often escalates during pregnancy
Booking l As a minimum, ensure routine enquiries
about domestic abuse are made at
l For women who disclose substance booking
misuse: l Whenever possible, woman should be
l book under consultant care to facilitate seen alone at least once during the
planning of maternity, neonatal and antenatal period to enable disclosure
social care within a multidisciplinary
team Screening for blood-borne viruses
l inform specialist midwife, if available
l In addition to routine hepatitis B and
locally
HIV screening, advise routine hepatitis
C screening
Specialist midwife/drug worker
will Hepatitis B and C
l Discuss neonatal abstinence syndrome l See Hepatitis guideline
and plan of care with woman and
appropriate family members HIV
l Initiate child safeguarding procedure
l See HIV positive women guideline
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SUBSTANCE MISUSE • 2/4
Plan of antenatal care
Gestation Action
l Consultant-led antenatal clinic
l Complete common assessment framework
At first disclosure
(CAF) form (if used locally)
l Liaise with specialist midwife, if available locally
l Find out which substances are being used and
in what quantities
l Arrange following tests:
l booking bloods
l hepatitis C
l dating scan
Booking l Discuss serum screening for Down syndrome
l Ensure follow-up with specialist drug workers
l Offer smoking cessation referral
l Initiate neonatal alert process in line with local
practice
l Plan subsequent antenatal visits with
community midwife/antenatal clinic
18–23 weeks l Anomaly scan
l Growth scan (according to local policy)
l Repeat bloods
Third trimester
l Ensure pre-birth plan in place, if appropriate
l Review plan of care for baby
41 weeks l Induction of labour for obstetric reasons
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SUBSTANCE MISUSE • 4/4
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THIRD AND FOURTH DEGREE PERINEAL TEARS –
OASIS (OBSTETRIC ANAL SPHINCTER INJURIES) • 1/2
l If practitioner inexperienced in assessing
CLASSIFICATION
perineal damage or unsure of degree of
Third degree tear trauma sustained, seek second opinion
INTRODUCTION Procedure
l In randomised clinical trials, l Ensure woman’s bladder is empty and
transcervical catheter induction has transfer to delivery suite
been shown to be safe and effective l Insert Instillagel® into vagina 5–10 min
in inducing labour in women with an before procedure to reduce discomfort
unfavourable cervical score when manipulating cervix. Entonox
l Its aim is to gradually dilate the cervix should be available
by gentle and constant pressure of l Place woman in lithotomy position
the catheter balloon at the level of the
cervix l Clean vulva with antiseptic solution
l It may be necessary to gently
INDICATIONS grasp the anterior cervical lip with
sponge-holding forceps to achieve a
l Unfavourable cervix requiring induction good view and facilitate procedure.
of labour where artificial rupture of This can be uncomfortable and should
membranes (ARM) is not possible not be done routinely
l Previous caesarean section (CS)
l Failed attempt at prostaglandin Foley catheter
induction l Hold (do not clamp) catheter with
Rampley’s forceps 1–3 cm (i.e.
