This document provides guidelines for intrapartum care for women with existing medical conditions. It discusses considerations for women with asthma, those taking long-term steroids, bleeding disorders, and obesity during labor and delivery. For asthma, it recommends the same analgesia options as women without asthma and notes prostaglandins may be used for labor induction. For steroids, it provides steroid replacement regimens. For bleeding disorders, it discusses regional anesthesia risks and modifying birth plans based on platelet counts. Finally, for obesity, it emphasizes early fetal presentation assessment, fetal monitoring challenges, recommended positions in labor, and necessary medical equipment.

1. INTRAPARTUM
CARE
for
Women With Existing
Medical Conditions
NICE, March 2019
Prof. Aboubakr
Elnashar
ABOUBAKR M ELNASHAR

2. CONTENTS
1. ASTHMA
2. LONG-TERM SYSTEMIC STEROIDS
3. BLEEDING DISORDERS
4. OBESITY
ABOUBAKR M ELNASHAR

3. 1. ASTHMA
I. Analgesia for women with asthma
 Offer women the same options as women without
asthma:
 Entonox (50% nitrous oxide plus 50% oxygen)
 IV & IM opioids
 Epidural, combined spinal–epidural analgesia.
 {No evidence of harm}
ABOUBAKR M ELNASHAR

4. II. Prostaglandins for women with asthma
 Prostaglandin F2 alpha (carboprost)
 Not given
{risk of bronchospasm}.
 Prostaglandin E1 or
 Prostaglandin E2
for inducing labour
{no evidence that they worsen asthma}.
ABOUBAKR M ELNASHAR

5. 2. LONG-TERM SYSTEMIC STEROIDS
Steroid replacement regimens
 Long term
5 mg or more prednisolone daily for ≥3 w
 have adrenal insufficiency
ABOUBAKR M ELNASHAR

6. 1. For women planning vaginal birth
 continue their regular oral steroids
{the effects of stopping are uncertain
there could be problems restarting the dose in
the postpartum period}
 when they are in established first stage of labour:
 add IV or IM hydrocortisone
 50 mg/6 h until 6 hs after the baby is born.
{women who have been taking long-term steroids are
at risk of adrenal crisis under stress of labour}
ABOUBAKR M ELNASHAR

7. 2. For women having a planned or emergency CS:
 continue their regular oral steroids
 give IV hydrocortisone when starting anaesthesia
 Dose
 if she has had hydrocortisone in labour:
 50mg
 If she has not had hydrocortisone in labour
 100 mg
 give a further dose of hydrocortisone 6h after
the baby is born
ABOUBAKR M ELNASHAR

8. 3. Women taking inhaled or topical steroids.
 Do not offer supplemental hydrocortisone in the
intrapartum period
 {the lower doses.}
ABOUBAKR M ELNASHAR

9. 3. BLEEDING DISORDERS
I. Regional anaesthesia& analgesia
 Benefits& risks of regional analgesia& anaesthesia
are assessed
 Risk of bleeding associated with the technique
 Corrective treatment
{the risk-benefit ratio will be highly individual}
ABOUBAKR M ELNASHAR

10.  Sometimes, regional analgesia& anaesthesia
(especially spinal)
 can be considered for women with low platelet
counts
 {No serious harm (such as epidural haematoma) from
regional analgesia or anaesthesia even with a platelet
count below 50×109/l.
 Bleeding complications
 more likely with epidural rather than spinal
(smaller needles are used for the latter)}.
ABOUBAKR M ELNASHAR

11. II. Modifying the birth plan according to platelet count
Gestational thrombocytopenia
 Thrombocytopenia in the first half of pregnancy:
less likely to be gestational: possible diagnosis of
ITP.
 At low risk of bleeding complications during birth
 No alloantibody that affects the fetal platelet count.
 Only woman at risk of bleeding, not her baby.
ABOUBAKR M ELNASHAR

