Obstetric Guidelines 2017

Obstetric
Guidelines
2017-19
The Bedside Clinical Guidelines Partnership
in association with the
Staffordshire, Shropshire & Black Country

Newborn and Maternity Network
and
Southern West Midlands
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: sarah.carnwell@nhs.net
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 pregnancy 14
Antepartum haemorrhage (APH) including placental abruption 18
Bladder care 22
Caesarean section 26
Cardiopulmonary resuscitation of the newborn 29
Care of the newborn at delivery 35
Cell salvage NEW 41
Collapse (including amniotic fluid embolism) 43
Delay in labour 48
Diabetes – Antenatal care 50
Diabetes – Labour 54
Diabetes – Screening for gestational diabetes 57
Diminished fetal movements (DFM) 58
Eclampsia 61
Electronic fetal monitoring (EFM) – Antenatal NEW 62
Electronic fetal monitoring (EFM) – Labour 66
Epidural analgesia 72
Episiotomy 78
Extreme prematurity (<24 weeks’ gestation) 80
Fetal abnormality – Antenatal detection 85
Fetal blood sampling 87
Fetal loss – see Perinatal bereavement
General anaesthesia and failed intubation 91
Genital herpes 95
Group B streptococcal disease 97
Hepatitis 99
High dependency care 102
HIV positive women 106
Home birth 109
Hypertension in pregnancy 112
Induction of labour 119
Infant feeding 124
Intermittent auscultation 136
Labour management (including clinical risk assessment) 138
Latent phase of labour 142
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CONTENTS • 2/2
Maternal death 144
Maternal transfer (including in-utero transfer) 146
Meconium stained liquor 150
Medical termination of pregnancy for fetal abnormality and fetocide 152
Mental health in pregnancy NEW 154
Morbidly adherent placenta 166
Multiple pregnancy 168
Neurological deficits after regional anaesthesia or analgesia 171
Normal laboratory values in pregnancy 175
Obese mother (care of) 176
Operative vaginal delivery 180
Oxytocin 183
Perinatal bereavement (previously Fetal loss) 185
Perineal trauma suturing (tears and episiotomy) 192
Postpartum haemorrhage (PPH) 195
Pregnant woman with a non-obstetric problem (management of) 201
Pre-labour rupture of membranes (PROM) at term 202
Preterm labour 204
Recovery 210
Refusing blood and blood products 213
Remifentanil patient controlled analgesia (PCA) use in labour NEW 217
Retained placenta 219
Routine postnatal care of women and babies 221
Sepsis 232
Severe pre-eclampsia 237
Shoulder dystocia 245
Stem cell banking 249
Substance misuse 251
Third and fourth degree perineal tears - OASIS (obstetric anal sphincter injuries) 255
Third stage labour 257
Transcervical catheter induction 258
Umbilical cord prolapse 260
Umbilical cord sampling 263
Uterine rupture 264
Vaginal birth after caesarean section (VBAC) 266
Vaginal breech delivery 268
VTE – Deep venous thrombosis 271
VTE – Pulmonary embolism 274
VTE – Thromboprophylaxis 277
Waterbirth 282
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ACKNOWLEDGEMENTS • 1/1
We would like to thank the following for their assistance in producing this edition of
the Obstetric Guidelines on behalf of the Bedside Clinical Guidelines Partnership and
Staffordshire, Shropshire & Black Country Newborn and Maternity Network
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 (Stillbirth and Neonatal Death Society)
Nicola Staton Nathalya Kennedy
Cheryl Titherly
Microbiology
Seema Desai
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COMMONLY USED ABBREVIATIONS • 1/3
A CVS Chorionic villus sampling
AAGBI Association of Anaesthetists of CX Cervix
Great Britain and Ireland CXR Chest X-ray
ABG Arterial blood gases
ACEI Angiotensin-converting enzyme D
inhibitor DAS Difficult Airway Society
AFE Amniotic fluid embolism DFM Diminished fetal movements
AFP Alpha-fetoprotein DIC Disseminated intravascular
ALS Advanced life support coagulation
AN Antenatal DNA Did not attend
ANC Antenatal clinic DoH Department of Health
ANNP Advanced neonatal nurse DVT Deep venous thrombosis
practitioner
APH Antepartum haemorrhage E
ARB Angiotensin II receptor blockers EAS External anal sphincter
ARM Artificial rupture of membranes EBL Estimated blood loss
ECG Electrocardiography
B ECV External cephalic version
BBA Born before arrival EDD Expected date of delivery
BCG Bacilli calmette-guerin EFM Electronic fetal monitoring
BD Twice daily (BIS Die) EGC Emergency gynaecology clinic
BLS Basic life support ELLSCS Elective lower segment
BMI Body mass index caesarean section
BO Bowels opened EMLSCS Emergency lower segment
BP Blood pressure caesarean section
BPM Beats per minute EPU Early pregnancy unit
ERPC Evaluation of retained products
of conception
C
ETT Endotracheal tube
CBD Catheter bag drainage
Ceph Cephalic
F
CESDI Confidential enquiry into
stillbirths and deaths in infancy FBC Full blood count
CMACE Centre for Maternal and Child FBS Fetal blood sampling
Enquiries FHR Fetal heart rate
CEMACH See CMACE FSE Fetal scalp electrode
CMW Community midwife
CPR Cardio-pulmonary resuscitation G
CRP C reactive protein GBS Group B streptococcus
CS Caesarean section GCS Glasgow coma scale
CSU Catheter specimen of urine G Gravida
CVA Cerebrovascular accident GTN Glycerol trinitrate
CVP Central venous pressure GTT Glucose tolerance test
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H M
Hb Haemoglobin MAC Minimum alveolar concentration
HBIG Hepatitis B immunoglobulin MAP Mean arterial pressure
HBV Hepatitis B virus MAU Maternal assessment unit
Hcg Human chorionic gonadotrophin MBC Midwife birth centre
HCV Hepatitis C virus MEOWS See MEWS
HDC High dependency care MEWS Maternity Early Warning Scoring
HDU High dependency unit MgSO4 Magnesium sulphate
HELLP Haemolysis, elevated liver MROP Manual removal of placenta
enzymes and low platelet count MSSU Midstream sample of urine
H/O History of
HVS High vaginal swab N
NAD No abnormality detected
I NEWS Neonatal early warning score
IAP Intrapartum antibiotic prophylaxis NICE National Institute for Health and
IAS Internal anal sphincter Care Excellence
ICS Intra-operative cell salvage NICU Neonatal intensive care unit
NIPE Neonatal and infant physical
INR International normalised ratio
examination
IOL Induction of labour
NLS Neonatal life support
IPPV Intermittent positive pressure NNU Neonatal unit
ventilation
ITP Idiopathic thrombocytopenic O
purpura
OAA Obstetric Anaesthetists’
IUD Intrauterine death Association
IUGR Intrauterine growth restriction OASIS Obstetric anal sphincter injuries
IUT Intrauterine transfer ODP Operating department practitioner
IV Intravenous OGTT Oral glucose tolerance test
IVI Intravenous infusion
P
P Parity
J
PCEA Patient-controlled epidural
JVP Jugular venous pressure
anaesthesia
PE Pulmonary embolism
L
PEA Pulseless electrical activity
LFT Liver function tests
PET Pre-eclamptic toxaemia
LGA Large for gestational age
PIH Pregnancy induced hypertension
LMA Laryngeal mask airway PM Post mortem
LMP Last menstrual period PN Postnatal
LMWH Low molecular weight heparin PPH Postpartum haemorrhage
LSCS Lower segment caesarean PR Per rectum
section
PROM Pre-labour rupture of membranes
LVS Low vaginal swab
PV Per vagina
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Q V
QDS Four times daily VBAC Vaginal birth after caesarean
section
R VE Vaginal examination
RCM Royal College of Midwives VF Ventricular fibrillation
RCOG Royal College of Obstetricians VIP Visual infusion phlebitis
and Gynaecologists VTE Venous thromboembolism
RCT Randomised controlled trial vWD von Willebrand disease
Rh Rhesus
RM Registered midwife
RTC Road traffic collision
S
SAD Supraglottic airway device
SGA Small for gestational age
SNRI Serotonin norepinephrine
reuptake inhibitor
SROM Spontaneous rupture of
membranes
SSRI Selective serotonin
reuptake inhibitor
ST Specialist trainee
SVD Spontaneous vaginal delivery
T
TAP Transversus abdominis plane
TEDS Thromboembolic deterrent
stockings
TENS transcutaneous electrical nerve
stimulation
TIVA Total intravenous anaesthesia
TOP Termination of pregnancy
U
U&E Urea and electrolytes
UKOSS UK Obstetric Surveillance Survey
USS Ultrasound scan
UTI Urinary tract infection
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PREFACE • 1/2
This is the fourth edition of the Obstetric guidelines. It has been compiled as an
aide-memoire for all staff concerned with obstetric management, towards a more
uniform standard of care across the Staffordshire, Shropshire & Black Country and
Southern West Midlands Newborn and Maternity Networks’ hospitals.
The Staffordshire, Shropshire & Black Country and Southern West Midlands
Newborn and Maternity Networks and the Bedside Clinical Guidelines Partnership
have provided the logistical, financial and editorial expertise to produce these
guidelines.
These guidelines have been drafted with reference to published medical
literature and amended after extensive consultation. Wherever possible, the
recommendations made are evidence based. Where no clear evidence has been
identified from published literature the advice given represents a consensus of the
expert authors and their peers and is based on their practical experience.
No guideline will apply to every patient, even where the diagnosis is clear-cut;
there will always be exceptions. These guidelines are not intended as a substitute
for logical thought and must be tempered by clinical judgement in the individual
patient and advice from senior colleagues.
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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PREFACE • 2/2
Treatment
Level Treatment harms Prognosis Diagnosis
benefits
Systematic review of Systematic review of Systematic review Systematic
randomized trials or randomized trials, of inception review of cross
n-of-1 trials systematic review of nested cohort studies sectional studies
case-control studies, n-of-1 with consistently
1 trial with the patient you are applied reference
raising the question about, standard and
or observational study with blinding
dramatic effect
Randomized trial or Individual randomized Inception cohort Individual cross
observational study trial or (exceptionally) studies sectional studies
with dramatic effect observational study with with consistently
2
dramatic effect applied reference
standard and
blinding
Non-randomized Non-randomized Cohort study or Non-consecutive
controlled cohort/ controlled cohort/follow-up control arm of studies, or studies
follow-up study study provided there are randomized trial without
3
sufficient numbers to rule consistently
out a common harm applied reference
standards
Case-series, case- Case-series, case-control, Case-series or Case-control
control studies, or or historically controlled case-control studies, or poor or
4 historically con- studies studies, or poor non-independent
trolled studies quality prognostic reference
cohort study standard
Mechanism-based Mechanism-based n/a Mechanism-based
5
reasoning reasoning reasoning
Excerpt from: OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Oxford
Centre for Evidence-Based Medicine. 2011. http://www.cebm.net/index.aspx?o=5653
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
bedsideclinicalguidelines@uhnm.nhs.uk
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 bedsideclinicalguidelines@uhnm.nhs.uk), 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.
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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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GUIDELINES
These guidelines are advisory, NOT mandatory
ANAEMIA IN PREGNANCY • 1/4
l Vitamin B12 deficiency
INTRODUCTION
l Hb variants
l In normal pregnancy, maternal plasma
l Other causes
volume increases by up to 50%, red
cell mass gradually increases by l exclude chronic illness [e.g. recurrent
approximately 20% and haemoglobin urinary tract infection (UTI), chronic
(Hb) concentration drops. This normal inflammatory bowel disease]
physiological response may resemble l women born outside the UK or with a
iron deficiency anaemia history of foreign travel
l Do not give routine iron and folic l consider less common causes (e.g.
acid supplementation until anaemia chronic infections and parasitic
diagnosed (using pregnant ranges) infections)
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
perioperative morbidity in mother l Nausea
l Amount of iron baby will store during l 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 Women with malabsorption syndrome, l Offer screening to women identified for

haemoglobinopathy, epilepsy haemoglobinopathies (i.e. sickle cell
requiring anticonvulsants and multiple and thalassaemia) following completion
pregnancies are at increased risk of of the Family Origin Questionnaire
folate deficiency (FOQ) at booking
l offer iron and folic acid l Diagnose iron deficiency anaemia if

supplementation mean corpuscular volume (MCV) <80 fl
l Other groups may have an increased l Check serum ferritin, serum iron and
risk based on dietary or cultural factors. total iron binding capacity (TIBC)
Assess on an individual basis saturation. Iron deficiency indicated by:
l ferritin level of <15 micrograms/L
Causes of anaemia in l serum iron level of <12 micromoles/L
pregnancy l TIBC saturation of <15%
l Iron deficiency
l Folic acid deficiency
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l Counsel woman to take oral iron
TREATMENT
supplements correctly
Advice to women with anaemia l on an empty stomach
l 1 hr before meals
Life-style
l with a source of vitamin C (ascorbic
l Avoid alcohol acid) e.g. orange juice/meat
l Stop smoking l avoid taking tablets with tea/eggs/
coffee/milk – may reduce absorption
Dietary advice l other medications/antacids should not
be taken at the same time
l Animal protein – well cooked red meat
(avoid pre-cooked chilled meat, and
Side effects
liver)
l Eggs l Advise woman that iron supplements
may cause:
l Milk
l gastrointestinal upset with nausea and
l Increase vitamin C to aid iron
epigastric pain
absorption (fresh orange juice, citrus
fruits) l Where there is a history of constipation,
use osmotic laxative
l Leafy green vegetables (not
over-cooked)
Monitoring
l If concerns regarding compliance
with dietary advice, give vitamin C as l Check Hb 4 weeks after starting
ascorbic acid 50 mg/day therapy
l an increase of 8 g/L/week is usual
TREATMENT OF IRON irrespective of the route of iron
DEFICIENCY ANAEMIA administration
Aim of treatment
Response to treatment
l Hb should rise by 20 g/L over 3–4
l Check compliance
weeks
l If not tolerant, try alternative
Elemental iron preparations
l If inadequate response (<32 g/L)
l Give up to 100–200 mg elemental iron
using 1 of the following preparations: l check iron studies, B12 and folate
levels and refer to named consultant’s
l ferrous sulphate 200 mg 8–12 hrly antenatal clinic for next available
(contains 65 mg elemental iron per appointment where IV iron therapy will
200 mg tablet) be considered – see Flowchart
l ferrous fumarate tablet 210 mg l In consultation with a haematologist,
8–12-hrly (contains 65–70 mg consider erythropoietin
elemental iron per 210 mg tablet) or
oral solution 10 mL/280 mg 12-hrly
MACROCYTIC ANAEMIA
(contains 90 mg elemental iron per
10 mL/280 mg)
Definition
l sodium feredetate 10 mL 8-hrly
(contains 27.5 mg elemental iron per l Hb value and red cell numbers are
5 mL dose) reduced but MCV is increased
l If these products are not tolerated, l In pregnancy an MCV >96 fl is
seek pharmacy advice regarded as abnormal
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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 B12 deficiency diagnosed, refer to GP
Brie)
or hospital antenatal clinic
l Give vitamin B12 injections
l If both B12 and iron supplementation
(hydroxocobalamin) 1 mg IM 3 times/
required, start B12 treatment first
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
Lifestyle as before in addition to vitamin B12 as
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 B12 and l Normal vitamin B12 l Decreased
folate and folate levels l Decreased
vitamin B12
folate levels
l Low iron levels l Low iron levels levels
Commence l Commence vitamin

Inform obstetric Commence B12 injections IM
intravenous consultant and folic acid
iron as per local refer for l hydroxocobalamin
5 mg daily
policy haematology 1 mg 3 times/week
opinion for 2 weeks, then
3 monthly
l Advise postnatal
follow-up by GP
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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 minor: <50 mL l 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 Inform junior doctor and/or middle l 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 placenta
praevia
MAJOR APH OR ABRUPTION
l examine abdomen for tenderness/ Presenting symptoms
tenseness/location of pain
l Perform vaginal speculum examination, l 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
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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
tasks and nominate a team member to l 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,
Breathing, Circulation l Fetal heart by EFM
l Record vital signs every 5 min (include l 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 fetus 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
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l Central venous pressure (CVP) line/
Caesarean section
arterial line may be inserted by
anaesthetic team to monitor fluid l With significant bleeding, consultant
balance and aid resuscitation obstetrician will deliver by caesarean
l In coagulopathy or massive section or directly supervise a middle
transfusion, seek advice from grade obstetrician (ST3–7 or equivalent
consultant haematologist, who will e.g. staff grade, clinical fellow)
arrange blood and blood products and l Crossmatch 4 units of blood and have
correct clotting factor deficiencies ready in delivery suite blood bank,
preferably before delivery achieved or,
Post-operative/ if available, group-specific blood
post-delivery care l Obtain informed consent
l Transfer woman to delivery suite high l Discuss possibility of hysterectomy
dependency area
l Set up cell saver if used locally
l If ventilation necessary, transfer
to acute Trust ITU – see Maternal Women with a previous caesarean
transfer guideline section and anterior placenta praevia
are at high risk of placenta accreta
PLACENTA PRAEVIA and should be managed by consultant
obstetrician and anaesthetist
Definition
Choice of anaesthesia
l Placenta wholly or partially inserted in
lower segment of uterus l Decided by anaesthetist and
woman – usually spinal but, in
Major or complete haemodynamically unstable woman,
general anaesthesia may be indicated
l Placenta encroaching on cervical
opening (determined by ultrasound Post-operative infusion
scan)
l Commence oxytocin infusion as per
l deliver by caesarean section local practice
Minor or partial PLACENTA ABRUPTION
l Placenta not encroaching on cervical
Definition
opening
l Accidental haemorrhage due to partial
Management of bleeding or complete separation of normally
situated placenta
l Woman to remain on delivery suite
l Bleeding may be concealed or visible
l Crossmatch minimum of 2 units of
blood to delivery suite blood bank Risk factors
urgently
l Trauma
Conservative management l Hypertensive disease or pre-eclampsia
l Administer corticosteroids (if indicated) l Previous abruption
to assist fetal lung maturity l High parity
l In a significant bleed, on-call consultant l Twin gestation
obstetrician will discuss plan of care for
l Polyhydramnios
conservative management or delivery
with mother and document in maternal l Smoking
healthcare record l Prolonged rupture of membranes
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Management
Dependent on severity
of bleed
l If minor APH, midwife will monitor:
l amount of vaginal blood loss
l abdominal tenderness
l pain
l vital signs
l If active bleeding, monitor fetus with
continuous EFM
Conservative management
l Administer corticosteroids (if indicated)
to assist fetal lung maturity
l If bleeding continues, consultant
obstetrician/middle grade obstetrician
(ST3–7 or equivalent e.g. staff grade,
clinical fellow) will consider delivery,
possibly by induction
EXTRAPLACENTAL BLEEDING
l Coagulation defects (e.g. von
Willebrand’s disease), cervical polyps,
cervical ectropion, cervical infection,
cervical carcinoma, ruptured vulval
varices and infection
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BLADDER CARE • 1/4
l document response in medical history
BACKGROUND
section of maternal healthcare record
l Childbirth has the potential to cause l if problem highlighted, refer to
long-term damage to the pelvic floor, appropriate healthcare professional
affecting bladder or bowel function (e.g. physiotherapist, urotherapist or
l Most women have the urge to void consultant obstetrician) for plan of action
≤6 hr postpartum l Ensure MSSU sent to rule out UTI
l 10–15% of women experience voiding l Discuss:
dysfunction to some degree and for
l pelvic floor and urethral sphincter exercise
some time following delivery
l diet to prevent constipation
l 5% have significant and longer lasting
dysfunction
Third trimester antenatal visit
l this may lead to bladder over-distension
and overflow incontinence with long-term l It is good practice to ask again if woman
significant bladder dysfunction has ever experienced problems with
bowel or bladder function. Women are
BLADDER DYSFUNCTION often reluctant to disclose symptoms
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
distends but lack of this sensation l 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 Catheterise Measure and measurements
EITHER VOID
with size 12 record volume required
≥150–200 mL
Foley using of next 2 voids l Document time
sterile single and volume of
use lubricant void
and measure BOTH VOIDS
residual volume <150–200 mL
l If residual
volume
≤150–200 mL,
remove catheter
and review
as per routine
postnatal checks
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
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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
consent l If oxytocin infusion in progress, switch
off
l verbal consent is acceptable in cases
of extreme emergency l 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 Complete WHO checklist
Anaesthetist, theatre team and
midwife
Obstetrician
l Place woman in left lateral tilt on
operating table; commence oxygen l Provides detailed information to woman
and obtains written consent
l Maternal monitoring – BP, ECG,
oximetry l 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
practitioner (ANNP) trained in l 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)
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CARDIOPULMONARY RESUSCITATION OF THE NEWBORN • 1/6
l Check equipment daily, and before
IMMEDIATE TREATMENT
resuscitation
l Follow Resuscitation Council UK Airway
Guidelines www.resus.org.uk
l Keep head in neutral position
DRY AND COVER l Use T-piece and soft round face mask,
extending from nasal bridge to chin
l Cord clamping – see Cord clamping
l Give 5 inflation breaths, sustaining
below
inflation pressure (Table 1) for 2–3 sec
l ≥28 weeks’ gestation, dry baby, for each breath
remove wet towels and cover baby
l Give PEEP of 5 cm H2O
with dry towels
l Begin inflation breaths in air
l <28 weeks’ gestation, do not dry body
but place baby in plastic bag feet first,
Table 1: Inflation pressure (avoid using
dry head only and put on hat
pressure higher than recommended)
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 Recommence cardiac compressions
Ideal hold (Figure 1/Figure 2)
and ventilation breaths ratio 3:1 after
l Circle chest with both hands so that each drug administration and re-assess
thumbs can press on the sternum just after 30 sec
below an imaginary line joining the l If no heart rate increase, progress to
nipples with fingers over baby’s spine next drug
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
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l If inflation breaths have been
WHEN TO STOP
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
paediatrician/2nd 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
H2O via mask ventilation with oxygen
steps in resuscitation
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:
SpO2 (%)
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 SpO2 monitoring is available with l Inform parents what has happened (the
a reliable trace target, saturations as in facts)
Table 3
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2015–17
Newborn
support life support algorithm
algorithm
Dry baby
Birth
Remove wet towels and cover
AT
Start clock or note time
Assess 30
tone, breathing and heart rate sec
ALL
If gasping or not breathing
Open airway 60
Give 5 inflation breaths sec
Consider SpO2 monitoring
STAGES
Re-assess
If no increase in heart rate, look
for chest movement
ASK:
If chest not moving
Re-check head position Acceptable
Consider 2-person airway Pre-ductal SpO2
control and other airway
manoeuvres 2 min 60%
Repeat inflation breaths
3 min 70%
Consider SpO2 monitoring
Look for a response 4 min 80%
5 min 85%
10 min 90%
Noincrease
No increaseininheart
heartrate
rate–
Look for
Look for chest
chest movement
movement
DO
When chest moving
If heart rate not detectable or
slow (<60/min),
start chest compressions
3 compressions to each breath YOU
NEED
Re-assess heart rate
Every 30 sec
If heart rate not detectable or
slow (<60/min), consider
HELP?
venous access and drugs
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CARE OF THE NEWBORN AT DELIVERY • 1/6
l Encourage first breast feed within 1 hr
INTRAPARTUM PREPARATION
and skin-to-skin contact for ≥1 hr
l Identify risk factors that may l Avoid performing routine postnatal
affect immediate care and devise procedures during first hour after
management plan birth unless requested by mother or
l Ensure delivery room warm treatment necessary for wellbeing of
baby
l Check resuscitation equipment
l Identify babies at increased risk of
l Pre-warm towels
hypothermia (<37 weeks or small for
l Summon multidisciplinary team dates) and hypoglycaemia (<37 weeks
members necessary for delivery and or <2.5 kg, infants of diabetic mothers)
inform of risk factors
Registration and identification
IMMEDIATE CARE
l Register and identify baby and mother
At delivery as soon as possible. See Registration
and identification
l If baby does not require immediate
resuscitation, clamp cord after 1 min THERMOREGULATION AND
l if local practice, document time cord is MANAGEMENT
clamped
l If immediate resuscitation is required Baby’s temperature in normal room
following assessment, clamp cord as environment should be 37ºC
soon as possible l Encourage uninterrupted skin-to-skin
l ≥28 weeks’ gestation, dry baby, contact with mother (or partner if
remove wet towels and cover baby appropriate)
with dry towels l document offer and whether accepted
l <28 weeks’ gestation, do not dry body by mother in intrapartum record. If
but place baby in plastic bag feet first, declined or not done, note reasons
dry head only and put on hat l Check baby’s initial axillary
l Assess wellbeing and, if necessary, temperature using digital thermometer
resuscitate – see Cardiopulmonary while cradled by mother/partner
resuscitation of the newborn (ideally 1–2 hr following birth). Record
guideline in intrapartum record
l Assess Apgar score at 1 and 5 min as l If temperature ≥36.4°C, do not recheck
a minimum. Document in intrapartum axilla temperature unless:
record l specific risk factors e.g. small for dates,
l If Apgar score at birth ≤5, continue preterm, maternal pyrexia during
to assess and record every 5 min. labour, group B streptococcus (GBS),
Document any appropriate action taken pre-labour spontaneous rupture of
until score is ≥6 or baby is transferred membranes (PROM) – see Group B
to neonatal care streptococcal disease guideline and
l If baby delivered in poor condition Pre-labour rupture of membranes
or risk factors identified during (PROM) guideline
intrapartum period: l baby unwell
l double clamp cord and take cord l Use digital thermometer and record
blood for paired cord samples – see subsequent temperature checks in
Umbilical cord sampling guideline postnatal record
l inform neonatal team of abnormal
results e.g. pH level <7
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l Keep warm and encourage to feed
Hypothermia
as soon as possible. They will suck
l Although babies are able to maintain well, settle between feeds and
stable body temperature, their ability will not require monitoring – see
to stay warm may be overwhelmed Hypoglycaemia guideline in the
by extremes of environmental Staffordshire, Shropshire & Black
temperatures and influenced by Country Newborn and Maternity
gestational age Network Neonatal guidelines (if used
locally)
l A newborn is more likely to develop
hypothermia because of large surface
area per unit of body weight Symptoms and signs
Close observation by healthcare l Signs of hypoglycaemia may require
providers can often prevent neonatal further investigation including possible
hypothermia admission to neonatal unit
l Blood glucose <2.6 mmol/L and any of
the following symptoms:
Temperature <36.4ºC in an
otherwise well baby l apnoeic/cyanotic episodes
l irritability
l Apply hat to prevent further heat loss
l hypotonia
l Encourage continued skin-to-skin
l poor responsiveness
contact with covering blanket
l seizures
l Initiate early feeding
l Observe for general wellbeing Management
l Recheck temperature ≤1 hr
l See Hypoglycaemia guideline in the
l If temperature remains <36.4°C,
Staffordshire, Shropshire & Black
consider heated cot and further
Country Newborn and Maternity
investigations – follow local protocol
Network Neonatal guidelines (if used
locally)
Temperature ≥38ºC
INITIAL CARE AND FIRST
Temperature ≥38°C is abnormal and
requires urgent attention.
EXAMINATION BY MIDWIFE
Notify neonatal team who will First hour of birth
undertake full assessment, including
physical examination l If baby appears unwell or has
symptoms of hypoglycaemia, attempt
l If baby appears unwell, or not to feed and refer to neonatal team
maintaining own temperature, refer to
l Explain feeding cues to mother and
neonatologist
offer help initiating first feed [see
l If problems identified, continue to Breastfeeding guideline in the
observe baby until resolved. Document Staffordshire, Shropshire & Black
all management in postnatal records, Country Newborn and Maternity Network
including discussions with parents Neonatal guidelines (if used locally)]
l Document first feed in intrapartum
HYPOGLYCAEMIA record, include:
l Unless unwell, babies do not become l feeding method
hypoglycaemic even if feeding is l time feed started
delayed
l duration of feed
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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 Place baby on his/her side or abdomen
Eyes
l Run fingers downwards along spine to
l Open gently exclude spina bifida 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
l Examine perineum to detect sinuses
locally)
If evidence of ambiguous genitalia,
avoid gender assignment before
expert evaluation to avoid
confirmation of wrong sex.
Ask consultant neonatologist to
discuss with parents as soon as
possible.
Always use the term ‘baby’ and avoid
using ‘he’, ‘she’ or, most importantly,
‘it’
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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,

