Obstetric Guidelines 2017–19 Obstetric 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 Guidelines Network hospitals

These guidelines are advisory, not mandatory

Every effort has been made to ensure accuracy The authors cannot accept any responsibility for adverse outcomes 2017-19

Published by the Staffordshire, Shropshire & Black Country Newborn and Maternity Network Obstetric Guidelines 2017-19

The Bedside Clinical Guidelines Partnership Copyright © Copyright holder in association with the ISBNISBN 978-0-9557058-8-5 978-0-9557058-6-1 Staffordshire, Shropshire & Black Country Newborn and Maternity Network 9 780955 705861 and Southern West Midlands Printed by: Sherwin Rivers Ltd, Waterloo Road, Stoke on Trent ST6 3HR Tel: 01782 212024 Fax: 01782 214661 Email: [email protected] Maternity and Newborn Network This copy belongs to Name…………...... ……………………………………………………………………… Further copies can be purchased from Staffordshire, Shropshire & Black Country Newborn and Maternity Network Administrator: Email: [email protected]

Published by the Bedside Clinical Guidelines Partnership, Staffordshire, Shropshire & Black Country Newborn and Maternity Network and Southern West Midlands Maternity and Newborn Network NOT TO BE REPRODUCED WITHOUT PERMISSION

Staffordshire, Shropshire & Black Country Newborn and Maternity Network comprises: The Dudley Group NHS Foundation Trust The Royal Wolverhampton NHS Trust The Shrewsbury and Telford Hospital NHS Trust University Hospitals of North Midlands NHS Trust Walsall Healthcare NHS Trust

Southern West Midlands Maternity and Newborn Network comprises: Birmingham Women’s NHS Foundation Trust Heart of England NHS Foundation Trust Sandwell and West Birmingham Hospitals NHS Trust Worcestershire Acute Hospitals NHS Trust Wye Valley NHS Trust Birmingham Children’s Hospital NHS Foundation Trust

The Bedside Clinical Guidelines Partnership comprises: Basildon and Thurrock University Hospital NHS Foundation Trust Burton Hospitals NHS Foundation Trust Circle Nottingham Ltd East Cheshire NHS Trust George Eliot Hospital NHS Trust Ipswich Hospitals NHS Trust Mid Cheshire Hospitals NHS Trust North Cumbria University Hospitals NHS Trust The Dudley Group NHS Foundation Trust The Pennine Acute Hospitals NHS Trust The Princess Alexandra Hospital NHS Trust The Royal Wolverhampton Hospitals NHS Trust The Shrewsbury and Telford Hospital NHS Trust University Hospitals of North Midlands NHS Trust University Hospitals Birmingham NHS Foundation Trust University Hospitals of Morecambe Bay NHS Trust Walsall Healthcare NHS Trust Wye Valley NHS Trust CONTENTS • 1/2

Acknowledgements 5 Commonly used abbreviations 6 Preface 9 Communication and documentation 11 GUIDELINES Anaemia in 14 Antepartum haemorrhage (APH) including placental abruption 18 Bladder care 22 26 Cardiopulmonary resuscitation of the newborn 29 Care of the newborn at delivery 35 Cell salvage NEW 41 Collapse (including 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 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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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 166 Multiple pregnancy 168 Neurological deficits after regional anaesthesia or analgesia 171 Normal laboratory values in pregnancy 175 Obese mother (care of) 176 Operative 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 237 245 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 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

Issue 4 4 Issued: April 2017 Expires: April 2019 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

Contributors Bedside Clinical Guidelines Partnership Robina Akhtar Kathryn McCarron Krishna Banavathi Naveed Mustfa Jacqui Bolton Mathew Stone Lynn Dudley Jackie Dunn Staffordshire, Shropshire & Black Fiona Garrington Country Newborn and Maternity Network Sarah Gibbs Sarah Carnwell Janet Herrod Ruth Moore Simon Jenkinson Hamza Katali Maria Lodge Paddy McMaster Elizabeth Pearson Ellen Pike Paula Pryce Helen Sullivan Maggi Umbers

Obstetrics editors The editors would like to thank the Jacqui Bolton following people/organisations for providing specialist information Lucy Morse Helen Sullivan Birmingham Women’s Hospital – Fetal Lakshmi Thirumalaikumar loss guideline

SANDS Pharmacist ( and Neonatal Death Society) Nicola Staton Nathalya Kennedy Cheryl Titherly Microbiology Seema Desai

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A CVS Chorionic villus sampling AAGBI Association of Anaesthetists of CX 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 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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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 J P Parity 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 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

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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

Issue 4 8 Issued: April 2017 Expires: April 2019 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.

The guidelines are advisory, NOT mandatory

The following guidelines are new to this edition: l Mental health in pregnancy l Cell salvage l Electronic fetal monitoring (EFM) – Antenatal l Remifentanil patient controlled analgesia (PCA) use in labour If there are any guidelines you would like to see in the next edition, please submit as soon as possible for editorial comment. The deadline for suggestions for revisions or new guidelines to be included will be November 2017

Supporting information

Where supporting evidence has been identified it is graded I to 5 according to standard criteria of validity and methodological quality as detailed in the table below. A summary of the evidence supporting each statement is available, with the original sources referenced. The evidence summaries are being developed on a rolling programme which will be updated as each guideline is reviewed.

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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 Evaluation of the evidence-base of these guidelines involves review of existing literature then periodical review of anything else that has been published since last review. The editors encourage you to challenge the evidence provided. If you know of evidence that contradicts, or additional evidence in support of, the advice given in these guidelines please forward it to the Clinical Guidelines Developer/Co-ordinator on [email protected]

Feedback and new guidelines The editors acknowledge the time and trouble taken by numerous colleagues in the drafting and amending of the text. The accuracy of the detailed advice given has been subject to exhaustive checks. However, any errors or omissions that become apparent should be drawn to the notice of the editors, via the Clinical Guidelines Developer/ Co-ordinator [email protected]), so that these can be amended in the next review, or, if necessary, be brought to the urgent attention of users. Constructive comments or suggestions would also be welcome.

Issue 4 10 Issued: April 2017 Expires: April 2019 COMMUNICATION AND DOCUMENTATION • 1/1

Effective communication is essential for delivery of high quality, safe care

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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These guidelines are advisory, NOT mandatory ANAEMIA IN PREGNANCY • 1/4 l Vitamin B deficiency INTRODUCTION 12 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)

DEFINITION Symptoms and signs Hb <110 g/L in the first trimester and l Pallor <105 g/L in the second and third l Lethargy trimesters; is associated with: l Shortness of breath l Low-birth-weight and preterm labour l Weight loss l Poor fetal outcome l Depression l Surgical complications and l perioperative morbidity in mother Nausea l l Amount of iron baby will store during Vomiting breastfeeding l Gingivitis l Neurological development and brain l Diarrhoea function l Tachycardia Consider most suitable place l Thready pulse of birth for women who are anaemic in labour and take DIAGNOSING IRON appropriate precautions to reduce DEFICIENCY ANAEMIA or manage blood loss l Screen for anaemia at booking and 28 weeks’ gestation unless otherwise RISK FACTORS indicated l l Women with malabsorption syndrome, Offer screening to women identified for haemoglobinopathy, epilepsy haemoglobinopathies (i.e. sickle cell requiring anticonvulsants and multiple and thalassaemia) following completion are at increased risk of of the Family Origin Questionnaire folate deficiency (FOQ) at booking l l offer iron and folic acid Diagnose iron deficiency anaemia if supplementation mean corpuscular volume (MCV) <80 fl l l Other groups may have an increased 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

Issue 4 14 Issued: April 2017 Expires: April 2019 ANAEMIA IN PREGNANCY • 2/4 l TREATMENT Counsel woman to take oral iron 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 l check iron studies, B and folate using 1 of the following preparations: 12 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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Treatment B12 deficiency known or diagnosed l Check levels of folate in blood and

red blood cells and B12 levels in first l Eat animal protein – fresh well-cooked instance meat (avoid pre-cooked chilled meat) l If folate deficiency diagnosed, start folic l Well-cooked eggs acid 5 mg/day. Iron supplementation l Milk may also be necessary l Cheese (avoid soft runny cheeses e.g. l If B deficiency diagnosed, refer to GP 12 Brie) or hospital antenatal clinic l Give vitamin B injections l If both B and iron supplementation 12 12 (hydroxocobalamin) 1 mg IM 3 times/ required, start B treatment first 12 week for 2 weeks, then 1 mg every l If folate and B12 levels are normal, refer 3 months according to response to consultant antenatal clinic who will l Take weekly red cell counts and Hb consider referral to haematology estimations until a maintenance dose is reached Advice to woman l Iron supplementation is prescribed as before in addition to vitamin B as Lifestyle 12 rapid response to regeneration of red l Avoid alcohol blood cells may deplete iron stores – l Stop smoking see Flowchart

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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Process pathway – management of anaemia in pregnancy

Anaemia Hb <105

l Oral iron See Elemental iron

Ensure compliance and provide good dietary advice

Check Hb 4 weeks later

Hb >105 Hb <105

Consider stopping oral iron or consider maintenance dose

Hb increase of >32 g/dL Hb increase of <32 g/dL

Continue iron therapy until Hb Check folate, vitamin B12 at desired level (>105) and iron studies

l MCV <96 l MCV >96 l MCV >96 l MCV >96 l Normal B and l Normal vitamin B l Decreased 12 12 l Decreased folate and folate levels vitamin B folate levels 12 l Low iron levels l Low iron levels levels

Commence l Commence vitamin Inform obstetric Commence intravenous B12 injections IM consultant and folic acid iron as per local l hydroxocobalamin refer for 5 mg daily policy haematology 1 mg 3 times/week opinion for 2 weeks, then 3 monthly l Advise postnatal follow-up by GP

Issue 4 Issued: April 2017 17 Expires: April 2019 ANTEPARTUM HAEMORRHAGE (APH) (including placental abruption) • 1/4

DEFINITION If placenta low lying, do NOT perform digital vaginal examination to avoid l Bleeding from the genital tract >24 accidental trauma to placenta and weeks of pregnancy and before birth possible severe haemorrhage l spotting/streaking l l minor: <50 mL Auscultate fetal heartbeat to determine presence l major: 50–1000 mL l Perform electronic fetal monitoring l massive: >1000 mL/compromise (EFM) to assess fetal wellbeing – see Electronic fetal monitoring – INITIAL MANAGEMENT Antenatal guideline l Admit to maternity unit l Consider maternal corticosteroids to facilitate fetal lung maturity <34+6 l Immediately assess severity of weeks’ gestation haemorrhage and whether immediate treatment required If minor APH progresses to major, l If maternal shock, marked abdominal delivery indicated pain or tenderness, or fetal heart-rate abnormalities, see Major APH or Monitor abruption below l l Inform junior doctor and/or middle Start Maternity Early Warning Scoring grade obstetrician (ST3–7 or equivalent (MEWS) chart e.g. staff grade, clinical fellow) who will review and formulate care plan Investigation l Obtain detailed history from woman or l Take bloods for: those accompanying her l FBC l Assess colour and amount of vaginal l group and save and crossmatch if blood loss to determine whether fresh significant bleed or stale, moderate or major bleed l consider coagulation studies Examination l in Rhesus negative women, perform Kleihauer test to quantify the degree l Full antenatal examination (in of any fetomaternal haemorrhage and accordance with local Trust admission determine dose of anti-D required. It is policy). Include: of little value in diagnosing abruption l fundal height For Rh negative women, obstetrician l lie, presentation and fifths palpable will prescribe anti-D immunoglobulin of presenting part. A high presenting part/abnormal lie can indicate MAJOR APH OR ABRUPTION l examine abdomen for tenderness/ Presenting symptoms tenseness/location of pain l l Perform vaginal speculum examination, Maternal shock except when known major placenta l Marked abdominal pain or tenderness praevia l Fetal heart-rate abnormalities l Assess cervix dilatation and l Bleeding may be concealed or visible appearance l Take triple swabs, including chlamydia l Refer to ultrasound scan to determine location of placenta Issue 4 18 Issued: April 2017 Expires: April 2019 ANTEPARTUM HAEMORRHAGE (APH) (including placental abruption) • 2/4

MANAGEMENT When infusing large amounts of intravenous fluids rapidly, infuse This is an obstetric emergency via blood warmer l Activate emergency buzzer and request assistance from: Analgesia l delivery suite team leader l Dosage and administration according l middle grade obstetrician (ST3–7 or to severity of pain. Opiates may be equivalent e.g. staff grade, clinical required for placental abruption fellow) and junior doctor Monitor l on-call obstetric anaesthetist and anaesthetic nurse or operating l Pulse department practitioner l BP l Notify consultant obstetrician and l Respiratory rate consultant anaesthetist l Oxygen saturation l Team leader will delegate management l tasks and nominate a team member to Renal function: monitor urine output document events hourly l report volume <30 mL/hr to attending Resuscitation obstetric and anaesthetic staff l Temperature l Manage and maintain – Airway, l Breathing, Circulation Fetal heart by EFM l l Record vital signs every 5 min (include if no signs of fetal heart rate – MEWS) ultrasound scan to confirm/rule out intrauterine death l Avoid aortocaval compression l Give high flow oxygen Caesarean section l If fetal heart rate present and maternal Replace blood volume loss condition stable, transfer to theatre for l Insert 2 large bore (14 or 16 gauge) IV emergency caesarean section cannulae l Set up cell saver if used locally l Take blood for: l Inform neonatologist and request l crossmatch attendance at delivery l FBC Intrauterine death l clotting screen and fibrinogen l Inform consultant obstetrician and l Request blood and blood products discuss plan of care with woman, urgently according to Trust Major considering severity of haemorrhage haemorrhage protocol and maternal condition l While awaiting blood, infuse compound l The longer the stays in-utero, sodium lactate (Hartmann’s) solution or the higher the risk of disseminated sodium chloride 0.9% and colloid intravascular coagulation (DIC) l If blood loss life-threatening un-crossmatched O Rhesus-negative Expect and be prepared for massive blood or group-specific blood (if postpartum haemorrhage (PPH) available) may be used from delivery whether delivered vaginally or suite blood refrigerator by lower segment caesarean section (LSCS) – see Postpartum l Insert indwelling urinary catheter haemorrhage guideline

Issue 4 Issued: April 2017 19 Expires: April 2019 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 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 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 Issue 4 20 Issued: April 2017 Expires: April 2019 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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l BACKGROUND document response in medical history section of maternal healthcare record l 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

Women at highest risk MANAGEMENT IN LABOUR l Primigravida First stage l Prolonged labour, especially prolonged second stage l Encourage 2–4 hrly voiding; ensure l Epidural for labour and delivery good void is documented l Frequent catheterisation during labour l threshold for catheterisation (in/ out) should be low if woman unable l Assisted vaginal delivery to void on 2 occasions (>4 hr) or l Caesarean section maternal bladder is palpable. If third l Perineal injury catheterisation is required, insert an indwelling catheter (IDC) l Big baby >4.5 kg l if any void measures >500 mL, bladder l Previous bladder problems (required should be emptied more frequently to individualised management plan for prevent over-distention labour and puerperium) l Maintain adequate hydration during Symptoms and signs labour l Urinalysis with dipstick every void and l Frequency/urgency/lower abdominal pain document in partogram l Prolonged voiding l No sensation to void or inability to void Second stage l Palpable bladder A full bladder may hinder descent of l Overflow incontinence presenting part ANTENATAL CARE l Ensure bladder is empty. If necessary, catheterise First antenatal visit l Bladder must be empty before l Ask woman if she has ever experienced instrumental delivery problems with bowel or bladder l consider use of in/out catheter or if IDC function. This can result in early already in situ deflate balloon detection of bladder/bowel dysfunction

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POSTNATAL ADVICE/ Voiding small amounts of urine DISCUSSION l If woman continues to void small l Ask again if woman has ever experienced volumes of urine (<150 mL) 6 hr problems with bowel/bladder function post-delivery, insert size 12 Foley l Document response in appropriate catheter or perform a bladder scan if section of maternal healthcare record available l If problem highlighted, document l Measure residual urine volume in management plan and refer to l if 200 mL, leave catheter in place appropriate healthcare professional freely draining for 24 hr and start fluid (e.g. physiotherapy, urotherapist) balance chart l Provide advice on: l if <150 mL, encourage increased fluid l diet and fluids intake l importance of avoiding constipation l record amount of urine passed l pelvic floor exercises l inform obstetric middle grade (ST3–7 l simple analgesia or equivalent e.g. staff grade, clinical fellow) POSTNATAL MANAGEMENT l Remove catheter after 24 hr and, if infection suspected, send catheter Most women will experience supra specimen of urine (CSU) for analysis pubic discomfort as their bladder l distends but lack of this sensation rapid diuresis may occur and will does not mean the bladder is not full depend on how much fluid has been consumed or infused l Encourage woman to void before l measure next 2 voids. If ≥150–200 mL leaving delivery suite or departing the (volume dependent on local guidance), home if homebirth discharge woman l Palpate abdomen for signs of palpable l Repeat question – has woman ever bladder, or deviation of uterus which experienced problems with bowel or may indicate urinary retention bladder function l Record time and volume of first void in l document response in appropriate maternal healthcare record section of maternal healthcare record l if volume ≥150–200 mL (volume and management plan dependent on local guidance), and If catheterisation required, discuss woman experiences no difficulty transfer to consultant-led unit with in micturation or any other urinary woman and consultant symptoms, cease recording l if volume <150–200 mL (volume dependent on local guidance), see Voiding small amounts of urine below l If clinical suspicion of dehydration, encourage fluids l If no dehydration and retention suspected, do not encourage fluids as this can exacerbate retention. Seek advice from junior doctor and/or middle grade obstetrician (ST3–7 or equivalent e.g. staff grade, clinical fellow) l establish when woman last passed urine in labour

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After removal of indwelling If not voided 4 hr after birth or catheter for voiding problems removal of IDC:

l Abdominal palpation l If still unable to void or continuing to void small volumes after catheter l Assess for signs of palpable bladder/ removal, inform consultant obstetrician deviated uterus l Measure residual urine volume or, l Inspect perineum if available, use bladder volume l Offer analgesia screening l Allow privacy and time l if <150 mL, consider repeating residual l Encourage fluids if clinically volume measurement in 12 hr dehydrated l if >300 mL, replace IDC for ≥48 hr and, more commonly, 7 days l if between 150–300 mL, discuss with woman and agree course of action, depending on her individual circumstances (e.g. repeat residual volume measurement after next void or insert catheter) l Discuss management plan with woman and document in maternal healthcare record l Arrange follow-up at 6 weeks postpartum e.g. in pelvic floor clinic (depending on local policy)

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Flowchart: Postnatal bladder care management

Spontaneous void ≤6 hr VOID ≥150–200 mL of birth or removal of IDC

UNABLE VOID TO VOID <150–200 mL

l No further l Measure and measurements Catheterise EITHER VOID record volume required with size 12 ≥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

CATHETERISATION MANAGEMENT l Spontaneous void ≤6 hr of l 1st catheterisation removal of IDC l leave in situ 24 hr l Measure volume of 2 voids l 2nd catheterisation following removal of IDC l leave in situ 48 hr–7 days l Commence fluid balance chart – record input and output BOTH VOIDS 150–200 mL l Inform obstetrician l If at MLU discuss plan and consider transfer to consultant unit l If infection suspected send CSU

Issue 4 Issued: April 2017 25 Expires: April 2019 CAESAREAN SECTION • 1/3

INTRODUCTION Caesarean section can be life-saving or can prevent serious morbidity to mother and fetus

CLASSIFICATION AND TIMING OF CAESAREAN SECTION l Use classification below to communicate degree of urgency to all staff and ensure caesarean section is undertaken within an acceptable timeframe l Prepare for a caesarean section to minimise risks of procedure and optimise mother’s and her birth partner’s experience. The shorter the decision to delivery interval the less optimal the preparation

Category Definition Standard 1 – Crash Immediate threat to life of Interval between decision to delivery woman and fetus time should be ≤30 min 2 – Urgent Maternal or fetal compromise Interval between decision to delivery not immediately life-threatening time according to local practice 3 – Scheduled Early delivery necessary – no Interval between decision to delivery maternal or fetal compromise time according to local practice 4 – Elective No maternal or fetal Undertaken at a time to suit both compromise woman and obstetric team

CATEGORY 1 CAESAREAN Documentation SECTION l Person making decision for caesarean Preparation section documents the following in intrapartum care record: l Middle grade obstetrician (ST3–7 or l indication and classification of equivalent e.g. staff grade, clinical emergency caesarean section fellow) decides if caesarean section indicated l time decision for caesarean section made l consultant obstetrician involved in making decision unless doing so would l any reason for a delay in performing be life-threatening to the woman or caesarean section fetus l Complete the WHO theatre check list l Follow local practice to summon theatre team and inform category 1 Midwife caesarean section l Remove woman’s jewellery or cover l Transfer to theatre immediately under adhesive tape l Provide woman with as much l Remove woman’s nail polish information as possible and obtain l consent If oxytocin infusion in progress, switch off l verbal consent is acceptable in cases l of extreme emergency Ensure patient identification (e.g. band) attached according to local practice l Ensure blood taken for the following and deliver to laboratory urgently: l FBC l group and save

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Anaesthetist CATEGORY 2, 3 AND 4 CAESAREAN SECTION l Pre-assesses woman (may be continued en-route to and/or in theatre) Preparation l Establish IV access 16 G cannula (if not l There is more time for preparation e.g: already done) l more detailed explanation to woman l Give antacid treatment as per local and written consent policy l dressing woman in hospital gown, hat Theatre team to cover long hair l Prepares theatre l fetal heart monitoring l administer antacids (e.g. ranitidine) as In theatre per local policy l Anaesthetist, theatre team and Complete WHO checklist midwife Obstetrician l Place woman in left lateral tilt on l operating table; commence oxygen Provides detailed information to woman and obtains written consent l Maternal monitoring – BP, ECG, l oximetry Documents indication for caesarean section in intrapartum maternal l Regional or general anaesthesia healthcare record administered l Prescribes antacids (e.g. ranitidine) as l Administer prophylactic antibiotics as per local policy per local guidance l Commences caesarean section audit l Catheterise woman form (if local practice) l Check resuscitaire and emergency neonatal resuscitation equipment Anaesthetist l Neonatologist or advanced neonatal l practitioner (ANNP) trained in Pre-assesses woman resuscitation of the newborn to be present at: Midwife l all category 1 and 2 emergency l Review woman’s birth plan caesarean section l If not already arranged, ensure a l caesarean section when general midwife is allocated to care for the anaesthesia used woman l When performing caesarean section l Midwife ensures: with a deeply impacted head (at level l continuous electronic fetal monitoring of/below ischial spines): (category 2) until surgery begins l a more experienced obstetrician may l pre-operative check list completed be required l VTE thromboprophylaxis as per local l consider use of fetal pillow if available policy locally l patient identification completed and in l Obtain paired cord gases – see situ Umbilical cord sampling guideline or follow local practice l blood for FBC and group and save l contact neonatal team if presence required

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FOLLOWING CAESAREAN Communication SECTION l Obstetrician to discuss procedure with l See Recovery guideline or local policy woman, offering advice about vaginal for enhanced recovery birth after caesarean section (VBAC) l if local practice, give VBAC information Obstetrician leaflet l Documents procedure in intrapartum maternal healthcare record according Documentation to local Trust procedure l Obstetric medical staff to document l Complete caesarean section audit form need for follow-up in maternal (if local practice) healthcare record 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)

Issue 4 28 Issued: April 2017 Expires: April 2019 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 H O with dry towels 2 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) Cord clamping Term baby 30 cm of water l If baby does not require immediate Preterm baby 20–25 cm of water resuscitation, clamp cord after 1 min l If immediate resuscitation is required No chest movement following assessment, clamp cord as Ask yourself: soon as possible l Is head in neutral position? ASSESS l Is a jaw thrust required? l Do you need a second person to help l Assess colour, tone, breathing and with airway to perform a jaw thrust? heart rate l Is there an obstruction and do you If baby very floppy and heart rate need to look with a laryngoscope and slow, assist breathing immediately suck with a large-bore device? l Reassess every 30 sec throughout l Consider placing oro-pharyngeal resuscitation process (Guedel) airway under direct vision l If help required, request immediately using laryngoscope l Is inflation time long enough? If baby not breathing adequately by 90 sec, assist breathing l if no chest movement occurs after alternative airway procedures above have been tried (volume given is a CHECK AIRWAY function of time and pressure), a larger volume can be delivered if necessary For baby to breathe effectively, by inflating for a longer time (3–4 sec) airway must be open l Attach saturation monitor to right l To open airway, place baby supine with hand – see Saturation monitoring for

head in ‘neutral position’ guidance on SpO2 targets l If very floppy, give chin support or jaw thrust while maintaining the neutral position

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Endotracheal intubation Do not move onto ventilation breaths unless you have a heart rate Indications response OR you have seen chest movement l Severe hypoxia (e.g. terminal apnoea or fresh stillbirth) Review assessment after l Stabilisation of airway inflation breaths l Extreme prematurity l Is there a rise in heart rate? l Congenital diaphragmatic hernia l Is there chest movement with the Safe insertion of endotracheal tube breaths you are giving? requires skill and experience l If no spontaneous breathing, but chest If you cannot insert a tracheal movement has been obtained, perform tube within 30 sec, revert to mask 30 sec of ventilation breaths, given ventilation at a rate of 30 breaths/min (1 sec Capnography can help to assess inspiration) endotracheal tube placement

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

Table 2: Outcome after 30 sec of ventilation breaths Heart rate Breathing Action Increases Not started breathing l Provide 30–40 breaths/min l Where available, use PEEP at 5 cm water with T-piece system <60 Obvious chest movement l Start chest compressions (see below) 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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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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l Ideal hold (Figure 1/Figure 2) Recommence cardiac compressions 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

Alternative hold (less effective) Adrenaline 1:10,000 l Compress lower sternum with fingers l 10 microgram/kg (0.1 mL/kg) IV while supporting baby’s back. The l If this dose is not effective, give 30 alternative hand position for cardiac microgram/kg (0.3 mL/kg) after sodium compressions can be used when bicarbonate has been given access to the umbilicus for UVC catheterisation is required, as hands l Adrenaline should only be given via around the chest may be awkward the ET tube (ETT) if venous access is taking time to achieve; it should Action not delay intravenous access and treatment; the dose is 0.5–1.0 mL/kg of l Compress chest quickly and firmly to 1:10,000 reduce the antero-posterior diameter of the chest by about one-third, followed Sodium bicarbonate 4.2% by full re-expansion to allow ventricles to refill l 1–2 mmol/kg (2–4 mL/kg) IV (never give via ETT) l remember to relax grip during IPPV, and feel for chest movement during ventilation breaths, as it is easy to Glucose 10% lose neutral position when cardiac l 2.5 mL/kg IV slowly over 5 min compressions are started Co-ordinate compression and Sodium chloride 0.9% ventilation to avoid competition. l 10 mL/kg IV Aim for 3:1 ratio of compressions to ventilations and 90 compressions and Naloxone 30 breaths (120 ‘events’) per min l Give only after ventilation by mask or Blood ETT has been established with chest movement seen and heart rate l If there is evidence of fetal >100 beats/min haemorrhage, consider giving O l If mother has been given pethidine negative emergency blood within 2–4 hr of delivery, give IM naloxone: Resuscitation drugs l 100 microgram (0.25 mL) for small l Always ask about drugs taken recently preterm babies by, or given to mother l 200 microgram (0.5 mL) for all other l Give drugs only if there is an babies undetectable or slow heartbeat despite effective lung inflation and effective chest compression l Umbilical venous catheter (UVC) is the preferred route for urgent venous access Issue 4 32 Issued: April 2017 Expires: April 2019 CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 5/6

l WHEN TO STOP If inflation breaths have been successful and chest movement seen l If no sign of life after 10 min, outlook but colour/SpO2 (if available) not is poor with few survivors, majority improved, increase oxygen to 30% will have cerebral palsy and learning l If no response, increase by increments difficulties of 30% every 30 sec i.e: l If no sustained spontaneous breathing Term air: 30–60–90/100% 30 min after a heart rate has been Preterm air: 30–60–90% established, majority also have poor prognosis l If chest compressions are required following chest movement with inflation Continue resuscitation until a senior breaths, increase oxygen to 90% neonatologist advises stopping l If SpO2 above levels in Table 3 or >95% at 10 min of life, reduce oxygen MONITORING Preterm deliveries Saturation monitoring l ≥26 weeks’ gestation do not require l Oxygen monitoring is activated when routine intubation if respiratory effort nd paediatrician/2 pair of hands arrives. good In the meantime, the person initiating l these babies can receive PEEP at 5 cm resuscitation carries out all the usual H O via mask ventilation with oxygen steps in resuscitation 2 supplementation as appropriate on the l Do not stop resuscitation for a resuscitaire continuing PEEP support saturation probe to be attached on transfer to NICU l Attach saturation probe to the right l If respiratory effort is poor, at any hand and connect to the monitor once point, or baby’s condition deteriorates, 5 inflation breaths have been given intubate and ventilate l SpO2 should spontaneously improve as Table 3 DOCUMENTATION

Table 3 l Make accurate written record of facts (not opinions) as soon as possible after Acceptable the event Time (min) pre-ductal l Record: SpO (%) 2 l when you were called, by whom and 2 60 why 3 70 l condition of baby on arrival 4 80 l what you did and when you did it l timing and detail of any response by 5 85 baby 10 90 l date and time of writing your entry l a legible signature Air to oxygen l If inflation breaths produce a response COMMUNICATION and SpO monitoring is available with 2 l Inform parents what has happened (the a reliable trace target, saturations as in facts) Table 3

Issue 4 Issued: April 2017 33 Expires: April 2019 – Resuscitation 2015CARDIOPULMONARY17 RESUSCITATION OF THE NEWBORN • 6/6 Newborn life support algorithm Newborn life support algorithm

Dry baby Birth Remove wet towels and cover Start clock or note time AT

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%

NoNo increase increase in in heart heart rate rate – Look for chest 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 venous access and drugs HELP?

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l INTRAPARTUM PREPARATION Encourage first breast feed within 1 hr 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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l Hypothermia Keep warm and encourage to feed 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 Temperature <36.4ºC in an the following symptoms: 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 EXAMINATION BY MIDWIFE requires urgent attention. 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

Issue 4 36 Issued: April 2017 Expires: April 2019 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

Skin Arms and legs l Hydration l Extend and check for: l Rashes: including erythema toxicum, l position, including talipes, symmetry of milia, miliaria, staphylococcal skin movement and muscle tone infection, candida l exclude trauma during delivery e.g. l Colour: pink/cyanosis/jaundice/pallor/ swelling, fractures and bruising plethora l presence/absence of digits and l Acrocyanosis webbing of fingers and toes l Cutis marmorata l Bruises: traumatic lesions, petechiae Hands

Head l Palmar creases – may indicate congenital abnormality l Palpate skull for: l Fingers – extra or absent digits and l sutures and fontanelle webbing l excessive moulding or tension of fontanelle Back l Eyes Place baby on his/her side or abdomen l Run fingers downwards along spine to l Open gently exclude or curvature l Confirm presence l Exclude subconjuctival haemorrhage

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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’

Issue 4 38 Issued: April 2017 Expires: April 2019 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

Babies with birth weight Babies with birth weight ≥2500 g <2500 g l Administer Konakion® MM Paediatric l Administer 400 microgram/kg (0.04 mL) 1 mg (0.1 mL) IM with a maximum of 1 mg (0.1 mL) of Konakion® MM Paediatric IM l this is approximately half the ampoule volume and should be drawn up using l round up dose to nearest hundredth 0.5 mL Omnican®-F syringe with [e.g. 300 microgram (0.03 mL), 0.01 mL graduations supplied with 500 microgram (0.05 mL) etc.] ampoule l draw up dose using a 0.5 mL Omnican®-F syringe with 0.01 mL graduations supplied with ampoule

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REGISTRATION AND l baby’s NHS number (if not available, IDENTIFICATION use local hospital number until NHS number available) Registration l if applicable, twin/triplet I/II/III l l Register birth – follow local birth Wristbands may cause damage registration procedure to premature baby’s skin – ensure alternative method of identification used Identification l Electronic security tag (if used locally) l For the purposes of this guideline, the term ‘wristband’ will cover wristbands Transferring baby and any other form of identity band l l If wristbands produced by a Before transfer to ward, NICU or other non-regulated person (e.g. maternity specialist unit, ensure baby has correct care assistant), they must be identification counter-checked by a registered l When baby being transferred home, professional mother and midwife check both l To reduce risk of mislabelling, do not identification bracelets prepare wristbands before delivery Checking wristbands l If used locally, apply security tag to baby as soon as possible l Check daily l ensure bands in situ as per local Before applying wristbands practice l Check information on wristbands with mother and/or her birth partner Detached wristband l Apply new wristband Mother l If both wristbands lost: l Mother’s wristband must contain the l inform midwife in charge of shift following information: l check wristbands of all other babies on l last name ward before replacing l first name l complete incident report l date of birth l If ≥2 babies do not have wristband, l NHS number (if not available, use local follow local practice for identification hospital number until NHS number available) l allergy information – according to local practice

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

Issue 4 40 Issued: April 2017 Expires: April 2019 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

Issue 4 Issued: April 2017 41 Expires: April 2019 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

Rhesus negative women l Give 1500 IU anti-D after any reinfusion l Send Kleihauer sample 30–40 min after reinfusion, in case more anti-D is required

Issue 4 42 Issued: April 2017 Expires: April 2019 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

If a cardiac or respiratory arrest has SUDDEN COLLAPSE occurred, call cardiac arrest team and commence cardiopulmonary Woman resuscitation – see Collapse algorithm at end of this guideline l Avoid aortocaval compression >20 weeks’ gestation l tilt the woman ≥30° using a wedged Organise resuscitation board or a wedge, or l Clearly state location of woman manually displace uterus l Crash-bleep resident anaesthetist, l Check A, B and C and give oxygen at junior doctor and middle grade maximum rate via face mask obstetrician (ST3–7 or equivalent e.g. staff grade, clinical fellow) l Inform consultant obstetrician l If antenatal arrest >22 weeks’ gestation, call neonatal team

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l Organise Obtain arterial blood gases and 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

Issue 4 44 Issued: April 2017 Expires: April 2019 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

Be aware of increase in Aortic dissection is a cause of cardiac causes of collapse chest or intrascapular chest pain, particularly in the presence of Risk factors for myocardial systolic hypertension. It is commonly infarction associated with Marfan’s syndrome. l Obesity If suspected, request urgent cardiologist review l Pre-existing hypertension l Diabetes mellitus AMNIOTIC FLUID EMBOLISM l Family history l Age >35 yr l Rare and often fatal l Presentation usually sudden during Symptoms and signs labour or immediately postpartum prompting investigation l Acute dyspnoea, cyanosis, shock, l Severe chest pain cardiac arrest, bleeding from disseminated intravascular coagulation l Chest pain radiating to neck, jaw or (DIC) and tonic-clonic seizures may all back occur l Chest pain associated with other l Sudden change in woman’s behaviour features (e.g. agitation, vomiting can be an early warning feature or breathlessness, tachycardia, tachypnoea and orthopnoea)

Issue 4 Issued: April 2017 45 Expires: April 2019 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)

Issue 4 46 Issued: April 2017 Expires: April 2019 Collapse 201719 COLLAPSE (Including amniotic fluid embolism) • 5/5

MaternalMaternal collapse collapse algorithm algorithm

Place woman in left lateral If >22 weeks’ position No Unresponsive? gestation, call Call for help if appropriate neonatal team Check maternal observations Assess fetal wellbeing Yes Call for obstetric review

Open airway Look for signs of life

Manually displace uterus Cardiorespiratory Call obstetric arrest resuscitation team

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

Immediately resume arrest treatment Immediately resume • Use ABCDE approach CPR for 2 min CPR for 2 min • Minimise interruptions Controlled oxygenation Minimise interruptions and ventilation • 12-lead ECG • Treat precipitating cause During CPR: Reversible causes: • Temperature • Ensure high-quality CPR: rate, • Hypoxia control/therapeutic 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

Issue 4 Issued: April 2017 47 Expires: April 2019 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

Assessment of progress l Advise woman that oxytocin will increase frequency and strength of contractions l Include: and, where anaesthetist available, offer l parity epidural before oxytocin started l rate of cervical dilatation l commence EFM l woman’s emotional state Monitoring l descent and rotation of baby’s head l Perform vaginal examination 4 hr after l changes in strength, duration and commencing oxytocin frequency of uterine contractions l if ≥2 cm progress, repeat vaginal Interventions examination 4-hrly l if <2 cm progress after 4 hr of regular l Give support, hydration and contractions, further review by obstetric appropriate and effective pain relief medical team and possible caesarean section Amniotomy SECOND STAGE l Advise this will shorten labour by approximately 1 hr but may increase Definition strength and pain of contractions l 2 hr after amniotomy, perform vaginal Passive second stage examination. Delay confirmed if cervix l has dilated <1 cm Full dilatation of cervix without involuntary, expulsive contractions l Amniotomy alone is not an indication for electronic fetal monitoring (EFM) Active second stage

Oxytocin l Vertex or breech visible l Expulsive contractions l Once diagnosis of delay made l by vaginal examination 2 hr after Active maternal effort in absence of amniotomy, consider oxytocin – see expulsive contractions Oxytocin guideline DELAY IN SECOND STAGE l in a nulliparous woman, midwife may start oxytocin after discussion with Definition of delay obstetric team Nulliparous women l Active second stage is delayed if baby not delivered after 2 hr

Issue 4 48 Issued: April 2017 Expires: April 2019 DELAY IN LABOUR • 2/2

Parous women Nulliparous women (Includes multipara women who have had l Allow up to 1 hr passive second stage previous caesarean section) (with/without epidural) l Active second stage is delayed if baby l Then, after 1 hr of active second stage, not delivered after 1 hr perform a repeat vaginal examination to assess progress and perform Assessment of progress amniotomy, if membranes still intact. Inform midwife co-ordinator l Include: l in absence of any progress, consider l maternal behaviour asking middle grade obstetrician l effectiveness of pushing (ST3–7 or equivalent e.g. staff grade, clinical fellow) to expedite delivery l fetal wellbeing l If delivery not occurred in a nulliparous l fetal position and station woman within 2 hr of start of active l These factors help determine timing second stage, call middle grade of vaginal examinations and need for obstetrician (ST3–7 or equivalent e.g. middle grade obstetrician (ST3–7 or staff grade, clinical fellow) equivalent e.g. staff grade, clinical l Repeat obstetric review every fellow) review 15–30 min until delivery l See Timing of delivery below Management Parous women All women l Allow up to 1 hr passive second stage l In nulliparous women with inadequate (with/without epidural) contractions at start of second stage, l After 1 hr of active second stage, call consider oxytocin with epidural middle grade obstetrician (ST3–7 or l If woman excessively distressed, support, equivalent e.g. staff grade, clinical fellow) sensitive encouragement and adequate l Repeat obstetric review every 15–30 min analgesia are particularly important until delivery l Continue epidural top-ups in second l See Timing of delivery below stage l Change position Monitoring l Ensure bladder empty l Review advancement of presenting part l Perform amniotomy every 15–30 min until delivery l If contractions adequate, there is no TIMING OF DELIVERY advantage to starting oxytocin l Delivery should occur within 3 hr for a Women who have received nulliparous and within 2 hr for a parous an epidural woman of the active second stage l If operative vaginal delivery is offered, l Following diagnosis of full dilatation, explain the reason to the woman and delay active pushing (active second her birth partner(s) stage) for 1 hr unless: l head visible The time taken to perform a caesarean section or instrumental l woman has urge to push delivery (especially if a trial in l concern about fetal wellbeing theatre indicated) must be taken into l Oxytocin is not routinely required in account when timing decision for second stage operative delivery