12.  Immune thrombocytopenic purpura (ITP)
 Regarded as high risk.
 Significant changes to the birth plan only if the
 ITP, or
 gestational thrombocytopenia with a low platelet
count.
ABOUBAKR M ELNASHAR

13.  Before admission for birth:
 Plan birth in an obstetric unit with a neonatal unit
that routinely provides high care
 Plan as if the baby will be at risk of bleeding
irrespective of the woman's platelet count
 Monitoring platelet count weekly from 36 w
 if below 50:
 multidisciplinary team, haematologist
 consider giving
 steroids or
 IV Igb to raise platelet count.ABOUBAKR M ELNASHAR

14.  Prednisolone
 20-30 mg/d
 then dose may be weaned to the lowest that will
maintain a satisfactory (>50 x 109/L) maternal
platelet count
 IV Ig:
 0.4 g/kg/ day for five days or
 1 g/kg over eight hours,
 repeated two days later if there is an inadequate
response.
ABOUBAKR M ELNASHAR

15.  On admission for birth:
 Measure platelet count
 Manage
ABOUBAKR M ELNASHAR

16. ABOUBAKR M ELNASHAR

17. III. Management of the third stage of labour for women
with bleeding disorders
1. Be aware that an increased risk of primary&
secondary PPH
2. Avoid giving uterotonics by IM injection.
3. Offer active management rather than physiological
management
ABOUBAKR M ELNASHAR

18.  Active management of
the third stage:
1. routine use of
uterotonic drugs
2. deferred
clamping&
cutting of cord
3. CCT after signs
of separation of
the placenta.
 Physiological management
of third stage:
1. no routine use of
uterotonic drugs
2. no clamping of the
cord until pulsation
has stopped
3. delivery of the
placenta by maternal
effort.
ABOUBAKR M ELNASHAR

19. 4. Offer individualised postpartum care:
 measurement of blood loss
 monitoring obstetric complications
 monitoring haematological parameters.
5. Be aware that non-steroidal anti-inflammatory drugs
can add to the risk of bleeding.
6. Before discharge from hospital, inform women of
risk of
 secondary PPH
 how to access care.
ABOUBAKR M ELNASHAR

20. 4. OBESITY
1. Assessing fetal presentation early in labour
 US
 {identifying the fetal position by palpation is difficult
particularly when the BMI is over 35 kg/m2.
 The degree of confidence in palpation often
decreases with increasing body weight}.
ABOUBAKR M ELNASHAR

21. 2. Fetal monitoring
 According to
 woman's preference
 obstetric indications
 {In obese.
 It is difficult to monitor
 FHR
 uterine contractions
 fetal position
 likely to have more complications
 accurate fetal monitoring is particularly important
 However, there was no evidence that continuous
CTG improves outcomes compared with intermittent
auscultation.
ABOUBAKR M ELNASHAR

22. 3. Position in labour
 Carry out a risk assessment in the third trimester.
 Develop birth plan with the woman, take into
account:
 woman's
 preference
 mobility
 current weight.
 comorbidities
ABOUBAKR M ELNASHAR

23.  The woman's position in the second stage
 Non obese
 Discourage the woman from lying
 supine or
 semi-supine
 Encourage her to adopt any other position that
she finds most comfortable.
 Obese:
 with reduced mobility
 lateral position.
 {this allows good access: reduces the risk of
adverse events}
 with adequate mobility
 As non obeseABOUBAKR M ELNASHAR

24. 4. Equipment needs
 Carry out a risk assessment at booking
 All obstetric units should have
 'birthing beds' able to take a load of 250 kg.
 surgical, obstetric& anaesthetic equipment
 blood pressure cuffs
 operating theatre tables
 Lifting& lateral transfer equipment
 anti-embolism stockings
 wheelchairs
 Monitoring& measuring equipment.ABOUBAKR M ELNASHAR

25. You can get this lecture and 440
lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3. elnashar53@hotmail.com
4.My clinic: Althwara st, Mansura, Egypt
ABOUBAKR M ELNASHAR