use local hospital number until NHS
IDENTIFICATION
number available)
Registration l if applicable, twin/triplet I/II/III
l Register birth – follow local birth l 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 If wristbands produced by a l 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
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CELL SALVAGE • 1/2
INTRODUCTION Collection
l Has a place in massive haemorrhage l Unless excessive blood loss
to reduce incidence and complications anticipated set up only the collection
of homologous blood transfusions element
l use endorsed by CEMACH, OAA, l processing part to be opened only
AAGBI and NICE when sufficient blood has been
collected
INDICATIONS FOR USE l Use 2-sucker technique to reduce
amniotic fluid contamination
l Placenta praevia/abruption
l in certain circumstances i.e. placenta
l Placenta accreta/percreta
praevia, may be appropriate to
l Classical incision commence cell salvage before delivery
l Maternal bleeding disorders or taking l Use large bore sucker with low vacuum
anticoagulants pressure of 150 mmHg
l Laparotomy following postpartum l in cases of heavy bleeding pressure
haemorrhage (PPH) may need to be increased to
l Women who refuse blood transfusion 300 mmHg
l Emergency situations where there l Gently wash swabs in isotonic sodium
is difficulty with crossmatching – chloride 0.9% in sterile bowl and
antibodies and blood not available process fluid
Discontinue cell saver if
CONTRAINDICATIONS contamination of the field by
l Contamination of surgical field substances not licensed for IV use/
bowel contents
l Malignancy
Do not suck blood from vaginal
l Homogenous sickle cell disease wounds and swabs
Remove obvious meconium
PREREQUISITES
Presence of urine is not a
l Informed consent is required from contraindication
woman before use
l outline procedure and theoretical risks
of amniotic embolism and haemolytic Processing
disease in future pregnancies l Wash collected blood in sodium
l provide information leaflet to woman; if chloride 0.9% and centrifuge
available locally l Label salvaged blood immediately
l may not be possible in emergency l Use within 6 hr of completion of
l Decision to use cell saver should be processing
made by senior clinicians l Use leucocyte depletion filter and
l All persons operating cell salvage standard blood giving set to reinfuse
machine to be trained in its use blood
l Stop transfusion if hypotension occurs
PROCEDURE OF COLLECTION
l For rapid transfusions filter may be
AND PROCESSING removed (at clinician’s discretion) as
l 2 disposable parts a last resort (e.g. women who decline
blood products)
l collection
l processing
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CELL SALVAGE • 2/2
SPECIAL CIRCUMSTANCES
Jehovah’s Witness
l To maintain continuity all parts of circuit
must be primed by sodium chloride
0.9% and attached to a dedicated
cannula
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
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COLLAPSE (Including amniotic fluid embolism) • 1/5
Use this guideline for antenatal and l Ensure arrest team can gain immediate
postnatal collapse access to maternity unit
l Station someone (e.g. healthcare
CAUSES assistant, student etc.) at delivery suite
door, to open door and direct team to
l Haemorrhage – see Antepartum
woman
haemorrhage and Postpartum
haemorrhage guidelines l Collect cardiac arrest trolleys and
defibrillator
l Pulmonary embolus
l Concealed haemorrhage (e.g. broad Woman
ligament haematoma, hepatic rupture)
l Amniotic fluid embolus l Avoid aortocaval compression
>20 weeks’ gestation
l Myocardial infarction
l Manually displace the uterus
l Aortic dissection
l An anaesthetist should protect the
l Peripartum cardiomyopathy airway as soon as possible with a
l Rheumatic mitral stenosis cuffed endotracheal tube
l Sepsis l Do not consider the baby in this
l Intracranial haemorrhage emergency
l Total spinal block (see Epidural l If resuscitative attempts to revive
analgesia guideline) >20 weeks’ gestation woman
have failed after 4 min, perform an
l Local anaesthetic or magnesium
immediate caesarean section to
toxicity
improve the chances of successful
l Hypoglycaemia maternal resuscitation. Do this
l Eclampsia (see Eclampsia guideline wherever the arrest has occurred
and Severe pre-eclampsia guideline) without further preparation as she will
l Anaphylaxis (follow local guideline for need to deliver within minutes, and
anaphylaxis) there will not be time for preparation or
transfer to theatre
CARDIAC OR RESPIRATORY l Caesarean section is of no benefit to
ARREST women <20 weeks’ gestation
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 Obtain arterial blood gases and
Organise
consider arterial line insertion
l Bleep consultant obstetrician, on-call l Check capillary blood glucose
obstetric anaesthetist, junior doctor
l Arrange portable chest X-ray,
and middle grade obstetrician (ST3–7
particularly if oxygen saturation
or equivalent e.g. staff grade, clinical
reduced or central venous catheter
fellow) – follow local practice
inserted owing to risk of pneumothorax
l Summon as many staff as possible and
l 12-lead ECG – particularly important if
allocate specific tasks, e.g:
any form of cardiac disease suspected
l taking observations
l ECG must be reviewed by a doctor
l recording events and their competent in ECG interpretation
management, with times
l communication History and examination
l runner for samples and equipment l Obtain history from those present
l support for family before collapse occurred
l Examine woman to try to identify most
Observations likely cause of collapse
l Commence HDU chart and observe:
IV access and fluids
l pulse
l blood pressure – at least every 15 min l Commence IV fluids
l respiratory rate l Unless cardiopulmonary function is
rapidly restored, consider a central
l pulse oximetry
venous catheter
l If possible, transfer woman to room
where HDU care can be provided
Investigations
l Insert ≥1 large IV cannula
l Take blood for:
l FBC
l clotting studies including fibrin
degradation products
l crossmatch 2 units of blood
l blood cultures
l U&Es and glucose
l LFTs
l Troponin T or Troponin I [(whichever is
used locally) (a marker for myocardial
infarction)]
It is the responsibility of person
obtaining sample to complete
blood bottles and forms
Send bloods urgently to laboratory
with healthcare assistant or porter
Phone laboratory to request
results urgently
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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)
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TREATMENT
As above, plus:
l If necessary, deliver immediately –
ideally vaginally. If not possible, by
caesarean section under general
anaesthetic
l Insert second large bore (16 G) IV
cannula and prepare to manage
massive obstetric haemorrhage (see
Postpartum haemorrhage guideline)
l Consider early insertion of central
venous catheter and arterial line
l Discuss need for blood products
(including fresh frozen plasma
to correct DIC) with consultant
haematologist, without waiting for
blood results
l Woman will require circulatory support,
which can include inotropes, with
invasive monitoring
l Transfer to critical care unit
l Report all cases of suspected or
proven amniotic fluid embolism,
whether fatal or not to National
amniotic fluid embolism register via
UKOSS (UK obstetric surveillance
system)
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Collapse 201719

MaternalMaternal
collapsecollapse 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
arrest treatment
Immediately resume Immediately resume
CPR for 2 min • Use ABCDE approach CPR for 2 min
Minimise interruptions • Controlled oxygenation Minimise interruptions
and ventilation
• 12-lead ECG
• Treat precipitating cause
During CPR: • Temperature Reversible causes:
• Ensure high-quality CPR: rate, control/therapeutic • Hypoxia
depth, recoil hypothermia • Hypovolaemia
• Plan actions before interrupting • Hypo-
CPR /hyperkalaemia/metabolic
• Give oxygen • Hypothermia
• Consider advanced airway and • Thrombosis – coronary or
capnography pulmonary
• Continuous chest compressions • Tamponade – cardiac
when advanced airway in place • Toxins
• Vascular access (intravenous, • Tension pneumothorax
intraosseous)
• Give adrenaline every 3–5 min
• Correct reversible causes
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DELAY IN LABOUR • 1/2
See also:
Before commencing oxytocin,
l Labour management guideline middle grade obstetrician (ST3–7 or
l Latent phase of labour guideline equivalent e.g. staff grade, clinical
fellow) must review parous woman.
DELAY IN FIRST STAGE If previous caesarean section,
discuss use of oxytocin with
l Cervical dilatation <2 cm in 4 hr in first obstetric consultant.
labours Perform at least an abdominal
l Cervical dilatation <2 cm in 4 hr, palpation
or slowing in progress of labour for Repeat vaginal examination may also
second or subsequent labours be appropriate
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
has dilated <1 cm l 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
by vaginal examination 2 hr after l 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
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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
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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
protein metabolism resulting from defects l 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 Defined as carbohydrate intolerance l 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 Miscarriage 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
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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 Anomaly scan (including 4 chamber view of fetal heart
and outflow tracts and 3 vessel view of heart)
24 weeks l Routine antenatal care
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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
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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
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DIABETES – LABOUR • 1/3
PREPARATION PRETERM LABOUR

l Discuss with woman l Pulmonary maturation delayed in
fetuses 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
umbilical artery doppier l 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
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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
pre-operative management l 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
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DIABETES – SCREENING FOR GESTATIONAL DIABETES • 1/1
INTRODUCTION
Optimisation of glycaemic control and advice on preparation for pregnancy have been
shown to improve pregnancy outcomes in type 1 and 2 women
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
trimester), and further 75 g 2-hr OGTT l 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
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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
oligohydramnios, 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
clinical fellow)
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l If symphysis fundal height reduced for
Second episode DFM
dates, arrange growth scan (unless
performed in previous 2 weeks) l EFM trace, ideally computerised (if
l If adequate EFM trace cannot be available)
obtained despite midwife sitting with l EFM trace normal:
woman, seek middle grade obstetrician l reassure, allow home and advise to
(ST3–7 or equivalent e.g. staff grade, return again if concerned about fetal
clinical fellow) opinion movements and expect to be contacted
for growth scan
>28 weeks’ gestation l arrange growth scan (unless performed
in previous 2 weeks), liquor volume
First episode DFM and umbilical artery Doppler
l EFM trace, ideally computerised (if l >28 weeks’ gestation, women with
available) second episode of DFM within 1 month
l Assess symphysis fundal height of first DFM:
l refer to their consultant’s next antenatal
l if symphysis fundal height reduced for
clinic
dates, arrange growth scan (unless
performed in previous 2 weeks) l EFM trace non-reassuring or
abnormal:
l EFM trace normal with fetal
movement felt and no risk factors l inform middle grade obstetrician
(see Risk factors below) for fetal (ST3–7 or equivalent e.g. staff grade,
growth restriction (FGR)/stillbirth clinical fellow) urgently
identified: l FBC and group and save
l reassure, allow home and advise to l consider cannulation
return again if concerned about fetal l transfer to delivery suite
movements
l EFM trace normal with persistent Risk factors
DFM and/or risk factor (see Risk
l Known FGR
factors below) for FGR/stillbirth
identified: l Hypertension
l reassure, allow home and advise to l Diabetes
return again if concerned about fetal l Extremes of maternal age
movements and expect to be contacted l Primiparity
for growth scan l Smoking
l arrange growth scan (unless performed l Placental insufficiency
in previous 2 weeks)
l Congenital malformation
l manage any abnormalities found l Obesity
l EFM trace non-reassuring or l Racial/ethnic factors
abnormal:
l Poor past obstetric history (e.g. FGR
l inform middle grade obstetrician and stillbirth)
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
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
e.g. staff grade, clinical fellow) or
consultant competent to use portable
labour ward ultrasound machine
l If scan identifies fetal death (second
trained operator to confirm this),
inform on-call consultant obstetrician.
It is unlikely that woman will need
immediate delivery – see Perinatal
bereavement guideline
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ECLAMPSIA • 1/1
Eclamptic seizures are often self-limiting. l If repeated seizures not responding
See also – Severe pre-eclampsia to magnesium sulphate, consultant
guideline obstetrician and anaesthetist decide
on use of diazepam 5–10 mg or
RESUSCITATION AND
thiopentone, together with intubation
STABILISATION and transfer to intensive care
l Airway, Breathing, Circulation and l consider CT scan to exclude other
lateral tilt causes
l Do not leave woman alone. Call for l Blood pressure control – see Severe
help from senior midwife, middle grade pre-eclampsia guideline
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 Magnesium sulphate is treatment of l 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
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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 no decelerations
Fetal
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 Set minimum duration of monitoring at
practice)
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)
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 While an abnormal 60 min STV is a
Dawes-Redman criteria not met
significant risk indicator, a normal STV
l If insufficient evidence of normality does not necessarily mean there is no
Dawes-Redman criteria will not be met risk of mortality or morbidity
l Continue CTG monitoring for 60 min l Consider gestational age, recording
duration and clinical indication
l at 60 min discontinue CTG; reason for
not meeting criteria may be on CTG l Normality is determined by a number
printout of Dawes-Redman criteria, with the
minimum duration of trace set at
l Woman to be reviewed by middle
10 min
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
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
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ELECTRONIC FETAL MONITORING (EFM) – LABOUR • 1/6
l Abnormal FHR on auscultation:
AIM
l baseline abnormality <110 bpm >160
Recognition and prevention of potential bpm, decelerations after a contraction
fetal acidosis in labour
l Postmaturity (>42+0 weeks’ gestation)
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
l Temperature ≥38°C on a single reading
Intrapartum
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)
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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.
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 Variable decelerations with any l Absence of
accelerations
concerning characteristics in >50%
of contractions for <30 min or on an
otherwise
l Late decelerations in >50% of normal
contractions for <30 min with no CTG trace
maternal or fetal clinical risk factors does not
(e.g. vaginal bleeding or significant indicate
meconium) fetal
Abnormal l <100 l <5 for l Variable decelerations with any acidosis
or >50 min concerning characteristics in >50%
l >180 or of contractions for 30 min or
l >25 for l Late decelerations for 30 min
>25 min l Act sooner than 30 min if any
or maternal/fetal clinical risk factors
l Sinusoidal (e.g. vaginal bleeding/significant
meconium) or
l Acute bradycardia, or single
prolonged deceleration lasting ≥3 min
l how long they have been present for

ACCELERATIONS
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
decelerates with a contraction l 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
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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
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 Make preparations for urgent birth
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
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EPIDURAL ANALGESIA • 1/6
l Raised intracranial pressure
INTRODUCTION
l Inadequately trained or competency
Epidural analgesia is the most effective assessed staff
method of pain relief in labour. If epidural
analgesia is available on a 24 hr basis, Anticoagulant therapy
time from informing anaesthetist until he/
she is able to attend should ideally not l Do not insert epidural:
exceed 30 min. Discuss the following l for ≥12 hr after last prophylactic dose
risks and benefits with the mother: l for ≥24 hr after last therapeutic dose
l Reduced neonatal respiratory
depression (repeat doses of IM opioids) Relative
l Improved uteroplacental blood flow in Discuss with consultant
the compromised fetus
obstetric anaesthetist
l Assists with controlled birth (e.g.
breech or multiple pregnancy) l Neurological disorders (spinal bifida
occulta)
l Can be used as regional anaesthesia if
required l Significant cardiac disease
l Anatomical deformity or back surgery
If delay anticipated l Haemorrhage, hypovolaemia
l Review necessity of epidural: purely PREPARATION
analgesic or medical indication
l If only for analgesia, midwife to Patient
discuss alternative form of pain relief
(remifentanil PCA) with the woman until l Explain technique, and risks and benefits
epidural service is available l Provide information leaflet if available
locally
l Document ‘exceptional circumstances’,
cause of delay and discussion with l Obtain and document verbal consent
woman in maternal healthcare record. l Obtain IV access
Involve on-call consultant anaesthetist
in the discussion Investigations
l In pre-eclamptic women, check FBC. If
INDICATIONS
platelet count <100,000 – APPT, INR
l Maternal request l Intra-uterine death >1 week: detailed
l Obstetric indications (e.g. coagulation profile, including D-dimer
pre-eclampsia, breech, multiple and fibrinogen levels
pregnancies, prolonged labour) l In septic woman: FBC and CRP
l Medical indication (CVS and respiratory
diseases, etc.) Equipment
l Morbid obesity l Oxygen and suction available
l Epidural trolley with:
CONTRAINDICATIONS
l epidural pack (16 G/18 G Tuohy
needle) or 19 G/23 G catheter
Absolute
l yellow epidural infusion lines labelled
l Patient refusal with yellow label from pack
l Local or systemic sepsis l sterile gown, gloves, hat and mask
l Known hypersensitivity to local l chlorhexidine skin preparation 0.5%
anaesthetic drugs l Use specific epidural pumps with
l Coagulopathy – see Investigations locking ability
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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
or consider alternative analgesia e.g. l 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
3. Bolus administration PRN l Do not give PCEA handset to
woman until 30 min after infusion
commenced
Drug used for all 3 procedures
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
of fetal status is made l 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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EPIDURAL ANAESTHESIA • 4/6
HIGH CONCENTRATION l adequate return of motor power to

legs and document – if not, contact
TOP-UPS
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
excessive force – catheter should come l 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 Provide information leaflet (if available
Pruritus
locally)
l If of sufficient severity to warrant l Ensure details recorded in audit book
treatment, administer one dose of or according to local practice
naloxone 40 microgram IV
l Offer postnatal anaesthetic clinic
l Alternatively, consider chlorpheniramine appointment if available locally
(Piriton®) 4 mg oral or 10 mg IM
l Notify GP
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

adequate circulation restored or
anaesthesia
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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EPISIOTOMY • 1/2
DEFINITION PROCEDURE
A surgical incision of the perineum to This procedure must only be
increase the diameter of the vulval outlet performed by appropriately trained
during childbirth to facilitate delivery but practitioners or under direct
minimise harm to mother and baby supervision of a mentor
Perform mediolateral episiotomy only
Mediolateral episiotomy
l Cut starts at centre of the vaginal
fourchette and directed to the right side
at an angle of 60° to the vertical axis
(see diagram below) Centre of
fourchette
INDICATIONS
The list below is not exhaustive – use
clinical judgement on an individual basis
l Fetal distress Position and preparation of
l Maternal reason to expedite delivery woman
(e.g. pre-eclampsia/eclampsia)
l Place in comfortable legs-open position
l Rigid perineum preventing delivery l Cleanse perineal area using aseptic
l Instrumental delivery (particularly technique
forceps) l Place index and middle fingers into vagina
l Occipitoposterior position (OP) between presenting part and perineum
l Shoulder dystocia l Insert needle fully into perineal tissue
l Breech presentation starting at centre of fourchette and
direct it midway between ischial
tuberosity and anus (protect fetal head)
Equipment
l Draw back plunger of syringe before
l Sterile or tap water to clean area before injecting 5–10 mL lidocaine 1% slowly
procedure as needle is withdrawn
l 1 x 10 mL syringe
Episiotomy incision
l 1 x 22 gauge (green) infiltration needle
l 10 mL lidocaine 1% l Insert middle and index fingers into
vagina and gently pull perineum away
l Mayo episiotomy scissors from fetal part to protect fetal head
l Perform incision when presenting part
Consent has distended perineum
l Reassure woman and partner l Insert open scissors between 2 fingers
l Explain procedure and indications and make incision in 1 single straight
cut to minimise damage and allow/
l Obtain and record consent facilitate optimal realignment
l begin at the centre of the fourchette
and extend 4 cm in a right mediolateral
direction midway between the ischial
tuberosity and anus, ideally at a 60°
angle to vertical axis
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EPISIOTOMY • 2/2
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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EXTREME PREMATURITY (<28 WEEKS’ GESTATION) • 1/5
INTRODUCTION
l Management of babies born at the threshold of viability presents some of the most
testing ethical and clinical problems
l If it seems likely that delivery will occur at an extremely premature gestation, there
may be a variable amount of time to counsel and prepare woman and partner for the
outcome
l Unless circumstances dictate otherwise, senior staff should always be involved
l Document all information given to parents in the maternal healthcare record
Table 1
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
28 weeks Yes Yes Yes Indicated Advise CS

Parents visit for fetal
* 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 as a minimum, a middle grade
OBSTETRIC RESPONSIBILITIES
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
steroids have been given
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
obstetrician (ST3–7 or equivalent e.g. l 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
doctor prints his/her name after the
PARENTS
signature and records their GMC
l Dependent upon labour timescales number
etc., a second counselling session may l If it is not possible for a doctor to see
be useful baby before he/she dies, document
l Following discussion, parents should be this clearly in the healthcare record.
aware of the options, their risks, benefits Doctor should see baby as soon as
and the implications of alternatives possible after death
l Reinforce verbal information by l In some areas, all deaths must be
providing printed leaflets (if available). discussed with the coroner’s office.
Give details of support services Check your local coroner’s requirements
available e.g. bereavement counselling before issuing death certificate and
and BLISS information (http://www. requesting post mortem consent
bliss.org.uk/shop)
l When talking to parents, survival Definition of signs of life
outcomes may need to be modified
l It is extremely important to distinguish
in light of clinical information available
between involuntary, physiological
see Table 3
movements and signs of life
l The RCOG states that ‘conveying
l A live birth is delivery of a baby,
the concept that fetal death is not
regardless of duration of pregnancy,
the worst outcome, and that severe
which, after delivery, breathes or
neonatal morbidity and maternal and
shows any other evidence of life, such
fertility morbidity are also important
as beating of the heart, pulsation
considerations to the woman and
of umbilical cord, or any definite
her partner, must be conducted with
movement of voluntary muscles,
kindness and sensitivity’
whether or not umbilical cord has been
l Doctor counselling parents should not cut or placenta delivered
impose his/her cultural or religious
l observed movement, such as a jerk of a
convictions on those whose beliefs
limb or occasional gasp, are involuntary,
may differ. When a doctor’s beliefs
physiological movements and not
prevent the disclosure of all available
necessarily signs of life or viability
management options, he/she has a
duty to refer woman to a colleague l in these circumstances, explanations
should be given to parents by a senior
l If there is a difference of opinion between
member of staff and registration as a
clinical staff and parents regarding
neonatal death is not necessary
management, seek second opinion
l Where signs of life are evident at
CERTIFYING NEONATAL DEATH birth, inform parents that their baby
may continue to show such signs
l Baby must be seen by a doctor while for minutes or even hours following
alive (if possible). This does not have to delivery and reassure them that baby
be a neonatologist will be treated with respect and dignity
l Doctor who saw baby before death l Give parents the opportunity to keep
issues a medical certificate certifying baby with them until he/she dies
death. The certificate must always be l Baby must then be registered as a
issued even if baby lived for only a few neonatal death
minutes
l Once a baby is born alive he/she
l Neonatal death certificates can only be acquires the same legal status as any
issued by a doctor. Midwives do not other human being and is owed a duty
certify neonatal deaths of care
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FETAL ABNORMALITY – ANTENATAL DETECTION • 1/2
l If woman does not wish to be informed
INTRODUCTION
of any fetal abnormalities, give her the
l Prenatal screening for fetal opportunity to decline anomaly scanning
abnormalities using second trimester but to have a scan to determine placental
ultrasound scan and maternal serum site and fetal growth
screening is offered routinely in the UK
l Routine second trimester ultrasound ABNORMALITY DETECTED
scans increase detection rate for fetal l Sonographer performing ultrasound
abnormalities compared to scans examination must report findings to
offered on a selective basis only woman and document the discussion
l Abnormalities may be detected on l Inform woman and her partner in
an ultrasound scan at any stage of descriptive but not diagnostic terms
pregnancy
l sensitivity of detection is determined If there is doubt about a diagnosis
by severity and type of abnormality. or a scan feature, refer woman to
More severe abnormalities and those appropriate expert, giving reason for
developing earlier have a higher referral
detection rate
l false positive rates from ultrasound Referral
scanning are <1%
l Within 1 working day, refer to consultant
SECOND TRIMESTER obstetrician with fetal medicine expertise
ANOMALY SCANNING l Fetal medicine consultant will re-scan
within 5 days and explain findings to
l To identify fetal conditions associated woman and her partner
with high morbidity and long-term
disability l it may be necessary to repeat
information. Written information and
l Performed between 18–23 weeks’ diagrams can be helpful
gestation
l When major fetal abnormalities are
Ultrasound imaging must only be identified, give parents the Antenatal
performed by person fully trained Results and Choices (ARC) booklet (if
in its use and qualified in detection used locally)
of fetal abnormality using this l It may be appropriate for consultant
technique with expertise in fetal medicine to offer
fetal karyotyping by amniocentesis or
Before scan chorionic villus sampling
l Refer confirmed fetal abnormalities in
l Ensure ultrasound equipment is of ongoing pregnancies to neonatologist
appropriate standard and in working
order l Feticide is recommended for termination
of pregnancy >22 weeks’ gestation,
l Check woman’s identity which is associated with increased
l Inform woman of nature and purpose difficulty in managing a woman who
of the screening proposed and discuss elects termination later than this stage
the limitations of ultrasound scanning l More complex cases may benefit
in detecting fetal abnormality i.e. from referral to a tertiary centre e.g. to
sensitivity of detection is only 76% even obtain access for magnetic resonance
for life-threatening abnormalities (MR) imaging or to receive antenatal
l Treat woman sympathetically and counselling from neonatal surgeon
address anxieties or concerns l Complete notification to the regional
congenital anomaly register
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FETAL ABNORMALITY - ANTENATAL DETECTION • 2/2
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
nuchal scan 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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FETAL BLOOD SAMPLING • 1/4
BACKGROUND CONTRAINDICATIONS
l Fetal blood sample (FBS) is a sample Absolute
of blood taken using aseptic technique
from the presenting part of the fetus l Acute fetal compromise (e.g. prolonged
in-utero deceleration): FBS should not be
undertaken and baby delivered urgently
l Fetal pH can identify fetal hypoxemia
and acidosis l Maternal infection e.g. HIV [viral load
>50 copies/mL not taking highly active
l when the fetus is hypoxemic, antiretroviral therapy (HAART)], hepatitis
metabolism changes from aerobic to viruses or herpes simplex virus. FBS
anaerobic, producing lactic acid and increases risk of transmission to baby
a subsequent drop in pH, providing a
l Group B streptococcus carrier status
measure of the degree of hypoxaemia
does not preclude FBS
l Electronic fetal monitoring (EFM) l Fetal bleeding disorders e.g. haemophilia
without supporting FBS in suspected
fetal distress in labour is associated l Prematurity (<34 weeks’ gestation)
with significant increase in caesarean l Face presentation
delivery, with no apparent improvement
in neonatal outcome (see Electronic Cautions with maternal
fetal monitoring guideline) bleeding disorders
l Sampling acceptable:
INDICATIONS
l type 1 von Willebrand disease (vWD)
l Consider fetal pH: l idiopathic thrombocytopenic purpura
(ITP) – providing previous children did
l with abnormal EFM, FBS can be helpful
not have low platelet count immediately
in planning further management and
following birth
can be performed in first and second
stage of labour l If vWD or ITP in first pregnancy/previous
children born with thrombocytopenia,
l if CTG is classified as abnormal, but do not undertake FBS without
urgent intervention is not required, discussion with consultant obstetrician
confirmation of fetal wellbeing to be and consultant haematologist
obtained through FBS where possible,
along with conservative measures (see
Relative
below)
l Gestation 34–36+6 weeks
Do not undertake FBS where there
is clear evidence of acute fetal l Maternal pyrexia >38°C
compromise. Make preparations for l Suspected/confirmed intrauterine sepsis
urgent birth l Discuss with consultant obstetrician
Assess and manage each woman
individually and, where there is FBS NOT POSSIBLE
cause for concern, seek advice from
on-call consultant obstetrician l If FBS necessary but cannot be
obtained due to technical difficulties or
l Take 2 samples, to ensure reliability of contraindications consider delivery –
result. Remember an FBS only reflects discuss with consultant obstetrician
the condition of the fetus at the time of l Urgency to deliver should take into
sampling account:
l severity of CTG abnormality
l relevant maternal factors
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l Avoid leaving woman alone while
PREPARATION
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 (pH value)
l Delay in processing (pH 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 Repeat FBS l Repeat FBS l Inform consultant
accelerations,
≤1 hr if trace ≤30 min if and plan to
decision should be
remains trace remains expedite delivery
made to continue with
abnormal/ abnormal (assisted
labour or expedite
non-reassuring, (if urgent delivery/CS)
delivery in light of all
or sooner if intervention not clinical circumstances
additional required)
non-reassuring/ l If NO improvement
l Action: in CTG trace, birth
abnormal conservative
features should be expedited
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
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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 Sodium citrate: 30 mL of 0.3 M sodium
Pre-induction planning and
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:
l provide counselling for woman
Intrauterine resuscitation for
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
pressure) l Range of endotracheal tubes (ETT)
l awake extubation l 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 Use atracurium or rocuronium after
INDUCTION
suxamethonium wears off
l Keep noise to minimum during induction l Maintain anaesthesia with oxygen and
l Establish full monitoring air or oxygen and nitrous oxide (usually
l pulse oximeter 50% N2O pre- and 67% post-delivery),
with an inhalational agent (isoflurane/
l non-invasive BP
sevoflurane) to keep a MAC of ≥1
l ECG
l Remember the possibility of patient
l capnography and airway gas monitoring
awareness at all times
l airway pressure
l Confirm sodium citrate and ranitidine AFTER DELIVERY
have been given, if not, consider
ranitidine 50 mg IV slowly after induction l After cord clamped, give opioid – e.g.
fentanyl 100 microgram and morphine
l Establish free-running IV infusion with a
10 mg. Alternatively, if epidural in situ,
16 G (or larger) cannula
top-up with local anaesthetic and
l Position woman supine on table with a epidural opioid
20–30° head up and 15° left lateral tilt
l At end of surgery, and if not
l In morbidly obese use ramped up
contraindicated, give 100 mg
position – align external auditory
diclofenac rectally
meatus with supra-sternal notch
l Perform TAP blocks at the end of
l Remove oral piercings and hair bands
surgery for post-operative pain relief
l Give appropriate antibiotics –
l Extubate woman awake in left lateral
according to local practice
position in theatre
Pre-oxygenation l Obese women may benefit from
waking up in upright position
l Consider attaching nasal cannulae
5 L/min before pre-oxygenation Transfer to recovery room
l Pre-oxygenate for 3 min with 100%
l Transfer to recovery room for ≥30 min
oxygen >10 L/min via close-fitting face
mask l See Recovery guideline
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
• Inform GP and woman in writing
GENERAL ANAESTHESIA AND FAILED INTUBATION •
• In complex cases offer anaesthetic outpatient appointment
4/4
Flowchart: Failed
Flowchart: failed intubation
intubation algorithmalgorithm
Pre-induction preparation
Algorithm 1 Rapid sequence induction