Issue 4 Issued: April 2017 49 Expires: April 2019 DIABETES – ANTENATAL CARE • 1/4

BACKGROUND PREGNANCY CONFIRMED Diabetes mellitus (DM) – metabolic Drugs disorder of multiple aetiology l Folic acid supplements 5 mg/day from characterised by chronic hyperglycaemia preconception until ≥12 weeks’ gestation with disturbances of carbohydrate, fat and l protein metabolism resulting from defects Aspirin 75 mg/day for pre-gestational in insulin secretion, insulin action, or both diabetes >12 weeks’ gestation l Review medications Pre-existing diabetes l metformin can be prescribed in preconception period, during pregnancy Type 1 and breastfeeding and can be used as an adjunct or alternative to insulin l Autoimmune process l stop any angiotensin converting l Pancreatic islet beta-cell destruction enzyme inhibitor (ACEI) medication and angiotensin receptor blocker (ARB) l Increased risk of maternal diabetic before conception/as soon as pregnancy ketoacidosis diagnosed and start methyldopa or l Characterised by: labetalol as an alternative for hypertension l absolute insulin deficiency l beta blockers can mask signs of l abrupt onset of severe symptoms hypoglycaemia l stop statins before conception/as soon l dependence on exogenous insulin to as pregnancy diagnosed sustain life l Refer women with diabetes or previous gestational diabetes to diabetic Type 2 antenatal clinic as soon as pregnancy l Common major form of diabetes diagnosed. See Care in diabetic antenatal clinic below l Defects in insulin secretion, almost l Use 75 g 2-hr oral glucose tolerance always from insulin resistance test (OGTT) to test for gestational l May be asymptomatic and remain diabetes in women with risk factors undiagnosed l Offer women who have had gestational diabetes in a previous pregnancy: Gestational diabetes l early self-monitoring of blood glucose or l l Defined as carbohydrate intolerance 75 g 2-hr OGTT as soon as possible of variable severity with onset of first after booking (whether in the first/ recognition during pregnancy second trimester) – if result normal, repeat at 24–28 weeks’ gestation l may have pre-existing diabetes l Women with any other risk factors for gestational diabetes: offer 75 g 2-hr OGTT at 24–28 weeks’ gestation Table 1: Risks from diabetes To mother To fetus l l Congenital malformation l Hypoglycaemia/hyperglycaemia l Stillbirth/neonatal death l Ketoacidosis l Premature delivery l Hypertension/pre-eclampsia l Fetal macrosomia l Retinopathy/nephropathy l Birth trauma l Induction of labour/caesarean section (CS) l Neonatal hypoglycaemia l Future diabetes l Polycythaemia l Future obesity and diabetes

Issue 4 50 Issued: April 2017 Expires: April 2019 DIABETES – ANTENATAL CARE • 2/4

CARE IN DIABETIC ANTENATAL CLINIC l Women with confirmed diabetes to have contact with diabetes team every 2 weeks for assessment of glycaemic control l timing of contact will depend on local policy and woman’s individual needs l Prompt diagnosis and treatment of UTI, hypertension and pre-eclampsia during pregnancy l Ketoacidosis – admit and seek early senior involvement l If fasting glucose 6.1–7 mmol/L without associated complications (macrosomia/ polyhydramnios) – consider metformin treatment l Consider variable rate intravenous insulin infusion (VRIII) for women nil-by-mouth (includes vomiting) who are usually treated with insulin/metformin

Table 2 – Antenatal care (joint obstetric/diabetic clinic) Appointment Care of women with diabetes during pregnancy 6–9 weeks l Confirm viability and gestational age by ultrasound scan l Information, advice and support on glycaemic control, establish extent of complications l offer smoking cessation advice/referral l Refer to dietitian for dietary assessment and advice l Review medications l BP, urinalysis for ketones and protein (ongoing in pregnancy) l Retinal and renal assessment if not in previous 12 months l Glucose targets: l fasting 3.5–5.3 mmol/L l 1 hr post meal <7.8 mmol/L l Check and demonstrate glucose meter and glucagon kit, and explain hypoglycaemia and hypo awareness l Advise to test for ketone if BG >10 mmol/L Booking appointment l Advice about how diabetes will affect pregnancy, birth (10 weeks) and early parenting l Advise aspirin 75 mg daily from 12 weeks to delivery, unless contraindicated l Additional to booking bloods: l HbA1c, TSH, T3, T4, U&E, LFT l urine for albumin/creatinine ratio l Full consultant booking ≤12 weeks’ gestation 16 weeks l Review glycaemic control l HbA1c levels, retinal (and renal) assessment if required 18–20+6 weeks l (including 4 chamber view of fetal heart and outflow tracts and 3 vessel view of heart) 24 weeks l Routine antenatal care

Issue 4 Issued: April 2017 51 Expires: April 2019 DIABETES – ANTENATAL CARE • 3/4

Table 2 – Antenatal care (joint obstetric/diabetic clinic) cont. Appointment Care of women with diabetes during pregnancy 28 weeks l Ultrasound monitoring of fetal growth and amniotic fluid volume l Retinal assessment (as required) for women with pre-existing diabetes who did not have diabetic retinopathy at their first antenatal clinic visit l Group and red cell antibodies, and FBC 32–34 weeks l Ultrasound monitoring of fetal growth and amniotic fluid volume l Plan mode and timing of delivery (see Diabetes – Labour guideline) l Explain benefits of breastfeeding and postnatal fasting glucose check 36 weeks l Ultrasound monitoring of fetal growth and amniotic fluid volume l Discuss: l analgesia/anaesthesia l therapy during and after birth l care of baby/breastfeeding l If CS planned <39 weeks, administer steroids with VRIII l Prescribe postnatal treatment and doses l Advise close monitoring of fetal movements 37–38+6 weeks l Induction of labour/CS l Weekly LV and Doppler scan >38+6 if not delivered 40 weeks l If well controlled, uncomplicated gestational diabetic on diet, can wait until 40+6 weeks

Management of diabetes Treatment

Monitor blood glucose targets l In most women, gestational diabetes will respond to changes in diet l Advise women to test fasting and 1 hr l if diet and exercise do not control postprandial blood glucose levels after blood glucose levels and if ultrasound every meal during pregnancy shows incipient fetal macrosomia, give l Aim for fasting blood glucose of metformin and/or insulin 3.5–5.3 mmol/L and 1 hr postprandial l In type 1 and 2 diabetes, adjust therapy blood glucose <7.8 mmol/L to maintain blood glucose targets l Teach women to adjust insulin l women with type 2 diabetes benefit dependent on glucose reading from continuing metformin treatment l Advise women who drive to check BG throughout pregnancy before driving, and to avoid driving if high frequency of hypoglycaemic Metformin and insulin are the only episodes diabetes medications safe for use in pregnancy l Check HbA1c each trimester

Issue 4 52 Issued: April 2017 Expires: April 2019 DIABETES – ANTENATAL CARE • 4/4

Women on insulin RETINOPATHY l Discuss risks of hypoglycaemia l Refer women with moderate l offer concentrated oral glucose retinopathy to ophthalmology solution to women taking insulin, (potential for rapid development of and glucagons to women with type 1 neovascularisation) diabetes. If accepted, train woman and l Offer assessment before conception/as partner to use soon as possible after first visit (16–20 weeks’ gestation) DIABETIC KETOACIDOSIS l if first assessment normal, repeat at 28 weeks l Check ketone level if: l BG >10 mmol/L or NEPHROPATHY AND l unwell with vomiting/fever/any systemic HYPERTENSION illness l Offer all women with type 1 and 2 l Diabetic ketoacidosis (DKA) is a diabetes low-dose aspirin (75 mg/day) medical emergency from 12 weeks’ gestation until delivery, l may contribute to intrauterine death to reduce risk of pre-eclampsia and significant maternal morbidity – l If serum creatinine >120 µmol/L, treat aggressively estimated GFR <45 or urine albumin/ l normal capillary ketone levels creatinine ratio >30 – refer to <0.6 mmol/L nephrologist l inform both obstetric and medical consultants and manage woman in a high dependency setting l stabilisation of DKA may be necessary before considering emergency delivery

Issue 4 Issued: April 2017 53 Expires: April 2019 DIABETES – LABOUR • 1/3

PREPARATION PRETERM LABOUR l Discuss with woman l Pulmonary maturation delayed in of diabetic women, particularly Time and mode of delivery where control has been poor l Where premature delivery anticipated l Woman with diet-controlled or for women with confirmed diabetes, metformin controlled diabetes with give betamethasone normally grown fetus: l woman will require additional insulin; l advise induction of labour not to be follow local policy delayed beyond 40+6 weeks’ gestation l Steroid administration worsens diabetic l Woman on insulin/metformin: control and may lead to ketoacidosis l advise induction of labour/caesarean in women with pre-existing type 1 section (CS) at 37–38+6 weeks’ diabetes – anticipate an increase in gestation insulin requirement and administer l Woman on insulin pump using local VRIII regimen l manage as per local Trust policy INDUCTION OF LABOUR l if planned CS and <39 weeks’ gestation administer course of l See Induction of labour guideline corticosteroids l if undelivered at 38+6 weeks, Diabetic control commence weekly liquor volume and l umbilical artery doppier Before labour established, normal metformin/insulin regimen and diet, together with blood glucose monitoring Analgesia and anaesthesia l Offer women with diabetes and DURING LABOUR co-morbidities (e.g. obesity or autonomic neuropathy) obstetric Risk anaesthetic assessment in third l Increased risk of shoulder dystocia trimester particularly if baby macrosomic – ensure middle grade obstetrician Care during and after labour (ST3–7 or equivalent e.g. staff grade, l Analgesia and anaesthesia clinical fellow) is available on delivery suite during second stage – see l Good glycaemic control Shoulder dystocia guideline l Continuous fetal monitoring l Increased risk of cephalopelvic l Prevention of neonatal hypoglycaemia disproportion – be vigilant for delay l Care of baby/breastfeeding and, if occurring, use oxytocin with caution l Planned delivery: l poor glycaemic control: normal insulin/ Monitoring during labour metformin dose evening before delivery; commence variable rate Woman intravenous insulin infusion [VRIII (formerly known as sliding scale)] by l Record capillary glucose level hourly 2200 hr l check capillary blood ketones if l good glycaemic control: commence glucose >10 mmol/L VRIII 0700–0800 hr on morning of l Once VRIII regimen commenced, delivery monitor blood glucose hourly

Issue 4 54 Issued: April 2017 Expires: April 2019 DIABETES – LABOUR • 2/3 l Monitor blood glucose at 30 min l Women on insulin: intervals after induction of general l admit as inpatient night before anaesthesia and birth of baby until procedure woman fully conscious l Commence insulin and fluid regimen l If blood glucose >10 mmol/L infuse following local policy sodium chloride 0.9% l Test all urine samples for ketones Emergency CS l if positive, woman to receive high l Check blood glucose level and dependency care commence insulin and IV fluid regimen below Continuous fetal monitoring l Maternal hyperglycaemia may INSULIN AND IV FLUID cause fetal acidosis. If any EFM REGIMEN abnormalities, check maternal glucose Insulin regimen l Fetal blood sampling if indicated, as normal labour – see Fetal blood l 50 units soluble insulin diluted to 50 mL sampling guideline with sodium chloride 0.9% in a 50–60 mL syringe (1 mL = 1 unit of insulin) Metformin and diet controlled l Administered via syringe pump l If blood glucose elevated e.g. l Adjust dose hourly according to persistently above local Trust policy glucose levels threshold, commence insulin and IV l Nil-by-mouth: administer IV fluids as fluid regimen below per Trust VRIII proforma via infusion l When labour established, stop pump metformin IV VRIII Gestational diabetes mellitus l Target blood glucose 4.0–7.80 mmol/L l During labour blood glucose l Insulin controlled – dependent upon 4.0–7.0 mmol/L amount of insulin required – dosage as per local Trust policy l Avoid large changes in insulin infusion rate and therefore in glucose l Measure capillary blood glucose concentration hourly during established labour and delivery l If blood glucose not maintained within normal range, contact diabetes team l if elevated twice, according to local threshold: l Observe for hypoglycaemia – diet controlled: start VRIII l consider increasing infusion to 150 mL/hr or glucose 10% – insulin/metformin treated: start VRIII l Check for blood/ketones and refer to Elective CS medical team for advice l If fluid restricted consider glucose 10% l Review at 34–36 weeks to discuss IV at 75 mL/hr management of glucose control and l pre-operative management Check potassium levels 4-hrly and adjust quantity in IV fluids accordingly l If CS carried out <39 weeks’ gestation, administer antenatal steroids with a Always use commercially produced VRIII. Refer to local Trust guideline for pre-mixed bags of infusion fluid and management potassium chloride

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POSTNATAL MANAGEMENT Neonatal care l Diabetes team will write management l See Staffordshire, Shropshire & Black plan Country Newborn and Maternity l Do not allow 6 hr (early) discharge Network Neonatal Hypoglycaemia guideline or follow local practice l Stop insulin and metformin for women with gestational diabetes FUTURE PLANS/ l Follow postnatal regime for women PRE-PREGNANCY ADVICE with pre-pregnancy diabetes l Woman to seek advice from l Ensure patient eating and drinking endocrinologist and diabetes specialist normally nurse regarding pre-conceptual care l provide meal/snack l Advise early contact with joint obstetric l Give insulin when next due and endocrinologist services once l Stop IV insulin and glucose after 30 min pregnancy is confirmed Inform women with insulin-treated diabetes that they are at increased risk of hypoglycaemia in postnatal period, especially when breastfeeding. Advise to have a meal or carbohydrate snack available before or during feeds and reduce insulin doses by 20%

Type 1 and 2 diabetes l Close monitoring of glucose levels l Type 2 diabetic wanting to breastfeed, and previously on oral hypoglycaemic agents (other than metformin), to remain on insulin l Observe and treat hypoglycaemia l Review by diabetes specialist midwife or medical team

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

Issue 4 56 Issued: April 2017 Expires: April 2019 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

INDICATIONS FOR WHO AND WHEN TO SCREEN

24–28 weeks – risk factors for Early screening gestational diabetes l Offer women who had gestational l BMI >30 kg/m2 diabetes in a previous pregnancy: l Previous macrosomic baby ≥4.5 kg l early self-monitoring of blood glucose l Previous gestational diabetes or l First degree relative with type 1 or type l 75 g 2-hr OGTT as soon as possible 2 diabetes after booking (whether in first/second l trimester), and further 75 g 2-hr OGTT Women on long-term antipsychotic at 24–28 weeks if results of first OGTT medications are normal l Family origin with a high prevalence of diabetes – south Asian (specifically country of family origin: India, Pakistan or Bangladesh), black Caribbean and middle Eastern (specifically country of family origin: Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt) l Previous unexplained stillbirth l Glycosuria l 1 episode of 2+ l 2 episodes of 1+

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

Issue 4 Issued: April 2017 57 Expires: April 2019 DIMINISHED FETAL MOVEMENTS (DFM) • 1/3

INTRODUCTION ≤24 weeks’ gestation l DFM may identify at-risk fetuses l Auscultate fetal heart, separately l The evidence that intervention can identifying maternal pulse improve the outcome is less convincing l If normal assessment: l reassure woman that irregular RECOGNITION movement patterns can be experienced in early pregnancy l Advise women to be aware of their baby’s individual pattern of movements l advise to return again if concerned about fetal movements l If ≤24 weeks’ gestation, arrange midwife to see woman within 24 hr in l Manage any abnormalities found hospital or community l If >24 weeks’ gestation, advise woman 24–26 weeks’ gestation to attend maternity department l Auscultate fetal heart and assess symphysis fundal height MANAGEMENT l If normal assessment: Assessment at any gestation l reassure l resume normal antenatal care l Check for previous or current medical problems (e.g. bleeding, l advise to return if further concerns , polyhydramnios, about movements small for dates, pre-eclampsia, l If reduced symphyis fundal height, refer hypertension, diabetes mellitus, for obstetric assessment previous poor obstetric history, smoking) Second episode of DFM l Blood pressure l Growth scan (unless performed in l Urinalysis previous 2 weeks) l Abdominal palpation to assess fetal growth; symphysis fundal height 26–28 weeks’ gestation measurements can be performed ≥24 weeks’ gestation l Perform EFM trace, ideally computerised (if available) l plot on a fetal growth chart according to local practice l Criteria met: reassure, allow home and advise to return if further concerns Investigations about fetal movements l EFM trace non-reassuring or l If fundus measures small for dates: abnormal l ultrasound scan for growth, liquor l inform middle grade obstetrician volume (ST3–7 or equivalent e.g. staff grade, l umbilical artery Doppler study clinical fellow) urgently l Electronic fetal monitoring (EFM) trace l consider cannulation dependent on gestation – see below l FBC and group and save l EFM trace is a test for hypoxia. l consider transfer to delivery suite When used in antenatal period, it is l Criteria not met after 45 min: continue essentially an assessment of immediate EFM and call middle grade obstetrician fetal condition (ST3–7 or equivalent e.g. staff grade, clinical fellow)

Issue 4 58 Issued: April 2017 Expires: April 2019 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 l reassure, allow home and advise to 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 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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DFM AND EFM TRACE NON-REASSURING/ABNORMAL l EFM trace non-reassuring/abnormal: l inform middle grade obstetrician (ST3–7 or equivalent e.g. staff grade, clinical fellow) urgently l FBC and group and save l All women with non-reassuring/ abnormal EFM must be reviewed by middle grade obstetrician (ST3–7 or equivalent e.g. staff grade, clinical fellow). It may or may not be appropriate to repeat EFM. If repeated, consider computerised EFM if available Remember EFM is an investigation. Continuing the monitoring will not improve fetal condition – use whole clinical picture to assess fetal wellbeing l If appropriately repeated EFM trace is normal, it may be reasonable to allow woman home l Arrange growth scan to exclude other cause for concern about fetal wellbeing, (e.g. reduced liquor), which might also predispose to decelerations from cord compression

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

Issue 4 60 Issued: April 2017 Expires: April 2019 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 RESUSCITATION AND on use of diazepam 5–10 mg or 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 l l Magnesium sulphate is treatment of Subsequent postnatal management – choice – see Severe pre-eclampsia see Severe pre-eclampsia guideline guideline, Magnesium sulphate l Record incident using local incident l Treat recurrent seizures with either reporting procedure further IV bolus of magnesium sulphate or increase in infusion rate – see Drugs Severe pre-eclampsia guideline, l See Severe pre-eclampsia guideline Magnesium sulphate

Issue 4 Issued: April 2017 61 Expires: April 2019 ELECTRONIC FETAL MONITORING (EFM) – ANTENATAL • 1/4

AIM Duration of monitoring To ensure fetal wellbeing in conditions/ l If using a traditional CTG monitor situations that increase the risk to the ≥20 min monitoring is required in order fetus before the onset of labour to assess CTG l 2 accelerations in 10 min is a Indications for EFM reactive trace. Sleep pattern with no (include but not limited to): acceleration does not exceed 40 min in vast majority Maternal l Document reasons for monitoring l Pre-eclampsia/eclampsia >40 min in maternal healthcare record l Antepartum haemorrhage l See section Dawes-Redman if in use l Prolonged rupture of membranes >24 hr INTERPRETATIONS AND l Prolonged pregnancy >42 weeks ACTIONS l Induced labour l Abdominal pain Normal/reassuring l Trauma/after a fall/RTC l Normal EFM has 4 reassuring features: l Cholestasis l baseline 110–160 bpm l Abnormality on auscultation (abnormal l baseline variability >5 and not >25 bpm baseline, decelerations) l accelerations present l Fetal no decelerations l Intrauterine growth restriction/abnormal While normal baseline range is Doppler 110–160 bpm consider gestation during monitoring. A fetus at 40 l Preterm labour weeks may have a lower baseline l Oligohydramnios/polyhydramnios range i.e. 110 bpm which is normal; l External cephalic version however, a fetus at 32 weeks is unlikely to have a low baseline l Iso-immunisation range, and would be non-reassuring l Suspicious antenatal EFM trace l Reduced fetal movements >26–28 weeks’ gestation as per local practice Action l Repeat according to clinical situation When to monitor and degree of fetal risk l >26–28 weeks’ gestation as per local practice Non-reassuring features l Baseline 161–170 bpm or 100–109 bpm How to monitor l Accelerations absent l Perform abdominal examination l Reduced variability <5 bpm for including symphyseal fundal height >30–50 min or >25 bpm for 5–25 min (SFH) l Any deceleration l Listen to fetal heart (FH) with a Pinard stethoscope before commencing EFM l Palpate maternal pulse simultaneously to differentiate fetal and maternal heart rates

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Abnormal features Action l Baseline <100 or >180 bpm l Review by middle grade obstetrician l Accelerations absent (ST3–7 or equivalent e.g. staff grade, clinical fellow) and decide if delivery l Reduced variability <5 bpm for indicated; if in doubt, discuss with >50 min or >25 bpm for 25 min consultant obstetrician l Any deceleration l Consider ultrasound scan for fetal l Sinusoidal pattern (oscillation growth, depending on the clinical frequency <2–5 cycles/min, depth situation, CTG liquor volume and 2–10 bpm for >40 min with no area of uterine artery Doppler studies normal baseline variability) l Babies can also be compromised from other causes e.g. sepsis, anaemia

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

Do not keep repeating a non-reassuring EFM. Decide if delivery is indicated. If necessary, consultant obstetrician to review EFM

Dawes-Redman fetal heart rate Dawes-Redman criteria met (FHR) assessment (if local l practice) Set minimum duration of monitoring at 10 min l When starting the CTG turn on l Analyse CTG every 2 min until antepartum analysis and enter Dawes-Redman criteria met gestation in weeks and days l When criteria met a ‘tick’ will appear on l If the CTG is suspicious/pathological the screen. Stop and remove CTG obstetric review required, regardless of l if the ‘tick’ is missed continue CTG analysis CTG until it is analysed again and l If a sinusoidal rhythm is present, notify Dawes-Redman criteria met (tick middle grade obstetrician (ST3–7 or appears again) equivalent e.g. staff grade, clinical l The evidence gained by the trace is fellow) that the fetus is normal and any further l Dawes-Redman analysis can be monitoring should be guided by other used for all antenatal CTG monitoring aspects of clinical assessment (including twin pregnancies) except l If the trace has met the criteria it is not when dinoprostone has been necessary to review the short-term administered – see Induction of variation (STV) parameter labour guideline

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l Dawes-Redman criteria not met While an abnormal 60 min STV is a 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: l Valid only when measured after 60 min – <4 msec = low of CTG monitoring – <3 msec = abnormal l STV >4.0: hypoxia is unlikely – <2 msec = highly abnormal l >37 weeks’ gestation: repeat CTG later the same day What to do when criteria met l <37 weeks’ gestation: repeat CTG the l Indicates a normal trace following day l Stop CTG subject to visual assessment l If fetal movements reduced, contact and clinical judgement medical staff – CTG to be repeated later the same day What to do when criteria l If STV 3.0–3.99: repeat CTG ≤4 hr and not met <60 min notify middle grade obstetrician (ST3–7 l Continue trace until criteria met, unless or equivalent e.g. staff grade, clinical there are clear pathological features or fellow) any cause for concern l If STV <3.0: pre-terminal trace – notify medical staff immediately What to do when criteria Assessment of fetal movements not met at 60 min when Dawes-Redman not met l Review to be performed by, or discussed with, senior obstetrician to l If the fetal movement count <5/hr repeat plan further management CTG on same day – even if STV is normal, and regardless of gestational age l Do not act on the basis of CTG analysis alone, this is an aid to l If problem persists, instigate other pregnancy management, not a tests of fetal wellbeing (ultrasound diagnostic tool assessment of movement, umbilical arterial cord Doppler) Using a computerised CTG does not l do not rely on STV in isolation. replace a clinical assessment and Base ongoing care planning on an interpretation of CTG assessment of the whole clinical scenario

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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

Issue 4 Issued: April 2017 65 Expires: April 2019 ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 1/6

l AIM Abnormal FHR on auscultation: 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) Indications for EFM l Multiple pregnancy l Abnormal lie/presentation Maternal l 2 episodes of reduced fetal movements in a 1 month period >28 weeks’ l Hypertensive disorders gestation, and/or reduced fetal l Antepartum haemorrhage movements in previous 24 hr l Trauma/RTC l Non-reassuring or abnormal EFM trace l Abdominal pain/unwell antenatally especially if performed for l Maternal pulse >120 bpm on 2 reduced fetal movements occasions 30 min apart Intrapartum l Temperature ≥38°C on a single reading or 37.5°C on 2 consecutive occasions l Prolonged membrane rupture interval 1 hr apart (>24 hr) before onset of established l Suspected chorioamnionitis or sepsis labour l Previous caesarean section/uterine l Pain not associated with contractions rupture l Oxytocin augmentation l Preterm PROM l Epidural anaesthesia l Induced labour where more than a l Fresh vaginal bleeding in labour single dose of prostaglandin has been l Delay in first or second stage of labour required l Instrumental birth l Diabetes l Preterm labour (<37+0 weeks’ l Recurrent antepartum haemorrhage gestation) l Maternal medical disease that may increase risk to fetus e.g. significant How to monitor cardiac disease, renal disease. If unsure, discuss with middle grade l Perform abdominal examination obstetrician (ST3–7 or equivalent e.g. l Listen to fetal heart with a Pinard staff grade, clinical fellow) stethoscope or handheld Doppler l Antiphospholipid antibody syndrome before commencing EFM l Obstetric cholestasis l Palpate maternal pulse simultaneously l Previous stillbirth to differentiate fetal and maternal heart rate l Obesity (BMI ≥40) Overall care Fetal l When CTG commenced due l Confirmed or suspected intrauterine to concerns from intermittent growth restriction auscultation, if after 20 min there are no l Abnormal Doppler non-reassuring or abnormal features l Oligohydramnios/polyhydramnios and CTG categorised as normal, return to intermittent auscultation after l Iso-immunisation discussion with the woman l Significant meconium stained liquor (see Meconium stained liquor guideline)

Issue 4 66 Issued: April 2017 Expires: April 2019 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

Principles for intrapartum CTG trace interpretation l Do not make any decisions about a woman’s care in labour on the basis of CTG findings alone l When reviewing CTG trace, assess and document contractions and all 4 features of fetal heart rate (FHR): baseline rate; baseline variability; presence or absence of decelerations (and concerning characteristics of variable decelerations if present) l An increase in baseline heart rate, even within normal range, with other non-reassuring or abnormal features should increase concern l Although a baseline fetal heart rate is 100–109 bpm is a non-reassuring feature, continue usual care if there is normal baseline variability and no variable or late decelerations l If it is difficult to categorise or interpret CTG trace, obtain review by senior midwife or ST3–7 or equivalent (e.g. staff grade, clinical fellow) l in the event of disagreement regarding CTG classification refer to consultant obstetrician

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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 Absence of l Variable decelerations with any accelerations concerning characteristics in >50% on an of contractions for <30 min or 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

l ACCELERATIONS how long they have been present for l whether they occur with >50% of l The presence of FHR accelerations, contractions even with reduced baseline variability, l presence/absence of biphasic (W) shape is generally a sign baby is healthy l presence/absence of shouldering Accelerations coinciding with uterine l presence/absence of reduced contractions, especially in second variability within the deceleration stage of labour, suggest possible erroneous recording of the maternal Early heart rate. Fetal heart more frequently l decelerates with a contraction True early uniform decelerations are rare and benign, and not significant, most decelerations in labour are variable DECELERATIONS l Describe decelerations as ‘early’, Variable ‘variable’ or ‘late’ l Regard the following as concerning l When describing decelerations in fetal characteristics: heart, specify: l lasting >60 sec l timing in relation to peaks of the l reduced variability within the deceleration contraction l biphasic (W) shape l duration of individual decelerations l no shouldering l whether or not FHR returns to baseline Issue 4 68 Issued: April 2017 Expires: April 2019 ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 4/6

Table 2: Management based on interpretation of CTG

Category Definition Interpretation Management Normal l All features l Fetus with no l Continue CTG normal probability of l if CTG commenced due to concerns hypoxia/acidosis arising from intermittent auscultation, remove CTG after 20 min if there are no non-reassuring or abnormal features and no ongoing risk factors l Talk to woman and her birth partner(s) about what is happening Suspicious l 1 non-reassuring l Fetus with low l Correct any underlying causes, feature and probability of such as hypotension or uterine l 2 reassuring hypoxia/acidosis hyperstimulation features l Perform FULL set of maternal observations l Start ≥1 conservative measure l Inform senior midwife or obstetrician

l Document plan for reviewing whole clinical picture and CTG findings l Talk to woman and her birth partner(s) about what is happening and take her preferences into account Pathological l 1 abnormal l Fetus with high l Obtain review by senior midwife or feature or probability of obstetrician l 2 non-reassuring hypoxia/acidosis l Exclude acute events (e.g. cord features prolapse, suspected placental abruption or uterine rupture) l Correct any underlying causes, e.g. hypotension or uterine hyperstimulation l Start ≥1 conservative measure l Talk to woman and her birth partner(s) about what is happening and take her preferences into account l If CTG trace still pathological after implementing conservative measures obtain further review by senior midwife and obstetrician l offer digital scalp stimulation and take woman’s preferences into account l If CTG trace still pathological after fetal scalp stimulation, consider fetal blood sampling/expediting the birth, and take woman’s preferences into account

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Table 2: Management based on interpretation of CTG cont.

Category Definition Interpretation Management Need for l Acute l Fetus with a high l Urgently seek obstetric help urgent bradycardia, or a probability of l If there has been an acute event intervention single prolonged having hypoxia/ (e.g. cord prolapse, suspected deceleration for acidosis placental abruption or uterine ≥3 min rupture) expedite the birth l Correct any underlying causes, e.g. hypotension or uterine hyperstimulation l Start ≥1 conservative measure l Make preparations for urgent birth l Talk to woman and her birth partner(s) about what is happening and taker her preferences into account l Expedite birth if acute bradycardia persists for 9 min l If FHR recovers at any time ≤9 min, reassess decision to expedite birth in discussion with woman

INTERPRETATIONS AND l Reduce contraction frequency by: ACTIONS l reducing or stopping oxytocin if it is being used and/or Frequency of assessment l offering tocolytic drug [e.g. l Undertake systematic assessment subcutaneous terbutaline 0.25 mg every hour to categorise CTG trace (unlicensed)] based on classification in Table 1 Inadequate quality l if concerns about CTG findings, undertake assessment more frequently l Check maternal pulse l ‘Fresh Eyes’ according to local practice l use pulse oximetry to record maternal l Document findings as per local pulse practice l Check position of transducer or fetal scalp electrode Conservative measures l Unless contraindicated (e.g. l If there are any concerns about baby’s prematurity <34 weeks, hepatitis B or wellbeing, be aware of possible C, HIV, malpresentation, fetal bleeding underlying causes disorders, maternal ITP), consider applying fetal scalp electrode l Inform senior midwife or obstetrician whenever conservative measures are implemented l Encourage the woman to mobilise or adopt an alternative position (and to avoid being supine) l Offer intravenous fluids if woman is hypotensive

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Fetal scalp stimulation and fetal blood sampling (FBS) l If CTG trace is pathological offer digital fetal scalp stimulation l if this leads to an acceleration in FHR, only continue/consider FBS if the CTG trace is still pathological – see Fetal blood sampling guideline l If digital scalp stimulation (during vaginal examination) leads to an acceleration in FHR, regard this as a sign that the baby is healthy

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

Issue 4 Issued: April 2017 71 Expires: April 2019 EPIDURAL ANALGESIA • 1/6

l INTRODUCTION Raised intracranial pressure 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 l required 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 l (remifentanil PCA) with the woman until 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 INDICATIONS In pre-eclamptic women, check FBC. If 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 Absolute needle) or 19 G/23 G catheter 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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Optional equipment Test dose for all epidural procedures l CSE pack/spinal needles 25 G l Administer a test dose of 5 mL from the Drugs epidural solution l Wait for 5 min to check for rapid onset l Lidocaine 1% of sensory changes and significant l Standard mixture (bupivacaine 0.1% decrease in blood pressure with fentanyl 2 microgram/mL) or a bag of bupivacaine 0.1% and fentanyl Procedures for establishing ampoule for mixture preparation analgesia in labour l Levobupivacaine (0.25 and 0.5%) (for bolus administration in second stage of 1. Procedure for continuous labour) infusion of dilute mix of local l Vasopressors anaesthetic and opioid l Sodium chloride 0.9% l After verification of correct catheter placement, administer loading dose INSERTION OF EPIDURAL (usually 10–15 mL of the mixture), then: l commence an infusion rate of l Use full aseptic technique wearing 10–12 mL/hr for maintenance gloves, gown, hat and mask l rate may be increased up to 15 mL/hr l Clean insertion site with alcoholic and rescue analgesia may be provided chlorhexidine gluconate solution and by a single bolus of 10 mL of the allow to air dry infusion mixture. Can be administered l Evidence suggests that loss of resistance by midwife via pump to sodium chloride 0.9% is a better technique than loss of resistance to air 2. Procedure for use of PCEA l If technical difficulty, seek help early l or consider alternative analgesia e.g. Anaesthetist will set up the machine remifentanil PCA l Administer the first 10 mL bolus dose of mixture ESTABLISHING AND l Set patient administered bolus of MAINTAINING EPIDURAL 10 mL infusion. Set a bolus lockout of ANALGESIA 20 min or as per local protocol l Commence a background infusion rate Accepted regimens: of 0–5 mL/hr of the mixture 1. Continuous infusion l Do not give first patient administered 2. Patient controlled epidural analgesia dose before 30 min after first (PCEA) therapeutic dose l 3. Bolus administration PRN Do not give PCEA handset to woman until 30 min after infusion Drug used for all 3 procedures commenced l if pain relief remains ineffective after l Mixtures of low concentration of local 2 boluses, request duty anaesthetist to anaesthetic (e.g. bupivacaine 0.1% or assess woman levobupivacaine) with an opiate (e.g. fentanyl 2 microgram/mL), as per local Trust protocol

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3. Procedure for bolus epidural Before weight-bearing top-up l Other requirements to be satisfied l Anaesthetist will administer first bolus include: dose of epidural (10–15 mL of the drug l no postural hypotension mixture) after the test dose l co-operative woman l Subsequent boluses are 10 mL of l A partner and/or midwife must be mixture administered by either midwife available at all times to accompany or anaesthetist woman while mobilising Top-up by midwife Bladder care l Midwife will check each prescribed l Epidural analgesia may make passing top-up (10 mL of drug mixture) with urine difficult and woman may not be another qualified professional before aware of a full bladder. Encourage her administering. Following administration, to void her bladder every 2–4 hr. See both will sign and record on regional Bladder care guideline anaesthesia chart or as per Trust policy

INTRAPARTUM CARE Diet and fluids l Acceptable drinks include water, tea, l Monitor: coffee, squash and non-fizzy isotonic l pulse, blood pressure, respiratory rate, sports glucose sensory, motor block and conscious l Oral ranitidine 150 mg every 6–8 hr level – as per local practice while in labour – woman’s temperature rises to 37.5–38°C with epidural (0.33°/hr) – Epidural management maternal and fetal implications of this during second and third stage are still unclear of labour l Maintain venous access for as long as epidural analgesia is maintained l Do not withhold epidural analgesia in l Continuous electronic fetal monitoring second stage when receiving epidural blockade l Usual top-up dose for second stage of throughout labour labour is 10 mL levobupivacaine 0.25% via epidural catheter. Do not leave If there are concerns for fetal woman unattended for 20–30 min after wellbeing at any stage, abandon the bolus procedure until a proper assessment l of fetal status is made Maintain epidural analgesia until perineal suturing has been performed Positioning An anaesthetist must give top- l To reduce the risk of hypotension, do ups in the following situations not allow woman to lie flat on her back l Midwife is concerned about level of block l For pressure care encourage woman to l An unusual prescription has been change position regularly ordered l A hypotensive episode (systolic blood Mobility pressure <100 mmHg) after previous l Assess ability to ambulate 20–30 min top-up after initial injection: l Analgesia is persistently inadequate l ability to raise each leg from bed for l To extend the block for caesarean section ≥5 sec l After suspected dural tap and with l ask if she feels capable of weight-bearing intrathecal catheter in situ

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HIGH CONCENTRATION l adequate return of motor power to TOP-UPS legs and document – if not, contact anaesthetist Caution: This type of epidural top-up COMPLICATIONS AND has a higher rate of hypotension, MANAGEMENT significant intravascular injection, difficulty in pushing and instrumental Managing incomplete analgesia delivery Incomplete block Indications l Check – has the catheter fallen out? l Has a role in managing inadequate Leak/disconnection? analgesia (OP position), premature l Try bolus of standard mix or stronger desire to push and instrumental delivery solution as indicated

Administration Unilateral block l Requires levobupivacaine 0.25% l Anaesthetist may consider pulling or lidocaine 2% (dose dependent catheter back 1–2 cm and try another on circumstances and anaesthetist dose with the painful side dependent. assessment) with or without Optimum is 3–4 cm of catheter in 100 microgram fentanyl epidural space l Care for woman on bed and encourage l If still not effective, consider resiting to change position regularly epidural

EPIDURAL CATHETER REMOVAL Missed segment, patchy block l Do not remove for ≥12 hr after l Try using 5 mL levobupivacaine 0.25% prophylactic and 24 hr of therapeutic l If block patchy and high, consider LMWH administration possibility of a subdural block – see l In severe PET and after a massive Accidental dural puncture below bleed, ensure normal FBC and clotting l If still not effective, consider resiting profile before removal epidural l Unless otherwise directed by anaesthetist, remove just before Perineal pain discharge back to ward l Give bolus of 10 mL infusion mixture l Pull firmly on catheter, but do not use l excessive force – catheter should come If pain persists, try topping up with out easily with minimal resistance. 50–100 microgram fentanyl in 8–10 mL If not, seek senior or consultant levobupivacaine 0.25% anaesthetist’s advice l If inadequate analgesia after bolus, l Remove catheter and check blue tip is anaesthetist to review complete Breakthrough pain through l Document removal of catheter and a good block whether tip intact l Inform anaesthetist of any problems l Consider uterine rupture or abruption l Assess woman and progress of labour TRANSFER BACK TO WARD If inadequate analgesia after 1 or 2 l Before transferring to ward, midwife top-ups and woman still unhappy, should ensure: anaesthetist to review in person, l vital signs are normal resite or seek senior help

