Intrapartum care for women with existing medical conditions or obstetric complications and their babies

Risk assessment for women with heart disease should follow the principles of multidisciplinary team working (outlined in the recommendation in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team). Include a cardiologist with expertise in managing heart disease in pregnant women in the multidisciplinary team discussions.

For women with heart disease diagnosed in the intrapartum period, urgent multidisciplinary discussions are needed to ensure that the woman is offered the same level of care as a woman with an existing diagnosis of heart disease and, where possible, that her preferences are taken into account.

Be aware that some women with heart disease are at low risk of complications and their care should be in line with the NICE guideline on intrapartum care, whereas others need individualised specialist care.

Risk is defined according to the modified World Health Organization (WHO) classification of maternal cardiovascular risk in the 2018 European Society of Cardiology guidelines published in the European Heart Journal.

For women with heart disease, reassess intrapartum risk regularly during pregnancy and the intrapartum period using all of the following:

• comprehensive clinical assessment, including history and physical examination

• the modified WHO classification of risk

• New York Heart Association (NYHA) functional class (see American Heart Association's information about classes of heart failure).

Offer the same investigations to pregnant women with heart disease as to women who are not pregnant. Review the results and act on them without delay.

When pregnancy is confirmed:

• involve women with mechanical heart valves in multidisciplinary discussion of plans for anticoagulation during the intrapartum period (see the recommendations in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team)

• consider including a haematologist in the multidisciplinary discussion

• explain to women that they will need individualised anticoagulation depending on their current treatment.

For women with mechanical heart valves who are taking warfarin in the third trimester, switch anticoagulation to low-molecular-weight heparin by 36⁺⁰ weeks of pregnancy or 2 weeks before planned birth (if this is earlier than 36⁺⁰ weeks). In hospital, consider doing this by:

• stopping warfarin, and 24 hours later, starting low-molecular-weight heparin using a twice-daily regimen at a dose based on the most recent weight available

• increasing the dose of low-molecular-weight heparin according to anti‑Xa levels; this should be done by:

  • checking anti‑Xa levels each day 3 to 4 hours after a dose of low-molecular-weight heparin, aiming for a peak anti‑Xa level between 1.0 and 1.2 IU/ml

  • checking that the anti‑Xa level before a dose of low-molecular-weight heparin (trough level) is above 0.6 IU/ml

• rechecking anti‑Xa level weekly once the target anti‑Xa level is achieved.

For women with mechanical heart valves, stop therapeutic low-molecular-weight heparin 24 hours before a planned caesarean section and consider:

• aiming to perform the caesarean section as near to 24 hours after stopping low-molecular-weight heparin as possible and no later than 30 hours after stopping or

• switching to intravenous unfractionated heparin (aiming for an activated partial thromboplastin time [aPTT] of at least twice control), then 4 to 6 hours before caesarean section, stopping intravenous unfractionated heparin.

For women with mechanical heart valves who are having an induction of labour, a senior obstetrician should be involved in:

• deciding when to stop low-molecular-weight heparin or intravenous unfractionated heparin in order to:

  • minimise the risk of maternal haemorrhage or valve thrombosis

  • enable the option of regional analgesia

• reviewing the progress of labour and:

  • the need for low-molecular-weight heparin every 12 hours, aiming for birth as close to 12 hours from the last injection as possible or

  • the need for unfractionated heparin, aiming for birth as close to 4 to 6 hours after stopping the infusion.

For women with mechanical heart valves who are taking warfarin and who present in established labour:

• check the international normalised ratio (INR) immediately and consult a haematologist

• do not give anticoagulation until the woman has had an assessment by an obstetrician, which should happen within 2 hours

• carry out a senior review (including at least a senior obstetrician, haematologist and a consultant obstetric anaesthetist) to discuss the mode of birth most likely to give the lowest risk of bleeding for the woman and the baby

• consider reversal of anticoagulation.

For women with mechanical heart valves, carry out a postpartum review, involving at least a senior obstetrician and anaesthetist, of the risk of haemorrhage and valve thrombosis within 3 to 4 hours of birth. Aim to restart therapeutic low-molecular-weight heparin or unfractionated heparin 4 to 6 hours after birth.