Safe GA
Success
Laryngoscopy Successful intubation
(max 2 attempts, 3rd by Proceed
senior only)
Fail
Success
Algorithm 2 Declare failed intubation Is it essential to proceed
Can’t Call for help with surgery?
intubate Maintain oxygenation
Can ventilate Supraglottic device
(2 attempts only) NO YES
Success
Wake Proceed
with
surgery
Declare can’t intubate can’t
Algorithm 3 ventilate
Can’t intubate Give 100% oxygen
Can’t ventilate Exclude laryngospasm
Ensure neuromuscular
blockage
Front of neck access
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GENITAL HERPES • 1/2
Neonatal herpes is a rare (1.65/10,000
Antiretroviral therapy
in the UK) but serious disease with a
significant mortality l Women with a history of recurrent
herpes may reduce the risk of active
Causes lesions at time of delivery by taking
oral aciclovir for the last 4 weeks of
Herpes simplex virus type 1 (HSV-1) or pregnancy. Refer them to GUM for
herpes simplex virus type 2 (HSV-2) further discussion
l If woman develops primary infection
Transmission before or earlier in pregnancy,
Transmission of virus from mother to prophylactic oral aciclovir is not
fetus occurs mostly by direct contact recommended in the last 4 weeks of
with virus in the genital tract during birth, pregnancy
although cases of transplacental infection
and postnatal transmission have been DELIVERY
reported
Mode of delivery
Maternal infection l If woman develops her first episode of
May be primary or recurrent active herpes >28 weeks’ gestation or
≤6 weeks of the onset of labour, offer
delivery by caesarean section (CS)
Primary infection
l If an attack occurs in the third trimester
l Risks are greatest in the third trimester, that is thought to be primary, send
particularly ≤6 weeks of delivery, swab and blood for HSV antibodies
as viral shedding may persist and
l if the virus types on swab and blood
baby is likely to be born before the
match the attack is recurrent – advise
development of protective maternal
against CS
antibodies
l There is no indication to deliver a
Recurrent infection woman by CS because of a history of
genital herpes before pregnancy or
l Is associated with a very low risk of earlier in pregnancy
neonatal herpes l Advise women with active recurrent
l Recurrent herpes at the time of delivery herpes lesions at the onset of labour
causes localised forms of neonatal that the risk of neonatal herpes is
herpes only very small and that CS is not routinely
recommended
ANTENATAL DIAGNOSIS AND
MANAGEMENT Care in labour
l Refer women who present with lesions Primary infection
that are thought to be herpes to
genitourinary medicine (GUM). Make it l If woman refuses delivery by CS,
clear the woman is pregnant avoid fetal scalp electrodes, fetal
l GUM clinic will arrange screening for blood sampling and, where possible,
other sexually transmitted infections instrumental delivery to minimise risk of
vertical transmission
l Active herpes is painful and analgesia
with lidocaine 2% gel may be required l Inform neonatologists during labour
l Ask directly whether woman can pass l Give aciclovir, 5 mg/kg (350 mg for a
urine. It is not unusual for an indwelling 70 kg woman) IV 8-hrly over 60 min
catheter to be required
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GENITAL HERPES • 2/2
l Give woman aciclovir 5 mg/kg IV 8-hrly
Recurrent infection
over 60 min
l Women with active recurrent genital l If woman has recurrent genital herpes
herpes and confirmed rupture of and has preterm pre-labour rupture of
membranes – augment labour as soon membranes <34 weeks, give aciclovir
as possible 400 mg oral 8-hrly
l In women with active recurrent
genital herpes, avoid invasive Care of neonate
procedures during labour and inform
neonatologists l Encourage breastfeeding unless
woman has herpetic lesions around
nipple
Preterm labour
l Advise woman and family about good
l If woman has primary genital herpes hand hygiene
and delivery is induced, deliver by CS
l Those with oral herpetic lesions (cold
l If managing conservatively give sores) should not kiss neonate
betamethasone for neonatal lung
function
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
delivery Baby l Inform neonatologist
Baby well
unwell l Normal postnatal care
l Discharge home if
l Normal postnatal care baby well at 24 hr
Start Perform
l Discharge home if aciclovir l Advise parents
lumbar
baby well at 24 hr 20 mg/kg regarding later
puncture
l Advise parents 8-hrly for management if any
for HSV
regarding later 10 days concerns
PCR
management if any while
concerns awaiting
results
Issue 4
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GROUP B STREPTOCOCCAL DISEASE • 1/2
l Antenatal antibiotics are not
BACKGROUND
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
neonates
Indications for intrapartum
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
Issue 4
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GROUP B STREPTOCOCCAL DISEASE • 2/2
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,
which will also cover Group B l 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
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HEPATITIS • 1/3
l Hepatitis B infection is not an indication
HEPATITIS B
for CS as there is insufficient evidence
Introduction that it reduces mother-to-child
transmission
Hepatitis B is a blood borne viral infection l If unbooked or untested woman accepts
affecting the liver. It is caused by the testing, send sample for antenatal
hepatitis B virus (HBV) transferred in screening to microbiology urgently
blood or body fluid (notify microbiologist on duty/on-call
via switchboard) to allow immunisation
Principles of isolation within 24 hr of delivery if required
l Body fluids are regarded as infectious l If woman requires in-utero transfer,
material. Take appropriate infection immunoglobulin (if indicated) must
control precautions in line with local accompany her
Trust policy
Postnatal care
Antenatal care l For all newborns, check antenatal
l As part of antenatal care, provide screening results for mother’s tests
all women with information on, and l If antenatal testing not done (e.g.
access to, HBV screening concealed pregnancy) request urgent
l If mother positive for HBV: maternal hepatitis B virus surface
antigen (HBsAg) test and other
l review in consultant-led antenatal clinic, infection screening bloods (HIV and
where an individualised management syphilis) – see HIV positive women
plan will be drawn up guideline
l alert neonatal team and inform l Wash baby immediately following birth
Public Health team and GP of plan to and cleanse oropharynx and nasal
immunise cavities of all visible maternal blood
l Arrange for prophylaxis and secretions by gentle wiping
l for multiple pregnancy arrange dose l Encourage and support breastfeeding
for each baby (unless mother also HIV +ve) but do
l Refer women with HBV infection to not allow mother to donate milk as the
a consultant with expertise in liver virus has been detected in breast milk
disease for further assessment l Inform postnatal ward baby will require
immunisation
Communication
IMMEDIATE POSTNATAL
l Give mother information about
TREATMENT OF BABY
hepatitis B, modes of transmission and
prevention of spread Immunisation
l Obtain parental consent for
immunisation l Some babies require hepatitis B
immunoglobulin (HBIG) as well as
immunisation
Intrapartum care
l Order immunoglobulin [HBIG
l When an HBsAg positive mother antenatally if required (see Table)],
arrives in labour or for CS, inform depending on mother’s antigen status
on-call neonatal team l Immunise baby of HBsAg positive
l Avoid fetal scalp sampling and fetal mother as follows, depending on other
scalp electrodes hepatitis B markers in mother during
pregnancy:
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HEPATITIS • 2/3
Vaccine Immunoglobulin
Maternal status required by (HBIG)
baby required by baby
HBsAg positive, HBeAg positive Y Y
HBsAg positive, HBeAg negative, Y Y
HBe antibody (anti-HBe) negative
HBsAg positive where e markers have not Y Y
been determined
Acute hepatitis B during pregnancy Y Y
HBsAg positive and baby <1.5 kg Y Y
HBsAg positive, anti-HBe negative Y N
HBsAg positive and >106 iu/mL Hepatitis B Y Y
DNA in antenatal sample
Other high risk group (e.g. HIV) Y N
l Give low birth weight and premature l HBIG 200 units additionally IM in
babies full neonatal dose of hepatitis B opposite thigh to that of the hepatitis
vaccine B vaccine soon after birth and no later
l Give HBIG and hepatitis B vaccine to than 24 hr simultaneously with vaccine
babies with birth weight <1.5 kg born to babies of highly infectious mothers
to mother with hepatitis B, regardless (see Table above)
of mother’s HBeAg status l 3 further doses of hepatitis B vaccine
will be given according to local policy
l obtain HBIG from regional virus
at aged 1 month, 2 months and 1 yr
laboratory service or local microbiology
as applicable How
l Give hepatitis B vaccine to HIV
l Use 2 separate injection sites for hepatitis
exposed/infected neonates
B vaccine and HBIG, in anterolateral
aspect of the thighs (not buttocks)
When
l Give hepatitis B vaccine IM, except
l Give first immunisation +/- HBIG within in bleeding disorder where it may be
24 hr of delivery on postnatal ward. given deep subcutaneously
Check that arrangements are in place Dose regimen for infants of
for further immunisations and follow-up
mothers with hepatitis B
to be provided in the community or
by paediatrician – see Hepatitis B l Vaccine is given at 0, 1, 2 and 12 months
and C guideline in the Staffordshire, l Book hospital outpatient appointment
Shropshire & Black Country Newborn for 12 months for testing for HBsAg
and Maternity Network Neonatal l see the Staffordshire, Shropshire &
guidelines (if used locally) Black Country Newborn and Maternity
Network Neonatal Hepatitis B and C
What guideline (if used locally)
l Hepatitis B vaccine, 0.5 mL IM. Relationship to other
Caution: brands have different immunisations
doses [e.g. engerix-B® 10 microgram
l No need to delay BCG following HBIG
(recommended), HBVaxPro Paediatric®
5 microgram] l Hepatitis B vaccine may be given with
other vaccines, but use separate site.
If same limb used, give vaccines
>2.5 cm apart
Issue 4
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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
l Avoid fetal scalp blood sampling and
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
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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
critical care unit (CCU). This can be l 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

(DIC)
AND 2 CRITICAL CARE
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
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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
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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HIV POSITIVE WOMEN • 1/3
Check latest version of individualised
MODE OF DELIVERY
maternal care plan
l Women known to be HIV positive will
TESTING have been counselled antenatally and
a plan made for mode of delivery and
l Recommend HIV testing to all pregnant care on delivery suite
women as a routine part of antenatal
screening l Normal vaginal delivery is now
recommended for women:
l if HIV testing declined, offer counselling
by HIV specialist (if available) l with a viral load of <50 copies/mL who
have been treated antenatally with
l do not test without consent, explore highly active antiviral therapy (HAART)
reasons for refusal, promote testing to
improve maternal health and reduce l who are elite controllers (have a viral
vertical transmission and document load of <50 copies/mL untreated)
discussion and who have been on zidovudine
monotherapy (zidovudine IV in labour
l Check HIV test result in notes at every is not required)
visit; if no result available, recommend
retesting. If not done early in l For women with a viral load of
pregnancy, offer at 28 weeks’ gestation 50–400 copies/mL who have been
treated antenatally with HAART,
l If in labour and no HIV test result, consider pre-labour caesarean section
request urgent testing with consent (CS), taking into account:
l actual viral load
ANTENATAL CARE
l trajectory of viral load
l Ensure consultant-led antenatal care in l length of time on treatment
conjunction with HIV physician and, if
available, HIV specialist nurses l adherence issues
l Amniocentesis or chorionic villus l obstetric factors
sampling should only be performed l woman’s views
with antiviral cover l Pre-labour CS is advised for women
l Advise mother not to breastfeed and with:
ensure she has formula and steriliser l a viral load of >50 copies/mL who were
l Ensure stock of zidovudine IV and not taking HAART, including women on
zidovudine, lamivudine and nevirapine zidovudine monotherapy
oral suspensions on labour ward l a viral load of >400 copies/mL for
l See woman’s individualised HIV care those who were taking HAART
plan l women with an unknown viral load
l untreated women
During pregnancy
l Arrange pre-labour CS at 38–39 weeks’
l If an HIV positive woman becomes gestation
acutely unwell in pregnancy liaise with
HIV physicians INTRAVENOUS ZIDOVUDINE
l If a woman taking antiretrovirals FOR DELIVERY
presents with GI upset, fatigue,
fever and breathlessness, check Indications
lactate levels; if raised do not give l Women with a viral load
antiretrovirals and inform HIV team >1,000 copies/mL
l Untreated women with an unknown
viral load
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l Women on zidovudine monotherapy.
PRETERM DELIVERY
An alternative for these women is to
continue their oral regime <34 weeks’ gestation
l There is no evidence that intrapartum
zidovudine IV is beneficial for women l In threatened preterm labour or if baby
taking HAART with a viral load of has absent/reversed umbilical artery
<1,000 copies/mL end diastolic flow, if mother’s viral load
>50 copies/mL, administer nevirapine
Medication 200 mg oral once to mother to load
baby who will be unable to take oral
l Start zidovudine IV 4 hr before elective medication after birth
CS (or for as long as possible before l give nevirapine >2 hr before birth if
emergency CS): possible
l prepare an infusion of 2 mg/mL in l Discuss with HIV consultant the use of
glucose 5% double dose tenofovir +/- raltegravir to
l run 1 mL/kg/hr for first hour (for a 70 kg reduce risk of vertical transmission
woman this is 70 mL/hr) l Continue mother’s current antiviral
l after 1 hr, reduce rate to 0.5 mL/kg/hr therapy
(for a 70 kg woman this is 35 mL/hr) l If preterm pre-labour rupture of
l use actual body weight even if >100 kg membranes occurs, on-call consultant
l Stop infusion after cord is clamped obstetrician will weigh the risk of
prematurity and vertical transmission.
Most recent viral load can be helpful
VAGINAL DELIVERY
l if conservative management is chosen
l Manage women with careful infection give erythromycin
control procedures
l There is no contraindication to steroids
l In women for whom intrapartum for mother to reduce risk of RDS in baby
zidovudine IV is indicated, see
Intravenous zidovudine for delivery TERM RUPTURE OF
above. It may be necessary to contact MEMBRANES
on-call pharmacist to ensure adequate
supply of zidovudine l In all cases of term pre-labour
spontaneous rupture of the membranes,
l If pre-labour rupture of membranes
expedite delivery following woman’s
occurs at term, or in any gestation
individual HIV care plan for birth
>34 weeks, commence oxytocin
without delay – see Oxytocin guideline l If indicated in individual care plan,
prepare for CS as soon as the
l If labour is progressing normally, avoid
zidovudine infusion is commenced
amniotomy
at initial rate. Do not wait to complete
l Be vigilant for pyrexia in labour and before delivering baby
have low threshold for antibiotic
l If pre-labour rupture of membranes
therapy
occurs after 34 weeks’ gestation
l Continue oral HAART medication expedite delivery
throughout labour
l Fetal blood sampling and fetal scalp
electrodes are not contraindicated for
woman with viral load <50 copies/mL
taking HAART
l If instrumental delivery required, prefer
low cavity forceps to Ventouse
Issue 4
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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
before CS even if nil-by-mouth l 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,
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
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HOME BIRTH • 1/3
l 34–36 weeks’ gestation:
COMMUNICATION WITH WOMAN
l carry out risk assessment and discuss
l Inform woman that: home birth arrangements/birth plan
l giving birth is generally very safe for l 36–37 weeks’ gestation:
both her and her baby
l check and arrange delivery of home
l there is a higher likelihood of a normal birth equipment to woman’s home
birth with less intervention among
l Women must be informed of possible
women who plan to give birth at home
complications during labour and
l there are rare events that, if occurring delivery which may necessitate transfer
at home, may have worse outcome for to hospital via ambulance
mother and baby than if occurring in
l midwife must document in detail that
hospital
discussion has taken place
Midwives undertaking home births If, at any time, woman’s risk category
must be competent in obstetric and changes, appropriate referral must
neonatal emergencies and must be made
attend annual mandatory training
Pethidine
Referral for home birth
l Follow local policy for making pethidine
l On confirmation of pregnancy, woman available
can either refer herself to a community l Midwife checks and administers the
midwife who is attached to a GP injection of pethidine according to NMC
surgery, or ask GP to refer her standards for medicines management
(2008) and NMC Rules and Standards
MANAGEMENT PLAN (2012)
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
to assessed risk l 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
those of the local maternity unit and l 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
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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
equipment is clean, complete and
Mother
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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HOME BIRTH • 3/3
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
risks, so that the woman may make a l 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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HYPERTENSION IN PREGNANCY • 1/7
Hypertensive disorders during pregnancy occur in women with pre-existing primary or
secondary chronic hypertension, and in women who develop new-onset hypertension
in the second half of pregnancy (gestational hypertension)
If occurring with significant proteinuria it is termed pre-eclampsia – see
Eclampsia and Severe pre-eclampsia guidelines
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 type 1 or type 2 diabetes

RISKS
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 Stop angiotensin-converting enzyme
SYMPTOMS AND SIGNS
inhibitors (ACEI) and/or angiotensin
l Advise woman to report any of the II receptor blockers (ARBs) within 2
following to a healthcare professional: days of notification of pregnancy and
offer alternative medication
l headache
l ACEI and ARB carry an increased risk
l visual disturbance (blurring or flashing)
of congenital abnormalities
l pain below ribs
l Limited evidence shows no increased
l sudden swelling of face, hands or feet risk of congenital abnormalities with
l vomiting other antihypertensive treatments but
discuss with healthcare professional
INVESTIGATIONS responsible for managing the
hypertension
l BP and urinalysis on each visit to a
l The antihypertensive medications
healthcare professional
commenced/used in pregnancy are
methyldopa, labetalol and nifedipine
TREATMENT
l Avoid anaemia – see Anaemia in
Antihypertensive treatment and pregnancy guideline
prenatal counselling
l Base antihypertensive treatment on
pre-existing treatment, medication
side-effect profile and risk of
teratogenicity
Intrapartum care
Mild or moderate hypertension Severe hypertension
(BP ≤159/109 mmHg) (BP ≥160/110 mmHg)
l Continue antenatal antihypertensive l Continue antenatal antihypertensive
treatment treatment
l Measure BP hourly l Measure BP continuously
l See Epidural analgesia guideline – l If BP controlled <150 mmHg systolic,
Investigations do not routinely limit duration of second
l If BP stable <150 mmHg systolic, do stage
not routinely limit duration of second l If BP does not respond to initial
stage treatment, advise operative birth
l Measure BP:
Postnatal care
l daily for first 2 days after birth
Antihypertensive treatment l at least once 3–5 days after birth
l Continue antenatal antihypertensive l as clinically indicated if
treatment antihypertensive treatment changed
l If methyldopa was used during l Maintain BP at 140/90 mmHg
pregnancy, stop within 2 days of birth l See Breastfeeding advice for women
due to risk of depression taking antihypertensive medication
l If no antenatal antihypertensive below
treatment was required, commence
antihypertensive treatment only if BP
≥150/100 mmHg
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l ACEI other than enalapril and captopril
Follow-up care
l Assess clinical wellbeing of baby,
l At transfer to community care, ensure especially adequacy of feeding, at least
care plan in place, including: daily for first 2 days after delivery
l who will provide follow-up care
(including medical review if required) CHRONIC HYPERTENSION
l frequency of blood pressure monitoring Antihypertensive treatment
l thresholds for reducing or stopping
treatment l See Antihypertensive treatment and
prenatal counselling above
l indications for referral to primary care
l In uncomplicated chronic hypertension,
for blood pressure review
maintain blood pressure at
l If antihypertensive treatment is to <150/100 mmHg
be continued, offer medical review 2 l In target-organ damage secondary
weeks after transfer to community care to chronic hypertension (e.g. kidney
l Offer medical review at 6–8 week disease), maintain BP at
postnatal GP review <140/90 mmHg
l If antihypertensive treatment is to be l Refer pregnant women with secondary
continued after the 6–8 week postnatal chronic hypertension to a specialist in
review, offer a specialist assessment of hypertensive disorders
hypertension
Aspirin therapy
Breastfeeding advice for l 75 mg daily from 12 weeks until delivery
women taking antihypertensive
medication Antenatal care
l If breastfeeding or expressing milk, l Consultant obstetrician as lead
avoid diuretic treatment professional
l Inform woman the following l Plan additional antenatal consultations
antihypertensive drugs have no known according to individual needs of
adverse effects on babies receiving woman and baby
breast milk:
l labetalol
Fetal monitoring
l nifedipine l At 28–30 and 32–34 weeks perform:
l enalapril l ultrasound for fetal growth and
amniotic fluid volume assessment
l captopril
l umbilical artery Doppler velocimetry
l atenolol l If results normal, do not repeat >34
l metoprolol weeks unless clinically indicated
l Inform woman that there is insufficient l If fetal activity abnormal, perform
evidence regarding the safety of babies electronic fetal monitoring – see
receiving breast milk where mother is Electronic fetal monitoring (EFM)
receiving: guideline
l ARBs
l amlodipine
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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
at <150/80–100 mmHg labetalol to maintain BP
l Measure BP weekly
(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 using an automated
protein:creatinine ratio twice a week
reagent-strip reading
l Perform routine l 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 woman and middle grade obstetrician l 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
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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
l Offer birth (after discussion with >37+0 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 In women with pre-eclampsia who
Fetal monitoring
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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INDUCTION OF LABOUR • 1/5
l History of precipitate labour
DEFINITION
l routine induction of labour to avoid
Artificially initiated uterine contractions unattended birth not recommended
leading to progressive dilatation and
l Macrosomia – in the absence of other
effacement of the cervix and delivery of baby.
indications, other than healthcare
Includes women with intact membranes
suspicion is not an indication for
and those with spontaneous rupture of
induction
membranes but who are not in labour
INDICATIONS PREGNANCY
>42 WEEKS’ GESTATION
Prevention of prolonged
pregnancy (term plus 10–14 days) l Advise women choosing to continue
pregnancy >42 weeks, despite
l Ultrasound at <20 weeks to confirm adequate explanation of risks, to
gestation reduces induction for closely monitor fetal movement pattern
perceived post-term pregnancy
l Refer to obstetric consultant for plan of
l In uncomplicated pregnancies, offer care
induction of labour between term plus
l ultrasound estimation of maximum
7–14 days
amniotic pool depth
l Pre-labour rupture of membranes
(>37 weeks’ gestation) – see l umbilical artery Doppler study
Pre-labour rupture of membranes l electronic fetal monitoring (EFM)
(PROM) at term guideline
l Intrauterine fetal death – see Perinatal METHODS OF INDUCTION
bereavement guideline OF LABOUR
Other (this list is not exhaustive) Membrane sweeping
l Diabetes l Before considering other methods
l Hypertension for induction, offer membrane sweep
l Fetal growth restriction (FGR) according to local practice. This has
been shown to increase probability of
l Antepartum haemorrhage (APH)
labour starting naturally within 48 hr
l Multiple pregnancy
l May be carried out in woman’s home,
l Cholestasis antenatal clinic or hospital
l Previous stillbirth
l Offer nulliparous membrane sweep at
l Breech presentation 40 and 41 weeks
l Previous caesarean section (CS) l Offer parous women membrane sweep
at 41 weeks
Maternal request <41 weeks’
gestation l If labour does not start spontaneously
additional membrane sweeps may be
l Do not offer routinely at maternal offered
request alone Membrane sweep not recommended
l Consider when compelling if membranes have ruptured
psychological or social reasons
>40 weeks. Refer to a consultant clinic
Midwife/doctor will:
CONTRAINDICATIONS
l Provide full explanation of procedure
l Severe FGR with confirmed fetal l Obtain and record consent
compromise (requires LSCS)
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l Inform woman that membrane sweeping l In nulliparous or multiparous women
is not associated with an increase in with ruptured membranes regardless
maternal or neonatal infection but the of cervical status, prostaglandin
procedure can result in increased levels or oxytocin are equally effective in
of discomfort and bleeding induction of labour
l Provide ‘Induction of labour’ leaflet (if
available locally)
Midwife/doctor will:
l Ensure woman has relevant contact l Provide full explanation of procedure,
telephone numbers including associated risks of
hyperstimulation
MEDICAL INDUCTION
l Obtain and record consent
OF LABOUR
l In nulliparous or multiparous
women with intact membranes with
unfavourable cervix, use prostaglandin
in preference to oxytocin unless
specific clinical contraindications
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
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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 Following explanation of procedure,