CONTRAINDICATIONS measured cervical length from vaginal
examination) from end of balloon area
l Ruptured membranes
l Advance into the cervical canal until
1–3 cm below the balloon area has
METHOD
entered the canal and inflate balloon
with sterile water or sodium chloride
Consent
0.9% 30 mL
l Discuss procedure with woman and l Gently pull catheter back to ensure
obtain and document verbal consent balloon is resting at the internal cervical
os
Equipment l Apply a spigot to the catheter and
tape catheter to the thigh under gentle
l Foley balloon catheter 30 mL balloon
tension
or Cook® cervical ripening balloon
catheter
Cook® catheter
l both are effective but the Foley
catheter is cheaper and has a shorter l Pass catheter through cervix until both
placement-to-delivery interval balloons have entered cervix
l Instillagel® (local anaesthetic and l Inflate the intrauterine (red) balloon
antiseptic) with sterile water or sodium chloride
l Sterile vaginal examination pack 0.9% 40 mL
l Sterile Cusco speculum l Pull catheter back until balloon is
against the internal os
l Sponge-holding forceps (Rampley)
l Fill the visible vaginal (green) balloon
l Entonox with sterile water or sodium chloride
l Antiseptic solution 0.9% 20 mL
l sterile water or sodium chloride 0.9%
100 mL
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TRANSCERVICAL CATHETER INDUCTION • 2/2
Post-insertion
l Perform electronic fetal monitoring. See
Electronic fetal monitoring guideline
l Observe for signs and symptoms of
labour, spontaneous expulsion of
balloon, ruptured membranes, febrile
symptoms, pain and vaginal bleeding
l If catheter has not been passed
vaginally (12 hr for Cook® or 18 hr for
Foley), remove
l Middle grade obstetrician (ST3–7 or
equivalent e.g. staff grade, clinical
fellow) or consultant will decide
whether ARM is possible. If not, options
include a further attempt or CS
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UMBILICAL CORD PROLAPSE • 1/3
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UMBILICAL CORD PROLAPSE • 2/3
IMMEDIATE TREATMENT
Follow Flowchart and General principles below
Vaginal delivery
imminent Consider tocolysis Consider operative
vaginal delivery – see
Operative vaginal
Consider operative delivery guideline
vaginal delivery – see
Operative vaginal
delivery guideline
Caesarean section (CS)
l Is regional anaesthesia appropriate?
l Category 1 or 2 depending on FHR
pattern. See Delivery overleaf
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UMBILICAL CORD PROLAPSE • 3/3
l Empty bladder just before any delivery
General principles
attempt
l To prevent vasospasm, minimise handling l woman adopting knee-chest position
of loops of cord lying outside vagina or head-down tilt (preferably in
l Manual replacement of prolapsed left-lateral position)
cord above presenting part is not l While preparing for caesarean section,
recommended consider tocolysis if FHR abnormalities
l Wrapping cord in swabs soaked in persist after attempts to prevent
warm sodium chloride 0.9% is of no compression and when delivery is
proven benefit likely to be delayed
l Attempt to prevent cord compression by: l do not allow above to cause
unnecessary delay
Manual elevation of
presenting part Gestational age at the limits of
Contraindications viability
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UTERINE RUPTURE • 1/2
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UTERINE RUPTURE • 2/2
SUBSEQUENT MANAGEMENT
Scar rupture confirmed
(not simple dehiscence)
l Call consultant obstetrician and
consultant anaesthetist
l Manage haemorrhage
l activate major haemorrhage protocol if
required
l It may be possible to repair uterus.
Hysterectomy or subtotal hysterectomy
may be required
l Method of repair depends on nature
of tear, degree of haemorrhage and
woman’s future fertility wishes
l Give broad spectrum IV antibiotics –
according to local Trust policy
l Provide mother with high dependency
care – see High dependency care
guideline
Communication
l Explain events fully to woman and
family including implications for future
pregnancies
l Report clinical incident using local
incident reporting system
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VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) • 1/2
l ≥1 previous vaginal births (particularly
ANTENATAL CARE
previous VBAC) is associated with a
l Women who have history of an planned VBAC success rate of 85–90%
uncomplicated lower-segment transverse Rates of hysterectomy and blood
caesarean section (CS) and an otherwise transfusion increase in women who
uncomplicated pregnancy with no have had ≥2 previous caesarean
contraindications to vaginal birth, discuss births
options of VBAC or elective CS
l Discuss previous birth experiences with Contraindications to VBAC
woman. Take her wishes into account
and document discussion in maternal l Previous upper segment CS – advise
healthcare record woman to give birth by elective CS
l Review notes or request information l previous uterine incision other than an
from other hospital (if applicable) to uncomplicated low transverse CS incision
obtain details of previous CS l Previous uterine rupture
l To enable woman to make informed l >2 previous caesarean deliveries
choice, give VBAC leaflet (if available l Women with this history who wish
locally) during antenatal period, which to consider vaginal birth should be