For women with mechanical heart valves at high risk of peripartum haemorrhage, consider the following options until hourly review indicates that therapeutic anticoagulation can be re-established:

• prophylactic low-molecular-weight heparin or

• no low-molecular-weight heparin.

For women with mechanical heart valves, consider delaying restarting warfarin until at least 7 days after birth and arrange specialist follow‑up as outlined in the multidisciplinary care plan (see recommendation 1.3.6).

Develop an individualised birth plan with the woman with heart disease covering all 3 stages of labour following multidisciplinary discussion (outlined in the recommendation on the plan in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team). Consider including a cardiologist with expertise in managing heart disease in pregnant women in the multidisciplinary team discussions.

Throughout pregnancy, manage pulmonary arterial hypertension in consultation with a specialist pulmonary hypertension centre.

Offer planned birth (induction of labour or caesarean section) for women with mechanical heart valves.

Consider planned caesarean section for women with:

• any disease of the aorta assessed as high risk

• pulmonary arterial hypertension

• NYHA class III or IV heart disease.
  
  Explain the benefits and risks of caesarean section. If the woman chooses not to have a caesarean section, explain the benefits and risks of an assisted second stage of labour compared with active pushing alone.

For women with heart disease who have a planned caesarean section, develop an individualised emergency care plan with the woman in case she presents in early labour, with new symptoms or with obstetric complications.

During pregnancy, plan the management of fluid balance during the intrapartum period for women with heart disease with the multidisciplinary team (outlined in the recommendation on team members in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team). Include a cardiologist with expertise in managing heart disease in pregnant women. Multidisciplinary discussion should include:

• how the condition affects fluid balance

• optimum fluid balance and how this might be achieved

• plans for risk assessment and monitoring.

Identify women with heart disease for whom fluid balance is critical to cardiac function. These include women with:

• severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)

• hypertrophic cardiomyopathy

• cardiomyopathy with systolic ventricular dysfunction

• pulmonary arterial hypertension

• Fontan circulation and other univentricular circulations

• NYHA class IV heart disease.

For women with heart disease in whom fluid balance is critical for optimal cardiac function, offer tailored monitoring and clinical review during the intrapartum period, and consider escalation as follows:

• hourly monitoring of fluid input and output (with at least 4‑hourly assessment by a senior clinician), blood pressure, pulse, respiratory rate and oxygen saturation

• continuous electrocardiogram (ECG) and pulse oximetry with interpretation by trained staff

• continuous intra-arterial blood pressure monitoring

• cardiac output monitoring with non-invasive techniques, or serial echocardiography by trained staff.
  
  Advise women who need intensive monitoring that this may have to be carried out in an intensive care unit where the necessary equipment and expertise is available.
  
  Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

Offer standard fluid management during the intrapartum period for women with modified WHO 1 and NYHA class I heart disease.

Consider standard fluid management during the intrapartum period for women with modified WHO 2 to 3, or NYHA class II to III heart disease after a multidisciplinary discussion (outlined in the recommendation on the plan in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team).

Take a cardiac-specific history and suspect heart failure if there is not another likely cause of any of the following symptoms:

• breathlessness when lying down (ruling out aortocaval compression) or at rest

• unexplained cough, particularly when lying down or which produces frothy pink sputum

• paroxysmal nocturnal dyspnoea – being woken from sleep by severe breathlessness and coughing, which may produce pink frothy sputum and is improved by moving to an upright position

• palpitation (awareness of persistent fast heart rate at rest).

Consider heart failure in the intrapartum period if there are any of the following signs:

• pale, sweaty, agitated with cool peripheries

• heart rate persistently greater than 110 beats per minute at rest

• respiratory rate persistently greater than 20 breaths per minute at rest

• hypotension (systolic blood pressure less than 100 mmHg)

• oxygen saturation less than 95% on air

• elevated jugular venous pressure

• added murmur or heart sound

• reduced air entry, basal crackles or wheeze, on listening to the chest.
  
  Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

If any of the symptoms or signs in recommendations 1.3.24 and 1.3.25 suggest heart failure, a senior clinician should review the woman's condition without delay.

When there is a clinical suspicion of heart failure in any woman in the intrapartum period:

• establish peripheral venous access

• measure urea and electrolytes, and perform a full blood count

• measure arterial blood gases

• perform an ECG

• perform a chest X‑ray.