OXYTOCIN
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
l Perform routine antenatal assessment,
(LOW-RISK PREGNANCIES)
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
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l Obtain and review full history, confirm
gestation and reason for induction and
ANTENATAL MANAGEMENT
carry out: OF PLANNED INDUCTION
OF LABOUR
l abdominal examination to determine
lie and fifths of the head palpable in the (HIGH-RISK PREGNANCIES)
abdomen l Consultant obstetrician will be lead
l fetal heart assessment professional for all cases
l Give woman information regarding l Obstetric medical staff will decide
discomfort associated with procedure place of induction (routine antenatal
and pain relief options wards are not appropriate in certain
l Explain there is no association with circumstances e.g. vaginal birth after
an increase in maternal or neonatal CS)
infection or bleeding l Obstetric medical staff will determine
l Obtain consent and document frequency of maternal
and fetal observations required over
l Perform external EFM for 20 min to
and above those for low-risk pregnancy
confirm fetal wellbeing
l Discuss plan of care with all high-risk
l Assess cervix using Bishop’s score and
women to decide timing and method of
record findings
induction of labour
l Administer prostaglandin as per local
l Provide ‘Induction of labour’
guidance
information leaflet (if available locally)
l Advise woman to remain recumbent for
l Follow procedure in Low-risk
30–60 min
pregnancies
l Provided initial monitoring on
admission is within normal parameters, INDUCTION OF LABOUR WITH
reassess fetal wellbeing: A PREVIOUS CS
l EFM trace of 20 min once contractions
have commenced l The decision to induce a woman with
a previous CS should be made by an
l discontinue EFM after 20 min providing obstetric consultant following a vaginal
fetal heart remains within normal examination. Vaginal examination
parameters is useful in determining method of
l If, at any time throughout the induction
procedure, fetal heart rate is outside l Offer membrane sweeping
normal parameters, continue EFM
and inform middle grade obstetrician l Discuss risks of induction of labour with
(ST3–7 or equivalent e.g. staff grade, woman (e.g. failed induction/repeat
clinical fellow) or consultant CS, scar rupture) and document in
l Encourage woman to mobilise freely,
eat and drink normally, and consider l risk of scar rupture is approximately
using non-pharmacological pain relief/ doubled with ARM and oxytocin and
simple analgesia increased five-fold with prostaglandin. If
both oxytocin and prostaglandin used
Uterine hypercontractility with risk is further increased 9–15 times
prostaglandin l With a relatively low modified Bishop’s
score, consider proceeding directly to
l In the presence of abnormal fetal ARM or use of transcervical catheter
heart rate patterns and uterine induction – see Transcervical catheter
hypercontractility, consider induction guideline
administration of subcutaneous
l Discuss and document individualised
terbutaline 250 microgram
management plan using local proforma
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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
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INFANT FEEDING • 1/12
l Never interrupt skin-to-skin contact
INTRODUCTION
to perform routine procedures (e.g.
l Unless otherwise stated, this guideline weighing baby)
applies to healthy term infants l Where condition of mother or baby
l Where expressed breast milk (EBM) is requires medical intervention, this
mentioned, it refers to mother’s own will take precedence over immediate
EBM skin-to-skin contact
l commence contact once condition of
ANTENATAL PERIOD mother and baby stable
l Promote the value of breastfeeding as l 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
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l When baby showing feeding cues, offer
Breastfed babies
assistance to breastfeed
l Unless it is necessary, for clinical l Early and frequent breastfeeding has
reasons, to separate mother and baby, many benefits including:
mother has primary responsibility l enhances milk supply – the more milk
for baby’s care on postnatal areas. removed from the breast, the more milk
Baby will remain with mother 24 hr/ the mother will produce
day to allow her to recognise feeding
l reduces incidence of physiological
cues (see Responsive feeding) and
jaundice
encourage night-time breastfeeds/
formula feeds l Inform mother that it is acceptable
to wake baby for feeding if her
Do not routinely separate mother and breasts become overfull. Explain the
baby at night whether formula-fed, importance of night-time feeding for
breastfed or delivered by CS milk production
l If mother requests separation from l Length of individual feeds will vary
baby for ‘settling’ by staff, explain considerably. The length of the feed is
the benefits of staying close to baby determined by the rate of milk transfer
and document decision and length from mother to baby. Encourage
of separation in maternal healthcare mother to allow baby to empty the first
record. Return baby to mother as soon breast before offering the second
as baby settles l Babies who are not removed from
the breast but allowed to finish a feed
RESPONSIVE FEEDING spontaneously are more likely to
take the high fat hind milk which will
l Encourage woman to breastfeed not encourage satisfaction and weight gain
only for nutrition, but for comfort and
calming of baby, or if woman has full Formula-fed babies
breasts or needs to rest
l Ensure mother understands the nature l After explaining the avoidance of ‘over
of feeding cues, the importance of feeding’, encourage mothers to feed in
quick response (rather than waiting the same way taking amounts of milk
until baby cries) and is aware of normal that the baby wishes at each feed, and
feeding patterns, including cluster allowing baby to ‘pace’ the feed
feeding and ‘growth spurts’. This is l ensure number of feeders are limited
applicable to breast and formula-fed
babies BREASTFEEDING
l Unless, clinically inappropriate, l Human milk is important in establishing
encourage responsive feeding, enteral nutrition
allowing baby to feed for as long
l To promote optimum health benefits,
and as often as he/she wants. Where
babies should be breastfed exclusively
clinical procedures are necessary, they
until aged 6 months and should
should not interfere with this process
continue to breastfeed until aged 2 yr
l Observation of the sleepy baby (for
l Frequent feeds during the initial period
either method of feeding) is important
will help prevent breast engorgement
to ensure vital signs such as colour,
and encourage a good milk supply
respiration rate, heart rate and
temperature are stable and that there l Midwife or skilled support worker to be
are no signs of hypoglycaemia available during mother’s hospital stay
to assist with breastfeeding
l support should also be available to
mothers who choose to deliver at home
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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

midwife or neonatologist will make the
immediately after delivery
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
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How to breastfeed and l Home birth: Instruct mother as soon as

possible after birth
maintain lactation
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
advised (8–12 times in 24 hr)
Avoid teats and dummies
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
Expressing breast milk
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 associated with
Other factors 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 Some babies will feed <4 times in
HEALTHY TERM BABY WHO IS
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
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l Encourage skin-to-skin contact l Recent cytotoxic chemotherapy
between mother and baby (see l Certain medications – see https://toxnet.
Skin-to-skin contact) nlm.nih.gov/newtoxnet/lactmed.htm
l Encourage responsive feeding from l Active herpes on breast
birth (see Responsive feeding)
l Assist mother to initiate breastfeeding Medical indications when
formula supplementation may
Artificial teats, dummies and be necessary:
nipple shields
l Each baby and situation will be
l Discourage the use of artificial individually assessed. Indications include:
teats or dummies to breastfeeding l low birth weight <1500 g
babies during the establishment of
l metabolic disorders e.g.
breastfeeding. If a breastfed baby
galactosaemia, maple syrup urine
seems unsettled, it is more important
disease, phenylketonuria (PKU)
to assess carefully and, if necessary,
improve mother’s feeding technique l very preterm e.g. <32 weeks’ gestation
l If parents wish to use teats, dummies or l at risk of hypoglycaemia e.g. preterm,
nipple shields, advise that dummies may small for gestational age, intrapartum
have a detrimental effect on breastfeeding stress, illness or maternal diabetes
and lactation. Document discussion and – if blood glucose fails to respond
parent(s) decision in postnatal record to optimal breastfeeding in spite of
l If baby requires additional fluids, give frequent effective suckling
these by cup rather than by bottle l persistent faltering growth/significant
to avoid nipple/teat confusion and weight loss/hypernatraemia
encourage baby to develop correct l breast abscess where there is pus
tongue technique. Offering bottles coming from the nipple
may encourage baby to develop a l See Breastfeeding guideline and
preference for a teat Abstinence syndrome guideline in
l Nipple shields are not recommended the Staffordshire, Shropshire & Black
except in extreme circumstances Country Newborn and Maternity Network
and then only for as short a time as Neonatal guidelines (if used locally)
possible. If used, mother must be
l When breastfeeding is temporarily
supervised by a skilled practitioner
delayed or interrupted, assist mother in
and given assistance to discontinue
establishing and maintaining lactation
use as soon as possible. Explain
e.g. through manual or hand pump
the disadvantages to mother before
expression of milk, in preparation for
commencing use, which may include:
resumption of breastfeeding
l nipple soreness caused by incorrect
positioning and attachment Documentation
l difficulty in improving positioning and
attachment l Record the following in maternal
healthcare record:
l reduced milk transfer to baby
l discussions with parent(s) and
l increased risk of mastitis and breast
informed consent obtained
abscess
l reason for administering supplements,
SUPPLEMENTATION whether for clinical reasons or parents’
request
Medical indications for l supplements used
formula supplementation: l Complete appropriate formula audit
l HIV positive mother – see HIV positive form and send to breastfeeding
women guideline co-ordinator
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Baby has breastfed l low-risk babies can mobilise alternative
fuels like ketones as an energy source
at delivery
in the presence of low glucose
≤6 hr of birth l Encourage mother to express milk
8 times in 24 hr, (including during
l Offer assistance with second the night) and give colostrum, when
breastfeed and document available, via cup or syringe or by
l If baby sleeping or unwilling to feed, try direct expression into baby’s mouth
again in 2 hr, or earlier if baby shows l Stop monitoring temperature,
signs of hunger/wakefulness respirations, heart rate and muscle
tone once baby is feeding regularly
Baby has not fed since birth and neonatal/midwifery staff are happy
with progress
At 4 hr
l Use feeding chart to assess whether
l Check heart rate, temperature, feeding is established for a minimum of
respiration rate, tone, colour and 24 hr
baby’s general appearance again. If l Observe a breastfeed to ensure correct
baby appears well and is still reluctant positioning and attachment and take a
to feed, gently stimulate by: thorough breastfeeding history
l unwrapping l Complete feeding assessment sticker
l resuming skin-to-skin contact in woman’s hand held notes
l gentle massage Reluctance to feed may be the only
l tempt at the breast sign of a sick baby. Consider the
l Encourage mother to hand-express possibility of septicaemia or inborn
colostrum and give via cup/syringe errors of metabolism. Careful clinical
(use of a breast pump is unlikely to surveillance is key to management
obtain any colostrum)
l Review baby 2-hrly and repeat above Amount not increasing
process until baby has successfully l If, after 12 hr, amount of colostrum only
breastfed ‘droplets’, support mother and attempt
l Document all care given on a feeding to allay anxiety, which is helpful in
chart establishing colostrum/milk flow by the
natural release of oxytocin
Baby not taken feed by 12 hr l Increase expressing frequency from 8
l If baby refuses to breastfeed, is unable to 10–12 times in 24 hr to ensure more
to cup feed, or no colostrum available, stimulation of breasts and increased
midwife to assess baby to determine amounts given to baby
whether neonatal referral necessary l explain carefully to mother the rationale
l Midwife/neonatologist and mother will for temporarily increasing expressing
formulate an individualised care plan frequency
l If baby will not accept cup or l Ensure mother is hand-expressing and
small syringe feeds, partnership using the pump effectively and safely
decision-making with neonatal medical l All colostrum expressed must be given
colleagues is recommended to establish to baby
why and agree management plan. l Observe breastfeeding attempts and
Explain suggested care plan to mother encourage skin-to-skin contact as
l If baby is otherwise well and clinical much as possible in a dimly lit quiet
signs are stable, blood glucose testing environment
is not routinely required
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l Complete feed chart until breastfeeding l Continue to express and cup feed
established and record baby’s urine colostrum frequently
and stool output. Report any deviations l Maintain feed chart until breastfeeding
from normal to neonatal medical staff established
l Record plan (agreed with mother,
Breastfed baby ‘sleepy’ or
midwife and neonatal team) in maternal
‘reluctant to feed’ in second healthcare record/neonatal notes
24 hr of life
l Review progress with mother 12-hrly,
l Refer to the neonatal team for ensuring baby has at least 8–12 feeds
assessment in this time period
l Ensure there are no anatomical l Observe wet and dirty nappies
reasons preventing breastfeeding l Consider biological nurturing positions
attachment e.g. cleft palate/tongue tie/
mother’s breast or nipple anatomy
Assessment of output
l Keep baby close to mother –
skin-to-skin contact l At each postnatal visit, enquire about
babies output, together with ongoing
l Provide emotional reassurance and
monitoring by mother
support for mother
l inadequate output (less than that
l Ensure mother understands feeding
specified – see Table below) triggers
cues and is trying at every opportunity
weight assessment and implementation
to breastfeed
of appropriate management plan
l Observe and assess a full breastfeed,
l The following findings are ‘reassuring’
and offer breastfeeding support where
in a breastfed baby. Any deviation from
necessary
this should trigger further assessment
l Avoid teats and dummies
Day 7–28
Age Day 1–2 Day 3–4 Day 5–6 and
beyond
Urine ≥1–2 ≥3
≥6
Number of wet Urates may be Nappies feel ≥5
Heavy
nappies per day present* heavier
Stools ≥1 ≥2 ≥2 ≥2
Number per Dark Change in Yellow At least size
day, colour, green/black colour May be of £2
consistency ‘tarlike’ and consistency quite coin, yellow
(meconium) – brown/green/ watery and watery,
yellow
‘seedy’
becoming looser
appearance
(‘changing stool’)
* Urates are normal bladder discharges in the first few days but persistent urates may
indicate insufficient milk intake
l After 28 days, baby will establish own frequency of passing stools – may pass
several per day or have several days’ gap between
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l always wash hands before removing
FORMULA FEEDING
equipment from the steriliser
Early postnatal period l make a fresh solution every 24 hr
l rinse equipment with cool boiled water
l Encourage mother to hold baby in a
(optional)
calm environment as soon as possible
after delivery – see Skin-to-skin contact
Formula milk preparation/storage
l Explain how mother may obtain help
with feeding while in hospital l Discuss with parent(s) and give leaflets
l Ensure mother is supported with on bottle feeding (if available locally)
feeding until she feels confident l Demonstrate technique in early
l Document formula feeding progress and postnatal period before discharge
all information given on the feeding care home and, if necessary, again in the
plan, and maternal healthcare record home environment. Document in
Sterilising equipment l Wash, rinse and dry hands thoroughly
l Use a clean work surface
l Equipment that is used to store formula
or feed an infant must be kept very clean l Use boiled tap water that has been left
to cool for a few minutes (<30 min – it
l Discuss with parents and offer the
should still be >70°C) – to reduce the
following information:
risk of growth of bacteria found in infant
l wash milk-related feeding equipment formula powder
thoroughly in hot soapy water, using a
l Remind parents not to use bottled
clean brush, inside and out (especially
water due to variable mineral content
the rim) before sterilising, until baby
aged 1 yr l Make up a fresh bottle for each feed,
following preparation instructions on tin
l rinse well in clean water after washing
l check equipment regularly for signs of Storing prepared formula milk
deterioration. If any doubt, throw away increases the risk of bacterial
growth (powdered infant formula
is not sterile)
Technique
l If using cold water sterilisation, rinse
l Boiling (saucepan) – all equipment
feeding equipment with cooled boiled
must be under the water level of the
water (not water straight from tap), or
pan, with no air bubbles trapped inside
shake solution off well
l Do not allow the pan to boil dry
l Fill bottle to required mark – always
l Boil for ≥10 min water first before powder
l Keep pan covered with a lid until l Add powder using only the scoop
equipment is used provided with the tin – level off with
l Steam or microwave sterilisers – a plastic knife or spatula (1 scoop of
follow manufacturer’s instructions powder to 30 mL of water)
l Chemical sterilisation (tablets or fluid) l Place the disc, teat and cap onto
– follow manufacturer’s instructions bottle, and shake well until all powder
l ensure all equipment is under the has dissolved
fluid – with no trapped air bubbles – a l To cool the milk, hold bottle, with cap
plunger or plate can be used to keep covering teat, under cold running
items under water water, or stand in jug of cold water
l leave submersed for ≥30 min or as per l Remind parents to check temperature of
manufacturer’s instructions feed on inner wrist before giving to baby
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l After feeding, throw away any unused
Feeding away from home
milk
l Freshly prepared powdered formula l It is safest to carry a measured amount
milk will keep for 2 hr at room of milk powder in a small clean and dry
temperature, after which time, discard container, a flask of hot water that has
been boiled and an empty sterilised
How to bottle-feed feeding bottle
l Hold baby upright with head supported l Bottle must be cooled before feeding
in a comfortable neutral position (twisted l If the above is not possible, the feed can
neck makes swallowing difficult) be prepared at home and cooled at rear
l To start the feed, brush the teat against of fridge. Take out of fridge before leaving
baby’s lips. Baby will open mouth with home and carry in a cool bag with an
tongue down, which helps draw the ice pack. Use within 4 hr or, if destination
teat in reached within 4 hr, store at rear of fridge
l Keep teat full of milk, to avoid intake of l Never store feeds for >24 hr. It is
air always safer to make up a fresh bottle
l Hold bottle horizontal to the ground, l Ready-to-drink, formula milk is an
tilting just enough to ensure baby is alternative
taking milk Formula-fed baby who is
l Babies feed in bursts of sucking with reluctant to feed
short pauses. In this position the milk
will stop flowing when baby pauses – l Encourage skin-to-skin contact to
allowing baby to rest stimulate feeding cue
l There should be bubbles in the bottle l Offer frequent opportunities to feed
as baby feeds, if not, break the suction l If unwilling to suck from teat – try cup
– you should see bubbles rushing back feeding
into the remaining milk
l small volumes in first 2 days is normal
l Babies may need short breaks during
l Clinically assess baby at 12 hr
the feed and may need to be winded
(colour, tone, behaviour, temperature,
l Discuss responsive feeding – babies respiration, heart rate). If concerns,
may take different amounts at different seek neonatal team assessment
times – and the tin provides a guide only
l If baby not waking for feeds or sucking
l Advise parents not to try to give more milk eagerly at the bottle by 36–48 hr,
at 1 feed in the hope baby will go longer request neonatal team assessment
before needing another feed. If baby is
given more milk than necessary, he/she is l Alternative feeding methods may be
likely to gain too much weight, or be sick required based on clinical indication
l Discuss feeding cues with parents so DISCHARGE AND FOLLOW-UP
that they can recognise when their
baby is hungry and encourage parents Before discharge home
to stay close to baby in order to
recognise these cues Rooming in
l Encourage parents to hold baby close
for feeding, offering eye contact. l Explain and encourage parent(s) to
Skin-to-skin contact can be enjoyed stay close to baby, sharing the same
bedroom at night for first 6 months of
l As with breastfeeding, bottle feeding is a
life
social interaction, not just for delivering
nutrition. Aim to keep number of people l Ensure parent(s) are aware of the
feeding baby to a minimum appropriate age for introducing
complimentary foods
l Never leave baby alone with a bottle
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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 Healthcare professionals and trained

Support in the community
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
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INFANT
InfantFEEDING
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 Responsive feeding • Check newborn
• Once baby feeding
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
necessary until feeding
• use feeding chart
to assess whether established
feeding established • if any concerns or
signs of illness,
neonatal referral
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INTERMITTENT AUSCULTATION • 1/2
DEFINITION Fetal
l The interval monitoring of fetal heart l Intrauterine growth restriction/abnormal
using Doppler ultrasound or Pinard to Doppler
assess fetal wellbeing in labour l Macrosomia
l Prematurity <37 weeks’ gestation
Who
l Oligohydramnios/polyhydramnios
l Advise low-risk women to have l Multiple pregnancy
baby’s heart monitored by intermittent
auscultation l Abnormal presentation
l Risk factors below indicate the woman l High (4/5–5/5 palpable) or free floating
is not low-risk head in nulliparous woman
l If risk factors present or structured l Iso-immunisation
intermittent auscultation not possible, l Non-reassuring antenatal EFM
use continuous electronic fetal l Reduced fetal movements in last 24 hr
monitoring (EFM) – see Electronic
l Abnormality on auscultation (abnormal
fetal monitoring guideline
baseline, decelerations)
Contraindications
How
Maternal l Start intermittent auscultation as
l Previous caesarean section/uterine soon as established labour has been
scar diagnosed
l Pre-eclampsia/eclampsia l 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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INTERMITTENT AUSCULTATION • 2/2
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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LABOUR MANAGEMENT
(including clinical risk assessment) • 1/4
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
assessment l 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
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LABOUR MANAGEMENT
l examination
Fetal wellbeing
l observations
l Auscultate fetal heart rate (FHR) for a
l current complaint
minimum of 1 full minute immediately
after a contraction Identified risks
l Ask about fetal movements in last 24 hr
l To minimise risk to mother and baby,
l Palpate maternal pulse rate to instigate a management plan for each
differentiate between maternal and FHR risk identified
l If there is a clinical indication, perform l If risk is such that midwifery-led care
electronic fetal monitoring (EFM) – see is no longer appropriate, discuss with
Electronic fetal monitoring guideline middle grade obstetrician (ST3–7 or
equivalent e.g. staff grade, clinical fellow)
Blood and blood products
and transfer care to obstetric team
l If not already done, ask woman if she l Advice for management can also be
is prepared to accept blood or blood obtained from resident anaesthetist
products – see Refusing blood and
blood products guideline Assess risk status continuously and
change management plan accordingly
Thromboembolism
Documentation and handover
l Carry out VTE risk assessment using
local protocol l Document risk assessment clearly in
Communication and l Ensure thorough face-to-face verbal
documentation handover between midwives and
document (including identified risks) using
l Document findings of assessments
appropriate structured handover tool
l Discuss findings, birth plan and
l Repeat risk assessment at handover
analgesia with woman/and her partner
of care from each midwifery shift and
CLINICAL RISK ASSESSMENT document any supplementary risks
identified
l Must be performed in all women by a
midwife in all clinical settings, whether FIRST STAGE OF LABOUR
in maternity unit or at home
Observations and
l Once labour diagnosed, complete
intrapartum risk assessment and
assessment during first stage
devise individualised management plan l As a minimum, perform and document
l If an obstetrician is involved in the following on partogram at frequencies
woman’s care, he/she should repeat indicated, unless other clinical reasons to
risk assessment document more frequently:
l temperature: 4-hrly
Full risk assessment
l blood pressure: 4-hrly
l Determine level of risk based on: l maternal pulse: hourly
l medical comorbidity l abdominal palpation followed by
l anaesthetic history vaginal assessment: 4-hrly
l previous obstetric history l frequency of contractions: every 30 min
l lifestyle history l frequency of bladder emptying (test
and measure amount voided) – see
l any concerns with this pregnancy e.g.
Bladder care guideline
IUGR
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LABOUR MANAGEMENT
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
IV fluids, either 1 L sodium chloride l 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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LABOUR MANAGEMENT
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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LATENT PHASE OF LABOUR • 1/2
l if contact is from woman’s support
INTRODUCTION
person, advise him/her that it would be
l Latent phase of labour is a normal more appropriate for midwife to speak
process during which dynamic to the woman directly
physiological and emotional changes l In order that advice and reassurance
(unique to each woman) occur. It is can be based on individual need,
vital that healthcare professionals obtain a detailed history
caring for women in the latent phase
l Document discussions, information
of labour appreciate this physical and
and advice given
psychological process
l retain a record for future reference if
l This guideline is applicable to women
woman makes contact again regarding
expecting a vaginal birth 37–42 weeks’
her labour
gestation
l Midwife must exercise professional
DEFINITION judgement when diagnosing latent
phase of labour
l Onset of short, mild, irregular
contractions that soften, efface and Action
begin to dilate the cervix from 0–4 cm.
Average duration is poorly understood l If appropriate, encourage woman to
stay at home and continue normal daily
ANTENATAL ADVICE activities, light diet and plenty of fluids,
ideally with company, but to make
l Midwife will discuss process of further contact if her needs change or
latent phase of labour with woman she requires midwife support
in antenatal period <37 weeks’ l Advise about pain relief strategies (see
gestation, providing her with a realistic below)
understanding of what to expect
l On the third telephone assessment
l Include this topic in parent education made by a midwife, arrange for woman
classes and, if available locally, provide to attend maternity unit for full maternal
woman with an information leaflet and fetal assessment and plan of care
l Provide woman and her birth partner(s) After 3 telephone assessments,
with information about the type of midwife must see woman
support available during the latent
phase of labour
l When developing birth plan, discuss Assessment on admission
coping strategies, as anxiety can l See Labour management guideline
impact on the effectiveness of other
l Midwife should undertake a full
relaxation techniques
assessment, taking into consideration
the woman’s reactions to the
MANAGEMENT physiological and emotional changes
Telephone assessment
Vaginal examination
l Most women who feel they are in
labour make their first contact with l Following discussion with woman,
midwife by telephone, in order to seek consider need for vaginal examination
help and advice. This first contact is l if, after examination, it is decided
an important initial assessment, and woman is not in active labour,
it is preferable for a midwife to speak encourage her to go home with advice
directly with the woman about when and who to contact
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LATENT PHASE OF LABOUR • 2/2
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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MATERNAL DEATH • 1/2
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 abortion 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
Resulting from obstetric complications l 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
occur in the pregnancy or puerperium, l Offer support to family
e.g. road traffic collision l Document events and secure in
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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MATERNAL DEATH • 2/2
Member of staff supporting l Review maternal healthcare record