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l Pruritus Provide information leaflet (if available 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 Accidental dural tap MANAGING SERIOUS COMPLICATIONS l Incidence of dural puncture whilst siting an epidural is 1–2% Total spinal and unanticipated l Overall incidence of post dural high block puncture headache (PDPH) following l Can occur after first dose of epidural or inadvertent dural puncture is 75% any time during labour If recognised at time of insertion l Monitor as per local protocol l Leave catheter intrathecally for at least It is an acute emergency, 24 hr or resite characterised by: l Label clearly as a spinal/intrathecal l Rapidly progressive sensory and motor catheter block of legs and arms l Give 1 mL bupivacaine 0.25% with l Severe hypotension and bradycardia fentanyl 25 microgram. Alternatively, l Reduced or absent respiration use 2 mL of the infusion mixture. Flush with 2 mL sodium chloride 0.9% after l Altered level of consciousness every top-up Management l Subsequent boluses must be 2 mL of the infusion mixture administered by l Call for help – including an anaesthetist anaesthetist only l Relieve aortocaval compression by left lateral displacement of the uterus – Monitor manually or with a wedge l If CPR not required, full lateral position l Regular BP (timing according to local practice) l Use ABC approach l Keep vasopressors handy l Administer 100% oxygen and, if respiration inadequate or woman has l Keep woman on labour ward until lost consciousness, be ready to intubate catheter removed l Cardiovascular support in the form of If intrathecal catheter placement fluids, vasopressors (phenylephrine, difficult, seek senior help or provide ephedrine, adrenaline) alternative methods of analgesia l In case of cardiac arrest or severe e.g. remifentanil PCA cardiac depression, initiate CPR – see Maternal collapse algorithm in Follow-up after dural puncture Collapse guideline l If no return of spontaneous circulation, l Anaesthetist to discuss dural puncture consider peri-mortem caesarean management with woman section within 5 min l assess for symptoms of PDPH and l After successful resuscitation, woman treatment options available with must be managed by on-call consultant attendant risks and benefits anaesthetist (if not already there)

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Intravascular injection of local l Continue infusion until stable and anaesthesia adequate circulation restored or maximum dose of lipid emulsion given l Arises as a result of incorrect site of l Recovery after a cardiac arrest will take administration (IV) or incorrect dose >1 hr administered l Consider drawing blood for analysis Symptoms and signs Do not exceed a maximum cumulative Intralipid® dose of l Peri-oral numbness, difficulty speaking 12 mL/kg l Tinnitus l Dizziness l Restlessness l Dysrhythmia (bradycardia, VT and VF) l Hypotension l Convulsions l Loss of consciousness

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

Use of 20% Intralipid® l Early use of Intralipid® 20% 1.5 mL/kg IV over 1 min, followed by an infusion of 15 mL/kg/hr l After 5 min, give maximum of 2 repeat boluses (same dose) if: l CVS stability is not achieved or adequate circulation deteriorates l Leave 5 min between boluses l maximum of 3 boluses can be given (including the initial bolus), followed by infusion dose to 30 mL/kg/hr

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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 Equipment tuberosity and anus (protect fetal head) 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 l 10 mL lidocaine 1% 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

Issue 4 78 Issued: April 2017 Expires: April 2019 EPISIOTOMY • 2/2 l Withdraw scissors carefully l After third stage, with informed l Control delivery of the presenting part consent, thoroughly inspect vagina, and shoulders to avoid extension perineum and rectum to ascertain extent of trauma prior to repair in the l If delay in delivery, apply pressure to appropriate setting episiotomy between contractions to control bleeding

COMPLICATIONS

A: B: C:

Figure A Figure B Figure C Correct anatomical Incorrect Incorrect position l Cut begins lateral to the l Cut is too small resulting centre of the fourchette in extension of incision l Will not increase towards the anus and diameter of vulval outlet increasing risk of anal sphincter injury l Will cause damage to bartholins gland l Will affect lubrication and may cause complications e.g. dyspareunia

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

Discharge and follow-up See Perineal trauma suturing (tears and episiotomy) guideline

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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

Neonatal middle Caesarean CS Senior Electronic grade* or section indicated Gestation neonatologist fetal consultant at (CS) if breech/ to counsel monitoring delivery indicated non-cephalic

<22 weeks No No No Not for fetal No indications

22–22+6 Yes, if parents No No Not for fetal No weeks request indications

23–23+6 Yes Yes No Not for fetal No weeks indications

24–24+6 Yes Yes Fetal heart Not for fetal No weeks Parents visit auscultated indications NNU if possible 2nd stage

25–25+6 Yes Yes Yes May be No weeks Parents visit justifiable NNU if possible for fetal indications

26–26+6 Yes Yes Yes Indicated Uncertain weeks Parents visit for fetal NNU if possible compromise

27–27+6 Yes Yes Yes Indicated Uncertain Parents visit for fetal NNU if possible compromise

28 weeks Yes Yes Yes Indicated Advise CS Parents visit for fetal NNU if possible compromise

* ST3–7 or equivalent e.g. staff grade, clinical fellow

These are guidelines only An alternative management plan, based on individual circumstances, can be made by a middle grade obstetrician (ST3–7 or equivalent e.g. staff grade, clinical fellow) or consultant Record management plan clearly in maternal healthcare record and ensure it is accessible to all staff

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l OBSTETRIC RESPONSIBILITIES as a minimum, a middle grade 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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Dosage NEONATAL RESPONSIBILITIES l Give loading dose of 4 g (8 mL) IV over l Wherever possible, inform neonatal 20 min team of woman’s admission to delivery l mix 4 g (8 mL) magnesium sulphate suite 50% with 12 mL sodium chloride 0.9% l If appropriate, neonatologist will review (total 20 mL) and set syringe driver at woman and discuss care of baby 60 mL/hr following delivery l Give maintenance dose of 1 g/hr IV via l Counselling provided by a senior syringe pump until delivery or for 24 hr, neonatologist, depending on gestation whichever is sooner (see Table 1), should include the role l mix 5 g (10 mL) magnesium sulphate of resuscitation, use of cardiac drugs 50% with 40 mL sodium chloride 0.9% and risks and benefits (total 50 mL) and set syringe driver at l Use EPICure research study data to 10 mL/hr give a percentage for survival and risk l If woman did not deliver as expected, of disability (see Tables 2 and 3). Local a repeat dose can be given later in the data may also be useful pregnancy Neonatal resuscitation Observations and monitoring Certain gestation of <22+0 weeks l Commence hourly observations of: l Advise parents that survival is not l respiratory rate possible l level of consciousness l Check deep tendon reflexes regularly Certain gestation (according to local practice). In of 22+0–22+6 weeks general, use patella tendon reflexes, use reflexes at elbow or wrist in women l Advise parents that survival is who have a working epidural in situ extremely rare (see EPICure data) and it would be in baby’s best interests, and l Check reflexes more often when: standard practice, not to resuscitate l there is oliguria l woman is also taking nifedipine Certain gestation l magnesium sulphate dosage has of 23+0–23+6 weeks required adjustment l Decision not to start resuscitation may l Monitor oxygen saturation continuously be appropriate, particularly if parents with pulse oximeter. Stop infusion have expressed this wish immediately and call middle grade l obstetrician (ST3–7 or equivalent e.g. If resuscitation is started, initiate mask staff grade, clinical fellow) if: ventilation and observe heart rate response l tendon reflexes absent l if there is a very rapid improvement, l respirations <12/min intubation, stabilisation and transfer to l SpO2 <96% NNU is appropriate l abnormal conscious level l There is no evidence to support the use l urine output <1.5 mL/kg over 4 hr of chest compression or epinephrine in babies <25 weeks Antidote l Calcium gluconate 1 g (10 mL 10% solution) IV over 3 min

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Certain gestation Certain gestation of ≥26+0 weeks of 24+0–24+6 weeks l Advise parents that survival at this l Unless parents and clinicians have gestation is usual considered baby will be born severely l It is considered good practice to compromised, start resuscitation offer parents the opportunity to l Initiate mask ventilation and observe raise questions regarding care of baby’s heart rate. If there is a very rapid the newborn with a member of the improvement, intubate, stabilise and neonatal team. Include a visit to the transfer to NNU NNU if feasible l There is no evidence to support the use l If complications anticipated e.g. of chest compressions or epinephrine known congenital anomaly, provide in babies <25 weeks counselling by a senior member of the neonatal team (who should document Certain gestation the discussion in the woman’s of 25+0–25+6 weeks healthcare record) l Start resuscitation l Initiate mask ventilation and observe heart rate response. If there is a very rapid improvement, intubate, stabilise and transfer to NNU l If appropriate, initiate chest compressions and epinephrine – follow NLS guidelines and Cardiopulmonary resuscitation of the newborn guideline

EPICURE STUDIES OF SURVIVAL AND DISABILITY Table 2: EPICure 2 study – Survival and disability Completed weeks of gestation 22 23 24 25 26 Survival to discharge as % live births % 1 15 36 62 75 Survival to discharge as % babies admitted to NICU % 16 29 46 69 78 Survival without disability at 3 years % 1 15 36 43 59 Survival without disability of those admitted to NICU % 5 15 28 47 61

Table 3: Factors affecting chance of survival Increase Decrease Female sex Prolonged membrane rupture interval Birth weight 50–85th centile Sepsis Birth weight >600 g Birth weight <500 g Delivery in unit with level 3 NICU Abnormal umbilical artery Doppler flow

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COMMUNICATION WITH l When completing the certificate, the PARENTS doctor prints his/her name after the 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

Issue 4 84 Issued: April 2017 Expires: April 2019 FETAL ABNORMALITY – ANTENATAL DETECTION • 1/2 l INTRODUCTION If woman does not wish to be informed 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 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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Normal variants INVASIVE TESTING FOR FETAL ABNORMALITY l It is no longer recommended to screen for ‘soft markers for Down’s syndrome’. l Performed for fetal karyotyping or other However, the following appearances genetic testing should be reported and the woman referred for further assessment: Amniocentesis l nuchal fold >6 mm l Performed >15 weeks, by an l ventriculomegaly (atrium >10 mm) appropriately trained operator l echogenic bowel (with density l rate of miscarriage associated with equivalent to bone) amniocentesis is approximately 1% l renal pelvic dilatation (AP measurement >7 mm) Chorionic villus sampling (CVS) l standard growth measurements l Performed >11 weeks, by an compared to dating scan (significantly appropriately trained operator <5th centile on national charts) l rate of miscarriage following CVS is approximately 1–2% Documentation l A printed formal report must be produced and a copy placed in maternal healthcare record l Record positive and relevant negative findings that are important to that particular clinical situation l Store relevant images l Trigger a neonatal alert

SCREENING FOR DOWN’S SYNDROME l Offer Down’s syndrome screening l combined test (11+2–14+1 weeks) with or quad test (14+2–20 weeks) l Women with a multiple pregnancy who wish to have Down’s screening: l offer combined test (11+2–14+1 weeks) or quad testing, having had the opportunity to discuss implications of screening in twin pregnancy with either an antenatal screening midwife or fetal medicine midwife – see Multiple pregnancy guideline l Some women choose to have a blood test to examine cell free fetal DNA (not currently available on the NHS)

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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 l and acidosis 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 l fetal distress in labour is associated 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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l PREPARATION Avoid leaving woman alone while sample is processed, especially if her Equipment legs are on supports l Sterile FBS pack Obstetrician l Chlorhexidine acetate BP 0.05% l Cleanse vulva cleansing solution l Drape with sterile towel l Sponge holder l Insert lubricated amnioscope to access l Amnioscope fetal scalp and connect/position light l Light source source l Blade l Clean fetal scalp l Blade holder l Spray scalp with ethyl chloride spray l Capillary tube pack l Apply white soft paraffin to area of l White soft paraffin scalp where FBS sample is to be taken l Lubricant gel l Incise scalp with blade, collect sample with capillary tube and give to assistant l Ethyl chloride spray l Take a second sample (for immediate l Urinary catheter (if required) analysis in blood gas analyser) l Fetal scalp electrode (if required) l Clean the area and reposition woman to minimise discomfort Consent l Attempts to obtain sample not >30 min l Explain procedure to woman and obtain verbal consent Analysing sample l document consent in maternal l A healthcare professional trained in healthcare record the use of the blood gas analyser will take samples to the analyser, process PROCEDURE sample and inform obstetrician of result Take preparation time into pH values may be altered by consideration when performing repeat samples. the following events: If sample result is not available l Contamination with amniotic fluid ≤30 min, consider need for delivery l Contamination with meconium Timing of any subsequent test(s) l Presence of air bubbles (‹pH value) should take into account the time also required to obtain sample(s) l Fetal scalp oedema or caput (ŒpH value) l Delay in processing (ŒpH value) Midwife Umbilical cord samples l Prepare equipment l Assistant to (ideally) position woman in l For all deliveries requiring FBS in left lateral position labour, take paired cord umbilical cord l Continue EFM. If significant fetal samples at delivery – see Umbilical deterioration e.g. bradycardia, proceed cord sampling guideline to urgent delivery l Inform delivery suite team leader, who will escalate to other staff involved e.g. anaesthetist

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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

Response to fetal scalp stimulation l If fetal scalp stimulation leads to acceleration in FHR – regard as reassuring feature l take into account when reviewing whole clinical picture l If FBS unsuccessful or contraindicated – use FHR response after fetal scalp stimulation during vaginal examination to elicit information about fetal wellbeing

Table 1: Results classification Lactate pH Interpretation Range Action (mmol/L) ≤4.1 ≥7.25 Normal – – 4.2–4.8 7.21–7.24 Borderline Pre-acidotic Repeat ≤30 min, or sooner if deteriorates further ≥4.9 ≤7.20 Abnormal Acidotic Inform consultant obstetrician delivery indicated l If results seem completely out of Communication keeping with clinical picture (lactate or pH higher/lower than expected) l Ensure parents and family are discuss with consultant obstetrician reassured and fully informed of l Timing of repeat samples should take procedures, individualised plan of care into consideration time taken to obtain and sequence of events at all times another sample by attending obstetric, neonatal and midwifery staff DOCUMENTATION l parents may also require a debrief following delivery l Ensure results sheet is secured in maternal healthcare record and written in intrapartum documentation l If expediting birth, record time at which decision is made and the management plan

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Flowchart – Fetal blood sampling

FBS required Woman ideally in left lateral position

Normal Borderline Abnormal l If FBS cannot be pH ≥7.25 pH 7.21–7.24 pH ≤7.20 obtained discuss Lactate ≤4.1 Lactate 4.2–4.8 Lactate ≥4.9 with consultant obstetrician l If scalp simulation results in l Inform consultant l Repeat FBS l Repeat FBS accelerations, and plan to ≤1 hr if trace ≤30 min if decision should be expedite delivery remains trace remains made to continue with (assisted abnormal/ abnormal labour or expedite delivery/CS) non-reassuring, (if urgent delivery in light of all or sooner if intervention not clinical circumstances additional required) l If NO improvement non-reassuring/ l Action: abnormal in CTG trace, birth conservative should be expedited features measures (see l Action: Electronic fetal conservative monitoring measures (see guideline) Electronic fetal monitoring guideline) Additional considerations when offering/ undertaking FBS l Inform woman of ALL clinical decisions made and rationale l Interpret results against: Second FBS l any previous lactate/pH measurement l rate of progress in labour l any other maternal/fetal clinical features l Document the requirement and timing for repeat FBS, all results, discussions with consultant obstetrician and the mother, clearly in maternal notes Normal Borderline pH ≥7.25 pH ≥7.21–7.24

CTG unchanged and FBS result stable l Defer 3rd/further FBS unless additional abnormalities on trace develop l If 3rd FBS considered – discuss with consultant obstetrician

Issue 4 90 Issued: April 2017 Expires: April 2019 GENERAL ANAESTHESIA AND FAILED INTUBATION • 1/4

INTRODUCTION Antacid regimen

Read this guideline in conjunction l High-risk labouring women – ranitidine with the Caesarean section guideline 150 mg oral 6-hrly l Elective lower segment caesarean Risk of failed intubation in the obstetric section (LSCS) – ranitidine 150 mg population is approximately 10 times night before and on morning of surgery greater than in non-obstetric population. Most difficult airways are unanticipated l Emergency LSCS – ranitidine 50 mg IV (if not already receiving orally) SAFE OBSTETRIC GENERAL l Consider prokinetic drug e.g. ANAESTHESIA metoclopramide l Pre-induction planning and Sodium citrate: 30 mL of 0.3 M sodium citrate drink ≤20 min of anaesthesia preparation for all grade 1–3 general anaesthesia l Perform anaesthetic risk assessment at caesarean section (CS) and, if local antenatal clinic through an anaesthetic policy to grade 4 CS referral to: Intrauterine resuscitation for l provide counselling for woman emergency CS l prepare a team management plan l If appropriate employ intrauterine Risk factors for identifying resuscitation difficult intubation l left lateral position l Previous surgery, radiotherapy or injury l 1 L Hartmann’s solution to head and neck l tocolytic e.g. terbutaline l Previous history of difficult intubation l pressors to correct hypotension l Congenital craniofacial abnormalities l Reassess urgency in theatre before l Raised BMI at booking and full term general anaesthesia l Large protruding incisors Rapid sequence induction l Restricted neck movement (full, unhindered range of at least 90°) If difficult intubation envisaged, call l Restricted mouth opening (<3 fingers for senior help. Mark cricothyroid breadth), jaw slide membrane with use of ultrasound l Abnormal Mallampati view (pharynx should be visible) Equipment l Appropriately checked anaesthetic Consent machine and suction l Obtain and record consent l Oro-pharyngeal airways and laryngeal l Discuss: masks [supraglottic airway device (SAD)] l rapid sequence induction (cricoid l pressure) Range of endotracheal tubes (ETT) l l awake extubation Range of laryngoscopes – including video laryngoscope (if available) l failed intubation l Other difficult airway adjuncts as per local protocol (e.g. gum elastic bougie) l Cricothyrotomy kits/jet ventilation equipment

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l INDUCTION Use atracurium or rocuronium after 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

Anaesthetic administration OBSTETRIC FAILED TRACHEAL INTUBATION l Administer rapid bolus dose of ≥5 mg/kg thiopentone or propofol Laryngoscopy l follow with suxamethonium 1 mg/kg l During first attempt: if failed call for l use rocuronium 1–1.2 mg/kg only if consultant anaesthetist help urgently ® Sugammadex 16 mg/kg available l Second attempt: consider simple l in high risk woman, consider use changes in technique (head position, of short-acting opiate to obtund laryngoscope blade, alteration of sympathetic response cricoid pressure). If failed focus on l Initially apply 10N cricoid pressure, oxygenation then increasing to 30N after loss of l Ventilate with 100% oxygen with bag consciousness and mask or SAD l Inflate cuff l Immediately insert SAD before drugs l check for audible leak wear off (2nd generation SAD advised) l check correct placement l Consider temporary release of cricoid during insertion – 2 attempts only l release cricoid pressure

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‘Can’t intubate but can ventilate’ Anaesthetic options situation l Regional anaesthesia l Decision to wake will depend upon on l Secure airway before general the following factors: anaesthesia l woman’s life at risk (cardiac arrest, massive haemorrhage) Extubation strategy l baby’s life at risk (severe fetal distress) l Ensure senior help has arrived l aspiration risk l Evaluate general clinical factors that l anaesthetist seniority may have an adverse impact on ventilation before extubation Anaesthesia with spontaneous l Ensure there is no upper airway respiration oedema (leak around a deflated cuff) l Call for senior help l Consider a strategy for reintubation if l Deepen anaesthesia with sevoflurane necessary (non-irritant) or total intravenous l Always perform an awake extubation anaesthesia (TIVA) l Paralyse with rocuronium only if Follow-up care Sugammadex® available l Document description of airway l Maintain cricoid pressure difficulties encountered (in ventilation l Prevent awareness and intubation). Include airway l Pass a nasogastric tube with 2nd management techniques employed generation SAD to suction gastric l Enquire directly about awareness contents l Counsel woman appropriately l Do not attempt intubation through an post-operatively LMA or fibre optic intubation without l Follow-up for potential complications: experienced senior help oedema, bleeding, tracheal and l Anticipate laryngospasm esophageal perforation, pneumothorax l Senior obstetrician to operate and aspiration l Inform GP and woman in writing MANAGEMENT AFTER FAILED l In complex cases offer anaesthetic INTUBATION outpatient appointment ‘Can’t intubate, can’t ventilate’ situation l Declare emergency: call for senior help and ENT surgeons l If due to intrinsic patient factors (laryngospasm, poor chest compliance) – consider giving muscle relaxants l Follow current Difficult Airway Society (DAS) guidelines for front of neck access

After waking patient l Review urgency of surgery l Intrauterine resuscitation

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• Follow-up for potential complications: oedema, bleeding, tracheal and esophageal perforation, pneumothorax and aspiration GENERAL• Inform GP and ANAESTHESIA woman in writing AND FAILED INTUBATION • 4/4 • In complex cases offer anaesthetic outpatient appointment

Flowchart:Flowchart: failed Failed intubation intubation algorithm algorithm

Pre-induction preparation

Algorithm 1 Rapid sequence induction Safe GA

Success Laryngoscopy Successful intubation (max 2 attempts, 3rd by Proceed senior only)

Fail Success

Declare failed intubation Algorithm 2 Is it essential to proceed Can’t Call for help with surgery? intubate Main tain 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

Issue 4 94 Issued: April 2017 Expires: April 2019 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 Primary infection delivery by caesarean section (CS) 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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l Recurrent infection Give woman aciclovir 5 mg/kg IV 8-hrly 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 Preterm labour nipple 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

Algorithm for the management of herpes in pregnancy and care of neonate

Recurrent genital herpes Primary acquisition of Primary acquisition of genital herpes in first or genital herpes in third second trimester trimester

Treat episodes with Treat primary episode Treat primary episode standard doses of with standard doses of with standard doses of aciclovir if necessary aciclovir aciclovir

Consider aciclovir 400 mg 8-hrly from 36 weeks’ gestation l Consider aciclovir 400 mg 8-hrly until delivery Offer vaginal delivery l Recommend planned If vaginal delivery ensues CS, especially if inform neonatologist ≤6 weeks of delivery Normal Genital postnatal HSV care lesions at Baby l Inform neonatologist delivery Baby well unwell l Normal postnatal care l Discharge home if l Normal postnatal care baby well at 24 hr Start Perform l l Advise parents Discharge home if aciclovir lumbar regarding later baby well at 24 hr 20 mg/kg puncture management if any l Advise parents 8-hrly for for HSV concerns regarding later 10 days PCR management if any while concerns awaiting results

Issue 4 96 Issued: April 2017 Expires: April 2019 GROUP B STREPTOCOCCAL DISEASE • 1/2

l BACKGROUND Antenatal antibiotics are not recommended as GBS is normal l Group B streptococcus (GBS) disease vaginal flora for many women in the newborn is defined as early l Clearly document the need for onset within first 7 days of life – over intrapartum antibiotics in maternal 90% present within first 24 hr of birth healthcare record l often with rapid onset in first hours after birth INTRAPARTUM MANAGEMENT l There is a 10% mortality rate in affected Indications for intrapartum neonates antibiotics l Risk can be reduced by giving maternal intrapartum antibiotics – see l Any one of the following: Intrapartum antibiotics below l previous infant with invasive GBS l Late onset cannot be prevented disease; arrange consultant-led unit care ANTENATAL MANAGEMENT l GBS bacteriuria this pregnancy l Routine antenatal screening not l GBS on vaginal swab in this pregnancy recommended l fever ≥38°C during labour at any gestation. Refer to local policy for GBS detected in current treatment of intrapartum pyrexia pregnancy l Inform mother of the risk of adverse reaction to antibiotics and that, despite MSSU positive attempts at prophylaxis, some babies l Recommend antenatal and intrapartum will still acquire infection antibiotics l In women with GBS and spontaneous l Antenatal antibiotics – oral penicillin rupture of membranes at term in the preparations. If allergic to penicillin, absence of labour, advise immediate according to sensitivities (e.g. induction of labour with intrapartum erythromycin) and local guidance. antibiotics once in labour If none available, discuss with microbiologist Intrapartum antibiotics l Intrapartum antibiotics – see l Vaginal delivery – give mother Intrapartum antibiotics below benzylpenicillin 3 g IV in 100 mL l Clearly document the need for sodium chloride 0.9% over 10 min then intrapartum antibiotics in maternal 1.5 g 4-hrly until delivery healthcare record l if allergic to penicillin, give clindamycin 900 mg IV in 50 mL sodium chloride Vaginal swab positive 0.9% over 30 min 8-hrly until delivery l give intrapartum antibiotics as soon as From high vaginal swab possible after the onset of labour and (HVS)/low vaginal swab (LVS) ≥2 hr before delivery l If detected at any gestation, advise intrapartum antibiotic prophylaxis (IAP). Place of birth will be dependent on locally agreed pathway for women with GBS detected in pregnancy – see Intrapartum antibiotics below

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Antibiotic prophylaxis not Recognition and assessment indicated l Signs of early GBS infection are non l Caesarean section – no investigation specific and could include: or treatment necessary if intact l grunting/tachypnoea/respiratory membrane, no suspicion of distress chorioamnionitis and no maternal fever l pallor/cyanosis If chorioamnionitis suspected, l lethargy give broad-spectrum antibiotics, l which will also cover Group B irritability streptococcal disease l poor feeding l tachycardia/bradycardia NEONATE l hypotension l Treat all babies from a multiple Risk factors for infection pregnancy if infection suspected in 1 l Maternity service to inform neonatal l For red flag signs, risk factors, and service of risk factors clinical indicators for treatment, follow Infection in first 72 hours of l antenatal detection of GBS colonisation life guideline in the Staffordshire, (unless intrapartum antibiotics Shropshire & Black Country Newborn received) and Maternity Network Neonatal l pre-labour rupture of membranes guidelines, if used locally l preterm birth (<37 weeks), especially with pre-labour rupture of membranes l confirmed or suspected chorioamnioitis (e.g. intrapartum fever) l invasive group B streptococcal (GBS) infection in a previous baby l antibiotic treatment given to mother for confirmed or suspected invasive bacterial infection 24 hr before, during, or post labour l Breastfeeding does not increase risk of neonatal GBS disease

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

Issue 4 98 Issued: April 2017 Expires: April 2019 HEPATITIS • 1/3

l HEPATITIS B Hepatitis B infection is not an indication 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 l immunisation 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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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

Issue 4 100 Issued: April 2017 Expires: April 2019 HEPATITIS • 3/3

HEPATITIS IMMUNISATION Principles of isolation

To whom l All body fluids are considered infectious material. Take appropriate l Hepatitis B immunisation is infection control precautions in line with recommended with other routine local Trust policy immunisations for high risk babies born to mothers: Antenatal care l with partners who are hepatitis B l A test for HCV infection is not part of surface antigen (HBsAg) positive routine antenatal screening, but should be offered to women who report a l who are or with partners who are IV history of IV drug use in themselves drug users (even if HBsAg negative) or their partner, and to women who l who change sexual partners frequently believe they had a positive test for HCV (e.g. commercial sex workers) Ab in the past. A positive HCV RNA l with close family contacts known to be report confirms current HCV infection HBsAg positive l Refer pregnant women with HCV l who intend to live in a country with high infection to a consultant with expertise prevalence of hepatitis B (Africa, Asia, in liver disease for further assessment Eastern Europe, Northern Canada, l Reassure woman with HCV infection Alaska) that pregnancy will not affect the course of the HCV infection and HCV Dose regimen for infants of infection will not affect the course of mothers HBsAg negative with the pregnancy, and that the risk of other indications for vaccination mother-to-child transmission of HCV is low in the absence of HIV infection l Vaccine is given at aged 0, 1 and l Alert neonatal team 6 months – see Hepatitis B and C guideline in the Staffordshire, Intrapartum care Shropshire & Black Country Newborn l Avoid fetal scalp blood sampling and and Maternity Network Neonatal fetal scalp electrodes guidelines (if used locally) l Because of increased risk of fetal abrasion or scalp trauma, avoid difficult HEPATITIS C instrumental delivery Introduction l Hepatitis C infection is not an indication for CS, as there is insufficient evidence l Hepatitis C is a blood borne viral infection that it reduces mother-to-child carrying a high risk of chronic infection transmission. However, if woman is and liver disease. Only 1–2% of pregnant co-infected with HIV, CS is indicated women are anti-HCV +ve in the UK Postnatal care l It is caused by the hepatitis C virus (HCV) transferred in blood and body l Presence of passively acquired maternal fluids antibodies that can persist in infants until aged 15–18 months renders High risk groups anti-HCV Ab detection of limited value l Current or former intravenous drug for diagnosis of infection. To investigate use or women with partners who are vertical transmission, review child at intravenous drug users aged 18 months and aged 3 and 12 yr l There is no contraindication to l From a country of high prevalence [e.g. breastfeeding unless dual HCV and HIV North Africa (particularly Egypt), Middle infection – see HIV positive women East] guideline Issue 4 Issued: April 2017 101 Expires: April 2019 HIGH DEPENDENCY CARE • 1/4

INTRODUCTION Available on delivery suite/unit l High dependency care (also known as l Thermometer enhanced maternity care) on delivery l Intravenous fluid warmers, forced air suite provides an intermediate level warming devices of care between that on a ward and l critical care unit (CCU). This can be Blood gas analyser level 1 and 2 critical care l Emergency major haemorrhage l Women requiring multiple organ equipment support or requiring mechanical l Emergency eclampsia equipment ventilation (level 3 care) will require l Access to blood results transfer to CCU l O-ve blood PRINCIPLES OF MANAGEMENT l Transfer equipment – monitor and ventilator l To care for women who have been recognised as unwell using the MEWS system to safely provide more frequent observation and monitoring in individual clinical cases l To provide individualised multidisciplinary care l To stabilise woman before transfer to critical care facilities EQUIPMENT l Ensure stock levels of appropriate equipment in the room used are maintained and checked as per local practice l Resuscitation trolley with defibrillator and airway management equipment l Resuscitation/emergency drugs l Monitoring equipment and accessories for: l pulse l BP l ECG l SaO2 and with transducer facility for invasive monitoring l Equipment for insertion and management of invasive monitoring (arterial and CVP) l Piped oxygen and suction l Intravenous fluid warmer l Forced air warming device l Infusion pumps

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LEVELS OF CRITICAL CARE

Level 0 Needs can be met through normal ward care

Level 1 Women at risk of deterioration and requiring a higher level of observation

Level 2 Invasive monitoring/intervention required that includes support for a single failing organ (excluding advanced respiratory support) Basic respiratory support l ≥50% oxygen via face mask to maintain oxygen saturation Basic cardiovascular support l IV anti-hypertensives e.g. pre-eclampsia l CVP and arterial line management Advanced cardiovascular support l Simultaneous use of ≥2 anti-arrhythmic/anti-hypertensive/vasoactive drugs IV Neurological support l Magnesium infusion to control seizures Hepatic support

Level 3 Advanced respiratory support required (mechanical ventilation) alone or CCU basic respiratory support together with support of ≥1 additional organ Advanced respiratory support l Invasive mechanical ventilation Support of ≥2 organ systems

INDICATIONS FOR LEVEL 1 l Disseminated intravascular coagulation AND 2 CRITICAL CARE (DIC) l Unstable medical condition e.g. l This list is not exhaustive diabetes, epilepsy, asthma l Women requiring invasive monitoring l MEWS >6, or an increasing score Staff responsibilities despite intervention l Women requiring maternal critical care l Severe pregnancy-induced must be discussed with consultant hypertension obstetrician, midwife co-ordinator and l PET, eclampsia, HELLP syndrome anaesthetist l Acute fatty liver l Midwives caring for the woman should l Major obstetric haemorrhage >2 L be trained in providing critical care and A-Line management/use of magnesium l causing maternal CVS compromise sulphate and anti-hypertensive l requiring acute transfusion >4 units medication blood l If woman receiving critical care, level 1 l Management of sepsis/suspected or greater, provide one-to-one care sepsis utilising the Sepsis Six Bundle l Sudden unexplained collapse l Anaphylaxis

Issue 4 Issued: April 2017 103 Expires: April 2019 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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Transfer DISCHARGE FROM HDU l Ensure documentation from all staff l Decision to discharge is made in groups is complete as per local consultation between obstetrician, guidance, with details of how to contact anaesthetist and midwife, provided: them if further information is required l all observations are stable and organ l Complete relevant transfer support no longer required documentation including handover tool l woman is alert and orientated and l Refer to Maternal transfer guideline no longer requires observation or treatment available on HDU Discharge to non-maternity l obstetrician has written an ongoing wards plan of care l Where maternal condition dictates l there has been careful handover to the that ongoing care is required by receiving ward using local handover another speciality, identify a named tool non-obstetric consultant to liaise with l After leaving HDU care, senior medical named obstetrician staff must review woman l Named obstetrician is responsible for l Provide woman with information about ensuring regular obstetric reviews what has happened and encourage her l Formally handover woman at each to participate in decisions relating to change of staff on labour ward as an recovery outlier l Outreach team to continue follow-up as l Continue midwifery input/checks daily appropriate or when appropriate document in l Arrange outpatient appointment for departmental notes consultant follow-up/debrief within l If woman is discharged home from a 3 months non-obstetric ward, inform labour ward co-ordinator to ensure community midwife is notified of discharge

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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 l screening Normal vaginal delivery is now recommended for women: l if HIV testing declined, offer counselling l by HIV specialist (if available) 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 l improve maternal health and reduce 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 l retesting. If not done early in 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

Issue 4 106 Issued: April 2017 Expires: April 2019 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. VAGINAL DELIVERY Most recent viral load can be helpful 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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CAESAREAN SECTION Baby

Preparation l Bath the baby and remove any secretions in mouth or nose with gentle l Midwife co-ordinator informs theatre wiping team of woman’s HIV status, which l Contact neonatal team while mother must not be recorded on theatre list still on delivery suite l For women who require intrapartum l High-risk (maternal viral load zidovudine IV >50 copies/mL or unknown): give baby l because delivery must occur during the zidovudine, lamivudine and nevirapine zidovudine infusion, ensure first or very <2 hr from birth early on theatre list l Low-risk (maternal viral load l If first on list, admit night before for IV <50 copies/mL in last 4 weeks): give cannula before midnight. Woman must baby zidovudine <4 hr of delivery take oral antiretrovirals at usual times l before CS even if nil-by-mouth Take 5 mL EDTA sample from mother to go with baby’s sample for HIV DNA l Antibiotic prophylaxis is particularly PCR testing important due to increased risk of postpartum fever l For neonatal care see Staffordshire, Shropshire & Black Country Newborn Surgery and Maternity Network Neonatal HIV guideline (if used locally) l Administer prophylactic antibiotics – see Caesarean section guideline l Keep surgical field as haemostatic as possible l Delay membrane rupture as long as possible l All healthcare professionals performing or assisting at CS where woman is known to be HIV positive should wear double gloves to reduce risk of transmission

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

Issue 4 108 Issued: April 2017 Expires: April 2019 HOME BIRTH • 1/3 l COMMUNICATION WITH WOMAN 34–36 weeks’ gestation: 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)

Community midwife Home birth cover l Take a comprehensive booking history l Woman contacts the maternity hospital, and perform risk assessment as discussed during her birth plan visit l Offer woman a choice of planning birth l Maternity unit will contact midwife as at home, in a midwife-led unit or in an per local arrangements obstetric-consultant-led unit, according l to assessed risk Community midwife will ensure all equipment is available and attend woman l Provide antenatal care l refer to local Lone worker policy l Provide contact details, together with l those of the local maternity unit and A second midwife will be requested document in maternal healthcare record by the midwife at a time she considers appropriate l Arrange a dating scan. Subsequent mid-trimester scan will be arranged Intrapartum care at home birth l Encourage woman to attend regular antenatal visits as per local care pathways l First midwife is responsible/accountable for care in labour and delivery l Complete notification of home birth as per local policy l Second midwife attends and supports first midwife during delivery and with l While home birth is predominantly a any obstetric/neonatal emergency as choice available for women meeting required the low-risk criteria, occasionally women who do not fit these criteria l Intrapartum care record is used to may request a home birth. In these record progress of labour and delivery cases, see High-risk care below Issue 4 Issued: April 2017 109 Expires: April 2019 HOME BIRTH • 2/3 l Intrapartum auscultation of the Baby fetal heart using a sonic aid – see Intermittent auscultation guideline. If l As routine following delivery: deviations from normal are identified at l obtain parental consent and administer any time during home birth, midwives vitamin K (Konakion® MM paediatric) must act accordingly – see Maternal 1 mg in 0.1 mL IM transfer guideline (or follow local practice) and NMC midwives rules General l Inform local maternity hospital when labour and placenta delivery are First midwife complete l Arranges home visit for next day or Born before arrival later that day if required (depending on time of delivery) l If born at home, unattended by a l Returns equipment to local maternity midwife, follow local Born before unit arrival policy l Obtains NHS number for baby l Consider safeguarding issues. Depending on condition of woman l Records delivery in maternal healthcare and/or baby, admission to hospital record via paramedic ambulance may be l Initiates Red Book necessary l Restocks home birth bag as per local practice and records this has taken POSTNATAL CARE AT A HOME place BIRTH l Ensures neonatal resuscitation Mother equipment is clean, complete and signed back in as per local practice l As routine, record a full set of maternal l On-call community midwives inform observations local maternity unit that they have l Initiate skin-to-skin contact and returned home breast or bottle feeding according to l Arrange hearing screening for baby woman’s preference and document using appropriate request form time – see Staffordshire, Shropshire & l Arrange appointment for initial Black Country Newborn and Maternity examination of the newborn to take Network Breastfeeding guideline or place follow local practice l ≤72 hr of birth as per local policy l If breastfeeding, arrange breastfeeding support l Inform woman’s GP that home delivery has taken place l Suture if required, see Perineal trauma suturing (tears and episiotomy) guideline l Assist mother with personal hygiene l If the woman is Rhesus negative, make arrangements to check cord blood and Kleihauer results, and to administer anti-D if required l Provide local contact numbers and tell mother who to contact for emergency medical relief (e.g. 999)

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HIGH-RISK CARE Documentation l Women who are booked for high-risk l Document all discussions between care may also wish to deliver their baby mother/community midwife/consultant/ at home, and have a right to do so PMA in the maternal healthcare record l Midwives discuss woman’s wishes l Formulate a detailed plan (agreed by with her in a non-judgemental manner, all parties) and place copies in: providing detailed information, options l woman’s hand held records for care and outlining any potential l risks, so that the woman may make a local maternity unit fully informed decision about place of l woman’s healthcare record delivery l If in line with local policy, offer high-risk woman the opportunity to deliver on the midwifery-led unit as a safer option, in agreement with her consultant, named midwife and unit manager l A professional midwifery advocate (PMA) must be available (contact via delivery suite) at all times for advice