If clinical suspicion of heart failure in the intrapartum period cannot be ruled out by the investigations in recommendation 1.3.27, arrange:

• review by a cardiologist (with interim review by a healthcare professional with expertise in this area if a cardiologist is not immediately available)

• a transthoracic echocardiogram by a trained technician or cardiologist

• measurement of N‑terminal pro‑brain natriuretic peptide (NT‑proBNP) levels.

Consider early birth for women with heart failure due to cardiomyopathy, depending on the severity of the condition and how well the condition has responded to treatment.

Optimise treatment for heart failure as soon as possible after birth even if the woman is breastfeeding.

If clinical suspicion of heart failure persists after birth, consider the continued involvement of a cardiologist.

During pregnancy, prepare a plan for managing anaesthesia and analgesia for women with heart disease involving a multidisciplinary team and the woman (outlined in the recommendation on the plan in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team). Consider including a haematologist for women on an anticoagulation regimen.

Consider offering the same information about anaesthesia and analgesia in labour to women with modified WHO 1 or modified WHO 2 heart disease as described in the NICE guideline on intrapartum care.

Consider regional anaesthesia for women with modified WHO 3 and modified WHO 4 heart disease, unless this is contraindicated.

Consider collaborative working in the intrapartum period between an obstetric anaesthetist and a cardiac anaesthetist for women with modified WHO 3 and modified WHO 4 heart disease.

When using regional anaesthesia for women with heart disease, aim to preserve cardiovascular stability by, for example, using a sequential combined spinal–epidural technique.

Offer intrapartum monitoring of the heart and circulation to all women with modified WHO 3 and modified WHO 4 heart disease; this will usually include continuous invasive intra-arterial pressure monitoring and may include central venous pressure monitoring and advanced cardiac output monitoring.

Offer low-dose regional analgesia to women with modified WHO 3 or modified WHO 4 heart disease because this is less likely to cause cardiac instability during labour and birth.

Consider regional analgesia for women who have been on low-molecular-weight heparin and who have not had a prophylactic dose for at least 12 hours, or a therapeutic dose for at least 24 hours.

For women taking low-molecular-weight heparin:

• wait 12 hours after a prophylactic dose before siting an epidural, or removing an epidural catheter

• wait 24 hours after a therapeutic dose before siting an epidural or spinal, or removing an epidural catheter

• after siting an epidural or a spinal, or removing an epidural catheter, wait 4 hours before administering a further dose of low-molecular-weight heparin

• do not administer therapeutic dose low-molecular-weight heparin while an epidural catheter is in place.

During pregnancy, prepare an individualised plan for managing the third stage of labour for women with heart disease, involving a multidisciplinary team and the woman (outlined in the recommendation on the plan in the section on planning for intrapartum care with women with existing medical conditions - involving a multidisciplinary team). Consider including a cardiologist with expertise in managing heart disease in pregnant women.

Treat women with modified WHO 1 heart disease as low risk and consider the full range of care options for healthy women in the third stage of labour described in the NICE guideline on intrapartum care.

Advise active management of the third stage of labour for women with modified WHO 2 heart disease, in line with the NICE guideline on intrapartum care.

Consider management of the third stage of labour for women with modified WHO 3 or modified WHO 4 heart disease according to table 1.

Offer women with asthma the same options for pain relief during labour as women without asthma, including:

• Entonox (50% nitrous oxide plus 50% oxygen)

• intravenous and intramuscular opioids

• epidural

• combined spinal–epidural analgesia.

Do not offer prostaglandin F2 alpha (carboprost) to women with asthma because of the risk of bronchospasm.

Consider prostaglandin E1 or prostaglandin E2 as options for inducing labour in women with asthma because there is no evidence that they worsen asthma.

Consider prostaglandin E1 as an option for treating postpartum haemorrhage in women with asthma because there is no evidence it worsens asthma.

Be aware that maternal corticosteroids given antenatally for fetal lung maturation should not affect the advice given in recommendations 1.5.2 to 1.5.4.

For women planning a vaginal birth who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks):

• continue their regular oral steroids and

• when they are in established first stage of labour, add intravenous or intramuscular hydrocortisone and consider a minimum dose of 50 mg every 6 hours until 6 hours after the baby is born.