includes risks of repeat CS and risks of assessed by a consultant obstetrician
scar rupture in labour with full access to details of previous
l Appropriate discussion using locally surgery (if possible)
available VBAC versus elective repeat l When considering planned VBAC in
CS checklist (recommended by RCOG woman with twin pregnancy, adopt a
to facilitate documentation of antenatal cautious approach
counselling and decision making)
l Refer women who are undecided to Risk factors for unsuccessful
the birth choices clinic (if available VBAC
locally) for further counselling l Previously failed induction of labour
l Obstetrician (ideally consultant, but l No previous vaginal birth
≥ST3), will agree mode of delivery
l Body mass index >30
with woman before expected/planned
delivery date (ideally by 36 weeks’ l Previous emergency CS for dystocia at
gestation) and document individual <8 cm
management plan for labour l VBAC ≥40 weeks’ gestation
l Offer women who opt for VBAC an ANC l Birth weight ≥4 kg
appointment at 40 weeks l Induction of labour for VBAC
l Women with previous CS to have l Short inter-delivery interval (<12 months
ultrasound scan to: since last delivery)
l determine placental localisation l Advanced maternal age
l to exclude placenta praevia l Non-white ethnicity
– if present enables further investigation
to identify praevia accreta and enable INTRAPARTUM MANAGEMENT
safe management l If local practice, establish IV access
l Individual management plan should be l FBC and group and screen
made if labour occurs before planned CS
l Midwife competent in the care of
l record woman’s choice high-risk conditions should care for
l Inform woman: woman during labour on a one-to-one
basis, and inform delivery suite
l chances of successful planned VBAC
co-ordinator of any change in care
are 72–75%
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VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) • 2/2
l Inform middle grade obstetrician (ST3–7 l loss of station of presenting part
or equivalent e.g. staff grade, clinical l If any of above detected, inform middle
fellow) that woman is on labour ward grade obstetrician (ST3–7 or equivalent
and if mode of delivery not previously e.g. staff grade, clinical fellow) and
agreed ensure a review is undertaken delivery suite co-ordinator immediately
l Epidural anaesthesia is not
contraindicated in planned VBAC INDUCTION OF LABOUR
l Offer continuous electronic fetal l Consultant obstetrician will discuss
monitoring (EFM) with onset of regular risks with woman
contractions
l 2–3-fold increased risk of uterine rupture
l When woman in labour, give ranitidine
and around 1.5-fold increased risk of CS
150 mg oral approximately 6–8-hrly
in oxytocin-induced and/or augmented
l Atypical abdominal pain, vaginal labours compared with spontaneous
bleeding and/or CTG abnormalities labour
must be regarded as potential uterine
l higher risk of uterine rupture where
rupture in women undergoing VBAC
prostaglandins used for induction of
Augmentation labour
l no increased risk of uterine rupture with
l Use oxytocin with caution induction using transcervical balloon
l although not contraindicated, decision catheter – see Transcervical catheter
to prescribe oxytocin must be made induction guideline
by consultant obstetrician after
l Women who wish to have VBAC should
obstetric assessment, including vaginal
be seen by consultant obstetrician in
examination and discussion with woman
antenatal clinic at 40 weeks and offered
l Normal regime until woman contracting membrane sweep, discussion on mode
3 in 10 (ideally not exceeding 4 in 10). of delivery and place of labour and an
Do not increase oxytocin further individualised and documented plan of
If no progress in labour in the delivery
presence of adequate uterine activity l Vaginal examination can help to assess
and oxytocin augmentation, proceed the favourability for induction and
to CS as soon as possible method of induction
l membrane sweeping is not
Uterine rupture contraindicated
l See Uterine rupture guideline
Monitoring
l Observe for symptoms and signs
including: l Once labour established, record careful
l tenderness or sudden pain over scar serial assessments on partogram – see
within abdomen, sudden cessation Labour management guideline
of uterine activity (especially if pain l Continuous EFM to detect signs of
breaks through epidural) or shoulder impending rupture, following the onset
tip pain of contractions – see Electronic fetal
l bleeding vaginally not associated to monitoring guideline
cervical dilatation l In uterine rupture, an abnormal EFM
l easily palpable fetal parts trace is present in 55–87% of cases
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VAGINAL BREECH DELIVERY • 2/3
l for planned vaginal breech delivery, l Encourage mother to actively push,
consider epidural analgesia to aid baby’s natural descent and
l Artificial rupture of membranes (ARM) ‘minimise handling’. Do not pull on
not usually performed due to risk of baby’s body or legs, flexed breech legs
umbilical cord prolapse usually deliver spontaneously
l If rupture of membranes occurs a vaginal l If assistance required to deliver legs,
examination may exclude cord prolapse once popliteal fossa visible, release
legs by flexing at the knees
l Avoid oxytocic drugs
l Observe for anterior scapula and allow
l Avoid use of fetal blood sampling time for arms to release spontaneously.