with midwife in charge of case and
relatives
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
woman had delivered or received care
PMA
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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MATERNAL TRANSFER
(INCLUDING IN-UTERO TRANSFER) • 1/4
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 Transfer into hospital from community l 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
assessment and complete local l 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
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MATERNAL TRANSFER
l Wherever appropriate and possible,
Prepare for transportation
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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MATERNAL TRANSFER
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
transportation required. Consultation l Regional Cot Locator can assist in
with neonatologist and anaesthetist finding appropriate unit. Telephone:
may be necessary 0300 200 1100
l Transfer co-ordinator will allocate l 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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MATERNAL TRANSFER
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)
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MECONIUM STAINED LIQUOR • 1/2
l Take umbilical cord sample – see
BACKGROUND
Umbilical cord sampling guideline
l Meconium stained liquor occurs in l Report meconium change from light to
10–20% of deliveries, increasing to over significant to middle grade obstetrician
30% after 42 weeks’ gestation (ST3–7 or equivalent e.g. staff grade,
l Meconium aspiration syndrome clinical fellow)
occurs in 2–5% of babies born through
meconium stained liquor
RESUSCITATION OF BABIES
BORN FROM MECONIUM
l Significant meconium at onset of
STAINED LIQUOR
labour carries the worst prognosis and
is associated with five to seven-fold Ensure resuscitation equipment is
increased risk of perinatal death checked and ready for use before
delivery
DEFINITION
In the presence of any degree
Significant of meconium:
l Dark green or black amniotic fluid that l Do not suction baby’s upper airways:
is thick or tenacious or any meconium l before birth of shoulders and trunk
stained amniotic fluid containing lumps l if baby has normal respiration, heart
of meconium rate and tone
l Do not intubate if baby has normal
Light respiration, heart rate and tone
l Staining of lesser severity l Tracheal intubation should not be
routine in presence of meconium,
MANAGEMENT and should only be performed for
suspected tracheal obstruction
l Unless birth imminent, transfer l Emphasis should be on initiating lung
from low-risk setting to care of an inflation within first minute of life in
obstetrician as per local protocol non-breathing or ineffectively breathing
l If woman is not in labour and thick infants, and this should not be delayed
meconium is present, arrange l If baby does not have normal
induction of labour respiration, heart rate and tone, follow
l Continuous electronic fetal monitoring nationally accredited guidelines on
(EFM) is advised for women with neonatal resuscitation, including early
significant meconium stained liquor – laryngoscopy and suction under direct
see Electronic fetal monitoring (EFM) vision
- Labour guideline l Obtain arterial and venous cord blood
to assess pH and blood gases – see
In labour Umbilical cord sampling guideline.
Record values in maternal healthcare
l Whatever the degree or time of passage record and, if local practice, in neonatal
of meconium, fetal risks are increased notes
l Document the presence or absence of l In the presence of significant meconium,
significant meconium or light with other fetal risk factors:
l If fetal heart rate abnormalities also l ensure that neonatologist/advanced
present, perform fetal blood sampling – nurse practitioner is available at birth
see Fetal blood sampling guideline l if baby is floppy and apnoeic and born
through thick particulate meconium it
l When delivery imminent, call neonatal
is reasonable to inspect oropharynx
team according to local practice
rapidly to remove potential obstructions
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MECONIUM STAINED LIQUOR • 2/2
Active baby
l If baby crying and active at birth:
l dry and cover to avoid hypothermia
l do not aspirate airways
l neonatologist does not inspect larynx
or aspirate trachea (unnecessary
intubation and lower airway suction
does more harm than good)
Floppy baby
l If baby floppy, pale and makes no
immediate respiratory effort at birth, call
neonatal team (if not already present)
and commence neonatal resuscitation
– see Cardiopulmonary resuscitation
of the newborn guideline (Airway) or
follow local guidance
Postnatal observations
l For any baby delivered with a history
of significant meconium, perform the
following observations at aged 1 and
2 hr and then 2-hrly until aged 12 hr
or as per local policy. Document in
neonatal observations chart:
l general wellbeing
l chest movement and nasal flare
l skin colour including perfusion by
capillary refill
l feeding
l muscle tone
l temperature
l heart rate and respiration
l If light meconium staining occurred,
observations for baby as above at aged
1 and 2 hr and document in neonatal
observations chart
l If baby’s condition causes concern at
any time, review by neonatologist
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MEDICAL TERMINATION OF PREGNANCY FOR FETAL
ABNORMALITY AND FETOCIDE • 1/2
l Provide contact telephone numbers
PROCEDURE
with instructions to call if she has any
l Obtain written informed consent, concerns while at home. Give patient
together with written agreement of 2 information leaflet, if available locally
certified medical practitioners who have
signed HSA1 form (Abortion Act 1967 Further drug regimen
revised 1991)
l No more than 24–72 hr after initial
l Guidance from Royal College of dose of mifepristone 200 mg oral, give
Obstetricians and Gynaecologists misoprostol:
on termination of pregnancy for fetal
abnormality stresses that a legal l <27 weeks’ gestation: 100 microgram
abortion ‘must not be allowed to result vaginally 6-hrly – maximum 4 doses
in a live birth’. Therefore, method of l ≥27 weeks’ gestation:
termination of pregnancy >21 weeks, 25–50 microgram vaginally 4-hrly –
should ensure fetus is born dead maximum 6 doses
l Where termination is planned >21+6 In previous caesarean section
weeks for abnormalities that are not (CS) or uterine surgery, where the
lethal, consultant in fetal medicine must cavity has been breached (e.g.
discuss fetocide with woman myomectomy, uterine perforation)
l If woman refuses fetocide, document use 25–50 microgram dosage
clearly in maternal health care records
that it has been offered and declined
Side effects/complications
l Inform women that even before cut off associated with misoprostol
of 21+6 weeks there is a chance the
baby may show signs of life l Pyrexia
l this does not mean the baby will l Diarrhoea
survive l Retained placenta
l the baby then needs to be registered l Hypovolaemic shock
as a neonatal death
l Ruptured uterus
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
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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MEDICAL TERMINATION OF PREGNANCY FOR FETAL
ABNORMALITY AND FETOCIDE • 2/2
INTRAPARTUM l For fetus with chromosomal

abnormality, scan features may not
MANAGEMENT
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
fetal heart until cardiac activity stops
Definition
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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MENTAL HEALTH IN PREGNANCY • 1/12
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
carers, and involve if acceptable to l Pervasive feelings of guilt and
woman hopelessness
l consider their needs l 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
ideas, concerns and expectations l Severe insomnia
l Be sensitive to the issue of stigma and l 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
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l If she has violent thoughts, plans, PREVENTION, DETECTION AND
images or impulses keep her and
INITIAL MANAGEMENT
her baby/children safe – see Acute
concerns below l Women at increased risk of postnatal
l Times of high suicide risk: mental illness are those who:
l conclusion safeguarding meetings l develop mental health problems during
this pregnancy
l removal of baby
l have previous history of postnatal
depression
Acute concerns
l with severe and enduring mental illness
l If the woman is at risk of harming herself/
others, ensure she is accompanied and At booking
kept in a safe environment
l In hospital: may be appropriate to call All women
police and/or hospital security staff,
particularly if: l Ask about mental health problems
using standard questions e.g. do you
l large number of people to control have a history of:
l area needs to be cordoned off l past/present mental illness?
l In community: call police, who will take l previous treatment/inpatient care?
woman to a place of safety and request
police surgeon to assess mental health l family history in first degree relative?
l Under common law it is reasonable l Consider asking about anxiety using
to use reasonable force to prevent a the 2-item Generalized Anxiety Disorder
person harming themselves, e.g. trying scale (GAD-2). Over the last 2 weeks,
to jump out of window how often have you been bothered by:
l Doctors can apply section 5(ii) of the l feeling nervous, anxious or on edge?
Mental Health Act (1983) to detain l not being able to stop or control
woman for ≤72 hr worrying?
l If woman is suffering from mental l Document responses in woman’s
illness/lacks capacity physical restraint healthcare record
can be used l If history of previous mental health
l must be proportionate to situation problems established see below
l large bean bag/pillow is ideal
History of severe postnatal
l If the woman is risk to herself/
depression/psychosis
others consider rapid sedation (e.g.
haloperidol 10 mg IM) l Midwife to obtain mental illness history/
l contact obstetric anaesthetist for advice relevant social information from GP
record
l if rapid sedation administered observe
woman for several hours for respiratory l do not rely on the woman’s history
depression, most appropriately alone
achieved where enhanced maternity l Women who have suffered puerperal
care is provided. Monitoring: psychosis have a 50% risk of
– oxygen saturation recurrence
– BP l should be cared for by local perinatal
mental health service or
– ECG
l booked under care of consultant
– RR
obstetrician with an interest in mental
– conscious level and airway assessment health disorders or
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l receive consultant-led care supported l At each postnatal contact ask women
by an appropriate midwife or midwifery about their emotional wellbeing,
team support systems and coping strategies
l If woman currently under care of l use above questions
community mental health team, refer to l encourage women and their families
named care co-ordinator – otherwise, to tell midwife about changes in mood/
refer to relevant community mental emotional state/behaviour
health team to plan postnatal care
l Recognise that women with a mental
health problem may be unwilling to
History of less severe
disclose/discuss their problem because
postnatal depression of:
l Discuss with woman, partner and l fear of stigma
family:
l negative perceptions of them as a
l recognition of symptoms of depression mother
l need to contact GP early l fear that their baby might be taken into
l Encourage: care
l gentle exercise l Avoidance may be associated with
l resting when necessary mental health problem or related to
drug/alcohol dependence
l obtaining help with baby care
l If concern about woman’s mental
l talking to someone about feelings and health, refer to GP/mental health
access to social support networks service for further management
l Consider enhanced schedule of visits
in first 2 weeks Treatment
l 50% of women who become psychotic
do so by day 7, and 75% by day 16 Women at increased risk of suicide are
characteristically white, older women
Detecting current concerns who may be socially advantaged
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

consider referral to local children’s
IN CURRENT PREGNANCY
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.
Connexions and the Youth Service
during pregnancy – signs of
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
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l Use minimal effective dose of drug with l Possibility of sudden onset of symptoms
best evidence base particularly in early puerperium
l If possible avoid polytherapy
When a woman with mental
l If woman has mental health problems
and been under sole care of GP, ask GP illness decides to stop
to review need to continue medication medication discuss:
l Direct communication between mental l Her reasons
health services and obstetric services is l Possibility of:
essential for some women
l restarting
l When talking to the woman about her
medication, explain all women are at l switching to another medication
risk of having a baby with a congenital l psychological intervention
abnormality l Increasing level of monitoring and
l 2–4 in 100 in general population – support
describe risk simply: e.g. 1 in 100 l Ensure she knows risk to herself and
rather than 1% and 1 in 4, not 25 in 100 the fetus/baby of stopping medication
l if possible give written information and l Risk of discontinuation symptoms in
use visual aids woman and baby with most tricyclic
l See Common mental health drugs antidepressants, selective serotonin
and pregnancy below reuptake inhibitor (SSRI) and serotonin
l Complete neonatal alert if required norepinephrine reuptake inhibitor
(SNRI)
l Strongly advise anomaly scan if required
l If a woman has taken medication Eating disorders
with known teratogenic risk in the first
trimester: l Most women with eating disorders
improve during pregnancy but may
l confirm gestation
relapse/develop postnatal depressive
l sensitively explain that stopping symptoms
medication may not remove risk to baby
l Perform GTT at 26–28 weeks’
l offer detailed ultrasound with fetal gestation, due to increased risk of
medicine consultant gestational diabetes
l explain risk to baby if she continues the
medication, balancing against risk of Child protection
discontinuing – see Deciding whether
to stop medication l If concerns about unborn child’s
wellbeing, follow routine safeguarding
Deciding whether to stop procedures
medication l Have a low threshold for referring
women with schizophrenia for
l Severity of mental health problem safeguarding of their unborn child
l Likely benefit treatment options l Some women avoid maternity care
l Previous response to treatment because of concerns about removal
l Background risk of harm to woman, of their child. Extra vigilance and
fetus and baby with no treatment support is required around time of case
conferences and afterwards, especially
l Risk to mental health and parenting
if recommendation is for removal of the
with no treatment
child
l What might happen if medication is
stopped abruptly
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l For complex cases, community mental
Missed appointments
health team will, after discussion with
l If woman with severe and enduring the woman and partner, forward mental
mental health problems misses health joint care plan
appointment: l If direct discussion between obstetric
l make contact to ensure she is well and community mental health teams
required, to include:
l if concerned about her mental health,
contact named mental health care l non-routine action required on admission
co-ordinator (identified on booking in labour and before discharge
letter) by phone, to allow earlier l crisis plan
follow-up by community mental health
l early relapse signs
team
l schedule of monitoring in community
Smoking l roles of professional; who co-ordinates
plan and agrees outcomes with woman
l Offer smoking cessation
l Co-ordinator must ensure:
l success rates equal to those for
l interventions occur promptly
general population
l effective information sharing
Physical symptoms l Share specific plan for delivery with
woman, her family, community midwife,
Women with mental health problems mental health team (in particular
can have serious physical illness. Do named care co-ordinator) and hospital
not assume that all symptoms are obstetric team
attributable to a mental health disorder l clearly display plan in woman’s
healthcare record
Childhood sex abuse l Inform GP of planned postnatal mental
health support
l See Sensitive practice below
l Obstetric team to inform relevant
l If woman discloses a history of sexual
community mental health team
abuse, a careful birth plan is required
consultant secretary when woman
l When discussing labour, it is important delivers, to allow plan to be
to carefully explain: implemented
l what a vaginal examination is and why
it is necessary Contraception
l not all women will achieve normal l Attempt to establish plan for postnatal
vaginal delivery and operative delivery contraception during pregnancy
may be necessary
l discuss various methods of analgesia Breastfeeding and neonatal care
Individual management plan for l Encourage women with a mental health
delivery and puerperium problem to breastfeed, unless they are
taking carbamezepine, clonazepam or
l Devise clear individual management
lithium. Valproate is not recommended
plan for pregnancy, labour and
to treat a mental health problem in
immediate postnatal period
women of child bearing potential
l for most women this happens at birth
l Support each woman in her choice of
planning antenatal appointment
feeding method
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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 Uterotonic 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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MORBIDLY ADHERENT PLACENTA • 1/2
l Discuss the risk of hysterectomy
DEFINITION
l Re-check haemoglobin >32 weeks’
l Placenta adheres to or invades the gestation and, if anaemic, prescribe
myometrium oral iron
l Refer woman to an obstetric anaesthetist
Increased incidence
l If placenta is located over a previous Advice to woman
scar
l If appropriate, inform woman and
l With increasing number of caesarean her partner about the risk of major
sections (CS) haemorrhage and advise to:
l Following myomectomy l avoid sexual intercourse for the
l If previous manual removal of placenta remainder of the pregnancy
from the same placental site l contact maternity triage to attend
Morbidly adherent placenta carries hospital immediately if any vaginal
an increased risk of mortality due to blood loss, contractions, pain or
massive obstetric haemorrhage at suprapubic period-like aches
delivery l ensure someone available at home who
can help and take to hospital if necessary
ANTENATAL CARE
ELECTIVE DELIVERY
l Advise ultrasound scan at 20 weeks’
gestation to determine placental site l Schedule elective CS at 36–37 weeks’
l if scan reveals a low or anterior gestation
placenta with a history of previous CS, l Give antenatal steroids to reduce risk
further ultrasound scan at 32 weeks’ of respiratory distress syndrome
gestation to identify distance from
l Multidisciplinary planning involving
lower edge of the placenta to cervical
consultant obstetrician, consultant
os and determine whether the placenta
anaesthetist and haematologist
overlies the old scar
l Ensure 4–6 units of packed red blood
l report signs of invasion of the scar by
cells available in delivery suite blood
placental tissue
fridge on morning of procedure and
l a colour-flow Doppler ultrasound senior haematologist available for
scan performed by an experienced advice
sonographer is the first line diagnostic
l Experienced neonatologist to be
test
present at birth
l Where the placenta lies over the old
l A scan on morning of procedure may
scar, or in placenta praevia, consultant
be useful in mapping placental site
obstetrician will discuss with woman
(and her partner if appropriate) l Where there is high probability of a
and plan antenatal care including morbidly adherent placenta it may
further imaging and multidisciplinary be appropriate to liaise with an
preparation and delivery interventional radiologist if available
locally
l MRI scan, arranged with a consultant
radiologist, can aid diagnosis and l may be appropriate to insert balloons
clarify depth of invasion in the femoral arteries before
procedure as a prophylactic measure
l Since up to 40% of cases are likely to
for inflation in the event of postpartum
require emergency delivery, place a
haemorrhage. Particularly appropriate
clear care plan in woman’s healthcare
for women who will not consent to a
record and hand-held notes
blood transfusion
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MORBIDLY ADHERENT PLACENTA • 2/2
l Set up cell salvage if used routinely, or l there is reduced need for transfusion
arrange a perfusionist to facilitate cell if no attempt is made to remove the
salvage if required placenta both before hysterectomy and
l Ensure local availability of enhanced before leaving placenta in situ
maternity care after surgery l If plan of care is to manage the
placenta in situ conservatively, unclamp
Consent the cord and drain the placenta of
blood before tying off and dividing the
l Must be taken by a consultant cord as close to its insertion into the
obstetrician who will discuss blood placenta as surgically practicable
transfusion, hysterectomy, admission
l Close the uterus in the routine way or
to critical care and the possibility of
proceed directly to hysterectomy
leaving the placenta in place. It will
include routine consent for CS l If the placenta separates, partially
adherent portion(s) can be left in place.
l If placenta left in situ – pregnancies
Heavy blood loss can occur – see
have been reported after this approach
Postpartum haemorrhage guideline
but so have cases of delayed
haemorrhage and hysterectomy
Postnatal care
Procedure l Provide enhanced maternity care after
delivery. Do not transfer to postnatal
l Consultant obstetric anaesthetist will
ward for ≥2 hr after delivery
determine and administer type of
anaesthetic l Regularly assess uterine fundus
and observe carefully for signs of
l Consultant obstetrician must perform
haemorrhage. Where a placenta totally
CS
covering the cervical os is left in situ, it
l It may be appropriate to open the lower can conceal bleeding within the uterine
segment of the uterus, thus leaving cavity. In this situation, woman should
a lower segment scar only. However, remain on delivery suite for 24 hr
it may be appropriate to access the
uterine cavity deliberately avoiding Management when placenta left
the placenta. This requires knowledge in situ postnatally
of the limits of the placental site. This
approach allows an assessment of l Carries risk of infection and
placental adherence without heavy delayed haemorrhage. Ensure
bleeding before a definitive decision is woman understands the need for
made a commitment to hospital visits for
l If the placenta separates, the operation clinical checks, blood tests and
continues as normal possibly imaging
l If it remains adherent, there are 2 l 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
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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 Twin-to-twin transfusion in monozygotic l 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 Follow local antenatal care pathway l if TTS suspected, refer to local fetal
medicine consultant
l For many women a multiple pregnancy
will be detected only after first l Dichorionic pregnancy and
ultrasound scan monochorionic pregnancy >24 weeks:
l If multiple pregnancy suspected arrange l 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
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 biophysical profile 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
spontaneous birth <37 weeks l On admission, inform middle grade
l elective birth ≥36 weeks for staff grade, clinical fellow) and consultant
monochorionic twins, and ≥37 weeks
for dichorionic twins, does not appear l 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 36 weeks for monochorionic l 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
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l Insert IV cannula and flush l Continuous electronic fetal monitoring
l Take blood for FBC and group and l Determine presentation and lie
save l Monitor vaginal loss
l Review obstetric records, fetal l Perform abdominal palpation to
presentation and plan for delivery determine presentation. At the same
l discuss plan of care with parents and time, perform a vaginal examination –
document in maternal healthcare record preferably by middle grade obstetrician
l While respecting woman’s choice, (ST3–7 or equivalent e.g. staff grade,
encourage her to use epidural analgesia clinical fellow) or consultant to allow
to facilitate delivery in the event of internal interventions, if appropriate, without
manoeuvres or urgent instrumental repeat examination
delivery becoming necessary l where second twin was not cephalic
l If oxytocin required to accelerate in first stage of labour, it may be
labour [prescribed by middle grade appropriate to deliver the woman
obstetrician (ST3–7 or equivalent e.g. in lithotomy to allow rapid vaginal
staff grade, clinical fellow) or consultant examination of second twin and
only], use with caution perform interventions as required
l Stabilise second twin as longitudinal lie
Second stage of labour l Prepare ultrasound machine in case
required to confirm position of second
Ensure twin
l Experienced obstetric consultant, l If necessary, perform external cephalic
middle grade obstetrician (ST3–7 or version
equivalent e.g. staff grade, clinical l If necessary, perform internal podalic
fellow), neonatology team and midwives version and breech extraction before
are present in room at delivery cervix can shrink
l Appropriate equipment, including: l If any delay in resumption of effective
l ultrasound machine uterine contractions, start oxytocin
infusion according to local practice at
l resuscitation equipment
maximum rate
l Anaesthetist and theatre team on
l If vertex or breech in pelvis, perform
standby on labour ward
artificial rupture of membranes at peak
l In the case of CS, 1 midwife per baby of contraction
is designated to receive the babies
l After delivery of second twin, place 2
l Oxytocin as per local practice clamps on umbilical cord
l If all normal, midwife will carry out
delivery, otherwise middle grade Active management of third
obstetrician (ST3–7 or equivalent e.g. stage of labour
staff grade, clinical fellow) or consultant
will perform l Routine active management third
stage, see Third stage of labour
l Deliver twin 1 and place 1 clamp on guideline. In addition:
umbilical cord
l oxytocin infusion as per local practice
Delivery of second twin l cord gases
l because of risk of haemorrhage, avoid
l Aim to deliver second twin ≤30 min
too rapid transfer to postnatal ward
l risk for second twin increases steeply
as time passes from delivery of first
twin
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NEUROLOGICAL DEFICITS AFTER REGIONAL ANAESTHESIA OR
ANALGESIA • 1/4
l Reconsider the use of large volumes
INTRODUCTION
for epidurals in the presence of spinal
l Neurological deficits after regional stenosis
anaesthesia or analgesia: l Chlorhexidine 0.5% in alcohol spray is
l can be temporary or permanent the skin preparation of choice
l have a variety aetiologies; caused l single spray is adequate
directly/indirectly l allow to dry completely
l Advise women about the risks, l do not splash chlorhexidine on spinal
including neurological deficit, before or epidural needles
administrating regional anaesthesia or
l If, on performing central nerve blockade
analgesia
(CNB), there are recurrent, persistent,
bilateral or severe symptoms of
PRE-EXISTING NEUROLOGICAL dysaesthesia, reconsider further attempts
DEFICITS
l Prevent prolonged periods of
l May increase risk of new and hypotensive episodes to maintain
progressive post-operative neurological spinal cord perfusion
complications l Follow local guidance for regional
l Risk-benefit assessment to be carried blocks and regional anaesthesia for the
out in women with: anticoagulated woman
l pre-existing central nervous system l Avoid neuroaxial procedures in the
(CNS) disorders: e.g. multiple sclerosis septic woman (discuss with on-call
l diabetes mellitus consultant anaesthetist) or in the
presence of localised infection
l spinal stenosis or mass in spinal canal
l When topping up with heavy
l extremes of body habitus
concentration of local anaesthetic,
position the woman appropriately
EPIDURAL AND SPINAL
l obese – lateral tilt and ramped-up position
ANAESTHESIA AFTER MAJOR
SPINAL SURGERY l non-obese – shoulders raised
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
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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
as: saddle anaesthesia, urinary l 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
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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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ANALGESIA • 4/4
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
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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
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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
venepuncture/ tube defect
l Increased risk of
abdominal emergency caesarean l Admission to
examination/ section (CS) neonatal intensive
blood pressure care unit (NICU)
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)
risk assessment and follow VTE
EQUIPMENT
thromboprophylaxis guideline
l Adequate doorway widths and thresholds
l Early booking visit to antenatal clinic to
l Theatre trolley and operating table able plan pregnancy
to take weight >180 kg
l Examination and ultrasound couch At booking
able to take weight >180 kg
l Delivery and ward bed able to take l Measure height and weight and
weight >180 kg calculate BMI for all women
l Moving equipment e.g. hover mattress l note interpregnancy weight change
or hoist l Record arm circumference (to ensure
l Large chairs without arms appropriate BP cuff used) in maternal
l Large wheelchairs healthcare record
l Calibrated weighing scale
Arm circumference
l Height measuring equipment Cuff range at midpoint
l Range of epidural and spinal needles, (cm)
including extra-long
Adult 27–34
l Appropriately sized thromboembolic
stockings Large adult 35–44
l Appropriately sized theatre gowns Adult thigh cuff 45–52
l Large blood pressure cuffs
l Assess VTE risk
MANAGEMENT BEFORE
l if low molecular weight heparin
CONCEPTION
indicated, give weight appropriate dose
l Offer pre-pregnancy counselling on
l Inform scan department of need
lifestyle, diet and smoking cessation
for appropriate couch and longer
l encourage women who wish to lose appointment time (if local practice)
weight to follow a weight reduction
programme and take regular exercise l Anticipate requirement for specific
≥2–3 months before pregnancy equipment during labour and document
in maternal healthcare record
l consider referral to dietitian
l consider referral to smoking cessation
Prophylaxis treatment
advisor (if available)
l Screen for diabetes l Advise vitamin D supplement (‘Healthy
l High dose folic acid 5 mg/day for Start’ vitamins)
3 months before conception l Severely obese women (BMI
l Record blood pressure >35 kg/m2) plus 1 additional risk factor
for hypertensive disease, prescribe
Obese women require the same
aspirin 75 mg/day from 12 weeks’
routine antenatal, intrapartum and
gestation
postnatal care as all other women
Discussion with woman
INITIAL ANTENATAL CARE l Explain significance of BMI to woman.
Provide advice on weight management,
l Refer for consultant-led care and advise
including lifestyle and diet
woman to give birth in a consultant-led
unit l where available, give written information
on diet and risk of obesity in pregnancy
l if woman requests home birth, inform
professional midwifery advocate (PMA)
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l Refer to dietitian and/or weight
Assessment
management programme according to
local protocol l Consider likelihood of difficult
l advise ≥30 min/day moderate physical intubation and airway management –
activity (e.g. walking, swimming, see General anaesthesia and failed
aqua-natal) on ≥5 days/week intubation guideline
l Refer for smoking cessation l Other comorbidities may impact on
anaesthesia:
l Advise breastfeeding
l hypertension
Communication l ischaemic heart disease
l respiratory distress
l Complete local alert form
l sleep apnoea
l Discuss with manual handling l diabetes
department to ensure appropriate
equipment available l assess difficult IV cannulation and
lumbar anatomy
l Inform senior delivery suite midwife
l Assess on individual basis and
to ensure availability of appropriate
according to local protocol
equipment – see Environment and
equipment
Management
l If mobility reduced, seek advice from
manual handling department l If anaesthetic or airway management
problems anticipated, ask anaesthetist
SUBSEQUENT ANTENATAL CARE to review who will:
l document plan of care clearly in
l Routine antenatal care and:
l it may be appropriate to re-weigh
l discuss plan of care with woman
woman in third trimester
l serial ultrasound scan for fetal growth INTRAPARTUM CARE
l increased risk of gestational diabetes –
book GTT at 26–28 weeks’ gestation l Individual plan of care depending on
woman’s needs
l If admitted to hospital or other
intercurrent problems develop, repeat l Review antenatal anaesthetic
VTE risk assessment assessment and obstetric plan
l In third trimester with BMI >40 l Tissue viability assessment and manual
handling assessment for labour as per
l provide information about tissue
local practice
viability
l Notify duty anaesthetist and middle grade
l manual handling assessment
obstetrician (ST3–7 or equivalent e.g. staff
l Offer continued advice and support. grade, clinical fellow) of admission
Encourage weight gain to be kept to
l Cannulate using wide bore cannula
7–10 kg
(BMI >40)
ANAESTHETIC ASSESSMENT l Bloods for FBC and group and save
AND MANAGEMENT (BMI >40)
l Risk assessment for thromboembolism,
l If BMI >40 refer to anaesthetist (give document and follow plan
anaesthetics information leaflet if
available locally) l thromboembolic stockings (if local
practice)
l Early epidural may be required for
regional analgesia
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l a suction drain can be left above
Monitor
sheath, and interrupted sutures can be
l Fetal monitoring – see Electronic fetal used for skin
monitoring (EFM) guideline l Use correct equipment for patient
l where difficulty monitoring fetal heart with handling including theatre table and
EFM, apply fetal scalp electrode (FSE) bed – see Equipment
l If uncertainty about fetal presentation,
consider ultrasound scan POSTPARTUM CARE
l Monitor progress in labour closely. Be l If operative delivery, consider transfer
aware of increased risk of shoulder to high dependency area for immediate
dystocia and postpartum haemorrhage postnatal care – see High dependency
(BMI >40) care guideline
First and second stage l Thromboembolism risk assessment
immediately after delivery
of labour
l thromboprophylaxis – see VTE –
l Keep as mobile as possible Thromboprophylaxis guideline
l Maintain hydration l adequate analgesia to allow early
l Antacid (e.g. ranitidine) as per local policy mobilisation
l Pressure area care l thromboembolic stockings
l If instrumental delivery contemplated, l encourage good hydration
consider performing trial in theatre l If intrathecal opiates not used, consider
with an experienced obstetrician patient controlled analgesia (PCA)
(following usual discussion of risks and
l Obesity carries increased risk of
alternatives). Obesity is a recognised
postnatal wound and genital tract
predictor of abandoned trial, shoulder
infection. Encourage good hygiene and
dystocia and birth injury
monitor for signs of infection
Third stage of labour l If CS carried out, observe for wound
infection, wound dehiscence, DVT, PE
l Active management and chest infection
l Oxytocin infusion over 4 hr following
delivery to reduce risk of postpartum PLAN FOR DISCHARGE
haemorrhage l Continue to encourage healthy eating
l Care when putting woman in lithotomy and exercise, reinforcing benefits of a
to avoid tissue damage healthy BMI for future wellbeing and
subsequent pregnancies. Consider
Caesarean section (CS) dietitian referral
l Consider referral to physiotherapist
l If CS considered – seek advice
from consultant obstetrician and l Unless contraindicated, encourage
anaesthetist – see Caesarean section breastfeeding. Obese women have
guideline decreased rates of breastfeeding
(initiation and maintenance) but it can
l Administer antibiotic prophylaxis at
help with postnatal maternal weight
time of surgery
loss
l Due to risk of poor wound healing,
l Postnatal visiting schedule based on
especially if BMI >40, use delayed
individual needs
absorbable suture e.g. PDS for rectus
sheath closure l Offer family planning and contraceptive
advice
l close subcutaneous fat to prevent
wound infection and dehiscence
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OPERATIVE VAGINAL DELIVERY • 1/3
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