For women having a planned or emergency caesarean section who have adrenal insufficiency or who are taking long-term oral steroids (equivalent to 5 mg or more prednisolone daily for more than 3 weeks):

• continue their regular oral steroids and

• give intravenous hydrocortisone when starting anaesthesia; the dose will depend on whether the woman has received hydrocortisone in labour, for example:

  • consider giving 50 mg if she has had hydrocortisone in labour

  • consider giving 100 mg if she has not had hydrocortisone in labour

• give a further dose of hydrocortisone 6 hours after the baby is born (for example, 50 mg intravenously or intramuscularly).

Do not offer supplemental hydrocortisone in the intrapartum period to women taking inhaled or topical steroids.

Discuss the balance of benefits and risks of regional analgesia and anaesthesia with women with bleeding disorders.

When considering regional analgesia and anaesthesia for women with bleeding disorders, take into account:

• the overall risk of bleeding and opportunity for corrective treatment

• therapeutic and prophylactic anticoagulation

• the risk of bleeding associated with the technique to be used

• the difficulty of needle siting or insertion

• the comparative risks associated with no analgesia or non-regional analgesia

• the comparative risks of general anaesthesia.

For woman with known immune thrombocytopenic purpura, before admission for birth:

• plan birth in an obstetric-led unit with a neonatal unit that routinely provides high-dependency care

• plan as if the baby will be at risk of bleeding irrespective of the woman's platelet count

• consider monitoring maternal platelet count weekly from 36 weeks, and if the platelet count is below 50:

  • discuss and agree a plan for intrapartum care with the multidisciplinary team, including a haematologist

• consider giving steroids or intravenous immunoglobulin to raise the maternal platelet count.

For women with known immune thrombocytopenic purpura, on admission for birth:

• measure maternal platelet count

• manage intrapartum care according to table 2.

For women with known or suspected immune thrombocytopenic purpura, take the following precautions to reduce the risk of bleeding for the baby:

• inform the neonatal team of the imminent birth of a baby at risk

• do not carry out fetal blood sampling

• use fetal scalp electrodes with caution

• do not use ventouse

• use mid-cavity or rotational forceps with caution

• bear in mind that a caesarean section may not protect the baby from bleeding

• measure the platelet count in the umbilical cord blood at birth.

Modify the birth plan based on maternal platelet count, using table 2 as a guide, for women with:

• gestational thrombocytopenia (without pre-eclampsia and HELLP syndrome, and otherwise well)

• an uncertain diagnosis of immune thrombocytopenic purpura.

Be aware that women with bleeding disorders are at increased risk of primary and secondary postpartum haemorrhage.

Offer active management rather than physiological management of the third stage of labour for women with bleeding disorders, in line with the NICE guideline on intrapartum care.

For women with bleeding disorders, avoid giving uterotonics by intramuscular injection.

Offer individualised postpartum care, as discussed with a senior haematologist, for women with bleeding disorders, to include:

• measurement of blood loss

• monitoring obstetric complications

• monitoring haematological parameters.

Be aware that non-steroidal anti-inflammatory drugs can add to the risk of bleeding.

Before discharge from hospital, inform women with bleeding disorders of the risk of secondary bleeding postpartum and how to access care.

Involve the multidisciplinary team in risk assessment for women with a cerebrovascular malformation or a history of intracranial bleeding. Include the woman in care planning and a clinician with expertise in managing neurovascular conditions in pregnant women.

During pregnancy, involve the multidisciplinary team in risk assessment for women with kidney disease. Include a clinician with expertise in managing renal conditions in pregnant women.

Ensure that women with chronic kidney disease stage 4 or 5 before pregnancy or women with progressive or active kidney disease are cared for in the intrapartum period by a midwife, obstetrician and obstetric anaesthetist with input from a clinician with expertise in managing renal conditions in pregnant women.

Ensure that a clinician with expertise in managing renal conditions in pregnant women is available for consultation during the intrapartum period for women with chronic kidney disease stage 4 or 5 before pregnancy or women with progressive or active kidney disease.

Manage acute kidney injury secondary to pre-eclampsia in line with the NICE guideline on hypertension in pregnancy.