during labour on a breech presentation If assistance required, hook arms down
If delay or fetal compromise at any from the elbow. If this is not sufficient, 2
stage during labour, consider CS fingers can be passed over the shoulder
to push the humerus across the chest
l Passage of meconium cannot be relied
upon as indicator of fetal distress l if other shoulder does not deliver
spontaneously, repeat manoeuvre
Second stage of labour l Allow baby to hang until nuchal
line visible. Deliver head using
l Inform middle grade obstetrician Mauriceau-Smellie-Veit manoeuvre –
(ST3–7 or equivalent e.g. staff grade, combination of maxillary and occiput
clinical fellow)/consultant and ask to pressure
attend for second stage of labour l If obstetrician is conducting delivery
l Until presenting part is below the they may decide to deliver the head
level of the ischial spines, discourage using forceps
bearing down l Perform active management of the third
l Undertake urinary catheterisation stage
l Perform vaginal examination to
confirm fully dilated cervix (particularly Management of malpositions/
important preterm) and position of complications in the second
breech stage
l In active second stage, assist into l If malposition/complications arise
lithotomy position to enable breech in second stage – obstetric middle
delivery grade to request on-call consultant
l Call anaesthetist and theatre team obstetrician to attend
l Request attendance of a neonatologist. l Nuchal arm: rotate fetal spine to
See Cardiopulmonary resuscitation enable internal Lovset’s manoeuvre
of the newborn guideline in the l Delayed engagement in the pelvis
Staffordshire, Shropshire & Black of the after-coming head: second
Country Newborn and Maternity Network attendant applies suprapubic pressure
Neonatal guidelines (if used locally) to assist flexion of head
l alternatively first attendant displaces
Delivery
head upwards and rotates to the oblique
l Allow natural descent of fetal buttocks diameter to facilitate engagement
– hands off l Delivery of the obstructed
l Evaluate the need for episiotomy; after-coming head: if usual breech
consider waiting until fetal anus visible delivery manoeuvres fail, consider
over fourchette tocolysis, McRoberts manoeuvre,
incision of the cervix, symphysiotomy
l Ensure fetal spine rotates uppermost
or CS
during delivery
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VAGINAL BREECH DELIVERY • 3/3
Preterm breech
l Perform vaginal examination to confirm
second stage of labour
l Discuss mode of delivery of a preterm
breech on an individual basis with
woman and partner wherever possible
l If labour well established, there may be
no choice but to proceed to a vaginal
delivery. In this case, most senior
person available must carry out
delivery
l Where there is entrapment of
after-coming head, consider lateral
incision of cervix
Post-delivery
l Obtain cord blood for venous/arterial
testing and record result – see
Umbilical cord sampling guideline
l Debrief parents
l Arrange neonatal review for newborn
and infant physical examination (NIPE)
l Refer to local guidance on screening
for congenital hip dysplasia
Documentation
l Ensure clear documentation of:
l procedure
l help summoned
l names and grades of personnel
attending
l timing of events
l communication with woman
l Follow local incident reporting
procedure
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VTE – DEEP VENOUS THROMBOSIS • 1/3