Good preparation is key. Midwives must not practice outside the scope of their abilities (NMC rules). He/she must ensure PMA is contacted and must not be drawn into unsafe practice l Consultant providing care will discuss woman’s wishes with her during antenatal period l Community midwife must make every effort to attend the appointment to ensure all parties have explored the risks of home birth. If it is not possible for the community midwife to attend the appointment, she should discuss with consultant before appointment date l If a woman chooses not to accept the advice provided by the consultant and community midwife, make an appointment for her to meet with PMA or attend a birth choice clinic (if available locally) to ensure all possibilities have been explained

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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

DEFINITION Gestational hypertension (GHT)

Chronic hypertension l New hypertension presenting >20 weeks’ gestation without l Hypertension present at booking visit significant proteinuria or <20 weeks’ gestation or if woman already taking antihypertensive GHT with significant proteinuria medication when referred to maternity services. Can be primary or secondary l New hypertension presenting in aetiology >20 weeks’ gestation with urinary protein:creatinine ratio >30 mg/mmol or a validated 24 hr urine collection result shows >300 mg protein

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

l RISKS type 1 or type 2 diabetes l chronic hypertension Woman l Moderate risk factors: l Increase in lifetime risk of chronic l first pregnancy hypertension and cardiovascular disease l age ≥40 yr l pregnancy interval of >10 yr Baby l body mass index (BMI) ≥35 kg/m2 at l Higher rates of perinatal mortality, first visit preterm and low birth weight l family history of pre-eclampsia l multiple pregnancy PREVENTION OF GESTATIONAL HYPERTENSION Aspirin therapy Risk factors l Women with ≥1 high risk factors or ≥2 l High risk factors: moderate risk factors of pre-eclampsia, start 75 mg aspirin daily from 12 weeks l hypertensive disease during a previous until delivery pregnancy l chronic kidney disease l autoimmune disease e.g. systemic lupus erythematosis or antiphospholipid syndrome

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l SYMPTOMS AND SIGNS Stop angiotensin-converting enzyme 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 Postnatal care Measure BP: 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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l Follow-up care ACEI other than enalapril and captopril 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 l treatment 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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Timing of birth Intrapartum care l Chronic hypertension with blood l See Intrapartum care above pressure <160/110 mmHg, with or without antihypertensive treatment: Postnatal care l do not offer delivery <37 weeks l See Postnatal care above l Chronic hypertension with blood pressure <160/110 mmHg >37 GESTATIONAL HYPERTENSION weeks, with or without antihypertensive WITHOUT PROTEINURIA treatment: l woman and obstetrician will agree Antenatal care timing of birth l Assessment by middle grade l Severe, uncontrolled chronic obstetrician (ST3–7 or equivalent e.g. hypertension: staff grade, clinical fellow) or consultant l offer delivery after a course of l Consultant obstetrician as lead corticosteroids completed (if required) professional

Assessment and antihypertensive treatment (see Antihypertensive treatment and prenatal counselling above) Mild hypertension Moderate hypertension Severe hypertension (BP 140/90– (BP 150/100– (BP ≥160/110 mmHg) 149/99 mmHg) 159/109 mmHg) l Do not admit to hospital l Do not admit to hospital l Admit to hospital l Do not treat l Treat with first-line oral l Keep mobile in hospital hypertension labetalol to maintain BP l Treat with first-line oral labetalol to maintain BP l Measure BP weekly at <150/80–100 mmHg (monitor via community at <150/80–100 mmHg l Test for proteinuria midwife or assessment l Measure BP ≥4 times at each visit using an unit) daily automated reagent-strip l Test for proteinuria daily reading device or urinary l Measure BP at least twice a week using an automated protein:creatinine ratio reagent-strip reading l l Perform routine Test for proteinuria at device or urinary antenatal blood tests each visit protein:creatinine ratio l If presenting at l Test renal function, l Test LFT, U&E, FBC, <32 weeks or at high electrolytes, FBC, transaminases, bilirubin risk of pre-eclampsia, transaminases, bilirubin at presentation and then test for proteinuria and l If no subsequent monitor weekly measure BP twice a proteinuria, no further l If receiving outpatient week blood tests required care after severe hypertension has been effectively controlled in hospital: l measure BP and test for proteinuria twice a week l perform weekly blood tests

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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

Timing of birth Recurrence risk and long-term health risks l GHT with blood pressure <160/110 mmHg, with or without l Women who experienced gestational antihypertensive treatment hypertension risk developing: l do not offer delivery before 37 weeks l gestational hypertension in future l GHT with blood pressure pregnancy ranges from about 1 in 6 <160/110 mmHg after 37 weeks, with (16%) pregnancies to about 1 in 2 (47%) or without antihypertensive treatment pregnancies l l woman and middle grade obstetrician pre-eclampsia in future pregnancy (ST3–7 or equivalent e.g. staff grade, ranges from 1 in 50 (2%) to about 1 in clinical fellow) or consultant agree 14 (7%) pregnancies timing of birth, and maternal and fetal Long-term health risks of indications for birth cardiovascular disease l Refractory severe gestational hypertension: l Women who have experienced gestational hypertension or l offer delivery after a course of pre-eclampsia have an increased risk corticosteroids (if required) has been of developing hypertension and its completed complications in later life Intrapartum care for woman Long-term risk of end-stage with GHT kidney disease l See Intrapartum care above l Inform women with a history of hypertension without proteinuria and Postnatal care no hypertension at the postnatal review (6–8 weeks after delivery) that although l See Postnatal care above the relative risk of end-stage kidney disease is increased, the absolute risk is low and no further follow-up is necessary Issue 4 116 Issued: April 2017 Expires: April 2019 HYPERTENSION IN PREGNANCY • 6/7

GESTATIONAL HYPERTENSION WITH PROTEINURIA (PRE-ECLAMPSIA) Introduction l Once a diagnosis of pre-eclampsia is made, risk of maternal and perinatal mortality and morbidity is increased (see Severe pre-eclampsia guideline) l Clinical management is often determined by drawing a balance between maternal and fetal considerations. For example, the timing of birth depends on mother’s condition and risk of intrauterine death of baby or, if born, neonatal death or morbidity as a result of prematurity Antenatal care (see Antihypertensive treatment and prenatal counselling above) Mild hypertension Moderate hypertension Severe hypertension (BP 140/90– (BP 150/100– (BP ≥160/110 mmHg) 149/99 mmHg) 159/109 mmHg) l Do not treat l Treat with first-line oral l Urgent referral to hospital hypertension labetalol to keep BP l Obstetric middle grade l Measure BP ≥4 <150/80–100 mmHg obstetrician (ST3–7 or times a day l Measure BP ≥4 times a equivalent e.g. staff grade, l Test kidney day clinical fellow) or consultant function, l Test kidney function, assessment electrolytes, FBC, electrolytes, FBC, LFT l Consultant obstetrician as lead LFT twice a week 3 times a week professional l Treat with first-line oral labetalol to keep BP <150/80–100 mmHg l Measure BP >4 times daily depending on clinical circumstances l Test kidney function, electrolytes, FBC, LFT 3 times a week l VTE risk assessment

Timing of birth 34–36+6 weeks

<34 weeks l If required course of corticosteroids completed, recommend birth after 34 l Aim to manage conservatively until weeks if pre-eclampsia with severe 34 weeks hypertension l Obstetric consultant or middle grade l If pre-eclampsia with mild or moderate obstetrician (ST3–7 or equivalent e.g. hypertension, offer birth at 34–36+6 staff grade, clinical fellow) to assess weeks depending on maternal and fetal daily to review management plan condition, risk factors and availability of l If delivery likely <35 weeks’ gestation, neonatal intensive care give corticosteroids +0 l Offer birth (after discussion with >37 weeks neonatologist and anaesthetist) if: l Recommend birth within 24–48 hr l severe refractory hypertension l maternal or fetal clinical condition deteriorates

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l Fetal monitoring In women with pre-eclampsia who have given birth, carry out a urinary l Ultrasound for fetal growth and reagent-strip test at the postnatal amniotic fluid volume. Umbilical artery review (6–8 weeks after birth) Doppler velocimetry at diagnosis if l In women who had pre-eclampsia and conservative management planned still have proteinuria (1+ or more) at l Do not repeat more than every 2 weeks postnatal review (6–8 weeks after birth) offer a further review at 3 months after l EFM at diagnosis. Repeat if change in birth to assess kidney function and fetal movement reported by woman, consider referral for specialist renal vaginal bleeding, abdominal pain, assessment deterioration in maternal condition

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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l DEFINITION History of precipitate labour 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 l (>37 weeks’ gestation) – see 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)

Issue 4 Issued: April 2017 119 Expires: April 2019 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 Midwife/doctor will: available locally) 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

Nulliparous women Multiparous women

l Administer first dose prostaglandin: l Administer first dose prostaglandin l 2 mg gel or l 1 mg gel or l 3 mg tablet or l 3 mg tablet or l 10 mg dinoprostone (Propess®) l 10 mg dinoprostone (Propess®) pessary (times will be unit specific) pessary (times will be unit specific)

l Midwife/doctor will perform vaginal examination to assess state of cervix, whether contracting or not: l 6 hr after initial dose of gel or tablet l 24 hr after initial dose of dinoprostone (Propess®) pessary l If, at next examination, artificial rupture of membranes (ARM) is possible, perform regardless of Bishop’s score l If ARM not possible, administer second dose but withhold if woman is contracting regularly, painfully and palpably For primips, maximum dose of prostaglandin is 3 mg gel, 6 mg tablet or 10 mg dinoprostone (Propess®) pessary in 24 hr For multips, maximum dose of prostaglandin is 2 mg gel, 6 mg tablet or 10 mg dinoprostone (Propess®) pessary in 24 hr

Contraindications to induction Relative contraindications of labour with prostaglandin l Previous CS – see Vaginal birth after l Sensitivity to prostaglandins caesarean section guideline l Clinical suspicion or definite evidence l Predisposition to uterine rupture of pre-existing fetal distress l Acute cervicitis and vaginitis l Uncontrolled asthmatic l Contraindications to vaginal birth e.g. uncontrolled severe pre-eclampsia, mechanical obstruction to delivery, placenta praevia Issue 4 120 Issued: April 2017 Expires: April 2019 INDUCTION OF LABOUR • 3/5

Inducability rating (modified Bishop’s score) For the purpose of this guideline modified Bishop’s score is used to assess cervical condition Cervical feature Pelvic score (circle appropriate number) 0 1 2 3 Cervix position Post Central Anterior – Consistency Firm Medium Soft – Length (cm) 3 2 1 0 Dilatation (cm) 0 1–2 3–4 5+ Station* to spines -3 -2 -1 0+ *Station is measured in cm relative to ischial spines

l OXYTOCIN Following explanation of procedure, perform membrane sweep and inform l After ARM or spontaneous rupture of woman of findings membranes, discuss commencement l Explain she may experience of oxytocin with woman and obstetric discomfort and the passing of a medical staff – see Oxytocin guideline show and advise to contact maternity for dose regimen unit if she experiences bleeding, Do not begin oxytocin infusion until spontaneous rupture of membranes, 6 hr elapsed following administration abdominal pain or contraction of prostaglandin gel or tablets, or l Arrange admission date and time for 30 min after removal of dinoprostone induction at 40 weeks plus 7–14 days’ (Propess®) pessary gestation l Provide ‘Induction of labour’ ANTENATAL MANAGEMENT information leaflet (if available locally) AND BOOKING OF PLANNED l Record all discussions indicating INDUCTION OF LABOUR woman’s understanding of her plan of (LOW-RISK PREGNANCIES) care

41 weeks ADMISSION AND MANAGEMENT OF Community midwife/doctor will: PROSTAGLANDIN INDUCTION (LOW-RISK PREGNANCIES) l Perform routine antenatal assessment, to include: l Admit and perform general observations: l blood pressure l temperature l urine for proteinuria and glycosuria l pulse l measure fundal height and plot on l blood pressure growth chart l respiratory rate and document MEOWS l check position of baby score l auscultate fetal heart and enquire l repeat in accordance with local guidance about fetal activity l urinalysis l full antenatal examination

Issue 4 Issued: April 2017 121 Expires: April 2019 INDUCTION OF LABOUR • 4/5 l Obtain and review full history, confirm ANTENATAL MANAGEMENT gestation and reason for induction and 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 l have commenced 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 l and inform middle grade obstetrician 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, l eat and drink normally, and consider 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

Issue 4 122 Issued: April 2017 Expires: April 2019 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

FAILED INDUCTION OF LABOUR l If amniotomy still not possible after 2 doses of prostaglandin gel or tablet or 24 hr dinoprostone (Propess®) use, induction of labour has failed l give third dose of prostaglandin (1 mg gel or 3 mg tablet) or extend dinoprostone (Propess®) use for a further 6 hr l If amniotomy still not possible, discuss with consultant obstetrician and arrange review l Discuss the following options with the woman: l CS l transcervical catheter induction (if used locally) – see Transcervical catheter induction guideline l abandon process and repeat after an interval i.e. 24 hr

Issue 4 Issued: April 2017 123 Expires: April 2019 INFANT FEEDING • 1/12

l INTRODUCTION Never interrupt skin-to-skin contact 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 l l Promote the value of breastfeeding as Reassure woman undergoing protection from infection, comfort and a caesarean section (CS) that food skin-to-skin contact will be initiated as soon as possible after birth, in theatre l If woman chooses to formula feed, or recovery room, depending on give support and information on safe clinical situation practices – see Formula feeding l Document skin-to-skin contact and l Avoid asking feeding intention, which record reason for any delay in maternal can limit further discussion and does healthcare record not allow for change of mind l If mother wishes to end skin-to-skin contact before first breastfeed, advise SKIN-TO-SKIN CONTACT that ending contact for anything other l Skin-to-skin contact immediately after than a short time may be detrimental to birth (following delayed cord clamping) initiation of breastfeeding. Document promotes an early feed mother’s decision in maternal healthcare record l Aim to provide an uninterrupted period of skin-to-skin contact in a quiet l Allow mother to transfer to postnatal environment for 1 hr, or at least until ward with baby still in skin-to-skin after first feed contact l Ensure mother comfortable and avoid l Women who choose to formula feed excessive heat-loss in baby to give first bottle feed in skin-to-skin contact l Throughout period of skin-to-skin contact continue normal observations of baby’s: Benefits l temperature l Keeps baby warm l breathing l Promotes bonding l colour l Helps baby’s heartbeat and breathing l tone to settle after birth l Continue to observe mother POSTNATAL WARD l Remove baby promptly if health of mother or baby gives rise for concern l Check baby’s temperature was normal l Ensure baby cannot fall to the floor, or before transfer become trapped in bedding or by the l On admission to postnatal ward, mother’s body observe colour and general l Position baby ensuring head is appearance of baby supported so baby’s airway does not l If baby is well and not showing signs of become obstructed wanting to feed, discuss early feeding cues with woman

Issue 4 124 Issued: April 2017 Expires: April 2019 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 Issue 4 Issued: April 2017 125 Expires: April 2019 INFANT FEEDING • 3/12

Information for mother l Give mother information on how to obtain advice and support in hospital and at home l Give verbal and written information on how to recognise effective feeding (UNICEF ‘Recognising breastfeeding is going well’ tool if available locally). Including signs that baby is receiving sufficient milk and what to do if not l Recognise when breastfeeding not progressing normally e.g. sore nipples, breast inflammation Health benefits Baby Mother l Reduced risk of: l Reduced risk of: l gastroenteritis l ovarian and breast cancer l diarrhoea l osteoporosis l urinary tract infection l chest infection l ear infection l obesity l diabetes l leukaemia

Initiating breastfeeding l if necessary for clinical reasons, trained immediately after delivery midwife or neonatologist will make the decision to offer supplementary feeds l Encourage mother to hold baby after discussion with parents (skin-to-skin contact) in a calm l Before introducing artificial milk to environment as soon as possible after breastfed babies, encourage mother delivery – see Skin-to-skin contact to express breast milk to be given by l Midwife will assist with first breastfeed feeding cup or syringe to reduce the as soon as baby shows interest need for artificial feeds l following a period of uninterrupted l If supplements of formula are given, skin-to-skin contact many babies will provide optimal care and support, and self-attach review each feed to ensure: l Early suckling helps promote uterine l minimal formula use contraction, facilitating early passage of l maximum breast milk use meconium and baby’s blood glucose l support to increase milk production stabilisation l cup feeding rather than teat feeding l If first feed not achieved ≤4 hr, start active intervention – see Healthy l support to express and stimulate term baby who is slow to establish breasts feeding l This proactive approach will reduce the need to offer artificial feeds and help to Exclusive breastfeeding/artificial support mother’s lactation supplements l Unless medically indicated or is parents’ fully informed choice, do not give food or drink (including water or artificial feed) other than breast milk to newborn breastfeeding infants

Issue 4 126 Issued: April 2017 Expires: April 2019 INFANT FEEDING • 4/12

How to breastfeed and l Home birth: Instruct mother as soon as maintain lactation possible after birth l Offer a visit by community staff Correct positioning and attachment Preterm/sick baby l Good positioning and attachment are l Encourage mothers who are separated key to successful breastfeeding. It from their babies to begin expressing ensures: milk as soon as possible after birth as l good milk supply and transfer from early initiation has long-term benefits mother to baby for milk production l prevents sore nipples l Neonatal nurse caring for baby, and l pain-free feeding mother’s midwife, will show mother how to express milk by hand and by l Poor positioning and attachment may pump result in unsettled baby in immediate postpartum period. Assist mother to l If available locally, give mothers the attach baby to breast correctly How to express your breast milk leaflet l Document assistance given and outcome in appropriate healthcare record l If baby very preterm or very low birth weight, more frequent expressing is Avoid teats and dummies advised (8–12 times in 24 hr) l If baby known to be at risk of l Teats and dummies can hinder baby’s developing hypoglycaemia is receiving ability to attach to the breast while care on the postnatal ward, midwife learning to breastfeed in the early weeks responsible for mother and baby will and can interfere with responsive feeding assist in initiating and maintaining lactation Assessment l practical care and help may be l Midwife will assess breastfeeding daily delegated to a skilled maternity support in hospital, and on Day 3 and Day 5, worker or healthcare assistant, but the to determine whether effective milk overall responsibility remains with the transfer is taking place and if further midwife support required l See also the following guidelines: l Document findings using local l Promotion, initiation and breastfeeding assessment tool maintenance of lactation in the l If assessment indicates a potential mother of a preterm or sick infant feeding problem, observe a full guideline (if available locally) breastfeed and document l Breastfeeding guideline, Breast l If mother experiences difficulty milk expression guideline, Breast breastfeeding, consider referral to the milk handling and storage guideline maternity infant feeding team and Hypoglycaemia guideline in the Staffordshire, Shropshire & Black Country Newborn and Maternity Expressing breast milk Network Neonatal guidelines (if used l It is important that mothers understand locally) why and when hand-expressing is useful l In hospital: As routine, before transfer home, teach mother to hand-express breast milk and, if available locally, give information leaflet

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Reasons why baby may not get enough breast milk (Note: several factors may contribute in any one situation)

Factors Factors rarely occasionally Factors related to Other factors associated with associated with breastfeeding breast milk breast milk insufficiency insufficiency l Poor attachment l Lack of l Dislike of l Retained l Delayed start in confidence in breastfeeding products of breastfeeding mother, either (indirectly) conception l Inefficient herself or those l Medication (e.g. l Rejection of baby suckling around her contraceptive pill, l Severe l Infrequent feeds (indirectly) diuretics) malnutrition l Scheduled feeds l Tiredness, stress, l Pregnancy l Inadequate l Short feeds worry (indirectly) l Alcohol/smoking breast l Supplementary l Prematurity, development feeds illness/abnormality l Use of a teat in baby l Use of a dummy

Assessment of breastfeeding

At each postnatal visit/check Abnormal findings trigger further action, see Table below Baby Breasts Breastfeeding l Jaundiced and sleepy l Engorgement or mastitis l Difficult attachment or difficult to rouse for l Trauma to nipples: l No change in sucking feeding l nipples misshapen or pattern i.e. from initial l Feeding <8 times in 24 hr ‘pinched’ at end of feeds rapid sucks with pauses and/or not sustaining and audible swallows effective suckling pattern l Baby ‘fussy’ at breast l Feeding very frequently e.g. on and off the breast i.e. consistently >12 frequently during feed or times in 24 hr refusing to breastfeed l Consistently feeding for >45 min or <5 min l Unsettled after or during feed l HEALTHY TERM BABY WHO IS Some babies will feed <4 times in the first 24 hr. At least 3–4 feeds are SLOW TO ESTABLISH FEEDING expected in this period increasing to l Hypoglycaemia is unlikely to be a 8–12 thereafter in any 24 hr period problem in healthy, term, well grown l Encourage healthy term babies to babies. These babies are low risk and breastfeed in the first hour after birth, routine blood glucose monitoring is preferably on delivery suite or, if not, unnecessary when baby is ready l There is no evidence that long intervals l Some babies may not be keen to feed between feeds in the first 24 hr will soon after delivery adversely affect healthy term newborns

Issue 4 128 Issued: April 2017 Expires: April 2019 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 l attachment 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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Baby has breastfed l low-risk babies can mobilise alternative at delivery fuels like ketones as an energy source 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

Issue 4 130 Issued: April 2017 Expires: April 2019 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 Breastfed baby ‘sleepy’ or Record plan (agreed with mother, 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 Urates may be ≥5 Number of wet Nappies feel 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

Issue 4 Issued: April 2017 131 Expires: April 2019 INFANT FEEDING • 9/12

l FORMULA FEEDING always wash hands before removing 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 Technique is not sterile) 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

Issue 4 132 Issued: April 2017 Expires: April 2019 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 l Hold baby upright with head supported 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 l Keep teat full of milk, to avoid intake of Never store feeds for >24 hr. It is air always safer to make up a fresh bottle l l Hold bottle horizontal to the ground, 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 l for feeding, offering eye contact. 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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Breastfed baby Formula-fed baby l Give mother: l Complete bottle-feeding checklist l verbal and written information about local l Offer demonstration of sterilisation of support groups, including contact details equipment and reconstitution for voluntary breastfeeding counsellors, l Document in postnatal section of 24 hr national help lines including National mother’s healthcare plan Breastfeeding helpline, the Breastfeeding l Mothers who do not wish this, or request Network, National Childbirth Trust, early transfer home before it can be La Leche League and Association of arranged should at least be Breastfeeding Mothers knowledgeable in the preparation, l Ensure breastfeeding mothers: administration and storage of formula milk l know how to recognise signs that baby l give Bottle feeding leaflet and A guide is receiving sufficient milk, and what to to infant formula for parents who are do if this is not the case bottle feeding leaflet if available l know how to recognise signs that breast- l Where English is not the first language, feeding is not progressing normally (e.g. seek assistance from an interpreter to sore nipples, breast inflammation) ensure effective demonstration/discus- l are confident with positioning and sion attaching baby for breastfeeding l Ensure mother understands feeding cues and the importance of responding, and awareness of normal feeding patterns, including ‘cluster feeding’ and ‘growth spurts’ l Provide written and verbal information on what constitutes healthy newborn behaviour and the signs that should cause concern l Advise mother to seek help urgently if baby is sleepy and reluctant to feed, after discharge home. Give midwives’ contact numbers (24 hr/7 days), infant feeding co-ordinator, breastfeeding support workers, and other professional support l Home support is provided by community midwives, and breastfeeding support workers l Further telephone support is available evenings, nights and weekends from local and national helplines, and services available from local maternity units l In order to identify potential difficulties, at each contact, healthcare professional will ask about the progress of breastfeeding and assess adequacy of milk transfer within the first 48 hr and on (or around) day 5 using local breastfeeding assessment form – see assessment tool www.babyfriendly.org.uk

l Support in the community Healthcare professionals and trained support workers will further instruct l Community midwives will check and on expressing milk, explaining reinforce learning the importance of prevention and management of engorgement and l Ensure particular care and planning so mastitis that mothers who begin breastfeeding but later change to formula feeding are l If breastfeeding difficulties present, given full support to breastfeed while look for causal factors e.g. tongue tie, they are doing so, but are provided cleft palate with appropriate information about formula feeding when decision to Re-admission to hospital change or combine is made with feeding problems within first 28 days l Follow local follow-up process

Issue 4 134 Issued: April 2017 Expires: April 2019 INFANTInfan tFEEDING feeding 201719 • 12/12

Flowchart: Management of breastfeeding in healthy term babies Flowchart: Management of breastfeeding in healthy term babies

At birth Dry baby and establish skin-to-skin contact with mother for 1 hr minimum First breastfeed when baby responsive (preferably within 1 hr of birth)

Yes Has baby initiated breastfeeding at birth? No

Offer assistance with second On admission to postnatal ward breastfeed within 6 hr of delivery/on • Observe temperature, colour and admission to ward and document baby’s general appearance • If baby well and no signs of wanting to feed – leave alone • If showing hunger cues – offer Did baby feed effectively? assistance to breastfeed

Yes No 4 hr after birth • Check newborn vital signs (temperature, respiration, heart Responsive feeding rate, colour tone, general wellbeing/level of consciousness) • Stimulate baby/tempt at breast • Skin-to-skin, encourage hand- • Recommence skin-to-skin contact expression and offer further

feeding assistance ≤3 hr • Document on feed chart and maternal healthcare record Did baby feed effectively?

Did baby feed effectively? Yes No

Yes No Hand-express and give colostrum via If observations cup/syringe normal, monitor and • Check newborn vital signs document • Hand-express and give subsequent feeds colostrum via cup/syringe • Once baby feeding Responsive feeding • Check newborn regularly and staff vital signs 2-hrly happy with and: progress: • encourage skin-to- • stop monitoring If baby has not breastfed skin contact temperature, effectively by 12 hr or no • tempt at breast respiration, heart colostrum available, review • hand-express and rate and muscle and assess to determine give colostrum via tone whether neonatal referral cup/syringe 3-hrly • use feeding chart necessary until feeding to assess whether established feeding established • if any concerns or signs of illness, neonatal referral

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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 l auscultation Abnormal presentation l l Risk factors below indicate the woman High (4/5–5/5 palpable) or free floating is not low-risk head in nulliparous woman l l If risk factors present or structured 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 l l Pre-eclampsia/eclampsia Perform abdominal palpation to ascertain optimal position for l Recurrent antepartum haemorrhage auscultation of fetal heart l Any vaginal blood loss other than a l Auscultate fetal heart using Doppler show ultrasound or Pinard stethoscope whilst l Prolonged rupture of membranes palpating maternal pulse to differentiate >24 hr between maternal and fetal heart rates l Prolonged pregnancy >42 weeks (FHR) l Diabetes or other significant medical l Listen for 1 full minute after a disorders contraction and record average rate l Raised blood pressure (see l in first stage – at least every 15 min Hypertension guideline) l in second stage – at least every 5 min l Labour with oxytocin l Document maternal and fetal heart l Abdominal pain without contractions rates in maternal healthcare record l Trauma/after a fall/RTC l Note any intrapartum events that may affect the FHR contemporaneously in l Cholestasis maternal healthcare record, sign and l Previous stillbirth or early neonatal note time death l If any concern about decelerations, palpate maternal pulse to differentiate the 2 heart beats

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Electronic fetal monitoring l Transfer to EFM if: l abnormal FHR: ≤100 bpm or ≥160 bpm or any decelerations after a contraction l intermittent auscultation is not possible l significant meconium stained liquor – see Meconium stained liquor guideline l suspected chorioamnionitis or sepsis, or maternal pyrexia ≥38.0°C l fresh bleeding developing in labour l severe hypertension >160/110 mmHg l oxytocin use for augmentation l epidural analgesia l woman’s request l Perform a full risk assessment and commence EFM if any of the following risk factors are present with another risk factor l >24 hr since membrane rupture l confirmed delay in first or second stage of labour (see Delay in labour guideline) l non-significant meconium l pain different to contraction pain l moderate hypertension (single reading 150/100–159/109 mmHg) l either, raised diastolic blood pressure of >90 mm/Hg or raised systolic blood pressure of >140 mmHg on 2 consecutive readings 30 min apart l 2+ protein on urinalysis and single reading of either diastolic blood pressure (>90 mmHg) or raised systolic blood pressure (>140 mmHg) l maternal pulse >120 bpm on 2 occasions 30 min apart l 2 consecutive readings of temperature >37.5°C 1 hr apart

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DEFINITION

Latent phase l Period of time, not necessarily continuous, where there are painful contractions and some cervical change ≤4 cm dilatation – see Latent phase of labour guideline First stage l Regular painful uterine contractions and progressive cervical dilatation >4 cm Second stage Passive l Full dilatation of cervix before or in the absence of expulsive contractions Active l Expulsive contractions with full dilatation of cervical os l Presenting part of baby visible or active maternal effort in the absence of expulsive contractions Third stage l Time of birth of baby to expulsion of placenta and membranes – see Third stage of labour guideline

ADVICE TO WOMAN AT ONSET Maternal and fetal observations OF LABOUR l Perform the following observations: l Advise woman to telephone nearest l maternal pulse labour ward for advice l blood pressure l If homebirth planned, community midwife will attend l temperature l If inpatient birth planned, advise l respiratory rate woman to attend the unit for l urinalysis assessment if: l contraction pattern suggesting Examination established labour l Abdominal palpation l history suggestive of rupture of l fundal height in centimetres membranes l lie l woman was advised during antenatal period to present early in labour l presentation and position l engagement INITIAL ASSESSMENT l Vaginal loss: OF LABOUR l liquor colour (e.g. clear or meconium) l In all clinical settings and in all women, l show midwife must perform an initial l assessment blood loss and amount l Review clinical records, ideally before Vaginal assessment admission, including any safeguarding concerns and anaesthetic and neonatal l If in established labour, offer vaginal alerts assessment l Take history l explain reason and what is involved l Assess emotional and physical needs l obtain verbal consent l Review of birth plan

Issue 4 138 Issued: April 2017 Expires: April 2019 LABOUR MANAGEMENT (including clinical risk assessment) • 2/4 l Fetal wellbeing examination 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 Blood and blood products equivalent e.g. staff grade, clinical fellow) 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 assessment during first stage intrapartum risk assessment and 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

Issue 4 Issued: April 2017 139 Expires: April 2019 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 Carry out continuous risk Delay in first stage of labour assessment to determine whether to transfer to high-risk labour care l See Delay in labour guideline

SECOND STAGE OF LABOUR Woman’s comfort Risk to mother and fetus increases l Midwife must provide: during second stage of labour l 1:1 care when labour is established when possible Presumptive diagnosis of l regular assessment of woman’s second stage emotional and physical state l Overwhelming urge to push l support and ensure that the woman is fully informed at all stages l Presenting part becomes visible l ongoing discussion regarding pain relief l Woman wants to empty bowels and has heavy mucoid show l Encourage the woman to have support from her birth partner(s) of her choice Definitive diagnosis Diet and fluids l Full dilatation of cervix on vaginal examination l Throughout first stage of established labour offer a light, easily digestible Maternal observations diet and encourage fluid intake l Monitor and record on partogram: l If clinical evidence of dehydration, give l IV fluids, either 1 L sodium chloride temperature: 4-hrly (unless clinical 0.9% or compound sodium lactate indications for more frequently) (Hartmann’s) solution IV (according to l blood pressure: hourly (unless other local practice) indications e.g. medical reasons, l High-risk women – no diet, clear epidural in situ) fluids (including isotonic drinks) only l pulse rate – every 15 min to differentiate between the 2 heart rates

H2 receptor antagonists l vaginal assessment hourly in active (antacids) second stage (after abdominal assessment and assessment of vaginal l Low-risk women – not routinely loss) offered (unless opioid analgesia used in labour) l frequency and length of contractions: 30 min intervals l High-risk women – offer ranitidine 150 mg oral 6-hrly (if oral inappropriate, l Encourage woman to void bladder and 50 mg IM 6-hrly) test each void for ketones and protein l Document fluids given

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Fetal observations

Carry out continuous risk assessment to see if transfer to high-risk labour care necessary l Unless continuous fetal monitoring, intermittent auscultation of FHR after each contraction for ≥1 full minute every 5 min l If fetal bradycardia suspected, palpate maternal pulse rate l Record FHR on partogram (even if using continuous monitoring) l Note colour of any liquor draining l Palpate fetal position and abdominal descent of fetal pole l Document all findings

Care and positioning during second stage l Provide emotional and psychological support l Respect woman’s choice of position but discourage from lying supine or semi-supine

Delay in second stage/fetal distress l If delay in second stage suspected, see Delay in labour guideline

Preparation for delivery l Prepare environment and equipment

THIRD STAGE LABOUR l See Third stage of labour guideline

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l INTRODUCTION if contact is from woman’s support 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 l labour make their first contact with 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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Prolonged latency Pain relief in latent phase l If woman readmitted for a third time, l Relaxation techniques including and still not in established labour, breathing methods, massage, consider electronic fetal monitoring and hydrotherapy, and effective support repeat assessment from birth partner(s) l discuss with obstetrician/delivery suite l Birthing ball co-ordinator l TENS machine l Advise woman to inform midwife if: l Hydrotherapy – consider upright l intensity and frequency of contractions positions using a shower as a more increases effective alternative to soaking in the l any change in fetal activity bath. However if woman becomes tired, soaking in a bath may provide l vaginal loss some relief l any other concerns, whether at home l Do not offer or advise aromatherapy, or within maternity unit yoga or acupressure for pain relief l If woman unable or reluctant to go during the latent first stage of labour home for whatever reason, or requires l if a woman wants to use any of these pain relief and support, care for her in a techniques, respect her wishes non-intrusive environment with access to food and drink l Paracetamol can be given 1 g every 4–6 hr, up to 4 g in 24 hr l Women remaining in hospital but not deemed to be in established labour l Consider giving pethidine or morphine require fetal and maternal assessment, prescribed by a medical practitioner depending on risk assessment l Women who have been given pethidine l Women in the latent phase of during the latent phase should not go labour should eat and drink as their home for ≥6–8 hr after administration, appetite dictates. Fasting can lead to and have CTG before discharge home dehydration and ketosis, resulting in Induction of labour may be the need for intervention considered for those women having a long latent phase. Decision must be taken based on individual risk factors following discussion with the woman and obstetrician

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DEFINITIONS DIRECT MATERNAL DEATH WHILE UNDER MATERNITY CARE Definition of nationally reportable maternal deaths Immediate action

Death while pregnant or within 1 yr of end Senior midwife in charge of shift of pregnancy, childbirth or from l Allocate a member of staff to act as any cause related to or aggravated by the support pregnancy or its management, but not from accidental or incidental causes l Inform: l head of midwifery Direct l on-call midwifery manager l Resulting from obstetric complications bereavement officer (where available) as of the pregnant state (pregnancy, labour, soon as possible within working hours and puerperium) from interventions, l on-call consultant omissions, incorrect treatment or chain of l mortuary events resulting from any of the above On-call consultant Indirect l Will meet and support relatives Resulting from previous existing l If cause of death known, request disease or disease that develops permission for post mortem during pregnancy not due to direct l If cause of death unknown, inform obstetric causes, but aggravated by the Coroner who will order a post mortem, physiological effects of pregnancy if he/she feels necessary l Issue death certificate Late death l Inform woman’s consultant as soon as Occurring between 42 days and 1 yr after possible after the death and transfer abortion, miscarriage or delivery owing to responsibility for the case if appropriate direct or indirect maternal causes l Ensure relatives meet with named obstetric consultant Coincidental death Midwife in charge of the case Occurring from unrelated causes that l occur in the pregnancy or puerperium, Offer support to family e.g. road traffic collision l Document events and secure in maternal healthcare record Legal requirements l Forward photocopy of documents to head of midwifery and/as per local It is a statutory requirement that protocol (original documents may have healthcare professionals provide to go to Coroner) information and participate in confidential l Participate in review of records enquiries. Head of midwifery must ensure other areas of the Trust e.g. A&E, ICU are l Inform GP aware of this requirement l Inform named community midwife l Inform health visitor Support for staff l If death occurs outside own area boundaries, notify senior midwife in Maternal death is a distressing event area woman is booked for all staff involved. Support should be provided as per local protocols l Complete local Trust checklist l Complete adverse incident form

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Member of staff supporting l Review maternal healthcare record relatives with midwife in charge of case and complete a summary. Note names of all l Provide ‘What should I do now?’ staff involved, particularly those who do booklet (if available locally) not normally work within the maternity l Liaise with hospital bereavement officer department e.g. resuscitation team, to arrange religious/spiritual support operating department practitioners and completion and issuing of death Through the risk management certificate process, identify and arrange l Ensure adequate provision made for support for all staff concerned baby: consider social services for help and advice particularly if parents not MATERNAL DEATH married (NOT IN MATERNITY UNIT) Bereavement officer l In the event of a maternal death in (where available) hospital but not in the maternity unit, department concerned must notify l Will be the point of contact for family head of midwifery as soon as possible and medical and midwifery staff within normal working hours l Offer expert advice and support l A designated PMA will inform LSA officer l It is the responsibility of the Head of midwifery and department in which the maternal risk manager death occurred to inform Coroner’s office (where necessary) and to ensure l Act as co-ordinator multidisciplinary decision-making in the l Maintain confidential and accurate management of maternal death and record of each stage of procedure level of investigation required (e.g. post l Retain information to feed into current mortem) is documented national process l In the case of a death occurring within l Work closely with professional A&E this is an automatic requirement midwifery advocate (PMA) DEATH IN PRIMARY CARE l Provide report detailing events and cause of death to departmental Indirect, coincidental and late clinical managers, divisional clinical governance manager and Trust chief l Deaths in primary care setting may executive include, murder, suicide, road traffic l Ensure that the duty of candour is collision, women with known terminal fulfilled illness and should be dealt with on an individual basis l Ensure that it is reported as Strategic l Woman’s midwife is responsible for Executive Information System (STEIS) ensuring supervisor of midwives is incident informed of any maternal death in the l Ensure that details are reported to primary care setting that comes to her MBRRACE UK (Mothers and Babies attention Reducing Risk through Audits and l Supervisor of midwives will inform head Confidential Enquiries across the UK) of midwifery and LSA https://www.mbrrace.ox.ac.uk/ l GP should notify the hospital where PMA woman had delivered or received care l If maternal death occurs in the l Will notify local supervising authority community, GP must notify director of (LSA) officer using appropriate form Public Health

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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) l l Transfer into hospital from community Stabilise woman for transfer l Transfer to another specialist unit within Documentation (requirements Trust for each staff group) l Transfer to maternity unit from within Trust Midwife l Transfer to another Trust l Documentation and handover l In-utero transfer responsibility, to include: l Postnatal transfer l summary of maternal transfer documented in woman’s healthcare PREPARATION FOR ALL record and continue to complete TRANSFERS appropriate tool for handover as per local policy l Before transfer, perform risk l assessment and complete local ensure full photocopy of maternal handover tool (e.g. ACCEPT, SBAR) healthcare record (including electronic fetal monitoring (EFM) traces, drug l Inform clinical staff and woman of charts, investigation results etc.) reason for transfer accompany woman. If results not l Document events leading up to available at time of transfer, telephone decision to transfer, together with a as soon as available provisional diagnosis l Before transfer complete local Medical staff handover tool including: l If transferring to another hospital, l summary of woman’s condition middle grade obstetrician (ST3–7 or l provisional diagnosis equivalent e.g. staff grade, clinical l Woman and baby’s medical record must fellow) to complete appropriate accompany them when they transfer handover tool as per local policy, including: l There should be local agreements with the ambulance service regarding l drugs prescribed and administered attendance at emergencies or when l investigation reports/results transfer required l description of fetal heart rate (FHR) l Urgency of transfer will determine trace personnel required and mode of l anaesthetic chart (if applicable) transport