For women with chronic kidney disease with or without pre-eclampsia, monitor fluid balance in the intrapartum period. Measure heart rate hourly and the following at least every 4 hours:

• blood pressure

• respiratory rate with chest auscultation

• fluid output and fluid intake

• oxygen saturation.
  
  After each assessment, develop an individualised plan for managing fluid balance, which may involve additional monitoring techniques, with the aim of maintaining normal fluid volume to reduce the risks of acute kidney injury and pulmonary oedema.

Assess renal function at least every 24 hours during the intrapartum period in all women with chronic kidney disease because prolonged labour may lead to dehydration and acute kidney injury.

For women with acute kidney injury:

• identify and correct the cause of the acute kidney injury

• measure heart rate hourly and monitor fluid balance in the intrapartum period by assessing the following at least every 4 hours:

  • blood pressure

  • respiratory rate and chest auscultation

  • fluid output and fluid intake

  • oxygen saturation

• develop an individualised plan for managing fluid balance, which may involve additional monitoring techniques, with the aim of maintaining normal fluid volume and avoiding both dehydration and pulmonary oedema

• consider giving a single small bolus of fluid (for example, 250 ml) as crystalloid if the woman is dehydrated and review the fluid status and urine output within an hour of giving the first fluid bolus and before considering giving a second

• continue to monitor fluid balance and renal function until the acute kidney injury has recovered.

Do not offer nephrotoxic drugs (for example, non-steroidal anti-inflammatory drugs) in the intrapartum period to women with kidney disease.

For all women with kidney disease during pregnancy:

• monitor the following at least every 4 hours for at least 24 hours after the birth:

  • heart rate and blood pressure

  • respiratory rate and chest auscultation

  • fluid output and fluid intake

  • oxygen saturation

• ensure postpartum assessment of renal function and follow‑up for women with persistent kidney disease.

As early as possible during pregnancy, plan intrapartum care for women with kidney disease due to lupus nephritis, vasculitis or glomerulonephritis with the woman and a clinician with expertise in managing renal conditions in pregnant women.

As early as possible during pregnancy, plan intrapartum care for women with a kidney transplant with the woman, a clinician with expertise in managing renal conditions in pregnant women and a kidney transplant surgeon.

For women with chronic kidney disease stage 1, stable renal function and non-nephrotic-range proteinuria (urine protein:creatinine ratio less than 300 mg/mmol), base decisions on timing and mode of birth on the woman's preference and obstetric indications.

Consider planned birth by 40⁺⁰ weeks of pregnancy for women with:

• chronic kidney disease stage 1 and nephrotic-range proteinuria (urine protein:creatinine ratio greater than 300 mg/mmol) or

• chronic kidney disease stage 2 to 4 with stable renal function.

For women with chronic kidney disease stage 5 or deteriorating stage 3b and stage 4, before 34⁺⁰ weeks of pregnancy, discuss the option of dialysis with the woman and the multidisciplinary team in an effort to prolong the pregnancy to at least 34⁺⁰ weeks.

For women with chronic kidney disease stage 5 or deteriorating stage 3b and stage 4, after 34⁺⁰ weeks of pregnancy, discuss the option of planned birth with the woman and the multidisciplinary team and consider birth no later than 38⁺⁰ weeks.

For all women with kidney disease, including those with a kidney transplant, base decisions on mode of birth on the woman's preference and obstetric indications.

Consider ultrasound scanning at the start of established labour if the baby's presentation is uncertain for women with a BMI over 30 kg/m² at the booking appointment, particularly those with a BMI over 35 kg/m².

Base intrapartum fetal monitoring on the woman's preference and obstetric indications (including no antenatal care), in line with the NICE guideline on fetal monitoring in labour, for women with a BMI over 30 kg/m² at the booking appointment and no medical complications.

For women with a BMI over 30 kg/m² at the booking appointment, carry out a risk assessment in the third trimester. When developing the birth plan with the woman, take into account:

• the woman's preference

• the woman's mobility

• comorbidities

• the woman's current or most recent weight.

For women with a BMI over 30 kg/m² at the booking appointment and reduced mobility in the third trimester, consider advising the lateral position in the second stage of labour.

For women with a BMI over 30 kg/m² at the booking appointment and adequate mobility, provide care in the second stage of labour in line with the NICE guideline on intrapartum care.

All obstetric units should have 'birthing beds' able to take a safe working load of 250 kg.