Compression ultrasonography
Discontinue
treatment Discontinue treatment
and repeat ultrasound
on days 3 and 7
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VTE – DEEP VENOUS THROMBOSIS • 2/3
5000 units 6000 units 8000 units 10,000 units 12,500 units
Dalteparin
12-hrly 12-hrly 12-hrly 12-hrly 12-hrly
40 mg 60 mg 80 mg 100 mg 120 mg
Enoxaparin
12-hrly 12-hrly 12-hrly 12-hrly 12-hrly
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VTE – DEEP VENOUS THROMBOSIS • 3/3
l If VTE occurs during labour and l If woman chooses to commence
delivery, consider using unfractionated warfarin postpartum, avoid until at least
heparin, as it is more easily the third postnatal day
manipulated l Regular INR testing is recommended
l If delivery is by caesarean section, during the transfer from LMWH to
consider the use of wound drains warfarin to avoid over-anticoagulation
(abdominal and rectus sheath and (especially in first 10 days)
interrupted closure of skin incision for l Monitor INR 4 days after starting
women on therapeutic doses) warfarin
Postnatal anticoagulation
l Continue therapeutic anticoagulant
therapy for ≥6 weeks postnatally and
until ≥3 months of treatment has been
given in total. Offer a choice of LMWH
or oral anticoagulant (warfarin)
l If starting warfarin, provide woman with
counselling and an oral anticoagulant
booklet. Document in book (including
dose to take until next INR check) with
follow-up appointment on discharge
l Heparin and warfarin are not
contraindicated in breastfeeding
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VTE – PULMONARY EMBOLISM • 1/3
RECOGNITION AND l classical S1Q3T3 rarely seen
ASSESSMENT l CXR (with fetal shielding) to exclude:
l Diagnosis of DVT and pulmonary l pneumonia
embolism in pregnancy can l lung collapse
be challenging because of the l pneumothorax
physiological changes that occur. Many
of the classical symptoms of venous l features seen in PE:
thromboembolism can occur in a low – areas of translucency in under
risk pregnancy without VTE perfused lungs
– atelectasis
Symptoms and signs
– wedge-shaped infarction
l Dyspnoea/cyanosis – pleural effusion
l Collapse l if another cause for pleuritic chest pain
l Chest pain found, treat appropriately
l Cough l Discuss choice of ventilation perfusion
l Haemoptysis (VQ) lung scan or computerised
l Faintness/shock tomographic pulmonary angiography
l Tachycardia (CTPA) with radiologist
l Tachypnoea l VQ scan: if CXR normal, perform lung
l Mild pyrexia perfusion scan (Q scan)
l Raised JVP l minimises radiation dose to the fetus,
l Loud heart sound and right ventricular but has higher negative predictive value
heave l CTPA: if CXR abnormal, CTPA is first
l Pleural rub/effusion choice for radiological imaging
l Reduced PaO2 +/- PaCO2 l advise woman that compared with
l A high clinical suspicion is critical to CTPA, VQ scanning may carry a slightly
diagnosis increased risk of childhood cancer
(1/280,000 versus 1/1,000,000) but is
If PE suspected, start treatment
associated with a lower risk of maternal
with low molecular weight heparin
breast cancer
(LMWH) until diagnosis confirmed or
refuted, unless contraindicated l Diagnosis of DVT may indirectly
confirm a diagnosis of PE and, since
Investigations anticoagulant therapy is the same for
both conditions, further investigation
l Oxygen saturation may not be necessary. This would
l ABG (limited value when used alone) limit the radiation doses given to