Issue 4 146 Issued: April 2017 Expires: April 2019 MATERNAL TRANSFER (INCLUDING IN-UTERO TRANSFER) • 2/4 l Prepare for transportation Wherever appropriate and possible, community midwife responsible for Personnel transfer should continue to care for woman l Midwife must accompany woman TRANSFER TO OTHER l Specialist personnel (e.g. anaesthetist, SPECIALIST UNIT WITHIN TRUST obstetrician) may be required to accompany woman, depending on her l Booking transport: condition and current condition of the l midwife will arrange transport (e.g. fetus after assessment by person(s) ambulance or porter) as per local making decision to transfer practice l Daily review by middle grade (ST3–7 Monitoring during transportation or equivalent e.g. staff grade/clinical l Continue appropriate monitoring fellow) or consultant obstetrician during ambulance transfer until l delivery suite team leader to make handover at receiving unit daily contact with the specialist unit to ensure antenatal/postnatal care TRANSFER IN FROM maintained as required COMMUNITY/FREESTANDING l document subsequent treatment/ MATERNITY UNIT (FMU) discussions in woman’s healthcare record l Midwife caring for woman will: Decision to transfer woman to other l identify need for transfer specialist unit within Trust (e.g. critical care area) must be made by l inform team leader of appropriate consultant obstetrician and consultant clinical area (depending on condition anaesthetist after discussion with necessitating transfer) senior staff in receiving area (e.g. l outline patient history and current intensive care consultant) maternal and fetal/baby condition using local risk assessment tool TRANSFER TO MATERNITY UNIT FROM WITHIN TRUST Requesting emergency ambulance transfer Multidisciplinary decision involving transferring team, receiving team, l Midwife caring for woman will call 999 consultant obstetrician and midwife and request ambulance with paramedic assistance l Delivery suite team leader will inform l Follow local home birth and transfer all appropriate members of maternity from FMU guidelines team of impending arrival l Transferring department to ensure On admission to delivery suite robust handover provided using appropriate tool as per local policy, to If admitted to delivery suite include: (e.g. from home birth) l reason for: l Woman to be seen and reviewed by – admission middle grade (ST3–7 or equivalent e.g. – referral staff grade/clinical fellow) or consultant obstetrician l history l aim for within ≤30 min of arrival onto l healthcare record (accompanies woman) delivery suite l drugs prescribed/administered l investigation requests/results

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TRANSFER FROM DELIVERY IN-UTERO TRANSFER SUITE TO ANOTHER TRUST l In-utero transfer is a major disruption l On-call consultant obstetrician will for women and their families and often make decision to transfer woman carries significant risks. It is essential l Once decision confirmed, delivery that the woman and her family are suite team leader and middle grade involved in the decision-making obstetrician (ST3–7 or equivalent process and have given their consent e.g. staff grade, clinical fellow) will to proceed co-ordinate arrangements and allocate l If woman is being transferred tasks to team members antenatally due to lack of neonatal l If anaesthetic referral required, consultant facilities, delivery suite team leader anaesthetist will contact consultant or consultant obstetrician to locate anaesthetist at receiving unit directly unit able to accept both mother and neonate Requesting ambulance transfer l agreements with local units may be in place l Person making decision will indicate l transportation required. Consultation Regional Cot Locator can assist in with neonatologist and anaesthetist finding appropriate unit. Telephone: may be necessary 0300 200 1100 l l Transfer co-ordinator will allocate Consultant obstetrician makes decision the task of booking ambulance (as for in-utero transfer after individualised per local agreement with ambulance risk assessment based on current service) to a team member, who will: clinical situation l book ambulance, indicating urgency Indications for in-utero transfer l request specific equipment (e.g. out stretcher, oxygen, portable ventilator) l Suspected or actual preterm labour l indicate number of personnel <34 weeks’ gestation when no accompanying woman (dependent appropriate level neonatal cots upon multidisciplinary team available in unit assessment) l Women <34 weeks’ gestation requiring l request estimated time of arrival delivery for fetal or maternal reasons when no NICU cot available Arrival at receiving unit l Unit unable to safely facilitate l Escorting staff should: management of high-risk cases due to delivery suite activity – see local l complete appropriate handover tool as maternity escalation and closure per local policy policies l ensure copy of relevant medical/ l Specialist neonatal care not available maternity notes/records at local unit e.g. elective early postnatal l document details of transfer process surgery indicated for neonate in maternal healthcare record until transfer of care completed

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Indications not to transfer out l Where transfer may pose a significant risk to mother or baby, continue management locally and instigate ex-utero transfer as necessary e.g.: l advanced labour l non-reassuring features on CTG l unstable mother l obstetric complications e.g. antepartum haemorrhage l This list is not exhaustive – discussion with neonatal and obstetric teams for agreed plan

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)

Issue 4 Issued: April 2017 149 Expires: April 2019 MECONIUM STAINED LIQUOR • 1/2 l BACKGROUND Take umbilical cord sample – see 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 RESUSCITATION OF BABIES meconium stained liquor 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

Issue 4 150 Issued: April 2017 Expires: April 2019 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

Issue 4 Issued: April 2017 151 Expires: April 2019 MEDICAL TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY AND FETOCIDE • 1/2

l PROCEDURE Provide contact telephone numbers 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 +6 l Where termination is planned >21 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 RECOMMENDED DRUG REGIMEN l Extra vigilance in women with: l severe asthma Initial drug dose l previous operative delivery l Mifepristone (Mifegyne® RU 486) l cardiovascular insufficiency 200 mg oral is administered by middle l previous CS grade obstetrician (ST3–7 or equivalent l anticoagulant treatment e.g. staff grade, clinical fellow) or consultant on licensed premises and a l renal/hepatic failure healthcare professional must observe l long-term corticosteroid therapy woman take tablet l Advise woman she may experience l Inform woman of possibility of flu-like symptoms e.g. feeling feverish abdominal discomfort and/or a small or rise in temperature amount of bleeding l reassure that this is normal and can be treated with regular paracetamol at home l Ask woman to remain on premises for 1 hr to observe side effects l if vomiting occurs, repeat dose

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INTRAPARTUM l For fetus with chromosomal MANAGEMENT abnormality, scan features may not be present. Laboratory report must be l See Perinatal bereavement guideline available to consultant before fetocide performed Management of third stage Procedure l Actively manage according to Third stage of labour guideline l Obtain potassium chloride solution l In general, woman should be cared for from pharmacy in accordance with as if she had experienced any other Trust policy fetal loss (see Perinatal bereavement l Midwife to provide emotional and guideline) psychological support l Give anti-D and send Kleihauer for l Identify suitable entry site and clean Rhesus-negative women abdomen and probe with antiseptic l 250 IU <20 weeks’ gestation solution l 500 IU ≥20 weeks’ gestation l Anaesthetise skin and subcutaneous tissues with lidocaine 1% 5–10 mL Notifying Department l Draw 1.5 g (10 mL potassium chloride of Health 15% KCI) into a new syringe l Place sterile aqueous gel onto probe to l Doctor responsible for commencing facilitate scanning termination of pregnancy is required, by law, to notify Department of Health by l Under ultrasound guidance, insert 21 submitting relevant (yellow HSA4) form gauge echo tip needle into fetal heart FETOCIDE l Using a 5 mL syringe, withdraw a small volume of fetal blood to confirm correct If not performed locally, refer to placement of needle. If required, send regional centre blood for cytogenetic analysis l Slowly inject 5–8 mL KCI solution into Definition fetal heart until cardiac activity stops l Allow mother to rest for several minutes l Intracardiac injection of potassium before performing a confirmatory scan chloride to induce fetal death before to check fetal cardiac activity has not termination of pregnancy resumed l Administer anti-D to Rhesus-negative Informed consent women l Counsel woman about reasons for l Transfer mother to delivery suite to carrying out fetocide and explain legal complete termination position and ethical implications should baby be born alive

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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Be aware of the nature of your RED FLAGS AND local perinatal mental health service ACUTE CONCERNS provision Red flags INTRODUCTION l Significant recent or rapidly changing alterations in mental state l When managing women with mental health problems in pregnancy, there l Emergence of new symptoms; are 3 groups to consider: can include psychotic symptoms (delusions, hallucinations) or severe l at increased risk of antenatal and anxiety in relation to her baby’s (and/or postnatal depression other children’s) welfare l mental health concerns in current l Psychotic symptoms that involve the pregnancy baby l pre-existing severe and enduring l Thoughts of violent self-harm or suicide mental health issues l New/persistent/non-reassurable ideas GENERAL PRINCIPLES and expressions of these ideas l woman believes she is incompetent/ l Provide non-judgemental inadequate as a mother compassionate care l feels estranged from her baby l Discuss role of partner, family and l carers, and involve if acceptable to Pervasive feelings of guilt and woman hopelessness l l consider their needs Deterioration in function as a consequence of symptoms e.g. self-care, l may require explanation and education care of baby, avoidance of baby about mental illness l Not eating l Explore and check regularly woman’s l ideas, concerns and expectations Severe insomnia l l Be sensitive to the issue of stigma and Psychomotor retardation shame in relation to mental illness Suicidal risk l Acknowledge the role of the woman in caring for her baby l If you establish a woman feels l Provide culturally relevant information hopeless and pessimistic about the on mental health problems in future for herself, her family and/or pregnancy and postnatal period to the baby, perform an urgent assessment of woman, and if she agrees, to family suicide risk and carers l ask her if: l Ensure the woman understands mental - she has thought about wanting health problems are not uncommon to die, not wanting to wake up or and instil hope about treatment wanting to end it all l Ensure interpreting services are - the thoughts are present for long available to women for whom English periods or are just fleeting is not their first language/who have - there is any accompanying image, sensory impairment e.g. deaf/ whether they are violent or of seeing deafened/deaf-blind herself dead l fully explore if she has any urges or impulses to harm herself/her baby - ask her if she has made any plans

Issue 4 154 Issued: April 2017 Expires: April 2019 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 Acute concerns depression 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

Issue 4 Issued: April 2017 155 Expires: April 2019 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 History of less severe health problem may be unwilling to 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 l Ask standard questions and document Mild–moderate postnatal in antenatal hand-held records depression l During the last month have you often been bothered by: l Self-help l feeling down/depressed/hopeless? l Refer to GP for: l having little interest/pleasure in doing l listening visits at home by health visitor/ things? GP l is this something you feel you need/ l cognitive behavioural therapy want help with? l medication if necessary l Over the last 2 weeks how often have you been bothered by: Severe/psychotic postnatal l feeling nervous/anxious/on edge? depression l not being able to stop/control l Care by specialist mental health worrying? services l If answers positive, consider whether there are concerns about the woman’s mental health l Repeat above questions later in pregnancy

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MENTAL HEALTH CONCERNS l If problem is simple social isolation IN CURRENT PREGNANCY consider referral to local children’s centre to arrange visit by support When assessing a mental worker health problem consider: l Antenatal parent craft classes may be helpful l History of mental health problems l Health visitor may commence visiting l Physical wellbeing early, working with community midwife l Alcohol and drug misuse to ensure increased frequency of l Woman’s attitude towards pregnancy visits (particularly in first 2 weeks after and baby delivery) l Woman’s past obstetric history l If concerns are more acute – refer to local community mental health team l Past and present treatment with response l If very acute concerns – contact community mental health team duty l Social networks, social isolation and officer quality of interpersonal relationships l Women who develop significant mental l Living conditions health problems during pregnancy l Family history of mental health require a careful plan for labour and problems immediate post partum period, as l Domestic abuse for women with severe and enduring l Child sex abuse/trauma/maltreatment mental health problems – see below l Housing/employment/economic/ Aged <18 yr immigration status l Responsibilities as carer l Refer to child and adolescent mental l Learning difficulties/cognitive health service (CAMHS) and inform impairment health visitor at earliest opportunity l If problem due to social isolation Postnatal depression can start etc. discuss alternative services e.g. during pregnancy – signs of Connexions and the Youth Service significant depression include: Starting medication l Gains no benefit from rest l Explain to the woman that there l Suicidal thoughts is a higher threshold for starting l Compulsive rituals pharmacological treatment in l Impaired concentration pregnancy and postpartum due to: l different risk benefit ratio and likely New concerns benefits of psychological interventions l When choosing medication take into l If woman is in the community, account: community midwife will request GP review l woman’s previous response to these drugs l if GP unable to help/difficult to access, may be possible to refer woman to l gestation hospital l safety of these medicines in pregnancy l If relatively minor concerns refer to GP – see Common mental health drugs for advice and pregnancy below

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PRE-EXISTING SEVERE AND Communication with community ENDURING MENTAL HEALTH mental health services PROBLEMS l Send copy of hospital antenatal clinic l Including women with diagnosis of: booking letter to GP and woman’s l schizophrenia named care co-ordinator in community l bipolar effective disorder/manic mental health team depression l Community mental health team l severe depression (that required can seek obstetric advice from lead in-patient admission) obstetrician for mental health/on-call l mental illness in association with obstetric consultant either learning difficulties/profound socio-economic deprivation Use of drugs in pregnancy l Pre-pregnancy counselling is the ideal l Risks of medication to the fetus to be to cover: balanced against risks of stopping l contraception medication to the woman and her l effect on mental health including risk of family relapse l effect of mental health and treatment (see below) on woman, fetus and baby breastfeeding l how mental health problem/treatment might affect parenting l Manage under consultant obstetrician-led care Table 1 Reasons to continue medication Reasons to stop medication l Relapse of mental health: l All mental health drugs cross placenta l poor antenatal care and neurodevelopment continues through pregnancy l poor self-care l Information about long-term child l interpersonal difficulties health after mental health drug use in l abuse pregnancy is lacking l impulsive behaviour l See Table 2 l suicide l Neonatal adaptation syndrome: l cigarette, alcohol/drug abuse l usually mild l relapse can affect attachment and emo- l begins ≤48 hr, lasts ≤72 hr tional, social and cognitive development l insomnia of a child l agitation, tremors, shivering l increased risk of infanticide and non- accidental injury and neglect l altered tone l breakdown in child care l restlessness or irritability l significant personal, family and social l poor feeding consequences for the woman l vomiting or diarrhoea l Baby already exposed to drug in early l poor temperature control pregnancy l rarely: seizure, tachypnoea, respiratory distress, nasal congestion

Issue 4 158 Issued: April 2017 Expires: April 2019 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 l medication, explain all women are at 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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l Missed appointments For complex cases, community mental 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

Issue 4 160 Issued: April 2017 Expires: April 2019 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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COMMON MENTAL HEALTH DRUGS AND PREGNANCY Table 2 (contact pharmacy for information for drugs not included)

DRUG RISKS ACTIONS Antipsychotics l Extrapyramidal symptoms in l Neonatal alert neonate (usually self-limiting), l Avoid depot preparations if respiratory depression, possible feeding problems and tremor l Do not routinely prescribe l Excessive weight gain anticholinergic drugs l Avoid excessive weight gain Haloperidol l Limb reduction disorder l Mid-trimester anomaly scan (very rare) Atypical antipsychotics l Folate deficiency l 5 mg folate daily until delivery l Gestational diabetes and for all excessive weight gain l Mid-trimester detailed scan l GTT l Avoid excessive weight gain Clonazepam l Theoretical risk of l Avoid if possible. agranulocytosis and Usually used when other myocarditis of neonate mental health drugs ineffective and it is unlikely that it can be stopped l Avoid breastfeeding Lithium l Fetal heart defects l Neonatal alert l Ebstein’s anomaly l 20/40 detailed scan ?cardiac l Neonatal toxicity; floppy baby scan syndrome and hypothyroidism l If can be stopped, gradually l Lithium toxicity to mother withdraw l ?polyhydramnios l Check lithium levels and main- tain in lower end of therapeu- tic range: l every 4 weeks l >36 weeks: weekly l ≤24 hr of delivery l Keep hydrated. Admit with hyperemesis l IV fluids in labour l Avoid breastfeeding

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Table 2 (contact pharmacy for information for drugs not included) cont.

DRUG RISKS ACTIONS Antidepressants l Stopping may result in net increased total dose because of risk of relapse and use of higher dose when restarted l Neonatal withdrawal (usually mild and self-limiting) Tricyclic l Neonatal withdrawal l Neonatal alert antidepressants l Very toxic to small children l More likely to cause death in overdose l Higher rate of side effects than SSRIs Selective serotonin reuptake inhibitors (SSRIs) l Neonatal persistent l Neonatal alert if taken after pulmonary hypertension if mid-trimester taken >20 weeks’ gestation Clomipramine l Avoid in first trimester if l Mid-trimester anomaly scan possible Fluoxetine l Avoid in first trimester if possible l Higher levels in breast milk Paroxetine l More significant neonatal l Mid-trimester anomaly scan withdrawal Venlafaxine l Maternal hypertension in high l Monthly BP checks dose Citalopram l Higher levels in breast milk (current SSRI of choice in pregnancy) Sertraline (current l Lower levels in breast milk SSRI of choice for breastfeeding) Monoamine-oxidase inhibitors l Hypertensive crises Avoid if possible Neonatal alert

St John’s wort l Neonatal colic, lethargy and Avoid if possible difficult breastfeeding Neonatal alert l activity

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Table 2 (contact pharmacy for information for drugs not included) cont.

DRUG RISKS ACTIONS Benzodiazepines l Facial clefts l Should only be used for l Floppy baby syndrome in short-term treatment of severe neonatal withdrawal anxiety/agitation l Mid-trimester anomaly scan l Neonatal alert Mood stabilisers Carbamazepine l Neural tube defects l Avoid if possible l Gastrointestinal anomalies l 5 mg folate daily throughout l Cardiac anomalies pregnancy l Mid-trimester anomaly scan Lamotrigine l Facial cleft l Avoid if possible l Stevens-Johnson syndrome l Monitor levels in pregnancy (rare) and puerperium l Serum concentration of l Mid-trimester anomaly scan lamotrigine in women taking l Inform woman of risks and concomitant sodium valproate benefits of breastfeeding is doubled l if breastfed, advise to take baby to emergency department if generalised rash develops Sodium valproate l Neural tube defects l Avoid if at all possible – if not l Craniofacial and cardiac use slow release abnormalities l 5 mg folate daily throughout l Affects intellectual pregnancy development l Mid-trimester anomaly scan l Neonatal alert

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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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l DEFINITION Discuss the risk of hysterectomy 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

Issue 4 166 Issued: April 2017 Expires: April 2019 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 l l If it remains adherent, there are 2 Antibiotic prophylaxis can be used a options: few days after delivery but postnatal follow-up with prompt recognition l proceed directly to hysterectomy or and treatment of any infection is more l leave the placenta in situ and manage important. This requires twice-weekly conservatively in the postnatal period hospital visits with clinical review, blood l Even if placenta is thought to be tests for FBC and C reactive protein morbidly adherent and not bleeding at l Monitor placental re-absorption weekly time of CS, give 5 units of Syntocinon® with serum Beta hCG levels and IV slowly to ensure placenta does not ultrasound. There have been reports of separate and is truly adherent methotrexate use and of elective ERPC l If placenta is clearly adherent, do not at 6 weeks postnatally continue to remove it Issue 4 Issued: April 2017 167 Expires: April 2019 MULTIPLE PREGNANCY • 1/3

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: l l Twin-to-twin transfusion in monozygotic first pregnancy twins l aged ≥40 yr l Cord entanglement and locking in l pregnancy interval >10 yr monochorionic monoamniotic twins l BMI of ≥35 kg/m2 at first visit l Preterm labour l family history of pre-eclampsia l Stillbirth l Monochorionic pregnancy between l Perinatal mortality (6 x higher) 16–24 weeks’ gestation: l scan every 2 weeks, looking for ANTENATAL MANAGEMENT twin-to-twin transfusion syndrome (TTS) l l Follow local antenatal care pathway if TTS suspected, refer to local fetal medicine consultant l For many women a multiple pregnancy l will be detected only after first Dichorionic pregnancy and ultrasound scan monochorionic pregnancy >24 weeks: l l If multiple pregnancy suspected arrange perform serial growth scan ≥4 weeks early ultrasound scan to confirm l 20 week detailed scan to detect fetal l In twin pregnancy ultrasonographer anomalies will determine chorionicity in the first l If growth of 1 of the fetuses falls below trimester. Chorionicity determines the projected centile, ask consultant degree of risk and management obstetrician to plan further management l When confirmed arrange consultant-led l In the event of death of 1 twin, discuss care with fetal medicine consultant

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Communication Triplets and higher order pregnancies l Discuss plan of care with parents, ensuring sufficient information given l Must be delivered in a unit with l Provide psychological support and, sufficient and appropriate neonatal where possible, written information and intensive care (NICU) facilities contact details of multiple pregnancy l Inform women that: support groups l 75% of triplet pregnancies result in spontaneous birth <35 weeks Delivery plan l continuing uncomplicated triplet l Discussion ≤24 weeks about risks, pregnancies >36 weeks increases the signs and symptoms of preterm labour risk of fetal death and possible outcomes of preterm birth l Offer elective birth from 35 weeks, after a l If delivery by pre-labour caesarean course of corticosteroids has been offered section (CS), administer antenatal steroids for fetal lung maturity If elective birth is declined in multiple pregnancy Twins l Offer weekly appointments with consultant obstetrician l Detailed counselling by middle grade obstetrician (ST3–7 or equivalent e.g. l offer ultrasound scan at each staff grade, clinical fellow) regarding appointment mode, place and timing of delivery l perform fortnightly fetal growth scans, <32 weeks and as a minimum weekly liquor and l Monochorionic monoamniotic UA Doppler assessments and weekly pregnancy: offer CS at 32 weeks assessments l consider earlier delivery and by pre-labour CS due to risk of cord INTRAPARTUM MANAGEMENT entanglement (TWIN PREGNANCY) l Inform women that: First stage of labour l 60% of twin pregnancies result in l spontaneous birth <37 weeks On admission, inform middle grade obstetrician (ST3–7 or equivalent e.g. l elective birth ≥36 weeks for staff grade, clinical fellow) and consultant monochorionic twins, and ≥37 weeks l for dichorionic twins, does not appear Confirm presence of 2 fetal hearts to be associated with increased risk of using Pinard stethoscope or sonic aid serious adverse outcomes l if 2 separate fetal hearts difficult to l continuing uncomplicated twin identify, ultrasound scan pregnancies >38 weeks increases risk l Unless contraindicated because of of fetal death extreme prematurity, continuous l Offer elective birth at: electronic monitoring of fetal hearts l l 36 weeks for monochorionic if difficulty monitoring 2 separate fetal twin pregnancies, after a course hearts at any time, consider fetal scalp of corticosteroids, 37 weeks for electrode or ultrasound scan dichorionic twin pregnancies Inability to continuously monitor both babies despite use of ultrasound scan to ascertain placement of transducers and a fetal scalp electrode if appropriate, is an indication for CS

Issue 4 Issued: April 2017 169 Expires: April 2019 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 l will perform 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

Issue 4 170 Issued: April 2017 Expires: April 2019 NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR ANALGESIA • 1/4 l INTRODUCTION Reconsider the use of large volumes 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 ANAESTHESIA AFTER MAJOR obese – lateral tilt and ramped-up position SPINAL SURGERY l non-obese – shoulders raised l Majority of these women suffer from Redosing of subarachnoid local chronic backache, have spinal stenosis anaesthetic beyond recommended and distorted spinal anatomy doses may increase the risk of spinal cord neurotoxicity l Epidural placement successful in majority of cases but complicated by: RECOGNITION OF l multiple repeated attempts NEUROLOGICAL DEFICIT l traumatic catheter placement l Early detection is critical in managing l inadequate epidural analgesia spinal cord ischaemia, vertebral canal l dural puncture haematoma and abscess. >8 hr, the likelihood of full or partial recovery PREVENTING NEUROLOGICAL rapidly diminishes DAMAGE Dense block after l Before performing regional anaesthesia regional analgesia and analgesia, enquire about, and document, pre-existing neurological l If abnormal block develops on routine symptoms epidural analgesia regimen, stop infusion immediately l Avoid vasoconstrictors in women with pre-existing neurological conditions l If a dense blockade develops, call consultant anaesthetist urgently

Issue 4 Issued: April 2017 171 Expires: April 2019 NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR ANALGESIA • 2/4 l If not recovered in 4 hr, consider l Severe or worsening backache prompt MRI scan l Bowel and bladder dysfunction l If recovery occurs, restart epidural infusion l Radicular pain but maintain neurological surveillance l If block recurs, abandon epidural and Urgent (infective/space investigate occupying lesions suspected) l Continue neurological assessment in HDU for 24 hr Infective meningitis suspected l If haematoma suspected, do not l Immediately consult neurologist remove catheter l Early diagnostic lumbar puncture and Subdural block can cause a antibiotics dense, very persistent block that is frequently unilateral Complete or progressive neurological deficits Neurological impairment after l Urgent evaluation by spinal surgeon CNB l Urgent MRI scan l See – Flowchart: Management of a neurological deficit after CNB Lesions with moderate–severe l Presentation will vary with aetiology deficits l Epidural haematoma progresses l Require urgent referral to either spinal rapidly; signs may be unilateral surgeon or neurologist l Cauda equina compression presents l as: saddle anaesthesia, urinary Consider MRI scan retention and reduced anal tone l Disc herniation presents as: severe Not urgent back pain, bilateral sciatica and motor Mild or resolving symptoms weakness in legs l Nerve damage by epidural and spinal l Without objective evidence of neural needles is associated with paraesthesia deficit typically indicates excellent l Meningitis after dural puncture usually prognosis requiring reassurance only presents with severe headache. l If no improvement in 4–6 weeks, Onset of nuchal rigidity, photophobia, seek neurological advice and refer to confusion and pyrexia may be delayed neurologist l Neurophysiological investigation with MANAGEMENT OF MRI scan can help quantify and locate NEUROLOGICAL INVOLVEMENT injury site. Neurophysiological changes most apparent >14–21 days of injury Review history – test for neurological involvement l After initial evaluation, follow-up incompletely and unresolved injuries in l Test myotomes, dermatomes, reflexes 3–5 months and sphincter tone

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

Issue 4 172 Issued: April 2017 Expires: April 2019 NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR ANALGESIA • 3/4

Flowchart: Management of a neurological deficit after CNB

Neurological deficit identified

History: Emphasis on labour, drugs and neurology Examination: Neurological and back examination Anaesthetic: Review technique

Clinical diagnosis suggestive of:

Spinal epidural space Suspected peripheral No evidence of occupying lesion nerve damage neurological deficit

l Urgent consultant If motor block present l Reassure woman review l Urgent MRI scan and l Arrange next day l Urgent MRI scan nerve conduction studies follow-up l Liaise with spinal l Refer to physiotherapist l Document findings surgeon l Follow-up in 6–12 weeks l Contact obstetrician If being discharged, warn about acute onset backache, radicular pain, lower extremity weakness and numbness, urinary and anal dysfunction

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Leg weakness with epidural analgesia – Management flowchart for midwife

Increasing leg weakness? Recommence epidural infusion Leg muscle strength score 3 or 4? and routine observations

Yes Yes Switch epidural infusion off

Patient comfortable? Reassess leg muscle strength every 30 min Yes No

Leg muscle strength improving? Contact consultant obstetric No anaesthetist

>4 hr since stopping epidural?

Yes

l Contact on-call consultant Recommence epidural infusion obstetric anaesthetist urgently at higher rate l Arrange MRI scan l Contact spinal surgeon

Issue 4 174 Issued: April 2017 Expires: April 2019 NORMAL LABORATORY VALUES IN PREGNANCY • 1/1

Laboratory test Value Hb 110–140 g/L

WCC 6–16 x 109/L

Platelets 150–400 x 109/L

MCV 80–100 fl

CRP 0–7 g/L

Sodium 130–140 mmol/L

Potassium 3.3–4.1 mmol/L

Urea <4.5 mmol/L

Creatinine <75 µmol/L

<380 µmol/L Urates If 350–380, registrar/consultant reviews notes

24 hr protein 0.3 g

Protein creatinine ratio <30 mg/mmol

Creatinine clearance 80–170 mL/min

Bilirubin ≤16 µmol/L

Total protein 48–64 g/L

Albumin 28–37 g/L

AST 10–30 iu/L

ALT 6–32 iu/L

Gamma GT 3–43 iu/L

Alkaline phosphate 30–418 iu/L

Bile acids ≤14 µmol/L

Issue 4 Issued: April 2017 175 Expires: April 2019 OBESE MOTHER (CARE OF) • 1/4

DEFINITION l Body mass index (BMI) = weight in kg/height in metres squared (m2)

Table 1: Classification of body mass index Classification BMI Risk of co-morbidities Low (but increased risk of Underweight <18.5 other clinical problems) Desirable weight 18.5–24.9 Average

Overweight 25.0–29.9 Mildly increased

Obese >30.0

Class I 30.0–34.9 Moderate

Class II 35.0–39.9 High

Class III (severely or >40.0 Very high morbidly obese) l WHO classifies women with BMI >30 as obese l Risks associated with pregnancy and childbirth are significant when BMI >35 l In this guideline, obesity will be defined as ≥35 kg/m2 during pregnancy, delivery and postnatal period RISKS OF OBESITY

Mother Baby Pregnancy Intrapartum Postnatal l Maternal death or l Increased risk l Thromboembolism l Congenital severe morbidity of difficult fetal l Increased maternal abnormalities l Cardiac disease monitoring mortality l Undetected l Spontaneous l Difficulty achieving l Post CS wound abnormalities first trimester effective regional and infection (limitations of and recurrent general anaesthesia l Infection from other ultrasound) miscarriage l Inadequate analgesia causes l Prematurity l Pre-eclampsia and l Increased l Postpartum l Stillbirth and hypertension anaesthetic risks haemorrhage neonatal death l Thromboembolism l Increased need for l Perineal tears l Macrosomia (birth l Gestational diabetes induction of labour l Low breastfeeding trauma) with l Infection e.g. urinary l Slow progress in rates associated risk of tract infection, labour shoulder dystocia genital infection l Shoulder dystocia l Fetal abnormalities l Difficulties with l Operative delivery including neural tube defect venepuncture/ l Increased risk of abdominal emergency caesarean l Admission to examination/ section (CS) neonatal intensive care unit (NICU) blood pressure l Difficult CS with assessment greater mortality and l Intrauterine growth morbidity restriction (IUGR) l Moving and handling l Obesity (in later life) injuries to woman and staff

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ENVIRONMENT AND l Venous thromboembolism (VTE) EQUIPMENT risk assessment and follow VTE 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 CONCEPTION if low molecular weight heparin 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 l programme and take regular exercise 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)

Issue 4 Issued: April 2017 177 Expires: April 2019 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 l equipment available 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 l available locally) thromboembolic stockings (if local practice) l Early epidural may be required for regional analgesia

Issue 4 178 Issued: April 2017 Expires: April 2019 OBESE MOTHER (CARE OF) • 4/4 l Monitor a suction drain can be left above 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 of labour immediately after delivery 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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Do not attempt procedure unless Delay in second stage of labour criteria for safe delivery have been met (see Table) l See Delay in labour guideline l In the absence of other concerns, INDICATIONS maternal exhaustion, etc.

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

CRITERIA FOR SAFE OPERATIVE VAGINAL DELIVERY

Essential Full abdominal and l Head <1/5 palpable per abdomen vaginal examination l Vertex presentation l Cervix fully dilated and membranes ruptured l Exact position of head determined so that instrument can be placed properly l Pelvis deemed adequate l Optimise contractions Mother l Clear explanation given and informed consent obtained and documented (including episiotomy) l Continuous electronic fetal monitoring l Appropriate analgesia in place: l regional block l pudendal block l local infiltration l Maternal bladder emptied – consider use of in/out catheter or, if indwelling catheter in situ, deflate balloon (recommended practice) l Aseptic technique Staff l Operator has been assessed as competent in the use of forceps and vacuum extractor l Adequate facilities and back-up personnel must be available l Back-up plan in place in case of failure to deliver l Anticipation of complications (e.g. shoulder dystocia, postpartum haemorrhage) l Personnel trained in neonatal resuscitation e.g. midwife or ANNP/ neonatologist (according to local policy) are present

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TRIAL OF OPERATIVE VAGINAL l Kielland’s forceps should be used DELIVERY IN THEATRE unsupervised only by those trained and assessed as competent in their use l If there is doubt as to whether instrumental delivery will succeed, Dual instrumental delivery conduct delivery as a trial of vaginal delivery in theatre where, should a l Dual instrumental delivery is associated caesarean section (CS) be required, with an increased risk of trauma and theatre team and anaesthetist are neonatal morbidity present l If satisfactory descent and/or rotation l appropriately trained person must achieved before displacement of the undertake or supervise in theatre vacuum, it is acceptable to complete a delivery with outlet forceps l Consider instrumental delivery in theatre particularly in the following l Attempt when it is very likely that a situations: vaginal delivery will be successful (e.g. good descent of head in the perineum l multiparous women; especially with a and detachment of Ventouse cup) previous vaginal delivery l mid-cavity deliveries or where head When to abandon operative palpable in the abdomen vaginal delivery l position is not occipito-anterior l When there is no evidence of l obese women where assessment of progressive descent with each pull, fetal size is difficult or where delivery is not imminent l there has been delay in labour despite following 3 tractions of correctly oxytocin applied instrument (cup or forceps) by l estimated fetal weight >4000 g an experienced doctor or application of Ventouse cup – should not exceed Higher rates of failure are 15 min associated with l If delivery is thought to be imminent, with head in the perineum, it may, after l Maternal obesity BMI >30 careful re-evaluation, be appropriate to l Clinically big baby/estimated fetal await one more contraction weight >4000 g l Poor progress or descent or concerns l Malposition about fetal wellbeing should indicate l Mid-cavity delivery the need to abandon the procedure (even if an episiotomy has been PROCEDURE performed) and perform CS for the safety of mother and baby What instrument? l Follow local incident reporting procedure for unsuccessful forceps/ l Doctor should choose instrument most vacuum delivery appropriate to clinical circumstances and their level of expertise. Forceps and are associated with different benefits and risks: l Ventouse associated with more neonatal trauma and higher risk of failure l forceps associated with more perineal trauma and 3rd and 4th degree tears

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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 l number of cup detachments FOLLOW-UP l total cup application time l An obstetrician (ideally who performed l Episiotomy/tear findings and repair delivery) should discuss procedure, technique management of any complications and l Paired cord gas blood results – see future deliveries with mother Umbilical cord sampling guideline l Swabs, needles, tampons (if used) to be counted before and on completion of procedure l Record of incident report (if local practice)

Issue 4 182 Issued: April 2017 Expires: April 2019 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

Issue 4 Issued: April 2017 183 Expires: April 2019 OXYTOCIN • 2/2

Suggested regimen

Time after starting (min) Equivalent milliunits/min 0 1

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

Issue 4 184 Issued: April 2017 Expires: April 2019 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

Miscarriage BEFORE ADMISSION TO DELIVERY SUITE l A baby born before 24 weeks completed gestation, with no signs Diagnosis of life where an intrauterine death, l or where an intrauterine death is Confirm diagnosis of intrauterine death diagnosed by ultrasound before 24 by ultrasound scan carried out by 2 weeks’ gestation qualified and experienced operators l Arrange review by consultant Stillbirth obstetrician and plan delivery l Perform observations, MEWS score l A baby born ≥24 weeks completed and record on local documentation weeks of pregnancy with no signs of life l Unless concerns for woman’s safety (e.g. placental abruption, active Neonatal death sepsis), offer the choice to go home and return to delivery suite at a l A death that occurs after birth, but convenient ≥24–48 hr later before 28 completed days of life l provide 24 hr contact number and where possible a named member of staff

Issue 4 Issued: April 2017 185 Expires: April 2019 PERINATAL BEREAVEMENT • 2/7 l Some women will not want to go home l Care should be parent-led where and will be admitted soon after being possible. Parents need non-biased and informed of diagnosis of fetal death accurate information about the choices l Advise the woman she may feel the they face; where possible their choices baby shifting in the amniotic fluid. This should be supported can be distressing l when diagnosis confirmed, gently explain to woman and family the Breaking difficult news process of induction and time it may take. Give available written information l Inform parents as soon as anything to parents to reinforce discussions worrying is suspected even if not yet l where English is not parents’ confirmed or certain first language or there is sensory l communicate this sensitively, impairment (e.g. deaf/deaf-blind), acknowledging the difficulty of ensure interpreter available managing uncertainty l unless an emergency, provide a Documentation woman who is alone the opportunity l Document all discussions with parents to call a partner, relative or friend for in maternal healthcare record support and ask if she wishes to wait until they arrive before the finding is explained in detail Liaison l If member of staff with parents at the time l Delivery suite obstetric and midwifery cannot provide accurate or sufficient team will liaise with: information, he/she should inform l specialist midwife for bereavement (if parents and arrange for a more senior available) person to see them as soon as possible l neonatal unit (if appropriate) l do not give parents inaccurate/ l fetal medicine incomplete information that they may l later discover is incorrect antenatal clinic l chaplaincy l Parents will often need time to take in what has been said to them. Give l general office them as much time as possible, and be l community midwives prepared to repeat some information. l GP Written information and a contact l health visitor telephone number are important DELIVERY Privacy l Discuss with woman the process, l Wherever possible, care for woman analgesia and support that will be and family in bereavement suite offered in labour l Ensure all staff likely to be in contact l Most women will be advised to have a with the family, including support and vaginal birth as it is safer and has less housekeeping staff, are aware of situation impact on future pregnancies l Inform the woman she determines who l For women who have had a previous visits and when caesarean section (CS), discuss mode of delivery with consultant obstetrician Information for parents l Complete a partogram during labour l Discuss pain relief options l Parents require information at every stage about what is happening, l a platelet count may be required before procedures and choices available epidural insertion where the woman has experienced an IUD Issue 4 186 Issued: April 2017 Expires: April 2019 PERINATAL BEREAVEMENT • 3/7