Carry out a risk assessment to ensure that essential equipment, in a size-appropriate form, is available for the intrapartum care of women with a BMI over 30 kg/m² at the booking appointment, including:

• surgical, obstetric and anaesthetic equipment

• blood pressure cuffs

• operating theatre tables

• lifting and lateral transfer equipment

• anti-embolism stockings

• wheelchairs

• monitoring and measuring equipment.

For women with a BMI over 50 kg/m² at the booking appointment, offer referral to an obstetric unit with suitable equipment and expertise as early as possible in pregnancy, if this is not available in their current unit.

Consider paracetamol for women in labour with a fever, a temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings (1 hour apart).

Be aware that paracetamol is not a treatment for sepsis and should not delay investigation if sepsis is suspected.

For women in labour with a fever, a temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings (1 hour apart), follow the recommendations in the section on fetal monitoring for women in labour with sepsis or suspected sepsis on fetal blood sampling for women with suspected sepsis.

Advise continuous cardiotocography during labour for:

• women with suspected sepsis and

• women with confirmed sepsis
  
  in line with the section on the use of cardiotocography for monitoring during labour in the NICE guideline on fetal monitoring in labour.

Explain to the woman and her birth companion(s) what fetal blood sampling involves and the uncertainty of the significance of the results, and support her decision to accept or decline testing.

Be aware that for women in labour with sepsis or suspected sepsis, fetal blood sample results may be falsely reassuring, and always discuss with a consultant obstetrician:

• whether fetal blood sampling is needed

• the results of any fetal blood sampling carried out.

For women in labour with sepsis or suspected sepsis and an abnormal cardiotocograph trace, think about the whole clinical picture and take account of the following before performing any fetal blood sampling and when interpreting the results:

• the woman's preferences

• stage and progress of labour

• parity

• likelihood of chorioamnionitis.

If sepsis continues to be suspected, only repeat fetal blood sampling with caution and in discussion with a consultant obstetrician.

For women in labour with sepsis or suspected sepsis:

• Take into account the whole clinical picture when thinking about antimicrobial treatment.

• Document the rationale for any decision to start antimicrobial treatment and the choice of antimicrobial.

• Take specimens for microbiological culture, including blood cultures, before starting antimicrobials in line with the NICE guideline on sepsis.

For women in labour with sepsis or suspected sepsis and a clear source of infection, use existing local antimicrobial guidance when offering an antimicrobial. [This recommendation is adapted from the NICE guideline on sepsis.]

For women in labour with sepsis or suspected sepsis and an unclear source of infection, offer a broad-spectrum intravenous antimicrobial from the agreed local formulary and in line with local (where available) or national guidelines. [This recommendation is adapted from the NICE guideline on sepsis.]

Explain to the woman in labour with sepsis or suspected sepsis and her birth companion(s):

• there is no evidence to support the use of one broad-spectrum antimicrobial over another

• the choice of antimicrobial will be guided by local antimicrobial guidelines.

For women with sepsis or suspected sepsis, ensure that there is ongoing multidisciplinary review (see the recommendations in the sections on multidisciplinary review for women in labour with suspected sepsis and with sepsis) in the first 24 hours after the birth. This should include a discussion about the need for:

• microbiological specimens for culture

• antimicrobial treatment

• increased frequency of monitoring

• an enhanced level of care and monitoring

• further investigations such as imaging

• support to enable the woman to feed her baby as she chooses (including keeping the woman and baby together wherever possible and maintaining skin-to-skin contact)

• additional support for the woman and her family.

If there are signs of shock in a woman with intrapartum haemorrhage, proceed with immediate resuscitation.

The maternity service and ambulance service should have strategies in place to respond quickly and appropriately if a woman has an intrapartum haemorrhage in any setting. [This recommendation is adapted from the NICE guideline on intrapartum care.]

If a woman in labour has any vaginal blood loss other than a 'show', transfer her to obstetric-led care, in line with the NICE guideline on intrapartum care.

If a woman in labour has any vaginal blood loss other than a 'show', explain to her and her birth companion(s) what is happening.

If a woman in labour has any vaginal blood loss other than a 'show':

• Take a history of the bleeding, asking about:

  • any associated symptoms, including pain

  • any specific concerns the woman may have

  • any previous uterine surgery.