l FBC woman and fetus for all suspected
l Coagulation profile non-massive PE (normal CXR, ECG
l U&Es and haemodynamically stable)
l LFTs l If woman is haemodynamically
l ECG unstable an echocardiogram is useful
to identify right ventricular dysfunction
l sinus tachycardia common
l with large PE there may be: l Pulmonary angiography: reserved for
severe cases before embolectomy
– T wave inversion (most common
abnormality) l Continue anticoagulant treatment until
– right-axis deviation PE definitely excluded
– right bundle-branch block
– peaked P waves in lead II due to
right atrial dilatation
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VTE – PULMONARY EMBOLISM • 2/3
l in women with renal impairment,
TREATMENT
seek advice on dose reduction from
Women at risk of haemorrhage: haematologist
l Decision of thoracotomy or surgical
l If at risk and continued heparin embolectomy to be made by
treatment essential, use unfractionated consultant obstetrician, consultant
heparin IV physician, consultant thoracic surgeon
l has a shorter half-life and its activity and radiologist
is more completely reversed with
protamine sulphate General
l If woman develops a haemorrhage
l Resuscitate and give oxygen to
while on LMWH: stop treatment and
maintain SpO2 between 94–98%
discuss with haematologist
l Adequate analgesia
Massive life-threatening
PE in pregnancy Specific
l Resuscitate and give oxygen l Blood for FBC, INR, APTT, U&E’s, LFTs,
ABGs
l Involve multidisciplinary resuscitation
team including consultant physician, l CXR
consultant obstetrician, consultant l ECG
anaesthetist and radiologist
l If platelet count <75 x 109/L, seek
l If PE confirmed, urgent CTPA or advice from on-call haematologist
portable ECHO and team decide before starting anticoagulation
whether IV unfractionated heparin,
l If platelet count ≥75 x 109/L, prescribe
thrombolytic therapy or thoracotomy
subcutaneous LMWH (dalteparin
and surgical embolectomy appropriate
or enoxaparin – according to local
l IV unfractionated heparin is preferred in practice)
massive PE because of its rapid effect
and extensive experience of use Initial anticoagulant
l indicated for massive PE and where treatment in pregnancy
aggressive management required
l In clinically suspected DVT or PE,
l loading dose of 80 units/kg (5000 units) administer LMWH at doses below until
over 5 min, followed by 18 units/kg/hr objective testing excludes diagnosis
(e.g. for 70 kg woman, usually 1500
l If weight is >125 kg – discuss with
units/hr) continuous IV infusion (based
haematologist
on booking weight) to maintain APTT
of 2–3 times average laboratory control
value. If thrombolysis is given, omit
loading dose of heparin
5000 units 6000 units 8000 units 10,000 units 12,500 units
Dalteparin
12-hrly 12-hrly 12-hrly 12-hrly 12-hrly
40 mg 60 mg 80 mg 100 mg 120 mg
Enoxaparin
12-hrly 12-hrly 12-hrly 12-hrly 12-hrly
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VTE – PULMONARY EMBOLISM • 3/3
l Heparin and warfarin are not
Monitoring LMWH treatment
contraindicated in breastfeeding
l If woman has not been given l If woman chooses to commence
unfractionated heparin, monitoring for warfarin postpartum, avoid until at least
heparin-induced thrombocytopenia is the third postnatal day
not required
l Regular INR testing is recommended
l If early pregnancy weight <50 kg or during the transfer from LMWH to
>90 kg and woman has bleeding warfarin to avoid over anticoagulation,