unsupervised only by those trained and
DELIVERY IN THEATRE
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 vacuum extraction 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
l Swabs, needles, tampons (if used) to
be counted before and on completion
of procedure
l Record of incident report (if local
practice)
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OXYTOCIN • 1/2
INDICATIONS Monitoring
l Induction of labour after artificial l Monitor fetus by continuous electronic
rupture of membranes (ARM) fetal monitoring (EFM)
l Acceleration/stimulation of labour l if EFM non reassuring or abnormal,
after pre-labour rupture of membranes stop oxytocin until assessment by
(PROM) middle grade obstetrician (ST3–7 or
l prostaglandin induction may be equivalent e.g. staff grade, clinical
appropriate before this – see fellow)
Pre-labour rupture of membranes l Perform routine maternal observations
(PROM) guideline – pulse, blood pressure and
l Augmentation when rate of progress in temperature and record in partogram
labour is considered unsatisfactory – l Perform vaginal examination ≤6 hr
see Delay in labour guideline after start of oxytocin and record
l For prevention of postpartum planned timing of next vaginal
haemorrhage following delivery where examination
there is an increased risk of bleeding l Record individual management plan in
– see Postpartum haemorrhage intrapartum notes
guideline
OXYTOCIN REGIMEN
Assessment before oxytocin
l Administer oxytocin through an
l Before commencing oxytocin, midwife infusion pump or syringe driver using a
must confirm presentation is cephalic Y-connector. This acts as a non-return
and membranes are ruptured valve to minimise risk of oxytocin being
forced up into a second infusion and
Before commencing oxytocin on
flushed through later as a bolus
a multiparous woman for delay in
labour, an obstetrician of at least l Use local regimen for oxytocin
middle grade (ST3–7 or equivalent l Increase infusion rate at ≤30 min
e.g. staff grade, clinical fellow) status intervals and by no more than the
must personally assess woman and steps in the table, until contractions are
perform abdominal palpation and adequate
vaginal examination l There should be <4–5 contractions
every 10 min
l If previous caesarean section, the use
of oxytocin should be or have been l Once contractions established,
discussed with a consultant especially in a parous woman, it may
be possible and desirable to stop
Contraindications the infusion. Experience in the use of
oxytocin is to be valued – seek the
l Non-rupture of membranes advice of midwife co-ordinator and
l there are rare exceptions but these are middle grade obstetrician (ST3–7 or
consultant decision only equivalent e.g. staff grade, clinical
fellow) or consultant early
Do not commence oxytocin within
6 hr of administration of
prostaglandin gel or tablet or
≤30 min of removal of Propess
pessary to prevent hyperstimulation
– see Induction of labour guideline
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OXYTOCIN • 2/2
Suggested regimen
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
l If stopping oxytocin does not correct
hyperstimulation, consider tocolysis
with terbutaline 250 microgram SC
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PERINATAL BEREAVEMENT • 1/7
INTRODUCTION Signs of life
l A parent’s relationship with their l A live birth is the delivery of a baby,
baby can begin long before birth. It is irrespective of duration of pregnancy,
possible for parents to grieve for babies which, after delivery, breathes or shows
who die before birth, who are born and, any other evidence of life, such as beating
for whatever reason, cannot survive of heart, pulsation of umbilical cord,
and where pregnancy is terminated or any definite movement of voluntary
owing to abnormality muscles, whether or not umbilical cord
l When a pregnancy ends or a baby has been cut or placenta attached
dies, for whatever reason, there are a l it is important to distinguish between
number of shared elements and needs involuntary, physiological movements
in the parents’ experience of loss. Some and signs of life. Observed movements
aspects of grief are individual and such as jerk of a limb, or occasional gasp
very private, but should be supported are not necessarily signs of life. Parents
by healthcare professionals. Aim to should be advised before birth, that this
support parents and facilitate, as far as may happen. In these circumstances
is possible, their individual needs explain formal registration of neonatal
l do not make assumptions about what death is not appropriate
each parent will feel, want or need l Required elements of care will depend
on circumstances of loss:
Treat parents and baby with respect,
sensitivity and dignity at all times. l termination of pregnancy for fetal anomaly
Inappropriate care can lead to l fetal loss <24 weeks’ gestation
immense dissatisfaction and
l stillbirth
additional trauma
l neonatal death
DEFINITIONS l Complete appropriate local checklist
for particular circumstance to ensure
Intrauterine death (IUD) no aspect of care is overlooked, even
if woman chooses to decline some
l The absence of cardiac activity before
management options
birth
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,
or where an intrauterine death is l 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
sepsis), offer the choice to go home
Neonatal death
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
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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
later discover is incorrect l 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
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Recommended drug regimen Side effects of misoprostol
Initial drug dose l Pyrexia

l Diarrhoea
l Mifepristone (Mifegyne RU 486)
200 mg oral administered by middle l 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
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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
discuss this with the woman
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
equivalent e.g. staff grade, clinical l 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
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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 In all cases there must be evidence
REGISTRATION
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
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PERINEAL TRAUMA SUTURING (TEARS AND EPISIOTOMY) • 1/3
INTRODUCTION DEFINITION
l Perineal trauma may occur Anterior perineal trauma
spontaneously during vaginal birth or Injury to labia, anterior vagina, urethra or
by a surgical incision (episiotomy). It clitoris
is possible to have an episiotomy and
a spontaneous tear (for example, an Posterior perineal trauma
episiotomy may extend into a third Injury to posterior vaginal wall, perineal
degree tear) muscles or anal sphincters – may include
l >85% of women who have a vaginal disruption of the anal epithelium
birth will sustain some degree of Classification of perineal tears
perineal trauma and of these 60–70% Midwife/doctor must identify the extent
experience suturing of perineal trauma and document it
according to the agreed classification
Definition of spontaneous tears
First degree Second degree Obstetric anal sphincter injury
l Injury to skin only l Injury to perineum l Injury to perineum involving anal
involving perineal sphincter complex
muscles but not l 3a: <50% of external anal sphincter
involving anal (EAS) thickness torn
sphincter l 3b: >50% of EAS thickness torn
l 3c: EAS and internal anal sphincter
(IAS) torn
See also Third and fourth degree
perineal tears - OASIS guideline
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
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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
healthcare record: l 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
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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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POSTPARTUM HAEMORRHAGE (PPH) • 1/6
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 Altered mental state
haemorrhage
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
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
bloods for FBC, clotting screen, group l 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 fundal massage. 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 Transfuse crossmatched packed cells
Fluids and fluid balance
as soon as possible if required
l Give fluids – compound sodium l Use best available device to deliver
lactate (Hartmann’s) solution 1 L stat warmed fluids rapidly
l Follow with blood, colloid or crystalloid l do not use blood filter
as indicated by availability, blood loss
l In a dire emergency while awaiting
and woman’s haemodynamic state
crossmatched blood, consider
l Do not give >3.5 L clear fluids, ideally requesting type specific blood or O
warmed [up to 2 L compound sodium negative blood
lactate (Hartmann’s) solution and 1.5 L
l If red cell antibodies present, liaise
colloid] while waiting for blood
closely with blood bank
l Insert urinary catheter with hourly
l Fresh frozen plasma (FFP) usually
urinometer attached and maintain urine
required if 4 units of packed red cells
output >0.5 mL/kg/hr
are given
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 If surgery to be carried out for major
Oxygen
PPH, it is usual to obtain consent for
l 15 L/min oxygen via face mask initially, hysterectomy
with woman lying flat l Involve consultant with greater
gynaecological surgical experience
Monitoring in complex cases. If available locally,
l Attach non-invasive blood pressure cuff consider contacting interventional
radiologist
l Monitor every 15 min and record on
MEOWS or HDU chart; act on promptly
Repeat blood tests
when there is deterioration in parameters
l BP l FBC
l pulse l APTT, PT (INR), fibrinogen
l SpO2 (maintain at >95%) l Ca2+
l respiratory rate l Blood gases including lactate
l urine output and fluid balance
Reassess
l core temperature
l State of haemorrhage and woman’s
Inform physiological state after initial
resuscitation
For massive obstetric haemorrhage,
use local trigger phrase to Central venous and
communicate the seriousness of the arterial lines
situation clearly
l If continuing haemorrhage (or
l Consultant obstetrician (who will haemorrhage >40 mL/kg), or need to
usually attend as soon as possible) go to theatre for second time, insert
l Consultant anaesthetist CVC and arterial lines (and monitor
l Theatre team (even if not immediately CVP and BP directly)
going to theatre) l Use early if cardiovascular system
l Haematology biomedical scientist compromised by disease
to allow them to prepare for major
haemorrhage Hypocalcaemia
l Haematologist if: l Suspect if massive (>10 units blood)
l blood products other than 4 units of transfusion with ongoing hypotension,
packed cells and 4 units of FFP are check Ca2+. Give calcium gluconate
required, or 10% 10–20 mL by IV infusion over 10
l if there is ongoing haemorrhage after min. Ensure ECG monitoring when
this has been given or administering calcium gluconate
l if clotting studies are abnormal
l Consider involving surgical colleagues
Support for woman
as required and family
l Ideally, midwife should remain with
Specific treatment woman and family throughout the
l For causes of haemorrhage (4 T’s) emergency situation
including surgery – see Tone (uterine
atony), Trauma, Tissue and Thrombin
below
l commonest cause is uterine atony
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l ergometrine 250 microgram IM with an
POST-EVENT
antiemetic [contraindicated in pregnancy
l As soon as practically possible after induced hypertension (PIH) or other
a massive haemorrhage, consultant significant cardiovascular disease]
obstetrician should counsel woman and l carboprost (Hemabate®) 250 microgram
her family providing explanation and IM or intramyometrially (unlicensed)
significance of cause of haemorrhage – repeated up to every 15 min to
maximum of 2 mg (unusual to reach
Thromboprophylaxis maximum dose)
l These women are at increased risk of l misoprostol 800 microgram
thromboembolism, whilst being nursed sublingually or 1 mg PR, if used locally
in HDU, consider thromboembolic
stockings and other methods of Continuing bleeding
mechanical thromboprophylaxis
l If above measures fail to prevent
l Unless advised to be inappropriate by
ongoing or recurrent bleeding, suspect
consultant obstetrician/anaesthetist,
Trauma, Tissue (e.g. retained products
give LMWH regardless of mode of
of conception) or Thrombin (e.g. a
delivery once bleeding has settled
coagulopathy)
Non steroidal l If pharmacological measures fail
anti-inflammatory drugs to control bleeding, initiate surgery
sooner rather than later
l Contraindicated for ≤12 hr after
haemorrhage has settled and platelet l Consider surgical examination under
count and renal function are normal anaesthesia
l if woman haemodynamically stable,
Documentation use pre-existent regional (epidural)
anaesthesia
l Carefully document:
l if woman not stable or (dilutional)
l times coagulopathy present, use general
l drugs, fluids and blood products anaesthesia
administered l If bleeding still not controlled,
l personnel consider uterine cavity balloon
l use of trigger phrase tamponade, haemostatic brace suture,
hysterectomy, uterine artery ligation/
l Complete incident forms as required
embolisation by an interventional
radiologist
A TONE (UTERINE ATONY)
l A consultant obstetrician must be
Immediate management involved
l A second consultant opinion before
l Fundal massage, empty bladder and hysterectomy can be helpful, but
consider bimanual uterine massage hysterectomy should be performed
l Oxytocin – start oxytocin infusion. sooner rather than later
Use local regimen for postpartum via
volumetric pump B TRAUMA
l Remember to inspect vulva, vagina and
cervix for trauma/lacerations Inverted uterus
l Consider: l Degree of haemodynamic shock is
l a first or repeat dose of oxytocin 5 or often disproportionate to the volume of
10 units slow bolus IV or 10 units IM the haemorrhage
(unlicensed)
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l Replace uterus as soon as possible
D THROMBIN
using manual, hydrostatic or surgical
methods Inherited coagulopathies
l Anticipate massive haemorrhage
l Several inherited conditions will
l Some women may experience a
give rise to excessive peripartum
vasovagal episode (hypotension and
haemorrhage if incorrectly managed
bradycardia) during uterine replacement
and not detected antenatally.
l Run an oxytocin infusion using local Seek advice from consultant
regimen for postpartum for ≥4 hr after haematologist at earliest opportunity
replacement (ideally antenatally) about the
investigation and treatment of these
Uterine rupture varied and uncommon conditions
l See Uterine rupture guideline
Acquired coagulopathies
Perineal trauma l Will often represent a form of
Disseminated Intravascular
l See Third and fourth degree Coagulation (DIC) and will usually
perineal tears – OASIS guideline and result in continuing or worsening
Perineal trauma suturing (tears and haemorrhage without blood product
episiotomy) guideline replacement therapy
l Suspect DIC in abruption, severe PIH,
Other
prolonged +/- infected retained fetus/
l Broad ligament haematoma products of conception, amniotic fluid
embolism or prolonged/untreated
l Extra genital bleeding e.g. sub capsular
hypovolaemic shock
liver rupture
l FBC, PT, INR, APTT, and APTTR in the
C TISSUE first instance in all those conditions
where there is a known associated
Retained placenta complication of DIC
l If platelet count <50 x 109/L or INR
l See Retained placenta guideline >1.6, check fibrinogen and fibrinogen
degradation products (FDP) levels
Placenta
l Give FFP, platelets, +/- cryoprecipitate
accreta/increta/percreta
as directed by investigations
l See Morbidly adherent placenta l Seek advice of consultant
guideline haematologist about treatment and
l If attempts are made to separate further investigations
adherent placenta (surgically/forcibly),
expect massive haemorrhage
l If expected or actual haemorrhage,
follow management plan for major
obstetric haemorrhage
l 1 option, after consultant review,
is to leave the placenta in situ and
monitor woman very closely for signs
of infection and bleeding in postnatal
period
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PREGNANT WOMAN WITH A NON-OBSTETRIC PROBLEM
(MANAGEMENT OF) • 1/1
l If the disease causes reduced mobility,
INTRODUCTION
consider VTE prophylaxis. Use local
l Assessment and management of obstetric VTE assessment tool
disease unrelated to the pregnancy are l Use early warning scoring system
altered by the pregnancy (MEWS) to help in the timely
l The need to consider 2 patients recognition, treatment and referral of
(mother plus fetus) may change women who have or are developing
treatment decisions critical conditions
l Anatomical and physiological changes
in pregnancy result in altered: Contact
l clinical features during CVS and l If ≥16 weeks’ gestation, contact
respiratory system and abdominal delivery suite co-ordinator, who will
examination advise which healthcare professional(s)
l biochemical and haematological values should review, if necessary after
l pharmacological management discussion with on-call obstetric middle
l response to any systemic pathology grade obstetrician (ST3–7 or equivalent
l protocols for the management of
critical illness l If any severely ill pregnant woman is
admitted outside the maternity service:
AIM l contact on-call middle grade
l To ensure obstetrician/consultant obstetrician
l every pregnant woman admitted is l if she is critically ill, or likely to need
managed promptly urgent surgery, refer early to critical
care team and/or anaesthetist
l communication link is established
between admitting team and obstetric l By giving consideration to the
team so that the most appropriate care pregnancy and the fetus, maternity
can be delivered service providers can help with:
l assessment of maternal and fetal
ACTIONS wellbeing
Accident and emergency l investigations
l treatment
l Ask apparently pregnant woman
presenting to Emergency department l Be aware of the significance of
for any reason (irrelevant of gestation) hypertension and proteinuria in
if she has booked for maternity care pregnant women
l if not booked for maternity care, inform Radiological investigations are not
delivery suite co-ordinator, who can contraindicated during pregnancy
advise on appropriate follow-up and where there is a significant clinical
booking arrangements indication. Discuss with obstetric team
l In cases of trauma or vaginal bleeding
at any gestation, give consideration to
woman’s blood group and need for
Documentation
anti-D. If in doubt, discuss with on-call l Document all communication
middle grade obstetrician (ST3–7 or (including inter-departmental)
equivalent e.g. staff grade, clinical fellow) in maternal healthcare record,
highlighting pregnant or newly
Nursing delivered woman’s attendance or
l To prevent aortocaval compression, do admission to non-midwifery ward or
not nurse women in the second and department
third trimester in supine position
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PRE-LABOUR RUPTURE OF MEMBRANES (PROM) AT TERM • 1/2
l Rupture of membranes before onset of
Indications for immediate IOL
labour ≥37 weeks’ gestation
l majority of women will labour l Induce labour immediately if:
spontaneously within 24 hr of PROM l maternal pyrexia
l PROM is associated with an increased l fetal distress
risk of intrauterine infection
l significant meconium stained liquor
RECOGNITION AND l blood stained liquor
ASSESSMENT l requiring group B streptococcus
prophylaxis
History and examination l HIV positive mother
l Take a careful history l unstable presenting part
l Full antenatal assessment, including l maternal choice
fetal and maternal observations and
abdominal palpation to confirm fetal lie MANAGEMENT
and presentation
l Assess fetal wellbeing As time between rupture of
membranes and onset of labour
l Speculum examination and indicator
increases, so does the risk of
swab test (if used locally), or pad test
maternal and fetal infection
(if used locally) is only required if there
is doubt about whether membranes
have ruptured Expectant management
l If contractions absent, do not perform l Until IOL commenced or if woman
digital vaginal examination, unless chooses expectant management
result necessary to guide or alter beyond 24 hr, care can be inpatient or
management outpatient
l Electronic fetal monitoring (EFM) 24 hr l Advise women that:
after PROM or earlier if other indications
e.g. decreased fetal movement l the risk of serious neonatal infection is
1%, rather than 0.5% for women with
intact membranes
Assessment and indications
for immediate induction of l 60% of women with PROM will go into
labour (IOL) labour within 24 hr
l IOL is appropriate approximately 24 hr
l When forming management plan, after rupture of membranes
determine if immediate IOL is
necessary – see below l If labour not started after 24 hr
of ruptured membranes, arrange
l consider duration of ruptured induction
membranes
l Until induction is started, or if expectant
Risk factors for intrauterine management beyond 24 hr is chosen
by the woman:
infection
l assess fetal movement and heart rate
l Maternal group B streptococcus status at initial contact and then every 24 hr
l Presence of meconium in amniotic fluid l do not offer lower vaginal swabs and
l Increasing time from rupture measurement of maternal C-reactive
l Number of vaginal examinations protein
l Use of internal monitoring

l Length of labour and mode of delivery
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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 If labour has not started 24 hr after l 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 Provide woman with information leaflet l Perform Neonatal Early Warning Score
before discharge home observations
l Include assessment of following – if
Evidence of infection in mother any abnormality or any of these are
observed, request assessment by a
l Prescribe broad spectrum antibiotics – neonatologist
as per local practice l temperature
l Babies born with symptoms of possible l heart rate
sepsis or to a woman with evidence
of chorioamnionitis, immediate l respiratory rate
referral to neonatologist (see Group B l presence of respiratory grunting
streptococcal disease guideline) l significant subcostal recession
l presence of nasal flare
Induction and delivery
l presence of central cyanosis,
l For women with previous caesarean confirmed by pulse oximetry if available
section (CS) – see Induction of labour l skin perfusion assessed by capillary refill
guideline
l floppiness, general wellbeing and
l Discuss with woman and explain feeding
procedure
l If there are no signs of infection in the
l Use either oxytocin or prostaglandin woman – see Sepsis guideline, do not
l On admission, perform digital vaginal give antibiotics to either her or baby,
examination using aseptic technique even if membranes have been ruptured
l if cervix unfavourable, use for over 24 hr
prostaglandin (see Induction of labour l If there is evidence of infection in the
guideline) – follow local practice woman, prescribe a full course of
l If local practice, consider antibiotic broad-spectrum intravenous antibiotics
prophylaxis to baby
l After 24 hr from membrane rupture l Refer baby with any symptom of
(if not already in established labour), possible sepsis, or born to woman
perform EFM with evidence of chorioamnionitis, to
neonatal care specialist immediately
l Perform EFM in labour
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PRETERM LABOUR • 1/6
l Palpate for contractions
INTRODUCTION
l note strength and frequency/
l Preterm birth is the most important tenderness
single determinant of adverse infant
l In all cases seek an underlying cause
outcome
e.g. placental abruption, infection
l preterm defined as delivery before 37
l >26 weeks’ gestation: perform CTG
completed weeks
l Perform speculum examination and 1 of
RISK FACTORS the following:
l fetal fibronectin test: avoid using gel
l Previous preterm birth with speculum – use only use sterile
l Infection/inflammation of genital tract water (see below)
l Cervical weakness l cervical length scanning: if cervical
l Uterine abnormality length is ≤15 mm, consider diagnosis
of preterm labour and offer treatment
l Substance abuse
l if extent of cervical dilatation cannot be
l Multiple pregnancy assessed: digital vaginal examination
l Polyhydramnios - to be performed by middle grade
l Bleeding/thrombosis obstetrician (ST3–7 or equivalent
l Early stress e.g. staff grade, clinical fellow) or
consultant only
l Low BMI
- only indicated if regular contractions
l Short conception cycle <1 yr are palpable
l Aged <17 and >35 yr - if pre-labour rupture of membranes
has occurred avoid digital vaginal
DIAGNOSIS AND ASSESSMENT examination
l Explain to woman: clinical assessment,
l All women with suspected preterm
available diagnostic tests, and how
labour/preterm ruptured membranes
these will be carried out
<34 weeks’ gestation to be assessed
by middle grade obstetrician (ST3–7 Test for preterm labour
fellow) or consultant l Follow manufacturer’s instructions
l Any woman <29 weeks’ gestation to l Only valid 23–35 weeks’ gestation
be seen by consultant obstetrician l To reduce the risk of false positive
within 24 hr of admission results use only water as lubricant for
l Confirm gestational age speculum examination
l Take thorough history l Take swab from posterior fornix before
any other vaginal/cervical swab or
l Record digital examination
l maternal temperature l Not indicated if evidence of membrane
l pulse rupture
l blood pressure l Do not use test if moderate/gross
l respiratory rate bleeding, or in women with suspected
placenta praevia or abruption
l MEOWS score
l If sexual intercourse has occurred in
l Perform abdominal palpation to the previous 24 hr, may be difficult to
determine presentation interpret
l if in doubt confirm using portable l Record result in hospital maternity care
ultrasound machine record
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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 Consider repeat FFN in ANC
≥500 50 75 l Admit
l Betamethasone with tocolysis
l MgSO4 if <30/40
Diagnosing preterm pre-labour l If the results of test for P-PROM are

positive, take into account clinical
rupture of membranes (P-PROM)
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
l HVS and endocervical swab for
MANAGEMENT OF P-PROM
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
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l Check availability of neonatal cots –
Follow-up
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 Discuss with consultant l 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
steroids have been given
or consultant to discuss with the woman l Consider giving ≤33+6 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
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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 facial flushing l 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 Monitor oxygen saturation continuously l If labour progresses, stop tocolysis
with pulse oximeter
Issue 4
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dependent on gestation
Nifedipine regimen
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
pressure in normotensive women) l 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
Atosiban regimen – 2nd line exposed, un-ruptured fetal membranes
l take into account gestational age
Initial treatment
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 See Extreme prematurity (<28
(up to 48 hr – via infusion pump)
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
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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 cardiotocography 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
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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 Ensure appropriate equipment is l blood pressure

