Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003. 1.17.2 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. 1.17.3 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. 1.3.19 During pregnancy, plan the management of fluid balance during the intrapartum period for women with heart disease with the multidisciplinary team (outlined in recommendation 1.2.2). ], 1.13.24 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. 1.16.1 Discuss with a woman whose baby is suspected to be small for gestational age: the chance of serious medical problems for her baby. 9 1.13.19 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: the results of any fetal blood sampling carried out. 1.13.15 For women in labour with suspected sepsis, carry out a multidisciplinary review of options for pain relief at least every 4 hours. 1.12.2 Be aware that paracetamol is not a treatment for sepsis and should not delay investigation if sepsis is suspected. To find out why the committee made the recommendations on mode of birth for women with heart disease and how they might affect practice, see rationale and impact. measurement of N‑terminal pro‑brain natriuretic peptide (NT‑proBNP) levels. To find out why the committee made the recommendations on anaesthesia and analgesia for women with heart disease and how they might affect practice, see rationale and impact. 9 1.18.12 Follow the recommendations in the NICE guideline on intrapartum care for healthy women and babies when no medical conditions or obstetric complications are identified in women who present in labour with no antenatal care. is presented as recommended in the NICE guideline on patient experience in adult NHS services. 1.13.1 Follow the NICE guideline on sepsis for the recognition of sepsis in pregnant women. 1.6.9 For women with bleeding disorders, avoid giving uterotonics by intramuscular injection. Eclampsia is defined as the occurrence of seizures in pregnancy or within 10 days of delivery, accompanied by at least two of the following features documented within 24 hours of the seizure: hypertension, proteinuria, thrombocytopenia or raised aspartate amino transferase. 1.19.7 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. 1.8.10 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. Marfan syndrome and Loeys–Dietz with aortic dilatation >40 mm.

1.8.14 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. To find out why the committee made the recommendations on planning for intrapartum care involving a multidisciplinary team and how they might affect practice, see rationale and impact.

1.1 Information for women with existing medical conditions, 1.2 Planning for intrapartum care with women with existing medical conditions – involving a multidisciplinary team, 1.7 Subarachnoid haemorrhage or arteriovenous malformation of the brain, 1.8 Acute kidney injury or chronic kidney disease, 1.10 Information for women with obstetric complications or no antenatal care, 1.11 Risk assessment for women with obstetric complications or no antenatal care, intrapartum care for healthy women and babies, information about classes of heart failure. Take account of previous discussions, planning, decisions and choices, and keep the woman and her birth companion(s) fully informed. To find out why the committee made the recommendations on antimicrobial treatment for women in labour with sepsis or suspected sepsis and how they might affect practice, see rationale and impact. 1.3.41 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 recommendation 1.2.1). 1.4.4 Consider prostaglandin E1 as an option for treating postpartum haemorrhage in women with asthma because there is no evidence it worsens asthma. rechecking anti‑Xa level weekly once the target anti‑Xa level is achieved. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. Regional anaesthesia includes spinal, epidural and combined spinal–epidural techniques. 1.6.8 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 healthy women and babies. 1.3.5 Offer the same investigations to pregnant women with heart disease as to women who are not pregnant.

1.3.40 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. Include a cardiologist with expertise in managing heart disease in pregnant women in the multidisciplinary team discussions. 1.7.1 Involve the multidisciplinary team in risk assessment for women with a cerebrovascular malformation or a history of intracranial bleeding. counsel a woman postnatally about the long-term effects of pre-eclampsia. Do not offer supplemental hydrocortisone in the intrapartum period to women taking inhaled or topical steroids. 330(7491):576-80. To find out why the committee made the recommendations on equipment needs for women in labour with a BMI over 30 kg/m2 and how they might affect practice, see rationale and impact.