problems, renal impairment, or massive especially in the first 10 days
PE, discuss need for anti-Xa monitoring
l Monitor INR for 4 days after
with consultant haematologist
commencing warfarin
Administration of LMWH
and use of epidural/spinal
anaesthesia
l See VTE – Deep vein thrombosis
guideline
Postnatal anticoagulation
l If no problems with bleeding, re-start
anticoagulation treatment 4 hr after
delivery
l Continue therapeutic anticoagulant
therapy for ≥6 weeks postnatally and
until ≥3 months of treatment has been
given in total. Offer a choice of LMWH
or oral anticoagulant (warfarin)
l LMWH:
l dalteparin (10,000–18,000 units
according to weight) OR
l enoxaparin (1.5 mg/kg daily)
l If starting warfarin, provide woman with
counselling and an oral anticoagulant
booklet. Document in book (including
dose to take until next INR check) with
follow-up appointment on discharge
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VTE – THROMBOPROPHYLAXIS • 1/5
Table 2: Postnatal
RISK FACTOR RISK LEVEL/ACTION
l Previous VTE l High risk
l Requiring antenatal LMWH l ≥6 week postnatal prophylactic
l High-risk thrombophilia LMWH
l Low-risk thrombophilia + family history
l Caesarean section (CS) in labour l Intermediate risk
l BMI ≥40 kg/m2 l ≥10 days postnatal
l Readmission or prolonged admission (≥3 days) prophylactic LMWH
in the puerperium l if persisting, or >3 risk
l Any surgical procedure in the puerperium factors, consider extending
except immediate repair of perineum thromboprophylaxis with LMWH
l Medical comorbidities e.g. cancer, heart
failure, active SLE, IBD or inflammatory
polyarthropathy, nephrotic syndrome, type
1 DM with nephropathy, sickle cell disease,
current intravenous drug user
l Age >35 yr l ≥2 risk factors – see
l Obesity (BMI ≥30 kg/m2) Intermediate risk above
l Parity ≥3
l <2 risk factors – lower
l Smoker risk: early mobilisation and
l Elective CS avoidance of dehydration
l Family history of VTE
l Low-risk thrombophilia
l Gross varicose veins
l Current systemic infection
l Immobility, e.g. paraplegia, PGP restricting
mobility, long-distance travel
l Current pre-eclampsia
l Multiple pregnancy
l Preterm delivery in this pregnancy (<37 weeks)
l Stillbirth in this pregnancy
l Mid-cavity rotational or operative delivery
l Prolonged labour (>24 hr)
l PPH >1 L or blood transfusion
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Table 3: Thromboprophylactic doses for antenatal and postnatal LMWH
Weight Enoxaparin Dalteparin
<50 kg 20 mg once daily 2500 units once daily
50–90 kg 40 mg once daily 5000 units once daily
91–130 kg 60* mg once daily 7500 units once daily
131–170 kg 80 mg* once daily 10,000 units once daily
>170 kg 0.6 mg/kg/day* 75 units/kg/day
High prophylactic dose for women
40 mg 12-hrly 5000 units 12-hrly
weighing 50–90 kg
*may be given in 2 divided doses
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Induction of labour
l If receiving high prophylactic or
therapeutic doses of LMWH: reduce
dose to normal thromboprophylactic
dose on day before induction of labour
l reassess before recommencing
l Anaesthetic review in labour
l Stop LMWH on day of induction
Elective CS
l Omit morning LMWH dose
l surgery to be performed that morning
l Increased risk of wound haematoma
with LMWH; consider use of wound
drains and interrupted closure of skin
l Carry out risk assessment before and
after delivery
l continue postpartum
thromboprophylaxis
l for persistent risk factors, e.g.