available in recovery room and l 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
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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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RECOVERY • 3/3
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 stage of recovery
postnatal ward
l nature of surgery
l May require further intensive
observations on delivery suite following l 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)]
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 Use this guideline in conjunction with l pain and sedation levels
your local MEWS system l nausea and vomiting
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REFUSING BLOOD AND BLOOD PRODUCTS • 1/4
l Where a woman aged <16 yr refuses
GENERAL PRINCIPLES
blood products, seek urgent advice
Consent from Trust manager/director on-call.
Consider second opinion from
l Transfusion against a woman’s consultant obstetrician/anaesthetist/
expressed view is a gross physical haematologist
violation – follow your local Trust
Consent policy Unconscious/incapable woman
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
capacity, her acceptance of treatment l If available at your Trust, give her a
cannot be nullified by parental ‘Receiving a blood transfusion’ leaflet
objection
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l If high blood loss during caesarean
Refusal
section anticipated (e.g. placenta
l If woman does not wish to praevia), discuss at multidisciplinary
accept blood transfusions in any level and make appropriate
circumstances, ask her to complete arrangements e.g. cell salvage
an advance directive/decision to
this effect. Place 1 copy in maternal Reversal of decision
healthcare record and the other in main l If woman changes her decision in any
case notes way, complete a ‘Reversal of advance
l Complete a neonatal alert/maternal decision’ form (if available locally) and
alert form and any other alert system file in front of the Advance decision
used locally l The maternal alert form will be updated
l Refer her to consultant obstetrician and to reflect this reversal of decision. All
consultant anaesthetist forms will remain in woman’s healthcare
record and will not be removed even if a
Investigations and preparation reversal of advanced decision is made
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
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)
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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
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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 inability to site epidural l 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
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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
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RETAINED PLACENTA • 1/2
l See Third stage labour guideline l Manual removal of placenta (MROP)
l If placenta has not delivered or has takes priority over elective cases, even
shown no signs of separation 20 min if woman not actively bleeding
after administration of Syntometrine® or l obstetric junior doctor can undertake
oxytocin, prepare to treat promptly for this procedure under the direct
retained placenta after 30 min supervision of a middle grade
l If woman has requested a physiological obstetrician (ST3–7 or equivalent e.g.
third stage of labour and placenta staff grade, clinical fellow)
has not delivered or shown signs of l if blood loss increases or maternal
separation 60 min after birth, advise condition deteriorates, accelerate
woman to allow active management of transfer to theatre
the third stage l Use gauntlets to protect the operator
l While waiting for placenta to separate, l Midwife can accompany woman into
follow Management below theatre to support her throughout
Unnecessary delay increases risk of l Administer broad spectrum IV antibiotics
postpartum haemorrhage
l Following placenta removal, middle
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 Inform woman of increased risk of
placental retention in future pregnancy
fellow) will perform vaginal examination
and check placenta not detached in
vagina
Do not attempt to remove an
adherent placenta in delivery room
or without anaesthetic
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RETAINED PLACENTA • 2/2
Documentation
l Ensure clear and accurate
documentation, including:
l procedure used
l total estimated blood loss since
delivery
RETAINED PRODUCTS
l Where there is any concern about the
completeness of delivered placenta,
midwife must notify middle grade
staff grade, clinical fellow) regardless of
mode of delivery
l Insert cannula, take blood for FBC and
group and save
l Where there is a confirmed incomplete
placenta, take woman to theatre for
evacuation of retained products as
above for a retained placenta
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ROUTINE POSTNATAL CARE OF WOMEN AND BABIES • 1/11
PRINCIPLES
l To encourage women to participate in planning postnatal care and to provide
information to enable them to make informed choices
l To provide woman with relevant and timely information to enable her to recognise
and respond to problems
l Identified lead professional will be responsible for co-ordinating care for woman and
baby in postnatal period, until they are discharged from midwifery care
Document all discussions in maternal healthcare record
POSTNATAL PERIOD
l A documented, individualised postnatal care plan to be developed with the woman
during antenatal period, or as soon as possible after birth. This should include:
l relevant factors from antenatal, intrapartum and immediate postnatal period
l details of healthcare professionals involved in care of her and baby
l plans for postnatal period
l review at each postnatal contact
EVERY POSTNATAL CONTACT
Maternal health Infant health
l Ascertain physical and emotional l Enquire about baby’s health
health and wellbeing l Provide information about:
l Offer woman opportunity to talk l promoting baby’s health and general
about her birth experience and to ask condition
questions about care received l recognising signs and symptoms of
l inform her about the debriefing service common health problems in newborns
and how/who to contact if required and how to contact healthcare
l Discuss vaginal loss and perineal professionals as soon as a problem is
healing suspected or in an emergency
l Look for signs and symptoms of mental l Advise woman to contact healthcare
health problems professionals if baby:
l Discuss coping strategies and support l becomes jaundiced (or is jaundiced
and it worsens)
l Encourage partner involvement
l passes pale stools
l Provide health promotion information
l Provide advice and support on infant
and how to recognise life-threatening
feeding
and common health problems – see
l discuss breastfeeding and document
Life-threatening conditions in women
any support required
and Common health problems in
women sections l Give information regarding local
support networks
l Confirm contact numbers (if woman
l Check healthcare record for previous
is at home and needs to report any
alerts
concerns)
l Women with physical, emotional, social
or educational needs – see Women
with multi-agency or multidisciplinary
needs section
l Be alert to signs of domestic abuse. If
concerned, follow local child protection
and domestic abuse guidance
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l During inpatient episodes on delivery l It is the responsibility of allocated
suite/midwifery-led unit or postnatal midwife on postnatal ward to ensure it
ward, allocate woman and baby a is safe to accept woman and/baby onto
named midwife for each shift who ward
will undertake care, including care as l Ensure all allergies and sensitivities are
described in Every postnatal contact documented
above
l Check baby is wearing 2 name bands
l Midwives have direct access for referral containing woman’s hospital number.
to a consultant obstetrician at all times Check this against mother’s name
during the postnatal period if required band
l Assess general condition of baby
Women with multi-agency or
multidisciplinary needs l Check that a birth weight has been
performed and recorded in all relevant
l Named midwife will: documentation
l co-ordinate woman’s multi-agency and l Establish vitamin K has been
multidisciplinary needs administered and recorded
l liaise with named community midwife, l Determine chosen method of feeding
lead midwife for vulnerable women and and obtain details of initial feed on
appropriate agencies and healthcare delivery suite
professionals
l Commence Red child health record
l with woman’s knowledge and, where book
possible and safe to do so, ensure
appropriate agencies and healthcare Allocated midwife on
professionals are involved according to postnatal ward will:
local practice
l document outcomes of multi-agency or l See woman at each handover, review
multidisciplinary meetings in woman’s care plan and document in maternal
postnatal care plan healthcare record
See also the following guidelines: l See Every postnatal contact section
l Local Safeguarding guideline or local l See specific guidelines for appropriate

Child protection guideline care:
l Local Mental health problems in l Infant feeding guideline

pregnancy guidance (if available) l Breastfeeding guideline in the
l Substance misuse guideline Staffordshire, Shropshire & Black
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
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
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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
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
medical advice’ form
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
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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
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l apply separate neonatal barcode label
Postnatal visiting
to each sheet of the card after checking
Community midwife will: details with parent(s)
l place specimen in correctly
l Visit woman at home on day following addressed envelope (use appropriate
discharge and offer ≥2 further addressograph label)
postnatal contacts (day of delivery is
l send to regional screening unit on day
day 0)
sample taken
l second contact: day 5, to weigh baby
l document according to local practice
and perform bloodspot test
l inform parent(s) that health visitor will
l third contact: on or after day 10, to
relay ‘normal’ results
weigh baby and transfer care to GP
and health visitor if appropriate l if any results abnormal or borderline,
parent(s) will be contacted directly
l date and venue to be agreed with
woman. Can be at home or clinic
Preterm baby
l Discuss individual social, clinical and (<36 weeks’ gestation)
emotional needs, taking into account
the views and beliefs of woman, her l If baby almost 36 weeks’ gestation,
partner and family sample may be postponed for a few
l See also Every postnatal contact days to prevent unnecessary repeat
section at beginning of guideline l Inform parent(s) baby will need a
repeat sample at 36 weeks corrected
Community team leader is age for congenital hypothyroidism and
responsible for ensuring all arrange to visit and repeat test at the
caseloads are picked up during appropriate time
periods of annual leave and/or
sickness
Newborn screening
l It is the midwife’s responsibility to:
l discuss newborn screening with
parents ≥1 day before being
performed
l provide national screening committee
leaflet ‘Screening tests for your baby’
l obtain consent and take sample on
day 5 (count date of birth as day 0).
See Bloodspot screening guideline
in the Staffordshire, Shropshire &
Black Country Newborn and Maternity
locally)
l ensure sufficient neonatal barcode
labels available (if used locally) for
when test is taken
l complete request card after performing
test
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First 24 hr following initial delivery assessment
Woman’s wellbeing Baby’s wellbeing and feeding
See also Every postnatal contact section
Midwife will: Midwife will:
l Give information related to physiological l Confirm and document urine passed
process of recovery in postnatal period
l Confirm meconium passed, if not,
l Discuss the following signs and
assess baby and seek medical
symptoms of life-threatening conditions
opinion
and how to contact their healthcare
professional or call for emergency help: l Ensure woman has received
l sudden profuse blood loss information regarding:
l offensive/excessive vaginal loss l bathing – advise that cleansing
l tender abdomen agents, lotions and medicated wipes
l fever are not recommended in first 6 weeks
l severe or persistent headache l keeping the umbilical cord clean and
l raised BP with other signs of pre-eclampsia dry (do not use antiseptic)
l chest pain and/or shortness of breath l cot safety
l unilateral calf pain/redness or swelling l parents aware of bed-sharing
l In first 6 hr following delivery, assess guidance from the Department of
and document BP (see Hypertension Health. The safest place for baby to
guideline) and first urine void (see sleep is in a cot in parents’ room for
Bladder care guideline) first six months
l Record maternal observations
l If offensive/excessive loss, abdominal
tenderness or fever, assess vaginal loss, Feeding
uterine involution and position l Observe a full feed and offer ongoing
l Offer assessment of the perineum to any feeding support
woman who suffered perineal trauma l Outline the benefits of colostrum
– see Episiotomy guideline, Perineal and breastfeeding (this information
trauma suturing (tears and episiotomy) should be culturally appropriate) –
guideline and Third and fourth degree see Breastfeeding guideline in the
tears – OASIS guideline Staffordshire, Shropshire & Black
l Ask about headache symptoms. If Country Newborn and Maternity
epidural or spinal used, advise woman to Network Neonatal guidelines (if used
report headache, particularly if occurring locally)
while sitting or standing
l If artificial feeding, see Infant
l Assess thrombosis risk – see VTE feeding guideline and Staffordshire,
guidelines and refer to obstetrician if Shropshire & Black Country Newborn
appropriate and Maternity Network Neonatal
l Give woman opportunity to discuss the Nutrition and enteral feeding
birth guideline (if used locally)
l Encourage gentle mobilisation
l Give information on mental wellbeing
l Update postnatal care plan Ensure all discussions/numbers
l Ensure all contact numbers are clearly given are clearly documented
documented in maternal healthcare
record and that woman and, if
appropriate, partner/family also aware
l Ensure all discussions clearly
documented in maternal healthcare record
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Care in first week
Mother’s wellbeing Baby’s wellbeing and feeding
l Ensure Rh–D negative woman is l Discuss all aspects of baby’s physical health
offered anti-D immunoglobulin and wellbeing with parent(s), including
within 72 hr of delivering an Rh-D continuous assessment of feeding
positive infant l Inform parent(s) a full examination of
l ≤3 days – discuss normal baby will be performed ≤72 hr of life and
patterns of emotional changes encourage them to be present. Provide full
in the postnatal period and that explanation including results of any tests
these usually resolve within l Review family health history and address
10–14 days parental concerns
l Discuss the importance of l Discuss neonatal screening
appropriate exercise, rest and
diet, including high fibre foods l Assess baby’s general condition. Healthy
and adequate fluid intake babies should have normal colour for their
ethnicity, maintain a stable body temperature
l If woman reports persistent and pass urine and stools at regular intervals
fatigue, and suffered a
postpartum haemorrhage, check l Assess feeding behaviour – see Infant
Hb feeding guideline and Breastfeeding,
Nutrition and enteral feeding and
l Offer information and Hypoglycaemia guidelines in the
reassurance on involuntary Staffordshire, Shropshire & Black Country
leakage of small amounts of urine Newborn and Maternity Network Neonatal
commonly experienced after birth guidelines (if used locally)
– see Bladder care guideline
l Look for signs and symptoms of baby
l Advise woman to report concerns becoming unwell e.g. excessive irritability,
about haemorrhoids, rectal pain tense, high temperature, sleepy or floppy
or bleeding, and if she has not
opened her bowels ≤3 days of l Assess parent(s) for emotional attachment
delivery or regained her normal and offer information and support in adjusting
pattern to their new parenting role
l Give perineal hygiene information l If any jaundice, record intensity, together with
baby’s hydration and alertness. If significantly
l Offer women with low-level or no jaundiced or unwell, inform medical staff and
immunity to rubella on antenatal arrange evaluation of serum bilirubin level –
screening an MMR vaccination see Jaundice guideline in the Staffordshire,
before discharge from maternity Shropshire & Black Country Newborn and
unit if possible. Can be given Maternity Network Neonatal guidelines (if
with anti-D injection, provided used locally)
separate syringe is used and
administered into different limb l provide parent(s) information on, reason
for and how to monitor jaundice (normally
l if not given simultaneously, give occurring around 3–4 days after birth)
MMR 3 months after anti-D
l Weigh baby once within first week of life. If
l advise woman to avoid problem identified, more frequent weighing
pregnancy for 1 month after may be necessary
receiving MMR, but breastfeeding
may continue l If weight loss not within normal limits, inform
parent(s) and take appropriate action
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Care in first week cont.
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
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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 Stinging l 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
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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
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Wellbeing and care in first 2–8 weeks
l Ask woman about her physical, emotional l Assess baby’s feeding
and social wellbeing, and the wellbeing of
l Provide advice and support woman’s
her baby. Recognise symptoms that may
choice of feeding and document in
need discussion/action
postnatal plan
l Discuss resumption of sexual
intercourse and possible dyspareunia l Reinforce relevant safety issues
for all family members in the home
l Use routine screening questions for
environment and promote safety
postnatal depression (within 10–14 days)
education (e.g. safe sleeping). If
l Enquire about and give information on: parents choose to bed-share with baby,
l headache explain the increased risk of sudden
l perineal pain, discomfort, stinging, infant death syndrome if either parent:
offensive odour or dyspareunia smokes, has recently drunk alcohol,
l persistent fatigue taken medication or drugs that make
l backache them sleep more heavily, or is very tired
l constipation l Discourage use of a dummy
l haemorrhoids l Discuss smoking, including passive
l urinary or faecal incontinence smoking and access to cessation of
l urine retention (within 6 hr of birth) smoking programme for woman and
other family members if required
l Promote emotional attachment and
improved parenting skills l Be alert to signs and symptoms of child
l Provide information on local/national/ abuse. If there are concerns, follow
voluntary groups that provide support local child protection procedures
and guidance in the postnatal period l Document all discussions in maternal
l Discuss sudden infant death syndrome healthcare record and baby healthcare
with parents, in line with DoH guidance record (Red book)
l Update postnatal care plan using
variances when required. Document all
discussions
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
comprehensive handover of care to
Community midwife will:
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
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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 Anaemia l 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
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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
disturbance, plasma lactate l 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 FBC and differential WBC l 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
pressure raised) l 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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SEPSIS • 3/5
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 FBC and blood l Broad spectrum l if likelihood of infection is high, Gram
cultures before antibiotics positive cover
antibiotics l IV fluids
l Measure serum l Oxygen
lactate
l Measure urine
output hourly
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SEPSIS • 4/5
FURTHER MANAGEMENT
l Remove source of infection
l closed-space infections need surgical
drainage including evacuation of
retained products of conception
l Consider VTE prophylaxis
l Consider delivery
l regional anaesthesia may be
contraindicated
l If woman already extremely ill,
deteriorates or does not improve,
consider additional or alternative IV
antibiotics – seek further early advice
from consultant microbiologist
l repeat microbiological specimens and
mark ‘urgent’
l In women with endometritis not
responding to antibiotics, consider
septic pelvic thrombosis
l In presence of uterine sepsis,
carefully counsel women requesting
conservative management about
maternal risks
l Necrotising fasciitis requires early
surgical intervention with fasciotomy
and aggressive antibiotic therapy
l If Group A streptococcus disease
suspected, inform neonatologists. If
confirmed, this is a notifiable disease
l Be prepared for haemorrhage from
uterine atony and DIC
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SEPSIS • 5/5
Sepsis/severe sepsis screening and management flowchart
Does woman have 2 of the following signs of infection?
l Temperature >38°C or <36°C
l Heart rate:
l >100 bpm (antenatal and intrapartum)
l >90 bpm (postnatal)
l Respiratory rate >20 bpm
l Acutely altered mental state
l WCC >12 OR <4 x 109/L (higher threshold in labour)
l Hyperglycaemia (blood glucose >7.7) in the absence of diabetes
Yes
Elicit history or signs of new infection or infective source and consult appropriate guideline
l Prolonged ruptured membranes or offensive smelling liquor
l Unexplained fetal tachycardia in the absence of a maternal tachycardia
l Recent delivery/offensive lochia
l Catheter or dysuria
l Line infection
l Headache with neck stiffness
l Endocarditis
l Breast redness and/or tenderness
l Fetal demise
l Sore throat/cough/sputum/chest pain
l Abdominal pain/distension/diarrhoea
l Cellulitis/wound infection/septic arthritis
l Other
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
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SEVERE PRE-ECLAMPSIA • 1/8
DEFINITIONS
l Pre-eclampsia: pregnancy induced hypertension with significant proteinuria +/-
oedema affecting virtually any organ system in the body
l Severe pre-eclampsia: diastolic blood pressure >110 mmHg or systolic blood
pressure ≥160 mmHg on >2 occasions, with significant proteinuria
l Mild to moderate pre-eclampsia: BP <160/110 and proteinuria with ≥1 of
symptoms and signs listed below (see RECOGNITION AND ASSESSMENT below)
Maternal and fetal complications associated with severe pre-eclampsia
Maternal Fetal
l Eclampsia l Prematurity
l Placental abruption l Intrauterine growth restriction
l Severe hypertension l Acute fetal distress
l Risk of cerebral haemorrhage l Placental abruption
l Pulmonary oedema l Intrauterine death
l Renal failure l Respiratory distress syndrome
l Liver failure or ruptured liver
l Disseminated intravascular coagulation (DIC)
l HELLP syndrome
l Pulmonary haemorrhage
l Aspiration pneumonia
l Retinal detachment
l Circulatory collapse
l Maternal death
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)
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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 Oxygen saturations continually and l 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 if oliguria <100 mL over 4 hr period,
Fluid management
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
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
anuria, prepare for delivery
Monitoring
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
severe pre-eclampsia. It is associated l 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
upper-quadrant pain l 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
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l If transferred to community – Common contraindications
measure BP every 1–2 days ≤2 weeks,
(see also current BNF)
until anti-hypertensive treatment
stopped and no hypertension. l Asthma
Medical team to include management l Cardiogenic shock
plan for monitoring on discharge
documentation l AV block
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 Hepatic impairment l 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
sulphate and nifedipine may cause a l 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 chloridesulphate 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
phlebitis using a recognised infusion l 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
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SHOULDER DYSTOCIA • 1/4
DEFINITION MANAGEMENT
Prolonged head to body delivery time Immediate action
requiring additional obstetric manoeuvres
to release shoulders from behind l Sound emergency call bell/buzzer and
mother’s pubic bone or, less commonly, summon:
sacral promontory l delivery suite co-ordinator
l middle grade obstetrician (ST3–7 or
RISK FACTORS equivalent e.g. staff grade, clinical
l If identified, middle grade obstetrician fellow) or consultant
(ST3–7 or equivalent e.g. staff grade, l neonatal team member (as per local
clinical fellow) to be on delivery suite at practice)
delivery or l anaesthetist
l in delivery room for women with l theatre staff
previous shoulder dystocia
l Quickly tell mother what is happening,
l No evidence to suggest that prophylactic reassure her
McRoberts position will be of any benefit
l Nominate a member of staff to
before delivery of fetal head
document events
Antepartum
Position woman and traction
Maternal l Position mother with buttocks at end of
bed lying flat
l Maternal obesity – body mass index
>30 kg/m2 [see Obese mother (care l Mother’s legs flexed, abducted
of) guideline] and rotated outwards (McRoberts
manoeuvre) and attempt delivery using
l Excessive weight gain
routine axial traction
l Previous big baby
To reduce risk of brachial plexus
l Previous shoulder dystocia
injury, use axial traction only
l Maternal diabetes mellitus – even in
absence of fetal macrosomia l Instruct mother not to push as may
cause further impaction of the shoulders
Fetal l Do not apply fundal pressure (associated
l Suspected or confirmed fetal macrosomia with a high neonatal complication rate
and may result in uterine rupture)
l Post-dated pregnancy
Suprapubic pressure
Intrapartum
l If delivery not successful with McRoberts
l Prolonged first or second stage
manoeuvre alone, ask assistant to apply
l Oxytocic augmentation suprapubic pressure for 30 sec with heel
l Assisted delivery of hand over posterior aspect of shoulder
l Signs in second stage: – assistant must be aware of position
l difficulty with delivery of face and chin of fetal back to ensure pressure
applied in the right direction
l head remaining tightly applied to vulva
or even retracting (turtle-neck sign) l if continuous pressure not successful,
attempt a rocking movement as there is
l failure of restitution of fetal head
no clear difference in efficacy between
l failure of shoulders to descend continuous pressure and rocking
Notify middle grade obstetrician of movement
any second stage risk factors l if shoulder disimpacted, encourage
mother to push and attempt delivery
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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 symphysiotomy
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
allows delivery l 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
successful, the shoulders will rotate 180° l Perform maternal observations and
in the opposite direction and then deliver estimation of blood loss
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l In all cases of shoulder dystocia, obtain l Baby appears well – transfer to
paired cord blood for gases – see postnatal ward with mother. Full
Umbilical cord sampling guideline neonatal assessment will take place,
l If baby well, encourage a period of and findings documented in maternal
skin-to-skin contact healthcare record, before discharge
from hospital
Documentation
Transfer to postnatal ward
l In all cases of shoulder dystocia,
regardless of outcome, midwife or l When transferring mother and baby to
doctor responsible for mother’s care postnatal ward, follow local practice
should: and ensure all events communicated to
postnatal ward midwives
l complete a shoulder dystocia
checklist and place 1 copy in maternal l Obstetrician involved in the shoulder
healthcare record dystocia will:
l record which shoulder was anterior at l visit woman and family on postnatal
delivery ward the following day to discuss
events in detail
l follow local adverse incident/near miss
reporting procedure l if appropriate speak to other
healthcare professionals involved e.g.
Communication with neonatologist or midwife
parents/family
Deterioration in baby’s condition
l Obstetrician and midwife must
discuss events with woman/family l If, at any time, midwifery staff in
and document discussion in maternal hospital or community detect
healthcare record deterioration in baby’s condition, refer
to neonatal team
Examination of baby
In hospital
l Neonatal team member who was
present at delivery will carry out a l Contact neonatal junior doctor and/or
detailed initial examination – see middle grade depending on severity of
Staffordshire, Shropshire & Black problem
Network Examination of the newborn In the community
guideline (if used locally), paying
particular attention to the arms for the l Contact woman’s GP/paediatric
presence of swelling, bruising, tone, assessment unit or A&E department
posture and movement. If concerns, depending on severity of problem
X-ray of affected side – arm and clavicle l For babies with a history of shoulder
l No movement noted – inform neonatal dystocia, follow local incident reporting
consultant on duty and refer to surgeons policy for re-admission
for review and investigation of possible
brachial plexus injury – see Staffordshire, DISCHARGE AND FOLLOW-UP
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
one fails, try the Wood’s screw manoeuvre
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
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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
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STEM CELL BANKING • 2/2
NON-COMMERCIAL BLOOD
COLLECTION
l Umbilical cord blood may be collected
via a third party agreement with a
Human Tissue Authority licensed
establishment. Collection may have
been recommended where family
members have:
l haemoglobinopathies
l acute inherited disorders
l acute lymphoblastic leukaemia
l In general, those caring for the family
member with the haematological
disorder have provided third party
agreement for cord blood collection.
They also have the responsibility to
provide training and clear instructions
for staff
l The National Blood Service in
Birmingham (if involved) provides 2
collection packs containing instructions
and contact details. 1 pack is for
staff (most likely to be present when
collection occurs) to open and
familiarise themselves with before
delivery. Do not open the second pack
until cord blood collection is about to
be performed
l Store the cool packs in a refrigerator at
4°C until required – do not freeze
l In addition to the collection packs,
ensure the following equipment is
available:
l Spencer Wells clamps
l scissors
l swabs, spray and gauze for cord
disinfection before venepuncture
Collection
l See NHS Blood and Transplant Service
http://www.nhsbt.nhs.uk/
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SUBSTANCE MISUSE • 1/4
l Encourage women using opiates who
INTRODUCTION
are not already in a drug treatment
l Maternal drug use in pregnancy programme, to accept referral to
increases perinatal mortality and specialist services for:
morbidity with an increased risk of l a full assessment of substance usage
placental abruption, fetal growth
l drug screening (to confirm present usage)
restriction etc.
l ongoing counselling
l Many drugs (opiates, benzodiazepines)
can cause severe neonatal withdrawal l support in stabilising usage through
symptoms substitute prescribing (e.g. methadone)
l Substance misuse can lead to l thorough assessment of woman’s
poor maternal health e.g. infective social circumstances to decide
endocarditis, VTE and blood borne appropriate referral (e.g. social care
viruses and health planning)
l Record and discuss with community
ANTENATAL CARE midwife
l Refer woman to appropriate professionals
l Initial contact between woman
and maternity services is likely to Documentation and confidentiality
influence their subsequent uptake
of care. Non-judgmental care from l Be aware – although the maternal
maternity unit staff encourages regular hand-held record is marked ‘confidential’,
attendance, which in turn improves anything written can be read by others.
antenatal care, detection of fetal Before recording explicit details of
growth restriction, neonatal care, substance misuse in this record, ensure
communication between members of woman agrees to their inclusion
the multi-agency team, and discharge
planning Domestic abuse
l Whilst respecting privacy and
l Staff should be aware that substance
confidentiality, routinely record problem
misuse may be associated with current
drug or alcohol use at booking risk
or past experiences of abuse. Domestic
assessment
abuse often escalates during pregnancy
Booking l As a minimum, ensure routine enquiries
about domestic abuse are made at
l For women who disclose substance booking
misuse: l Whenever possible, woman should be
l book under consultant care to facilitate seen alone at least once during the
planning of maternity, neonatal and antenatal period to enable disclosure
social care within a multidisciplinary
team Screening for blood-borne viruses
l inform specialist midwife, if available
l In addition to routine hepatitis B and
locally
HIV screening, advise routine hepatitis
C screening
Specialist midwife/drug worker
will Hepatitis B and C
l Discuss neonatal abstinence syndrome l See Hepatitis guideline
and plan of care with woman and
appropriate family members HIV
l Initiate child safeguarding procedure
l See HIV positive women guideline
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Plan of antenatal care
Gestation Action
l Consultant-led antenatal clinic
l Complete common assessment framework
At first disclosure
(CAF) form (if used locally)
l Liaise with specialist midwife, if available locally
l Find out which substances are being used and
in what quantities
l Arrange following tests:
l booking bloods
l hepatitis C
l dating scan
Booking l Discuss serum screening for Down syndrome
l Ensure follow-up with specialist drug workers
l Offer smoking cessation referral
l Initiate neonatal alert process in line with local
practice
l Plan subsequent antenatal visits with
community midwife/antenatal clinic
18–23 weeks l Anomaly scan
l Growth scan (according to local policy)
l Repeat bloods
Third trimester
l Ensure pre-birth plan in place, if appropriate
l Review plan of care for baby
41 weeks l Induction of labour for obstetric reasons
l If woman persistently fails to attend

