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Intrapartum care for women with existing medical conditions

About

What is covered

This interactive flowchart covers intrapartum care for women who need extra support because they have a medical condition. It covers women in spontaneous or induced labour (or who have a planned caesarean section) who are at high risk of adverse outcomes for themselves or their baby because of existing maternal medical conditions.
Supporting women to make decisions about their care is particularly important during the intrapartum period. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance and the 2015 Montgomery ruling.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on intrapartum care for women with existing medical conditions in an interactive flowchart

What is covered

This interactive flowchart covers intrapartum care for women who need extra support because they have a medical condition. It covers women in spontaneous or induced labour (or who have a planned caesarean section) who are at high risk of adverse outcomes for themselves or their baby because of existing maternal medical conditions.
Supporting women to make decisions about their care is particularly important during the intrapartum period. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance and the 2015 Montgomery ruling.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Modifying the birth plan according to maternal platelet count in women with immune thrombocytopenic purpura or gestational thrombocytopenia

Maternal platelet count
Maternal care
Fetal and neonatal care
Platelet count above 80 × 109/l
Treat the woman as healthy for the purpose of considering regional analgesia and anaesthesia
If the woman has ITP or suspected ITP, assume the baby is at risk of bleeding and take the following precautions:
  • 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.
If the woman has gestational thrombocytopenia, assume the baby has a normal risk of bleeding
Platelet count 50 to 80 × 109/l
Before considering regional analgesia and anaesthesia, take into account:
  • clinical history
  • the woman's preferences
  • anaesthetic expertise
Platelet count below 50 × 109/l
Avoid regional analgesia and anaesthesia under most circumstances

Management of the third stage of labour for women with modified WHO 3 or modified WHO 4 heart diseaseDefined according to the modified World Health Organization classification of maternal cardiovascular risk (European Society of Cardiology 2018).

Condition
First-line uterotonic
Second-line uterotonics
Drugs to avoid because of potential harm
Significant aortopathy
Marfan syndrome and Loeys–Dietz with aortic dilatation >40 mm
Bicuspid aortopathy and aortic dilatation >45 mm
Previous aortic dissection
Turner syndrome and aortic size index >25 cm/m2
Oxytocin
Misoprostol
Carboprost
Ergometrine (because of risk of hypertension-induced aortic dissection or rupture)
Limited or fixed low cardiac output, or preload-dependent circulation
Severe systemic ventricular dysfunction (ejection fraction <30%)
Severe valvular stenosis
Hypertrophic cardiomyopathy with diastolic dysfunction or significant outflow tract obstruction
Fontan circulation
Cyanotic heart disease
Slow infusion of oxytocin to avoid sudden haemodynamic change
Misoprostol
Carboprost
Long-acting oxytocin analogues and ergometrine (because of risk of hypertension-induced heart failure)
Pulmonary arterial hypertension
Oxytocin
Misoprostol
Ergometrine, carboprost and long-acting oxytocin analogues (because of risk of worsening pulmonary hypertension)
Coronary artery disease
Oxytocin
Misoprostol
Ergometrine (because of risk of coronary ischaemia)

Glossary

activated partial thromboplastin time
electrocardiogram
international normalised ratio
(from the onset of labour [spontaneous or induced] to 24 hours after birth)
immune thrombocytopenic purpura
(prosthetic heart valves that require long-term anticoagulation to prevent heart valve thrombosis [this is different from bioprosthetic heart valves, which do not need long-term anticoagulation])
N-terminal pro-brain natriuretic peptide
New York Heart Association
(includes spinal, epidurals and combined spinal–epidural techniques)
(includes spinal, epidurals and combined spinal–epidural techniques)
World Health Organization

Paths in this pathway

Pathway created: March 2019 Last updated: March 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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