prolonged admission, wound infection
or surgery in the puerperium: extend
for ≥6 week, or until additional risk
factor no longer present
Other thromboprophylactic
agents
l Warfarin:
l women receiving long-term warfarin can
be converted from LMWH to warfarin
postpartum when risk of haemorrhage
reduced (usually 5–7 days)
l safe when breastfeeding
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WATERBIRTH • 1/2
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WATERBIRTH • 2/2
EVACUATION POLICY
l In the event of an emergency where
mother unable to make an assisted
rapid exit from birthing pool
l Call for help, using emergency call bell
system
l Rapidly fill pool to allow woman to float
to the top. Support her head above
water
l Use evacuation equipment available
locally (kept in birthing pool room at all
times)
l Ensure minimum of 4 adults (ideally 6)
2 or 3 each side of the pool
l Remove foot of bed and bring bed to
foot of birthing pool
l Evacuate mother from pool with 2
consecutive manoeuvres, first to
bottom edge of bed, a short pause,
and then complete manoeuvre onto
bed
l Remember – the woman will be
wet and at risk of hypothermia – dry
immediately
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INDEX • 1/3
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INDEX • 2/3
H N
HELLP 103, 237, 240 Necrotising fasciitis 232, 235
Hepatitis 99 Neonatal resuscitation 29
High dependency care 102 Neurological deficits after regional
HIV 106 anaesthesia or analgesia 171
Home birth 109 Nifedipine 81–82, 113–114,
Hypertension 112 207–208, 238, 242
Neural tube defect 164, 176
I Normal laboratory values 175
Identification 26–27, 35, 40, 65, 71, 224, 248
Induction of labour 119 O
Infant feeding 124 OASIS
Intermittent auscultation 136
(Obstetric anal sphincter injuries) 255
In-utero transfer 99, 146–149
Obese mother (care of) 176
Operative vaginal delivery 180
J Oxytocin 183
Jehovah’s Witnesses 42
P
K Perinatal bereavement 185
Kleihauer test 18, 42, 110, 153, 189
Perineal trauma 192
Placenta accreta 20, 41, 200
L Placenta praevia 18, 20, 41, 120,
Labour (delay in) 48 166,168, 204,
Labour (induction of) 119 214, 266, 268, 280
Lactic acid 87 Placenta (retained) 152, 200, 224, 219, 257
Latent phase 142
Placental abruption 18
Podalic version 170, 260, 262
M Polyhydramnios 20, 51, 58, 62, 66,
136, 162, 204, 215, 260
Macrosomia 50–52, 119, 136, 176, 195, 245
Postpartum haemorrhage 195
Maternal collapse 43
Maternal death 144 Postpartum endometritis 232
Maternal transfer 146 Pregnant woman with
non-obstetric problem 201
Mauriceau-Smellie-Veit manoeuvre 269
Pre-labour rupture of membranes
Meconium stained liquor 150
(PROM) 202
Medical termination 152
Preterm labour 204
Membrane sweeping 119–122, 267
Primigravida 22
MEOWS – see MEWS
Prolapse (umbilical cord) 260
MEWS 18–19, 102–103, 185, 121, 198,
201, 204, 212, 232–233 Pre-eclampsia (severe) 237
Morbidly adherent placenta 166 Pyelonephritis 232
Multiple pregnancy 168
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R V
Recovery 210 Vacuum 180–181
Refusing blood and blood products 213 Vaginal birth after caesarean section 266
Registration and identification 35, 40 Vaginal breech delivery 268
Retained placenta 219 Vaginal delivery (operative) 180
Retained products of conception 128, Ventouse 107, 181, 208
199, 232, 235
Routine postnatal care of
women and babies 221 W
Rubin II manoeuvre 246 Waterbirth 282
Woods’ screw manoeuvre 246, 248
S
Sepsis 232
Severe pre-eclampsia 237 Z
Shoulder dystocia 245 Zavenelli manoeuvre 246, 248
T
Third and fourth degree
perineal tears 255
Third stage labour 257
Thromboprophylaxis 277
Tocolysis 184, 205, 207, 261, 262, 269
Transcervical catheter induction 258
Transfer (in-utero) 146
Transfer (maternal) 146
Twins 168–169, 190
U
Umbilical arterial vasospasm 260
Umbilical cord prolapse 260
Umbilical cord sampling 263
Unfavourable cervix 120, 258
Uterine rupture 264
Uterine scar 136, 268
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Obstetric Guidelines
2017–19
This book has been compiled as an aide-memoire for all staff
concerned with the management of pregnant women and newborn
babies, towards a more uniform standard of care across the
Staffordshire, Shropshire & Black Country Newborn and Maternity
Network and Southern West Midlands Maternity and Newborn
Network hospitals
9 780955 705861
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