• Check previous scans for placental position.

• Assess the volume of blood loss and characteristics of the blood, such as colour, and presence of clots or amniotic fluid.

• Carry out a physical examination, including:

  • vital signs

  • abdominal palpation

  • speculum examination

  • vaginal examination if placenta praevia has been excluded

  • fetal heart auscultation.

• Start continuous cardiotocography.

• Take a blood sample to determine full blood count and blood group.

Think about the possible causes of bleeding, for example:

• placental abruption

• placenta praevia

• uterine rupture

• vasa praevia.
  
  Recognise that in many cases, no cause will be identifiable.

If a woman in labour has any vaginal blood loss other than a 'show', agree a multidisciplinary care plan with the woman and document the plan. Include the following in plans for multidisciplinary care:

• a senior obstetrician

• a senior obstetric anaesthetist

• a senior midwife

• a labour ward coordinator.

If a woman has intrapartum bleeding and her condition is stable, management should include:

• establishing venous access

• maternal monitoring (see the recommendation on continuously monitoring vaginal blood loss in the section on risk assessment for women with obstetric complications or no antenatal care and table 4)

• monitoring the fetal heart rate with continuous cardiotocography.

If a woman with intrapartum bleeding has a large blood loss or her condition causes concern, management should be in line with recommendation 1.14.8 and also include:

• giving intravenous fluids urgently

• taking blood for full blood count and cross-matching

• seeking medical advice from a more experienced healthcare professional.
  
  Management may also include:

  • triggering the local major haemorrhage protocol

  • taking blood for clotting studies and blood gases

  • use of amniotomy or oxytocin

  • expediting the birth.

If a woman in labour has vaginal blood loss typical of a 'show', follow the NICE guideline on intrapartum care.

Discuss with women in labour with breech presentation the possible benefits and risks of vaginal birth and caesarean section, including:

• an increase in the chance of serious medical problems for the woman with caesarean section

• an increase in the chance of serious medical problems for the baby with vaginal birth

• what it might mean for them and the baby if such problems did occur.

Explain to women in labour with breech presentation that any benefit of caesarean section in reducing the chance of serious medical problems for the baby may be greater in early labour.

Offer women in labour with breech presentation a choice between continuing labour and caesarean section.

Assess progress of labour in line with the NICE guideline on intrapartum care.

Discuss with a woman whose baby is suspected to be small for gestational age:

• the chance of serious medical problems for her baby

• what it might mean for her and her baby if such problems did occur.

When discussing risk, explain that when a baby is suspected to be small for gestational age:

• it is sometimes difficult to be certain the suspicion is correct until the baby is born

• the chance of serious medical problems for the baby is greater with:

  • growth restriction

  • additional risk factors, such as preterm birth

  • complications during labour or birth.

Offer continuous cardiotocography to women whose babies are suspected to be small for gestational age after a full discussion of the benefits and risks (see recommendations 1.16.1 and 1.16.2). Respect the woman's decision if she declines continuous cardiotocography.

Explain to women in labour whose babies are suspected to be large for gestational age that:

• it is sometimes difficult to be certain the suspicion is correct until the baby is born

• when making decisions about mode of birth (for example, vaginal birth or caesarean section), this uncertainty needs to be taken into account.

Discuss with women in labour whose babies are suspected to be large for gestational age the possible benefits and risks of vaginal birth and caesarean section, including:

• a higher chance of maternal medical problems such as infection with emergency caesarean section

• a higher chance of shoulder dystocia and brachial plexus injury with vaginal birth

• a higher chance of instrumental birth and perineal trauma with vaginal birth.
  
  Explain to the woman and her birth companion(s) what it might mean for her and her baby if such problems did occur.

Offer women in labour whose babies are suspected to be large for gestational age a choice between continuing labour, including augmented labour, and caesarean section.

For women who have had no antenatal care, be aware of the particular importance of following the recommendations on establishing rapport and treating with respect in the NICE guideline on intrapartum care.

Provide obstetric-led intrapartum care for women who have had no antenatal care, and alert the neonatal team and, if relevant, the anaesthetic team. If the woman presents to a midwifery unit, arrange urgent transfer to an obstetric-led unit if appropriate.