Non-booked women
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
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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
services l timing of administration of opiate
replacement should follow woman’s
l Consider increasing methadone/ normal pattern
Subutex® dose in third trimester
(plasma concentrations may decrease l 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
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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.
Consider asking anaesthetist to insert a l 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
to attend routinely unless there are l 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)
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THIRD AND FOURTH DEGREE PERINEAL TEARS –
OASIS (OBSTETRIC ANAL SPHINCTER INJURIES) • 1/2
l If practitioner inexperienced in assessing
CLASSIFICATION
perineal damage or unsure of degree of
Third degree tear trauma sustained, seek second opinion
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
(IAS) torn l 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
suturing to assess the integrity of the
ASSESSMENT OF PERINEAL
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
anal sphincters and rectal mucosa) l 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
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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 Repair vaginal wall tissues with a l 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
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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
l perineum – see Perineal trauma
PHYSIOLOGICAL MANAGEMENT
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
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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
cervix l Clean vulva with antiseptic solution
l It may be necessary to gently
INDICATIONS grasp the anterior cervical lip with
sponge-holding forceps to achieve a
l Unfavourable cervix requiring induction good view and facilitate procedure.
of labour where artificial rupture of This can be uncomfortable and should
membranes (ARM) is not possible not be done routinely
l Previous caesarean section (CS)
l Failed attempt at prostaglandin Foley catheter
induction l Hold (do not clamp) catheter with
Rampley’s forceps 1–3 cm (i.e.
CONTRAINDICATIONS measured cervical length from vaginal
examination) from end of balloon area
l Ruptured membranes
l Advance into the cervical canal until
1–3 cm below the balloon area has
METHOD
entered the canal and inflate balloon
with sterile water or sodium chloride
Consent
0.9% 30 mL
l Discuss procedure with woman and l Gently pull catheter back to ensure
obtain and document verbal consent balloon is resting at the internal cervical
os
Equipment l Apply a spigot to the catheter and
tape catheter to the thigh under gentle
l Foley balloon catheter 30 mL balloon
tension
or Cook® cervical ripening balloon
catheter
Cook® catheter
l both are effective but the Foley
catheter is cheaper and has a shorter l Pass catheter through cervix until both
placement-to-delivery interval balloons have entered cervix
l Instillagel® (local anaesthetic and l Inflate the intrauterine (red) balloon
antiseptic) with sterile water or sodium chloride
l Sterile vaginal examination pack 0.9% 40 mL
l Sterile Cusco speculum l Pull catheter back until balloon is
against the internal os
l Sponge-holding forceps (Rampley)
l Fill the visible vaginal (green) balloon
l Entonox with sterile water or sodium chloride
l Antiseptic solution 0.9% 20 mL
l sterile water or sodium chloride 0.9%
100 mL
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TRANSCERVICAL CATHETER INDUCTION • 2/2
Post-insertion
l Perform electronic fetal monitoring. See
Electronic fetal monitoring guideline
l Observe for signs and symptoms of
labour, spontaneous expulsion of
balloon, ruptured membranes, febrile
symptoms, pain and vaginal bleeding
l If catheter has not been passed
vaginally (12 hr for Cook® or 18 hr for
Foley), remove
fellow) or consultant will decide
whether ARM is possible. If not, options
include a further attempt or CS
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UMBILICAL CORD PROLAPSE • 1/3
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 podalic version
l Polyhydramnios l Stabilising induction of labour
l Unengaged presenting part
l Low-lying placenta, other abnormal
placentation
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IMMEDIATE TREATMENT
Follow Flowchart and General principles below
Umbilical cord prolapse diagnosed
l Summon help Non-reassuring/

FHR pattern
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
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l Empty bladder just before any delivery
General principles
attempt
l To prevent vasospasm, minimise handling l woman adopting knee-chest position
of loops of cord lying outside vagina or head-down tilt (preferably in
l Manual replacement of prolapsed left-lateral position)
cord above presenting part is not l While preparing for caesarean section,
recommended consider tocolysis if FHR abnormalities
l Wrapping cord in swabs soaked in persist after attempts to prevent
warm sodium chloride 0.9% is of no compression and when delivery is
proven benefit likely to be delayed
l Attempt to prevent cord compression by: l do not allow above to cause
unnecessary delay
Manual elevation of
presenting part Gestational age at the limits of
Contraindications viability
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)
if cord prolapse associated with
Complications
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 Category 2 if FHR pattern normal
Bladder filling to elevate
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
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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 Fetal blood sample is taken during l Analyse in blood gas analyser
labour l difference ≥0.03 units indicates both
l Premature delivery arterial and venous blood obtained
l Vaginal breech delivery l 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
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UTERINE RUPTURE • 1/2
l Undue maternal distress, agitation

DEFINITION
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
crash team, which must include a
RECOGNITION AND
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
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UTERINE RUPTURE • 2/2
SUBSEQUENT MANAGEMENT
Scar rupture confirmed
(not simple dehiscence)
l Call consultant obstetrician and
consultant anaesthetist
l Manage haemorrhage
l activate major haemorrhage protocol if
required
l It may be possible to repair uterus.
Hysterectomy or subtotal hysterectomy
may be required
l Method of repair depends on nature
of tear, degree of haemorrhage and
woman’s future fertility wishes
l Give broad spectrum IV antibiotics –
according to local Trust policy
l Provide mother with high dependency
care – see High dependency care
guideline
Communication
l Explain events fully to woman and
family including implications for future
pregnancies
l Report clinical incident using local
incident reporting system
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VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) • 1/2
l ≥1 previous vaginal births (particularly
ANTENATAL CARE
previous VBAC) is associated with a
l Women who have history of an planned VBAC success rate of 85–90%
uncomplicated lower-segment transverse Rates of hysterectomy and blood
caesarean section (CS) and an otherwise transfusion increase in women who
uncomplicated pregnancy with no have had ≥2 previous caesarean
contraindications to vaginal birth, discuss births
options of VBAC or elective CS
l Discuss previous birth experiences with Contraindications to VBAC
woman. Take her wishes into account
and document discussion in maternal l Previous upper segment CS – advise
healthcare record woman to give birth by elective CS
l Review notes or request information l previous uterine incision other than an
from other hospital (if applicable) to uncomplicated low transverse CS incision
obtain details of previous CS l Previous uterine rupture
l To enable woman to make informed l >2 previous caesarean deliveries
choice, give VBAC leaflet (if available l Women with this history who wish
locally) during antenatal period, which to consider vaginal birth should be
includes risks of repeat CS and risks of assessed by a consultant obstetrician
scar rupture in labour with full access to details of previous
l Appropriate discussion using locally surgery (if possible)
available VBAC versus elective repeat l When considering planned VBAC in
CS checklist (recommended by RCOG woman with twin pregnancy, adopt a
to facilitate documentation of antenatal cautious approach
counselling and decision making)
l Refer women who are undecided to Risk factors for unsuccessful
the birth choices clinic (if available VBAC
locally) for further counselling l Previously failed induction of labour
l Obstetrician (ideally consultant, but l No previous vaginal birth
≥ST3), will agree mode of delivery
l Body mass index >30
with woman before expected/planned
delivery date (ideally by 36 weeks’ l Previous emergency CS for dystocia at
gestation) and document individual <8 cm
management plan for labour l VBAC ≥40 weeks’ gestation
l Offer women who opt for VBAC an ANC l Birth weight ≥4 kg
appointment at 40 weeks l Induction of labour for VBAC
l Women with previous CS to have l Short inter-delivery interval (<12 months
ultrasound scan to: since last delivery)
l determine placental localisation l Advanced maternal age
l to exclude placenta praevia l Non-white ethnicity
– if present enables further investigation
to identify praevia accreta and enable INTRAPARTUM MANAGEMENT
safe management l If local practice, establish IV access
l Individual management plan should be l FBC and group and screen
made if labour occurs before planned CS
l Midwife competent in the care of
l record woman’s choice high-risk conditions should care for
l Inform woman: woman during labour on a one-to-one
basis, and inform delivery suite
l chances of successful planned VBAC
co-ordinator of any change in care
are 72–75%
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VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) • 2/2
l Inform middle grade obstetrician (ST3–7 l loss of station of presenting part
or equivalent e.g. staff grade, clinical l If any of above detected, inform middle
fellow) that woman is on labour ward grade obstetrician (ST3–7 or equivalent
and if mode of delivery not previously e.g. staff grade, clinical fellow) and
agreed ensure a review is undertaken delivery suite co-ordinator immediately
l Epidural anaesthesia is not
contraindicated in planned VBAC INDUCTION OF LABOUR
l Offer continuous electronic fetal l Consultant obstetrician will discuss
monitoring (EFM) with onset of regular risks with woman
contractions
l 2–3-fold increased risk of uterine rupture
l When woman in labour, give ranitidine
and around 1.5-fold increased risk of CS
150 mg oral approximately 6–8-hrly
in oxytocin-induced and/or augmented
l Atypical abdominal pain, vaginal labours compared with spontaneous
bleeding and/or CTG abnormalities labour
must be regarded as potential uterine
l higher risk of uterine rupture where
rupture in women undergoing VBAC
prostaglandins used for induction of
Augmentation labour
l no increased risk of uterine rupture with
l Use oxytocin with caution induction using transcervical balloon
l although not contraindicated, decision catheter – see Transcervical catheter
to prescribe oxytocin must be made induction guideline
by consultant obstetrician after
l Women who wish to have VBAC should
obstetric assessment, including vaginal
be seen by consultant obstetrician in
examination and discussion with woman
antenatal clinic at 40 weeks and offered
l Normal regime until woman contracting membrane sweep, discussion on mode
3 in 10 (ideally not exceeding 4 in 10). of delivery and place of labour and an
Do not increase oxytocin further individualised and documented plan of
If no progress in labour in the delivery
presence of adequate uterine activity l Vaginal examination can help to assess
and oxytocin augmentation, proceed the favourability for induction and
to CS as soon as possible method of induction
l membrane sweeping is not
Uterine rupture contraindicated
l See Uterine rupture guideline
Monitoring
l Observe for symptoms and signs
including: l Once labour established, record careful
l tenderness or sudden pain over scar serial assessments on partogram – see
within abdomen, sudden cessation Labour management guideline
of uterine activity (especially if pain l Continuous EFM to detect signs of
breaks through epidural) or shoulder impending rupture, following the onset
tip pain of contractions – see Electronic fetal
l bleeding vaginally not associated to monitoring guideline
cervical dilatation l In uterine rupture, an abnormal EFM
l easily palpable fetal parts trace is present in 55–87% of cases
l haemodynamic instability (low BP, raised l 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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VAGINAL BREECH DELIVERY • 1/3
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
on mode of delivery. Document l Rapid progressive labour with insufficient
discussion and decision clearly in time to perform caesarean section (CS)
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)
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
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l for planned vaginal breech delivery, l Encourage mother to actively push,
consider epidural analgesia to aid baby’s natural descent and
l Artificial rupture of membranes (ARM) ‘minimise handling’. Do not pull on
not usually performed due to risk of baby’s body or legs, flexed breech legs
umbilical cord prolapse usually deliver spontaneously
l If rupture of membranes occurs a vaginal l If assistance required to deliver legs,
examination may exclude cord prolapse once popliteal fossa visible, release
legs by flexing at the knees
l Avoid oxytocic drugs
l Observe for anterior scapula and allow
l Avoid use of fetal blood sampling time for arms to release spontaneously.
during labour on a breech presentation If assistance required, hook arms down
If delay or fetal compromise at any from the elbow. If this is not sufficient, 2
stage during labour, consider CS fingers can be passed over the shoulder
to push the humerus across the chest
l Passage of meconium cannot be relied
upon as indicator of fetal distress l if other shoulder does not deliver
spontaneously, repeat manoeuvre
Second stage of labour l Allow baby to hang until nuchal
line visible. Deliver head using
l Inform middle grade obstetrician Mauriceau-Smellie-Veit manoeuvre –
(ST3–7 or equivalent e.g. staff grade, combination of maxillary and occiput
clinical fellow)/consultant and ask to pressure
attend for second stage of labour l If obstetrician is conducting delivery
l Until presenting part is below the they may decide to deliver the head
level of the ischial spines, discourage using forceps
bearing down l Perform active management of the third
l Undertake urinary catheterisation stage
l Perform vaginal examination to
confirm fully dilated cervix (particularly Management of malpositions/
important preterm) and position of complications in the second
breech stage
l In active second stage, assist into l If malposition/complications arise
lithotomy position to enable breech in second stage – obstetric middle
delivery grade to request on-call consultant
l Call anaesthetist and theatre team obstetrician to attend
l Request attendance of a neonatologist. l Nuchal arm: rotate fetal spine to
See Cardiopulmonary resuscitation enable internal Lovset’s manoeuvre
of the newborn guideline in the l Delayed engagement in the pelvis
Staffordshire, Shropshire & Black of the after-coming head: second
Country Newborn and Maternity Network attendant applies suprapubic pressure
Neonatal guidelines (if used locally) to assist flexion of head
l alternatively first attendant displaces
Delivery
head upwards and rotates to the oblique
l Allow natural descent of fetal buttocks diameter to facilitate engagement
– hands off l Delivery of the obstructed
l Evaluate the need for episiotomy; after-coming head: if usual breech
consider waiting until fetal anus visible delivery manoeuvres fail, consider
over fourchette tocolysis, McRoberts manoeuvre,
incision of the cervix, symphysiotomy
l Ensure fetal spine rotates uppermost
or CS
during delivery
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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
l Debrief parents
l Arrange neonatal review for newborn
and infant physical examination (NIPE)
l Refer to local guidance on screening
for congenital hip dysplasia
Documentation
l Ensure clear documentation of:
l procedure
l help summoned
l names and grades of personnel
attending
l timing of events
l communication with woman
l Follow local incident reporting
procedure
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VTE – DEEP VENOUS THROMBOSIS • 1/3
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
not recommended, as will not alter
Symptoms and signs
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 Increased skin temperature in affected l 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
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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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VTE – PULMONARY EMBOLISM • 1/3
RECOGNITION AND l classical S1Q3T3 rarely seen
ASSESSMENT l CXR (with fetal shielding) to exclude:
l Diagnosis of DVT and pulmonary l pneumonia
embolism in pregnancy can l lung collapse
be challenging because of the l pneumothorax
physiological changes that occur. Many
of the classical symptoms of venous l features seen in PE:
thromboembolism can occur in a low – areas of translucency in under
risk pregnancy without VTE perfused lungs
– atelectasis
Symptoms and signs
– wedge-shaped infarction
l Dyspnoea/cyanosis – pleural effusion
l Collapse l if another cause for pleuritic chest pain
l Chest pain found, treat appropriately
l Cough l Discuss choice of ventilation perfusion
l Haemoptysis (VQ) lung scan or computerised
l Faintness/shock tomographic pulmonary angiography
l Tachycardia (CTPA) with radiologist
l Tachypnoea l VQ scan: if CXR normal, perform lung
l Mild pyrexia perfusion scan (Q scan)
l Raised JVP l minimises radiation dose to the fetus,
l Loud heart sound and right ventricular but has higher negative predictive value
heave l CTPA: if CXR abnormal, CTPA is first
l Pleural rub/effusion choice for radiological imaging
l Reduced PaO2 +/- PaCO2 l advise woman that compared with
l A high clinical suspicion is critical to CTPA, VQ scanning may carry a slightly
diagnosis increased risk of childhood cancer
(1/280,000 versus 1/1,000,000) but is
If PE suspected, start treatment
associated with a lower risk of maternal
with low molecular weight heparin
breast cancer
(LMWH) until diagnosis confirmed or
refuted, unless contraindicated l Diagnosis of DVT may indirectly
confirm a diagnosis of PE and, since
Investigations anticoagulant therapy is the same for
both conditions, further investigation
l Oxygen saturation may not be necessary. This would
l ABG (limited value when used alone) limit the radiation doses given to
l FBC woman and fetus for all suspected
l Coagulation profile non-massive PE (normal CXR, ECG
l U&Es and haemodynamically stable)
l LFTs l If woman is haemodynamically
l ECG unstable an echocardiogram is useful
to identify right ventricular dysfunction
l sinus tachycardia common
l with large PE there may be: l Pulmonary angiography: reserved for
severe cases before embolectomy
– T wave inversion (most common
abnormality) l Continue anticoagulant treatment until
– right-axis deviation PE definitely excluded
– right bundle-branch block
– peaked P waves in lead II due to
right atrial dilatation
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l in women with renal impairment,
TREATMENT
seek advice on dose reduction from
Women at risk of haemorrhage: haematologist
l Decision of thoracotomy or surgical
l If at risk and continued heparin embolectomy to be made by
treatment essential, use unfractionated consultant obstetrician, consultant
heparin IV physician, consultant thoracic surgeon
l has a shorter half-life and its activity and radiologist
is more completely reversed with
protamine sulphate General
l If woman develops a haemorrhage
l Resuscitate and give oxygen to
while on LMWH: stop treatment and
maintain SpO2 between 94–98%
discuss with haematologist
l Adequate analgesia
Massive life-threatening
PE in pregnancy Specific
l Resuscitate and give oxygen l Blood for FBC, INR, APTT, U&E’s, LFTs,
ABGs
l Involve multidisciplinary resuscitation
team including consultant physician, l CXR
consultant obstetrician, consultant l ECG
anaesthetist and radiologist
l If platelet count <75 x 109/L, seek
l If PE confirmed, urgent CTPA or advice from on-call haematologist
portable ECHO and team decide before starting anticoagulation
whether IV unfractionated heparin,
l If platelet count ≥75 x 109/L, prescribe
thrombolytic therapy or thoracotomy
subcutaneous LMWH (dalteparin
and surgical embolectomy appropriate
or enoxaparin – according to local
l IV unfractionated heparin is preferred in practice)
massive PE because of its rapid effect
and extensive experience of use Initial anticoagulant
l indicated for massive PE and where treatment in pregnancy
aggressive management required
l In clinically suspected DVT or PE,
l loading dose of 80 units/kg (5000 units) administer LMWH at doses below until
over 5 min, followed by 18 units/kg/hr objective testing excludes diagnosis
(e.g. for 70 kg woman, usually 1500
l If weight is >125 kg – discuss with
units/hr) continuous IV infusion (based
haematologist
on booking weight) to maintain APTT
of 2–3 times average laboratory control
value. If thrombolysis is given, omit
loading dose of heparin
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
40 mg 60 mg 80 mg 100 mg 120 mg
Enoxaparin
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l Heparin and warfarin are not
Monitoring LMWH treatment
contraindicated in breastfeeding
l If woman has not been given l If woman chooses to commence
unfractionated heparin, monitoring for warfarin postpartum, avoid until at least
heparin-induced thrombocytopenia is the third postnatal day
not required
l Regular INR testing is recommended
l If early pregnancy weight <50 kg or during the transfer from LMWH to
>90 kg and woman has bleeding warfarin to avoid over anticoagulation,
problems, renal impairment, or massive especially in the first 10 days
PE, discuss need for anti-Xa monitoring
l Monitor INR for 4 days after
with consultant haematologist
commencing warfarin
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
guideline
Administration of LMWH
and use of epidural/spinal
anaesthesia
guideline
Postnatal anticoagulation
l If no problems with bleeding, re-start
anticoagulation treatment 4 hr after
delivery
l Continue therapeutic anticoagulant
therapy for ≥6 weeks postnatally and
until ≥3 months of treatment has been
given in total. Offer a choice of LMWH
or oral anticoagulant (warfarin)
l LMWH:
l dalteparin (10,000–18,000 units
according to weight) OR
l enoxaparin (1.5 mg/kg daily)
l If starting warfarin, provide woman with
counselling and an oral anticoagulant
booklet. Document in book (including
dose to take until next INR check) with
follow-up appointment on discharge
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VTE – THROMBOPROPHYLAXIS • 1/5
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 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 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 in antenatal clinic
thromboprophylaxis
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 Peripheral neuropathy
General
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 Any woman weighing >90 kg (booking l 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 anti-Xa cannot be carried out as an l 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
(≥230 mmHg systolic) l 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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WATERBIRTH • 1/2
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
Issue 4
Expires: April 2019
WATERBIRTH • 2/2
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
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
Amniotomy 48–49, 107, 123, 260
E
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
Issue 4
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INDEX • 2/3
H N
HELLP 103, 237, 240 Necrotising fasciitis 232, 235
Hepatitis 99 Neonatal resuscitation 29
High dependency care 102 Neurological deficits after regional
HIV 106 anaesthesia or analgesia 171
Home birth 109 Nifedipine 81–82, 113–114,
Hypertension 112 207–208, 238, 242
Neural tube defect 164, 176
I Normal laboratory values 175
Identification 26–27, 35, 40, 65, 71, 224, 248
Induction of labour 119 O
Infant feeding 124 OASIS
Intermittent auscultation 136
(Obstetric anal sphincter injuries) 255
In-utero transfer 99, 146–149
Obese mother (care of) 176

Operative vaginal delivery 180
J Oxytocin 183
Jehovah’s Witnesses 42
P
K Perinatal bereavement 185
Kleihauer test 18, 42, 110, 153, 189
Perineal trauma 192
Placenta accreta 20, 41, 200
L Placenta praevia 18, 20, 41, 120,
Labour (delay in) 48 166,168, 204,
Labour (induction of) 119 214, 266, 268, 280
Lactic acid 87 Placenta (retained) 152, 200, 224, 219, 257
Latent phase 142
Placental abruption 18
Podalic version 170, 260, 262
M Polyhydramnios 20, 51, 58, 62, 66,
136, 162, 204, 215, 260
Macrosomia 50–52, 119, 136, 176, 195, 245
Postpartum haemorrhage 195
Maternal collapse 43
Maternal death 144 Postpartum endometritis 232
Maternal transfer 146 Pregnant woman with
non-obstetric problem 201
Mauriceau-Smellie-Veit manoeuvre 269
Pre-labour rupture of membranes
Meconium stained liquor 150
(PROM) 202
Medical termination 152
Preterm labour 204
Membrane sweeping 119–122, 267
Primigravida 22
MEOWS – see MEWS
Prolapse (umbilical cord) 260
MEWS 18–19, 102–103, 185, 121, 198,
201, 204, 212, 232–233 Pre-eclampsia (severe) 237
Morbidly adherent placenta 166 Pyelonephritis 232
Multiple pregnancy 168
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INDEX • 3/3
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
Issue 4
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Obstetric Guidelines
2017–19
This book has been compiled as an aide-memoire for all staff
concerned with the management of pregnant women and newborn
babies, towards a more uniform standard of care across the
Staffordshire, Shropshire & Black Country Newborn and Maternity
Network and Southern West Midlands Maternity and Newborn
Network hospitals
These guidelines are advisory, not mandatory
Every effort has been made to ensure accuracy
The authors cannot accept any responsibility for adverse outcomes
Published by the Staffordshire, Shropshire & Black Country

Newborn and Maternity Network
Copyright © Copyright holder

ISBNISBN
978-0-9557058-8-5
978-0-9557058-6-1
9 780955 705861
Printed by: Sherwin Rivers Ltd, Waterloo Road, Stoke on Trent ST6 3HR
Tel: 01782 212024 Fax: 01782 214661 Email: sales@sherwin-rivers.co.uk

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Obstetric

Staffordshire, Shropshire & Black Country

Published by the Bedside Clinical Guidelines Partnership, Staffordshire, Shropshire

Staffordshire, Shropshire & Black Country Newborn and

Southern West Midlands Maternity and Newborn Network comprises:

The Bedside Clinical Guidelines Partnership comprises:

Contributors Bedside Clinical Guidelines Partnership

Obstetrics editors The editors would like to thank the

The guidelines are advisory, NOT mandatory

The following guidelines are new to this edition:

Where supporting evidence has been identified it is graded I to 5 according to

Evaluation of the evidence-base of these guidelines involves review of existing literature

Feedback and new guidelines

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

DEFINITION Symptoms and signs

l Women with malabsorption syndrome, l Offer screening to women identified for

l offer iron and folic acid l Diagnose iron deficiency anaemia if

Treatment B12 deficiency known or

Process pathway – management of anaemia in pregnancy

Ensure compliance and provide

Check Hb 4 weeks later

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

Continue iron therapy until Hb Check folate, vitamin B12

l MCV <96 l MCV >96 l MCV >96

Commence l Commence vitamin

DEFINITION If placenta low lying, do NOT perform

MANAGEMENT When infusing large amounts of

Women at highest risk MANAGEMENT IN LABOUR

POSTNATAL ADVICE/ Voiding small amounts of urine

After removal of indwelling If not voided 4 hr after birth or

Flowchart: Postnatal bladder care management

Spontaneous void ≤6 hr VOID ≥150–200 mL

CATHETERISATION MANAGEMENT l Spontaneous void ≤6 hr of

CLASSIFICATION AND TIMING OF CAESAREAN SECTION

Category Definition Standard

CATEGORY 1 CAESAREAN Documentation

Anaesthetist CATEGORY 2, 3 AND 4

FOLLOWING CAESAREAN Communication

Cord clamping Term baby 30 cm of water

l If baby does not require immediate Preterm baby 20–25 cm of water

Endotracheal intubation Do not move onto ventilation

Table 2: Outcome after 30 sec of ventilation breaths

Alternative hold (less effective) Adrenaline 1:10,000

Skin Arms and legs

Head l Palmar creases – may indicate

Babies with birth weight Babies with birth weight

REGISTRATION AND l baby’s NHS number (if not available,

l Register birth – follow local birth l Wristbands may cause damage

Rhesus negative women

If a cardiac or respiratory arrest has SUDDEN COLLAPSE

Be aware of increase in Aortic dissection is a cause of

COLLAPSE (Including amniotic fluid embolism) • 5/5

Place woman in left lateral If >22 weeks’

Manually displace uterus Cardiorespiratory Call obstetric

Assessment of progress l Advise woman that oxytocin will increase

Oxytocin l Vertex or breech visible

Parous women Nulliparous women

BACKGROUND PREGNANCY CONFIRMED

CARE IN DIABETIC ANTENATAL CLINIC

Table 2 – Antenatal care (joint obstetric/diabetic clinic)

Table 2 – Antenatal care (joint obstetric/diabetic clinic) cont.

Management of diabetes Treatment

Monitor blood glucose targets l In most women, gestational diabetes

Women on insulin RETINOPATHY