Recommended drug regimen Side effects of misoprostol

Initial drug dose l Pyrexia l Diarrhoea l Mifepristone (Mifegyne RU 486) l 200 mg oral administered by middle Inform woman she may experience grade obstetrician (ST3–7 or equivalent flu-like symptoms e.g. staff grade, clinical fellow) or l Particular care is required for women consultant on licensed premises. with: Healthcare professional must observe l severe asthma woman take tablet l previous CS l Inform woman of possibility of l CVS insufficiency abdominal discomfort and/or a small amount of bleeding l hepatic or renal failure l reassure that this is normal and regular l adrenal suppression including analgesia, e.g. paracetamol can be long-term corticosteroid use taken at home l Ask woman to remain on premises for FOLLOWING DELIVERY 1 hr to observe side effects Management of third stage l if vomiting occurs, repeat dose l Induction may commence at this point l Give syntometrine (oxytocin with or, should the woman wish, she may ergometrine) 1 mL IM after delivery go home and return ≤48 hr later l If woman hypertensive, give oxytocin l Provide telephone numbers for delivery 10 units IM or 5 mg as a slow IV bolus suite with instructions to call if she has as an alternative any concerns while at home For Rh negative women, obstetrician will prescribe anti-D immunoglobulin On admission/in labour l Consultant obstetrician to direct care Lactation suppression l Perform regular maternal observations l Inform women they may lactate (see Labour management guideline) l Provide general advice e.g. wear l Provide analgesia as required well-fitting bra l if woman requests an epidural, ensure l Offer cabergoline 1 mg for lactation platelet count is available suppression. Contraindicated for hypertensive women Further drug regimen l No more than 24–72 hr after initial Parent involvement dose of mifepristone 200 mg oral, give l If circumstances allow, involve parents misoprostol: in decisions regarding care of their baby l <27 weeks’ gestation: 100 microgram l Give parents the opportunity to see and vaginally 6-hrly – maximum 4 doses hold their baby as soon as possible l ≥27 weeks’ gestation: 25–50 microgram and for as long as they wish. Parents vaginally 4-hrly – maximum 6 doses may initially decline to see their baby but should be assured they can In previous CS or uterine surgery, change their mind at any time where the cavity has been breached (e.g. myomectomy, uterine l respect decision of parents who decide perforation) use 25–50 microgram not to see and hold their baby dosage

Issue 4 Issued: April 2017 187 Expires: April 2019 PERINATAL BEREAVEMENT • 4/7 l Make use of local equipment to reduce l Written consent for examination of a deterioration in baby e.g. ice packs, fetus or baby, regardless of gestational cool cots etc. age, must be obtained from parent by l They may wish to give their baby a name a healthcare professional competent to take consent for post mortem. Junior l When baby very small, it may be medical staff must not seek consent difficult to determine the sex by visual inspection. Where there is any doubt, l Allow time for questions midwife should not express an opinion l Record discussion and consent in even if pressed by parents to do so maternal healthcare record l Obtain consent before carrying out any procedure e.g. obtaining mementos, Placenta including taking hand and footprints, l Where family requests post mortem, photographs etc. Include parents in send placenta with baby decisions and be guided by their wishes l If family do not want a post mortem, l include parents in making these send placenta for histology to memories. Support them in washing/ Birmingham Women’s Hospital dressing their baby, taking photos or making the footprints themselves l consent from the parent is not a legal requirement, but it is best practice to l Middle grade obstetrician (ST3–7 or discuss this with the woman equivalent e.g. staff grade, clinical fellow) or consultant must see every baby following delivery regardless of gestation Cytogenetics and carefully record presence or l Indications for cytogenetics absence of any visible fetal abnormalities l severe IUGR or known visible fetal abnormality Religious needs l Obtain parental consent for cytogenetic l Ask parents if they have specific investigations or molecular genetic religious beliefs and offer to contact studies of any material from any hospital chaplain/faith representative pregnancy loss regardless of gestation l Do not make assumptions about l request by middle grade obstetrician what a parent may need/want (ST3–7 or equivalent e.g. staff grade, depending on their religious, ethnic or clinical fellow) or consultant and socio-economic background appropriate form signed. This will l Parents may wish to contact their own form evidence of discussion between faith representative clinician and parents and of their consent Investigations l unsigned requests will not be processed l Middle grade obstetrician (ST3–7 or l equivalent e.g. staff grade, clinical Send to regional genetics laboratory fellow), consultant or specialist midwife l if any uncertainty whether test is for bereavement will discuss with parents appropriate, phone the regional genetics laboratory for advice Post mortem l Obtaining consent from parents for post mortem can be difficult. Take into account feelings, emotions and religious beliefs of woman, partner and family

Issue 4 188 Issued: April 2017 Expires: April 2019 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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Neonatal death Clarification l If baby was born alive, regardless of l Department of Health and Office for gestation, a medical certificate for the National Statistics have agreed the cause of death in baby dying within the following under the above Act that: first 28 days of life must be issued l if a fetus (or more than one fetus) is l Medical certificates can only be expelled after 24 weeks of pregnancy, completed by a doctor, neonatologist then, provided it was no longer alive or obstetrician at the 24th week, (this fact being l Doctor must have seen the baby alive known or provable from the stage of but does not have to have seen the development of the dead fetus) it does baby after death not fall within the category of births to be registered as stillbirth(s) under the Babies born outside hospital above Act without a midwife or doctor l Royal College of Obstetricians and present Gynaecologists and Royal College of Midwives have agreed: In a number of l Where it is known that intrauterine situations where it is known that one or death occurred before delivery, midwife more fetuses have died before the 24th or doctor examining baby can issue a week of pregnancy, those fetuses do stillbirth certificate. If there is any doubt, not have to be registered as stillbirths. refer to the coroner For example: l If baby is born alive outside the l where there has been a delay between hospital but has died before arrival at diagnosed intrauterine death and hospital, the coroner must be informed, delivery regardless of gestation l vanishing twins or selective or multifetal l If parents request a cremation, midwife/ pregnancy reduction in multiple doctor to complete a cremation pregnancies certificate l fetus papyraceous l REGISTRATION In all cases there must be evidence that it was known that the fetus or l Give family information about how to fetuses had died before the 24th week register their baby. Ensure they have all of pregnancy. This evidence, usually the required certificates based on ultrasound imaging, must be clearly detailed in maternal healthcare l There is no legal requirement to record for future reference register a baby delivered <24 weeks’ gestation that shows no signs of life. l Occasionally there is no ultrasound However, a baby that shows signs evidence available when ≥1 fetus is of life, whatever gestation, must be born dead >24 weeks’ gestation. It registered as a neonatal death may be appropriate to use stage of development of the fetus(es) as an l A stillborn child is defined in the Births indicator of when death occurred and Deaths Registration Act 1953 (and relative to the 24th week limit. This must amended by Stillbirths Definition Act be determined on a case by case basis 1992) as ‘any child expelled or issued by an obstetrician of at least middle forth from its mother after the 24th week grade (ST3–7 or equivalent e.g. staff of pregnancy that did not breathe or grade, clinical fellow) – it is not the show any signs of life’, and should be responsibility of the attending midwife registered as a stillbirth l Where there is any doubt about when the fetus or fetuses have died, register as a stillbirth

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FOLLOW-UP In the community l Give parents adequate time to discuss l After discharge, the majority of parents issues and ask questions before whose baby has died will require care discharge. They may wish to speak and support in the community to the midwife looking after them, l Specialist midwife for bereavement obstetric staff or specialist midwife for services may (in conjunction with bereavement services community midwife/GP where l Give parents information and support appropriate) visit parents at home and contact numbers before discharge offer a telephone call l Arrange follow-up appointment with l GP and community midwife will be named obstetric consultant. In some informed of delivery. When delivery circumstances and with the agreement has occurred <24 weeks, woman of all parties, it may be more may choose not to have a community appropriate to arrange an appointment midwife visit; ≥24 weeks, there is a with the consultant who has been statutory requirement for community involved in mother’s care while in midwife to visit hospital l Complete all discharge paperwork carefully and completely

Issue 4 Issued: April 2017 191 Expires: April 2019 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

PRINCIPLES OF REPAIR Systematic assessment l All women receive a systematic l Further explain what is planned and assessment of the perineum, vagina why and rectum and an accurate evaluation l Timing of systematic assessment of any trauma sustained should not interfere with mother-infant l Give clear information regarding the bonding unless bleeding requires extent of perineal trauma sustained, urgent attention and how and when to seek advice if l Follow local guidance for invasive problems occur procedures to minimise the risk of an unintentionally retained foreign body Initial assessment l check equipment and count swabs, l Explain what is planned and why tampon (if used) and needles before commencing procedure and count l Offer entonox again following completion of repair l Ensure good lighting l Lithotomy is the usual position to allow l Position woman comfortably with adequate visual assessment of the genital structures clearly visible trauma and for the repair. If the tear is l Perform initial examination gently and easy to visualise and does not require with sensitivity soon after birth prolonged suturing lithotomy is not l if genital trauma identified, carry required. Maintain lithotomy only as out further systematic assessment long as necessary for assessment and including a rectal examination repair

Issue 4 192 Issued: April 2017 Expires: April 2019 PERINEAL TRAUMA SUTURING (TEARS AND EPISIOTOMY) • 2/3 l Confirm effective local or regional l Obstetric cream analgesia in place. ≤20 mL lidocaine l Local anaesthetic – lidocaine 1% 1% can be used ≤20 mL. If more required, consider l Assess trauma visually (with good spinal anaesthetic lighting) including structures involved, l Adequate lighting apex of injury and degree of bleeding l Drapes l Perform rectal examination to identify damage to the external or internal anal Procedure sphincter l Complex trauma must be repaired by Documentation an experienced obstetrician in theatre under regional or general anaesthesia l Clearly document in maternal l healthcare record: Suture as soon as possible following delivery to reduce blood loss and risk l examination findings, using agreed of infection, except in women who have classification above, consider using a laboured in the pool or had a water diagram birth, in which case, suture after an l if rectal examination performed as part hour of initial assessment l Use an aseptic technique l if rectal examination was not carried l If woman reports inadequate pain relief, out and reasons for not doing so provide immediately l Ensure good anatomical alignment of Perineal suturing the wound and give consideration to the cosmetic result Consent l Use a continuous non-locked suturing l Explain procedure, obtain and record technique for the vaginal wall and consent muscle l Women who refuse to be examined l If skin is opposed following muscle and/or decline perineal repair must be suturing it is not necessary to suture it given the opportunity to discuss their l Where skin does require suturing use a concerns with the person providing continuous subcuticular technique care. Discussion should include information about the potential risks l Suture first degree tears unless edges which may occur if trauma to the are well opposed sphincters remains undetected l On completion of repair, perform further l ensure discussion is clearly rectal examination to exclude any documented suture material inserted through rectal mucosa Equipment l Unless contraindicated, administer diclofenac (Voltarol®) 100 mg rectally l Suture pack with X-ray detectable gauze swabs Before and after suturing, perform and document a 2-person swab, tampon l Sterile gown and gloves (if used), needle and instrument l Protective glasses check. Be particularly vigilant if l Cleansing solution or sterile water there is heavy bleeding, a change of operator or transfer to theatre l Suture material – Vicryl Rapide™ 2–0 (or equivalent) on a 35 mm taper cut l If a vaginal pack is left in situ, needle document and communicate via l 10–20 mL syringe and green needle handover

Issue 4 Issued: April 2017 193 Expires: April 2019 PERINEAL TRAUMA SUTURING (TEARS AND EPISIOTOMY) • 3/3 l Ensure safe disposal of all equipment in accordance with local Trust policy and COSHH regulations l Document nature of trauma, method of repair and swab, tampon, needle and instrument count l Unless contraindicated, prescribe and administer pain relief l Advise woman about extent of trauma, type of repair, pain relief, diet, hygiene and the importance of pelvic floor exercises Problems with perineum after discharge from hospital l If GP or community midwife concerned about a woman’s perineum they should refer her urgently to the maternity unit or to the perineal trauma clinic

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INTRODUCTION Blood loss

Haemorrhage is a significant cause Definition of direct maternal death. Obstetric haemorrhage can become life-threatening l Loss of ≥500 mL of blood from genital tract ≤24 hr of birth of baby RECOGNITION AND l Minor: 500–1000 mL ASSESSMENT l Moderate: >1000–2000 mL l Normal blood volume from 13/40 is l Severe: >2000 mL approximately 100 mL/kg l Acceptable blood loss at vaginal Early signs haemorrhage delivery is ≤500 mL (loss of 1000–1500 mL) l Acceptable blood loss at caesarean l Tachycardia section (CS) is ≤1000 mL l Increased respiratory rate Primary postpartum l Slight fall in systolic blood pressure haemorrhage Late signs haemorrhage l Excessive blood loss at or after delivery (loss of >1500 mL) of fetus (see above for volumes) in first 24 hr l Decreased blood pressure l Affects approximately 5% of all l Worsening: deliveries in the UK l tachycardia l tachypnoea Secondary postpartum l haemorrhage Altered mental state Be aware that visual assessment of l Excessive blood loss from genital blood loss is inaccurate; include tract >24 hr after birth ≤12 weeks of signs and symptoms in assessment delivery

PREVENTION Table 1: Cause of haemorrhage (the 4 T’s)

4 T’s Specific cause Relative frequency A – Tone l Atonic uterus, multiple pregnancy, 70% previous PPH, fetal macrosomia, delayed second stage, prolonged third stage, general anaesthesia B – Trauma l Cervical, vaginal or perineal lacerations l Pelvic haematoma l Inverted uterus 20% l Uterine rupture C – Tissue l Retained tissue l Invasive placenta (accreta) 10%

D – Thrombin l Coagulopathies e.g. PET 1%

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Prevention is better than cure MASSIVE OBSTETRIC HAEMORRHAGE l Women at increased risk of bleeding, active management of third stage l Simultaneously perform resuscitation, advised monitoring, arresting bleeding and l Give Syntometrine® 1 mL (ergometrine communication 500 micrograms + oxytocin 5 units) IM l Manage as for all PPH above, in or oxytocin 10 units IM (unlicensed) or addition: 5 units by slow IV bolus in third stage l In first instance – follow management l If increased risk of PPH at CS, consider as above tranexamic acid 0.5–1 g slow IV at l Summon help: maximum rate of 100 mg/min, in l middle grade obstetrician (ST3–7 or addition to oxytocin equivalent e.g. staff grade, clinical fellow) IMMEDIATE MANAGEMENT l anaesthetist (ALL PPH) l senior midwives (e.g. midwife l Summon help – middle grade co-ordinator and another experienced obstetrician (ST3–7 or equivalent midwife) e.g. staff grade, clinical fellow) or l other personnel (e.g. porter/auxiliary/ consultant, anaesthetist, senior midwife HCA to run errands etc.) and ancillary staff if necessary l Consider: l Keep woman warm l A – AIRWAY – check airway not l Communicate clearly to woman and compromised her birth companion(s) l B – BREATHING – oxygenate with l Obtain venous access – insert large 15 L/min oxygen via face mask bore 14 or 16 gauge cannula and take l bloods for FBC, clotting screen, group C – CIRCULATION (below) and save and crossmatch if required Bloods l Commence crystalloid fluids, ideally warmed l Cannulate (insert two 14 or 16 gauge l Palpate uterus for atony and venous cannulae – 1 in each arm) and commence . Consider take blood for: bimanual compression l FBC l If woman did not receive l APTT Syntometrine® for management l PT (INR) of third stage and has not been hypertensive, and has had BP checked l fibrinogen since admission, give ergometrine l crossmatch (≥4 units of packed red 500 microgram IM cells) l If required, give an antiemetic l U&Es and LFTs l Empty bladder to assist with uterine l Clotting is particularly important if the contraction bleeding has been over a period of time l Commence oxytocin infusion using local regimen for postpartum l Monitor pulse, respiratory rate and blood pressure every 15 min initially l Document fluid balance

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l Fluids and fluid balance Transfuse crossmatched packed cells 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 Blood transfusion l Refer to Trust Massive haemorrhage guideline l Use local trigger phrase for massive obstetric haemorrhage: l when requesting blood products from the biomedical scientist for haematology l when contacting porters l to communicate the urgency of the need for blood products

Table 2: Blood product replacement

Blood product Indication Tranexamic acid l 20 mg/kg (max rate 100 mg/min) IV Packed red cells l Give fully crossmatched blood if possible. If insufficient time, give type specific and, only as an absolute necessity, give O negative blood Fresh frozen l Avoid dilutional coagulopathy by early and adequate use of plasma (FFP) FFP (and other blood products as required) l Give 4 units for every 6 units of red cells l Give early where coagulopathy suspected e.g. abruption, amniotic fluid embolus, delayed diagnosis PPH l Aim to maintain PT and APTT at <1.5 x normal Platelets l Give when count <75 x 109/L or on consultant haematologist advice Cryoprecipitate l Keep fibrinogen >2 g/L

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l Oxygen If surgery to be carried out for major 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 l Ca2+ SpO2 (maintain at >95%) 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 Support for woman l Consider involving surgical colleagues 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 (), Trauma, Tissue and Thrombin below l commonest cause is uterine atony

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l POST-EVENT ergometrine 250 microgram IM with an 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 l haemorrhage has settled and platelet 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)

Issue 4 Issued: April 2017 199 Expires: April 2019 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 Other Suspect DIC in abruption, severe PIH, 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 accreta/increta/percreta Give FFP, platelets, +/- cryoprecipitate 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

Issue 4 200 Issued: April 2017 Expires: April 2019 PREGNANT WOMAN WITH A NON-OBSTETRIC PROBLEM (MANAGEMENT OF) • 1/1 l INTRODUCTION If the disease causes reduced mobility, 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 l presenting to Emergency department 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 Documentation woman’s blood group and need for 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 Issue 4 Issued: April 2017 201 Expires: April 2019 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 l e.g. decreased fetal movement the risk of serious neonatal infection is 1%, rather than 0.5% for women with Assessment and indications intact membranes 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 l necessary – see below 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 Use of internal monitoring l Length of labour and mode of delivery

Issue 4 202 Issued: April 2017 Expires: April 2019 PRE-LABOUR RUPTURE OF MEMBRANES (PROM) AT TERM • 2/2 l Advise woman: POSTNATAL l bathing or showering not contraindicated l If delivery >24 hr following PROM, l to avoid sexual intercourse advise woman to remain in hospital l to record her temperature 4-hrly during with her baby ≥12 hr following delivery waking hours l Advise woman with PROM to inform l to report immediately any change in: midwife/GP immediately if concerned – the colour or smell of her vaginal loss about baby’s wellbeing in first 5 days – any change in fetal movement pattern following delivery, particularly in first 24 hr when risk of infection is greatest – if labour begins l If any fever or change in colour or odour Observations (baby) of amniotic fluid, commence induction l l If labour has not started 24 hr after Closely observe any baby born to a rupture of membranes, advise the woman with PROM (>24 hr before the woman to give birth where there is onset of established labour) at term for access to neonatal services, and to the first 12 hr of life (at 1 hr, 2 hr, 6 hr stay in hospital ≥12 hr after birth and 12 hr) in all settings l l Provide woman with information leaflet 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

Issue 4 Issued: April 2017 203 Expires: April 2019 PRETERM LABOUR • 1/6

l INTRODUCTION Palpate for contractions 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 test: avoid using gel l Previous preterm birth with speculum – use only use sterile l Infection/inflammation of genital tract water (see below) l 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

Issue 4 204 Issued: April 2017 Expires: April 2019 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

Diagnosing preterm pre-labour l If the results of test for P-PROM are rupture of membranes (P-PROM) positive, take into account clinical condition, medical and pregnancy l See Diagnosis and assessment above history, and gestational age, then: l Offer a sterile speculum examination to l offer management of P-PROM or look for pooling of amniotic fluid – use l re-assess in next 24 hr for clinical water only as lubricant evidence of P-PROM l Avoid digital examination MANAGEMENT OF P-PROM l HVS and endocervical swab for chlamydia l Assess risk of cord prolapse l if pooling of amniotic fluid observed, do l Admit unless reason to deliver not perform diagnostic test and offer l If discharged arrange follow-up to management of P-PROM investigate for infection (see below), l if pooling of amniotic fluid not and advise to return if signs of labour observed, consider performing or infection diagnostic test for ruptured membranes, if used locally Antibiotics l Follow manufacturers’ advice carefully l Oral erythromycin 250 mg 6-hrly for l Do not perform diagnostic tests for maximum of 10 days, or until labour is P-PROM if woman is in labour established l If results of test for P-PROM are negative l if woman is in labour, do not offer and no amniotic fluid is observed: erythromycin l do not offer antenatal prophylactic l women with P-PROM who cannot antibiotics tolerate/contraindicated – consider oral l explain to the woman that P-PROM is penicillin unlikely, but advise to return if there are l Do not offer women with P-PROM any symptoms suggestive of P-PROM co-amoxiclav as prophylaxis for or preterm labour intrauterine infection Issue 4 Issued: April 2017 205 Expires: April 2019 PRETERM LABOUR • 3/6

l Follow-up Check availability of neonatal cots – follow local procedure l Use the following in combination to diagnose intrauterine infection in Antenatal steroids women with P-PROM: l Antenatal steroids reduce neonatal l clinical assessment deaths within the first 24 hr l blood test (C-reactive protein, WBC) l Administer 2 doses of betamethasone l CTG 12 mg IM 12 hr apart, to promote fetal l do not use any of these alone for lung maturity follow-up l give even if delivery is expected within l if results not consistent with each other, 24 hr consider repeating l consider from 34–35+6 weeks or, if pre-labour caesarean section (CS) is Management 34+1–36 weeks planned <38+6 weeks’ gestation l l Discuss with consultant Discuss benefits and maternal and fetal risks with woman l Take into account other risk factors and l Betamethasone: discuss with clinical assessment when considering consultant obstetrician if: conservative management/induction of labour l signs of infection l >36 weeks offer induction of labour l woman is diabetic (see Diabetes in labour guideline) MANAGEMENT OF PRETERM l steroids have already been given LABOUR 24–33+6 WEEKS earlier in pregnancy l if risk of neonatal respiratory distress l <26 weeks’ gestation – see Extreme syndrome felt to outweigh the prematurity (<28 weeks’ gestation) uncertainty about possible long-term guideline effects, consider second course of l Woman reporting symptoms of preterm antenatal steroids (especially if first labour with intact membranes – explain: course was given <26 weeks’ gestation) l availability of neonatal cots and l between 23+0 and 23+6 weeks possible transfer if none available l benefits, risks and possible Magnesium sulphate consequences of clinical assessment l Protects premature babies’ brains from and diagnostic tests, including cerebral palsy consequences of false positive and false negative results, taking into l Administer to all women considered account gestational age likely to deliver in ≤24 hr who are <30 weeks’ gestation, regardless of l prognosis for baby, including survival mode of delivery and long-term outcomes (use ‘1 in 10’ rather than ‘10%’) l Can be given to women with a multiple pregnancy, irrespective of whether l Middle grade obstetrician (ST3–7 or steroids have been given equivalent e.g. staff grade, clinical fellow) +6 or consultant to discuss with the woman l Consider giving ≤33 weeks’ and her birth partner(s) what to expect gestation if woman in established immediately, including resuscitation, and preterm labour, or having planned in the longer term for the baby delivery in ≤24 hr l If appropriate, offer visit to neonatal unit l Ideally commence infusion 4 hr before delivery l If cervical suture in-situ, discuss removal with consultant obstetrician l may still be of benefit if given <4 hr before delivery

Issue 4 206 Issued: April 2017 Expires: April 2019 PRETERM LABOUR • 4/6 l Do not delay delivery in time critical l Stop infusion immediately and call situations e.g. fetal distress middle grade obstetrician (ST3–7 or l Administration may be impractical equivalent e.g. staff grade, clinical when delivery imminent fellow) if: l Inform woman about possible l tendon reflexes are absent side-effects: l respirations <12/min l l facial flushing SaO2 <96% l nausea and vomiting l abnormal conscious level l sweating l urine output <1.5 mL/kg over 4 hr l tachycardia l Antidote: calcium gluconate 1 g (10 mL l hypotension 10% solution) IV over 3 min l effect may be more pronounced when l Repeat dose can be given later in given with calcium channel blockers pregnancy if woman did not deliver as e.g. nifedipine expected l Loading dose of 4 g (8 mL) IV over 20 min l Discontinue 30 min before anaesthesia, as can prevent fasciculations with l mix magnesium sulphate 50% 4 g suxamethonium, prolong the action of (8 mL) with sodium chloride 0.9% other muscle relaxants and promote 12 mL (total 20 mL) hypotension l set syringe driver at 60 mL/hr l dose administered over 20 min Tocolysis l Administer maintenance dose of l Use if cervix ≤4 cm dilated, and either magnesium sulphate 1 g/hr IV via membranes are ruptured/vaginal syringe pump until delivery, or for 24 hr, fibronectin is positive whichever is sooner l Contraindications: l mix magnesium sulphate 50% 5 g l antepartum haemorrhage (10 mL with sodium chloride 0.9% 40 mL (total of 50 mL) l suspicion of intrauterine sepsis l set syringe driver to 10 mL/hr l Site IV line and run crystalloid solution in case of sudden change in blood l dose administered at 1 g/hr pressure l Commence hourly observations of: l Take the following factors into account l heart rate when making decision to start tocolysis: l blood pressure l other clinical features (e.g. bleeding l respiratory rate or infection), may suggest stopping l level of consciousness labour is contraindicated l Check deep tendon reflexes at least on l gestational age every obstetric ward round, and once l likely benefits of maternal corticosteroids in the middle of the night l availability of neonatal care (need for l use patella tendon reflexes transfer to another unit) l use reflexes at elbow or wrist in women l woman’s preference who have a working epidural l Offer nifedipine as first line for tocolysis l check reflexes more often when: l if contraindicated, offer oxytocin - there is oliguria receptor antagonists (atosiban) - woman taking nifedipine l Avoid using multiple tocolytics as - dose of magnesium has required higher risk of adverse events adjustment l l Monitor oxygen saturation continuously If labour progresses, stop tocolysis with pulse oximeter

Issue 4 Issued: April 2017 207 Expires: April 2019 PRETERM LABOUR • 5/6

Nifedipine regimen dependent on gestation l monitor blood loss after delivery l Contraindications: l Use with caution in presence of: l aortic stenosis l intrauterine growth retardation l heart failure l known hepatic impairment l porphyria l known renal impairment l severe hypotension l Initial treatment: nifedipine 2 x 10 mg Emergency cervical suture immediate release capsule (do not crush) l Consultant obstetrician decision l Observations: l Do not offer ‘rescue’ cervical cerclage l BP every 15 min for first 2 hr after first to women with: dose (should not cause drop in blood l pressure in normotensive women) signs of infection l monitor baby with CTG for the first 2 hr l active vaginal bleeding l Subsequent treatment up to 72 hr: l uterine contractions nifedipine retard (tablet) 10–20 mg 8-hrly, l After consultant review, consider adjusted according to uterine activity ‘rescue’ cervical cerclage for women 16+0–27+6 weeks, with dilated cervix and nd Atosiban regimen – 2 line exposed, un-ruptured fetal membranes l Initial treatment take into account gestational age l Bolus dose of 6.75 mg over 1 min LABOUR l ready prepared as 0.9 mL IV injection l Decide mode of delivery on individual containing 6.75 mg basis l can be diluted with sodium chloride l If presentation not cephalic, delivery 0.9% for infusion >1 min will generally be by CS once labour is confirmed Subsequent treatment l (up to 48 hr – via infusion pump) See Extreme prematurity (<28 weeks’ gestation) guideline l Dilute 2 x 5 mL vials (37.5 mg/5 mL) l Explain benefits and risk of CS specific in of sodium chloride 0.9% 90 mL to gestational age (solution of 0.75 mg/mL) l Highlight the difficulties associated l Infusion of 18 mg/hr for 3 hr (24 mL/hr with CS for a preterm birth, especially for 3 hr) increased likelihood of a vertical uterine l then infusion of 6 mg/hr for maximum incision, and implications for future of 45 hr (8 mL/hr for maximum of 45 hr) pregnancies l Decision to stop atosiban to be made l No evidence that routine episiotomy by middle grade obstetrician (ST3–7 prevents intracranial haemorrhage or equivalent e.g. staff grade, clinical l may be indicated to prevent delay in fellow) or consultant second stage of labour l Stop after 12 hr without significant l If delivery needs to be accelerated – contractions (may be appropriate to Ventouse contraindicated <34 weeks’ stop earlier) gestation l maximum duration of therapy: 48 hr l <32 weeks’ gestation: middle grade l maximum dose: 330 mg neonatologist (ST3–7 or equivalent e.g. l Observations and cautions: staff grade, clinical fellow) or consultant l monitor BP and pulse hourly to attend delivery (along with junior member of neonatal medical team) l continuous electronic fetal monitoring

Issue 4 208 Issued: April 2017 Expires: April 2019 PRETERM LABOUR • 6/6 l Premature babies are vulnerable to l Consider carefully 34–36 weeks’ gestation hypothermia – delivery room/theatre to l <34+0 weeks’ gestation: do not carry be warm (windows shut, fans turned out fetal blood sampling off) and Resuscitaire® heater turned on well before delivery Group B streptococcus (GBS) l <30 weeks’ gestation: place baby in polythene bag (without drying) ensure l Prematurity is an intrapartum risk factor hat to cover head for early onset GBS l If both mother and baby are stable, l if no other risk factors for early onset delay cord clamping for ≥30 sec, but GBS, discuss antibiotic treatment in <3 min, with baby held below mother labour with neonatologist to promote placenta-fetal transfusion l if there is P-PROM of any duration and l If a preterm baby needs to be moved woman starts active preterm labour, away for resuscitation, or there is consider intrapartum antibiotics for significant maternal bleeding: GBS prophylaxis l milk cord l Women who have had P-PROM l clamp cord as soon as possible may have been commenced on l Obtain paired cord blood samples for erythromycin blood gas analysis and inform neonatal l If woman is pyrexial, erythromycin or unit of results GBS prophylaxis are not adequate to cover Gram negative and anaerobic Fetal heart rate (FHR) infections monitoring l administer antibiotics to cover Gram positive, Gram negative and anaerobic l See Extreme prematurity (<28 weeks’ organisms, e.g. cefuroxime and gestation) guideline metronidazole l Offer women in established preterm labour but with no other risk factors PREVENTION OF PRETERM either: LABOUR l continuous or l After discussion with consultant l intermittent auscultation obstetrician: l Explain to the woman that there is l offer prophylactic vaginal progesterone an absence of evidence that using or prophylactic cervical cerclage to cardiotocography improves outcomes of women with history of spontaneous preterm labour for the woman or baby, preterm birth or mid-trimester loss compared with intermittent auscultation 16+0–34+0 weeks’ gestation and cervical length <25 mm Fetal scalp electrode and fetal l offer vaginal progesterone to women blood sampling with no history of spontaneous preterm l Do not use a fetal scalp electrode for birth or mid-trimester loss and cervical FHR monitoring if the woman is <34+0 length of <25 mm weeks’ gestation, except when: l consider offering prophylactic cervical l it has been discussed with consultant cerclage for women with cervical length obstetrician <25 mm, and who have either: l it is not possible to monitor the FHR - had P-PROM in a previous using either external cardiotocography pregnancy or or intermittent auscultation - history of cervical trauma l benefits are likely to outweigh potential risks

Issue 4 Issued: April 2017 209 Expires: April 2019 RECOVERY • 1/3

STAFFING MONITORING AND DISCHARGE CRITERIA (RECOVERY ROOM) l Recovery staff (ODP, midwife or nurse) must be appropriately trained to the Mother standard required for general recovery facilities and maintain their skills l Monitor and record on local documentation l Observe all women on a one-to-one basis l For all women, monitor the following parameters ≥10 min, as a minimum: Equipment l heart rate l l Ensure appropriate equipment is blood pressure l available in recovery room and SpO2 meets Association of Anaesthetists l respiratory rate of Great Britain and Ireland (AAGBI) l temperature once requirements l Other parameters that may need to be POST-ANAESTHETIC CARE monitored and that must be assessed before discharge are listed in Table l Begins as soon as surgical procedure overleaf completed l Woman must be physiologically stable Baby on departure from operating theatre l See Care of the newborn at delivery l Anaesthetist must determine need for guideline monitoring during transfer l If woman conscious and baby well, l If GA, extubate in theatre hand baby to her immediately. l Transfer woman to recovery room Encourage skin-to-skin l Anaesthetist formally hands over care to recovery room nurse, operating department practitioner (ODP) or appropriately trained midwife, but remains responsible for the woman and must be readily contactable l Recovery room nurse, ODP or appropriately trained midwife must provide one-to-one care l Woman remains in recovery room for ≥30 min or until discharge criteria met – see below l Midwifery care is required l to assess fundal height and lochia l to commence skin-to-skin contact (if not already started in theatre) and offer help with first breast feed l If woman conscious, birth partner can accompany her to recovery

Issue 4 210 Issued: April 2017 Expires: April 2019 RECOVERY • 2/3

MONITOR DISCHARGE CRITERIA General Temperature 36–37.5°C Airway Able to breath deeply and cough on command Blood glucose – if appropriate Urinary output – amount and colour Adequate and clear l IV infusion running: l type of fluid l rate of administration Respiratory status

SpO2 94–98% with room air or supplemental oxygen Respiratory rate 10–20/min Cardiovascular status 50–100 beats/min. No unexplained cardiac Pulse rate arrhythmias Systolic blood pressure Within 20% of pre-anaesthetic level Neurological status Conscious state Easily rousable and able to respond appropriately to questions Motor status l Able to: l sustain head lift ≥5 sec l move limbs in a co-ordinated manner l signs of motor recovery Post-surgical status Surgical drainage l No active signs of blood loss from wound/ drainage sites/vagina l Acceptable fundal height Pain control if opioids administered – 20 min observations l Pain assessment l Analgesia administered and Woman must be pain-free or acknowledge pain documented score ≤3 or mild Post-operative nausea and vomiting (PONV) Document treatment for PONV and effectiveness, e.g. treatment Must be controlled before discharge to ward sheet, healthcare record Personal hygiene Check Ensure woman clean, dry and comfortable

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DISCHARGE FROM On postnatal ward RECOVERY l Close monitoring during first 24 hr. l If discharge criteria not achieved, keep If available at your Trust, nurse in a woman in recovery room and inform 4-bedded room anaesthetist who must review l Intensity and frequency of observations will depend upon: Unsuitable for transfer to l postnatal ward stage of recovery l nature of surgery l May require further intensive l observations on delivery suite following clinical condition of woman assessment by anaesthetist and middle l type of analgesia [e.g. PCA i.e. grade obstetrician (ST3–7 or equivalent intrathecal opioids (diamorphine)] e.g. staff grade, clinical fellow) l Frequency of observations will depend Observations on ward on woman’s condition l On admission, perform initial assessment: Documentation l BP l Must be completed and accompany l pulse woman on discharge: l oxygen saturation levels l clinical notes l respiratory rate l nursing record, midwifery notes l temperature l post anaesthetic care record l conscious level l operation notes l Assess the following as appropriate: l anaesthetic record l surgical site and drains l treatment sheet/drug chart l vaginal loss l fluid infusion chart l palpate uterine fundus CARE DURING 24 HR l catheter bag drainage – urine output FOLLOWING RECOVERY l IV infusions l l Use this guideline in conjunction with pain and sedation levels your local MEWS system l nausea and vomiting

Issue 4 212 Issued: April 2017 Expires: April 2019 REFUSING BLOOD AND BLOOD PRODUCTS • 1/4

l GENERAL PRINCIPLES Where a woman aged <16 yr refuses 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

Mentally competent women l If an unconscious or apparently incapable woman is admitted, treat in Aged ≥18 yr the normal way, except where: l there is compelling evidence that the l Have a fundamental legal and ethical person, if capable, would refuse to right to refuse treatment (including accept blood (e.g. carrying a card or blood transfusions) even if it is likely document rejecting blood transfusion that refusal will result in their death in all circumstances, especially if l No other person is legally able to noted at booking). Her wishes must consent to treatment for that adult or to be respected provided the decision refuse treatment on their behalf is clearly applicable to the present l Administration of blood or blood circumstances and there is no reason products to a competent adult without to believe she has changed her mind consent or against their wishes is l Views of close relatives or friends could unlawful and ethically unacceptable be taken into account but would not and may lead to criminal, civil or be decisive (General Medical Council disciplinary proceedings 1998) l Women may refuse blood transfusions l in cases of dispute, seek urgent advice for many reasons, including: from on-call consultant haematologist l religion and Trust manager/director on-call l safety concerns AT BOOKING l previous transfusion reactions l previous negative experience Discussion and documentation l Ask all women if they have any Aged <18 yr objection to blood transfusion – l In law women aged 16–18 yr have the document response same capacity and right to consent l Wherever possible, see woman on her to treatment as persons aged ≥18 yr. own without outside influence Case law has extended the right to l discuss risks of refusing blood e.g. persons aged <16 yr who are judged may be life-threatening if massive to have the capacity to fully understand haemorrhage what is proposed l Document conversation and woman’s l Where a woman aged <16 yr is decision in maternal healthcare record believed to have the necessary l capacity, her acceptance of treatment If available at your Trust, give her a cannot be nullified by parental ‘Receiving a blood transfusion’ leaflet objection

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l Refusal If high blood loss during caesarean 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 l Check blood group, antibody status, LABOUR haemoglobin and serum ferritin l When a woman refusing blood l start ferrous sulphate and folate to transfusion is admitted, follow be given throughout pregnancy to individualised management plan and maximise iron store inform consultant obstetrician and l Ultrasound scan to identify placental consultant anaesthetist on-call site l Routine labour management, by ANTENATAL experienced staff l Consent obtained for active third stage l Prepare a detailed birth management of labour – see Third stage of labour plan with woman guideline l She must be informed of services available e.g. cell salvage, At delivery haemodilutation and interventional l When baby delivered, give mother radiology Syntometrine® 1 mL IM l Aggressively manage anaemia l Do not leave mother alone for ≥1 hr l in anaemia, consider erythropoietin following delivery after discussion with haematologist l Monitor lochia closely for ≥1 hr after l If unusual bleeding occurs at any time delivery during pregnancy, advise woman to l If increased risk of postpartum attend hospital for review by a middle haemorrhage, oxytocin infusion as per grade obstetrician (ST3–7 or equivalent local regimen. This will include women e.g. staff grade, clinical fellow). If with: actively bleeding, on-call consultant obstetrician will be informed. Threshold l history of bleeding (post or antenatal for intervention will be lower than in any haemorrhage) other woman l prolonged labour especially if l Bleeding must be quantified as augmented with oxytocin accurately as possible l maternal age >40 yr l In the event of a significant l ≥4 children haemorrhage, involve duty consultant l multiple pregnancy anaesthetist and on-call consultant haematologist in management l large baby (>3.5 kg) Issue 4 214 Issued: April 2017 Expires: April 2019 REFUSING BLOOD AND BLOOD PRODUCTS • 3/4 l maternal obesity Intra-operative cell salvage (ICS) l polyhydramnios l Collection of blood from the operative l fibroids field l If baby transferred to neonatal unit, l Collected blood is citrated, filtered, ensure neonatologists are aware of washed with sodium chloride, mother’s views concentrated and returned to woman CAESAREAN SECTION l This technique requires specialist equipment and a dedicated l If caesarean section necessary, it must perfusionist – see Cell salvage be carried out by senior obstetrician guideline and senior anaesthetist MANAGEMENT OF Elective surgery HAEMORRHAGE l Inform consultant obstetrician and anaesthetist responsible for woman’s Post-operative care care as soon as possible so they can l Give ≥40% oxygen for 24 hr and meet with woman and discuss options manage in high dependency care area l Consider techniques available to l Monitor closely (including reduce intra-operative blood loss, post-operative blood loss) and inform including: consultant obstetrician/surgeon l normovolaemic haemodilution immediately of any post-operative l intra-operative cell salvage complications l tranexamic acid (if available locally) l If admission to critical care likely, discuss with on-call critical care TECHNIQUES FOR consultant BLOOD CONSERVATION IN l In extreme cases, in order to lessen OBSTETRIC CARE oxygen requirement, sedation, analgesia, IPPV with muscle relaxation Acute normovolaemic and controlled hypothermia may be haemodilutation (ANH) necessary l Immediate pre-operative collection of l Keep woman informed about what is 2–3 units of whole blood from mother happening in citrated bags with simultaneous volume replacement with crystalloid/ If any bleeding, act quickly. Inform colloid to maintain normovolaemia consultant obstetrician and l Reduces the number of red cells lost at anaesthetist on-call. surgery See Antepartum haemorrhage and l Can be a primary means of conserving Postpartum haemorrhage guidelines and re-transfusing platelets/coagulation factors – each unit of ANH blood is equivalent to 1 unit RBC + 1 unit FFP + 1.5–2 units of platelets Do not suggest autologous blood storage to pregnant women, as the amount of blood required to treat massive obstetric haemorrhage is far in excess of that which could be donated during pregnancy

