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.
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
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
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