For a woman with no antenatal care who has difficulty understanding, speaking and reading English, provide an interpreter (who may be a link worker or advocate and should not be a member of her family, her legal guardian or her partner), who can communicate with her in her preferred language. [This recommendation is adapted from the NICE guideline on pregnancy and complex social factors.]

If possible, take a full medical, psychological and social history from women who have had no antenatal care.

• Try to find out why there has been no care during pregnancy.

• Ask the woman who, if anyone, she would like to support her as her birth companion(s) during labour.

• Explore sensitively any possible vulnerability or safeguarding concerns, including:

  • young maternal age

  • maternal mental health

  • maternal learning disability

  • maternal substance misuse

  • domestic or sexual abuse

  • homelessness

  • human trafficking

  • undocumented migrant status

  • female genital mutilation

  • the woman or family members being known to children's services or social services.

Carry out an obstetric and general medical examination of a woman with no antenatal care as soon as possible. This should include the initial assessment described in the NICE guideline on intrapartum care.

Carry out an assessment of the unborn baby, including ultrasound if possible, to determine:

• viability

• the presentation

• an estimate of gestational age

• the possibility of multiple pregnancy

• the placental site.

Offer women who have had no antenatal care, tests for:

• anaemia (full blood count)

• haemoglobinopathies

• blood group and rhesus D status

• atypical red cell alloantibodies

• random blood glucose

• asymptomatic bacteriuria

• HIV, hepatitis B and syphilis.

Offer rapid HIV testing to women thought to be at high risk of infection, which might include:

• recent migrants from countries with high rates of HIV infection

• women who misuse substances intravenously

• suspected sexual abuse.

Explain to a woman who has had no antenatal care why and when information about her pregnancy may need to be shared with other agencies. [This recommendation is adapted from the NICE guideline on pregnancy and complex social factors.]

Contact the woman's GP and, if appropriate, other health or social care professionals for more information about the woman's history and to plan ongoing care.

If there are safeguarding concerns, refer the woman to safeguarding services, document the referral and inform healthcare professionals such as the GP, health visitor and paediatric teams, and social care professionals (see the NICE guidelines on pregnancy and complex social factors, child maltreatment and child abuse and neglect).

Follow the recommendations in the NICE guideline on intrapartum care when no medical conditions or obstetric complications are identified in women who present in labour with no antenatal care.

Do not routinely insert an intravenous cannula for women in labour who have had a previous caesarean section.

Explain to women in labour who have had a previous caesarean section that:

• a vaginal birth is associated with a small chance of uterine rupture

• an emergency caesarean section may mean a higher chance of:

  • heavy bleeding needing a blood transfusion

  • infection, for example, intrauterine infection

  • a longer hospital stay

  • complications in a future pregnancy, for example, placenta praevia and placenta accreta (see the NICE guideline on caesarean birth).

Explain to women in labour who have had a previous caesarean section that there is little evidence of a difference in outcomes for the baby between a vaginal birth or another caesarean section.

Explain to women who have had a previous caesarean section that they are likely to have a lower chance of complications in labour if they have also had a previous vaginal birth.

When discussing oxytocin for delay in the first or second stage of labour, explain to women who have had a previous caesarean section that this:

• increases the chance of uterine rupture

• reduces the chance of another caesarean section

• increases the chance of an instrumental birth.

For guidance on continuous cardiotocography in labour for women with a previous caesarean section, see NICE's guideline on caesarean birth.

Support informed choice of a full range of options for pain relief for women who have had a previous caesarean section, including labour and birth in water.

Explain to women in labour who have had a previous caesarean section that regional analgesia is associated with:

• a reduced chance of another caesarean section

• an increased chance of an instrumental birth.

Do not routinely offer amniotomy to women in labour who have had a previous caesarean section.

This recommendation on continuous cardiotocography has been withdrawn (see recommendation 1.19.6).

For women who have had a previous caesarean section, be aware of the particular importance of following the recommendations from the NICE guideline on intrapartum care on:

• food and drink in labour

• controlling gastric acidity

• position in labour, including the latent first stage, and birth.

Offer continuous cardiotocography to women in labour after 42 weeks of pregnancy after a full discussion of the benefits and risks to the woman and her baby. Respect the woman's decision if she declines continuous cardiotocography.