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If standard treatment not controlling bleeding l Strongly recommend blood transfusion. Woman is entitled to change her mind about a previously agreed treatment plan l Staff must be satisfied that the woman is not being subjected to pressure from others. It is reasonable to ask accompanying persons to leave the room in order that a senior doctor (with midwife or other colleague) can confirm she is making the decision of her own free will l If she maintains her refusal to accept blood or blood products, respect her wishes

Hysterectomy l Early recourse to surgery may be necessary

DEATH l See Maternal death guideline

DISCHARGE AND FOLLOW-UP l Majority of pregnancies end without serious haemorrhage l When discharging mother, advise her to report promptly if she has any concerns about bleeding during the puerperium

Issue 4 216 Issued: April 2017 Expires: April 2019 REMIFENTANIL PATIENT CONTROLLED ANALGESIA (PCA) USE IN LABOUR • 1/2

INTRODUCTION Preparation of the PCA l Remifentanil is a short-acting opioid l Use a dedicated 20 G intravenous analgesic drug cannula for the PCA (do not use l rapid onset, acting within 1–2 min, with Y-piece connectors) a rapid offset l do not use for other drugs l non-cumulative irrespective of duration l Do not flush it of use l Dilute remifentanil 1 mg in sodium l Provides effective labour analgesia chloride 0.9% 40 mL (25 microgram/mL) following intravenous administration via l Start setting of PCA to deliver PCA pump 25 microgram (1 mL) boluses with a l Use in labour is widespread, but 3 min lock-out period unlicensed l Do not use a background infusion l Can lead to transient loss of variability l Delivery time of bolus should be <20 sec in CTG trace, but is rapidly metabolised and redistributed by the fetus Maternal instructions l Advise woman to press button as soon Indications for use as she starts to feel tightening l Remifentanil PCA is less effective than l IV bolus has onset time of 30–60 sec, epidural, but can be considered in the peak effect after 2.5 min, and duration following circumstances: of action around 6–7 min l coagulopathy l Do not use in between contractions l previous spinal surgery l Woman only to use handset (not midwives or birth partner) l existent structural or functional deficit of spine Regulating dose l localised or systemic infection l l inability to site epidural Adjustment of dose or lock-out period may be required as labour progresses l intrauterine death l from 25–37 or 50 microgram bolus (50 microgram bolus most effective Criteria for use dose), or l Adequate monitoring and staffing is l lock-out period decreased from 3 to 2 min mandatory as can lead to: l If excessive sedation reduce bolus dose l maternal sedation l respiratory depression MONITORING l nausea l Use remifentanil PCA record form l vomiting (transient) l Monitor continuous oxygen saturation l Established labour l if woman persistently desaturates l Oxygen saturations must be >95% below 90%: – administer oxygen 2 L/min with nasal l Can be used in conjunction with prongs Entonox® and transcutaneous electrical nerve stimulation (TENS) – if no improvement use 4 L/min with mask Pump l temporarily remove PCA handset until reviewed by anaesthetist l Use dedicated PCA pump, e.g. l reset at lower dose or increase lock-out Graseby™ 3300 times

Issue 4 Issued: April 2017 217 Expires: April 2019 REMIFENTANIL PATIENT CONTROLLED ANALGESIA (PCA) USE IN LABOUR • 2/2 l Record every 5 min, record for 15 min Sedation score when started, then half hourly: l non-invasive blood pressure amplifier l A – fully Awake (NIBP) l V – responds to Voice l respiratory rate l P – needs Painful stimulus to get l heart rate response l applies if and when program changed l U – Unrousable l CTG monitoring COMPLETION OF USE OF APNOEA REMIFENTANIL PCA l Midwife to dispose of any remaining l If no respiratory response by 20 sec, drug in syringe as per local controlled sound emergency call bell/buzzer and drug policy summon help l Remove 20 G (pink) IV cannula – do l Lie patient flat in full left lateral position not flush l administer 100% oxygen via self-inflating bag, valve, face mask until return of spontaneous respiration (or by Hudson mask if making respiratory effort) l continue until arrival of anaesthetist

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

Issue 4 218 Issued: April 2017 Expires: April 2019 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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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

Issue 4 220 Issued: April 2017 Expires: April 2019 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 l Discuss coping strategies and support 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 l women sections 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

Issue 4 Issued: April 2017 221 Expires: April 2019 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 Women with multi-agency or Assess general condition of baby 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 l document outcomes of multi-agency or See woman at each handover, review multidisciplinary meetings in woman’s care plan and document in maternal postnatal care plan healthcare record l See also the following guidelines: See Every postnatal contact section l l Local Safeguarding guideline or local See specific guidelines for appropriate Child protection guideline care: l l Local Mental health problems in Infant feeding guideline pregnancy guidance (if available) l Breastfeeding guideline in the l Substance misuse guideline Staffordshire, Shropshire & Black Country Newborn and Maternity l Local Management of domestic Network Neonatal guidelines (if used violence in pregnancy guideline (if locally) available) l Hypoglycaemia guideline in the l Infant feeding guideline Staffordshire, Shropshire & Black Country Newborn and Maternity Initial postnatal period Network Neonatal guidelines (if used locally) l See Care of the newborn at delivery guideline l Care of the newborn at delivery guideline l Check woman’s wellbeing, ensuring ≥1 set of general observations have l Caesarean section guideline been taken and recorded and are l Bladder care guideline within normal limits

Issue 4 222 Issued: April 2017 Expires: April 2019 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)

Issue 4 Issued: April 2017 223 Expires: April 2019 ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 4/11

Discharge directly Discharge from delivery suite/birth unit/ following delivery postnatal ward l Provided no risk factor identified and See also Every postnatal contact section no neonatal indication for admission, Midwife will ensure: the following women may transfer l Physical condition of mother and baby is home: satisfactory, and confirm identification of l normal, complication-free vaginal baby delivery l Referrals for mother and baby organised l insignificant meconium stained liquor l Woman’s Hb, rubella and rhesus in labour status have been checked and treated l any significant problem in previous appropriately pregnancy not affecting this birth l Contraception has been discussed e.g. previous retained placenta, third l Analgesia has been discussed degree tear, instrumental delivery l if breastfeeding advice given to avoid l walked to bathroom and passed codeine/co-codamol urine – see Bladder care guideline l Smoking, including passive smoking l Discuss with team leader/middle and access to cessation of smoking grade obstetrician (ST3–7 or programme for woman and other family equivalent e.g. staff grade, clinical members discussed fellow) l Understanding of effective breastfeeding l any mother who does not fit the and, if planning to formula feed, correct above criteria but requests early preparation, sterilisation of equipment transfer home. Discuss neonatal and storage of feeds discussed concerns with ANNP/neonatal staff l Cot safety discussed and leaflet provided (if available locally) l Baby car seats discussed l Concerns relayed directly by postnatal midwife to community midwife l Inform woman that community midwife will visit the day after discharge and a subsequent visit will be arranged at that time l ensure address documented is where the woman will be staying for first community visit, and confirm contact details are correct l Examination of newborn discussed (if not performed in hospital) l Any necessary appointments are arranged for woman/baby l Parents advised how to register birth l File copy of discharge documentation l Woman has all relevant documentation, leaflets and prescribed medication l Give contact numbers to enable woman to report any concerns

Issue 4 224 Issued: April 2017 Expires: April 2019 ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 5/11

l Postnatal visiting apply separate neonatal barcode label 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

Issue 4 Issued: April 2017 225 Expires: April 2019 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

Issue 4 226 Issued: April 2017 Expires: April 2019 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 l diet, including high fibre foods 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 l postpartum haemorrhage, check 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 l opened her bowels ≤3 days of 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 l Give perineal hygiene information 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 l administered into different limb 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 l may continue If weight loss not within normal limits, inform parent(s) and take appropriate action

Issue 4 Issued: April 2017 227 Expires: April 2019 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)

LIFE-THREATENING CONDITIONS IN WOMEN Possible sign/symptom Evaluate for l Tachypnoea l Sudden or profuse blood loss l Blood loss and signs and symptoms of shock, including: Postpartum haemorrhage (PPH) – see Postpartum haemorrhage (PPH) l tachycardia and hypotension guideline l hypoperfusion l hypovolaemia l change in consciousness

l Offensive/excessive vaginal loss PPH/sepsis/other pathology – see Postpartum haemorrhage (PPH) l Tender abdomen or fever guideline and Sepsis guideline l Fever l Shivering l Abdominal pain Infection/genital tract sepsis l Tachypnoea l Offensive vaginal loss l Severe or persistent headache Pre-eclampsia/eclampsia – see l Diastolic BP >90 mmHg and other Eclampsia guideline and Severe signs of pre-eclampsia pre-eclampsia guideline l Shortness of breath or chest pain Pulmonary embolism l Unilateral calf pain Deep vein thrombosis

Issue 4 228 Issued: April 2017 Expires: April 2019 ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 9/11

COMMON HEALTH PROBLEMS IN WOMEN Condition Action l If symptoms persist >10–14 days, refer to GP for Baby blues postnatal depression assessment Perineal l Perineal assessment and evaluate for signs of: l Pain l infection l Discomfort l inadequate repair l l Stinging wound breakdown or non-healing l Refer as appropriate to GP/middle grade obstetrician l Offensive odour or (ST3–7 or equivalent e.g. staff grade, clinical fellow) dyspareunia l Advise topical use of cold therapy and paracetamol (if not contraindicated) l if neither effective, consider oral or rectal non-steroidal anti-inflammatory drug l Advise women who have had an epidural/spinal anaesthesia to report positional headache Headache l For tension/migraine headaches, offer advice on relaxation and avoiding precipitating factors l Ask about general wellbeing and provide advice on diet and exercise l If condition affects woman’s care of herself or baby, Persistent fatigue evaluate underlying causes l Measure Hb and, if low, treat according to local practice Backache l Manage as general population l Assess diet and fluid intake Constipation l if changes in diet ineffective, advise use of gentle laxative l If severe, swollen or prolapsed, evaluate and refer to GP for further evaluation/treatment Haemorrhoids l otherwise, treat with haemorrhoid cream and provide advice on dietary measures to avoid constipation l Assess severity, duration and frequency. If symptoms do not resolve, refer to middle grade obstetrician Faecal incontinence (ST3–7 or equivalent e.g. staff grade, clinical fellow)/ incontinence nurse l Teach pelvic floor exercises Urinary incontinence l If symptoms persist refer to incontinence nurse

Issue 4 Issued: April 2017 229 Expires: April 2019 ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 10/11

HEALTH PROBLEMS IN BABIES Problem Action Jaundice in first 24 hr l Refer urgently to paediatrician l Monitor and record jaundice and overall Jaundice in babies aged >24 hr wellbeing, hydration and alertness Jaundice from aged 7 days or l Refer to paediatrician lasting >14 days Significant jaundice or unwell l Evaluate serum bilirubin and refer to babies paediatrician l Advise frequent feeding, waking baby to feed Jaundice in breastfed babies if necessary, routine supplementation is not recommended l Offer information and guidance on hygiene. If Thrush appropriate, refer to GP for antifungal treatment l Consider hygiene and skin care, sensitivity, Nappy rash infection, e.g. thrush l Refer to GP for consideration of antifungal Persistent nappy rash medication No meconium in first 24 hr l Refer to paediatrician urgently Diarrhoea l Refer to paediatrician urgently Excessive inconsolable crying l Needs urgent action l Reassure parents l Assess general health: l antenatal and perinatal history l onset and length of crying l nature of stools l feeding l woman’s diet if breastfeeding l family allergy l parents’ response l factors that make crying better/worse l Advise parents that holding baby during a Colic crying episode and peer support may be helpful l Do not use dicycloverine Colic in formula-fed babies l Consider hypo-allergenic formula Unwell baby l Refer urgently to paediatrician

Issue 4 230 Issued: April 2017 Expires: April 2019 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 l intercourse and possible dyspareunia 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

Discharge from community l Reinforce how to register baby’s birth midwifery care l Discuss role of health visitor with parent(s) l See also Every postnatal contact l Complete necessary documentation section in child healthcare record, to ensure Community midwife will: comprehensive handover of care to health visitor l Assess physical/emotional and social l Reinforce advice regarding local wellbeing of mother and baby before postnatal support/drop-ins/contact discharge numbers and how to access them l Discuss health issues e.g. breast l Ensure postnatal record completed awareness, cervical cytology, and returned to hospital to enable contraception and preconception advice maternal healthcare record to be filed l Discuss arrangements for woman to and returned to medical records attend for postnatal examination with l In all out of area deliveries, ensure GP approximately 6 weeks after birth midwifery postnatal records are l Ensure necessary referrals for mother returned to appropriate hospital as per and baby have been completed local practice

Issue 4 Issued: April 2017 231 Expires: April 2019 SEPSIS • 1/5

BACKGROUND RECOGNITION AND ASSESSMENT l Sepsis is any suspected or known infection associated with a systemic Use a MEWS chart for all maternity inflammatory response inpatients to identify seriously ill pregnant l Sepsis is a leading cause of maternal women and refer them to critical care mortality in the UK and the most and obstetric anaesthetic colleagues common cause of maternal mortality in according to local guidance the critical care unit (CCU) Consider sepsis in any woman with l If septicaemic shock develops, symptoms and signs suggestive of mortality rates approach 60% in CCU abruption l Early detection, accurate diagnosis and Symptoms, signs and aggressive appropriate treatment can significantly improve outcome laboratory results l One-third of women who die do so l Rigors, sweating, fever because of refractory hypotension l Headache, muscle pain, altered mental whilst the rest die later from multi-organ state, lethargy, poor appetite failure l Features of primary infection. Consider especially genital tract Risk factors for maternal sepsis sepsis (chorioamnionitis, postpartum endometritis); also wound infection, l Obesity pyelonephritis, pneumonia, acute l Impaired glucose tolerance/diabetes appendicitis, acute cholecystitis, l Impaired immunity pancreatitis, necrotising fasciitis, mastitis l l Anaemia An abnormal or absent fetal heart beat with or without placental abruption l Vaginal discharge may be the result of sepsis l History of pelvic infection l Sepsis is the presence of 1 of the above l Amniocentesis and other invasive symptoms plus 2 of the following: intrauterine procedures l heart rate >100 beats/min l Cervical cerclage l respiratory rate >20 breaths/min l Prolonged rupture of membranes l temperature >38°C or <36°C (PROM) l WBC >12 or <4 x 109/L – WBC l Vaginal trauma normally raised in labour l Caesarean section l normal WCC with >10% immature forms or increased CRP l Wound haematoma l hyperglycaemia in the absence of l Self or family history of, or contact with diabetes (plasma glucose >7.7 mmol/L) upper respiratory tract infection l acutely altered mental state l Group A streptococcus disease in close family/contacts Genital tract sepsis l Sickle cell disease/trait l Vomiting and diarrhoea, and/or l Black/ethnic minority abdominal pain l Retained products of conception after l often attributed to gastroenteritis miscarriage, termination of pregnancy l Vaginal discharge, wound infection or delivery l Rash (generalised streptococcal maculopapular rash) l discolouration or mottling of the skin may indicate cellulitis Issue 4 232 Issued: April 2017 Expires: April 2019 SEPSIS • 2/5

Life-threatening features Severe sepsis l Severe sepsis: sepsis with impaired Add organ function [e.g. diminishing renal l Measure venous plasma lactate function, impaired cardiac function, l Arterial blood gases (ABG), acid-base hypoxia, acidosis, acute respiratory and lactate distress syndrome (ARDS), clotting l disturbance, plasma lactate Chest X-ray >4.0 mmol/L] l If source of infection not apparent, consider CT scan, ultrasound scan and l Septic shock: severe sepsis with nuclear medicine imaging systolic BP <90 mmHg or mean arterial pressure (MAP) <65 mmHg l If woman known to be positive for ESBL or MGNB, re-screen for carriage Investigations of multi-resistant Gram-negative bacilli with rectal swab and, if urinary catheter Sepsis in situ, CSU l Swabs: Differential diagnosis l vaginal l Systemic disease: occult haemorrhage, l endo-cervical (if swabs for chlamydia myocardial infarction, adrenal PCR, use chlamydia detection kit; if for insufficiency, pulmonary embolism N. gonorrhoea culture, place swab in charcoal medium) OBSERVATIONS l wound Take and record on high dependency l throat when indicated – dependent on chart or maternity early warning local pathway scoring (MEWS) chart l l FBC and differential WBC Temperature l Heart rate l INR, APTT l Blood pressure using automated l Group and save non-invasive blood pressure device l Biochemical screen (U&E, LFT and l Respiratory rate C-reactive protein) l Oxygen saturation l Glucose l Peripheral perfusion l Culture l Urinalysis l blood x 2 (take 3 only if infective l Hourly urine output endocarditis suspected) l Fluid intake, oral and IV l urine l Lochia if appropriate l if woman has travelled abroad recently or enteric infections suspected, faeces Severe sepsis l if any hint of meningitis, CSF (omit Observations listed above plus if woman confused or intracranial l pressure raised) Level of consciousness, use Glasgow coma scale l If infection suspected during labour l Commence 3-lead ECG or delivery (e.g. pyrexia, offensive smelling liquor, smelly baby, l If central line inserted, central venous unexpectedly flat baby at birth), take pressure (CVP) swabs from vagina, placenta and baby l If gestation appropriate and not (ear, throat, skin) for microbiology delivered, continuous electronic fetal l Send placenta to histology monitoring (EFM)

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MANAGEMENT OF PYREXIA IN Airway and breathing LABOUR l Adequate oxygen therapy to maintain l If maternal temperature >37.5°C on 1 SpO2 94–98% occasion: l If increased difficulty in breathing, l keep woman cool contact critical care team to consider l administer paracetamol 1 g oral intubation and ventilation repeated 6-hrly as required l avoid dehydration Circulation l record temperature hourly until l Secure IV access with 2 large bore apyrexial cannulae l note: temperature rises with epidural in l Avoid siting epidural or spinal situ anaesthesia l Ensure adequate fluid replacement High or prolonged pyrexia l colloid 20 mL/kg or crystalloid l If maternal temperature >38°C once or [compound sodium lactate >37.5°C on 2 occasions 2 hr apart: (Hartmann’s) or sodium chloride 0.9%] 40 mL/kg over <30 min then reassess l commence external EFM l If no response to simple resuscitation l MSU or catheter specimen of urine measures, insert CVP line and monitor l high vaginal swab or low vaginal swab to guide further fluid replacement l blood culture x 2 l If anaemic, transfuse blood l Liaise with neonatologists to consider l If woman remains hypotensive despite their presence at delivery adequate fluid replacement, transfer to l Start IV antibiotics critical care for further management

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 l FBC and blood 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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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/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

If yes, woman has sepsis

Does woman have signs of organ dysfunction? l Systolic blood pressure <90 or mean arterial pressure <70 mmHg l Urine output <0.5 mL/kg/hr for 2 hr l Platelets <100 x 109/L l Creatinine rise of >44.2 mmol/L or level of >177 mmol/L l Lactate >2 mmol/L l New need for oxygen to maintain SpO2 >90% l INR >1.5 or PTT >60 sec l Bilirubin >70 µmol/L

No Yes

Treat for sepsis Woman has severe sepsis l Blood cultures l Start the clock l Lactate l Refer to critical care l Fluid balance and catheterise l Administer IV antibiotics within 1 hr – l Oxygen start with stat dose l IV antibiotics l Consider operative intervention l Fluid therapy l Consider VTE prophylaxis

Issue 4 236 Issued: April 2017 Expires: April 2019 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

RECOGNITION AND Investigations ASSESSMENT Urine Symptoms l Dipstick measurement; proteinuria l Headache ≥1+ l Visual disturbance l Confirm significant proteinuria with/ l Epigastric pain without symptoms if: l Vomiting l ≥300 mg protein in validated 24 hr urine collection or l Sudden swelling of face, hands or feet l urinary protein/creatinine ratio l Oedema >30 mg/mmol Signs Blood l Hyperreflexia with clonus l Abdominal tenderness – right upper l FBC quadrant l If platelet count <100 x 109/L, perform l Proteinuria ≥1+ or protein/creatinine clotting studies ratio of >30 mg/mmol or >0.3 g in 24 hr l LFT l Papilloedema l U&E and uric acid l Liver tenderness l Group and save l Platelet count falling or <100 x 109/L l Abnormal liver enzymes (ALT or AST rising or >70 IU/L) Issue 4 Issued: April 2017 237 Expires: April 2019 SEVERE PRE-ECLAMPSIA • 2/8

IMMEDIATE MANAGEMENT TREATMENT l Admit all women with severe l Give antacid prophylaxis e.g. ranitidine pre-eclampsia or eclampsia 150 mg oral 6-hrly (if oral inappropriate, l Give high dependency care – see High 50 mg IM 6-hrly) dependency care guideline l If fetus <35 weeks’ gestation, give betamethasone two 12 mg doses IM l Carefully explain problem and 12 or 24 hr apart (depending on clinical management to woman and birth situation) to promote fetal lung maturity partner

Multidisciplinary team planning Blood pressure control l Ensure early involvement and liaison The aim of antihypertensive therapy is between middle grade obstetrician to maintain systolic BP <150 mmHg (ST3–7 or equivalent e.g. staff grade, and prevent cerebral haemorrhage clinical fellow) or consultant, anaesthetist, and hypertensive encephalopathy intensive care specialists, delivery suite midwife co-ordinator and neonatologist When in assessment and management of women with suspected or proven severe l In women with a systolic blood pre-eclampsia and eclampsia pressure >160 mmHg or diastolic blood pressure >110 mmHg, begin Monitoring antihypertensive treatment l If in labour, start high dependency care How chart in addition to partogram l Labetalol oral and IV, nifedipine oral Minimum requirement (unlicensed) and hydralazine IV are commonly used agents of choice l Maternal pulse and BP – with woman for severe hypertension – see Drug rested and sitting at a 45° angle every treatment regimen below 15 min until stabilised, then every 30 min l ensure appropriate cuff size used and Notes placed at level of heart l Consider insertion of arterial line l use multiple readings to confirm diagnosis in woman who will be receiving l use an automated machine that has continuous IV antihypertensive; close been validated for use in pregnancy liaison with anaesthetist is essential l l Oxygen saturations continually and Consider giving up to 500 mL recorded hourly – obstetric review if crystalloid fluid before or at the same <95% time as first dose of hydralazine IV in antenatal period l Respiratory rate hourly l IV anti-hypertensives are an indication l Urine volumes via indwelling urinary for EFM catheter hourly l Avoid rapid fall in blood pressure as l Fetal heart rate – continually by this can potentiate fetal distress electronic fetal monitoring (EFM) – see l Aim to keep blood pressure Electronic fetal monitoring guideline <150/80–100 mmHg

Examine Prevention of seizures l Optic fundi for signs of haemorrhage l Administer magnesium sulphate and papilloedema prophylaxis – see Magnesium l Assess for hyperreflexia and clonus sulphate overleaf

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l Fluid management if oliguria <100 mL over 4 hr period, stop magnesium sulphate and request Amount of fluid middle grade (ST3–7 or equivalent e.g. staff grade, clinical fellow) or consultant l Unless ongoing haemorrhage, avoid review fluid overload – limit total IV input to l If oliguria <100 mL over 2 consecutive 1 mL/kg/hr 4 hr periods, check catheter draining, l include all drugs administered in the auscultate chest and check U&E, hourly volume input of fluid platelet and LFT urgently l increased fluids may be required l Middle grade obstetrician (ST3–7 or at insertion of regional analgesia/ equivalent e.g. staff grade, clinical anaesthesia fellow) or consultant review l Always use syringe driver or infusion l If signs of pulmonary oedema, or input pump to control delivery of fluids >750 mL in excess of output, give l Continue fluid restriction until middle furosemide 20 mg IV grade obstetrician (ST3–7 or equivalent l if no signs of fluid overload, give e.g. staff grade, clinical fellow) or 250 mL colloid fluid challenge and consultant confirms diuresis is occurring assess response l if oliguria persists (<50 mL over Type of fluid 4 hr), middle grade obstetrician (ST3–7 or equivalent e.g. staff grade, l If marked hypovolaemia due to clinical fellow) to review and consider haemorrhage (>500 mL), haemolysis furosemide and central venous or DIC, give blood +/- blood products pressure (CVP) monitoring – discuss with haematologist l if prolonged antenatal oliguria or Monitoring anuria, prepare for delivery l Measure fluid input and output hourly Thromboembolism via urinometer l Give thromboprophylaxis (see VTE – l insert Foley indwelling catheter to Thromboprophylaxis guideline) measure urine output l When pre-eclampsia is complicated by DELIVERY pulmonary oedema, persistent oliguria or significant blood loss, consider l Once woman stable, consultant CVP monitoring after discussion with obstetrician and anaesthetist make anaesthetist decision to deliver. Liaise with neonatology team Oliguria l Consider fetal presentation and condition, together with likelihood of l During labour and after delivery, success of induction of labour oliguria is not uncommon l >34 weeks’ gestation with cephalic l renal failure is unusual in pre-eclampsia presentation, consider vaginal delivery and is usually associated with additional problems e.g. haemorrhage l in <32 weeks’ gestation, prefer and sepsis caesarean section l give woman with severe pre-eclampsia l If vaginal delivery planned, plan short controlled fluid and wait for natural second stage with consideration of diuresis to occur approximately elective operative vaginal delivery 36–48 hr after delivery

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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 l Manage third stage with oxytocin Management 10 units IM (unlicensed) or 5 units IV As for severe pre-eclampsia plus: Do not give ergometrine or l Evaluate severity Syntometrine® in any form for prevention of haemorrhage as this l Hourly BM can further increase blood pressure l Monitor conscious level and look for signs of confusion ECLAMPSIA l Stabilise l ≥1 convulsion superimposed on l Do not use betamethasone or pre-eclampsia dexamethasone for treatment of HELLP syndrome l See Eclampsia guideline l Early blood transfusion – these women are often profoundly anaemic HELLP SYNDROME l Contact haematologist early for advice l Haemolysis, elevated liver enzymes about replacement of clotting factors and low platelets (HELLP) occurs in l Deliver approximately 4–12% of women with l severe pre-eclampsia. It is associated Postnatal recovery often more with high perinatal mortality complicated, with oliguria and a slow recovery of biochemical parameters Symptoms POSTNATAL MANAGEMENT l Can present with vague symptoms AND FOLLOW-UP which often delay diagnosis l Up to 44% of convulsions occur l nausea postpartum especially at term. l vomiting Assess carefully and continue high dependency care for ≥24 hr l epigastric pain and right l upper-quadrant pain Continue anti-hypertensive medication after delivery l A unique feature of HELLP syndrome l If BP falls to <130/80 mmHg, reduce is ‘coca-cola’ appearance of urine; anti-hypertensive treatment small amounts of dark black urine are produced l While inpatient – measure BP ≥4 times/day

Issue 4 240 Issued: April 2017 Expires: April 2019 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 l documentation AV block l Persisting hypertension and proteinuria Cautions at 6 weeks can indicate renal disease, investigate further l Heart failure l Be aware of risk of late seizures and l Diabetes review carefully before discharge Side effects l Offer follow-up to discuss events, treatment and future pregnancy care l Postural hypotension l Follow-up at 6 weeks l Tiredness l Discuss events, treatment and future l Headache pregnancy care l Weakness l Check BP and urine. Investigate persisting hypertension and proteinuria l Rashes at 6 weeks as may indicate renal l Tingling scalp disease, investigate further l Difficult micturation DRUG TREATMENT REGIMENS l Epigastric pain l Nausea, vomiting LABETALOL l Beta-blocker with additional arteriolar vasodilating action

Labetalol regime on delivery suite l Oral therapy 200 mg stat with further 200 mg after 1 hr Acute treatment (IV) Maintenance treatment (IV) l 50 mg IV bolus over 1 min (10 mL l Where continuous IV doses required, labetalol 5 mg/mL) consider insertion of arterial line in l Can be repeated every 5 min to a discussion with anaesthetist maximum of 200 mg l Neat labetalol 5 mg/mL at a rate of l Can cause excessive bradycardia 4 mL/hr via syringe driver reversed by giving atropine sulphate l Set target BP and record 600 microgram IV l Start infusion at 4 mL/hr and double every 30 min to maximum 32 mL/hr (160 mg) until BP lowered and stabilised at acceptable level l Start at: l 4 mL/hr (double every 30 min if necessary) l 8 mL/hr l 16 mL/hr l 32 mL/hr (maximum) l Convert to oral therapy – dose dependent on IV dose that was required

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NIFEDIPINE HYDRALAZINE l Calcium-channel blocker, relaxes l Direct acting vasodilator vascular smooth muscle and dilates coronary and peripheral arteries Contraindications

Contraindications l Known hypersensitivity l Idiopathic systemic lupus erythematosus l Known hypersensitivity l Severe tachycardia l Gastrointestinal obstruction l l Hepatic impairment High output heart failure l Inflammatory bowel disease l Myocardial insufficiency due to mechanical obstruction l Crohn’s disease l Cor pulmonale l Cardiogenic shock l Dissecting aortic aneurysm Concurrent use of magnesium l sulphate and nifedipine may cause a Acute porphyria precipitous drop in blood pressure Cautions Treatment l Renal impairment l Hepatic impairment l Pre-load with colloid 300 mL IV before administration l Ischaemic heart disease l 10 mg capsule orally, repeat every l Cerebrovascular disease 30 min, up to 3 doses – consider SR tablets for longer-term regulation of BP Side effects Nifedipine must be swallowed whole l Tachycardia – do not give sublingually l Palpitations l Flushing l Monitor fetal heart rate by continuous electronic fetal monitoring (EFM) – see l Hypotension Electronic fetal monitoring guideline l Fluid retention l Measure maternal BP every 5 min in l Gastrointestinal disturbances first 30 min after initial administration as l Headache may reduce quickly l Dizziness Side effects l Rarely: rashes, fever, peripheral neuritis, polyneuritis, paraesthesia, l Headache abnormal liver function, agitation, l Flushing anxiety, dyspnoea l Dizziness l Tachycardia l Palpitation l May induce exaggerated fall in blood pressure

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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

MAGNESIUM SULPHATE 50% Seizure prophylaxis

Cautions l Administer 2 concentrations: l 1 as loading dose l Renal impairment l 1 as continuous infusion for 24 hr or l Hepatic impairment until 24 hr after delivery (or after last seizure or until diuresis, whichever is Side effects (generally associated later) with hypermagnesaemia) l can be stopped without tapering dose l Nausea l Vomiting l Thirst l Flushing of skin l Loss of tendon reflexes l Muscle weakness l Hypotension l Arrhythmias l Respiratory depression l Drowsiness l Confusion l Coma

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Magnesium sulphate 50% regimen

Dose for recurrent Loading dose Maintenance dose seizures l 4 g IV l 1 g/hr IV l Give 2 g bolus for weight l Add magnesium l Add magnesium <70 kg sulphate 50% 8 mL sulphate 50% 10 mL l Add magnesium (4 g) to sodium chloride (5 g) to sodium chloride sulphate 50% 4 mL 0.9% 12 mL – total 0.9% 40 mL – total (2 g) to sodium chloride volume 20 mL volume 50 mL 0.9% 12 mL and l Administer via syringe l 10 mL = 1 g magnesium administer by slow bolus driver over 10–20 min sulphate injection over 5–10 min (infusion rate of l Start IV infusion via l Give 4 g bolus for weight 60–120 mL/hr) syringe driver at >70 kg 10 mL/hr l Add magnesium sulphate 50% 8 mL (4 g) to sodium chloride 0.9% 12 mL and administer by slow bolus injection over 5–10 min l Increase maintenance dose to 2 g/hr IV

Observations Check serum magnesium levels l Continuous pulse oximetry Stop magnesium sulphate if: l Urine output hourly l Urine output <100 mL in 4 hr l Respiratory rate hourly l Respiratory rate ≤12 breaths/min l Deep tendon reflexes l Oxygen saturation <90% l Monitor insertion site closely for l phlebitis using a recognised infusion Patellar reflexes absent (not due to phlebitis scoring tool regional anaesthesia) 97% of magnesium is excreted in urine. Oliguria can lead to toxicity. Antidote – calcium gluconate 10% 10 mL IV over 10 min

Issue 4 244 Issued: April 2017 Expires: April 2019 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 Issue 4 Issued: April 2017 245 Expires: April 2019 SHOULDER DYSTOCIA • 2/4

Subsequent management Above actions unsuccessful l If delivery unsuccessful, performing l Position mother on all-fours (Gaskin clinician should attempt either of the 2 manoeuvre) and attempt delivery of manoeuvres below independently to posterior shoulder repeating above attempt rotation of the shoulders manoeuvres l base decision on which manoeuvre l When all above manoeuvres have been to use first on training and clinical attempted, choose either the Zavenelli expertise, and clinical circumstances manoeuvre or l if first fails try second manoeuvre l Perform episiotomy to facilitate access Zavenelli manoeuvre l A middle grade obstetrician (ST3–7 Delivery of posterior arm or equivalent e.g. staff grade, clinical l Attempt delivery of posterior arm and fellow) or consultant may use the shoulder: Zavenelli manoeuvre: rotation, flexion and reinsertion of fetal head l introduce hand into pelvis posteriorly at into vagina, followed by emergency 5 o’clock or 7 o’clock, with palm facing caesarean section baby’s face l find posterior shoulder and using 2 fingers Symphysiotomy follow arm and flex elbow to the chest l grasp the fetal wrist and gently withdraw l Syphysiotomy: attempt as a last posterior arm from the vagina, sweeping resort and only by, or in the presence across chest and face in a straight line of consultant obstetrician l insert a urethral catheter to move Rotational manouevre urethra to one side, make a midline incision in symphyseal joint and Wood’s screw/Rubin II perform delivery manoeuvre l to avoid sudden abduction, ensure l Insert hand into vagina and approach mother’s legs are supported at all times posterior shoulder from front of fetus, aiming to rotate shoulder towards AFTER DELIVERY symphysis pubis l Hand baby to waiting neonatal l Insert fingers of opposite hand behind team member who will perform anterior shoulder, pushing shoulder resuscitation where required – see towards the chest Cardiopulmonary resuscitation of the l combination of these 2 manoeuvres newborn guideline frees the impacted shoulders and l allows delivery Delivering midwife/medical staff will perform active management of the third l If unsuccessful, consider reverse stage Wood’s screw manoeuvre l inspect genital tract thoroughly and Reverse Wood’s screw repair manoeuvre l ensure adequate analgesia prescribed and antibiotics and/or laxatives if l Insert hand into vagina and approach indicated, see Perineal trauma posterior shoulder from behind the suturing (tears and episiotomy) fetus in an attempt to rotate in opposite guideline direction to the original Wood’s screw. If l successful, the shoulders will rotate 180° Perform maternal observations and in the opposite direction and then deliver estimation of blood loss

Issue 4 246 Issued: April 2017 Expires: April 2019 SHOULDER DYSTOCIA • 3/4 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 l particular attention to the arms for the 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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Algorithm: Management of shoulder dystocia (MOET course manual 2007)

Include middle grade Shoulder dystocia suspected obstetrician (ST3–7 or equivalent e.g. staff grade, clinical fellow) or consultant, Call for help anaesthetist and neonatologist

Draw buttocks to edge of bed Lay woman more supine e.g. with 1 pillow

McRoberts manoeuvre – hyperflexion of legs ‘Knee-to-chest’ and abducted

Suprapubic pressure and McRoberts manoeuvre moderate traction can be maintained

To facilitate access for Perform episiotomy internal manoeuvres

Operator to Deliver posterior arm and decide which shoulder manoeuvre to use first REMEMBER – if With other internal rotary Wood’s screw manoeuvre one fails, try the manoeuvres other method

Move onto ‘all-fours’ Aim to deliver uppermost (Gaskin manoeuvre) shoulder first

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

Document delivery fully in Include date, time, signature maternal healthcare record and printed identification. Record cord gases and which fetal shoulder was ANTERIOR Consider risk management issues

Issue 4 248 Issued: April 2017 Expires: April 2019 STEM CELL BANKING • 1/2

INTRODUCTION COMMERCIAL BLOOD COLLECTION l Some Trusts do not support commercial stem cell collection l If woman is interested in commercial cord blood collection, advise her that l If your Trust is not licensed for the collection for commercial storage is not collection of cord blood collection permitted on most NHS Trust premises for commercial or non-commercial unless there is a private arrangement reasons must be performed under a with a company licenced under third party agreement with a Human Regulation 7 (1) and Schedule 2 of the Tissue Authority licensed establishment Human Tissue (quality and safety for l The professional collecting cord blood human application) Regulations 2007 must be appropriately trained to ensure l Woman is responsible for this private an uncontaminated sample that is safe arrangement. She will inform her to use community midwife of her plan l Fetal wellbeing takes priority. If l Community midwife or other maternity compromised for any reason, stem cell professional will inform midwifery collection will be delayed or, in some manager according to local protocols circumstances, not possible and document in maternal healthcare l Umbilical cord collection must not record interfere with the care of mother or l The company will confirm the plan in baby writing for the woman. File this in the l Do not delay mother and baby maternal healthcare record skin-to-skin contact l Woman’s birth partner will contact the If a family wishes to undergo private phlebotomist to arrange stem umbilical cord blood collection, cell collection following birth discussion must take place as l Midwives or doctors must never, in early in the antenatal period as any circumstances, be involved in the possible to allow time for necessary collection of cord blood for commercial arrangements stem cell storage l The company accepts liability for failed l Cord blood collection is particularly sample. Therefore, the Trust does not unlikely to be possible in the following have legal responsibility or liability for circumstances: samples taken on their premises l prematurity l nuchal cord l multiple pregnancy l emergency caesarean section l postpartum haemorrhage

Issue 4 Issued: April 2017 249 Expires: April 2019 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/

Issue 4 250 Issued: April 2017 Expires: April 2019 SUBSTANCE MISUSE • 1/4

l INTRODUCTION Encourage women using opiates who 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 Specialist midwife/drug worker C screening 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

Issue 4 Issued: April 2017 251 Expires: April 2019 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 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

l Non-booked women If woman persistently fails to attend booked antenatal clinic appointments, l On admission, women who have not refer to specialist midwife, if available engaged with maternity services (who locally deliver within the Trust) require: l urgent screening for blood-borne viruses CANNABIS MISUSE l detailed multi-agency discharge l Cannabis can be taken orally or planning smoked with tobacco l referral to social services (via CAF form if used locally) Risks l Smoking tobacco can cause fetal DNAs growth restriction, preterm labour, l See local protocol for follow-up of stillbirth and sudden infant death. women who do not attend scheduled Encourage smoking cessation antenatal clinical appointments l Ensure specialist drug worker or team Action is informed of woman’s failure to l Follow local policy attend. They may be able to encourage attendance by engaging with her in a non-hospital setting

Issue 4 252 Issued: April 2017 Expires: April 2019 SUBSTANCE MISUSE • 3/4

ALCOHOL MISUSE BENZODIAZEPINES (DIAZEPAM, TEMAZEPAM) MISUSE l Consuming alcohol during pregnancy can damage the fetus. Explain the risks l Benzodiazepine misuse is commonly and advise woman to avoid alcohol associated with other substance consumption (including binge-drinking misuse. Maternal benzodiazepine in early pregnancy) dependence is associated with l Ask woman about alcohol intake neonatal abstinence syndrome, during pregnancy, but be aware of sometimes prolonged, but is not under-reporting and underestimating associated with other adverse their true intake pregnancy outcomes l Avoid abrupt withdrawal – sudden Action withdrawal from benzodiazepines can precipitate severe anxiety, l If woman is drinking heavily, stopping hallucinations and seizures suddenly may be hazardous to her and the baby – seek specialist advice and ADMISSION AND MATERNAL referral INPATIENT CARE l Check booking liver function tests and consider liver scan if markedly On admission to maternity unit abnormal l For any planned admission, ensure l Fetal anomaly scan clear plan to prescribe appropriate l Growth scan as local policy dose opiate replacement l The use of Antabuse® (disulfiram) is l involving service provider of contraindicated in pregnancy and prescription and community pharmacy breastfeeding where woman is obtaining opiate replacement therapy OPIATE MISUSE l If admitted as an emergency, inform specialist drug worker/team who can Action advise on dose of opiate replacement. If unavailable, consultant obstetrician to l Encourage woman to enter into an decide appropriate opiate replacement opiate maintenance programme dosage (follow local policy to ascertain [methadone or buprenorphine usual dosage) (Subutex®)] with drug treatment l services timing of administration of opiate replacement should follow woman’s l Consider increasing methadone/ normal pattern Subutex® dose in third trimester l (plasma concentrations may decrease do not prescribe methadone to as gestation increases). Increase will a woman not on a replacement need to be reversed in the postpartum programme, await referral to drug team period (if mother is highly motivated) l Do not prescribe opiate replacement therapy to take home – arrange supply to be available from woman’s usual source

Issue 4 Issued: April 2017 253 Expires: April 2019 SUBSTANCE MISUSE • 4/4

Labour and pain relief POSTNATAL CARE l Inform specialist drug worker/team Neonatal abstinence l Give usual dose of methadone during syndrome labour at the regular time, although this l See Staffordshire, Shropshire & Black will not be adequate for pain relief in Country Newborn Network Abstinence labour syndrome guideline (if used locally) l If woman Subutex® (buprenorphine) user, adequate pain relief can be Baby difficult as it can reduce the effects of opioid analgesics l Encourage breastfeeding l Standard opiate analgesia can safely l Be aware of: be given l late neonatal abstinence syndrome l Morphine and pethidine may be (>72 hr) inadequate for pain relief; regional l benzodiazepines have longer analgesia may be preferable – involve withdrawal period on-call anaesthetist early l Advise mothers of neonatal abstinence l In women with a history of intravenous syndrome symptoms and signs drug use, review venous access. l Consider asking anaesthetist to insert a Give contact number for community cannula early if difficulty anticipated midwife and provide a means for mother and baby to return if worried l Inform neonatologists when delivery (fast track, symptom awareness) imminent. It is not necessary for them l to attend routinely unless there are Arrange community midwife visit other indications l Arrange follow-up clinic appointment. Duration and frequency of follow-up will DO NOT GIVE naloxone to baby as be individualised there is a major risk of respiratory depression and seizures Mother l Inform woman’s specialist drug worker of discharge l Multi-professional meeting with social care and health plan l Ensure prescriptions in place in the community (especially if discharged before a weekend)

Issue 4 254 Issued: April 2017 Expires: April 2019 THIRD AND FOURTH DEGREE PERINEAL TEARS – OASIS (OBSTETRIC ANAL SPHINCTER INJURIES) • 1/2 l CLASSIFICATION If practitioner inexperienced in assessing perineal damage or unsure of degree of Third degree tear trauma sustained, seek second opinion l Injury to perineum involving the anal Documentation sphincter complex: l Clearly document in mother’s l 3a: <50% of external anal sphincter healthcare record: (EAS) thickness torn l examination findings, using agreed l 3b: >50% of EAS thickness torn classification above l 3c: EAS and internal anal sphincter l (IAS) torn if rectal examination performed as part of initial assessment before suturing Fourth degree tear l if rectal examination was not carried out and reasons for not doing so l Injury to perineum involving anal sphincter complex (EAS and IAS) and PRINCIPLES OF REPAIR anal epithelium If tear involved anal mucosa only Obstetric anal sphincter repair to be with intact anal sphincter complex performed only by an appropriately (buttonhole tear), document as a trained, competent practitioner separate entity Practitioners who have not been If not detected and repaired, assessed as competent must be this type of tear may result in a supervised by an experienced recto-vaginal fistula clinician

RISK FACTORS Technique and position of woman l Forceps delivery l Second stage >1 hr Use aseptic technique at all stages l Shoulder dystocia of procedure l Nulliparity l Suture as soon as possible following l Persistent occipitoposterior position delivery, ideally ≤1 hr, to reduce l Midline episiotomy bleeding and risk of infection l Birth weight >4 kg l Obtain written informed consent before l Induction of labour undertaking repair l Asian ethnicity l Perform rectal examination before ASSESSMENT OF PERINEAL suturing to assess the integrity of the rectal mucosa and confirm extent of TRAUMA damage l See also Perineal trauma suturing l Perform repair, in theatre, with mother (tears and episiotomy) guideline in lithotomy position using good l Systematically examine women who lighting sustain genital tract trauma during l Use regional or general anaesthesia vaginal birth to assess severity of (to allow relaxation of anal sphincter damage, include: to enable torn ends to be brought l rectal examination to exclude damage to together without tension) sphincter complex (external and internal l anal sphincters and rectal mucosa) Follow local antibiotics prescribing policy l Depending on full extent of injury, Informed verbal consent must be perform repair to anal sphincter obtained before performing rectal complex in following sequence examination

Issue 4 Issued: April 2017 255 Expires: April 2019 THIRD AND FOURTH DEGREE PERINEAL TEARS – OASIS (OBSTETRIC ANAL SPHINCTER INJURIES) • 2/2

Rectal mucosa Laxatives l Use interrupted or continuous sutures l Lactulose 10 mL 8-hrly for 10 days with 3–0 Vicryl Rapide™ or equivalent on round bodied needle Analgesia

Internal anal sphincter (IAS) l Diclonfenac 100 mg PR 8-hrly (check not allergic to NSAID or any other l Use interrupted mattress sutures using contraindications) ® 3–0 PDS or equivalent on round l Appropriate non-codeine based oral bodied needle or 2–0 Polysorb™ or analgesia e.g. paracetamol equivalent on round bodied needle Oral antibiotics External anal sphincter (EAS) l Follow local antibiotic prescribing policy l Identify torn ends of the EAS and apply Allis tissue forceps DOCUMENTATION l Repair using either an overlap or end-to-end approximation technique In cases of obstetric anal sphincter ® with either 3–0 PDS round bodied injury, follow local risk management needle or 3–0 Vicryl™ or equivalent on procedure and document in medical round bodied needle record l If overlap technique used it may be necessary to dissect the EAS l The following must be documented: to facilitate this (remember not to l classification of injury including over-dissect as this may cause anatomical structures involved pudendal nerve damage) l method of repair and suture materials used l anaesthetic used l if rectal examination carried out following repair and verbal consent obtained Overlap method End-end method l estimated blood loss Vagina, perineal muscles and skin l instruments, sharps and swabs accounted for, including names of l Identify apex of vaginal mucosa and those checking place first stitch slightly beyond it l l Repair vaginal wall tissues with a whether woman fully informed about continuous non-locking stitch the nature of her injury l Repair deeper perineal muscles using l appropriate information given to a continuous suture, closing the skin the woman – extent of trauma, diet, with a continuous subcutaneous perineal hygiene, pelvic floor exercises suture using 3–0 Vicryl™ or equivalent and follow-up arrangements Rapide™ on taper cut needle DISCHARGE AND FOLLOW-UP l Following completion of repair, carry out rectal examination to ensure l Give woman instructions on pelvic floor sutures have not been placed through exercises, diet, hygiene and pain relief the rectal mucosa l Arrange review appointment at 6–12 weeks postpartum – if available, in POST-OPERATIVE MANAGEMENT perineal care clinic, otherwise follow l Insert an indwelling Foley catheter and local practice leave in situ in accordance with local l If available locally, provide patient practice information leaflet Issue 4 256 Issued: April 2017 Expires: April 2019 THIRD STAGE OF LABOUR • 1/1

DEFINITION Third stage is prolonged if not completed ≤30 min with active Time from birth of baby to expulsion of management and 60 min with placenta and membranes and control of physiological management – see bleeding Retained placenta guideline

Information for woman OBSERVATIONS Inform woman in the antenatal period, l Observe and record at least once after that active management of third stage delivery: shortens its duration and reduces risk l temperature of postpartum haemorrhage (PPH). However, women at low risk of PPH and l pulse who request a physiological third stage l blood pressure should be supported in their choice l respiratory rate

ACTIVE MANAGEMENT ASSESS l Care package including: l General physical condition l routine use of uterotonic drugs – l Maternal colour oxytocin alone (Syntocinon® 10 units IM or 5 units by slow IV bolus), or with l Uterine tone ergometrine (Syntometrine®) l Blood loss l do not give Syntometrine® to a l Is bladder empty? See Bladder care woman who has been hypertensive guideline or whose blood pressure has not l Emotional/psychological condition been checked since admission l clamping and cutting of cord, after EXAMINE ≥1 min for a healthy term infant to allow placental fetal transfusion to l When delivered: occur l cord l controlled cord traction (CCT) after l placenta signs of separation l membranes PHYSIOLOGICAL MANAGEMENT l perineum – see Perineal trauma suturing (tears and episiotomy) l Care package including: guideline l no uterotonic drugs l Take umbilical cord blood sample for l encourage skin-to-skin contact and gases (see Umbilical cord sampling early breastfeeding guideline) and for haemolytic disease of the newborn (HDN) testing if l no clamping and cutting of cord until required pulsation has ceased l placenta delivered by maternal effort COMPLICATIONS and gravity l In postpartum haemorrhage, l Do not pull cord or palpate uterus emergency action is required – see l if delivery of placenta required owing Postpartum haemorrhage guideline to bleeding or delay or if requested by l See also, Third and fourth degree woman, administer a uterotonic drug perineal tears – OASIS guideline, as part of active management Collapse guideline and Retained placenta guideline

Issue 4 Issued: April 2017 257 Expires: April 2019 TRANSCERVICAL CATHETER INDUCTION • 1/2

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 l cervix 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 Consent with sterile water or sodium chloride 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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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

Issue 4 Issued: April 2017 259 Expires: April 2019 UMBILICAL CORD PROLAPSE • 1/3

All staff involved in maternity care RECOGNITION AND should receive at least annual ASSESSMENT training in the management of obstetric emergencies including Symptoms and signs umbilical cord prolapse l Cord presentation and prolapse may occur with no outward physical signs DEFINITION and with a normal fetal heart rate (FHR) Descent of umbilical cord through cervix pattern alongside (occult) or past presenting l Abnormal fetal heart rate pattern (e.g. part (overt) in the presence of ruptured bradycardia, variable decelerations, membranes prolonged deceleration of >1 min – particularly if soon after membrane Background rupture) l Incidence of cord prolapse is between l Cord seen or felt at vaginal examination 0.1–0.6% l 50% of cases are preceded by obstetric Investigations manipulation l Auscultate fetal heart soon after rupture l Cord prolapse carries a perinatal of membranes mortality rate of 91/1000 l Routine vaginal examination is not l in hospital settings, mortality is indicated if liquor clear with spontaneous largely secondary to prematurity and rupture of membranes in the presence of congenital malformations normal FHR and absence of risk factors l Cord prolapse is also associated with birth asphyxia Cord prolapse suspected l asphyxia, predominantly caused by l Suspect where there is an abnormal cord compression and umbilical arterial FHR pattern (e.g. bradycardia, variable vasospasm, can result in long-term decelerations), particularly if such morbidity because of hypoxic changes occur soon after membrane ischaemic encephalopathy rupture, spontaneously or with amniotomy l Perform speculum and/or digital vaginal examination (even at preterm gestation) l Do not perform ultrasound examination to predict increased probability of cord prolapse

Risk factors associated with cord prolapse General risk factors Procedure related l Low birth weight (<2.5 kg) l Artificial rupture of membranes l Prematurity (<37 weeks) l Vaginal manipulation of fetus with l Fetal congenital anomalies ruptured membranes l Breech presentation l External cephalic version (during l Transverse, oblique and unstable lie procedure) l Second twin l Internal l Polyhydramnios l Stabilising induction of labour l Unengaged presenting part l Low-lying placenta, other abnormal placentation

Issue 4 260 Issued: April 2017 Expires: April 2019 UMBILICAL CORD PROLAPSE • 2/3

IMMEDIATE TREATMENT Follow Flowchart and General principles below

Umbilical cord prolapse diagnosed

Non-reassuring/ FHR pattern l Summon help abnormal/unavailable normal l Monitor FHR FHR pattern

If extreme In-utero death l Elevate presenting part prematurity, confirmed by manually or by urinary consider ultrasound bladder filling expectant l If in community, urgent management transfer to hospital See Perinatal bereavement guideline

Vaginal delivery not Vaginal delivery imminent imminent

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

Issue 4 Issued: April 2017 261 Expires: April 2019 UMBILICAL CORD PROLAPSE • 3/3 l General principles Empty bladder just before any delivery 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 l Procedure resulting in unnecessary l In cases of cord prolapse complicating delay in delivery pregnancies with gestational age at the limits of viability: Procedure l counsel mother on continuation and termination of pregnancy l Insert gloved hand or 2 fingers into vagina and apply pressure to presenting part pushing it upwards Delivery l Variation is to remove hand from vagina l When vaginal delivery not imminent, CS once presenting part above pelvic brim, l Category 1 (CS performed with the and apply suprapubic pressure upwards aim of delivering within ≤30 min) Complications if cord prolapse associated with suspicious or pathological FHR pattern l Excessive displacement of presenting – providing maternal safety is not part may result in more cord prolapsing unduly compromised l Bladder filling to elevate Category 2 if FHR pattern normal presenting part l If vaginal birth imminent, vaginal birth is preferable to CS Indications l if quick and safe delivery anticipated, attempt vaginal birth (in most cases l Decision-to-delivery interval likely to be operative) at full dilatation prolonged and/or involve ambulance transfer l In some circumstances (e.g. internal podalic version for a second twin) Contraindications breech extraction may be performed l Procedure resulting in unnecessary l Cord blood samples for pH and base delay in delivery excess measurement – see Umbilical cord sampling guideline Procedure SUBSEQUENT MANAGEMENT l Catheterise woman with appropriate Foley catheter l Offer mother postnatal debriefing l Insert end of a blood-giving set into end l Follow local clinical incident reporting of Foley catheter and, once sodium procedure chloride 0.9% 500–750 mL instilled, clamp catheter

Issue 4 262 Issued: April 2017 Expires: April 2019 UMBILICAL CORD SAMPLING • 1/1

Although sometimes difficult to obtain, Method both arterial and venous blood samples are required to make a more accurate l Once baby separated from placenta, assessment of condition of the baby isolate and double clamp section of cord selected for sampling as soon as INDICATIONS possible l Insert needle at 30° angle to vessel to May include ensure sampling from single vessel l Baby born in poor condition – Apgar l For best results, fill 2 mL score of <7 at 5 min pre-heparinised syringe. Ensure all l Non-reassuring or abnormal electronic air bubbles expelled, and syringe is fetal monitoring (EFM) trace capped and not left open-ended l Shoulder dystocia l Obtain sample from both artery and vein l Instrumental delivery l Caesarean section – elective (if local Results practice) and emergency l l Fetal blood sample is taken during Analyse in blood gas analyser labour l difference ≥0.03 units indicates both l Premature delivery arterial and venous blood obtained l l Vaginal breech delivery Secure results in intrapartum notes. As a minimum, document cord pH and l Maternal pyrexia in labour base excess in maternal healthcare l Multiple pregnancy record l Medical conditions, including ITP, as per plans made in antenatal period Action (cord FBC) l Inform neonatal team if low cord pH PROCEDURE l Inform postnatal ward on transfer of any low pH and high base excess Timing obtained from blood analysis, even if baby in good condition l Collect samples ideally ≤30 min l Babies born with cord pH levels following delivery <7.0 – follow local incident reporting l blood will not normally clot while still in procedure cord l sampling ≤30 min with cord stored at room temperature and taken with a good technique will provide most reliable results l If delay of >30 min anticipated, refrigerate section of cord and sample within 1 hr – results from sampling after this time will be unreliable

Issue 4 Issued: April 2017 263 Expires: April 2019 UTERINE RUPTURE • 1/2

l DEFINITION Undue maternal distress, agitation l Cessation of previously efficient uterine Uterine rupture activity l Loss of station of presenting part l Separation of uterine muscle requiring operative intervention or is symptomatic. Involves full thickness of IMMEDIATE MANAGEMENT the uterine wall Scar rupture suspected l uterine rupture is most often seen in women with a scarred uterus [usually General from a previous caesarean section (CS)] l Ensure maternal resuscitation is l risk is increased by the use of oxytocin managed effectively and more so with prostaglandins l Stop oxytocin if in progress l uterine rupture can occur in women l Administer oxygen at maximum flow who have not had uterine surgery l Crossmatch 4 units of blood urgently l can be life-threatening l Insert a second large-bore cannula l Assist mother into left lateral position Dehiscence with tilt l Scar starts to separate, but mother and l Inform consultant obstetrician baby are not affected. No symptoms l Call anaesthetist and theatre team are evident. Dehiscence is noted at urgently repeat CS l Anticipate a sick baby and call neonatal RECOGNITION AND crash team, which must include a senior clinician ASSESSMENT l If any of the following occur in a woman Specific treatment with a scarred uterus, call middle grade obstetrician (ST3–7 or equivalent e.g. l If woman fully dilated, perform vaginal staff grade, clinical fellow) or consultant instrumental delivery immediately obstetrician to review woman urgently l If not favourable for instrumental delivery, obtain informed consent for Symptoms and signs of laparotomy and possible hysterectomy scar rupture and perform a grade 1 emergency CS – see Caesarean section guideline l Abnormal electronic fetal monitoring l See Postpartum haemorrhage (EFM) trace guideline l Acute onset of scar tenderness l Severe abdominal pain especially if between contractions l Breakthrough pain during epidural analgesia l Chest or shoulder tip pain, or sudden onset of shortness of breath l Vaginal bleeding or haematuria l Maternal tachycardia, hypertension or shock

Issue 4 264 Issued: April 2017 Expires: April 2019 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

Issue 4 Issued: April 2017 265 Expires: April 2019 VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) • 1/2

l ANTENATAL CARE ≥1 previous vaginal births (particularly 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%

Issue 4 266 Issued: April 2017 Expires: April 2019 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 l l haemodynamic instability (low BP, raised Careful serial cervical assessments, pulse, feeling unwell, unresponsive) preferably by the same person (for both augmented and non-augmented l EFM changes showing sudden labours) to ensure adequate progress bradycardia or changes to variability for VBAC to continue

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INTRODUCTION INDICATIONS FOR VAGINAL BREECH DELIVERY l The incidence of breech presentation decreases from approximately 20% l Maternal choice (in some units, vaginal at 28 weeks’ gestation to 3–4% at breech delivery is offered as an option) term, when most babies will turn l Extreme prematurity spontaneously to cephalic presentation l Stillbirth After discussion with woman, l Second twin consultant obstetrician will advise l on mode of delivery. Document Rapid progressive labour with insufficient discussion and decision clearly in time to perform caesarean section (CS) maternal healthcare record Favourable features DEFINITION l Estimated fetal weight 2.0–3.8 kg l Presentation of fetal buttocks or feet in l Clinically adequate pelvis (presenting labour part engaged) l Complete breech presentation ANTENATAL MANAGEMENT INTRAPARTUM MANAGEMENT l Unless contraindicated, offer external cephalic version (ECV) preferably at l Perform planned vaginal breech 36–38 weeks’ gestation deliveries on consultant-led delivery l Advise women with unfavourable unit with access to facilities for clinical indicators of increased risks to emergency CS them and their babies if considering l Planned vaginal breech delivery must vaginal breech delivery only be undertaken by an experienced obstetrician or experienced midwife CONTRAINDICATIONS TO ECV l In an emergency situation, midwife is expected to manage delivery Absolute l Lower segment caesarean section First stage of labour (LSCS) to be performed for another l On admission, inform middle grade reason (e.g. placenta praevia) obstetrician (ST3–7 or equivalent e.g. l ≥2 previous LSCS staff grade, clinical fellow), who will l Severe oligohydramnios (ECV usually discuss with consultant obstetrician impossible) l Full intrapartum assessment by l Multiple pregnancy midwife/middle grade obstetrician l Fetal compromise l Abdominal palpation l Commence continuous electronic fetal Relative heart monitoring. If difficulty recording fetal heart rate (FHR) abdominally, use l Intrauterine growth restriction (IUGR) fetal scalp electrode applied to buttock l Uterine scar only l Known Rh isoimmunisation l Vaginal examination l Antepartum haemorrhage l Insert cannula and obtain blood for l Women in labour FBC and group and save l Offer woman choice of analgesia for labour and delivery

Issue 4 268 Issued: April 2017 Expires: April 2019 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 l upon as indicator of fetal distress 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 Delivery alternatively first attendant displaces 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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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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RECOGNITION AND Investigations ASSESSMENT If DVT suspected, start therapeutic l Diagnosis of DVT and pulmonary treatment with low molecular embolism in pregnancy can weight heparin (LMWH), unless be challenging because of the contraindicated until diagnosis physiological changes that occur. Many refuted. FBC, coagulation profile, of the classical symptoms of venous U&E’s and LFTs to be taken before thromboembolism can: anticoagulation therapy l occur in a low risk pregnancy l be normal in pregnancy l Thrombophilia screen before starting anticoagulant treatment Symptoms and signs not recommended, as will not alter immediate treatment and is affected by l Pain in affected leg/calf (more common pregnancy in left leg) l Compression or duplex (Doppler) l Calf tenderness and swelling >3 cm ultrasound is the first line diagnostic asymmetry between calves test for DVT in pregnancy. It is non-invasive, highly sensitive (97%) l Swelling of entire leg (usually unilateral) and specific (96%) for symptomatic l Pitting oedema proximal vein DVT, but less accurate for l Calf tenderness isolated calf DVT l Erythema l if symptoms suggestive of PE, see VTE l Collateral superficial veins – Pulmonary embolism guideline l l Increased skin temperature in affected If iliac vein thrombosis suspected leg (back pain and swelling of entire limb), discuss with radiologist l Raised WCC l Leg elevation and thromboembolic l Lower abdominal pain (pelvic extension decompression stockings to reduce of VTE) oedema and encourage mobilisation

Clinical suspicion of DVT

FBC, U&E’s, coagulation profile Commence therapeutic LMWH until objective testing +thromboembolic decompression stockings

Compression ultrasonography

Ultrasound positive Ultrasound negative

Low clinical suspicion Continue treatment High clinical suspicion

Discontinue treatment Discontinue treatment and repeat ultrasound on days 3 and 7

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TREATMENT Monitoring LMWH treatment General l If woman has not been given unfractionated heparin, monitoring for l Adequate analgesia heparin-induced thrombocytopenia is l in initial management of DVT, elevate leg not required and fit graduated elastic compression l If early pregnancy weight <50 kg or stocking to reduce oedema >90 kg and woman has bleeding problems, renal impairment, or massive Specific PE, discuss need for anti-Xa monitoring l Blood for FBC, INR, APTT with consultant haematologist l If platelet count <75 x 109/L, seek l if monitoring required undertake advice from on-call haematologist 3–4 hr after injection; aiming for levels before starting anticoagulation 0.7–1.1 unit/mL l If platelet count ≥75 x 109/L, prescribe l if levels raised reduce dose of LMWH – subcutaneous LMWH discuss with consultant haematologist Initial anticoagulant l Check anti-factor Xa levels every 4 weeks treatment in pregnancy l If post-operative and receiving unfractionated heparin, monitor platelet l In clinically suspected DVT, administer count every 2–3 days from day 4–14, LMWH (dalteparin or enoxaparin – or until heparin is stopped, whichever according to local practice) at doses in occurs first Table 1 until objective testing excludes diagnosis Maintenance treatment l titrate dose against the woman’s booking/early pregnancy weight l Therapeutic LMWH during remainder of l In women with renal impairment, seek pregnancy and ≥6 weeks postnatally, advice on dosage from haematologist until ≥3 months of treatment given l If weight is >125 kg – discuss with Anticoagulant therapy during haematologist labour and delivery l Postnatal LMWH dose: l Discontinue LMWH maintenance l enoxaparin: 1.5 mg/kg daily therapy 24 hr before planned delivery l dalteparin: 10,000–18,000 units daily e.g. elective caesarean section, according to weight including planned induction of labour l Advise woman that once she is established in labour or thinks she is in labour, no further heparin or other anticoagulant should be injected Table 1 EARLY PREGNANCY WEIGHT (KG) Initial dose <50 50–69 70–89 90–109 110–125

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

Issue 4 272 Issued: April 2017 Expires: April 2019 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

Administration of LMWH DISCHARGE AND FOLLOW-UP and use of epidural/spinal anaesthesia l Offer women who have been diagnosed with VTE during pregnancy l Before carrying out regional or postnatal period a 6 week–3 month anaesthetic procedures, (i.e. insertion postnatal appointment with consultant of epidural catheter or administration haematologist of spinal injection) record when most l assess post-thrombotic venous damage recent dose of LMWH was given and follow the steps below: l perform thrombophilia test as necessary l wait 12 hr after prophylactic dose of l Give advice on need for LMWH thromboprophylaxis in future pregnancy(s) and at other times l wait 24 hr after therapeutic dose of of increased risk, i.e. hormonal LMWH contraception and HRT l After insertion/removal of epidural catheter (or after insertion of spinal anaesthetic) review the time elapsed before administering dose of LMWH. LMWH can be given postnatally while epidural is in situ: l a thromboprophylactic dose of LMWH can be given 4 hr after removal of epidural catheter l Do not remove epidural catheter ≤12 hr of most recent LMWH

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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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 l of the classical symptoms of venous 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 Issue 4 274 Issued: April 2017 Expires: April 2019 VTE – PULMONARY EMBOLISM • 2/3

l TREATMENT in women with renal impairment, 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 SpO between 94–98% discuss with haematologist 2 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

Therapeutic dose of LMWH EARLY PREGNANCY WEIGHT (KG) Initial dose <50 50–69 70–89 90–109 110–125

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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l Monitoring LMWH treatment Heparin and warfarin are not 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

Maintenance treatment DISCHARGE AND FOLLOW-UP l Therapeutic LMWH during remainder of l See VTE – Deep vein thrombosis pregnancy and ≥6 weeks postnatally, guideline until ≥3 months of treatment given

Anticoagulant therapy during labour and delivery l See VTE – Deep vein thrombosis guideline

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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INTRODUCTION RISK ASSESSMENT AND MANAGEMENT l Venous thromboembolism (VTE) is up to 10 times more common in pregnant l Complete local risk assessment women than in non-pregnant women proforma for thromboprophylaxis at: of the same age and can occur at any l antenatal booking (or before stage of pregnancy, but the puerperium pregnancy if possible) is the time of highest risk l antenatal admission or if intercurrent l MBRRACE report highlighted 50% of problems develop fatal VTE occurred antenatally, half of l risk assessment in labour which were in the first trimester l post-delivery Table 1: Antenatal RISK FACTOR RISK LEVEL/ACTION l Any previous VTE except a single event related l High risk to major surgery l antenatal prophylaxis with LMWH. Refer to local thrombosis in pregnancy expert/team l Hospital admission l Intermediate risk l Single previous VTE related to major surgery l consider antenatal prophylaxis l High risk thrombophilia + no VTE with LMWH l Medical comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, type 1 diabetes mellitus (DM) with nephropathy, sickle cell disease, current intravenous drug user l Any surgical procedure e.g. appendectomy l Ovarian hyperstimulation syndrome (first trimester only) l Obesity (BMI >30 kg/m2) l ≥4 risk factors: prophylaxis l Age >35 yr from first trimester l Parity ≥3 l 3 risk factors: prophylaxis from l Smoker 28 weeks l Gross varicose veins l <3 risk factors – lower risk: l Current pre-eclampsia mobilisation and avoidance of l Immobility, e.g. paraplegia, pelvic girdle pain dehydration (PGP) l Family history of unprovoked or oestrogen-provoked VTE in first-degree relative l Low risk thrombophilia l Multiple pregnancy l IVF/ART l Transient risk factors l dehydration/hyperemesis l current systemic infection l long-distance travel (>4 hr)

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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

Perform VTE risk assessment and initiate appropriate action using local VTE assessment tool

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Special circumstances requiring l See all women treated with thromboprophylaxis thromboprophylaxis in antenatal clinic in third trimester to discuss plan of l Unless contraindicated, the following delivery and treatment regimen require thromboprophylaxis: l Warfarin: avoid in pregnancy (except l massive PPH for mechanical heart valve – discuss with cardiologist) l severe PET l severe post dural puncture headache Graduated compression stockings (GCS) Oral anticoagulants l On admission, offer GCS, unless l Women on long-term warfarin or other contraindicated (see below) oral anticoagulants: l Staff trained in the use of compression l counsel about risks of agents to fetus stockings to show woman how to wear l advise to stop oral anticoagulant, them correctly and monitor use except for mechanical heart valve l Encourage women to wear GCS from l change to LMWH as soon as admission until they return to their pregnancy confirmed (ideally ≤2 week usual levels of mobility of missed menstrual cycle and <6 weeks’ gestation) Contraindications to GCS l if exposed to warfarin in early l Peripheral vascular disease pregnancy refer to fetal medicine l Severe dermatitis department l Recent skin graft MANAGEMENT l Leg deformity l General Peripheral neuropathy l Do not allow woman to become LMWH dehydrated l If risk of bleeding, give l Encourage mobilisation thromboprophylaxis in 2 divided doses l if immobilised, arrange leg exercises as l One week thromboprophylaxis for soon as possible after surgery most women but 6 weeks if high risk, l Consider using regional anaesthesia if including previous VTE appropriate (risk of VTE is higher with general anaesthesia) l Risk assessment (using local VTE assessment tool) to ascertain if further measures necessary [e.g. graduated compression stockings (GCS), LMWH] l In some circumstances, mechanical compression devices will be used e.g. where GCS or LMWH contraindicated l If original VTE provoked by major surgery from which woman now recovered, and providing no other risk factors: LMWH from 28 weeks’ gestation

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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

High thromboprophylaxis dose Epidural/spinal anaesthesia – precautions l If high thromboprophylaxis dose required, seek advice from l If vaginal bleeding or labour begins, haematologist stop LMWH l l Any woman weighing >90 kg (booking If elective CS: give thromboproplylactic weight) receiving high dose low dose of LMWH on day before delivery molecular weight thromboprophylaxis – l morning dose should be omitted and check anti-Xa levels operation performed that morning l l anti-Xa cannot be carried out as an High prophylactic dose or therapeutic urgent test and result may not be dose – change to prophylactic dose on available for 2–3 days but would at day before planned delivery least guide subsequent treatment l Before carrying out regional anaesthetic procedures, (i.e. insertion l If woman at very high risk of VTE or of epidural catheter or administration previously on long-term anticoagulation of a spinal injection) record when the – refer to thrombosis clinic or seek most recent dose of LMWH was given advice from haematologist and follow the steps below: l wait 12 hr after prophylactic dose of Contraindications to LMWH LMWH l Active bleeding l wait 24 hr after therapeutic dose of l High risk of major haemorrhage (e.g. LMWH placenta praevia) l After insertion/removal of epidural catheter (or after insertion of spinal l Platelet count <75 x 109/L anaesthetic) review time elapsed l Coagulopathies (including low platelet before administering a dose of LMWH. count <75 x 109/L) LMWH can be given postnatally while l Severe renal impairment or established epidural is in situ renal failure l can be given ≥4 hr after use of spinal l Liver disease anaesthesia or after removal of epidural catheter l Uncontrolled hypertension l (≥230 mmHg systolic) Do not remove epidural catheter ≤12 hr of most recent LMWH l Allergy to heparin/LMWH l If regional technique was traumatic or l Acute stroke in previous 4 weeks had a bloody tap, consider skipping next dose of LMWH

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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

Labour and delivery l Stop LMWH injections once labour commences or if any vaginal bleeding l if no PPH and regional analgesia not used, give first dose as soon as possible after delivery l Restart thromboprophylaxis as soon as immediate risk of haemorrhage reduced and platelets/clotting within acceptable range

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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INDICATIONS SECOND STAGE LABOUR l Pregnant woman at term who is l 2 midwives must be present at birth suitable for low-risk care in labour l Delivery is mainly a ‘hands-off’ l Women who request waterbirth against procedure and control of the head is advice must be seen by consultant therefore unnecessary as immersion obstetrician as soon as possible. Refer in water appears to facilitate slow to local guidance on management for crowning waterbirth on a consultant unit l Following delivery of the head, the trunk should be expelled with next Preparation and cleaning contraction of pool l Deliver baby completely under l Follow local infection control measures the water and bring to the surface immediately with the face uppermost FIRST STAGE LABOUR l If baby does not deliver with next contraction, change mother’s position Before entering pool in pool to all-fours or deep squat where birth can be completed in the pool, or l Labour should be established standing with a leg on side of the pool, where baby will be delivered into air During labour Do not re-submerge baby once baby Do not leave woman unaccompanied has taken its first breath in the pool THIRD STAGE MANAGEMENT l Fill pool to level of mother’s breasts l In warm, humid environment, l Placental delivery and control of encourage fluids to prevent maternal bleeding will be dependent on maternal dehydration consent for active or physiological management l Monitor maternal temperature closely and discontinue use of pool if a rise of l Physiological management may be 1°C above baseline completed in the pool, dependent on maternal request and local policy l Monitor and record fetal heart rate with watertight doppler – see Intermittent l Observe for deviations from the norm auscultation guideline l Manage signs of maternal compromise l Monitor water hourly to maintain a as per local practice temperature that is comfortable for the woman but do not exceed 37.5°C at Postpartum haemorrhage any time l Maternal compromise may indicate l Keep water clear of debris postpartum haemorrhage l Woman to be attended at all times (this l Estimation of blood loss is difficult in can be by her birth partner) water and therefore it is estimated at l Use only nitrous oxide and oxygen < or >500 mL (50/50) for analgesia in waterbirth l For major obstetric haemorrhage – see Antepartum haemorrhage guideline and Postpartum haemorrhage guideline l If perineal suturing required, allow 1 hr for oedema to reduce

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REASONS FOR MOTHER LEAVING POOL l Fetal distress l Meconium stained liquor l Failure to progress l Mother becomes unsuitable for low-risk care e.g. pyrexia, bleeding, fainting l Maternal request or to pass urine l Maternal request for analgesia other than inhaled (50/50) nitrous oxide and oxygen l Excessive water contamination

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

Issue 4 Issued: April 2017 283 Expires: April 2019 INDEX • 1/3 A Diabetes in pregnancy 50, 54, 57 Abdominal palpation 24, 48, 58, Diminished fetal movements 58 136, 138–139, 170, Disseminated intravascular 183, 202, 204, 268 coagulation (DIC) 19, 45–46, 103, 200, Acute respiratory distress 204, 235, 237, 239 syndrome (ARDS) 233 Amniotic fluid embolism 43–47, 200 E Amniotomy 48–49, 107, 123, 260 Early warning scoring 18–19, 102–103, Anaemia in pregnancy 14 121, 185, 198, 201, Anaesthesia – epidural 72 203, 212, 232–233 Anaesthesia – general 91 Eclampsia 61 Antepartum haemorrhage 18 Electronic fetal monitoring 62, 66 APH 18 Emergency caesarean section 19, 26–27, 176, 246, 249 Endometritis 232, 235 B Epidural analgesia 72 Betamethasone 54, 81, 96, 205–206, 238, 240 Episiotomy 78 Bishop’s score 120–122 External cephalic version (ECV) 62, 170, 260, 268 Bladder care 22 Extraplacental bleeding 21 Blood transfusion (refusing) 41, 166, 213, 216 Extreme prematurity 30, 80–84, 169, 206, 208, 209, 261, 268 Breech delivery 268

F C Failed intubation [see General Caesarean section 26 anaesthesia (including failed Cardiopulmonary intubation)] 91 resuscitation of the newborn 29 Fetal abnormality – Care of the newborn at delivery 35 Antenatal detection 85 Clinical risk assessment – Labour 138 Fetal blood sampling 87 Care of the obese mother 176 Fetal loss 185 Cellulitis 232, 236 Forceps 78, 107, 180–181, Cerebral palsy 33, 81, 168, 206 255–256, 258, 269 Chorioamnionitis 66, 98, 137, 203, 232 Fourth degree tear 226, 255 Collapse (including amniotic fluid embolism) 43 G Cord prolapse (umbilical) 260 GBS 97 Cot locator 148 General anaesthesia (including failed intubation) 91 D Genital herpes 95 Delay in labour 48 DFM 58

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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 Spinal anaesthesia 171, 229, 234, 273, 276, 280 Spontaneous rupture of membranes 35, 97, 119, 121, 260 Substance misuse 251 Stem cell banking 249 Symphyseal joint 246 Symphysiotomy 246, 248, 269

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 Obstetric 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 Guidelines Network hospitals

These guidelines are advisory, not mandatory

Every effort has been made to ensure accuracy The authors cannot accept any responsibility for adverse outcomes 2017-19

Published by the Staffordshire, Shropshire & Black Country Newborn and Maternity Network Obstetric Guidelines 2017-19

The Bedside Clinical Guidelines Partnership Copyright © Copyright holder in association with the ISBNISBN 978-0-9557058-8-5 978-0-9557058-6-1 Staffordshire, Shropshire & Black Country Newborn and Maternity Network 9 780955 705861 and Southern West Midlands Printed by: Sherwin Rivers Ltd, Waterloo Road, Stoke on Trent ST6 3HR Tel: 01782 212024 Fax: 01782 214661 Email: [email protected] Maternity and Newborn Network